Managing Uncertainty Day-to-Day

Breast cancer is the most common cancer in American women, and over 95% of those diagnosed with localized breast cancer and over 75% of those with regional disease will survive for 5 years or more. Breast cancer survivors are predominantly over the age of 60 and face emotional distress caused by the long-term symptoms of treatment and uncertainty about the possible recurrence of cancer. Moreover, older breast cancer survivors have voiced concerns about distinguishing between signs of aging and long-term symptoms from treatment, which may exacerbate uncertainty of recurrence. Uncertainty in illness theories propose that uncertainty about recurrence can reduce resourcefulness and a sense of control over life, and increase emotional distress. Programs are needed to provide survivors information and techniques to manage uncertainty about recurrence and improve coping.

Managing Uncertainty Day-to-Day is designed to help older breast cancer survivors manage uncertainty about recurrence of cancer and improve coping skills. The intervention has two main components:

• Cognitive strategies delivered via audiotape to teach active emotion-focused coping responses to threats of recurrence; and
• Behavioral strategies packaged in a self-help manual designed to provide management skills, information and resources on long-term treatment side effects, and cancer resources

The program includes four weekly phone calls from nurses to orient the survivors to the use of the materials. The cognitive tapes and the 125-page manual are packaged in a binder that includes three audiotapes and an instruction booklet. The manual and other program materials prompt use of certain skills; for example, a refrigerator magnet conveys the message "Relax", and a laminated card briefly describes steps to relax, distract oneself, and use calming self-talk.

The intervention is designed to be used by survivors as needed in their homes. The delivery protocol recommends that nurses make four phone calls (approximately 20-30 minutes in length) to orient survivors to use of the materials.

The intervention targets Caucasian and African American breast cancer survivors who are over the age of 60 and the health care professionals who serve them.

Managing Uncertainty Day-to-Day is designed to be portable and can be used in various places and at various times.

The required resources for program implementation include the Managing Uncertainty Day-to-Day manual, audiotapes, and the implementation protocol.  Nurses guide the cancer survivors in the use of the audiotaped strategies by telephone.

Breast cancer survivors (360 Caucasian and 149 African American women) who were 5-9 years post-treatment and recurrence-free were randomly assigned to a treatment group or a no-treatment control group. The treatment group received the Self-Help Manual for Managing Uncertainty Day-to-Day and audiotapes and four weekly phone calls from nurses who guided their use of the materials. The outcomes included increases in patient-provider communication, cognitive reframing, calming self-statements about one's ability to cope, behavioral activities to manage stress, cancer knowledge, and satisfaction with social support. There was also reduced catastrophizing of symptoms (e.g., characterizing pain as unbearable). The measures included:

• The Cancer Survivor Knowledge Scale
• The Patient/Provider Communication Scale
• A subscale of the Social Support Questionnaire
• Subscales of the Self-Control Schedule (for cognitive reframing/problem solving)
• Modified version of the Cognitive Coping Strategies Questionnaire

Measurement occurred at baseline immediately after entry into the study and 10 months post-baseline.

Key Findings 

• African American women in the treatment group reported an increased use of cognitive reframing, while similar women in the control group reported a decrease (p=.01). The finding was not statistically significant for Caucasian women.

• African American women in the treatment group reported increased patient/provider communication with a nurse, while similar women in the control group reported a decrease (p=.004). The finding was not statistically significant for Caucasian women.

• Caucasian women in the treatment group reported an increased use of calming self-statements, while similar women in the control group reported a decrease (p<.05). The finding was not statistically significant for African American women. 

• Overall, Caucasian women in the treatment group reported an increased use of behavioral activities to manage stress, relative to similar women in the control group (p<.05). The finding was not statistically significant for African American women.

• Caucasian women in the treatment group reported an increased use of diverting attention as a coping mechanism, relative to similar women in the control group (p<.05). The finding was not statistically significant for African American women.

• African American women in the treatment group reported a decrease in catastrophizing their symptoms, relative to similar women in the control group (p<.05). The finding was not statistically significant for Caucasian women.

• Women in the treatment group exhibited greater cancer knowledge than women in the control group (p=.0001). 
• Caucasian women in the treatment group reported a larger increase in satisfaction with their social support, compared to similar women in the control group (p=.03). The finding was not statistically significant for African American women.