Contemplative self healing in women breast cancer survivors: a pilot study in underserved minority women shows improvement in quality of life and reduced stress
© Charlson et al.; licensee BioMed Central Ltd. 2014
Received: 10 April 2014
Accepted: 13 August 2014
Published: 23 September 2014
Among underserved, largely minority women who were breast cancer survivors, this pilot project was designed to evaluate the quality of life outcomes of a 20 week Contemplative Self-Healing Program.
Women previously treated for stage I-III breast cancer were assessed before and after the 20 week program with the FACT-G, FACT-B, FACIT-Spirituality, ECOG, and the Impact of Events Scale. They participated in a 20-week intervention involving guided meditation and cognitive-affective-behavioral learning.
With an average age of 63, 62% of the participants were African-American or Latino. With an average of 5.4 years since the diagnosis of breast cancer, 72% had an ECOG performance status of 1. 57% were currently working.
Their baseline FACT-G was 80.5 ± 15.1, and their baseline Impact of Events Scale was 26.3 ± 18.9. The within-patient improvement on the FACT-G was 4.6 ± 10.9 (p = .01); in parallel the FACT-B improved by 2.8 ± 12.8 points (p = .03). The Impact of Events Scale improved by 6.6 ± 15.5 points (p = .01). There was significant within-patient improvement on both the avoidance scale (3.8 ± 9.2) and on the intrusion scale (2.9 ± 7.9). Patients who attended more sessions and conducted more home practice had greater improvements in quality of life.
Persons receiving a 20-session contemplative self healing intervention showed improved quality of life, with a clinically and statistically significant increase in the FACT-G. In addition, this population showed a significant reduction in post-traumatic stress symptoms assessed by the Impact of Events Scale.
Clinical Trials Gov NCT00278837.
Even after five years, when most other cancers are viewed as cured, women with breast cancer face an ongoing threat of recurrence, at about 5% per year [1, 2]. While it is often assumed that the stress experienced by women with breast cancer abates after initial treatment, paradoxically, stress-related symptoms may increase when treatment is finished and they leave the ‘safety net’ provided by their oncologist and their staff . Patients may experience feelings of uncertainty as they try to reintegrate themselves back into their pre-diagnosis lives and roles . If patients cannot address and resolve such feelings, they may experience persistent stress symptoms [3, 4]. Thirty to forty percent of breast cancer survivors experience distress and stress-related symptoms that do not abate with time . In fact, twenty years after treatment, women who are disease-free may experience ongoing distress .
In a large pilot study of 50 predominantly white, college educated, and with higher socioeconomic status breast cancer survivors, we previously demonstrated that a contemplative self-healing intervention resulted in a clinically significant improvement in within-patient differences in quality of life, using the FACT-G, a cancer-specific scale . This contemplative intervention was based on two thousand year old practices of healing visualization and lifelong health education preserved in the Tibetan Buddhist traditions of integrative medicine and universal public health education . The visualization-based health educational practice incorporates an imagery-based mindfulness practice for meditation-based stress reduction with an imagery-based contemplation practice for cognitive-affective-behavioral learning . Since underserved and minority breast cancer survivors have more stress and lower quality of life [3, 7–13], this study was designed to assess the impact of the contemplative intervention on minority cancer survivors.
Among underserved, predominantly minority women who had completed treatment for stage I-III breast cancer, the objective of this pilot study was to evaluate the impact of our Contemplative Self-Healing Program on quality of life (FACT-G, FACT-B) and post-traumatic stress symptoms.
Screening and eligibility
The Montefiore-Einstein Center for Cancer Care (MECCC) provides cancer care to residents of Bronx County, NY and surrounding areas. The poorest urban county in the U.S., the Bronx consists of nearly 1.4 million residents, most of whom are members of ethnic minorities. The primary racial/ethnic groups represented in the Bronx are Hispanics (51%), Blacks (34%), and non-Hispanic Whites (22%), with 30% living at or below the poverty level.
Psychosocial Oncology program staff selected potentially eligible participants, who were then contacted over the phone and screened for eligibility by study personnel. Women with stage I-III breast cancer who had completed initial treatment were eligible for inclusion in this program. Patients who were male, were known to have stage IV (metastatic) breast cancer, or were unable to return to the MECCC Center for classes were excluded. Women who were not fluent in English, those enrolled in other studies involving psychosocial interventions for breast cancer survivors, or those with cognitive impairment were excluded. The study was approved by the Weill Cornell Medical College Institutional Review Board and written informed consent was obtained.
Demographic and clinical status
Baseline evaluation included data about demographics, acculturation , and living situation. Clinical information— including the cancer stage, axillary node status, estrogen/progesterone receptor status, HER-2, and specific course of chemotherapy, radiation, and surgery—was obtained from clinical records. Comorbidity was assessed with the Charlson Comorbidity Index . Cognitive function was measured through the EORTC cognitive function questionnaire . The Eastern Cooperative Oncology Group Performance Status Rating was assessed. (ECOG PSR) . The patient’s smoking history, physical activity, nutritional, and other lifestyle practices were also documented.
Psychosocial impact of disease
The Impact of Events Scale (IES) was used to assess post traumatic stress symptoms on two subscales: intrusion and avoidance with higher scores indicating a greater number of post traumatic stress symptoms . The IES provides a dimensional measure of severity, rather than the DSM categorical assessment. However, IES Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD .
Quality of life outcomes
Quality of life was measured by the general Functional Assessment of Cancer Therapy Scale (FACT-G, Version 4) . The FACT-G measures quality of life, evaluating 28 items across four domains: physical well being (7 items); social/family well-being (7 items); emotional well-being (5 items); and functional well-being (7 items). A higher score indicates higher Quality of Life. In addition, the Breast Cancer Subscale, which has disease-specific questions including treatment sequelae, was administered [20, 21]. The BCS and FACT-G are added to form the FACT-B. The FACIT Spirituality scale was also given [22, 23], with a range of 0–48 . The 9-item Ryff scale was also administered; this scale assesses psychological well-being across multiple distinct dimensions: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance [24–26].
All quality of life and psychosocial scales were repeated at program completion. Patients were also asked about any interval medical events. Finally, patients were asked open-ended questions about their experience with the program, what they would tell others about the program, and what the program effects for them.
Contemplative self-healing intervention
The intervention program is a 20 week meditation-based stress reduction program organized in two parts . The first part consists of eight weekly 90-minute group sessions focus on teaching meditation skills. During these sessions, participants were guided through exercises emphasizing awareness of breath, healing imagery, and deep breathing to help them better control their responses and practice self-change. The second part of the course was a 12-session cognitive-affective-behavioral learning program. Participants were exposed to new ideas and tools to better understand and cope with their reactions to the challenges of living with illness. The weekly sessions emphasized mind/body skills to help participants unlearn disease-prone habits and develop a healthier outlook, attitude, and lifestyle.
Daily practice was supported by homework consisting of visualization guided by audio tapes and structured assignments for reading and reflection. There were four separate groups held in 2008-2009--two offered in the morning and two in the evening. The sessions were led by four different interventionists who were trained by its developer (J.L.). The four interventionists were all psychologists – two with extensive experience and two still in training. Two of the four leaders had no experience with contemplative group interventions and none had previously led this intervention. There was ongoing supervision throughout the study.
All data was entered into a web-based, secure, HIPPA compliant data management system, Clinvestigator©. Data analysis was conducted using SAS 9.2. Bivariate differences were assessed by Chi-square for differences in proportions and the Student-paired t-test was used to evaluate within-patient differences in scores. PROC GLM in SAS 9.2 was employed for regression analysis.
A total of 46 women consented to participate and provided informed written consent. Of those 46, four of the patients (10%) were lost to follow-up. They were more likely to be primary Spanish speakers (p = .0005). There were no other baseline differences in FACT-G, Ryff, or IES scores between those who were lost and those who were not.
Sociodemographic and clinical characteristics of participants
Baseline demographic and clinical characteristics of the participants in the Contemplative Self Healing Program
Completed (N = 42)
Age (mean years ± SD)
63 ± 11
Primary language Spanish
Time since breast cancer diagnosis (years ± SD)
5.7 ± 5.8
Breast cancer treatment
Current hormonal therapy
Previous breast cancer recurrence
ECOG Performance Status
Limited strenuous activity
Ambulatory but unable to work
No difficulty (2–3)
Some difficulty (4–5)
A lot of difficulty (6–8)
Needs to cut back alcohol
>6 hours a night
4-5 hours a night
<4 hours a night
Ever meditated before
Few times a week to daily
Less than once a week
Stress with health
Stress with relationships
Stress with job
Stress with money
38.9 ± 7.0
Ryff Personal Well Being Scale
44.6 ± 6.5
42.9 ± 6.2
42.9 ± 7.2
43.2 ± 7.5
Purpose in life
40.3 ± 6.6
41.2 ± 6.8
The baseline FACT-G score was 80.8 (the principal outcome) almost identical to the average FACT-G for the general population and for cancer survivors . The scores for FACT-G subscales -- emotional, physical, social, and functional well being -- were also almost identical to the general population. The Breast Cancer Subscale score (BCS) was 24.3, similar to the BCS reported for other breast cancer patients . The baseline FACIT spirituality was 38.9, similar to scores previously reported . Before starting the program, 17% of participants had meditated more than a few times a week and 79% prayed daily. Of note, the baseline FACT-G score was significantly was not significantly associated with prior recurrence (p = .26), although it was lower in patients with higher comorbidity (p < .02) and higher in patients with a higher FACIT spirituality score (p < .001). The scores on the Ryff Personal Well Being were similar to those previously reported for breast cancer survivors and healthy controls . Therefore, with regard to quality of life and personal well being at baseline, the participants had comparable scores both to women of a similar age and to other women who were cancer survivors. At baseline, 37% reported one or two stresses, and 34%, three or more, attributed equally to health and money followed by relationship and job stresses. On the Impact of Events Scale, our patients had 15.0 for the avoidance scale and 11.0 for the intrusion scale, similar to other reports for early stage breast cancer patient [33, 34].
The principal outcome was the FACT-G which focuses on overall quality of life. Among all participants, the FACT-G improved by 3.7 points after completion of the program (p = .04), which is a clinically important improvement in FACT-G [35, 36]. Importantly, three women developed a new recurrence of breast cancer during the 20-week program; not surprisingly, they had a worsening of 7.7 on the FACT-G. The remainder of the analysis will focus on patients without an interval recurrence.
Outcomes among patients without interval recurrence
Quality of life
Outcomes in breast cancer patients without interval recurrence (n = 39)
Within patient change
80.5 ± 15.1
85.1 ± 14.0
+4.6 ± 10.9
18.5 ± 5.0
19.3 ± 4.3
0.8 ± 4.1
22.8 ± 4.2
23.5 ± 4.2
0.7 ± 3.5
20.1 ± 6.3
+21.7 ± 4.9
+1.6 ± 4.6
19.1 ± 6.6
20.5 ± 5.5
+1.4 ± 4.5
24.3 ± 6.6
24.5 ± 6.5
+0.2 ± 5.2
104.9 ± 19.9
109.6 ± 18.6
+4.8 ± 12.8
37.2 ± 8.2
38.9 ± 7.1
+1.4 ± 1.0
Impact of events
26.3 ± 18.9
19.8 ± 15.5
−6.6 ± 15.5
15.5 ± 10.6
11.4 ± 8.1
−3.8 ± 9.2
11.5 ± 9.3
8.4 ± 8.3
−2.9 ± 7/9
Post-traumatic stress symptoms
The total score on the Impact of Events Scale (IES) improved by 6.6 (p = .01), with an improvement of 3.8 for avoidance (p = .01 and 2.9 for intrusion subscale (p = .03).
Other health measures
Between baseline and follow-up, there were minimal changes in other health behaviors. There were no reported changes in number of hours of sleep, weight, or smoking. For the most part, physical activity remained the same. There were also no significant changes in any of the Ryff Well Being Subscales. ECOG performance status was the same in 71% of patients, improved by a rank of one in 16% of patients, and worse in 13% of patients. There was also a significant improvement in the cognitive domain of the EORTC (p < .0001); 43% of the women (17/39) reported an improvement in thinking or concentration by at least a rank of 1, while 28% reported an improvement by a rank of 2 or more.
Changes in FACT-G and IES according to program participation: Class attendance and meditation at home
Within-patient change in FACT-G
Within patient change in IES
Meditation never, rarely or some days
+3.3 ± 10.3
−7.0 ± 21.4
Meditation most days or every day
+5.5 ± 4.9
−5.5 ± 21.9
Meditation never,rarely or some days
+5.1 ± 11.4
−3.6 ± 13.2
Meditation most days or every day
+6.5 ± 13.5
−7.7 ± 15.2
Comments of participants
What was your experience?
I really found it much better than I truly anticipated.... When people brought things up it was relatable. It brought things to light and clicked like a puzzle put in.
I want to know why I didn’t know about something like this before. If I had this earlier in my diagnosis and after my surgery it would have helped a lot. I would have taken a different turn.
I was able to talk and get all these things out of me to make myself calmer. It helps me to relieve myself and relax.
I found myself honored and blessed to be in the company of my cohort and facilitators. We come from disparate backgrounds, yet we experience a one-ness that was nothing less than divine.
What was its effect?
I used to be so angry but since this I’ve been so mellow. I have to worry about my sick husband and not myself and I one time felt like just packing up and running away from everyone. Until I listened to these CDs and reading and just meditated and listened.
Positive, empowering, emotionally freeing. It took a couple of rocks from my bag.
The change in the way we feel about ourselves. It helps you w/every aspect of your life. Sometimes you see some of those ladies with breast cancer and they feel so sorry for themselves. They don’t realize the power they have to heal themselves.
I knew nothing before and I had a lot of stress and it helped me be more positive. It taught me to take my time to think before acting. I think about giving people a chance.
I’m less anxious and more relaxed and it helped me realize when I’m anxious and then I use what I’ve learned.
I don’t worry about dying as I did before when it was a lingering thing. I have a new out look now with the meditation. I do need that meditation. It made me a new person in dealing with my cancer. It helped me to get off and slow the spinning wheel.
Made me stronger and less critical of myself more accepting of myself.
In a good way. I feel more competent that I could do whatever I want and that nothing is impossible.
It was great bcs I was able to go to the past and it wasn’t as bad as I thought it was going to be. I brought it to the future and it wasn’t as scary. It helped calm me down so I can get my life in order and not worry about dying.
What would you tell others?
That it would be good and it helps to deal with the stress--how to deal.
I would tell everyone that they would learn about taking away your stress and anger. The teacher was very patient.
It helps you to relax and to understand more about yourself and your illness.
That they should go; they should make the time. There are many benefits.
Very helpful with everyday life even if you’re not sick it helps you with everyday living.
That it was quite helpful in concentration, learning to meditate, bring your body into one.
It’s very good. I recommend it to cancer patients and any other program. It helped me immensely.
Maybe doctors could learn from this. They could learn something for their patients. It’s helpful and it’s a worthwhile program.
I would tell them how helpful it is with not just your physical situation but also the general situation.
The overall quality of life of women with breast cancer is directly related to whether they have ongoing stress-related symptoms . Such stress–related symptoms have a significant adverse impact on quality of life and function, especially emotional wellbeing . Stress-related symptoms include intense fear, avoidance, intrusive thoughts, impaired sleep, difficulty concentrating, increased irritability and apprehensiveness—symptoms primarily associated with fear of recurrence [4, 37–39].
We believe that the stress and distress experienced by breast cancer patients is a relatively normal reaction to a life-threatening event. Breast cancer forces women to face life’s impermanence, as well as its meaning and purpose . This may explain why such distress is often not relieved by the passage of time [41–45]. Moreover, the distress is not less among patients who have excellent outcomes [4, 46, 47], because these women still have an increased sense of vulnerability and loss of control [45, 48]. Quality of life and stress-related conditions do improve for those patients who have an enhanced sense of purpose after experiencing breast cancer [49, 50].
Findings in context
With a few exceptions, most conventional interventions--including professional counseling , peer support , and telephone support groups [53, 54]—have not improved quality of life or reduced stress–related symptoms in breast cancer patients. Cognitive behavioral therapy has had modest benefits [34, 55, 56]. The only intervention that has markedly improved quality of life for breast cancer survivors is aerobic exercise; the exercise group improved by 5.0 more than the control as measured by within-patient change in the FACT-G (+5.7 vs. +0.7) . This intensity of aerobic exercise, three times a week for 15 weeks , is also as effective as anti-depressant medications in treating major depression . Lesser levels of supervised exercise or home-based physical activity were not effective. In our previous study involving primarily Caucasian patients , the improvement in overall FACT-G was slightly greater with an improvement of 6.4 vs. 4.6 in the current study. This is remarkable because women in this study reported a lower level of adherence regarding meditation. Since individual levels of improvement in this study were correlated with class attendance and practice, increased adherence might enhance the intervention effect.
There is limited evidence that any intervention in breast cancer patients has been efficacious in decreasing post-traumatic stress related symptoms. In contrast, the qualitative and quantitative results of our contemplative self-healing intervention resulted in improved quality of life and stress-reduction ratings—a significant potential benefit to be analyzed further in future randomized trials.
IES total and subscale scores in longitudinal studies of breast cancer patients
Between patient changes
Between patient changes
Type of study
Baseline new surgery
Six months after baseline
Baseline: 3 months after surgery
12 months after baseline
Baseline: 2 months after surgery
9 months after baseline
Our qualitative results demonstrated that participants benefited from participating in a positive, supportive group format that enhanced their ability to cope with cancer. In a qualitative study of 66 African American women with breast cancer, support networks and spirituality were both important coping mechanisms reported by participants . The women in our study also reported feelings of empowerment and personal strength. Finally, our participants told us that the group provided them with a sense of balance and less preoccupation with fear of dying. Such existential fears are common among female breast cancer survivors . Our intervention deals directly with fear of death, and thus we hypothesize that participants were able to work through fears that they may have been unable to discuss with their family and oncologists.
The principal limitation is that we conducted this pilot study without a control group. As a result, we cannot definitively conclude that the results of the intervention differed from results that would be produced in a control. However the findings of this pilot study suggest important potential benefits for contemplative self-healing methods. Previously, only intensive aerobic exercise had a clinically significant impact on improving quality of life as assessed by the FACT-G, our principal outcome, but these exercise interventions are very difficult for most patients to adopt and sustain. The FACT-G was selected as the principal measure, because it more accurately reflects overall quality of life, than the BCS.
In conclusion, among predominantly Black and Latino women, the 20-week Contemplative Self healing intervention had a clinically important improvement in FACT-G. Significantly, it also had a clinically important impact on post-traumatic stress symptoms, especially avoidance, as measured by the Impact of Events Scale.
Funding provided by Avon Foundation.
Center for Integrative Medicine, Weill Cornell Medical Center, Nalanda Institute for Contemplative Science, Albert Einstein College of Medicine, Yeshiva University: Ferkauf Graduate School of Psychology.
- Weiss RB, Woolf SH, Demakos E, Holland JF, Berry DA, Falkson G, Cirrincione CT, Robbins A, Bothun S, Henderson IC, Norton L: Natural history of more than 20 years of node-positive primary breast carcinoma treated with cyclophosphamide, methotrexate, and fluorouracil-based adjuvant chemotherapy: a study by the Cancer and Leukemia Group B. J Clin Oncol. 2003, 21 (9): 1825-1835. 10.1200/JCO.2003.09.006.View ArticlePubMedGoogle Scholar
- Early Breast Cancer Trialists’ Collaborative Group (EBCTCG): Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005, 365 (9472): 1687-1717.View ArticleGoogle Scholar
- Arnold EM: The cessation of cancer treatment as a crisis. Soc Work Health Care. 1999, 29 (2): 21-38. 10.1300/J010v29n02_02.View ArticlePubMedGoogle Scholar
- Gurevich M, Devins GM, Rodin GM: Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics. 2002, 43 (4): 259-281. 10.1176/appi.psy.43.4.259.View ArticlePubMedGoogle Scholar
- Loizzo JJ, Peterson JC, Charlson ME, Wolf EJ, Altemus M, Briggs WM, Vahdat LT, Caputo TA: The effect of a contemplative self-healing program on quality of life in women with breast and gynecologic cancers. Altern Ther Health Med. 2010, 16 (3): 30-37.PubMedGoogle Scholar
- Loizzo J, Charlson M, Peterson J: A program in contemplative self-healing: stress, allostasis, and learning in the Indo-Tibetan tradition. Ann N Y Acad Sci. 2009, 1172: 123-147. 10.1111/j.1749-6632.2009.04398.x.View ArticlePubMedGoogle Scholar
- Rodrigue J: An examination of race differences in patients’ psychological adjustment to cancer. J Clin Psychol Med Settings. 1997, 4: 271-280. 10.1023/A:1026271431384.View ArticleGoogle Scholar
- Spencer SM, Lehman JM, Wynings C, Arena P, Carver CS, Antoni MH, Derhagopian RP, Ironson G, Love N: Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients. Health Psychol. 1999, 18 (2): 159-168.View ArticlePubMedGoogle Scholar
- Aziz NM, Rowland JH: Cancer survivorship research among ethnic minority and medically underserved groups. Oncol Nurs Forum. 2002, 29: 789-801. 10.1188/02.ONF.789-801.View ArticlePubMedGoogle Scholar
- Bourjolly J, Kerson T, Nuamah I: A comparison of social functioning among black women with breast cancer. Social Work Health Care. 1999, 28: 1-20.View ArticleGoogle Scholar
- Ashing-Giwa K: Quality of Life and psychosocial outcomes in long-term survivors of breast cancer: a focus on African-American women. J Psychosoc Oncol. 1999, 17: 47-62.View ArticleGoogle Scholar
- Moadel A, Perez A, Gharraee Z, Jones C, Sparano J: Examining quality of life after breast cancer: cultural, treatment, and menstrual factors. Psychosom Med. 2002, 64: 106-Google Scholar
- Culver JL, Arena PL, Antoni MH, Carver CS: Coping and distress among women under treatment for early stage breast cancer: comparing African Americans, Hispanics and non-Hispanic Whites. Psychooncology. 2002, 11 (6): 495-504. 10.1002/pon.615.View ArticlePubMedGoogle Scholar
- Marin G, Sabogal F, VanOss Marín B, Otero-Sabogal F, Pérez-Stable EJ: Development of a short acculturation scale for Hispanics. Hispanic J Behav Sci. 1987, 9: 183-205. 10.1177/07399863870092005.View ArticleGoogle Scholar
- Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987, 40 (5): 373-383. 10.1016/0021-9681(87)90171-8.View ArticlePubMedGoogle Scholar
- Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC, Kaasa S, Klee M, Osoba D, Razavi D, Rofe PB, Schraub S, Sneeuw K, Sullivan M, Takeda F: The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993, 85 (5): 365-376. 10.1093/jnci/85.5.365.View ArticlePubMedGoogle Scholar
- Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP: Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982, 5 (6): 649-655. 10.1097/00000421-198212000-00014.View ArticlePubMedGoogle Scholar
- Horowitz M, Wilner N, Alvarez W: Impact of event scale: a measure of subjective stress. Psychosom Med. 1979, 41 (3): 209-218. 10.1097/00006842-197905000-00004.View ArticlePubMedGoogle Scholar
- Joseph S: Psychometric evaluation of Horowitz’s impact of event scale: a review. J Trauma Stress. 2000, 13 (1): 101-113. 10.1023/A:1007777032063.View ArticlePubMedGoogle Scholar
- Cella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, Silberman M, Yellen SB, Winicour P, Brannon J, Eckberg K, Lloyd S, Purl S, Blendowski C, Goodman M, Barnicle M, Stewart I, McHale M, Bonomi P, Kaplan E, Taylor S, Thomas CR, Harris J: The functional assessment of cancer therapy scale: development and validation of the general measure. J Clin Oncol. 1993, 11 (3): 570-579.PubMedGoogle Scholar
- Brady MJ, Cella DF, Mo F, Bonomi AE, Tulsky DS, Lloyd SR, Deasy S, Cobleigh M, Shiomoto G: Reliability and validity of the functional assessment of cancer therapy-breast quality-of-life instrument. J Clin Oncol. 1997, 15 (3): 974-986.PubMedGoogle Scholar
- Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D: Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy–Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med. 2002, 24 (1): 49-58. 10.1207/S15324796ABM2401_06.View ArticlePubMedGoogle Scholar
- Cella D, Lai JS, Chang CH, Peterman A, Slavin M: Fatigue in cancer patients compared with fatigue in the general United States population. Cancer. 2002, 94 (2): 528-538. 10.1002/cncr.10245.View ArticlePubMedGoogle Scholar
- Ryff CD: Happiness is everything, or is it? Exporations on the meaning of psychological Well-being. J Pers Soc Psychol. 1989, 57: 1069-1081.View ArticleGoogle Scholar
- Ryff CD, Keyes CL: The structure of psychological well-being revisited. J Pers Soc Psychol. 1995, 69 (4): 719-727.View ArticlePubMedGoogle Scholar
- Ryff CD, Singer B: Psychological well-being: meaning, measurement, and implications for psychotherapy research. Psychother Psychosom. 1996, 65 (1): 14-23. 10.1159/000289026.View ArticlePubMedGoogle Scholar
- Glaser B, Straus A: The discovery of grounded theory: strategies for qualitative research. 1967, New York: AldineGoogle Scholar
- Basics of qualitative research. Edited by: Corbin J, Strauss A. 2008, Thousand Oaks, California: Sage Publications, 3Google Scholar
- Wuest J: Grounded theory: the method. Nursing Research: A Qualitative Perspective. Edited by: Munhall P. 2012, Sudbury, MA: Joans & Barlett Learning, 225-256.Google Scholar
- Lietz C, Langer C, Furman R: Establishing trustworthiness in qualitative research in social work. Qual Soc Work. 2006, 5 (4): 441-458. 10.1177/1473325006070288.View ArticleGoogle Scholar
- Brucker PS, Yost K, Cashy J, Webster K, Cella D: General population and cancer patient norms for the Functional Assessment of Cancer Therapy-General (FACT-G). Eval Health Prof. 2005, 28 (2): 192-211. 10.1177/0163278705275341.View ArticlePubMedGoogle Scholar
- Cordova MJ, Cunningham LL, Carlson CR, Andrykowski MA: Posttraumatic growth following breast cancer: a controlled comparison study. Health Psychol. 2001, 20 (3): 176-185.View ArticlePubMedGoogle Scholar
- Sears SR, Stanton AL, Danoff-Burg S: The yellow brick road and the emerald city: benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer. Health Psychol. 2003, 22 (5): 487-497.View ArticlePubMedGoogle Scholar
- Antoni MH, Lehman JM, Kilbourn KM, Boyers AE, Culver JL, Alferi SM, Yount SE, McGregor BA, Arena PL, Harris SD, Price AA, Carver CS: Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol. 2001, 20 (1): 20-32.View ArticlePubMedGoogle Scholar
- Nosarti C, Roberts JV, Crayford T, McKenzie K, David AS: Early psychological adjustment in breast cancer patients: a prospective study. J Psychosom Res. 2002, 53 (6): 1123-1130. 10.1016/S0022-3999(02)00350-1.View ArticlePubMedGoogle Scholar
- Cella D, Hahn EA, Dineen K: Meaningful change in cancer-specific quality of life scores: differences between improvement and worsening. Qual Life Res. 2002, 11 (3): 207-221. 10.1023/A:1015276414526.View ArticlePubMedGoogle Scholar
- Andrykowski MA, Cordova MJ, McGrath PC, Sloan DA, Kenady DE: Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: a 1-year follow-up. Psychooncology. 2000, 9 (1): 69-78. 10.1002/(SICI)1099-1611(200001/02)9:1<69::AID-PON439>3.0.CO;2-R.View ArticlePubMedGoogle Scholar
- Palmer SC, Kagee A, Coyne JC, DeMichele A: Experience of trauma, distress, and posttraumatic stress disorder among breast cancer patients. Psychosom Med. 2004, 66 (2): 258-264. 10.1097/01.psy.0000116755.71033.10.View ArticlePubMedGoogle Scholar
- Green BL, Rowland JH, Krupnick JL, Epstein SA, Stockton P, Stern NM, Spertus IL, Steakley C: Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics. 1998, 39 (2): 102-111. 10.1016/S0033-3182(98)71356-8.View ArticlePubMedGoogle Scholar
- Vickberg SM, Bovbjerg DH, DuHamel KN, Currie V, Redd WH: Intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor. Behav Med. 2000, 25 (4): 152-160. 10.1080/08964280009595744.View ArticlePubMedGoogle Scholar
- Meyer L, Aspegren K: Long-term psychological sequelae of mastectomy and breast conserving treatment for breast cancer. Acta Oncol. 1989, 28 (1): 13-18. 10.3109/02841868909111174.View ArticlePubMedGoogle Scholar
- Omne-Ponten M, Holmberg L, Sjoden PO: Psychosocial adjustment among women with breast cancer stages I and II: six-year follow-up of consecutive patients. J Clin Oncol. 1994, 12 (9): 1778-1782.PubMedGoogle Scholar
- Hughes J: Emotional reactions to the diagnosis and treatment of early breast cancer. J Psychosom Res. 1982, 26 (2): 277-283. 10.1016/0022-3999(82)90047-2.View ArticlePubMedGoogle Scholar
- Carver CS, Smith RG, Antoni MH, Petronis VM, Weiss S, Derhagopian RP: Optimistic personality and psychosocial well-being during treatment predict psychosocial well-being among long-term survivors of breast cancer. Health Psychol. 2005, 24 (5): 508-516.View ArticlePubMedGoogle Scholar
- Kornblith AB, Herndon JE, Weiss RB, Zhang C, Zuckerman EL, Rosenberg S, Mertz M, Payne D, Jane Massie M, Holland JF, Wingate P, Norton L, Holland JC: Long-term adjustment of survivors of early-stage breast carcinoma, 20 years after adjuvant chemotherapy. Cancer. 2003, 98 (4): 679-689. 10.1002/cncr.11531.View ArticlePubMedGoogle Scholar
- Tjemsland L, Soreide JA, Malt UF: Posttraumatic distress symptoms in operable breast cancer III: status one year after surgery. Breast Cancer Res Treat. 1998, 47 (2): 141-151. 10.1023/A:1005957302990.View ArticlePubMedGoogle Scholar
- Cordova MJ, Andrykowski MA, Kenady DE, McGrath PC, Sloan DA, Redd WH: Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. J Consult Clin Psychol. 1995, 63 (6): 981-986.View ArticlePubMedGoogle Scholar
- Dow KH, Ferrell BR, Leigh S, Ly J, Gulasekaram P: An evaluation of the quality of life among long-term survivors of breast cancer. Breast Cancer Res Treat. 1996, 39 (3): 261-273. 10.1007/BF01806154.View ArticlePubMedGoogle Scholar
- Carver CS, Antoni MH: Finding benefit in breast cancer during the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis. Health Psychol. 2004, 23 (6): 595-598.View ArticlePubMedGoogle Scholar
- Cotton SP, Levine EG, Fitzpatrick CM, Dold KH, Targ E: Exploring the relationships among spiritual well-being, quality of life, and psychological adjustment in women with breast cancer. Psychooncology. 1999, 8 (5): 429-438. 10.1002/(SICI)1099-1611(199909/10)8:5<429::AID-PON420>3.0.CO;2-P.View ArticlePubMedGoogle Scholar
- Allen SM, Shah AC, Nezu AM, Nezu CM, Ciambrone D, Hogan J, Mor V: A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial. Cancer. 2002, 94 (12): 3089-3100. 10.1002/cncr.10586.View ArticlePubMedGoogle Scholar
- Helgeson VS, Cohen S, Schulz R, Yasko J: Education and peer discussion group interventions and adjustment to breast cancer. Arch Gen Psychiatry. 1999, 56 (4): 340-347.View ArticlePubMedGoogle Scholar
- Heiney SP, McWayne J, Hurley TG, Lamb LS, Bryant LH, Butler W, Godder K: Efficacy of therapeutic group by telephone for women with breast cancer. Cancer Nurs. 2003, 26 (6): 439-447.View ArticlePubMedGoogle Scholar
- Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS: Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. J Clin Oncol. 2003, 21 (9): 1660-1668. 10.1200/JCO.2003.04.093.View ArticlePubMedGoogle Scholar
- Sandgren AK, McCaul KD, King B, O’Donnell S, Foreman G: Telephone therapy for patients with breast cancer. Oncol Nurs Forum. 2000, 27 (4): 683-688.PubMedGoogle Scholar
- Andersen BL, Farrar WB, Golden-Kreutz DM, Glaser R, Emery CF, Crespin TR, Shapiro CL, Carson WE: Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial. J Clin Oncol. 2004, 22 (17): 3570-3580. 10.1200/JCO.2004.06.030.View ArticlePubMedPubMed CentralGoogle Scholar
- Blumenthal JA, Babyak MA, Moore KA, Craighead WE, Herman S, Khatri P, Waugh R, Napolitano MA, Forman LM, Appelbaum M, Doraiswamy PM, Krishnan KR: Effects of exercise training on older patients with major depression. Arch Intern Med. 1999, 159 (19): 2349-2356.View ArticlePubMedGoogle Scholar
- O’Connor M, Christensen S, Jensen AB, Møller S, Zachariae R: How traumatic is breast cancer? Post-traumatic stress symptoms (PTSS) and risk factors for severe PTSS at 3 and 15 months after surgery in a nationwide cohort of Danish women treated for primary breast cancer. Br J Cancer. 2011, 104 (3): 419-426. 10.1038/sj.bjc.6606073.View ArticlePubMedPubMed CentralGoogle Scholar
- Davidson J, Kudler H, Smith R, Mahorney SL, Lipper S, Hammett E, Saunders WB, Cavenar JO: Treatment of posttraumatic stress disorder with amitriptyline and placebo. Arch Gen Psychiatry. 1990, 47 (3): 259-266. 10.1001/archpsyc.1990.01810150059010.View ArticlePubMedGoogle Scholar
- Koopman C, Butler LD, Classen C, Giese-Davis J, Morrow GR, Westendorf J, Banerjee T, Spiegel D: Traumatic stress symptoms among women with recently diagnosed primary breast cancer. J Trauma Stress. 2002, 15 (4): 277-287. 10.1023/A:1016295610660.View ArticlePubMedGoogle Scholar
- Henderson PD, Gore SV, Davis BL, Condon EH: African American women coping with breast cancer: a qualitative analysis. Oncol Nurs Forum. 2003, 30: 641-647. 10.1188/03.ONF.641-647.View ArticlePubMedGoogle Scholar
- Knobf MT: Clinical update: psychosocial responses in breast cancer survivors. Semin Oncol Nurs. 2011, 27 (3): e1-e14. 10.1016/j.soncn.2011.05.001.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/14/349/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.