Study: Healthy romantic relationships may decrease stress and inflammation for breast cancer survivors
|At a glance||Questions for your doctor|
|What does this mean for me?||In depth|
|Clinical trials||Strengths and limitations|
This study is about
Whether the known impact of romantic relationships—that they reduce inflammation—is because they affect stress levels. This study tests how three factors are linked: how satisfied women are with their partners, how stressed they feel and their level of inflammation.
Why is this study important?
Inflammation is associated with poorer outcomes in breast cancer survivors. Understanding what factors influence inflammation would allow development of ways to reduce inflammation.
Breast cancer survivors in satisfying romantic relationships had low stress and low inflammation. How satisfied a woman was in her romantic relationship was a good predictor of her inflammation levels.
But does a woman's satisfaction with her relationship directly lead to lower inflammation? Or do relationships affect stress, which in turn impacts inflammation?
- Statistical analyses showed that relationship satisfaction indirectly affected inflammation. How much stress a woman perceived was associated with her level of inflammation.
- Statistical models support the idea that relationships that are satisfying lead to lower stress; not that lower stress leads to relationship satisfaction.
These results show a link between relationship satisfaction, stress and inflammation. However, the data does not show whether these links are causal. For example, it is not known whether one factor (e.g., relationship satisfaction) that is linked with another (e.g., stress) actually causes the other. Whether relationship satisfaction leads to differences in stress levels will require additional testing to see whether an intervention to improve relationship satisfaction leads to decreased stress).
Women who were more satisfied with their romantic partners had less stress and lower inflammation. In other words, supportive relationships may lower stress levels and, in turn, decrease inflammation. A woman’s level of satisfaction with her romantic relationship is a good predictor of her inflammation levels.
Although not addressed in this study, women without partners may have other types of relationships that can help reduce stress. A support network may help you cope physically as well as emotionally with cancer treatment and recovery. XRAY reviewed a study that examined how support networks affect breast cancer outcomes. Relationships that satisfy you may be the key factor in maintaining your health.
You may want to consider strategies to reduce stress. Therapies such as meditation, mental health therapy, yoga and massage may help you to actively manage stress. Because stress affects overall health and inflammation, take time for self-care regularly.
Share your thoughts on this XRAYS article by taking our brief survey.
Shrout MR, Renna ME, Madison AA, et al., Relationship satisfaction predicts lower stress and inflammation in breast cancer survivors: A longitudinal study of within-person and between-person effects. 2020. Psychoneuroendrocrinology 118: 104708.
FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.
IN-DEPTH REVIEW OF RESEARCH
A key factor affecting health is the intimate relationships in a person's life. People with satisfying relationships live longer and are healthier than people who are in dissatisfying relationships or are without a partner. Breast cancer survivors with supportive partners have lower stress than those with conflicting or avoidant partners.
Stress is associated with physical as well as emotional effects. Healthy people with elevated stress have increased levels of inflammation, seen as higher amounts of certain immune system components in the blood, e.g., C-reactive protein (CRP) or inflammatory cytokine proteins.
For people with breast cancer, inflammation is linked to poorer outcomes, including increased recurrence, increased rates of other diseases and earlier mortality. Prior studies showed that breast cancer patients with higher levels of stress have more inflammation that those with lower stress.
Stress may be a connector between relationship satisfaction and inflammation. People in less secure relationships have higher cortisol levels (a hormone that regulates stress responses) and poorer immune system function. Most previous studies focused on negative aspects of relationships, looking at the effect of poor quality and hostile relationships on inflammation. In this study, researchers were interested to see whether positive, stable relationships benefit women with breast cancer.
Researchers of this study wanted to know:
Whether romantic relationships directly or indirectly affect inflammation by influencing stress levels. This study tests that idea that breast cancer patients who are satisfied in their romantic relationships also have lower stress and less inflammation.
Populations looked at in this study:
The study participants were 139 women with breast cancer ( 0-3C) who were married or had a domestic partner. Average age was 55. Among participants, 85 percent were White, 7 percent were Black and 7 percent did not indicate their race.
These participants were enrolled in a larger study (209 women) on fatigue and immune function. Seventy of the women from the larger study were excluded because they were single, divorced or widowed. Women with a prior history of cancer other than skin cancer were also excluded, as were those with visual, hearing or problems that prevented completion of the study. Researchers enrolled participants in the study within three months of their breast cancer diagnosis and before they began treatment.
Researchers met with each participant three times: before their cancer treatment began, and then at six months and 18 months after their treatment ended. At each visit, participants filled out surveys about their relationship satisfaction and their stress level in the week prior. The surveys allowed researchers to quantify relationship satisfaction and stress. Researchers also evaluated participants’ blood samples for proteins that are related to inflammation by measuring the levels of CRP and a combined measure of cytokine proteins. To look at the interaction between relationship satisfaction, stress and inflammation, researchers calculated the correlations using a statistical analysis called multilevel mediation analysis.
Researchers analyzed data from the group as a whole to see how these factors changed with time among the participants. They also looked at the data for each woman. This allowed them to track how a particular woman's relationship satisfaction changed during the study and how it impacted her own stress and inflammation rather than in comparison to other participants.
Breast cancer survivors who were highly satisfied with their relationships had lower stress and lower levels of inflammation. A woman’s level of satisfaction in her romantic relationship is a good predictor of her inflammation levels.
- Satisfaction with relationships was highest before treatment and lower after treatment, but did not change between 6 and 18 months posttreatment.
- Higher stress was linked to greater levels of the inflammatory protein C-Reactive Protein (CRP)
- Higher stress was also linked to greater levels of inflammatory cytokines (interlukin-6, interlukin-1-beta and tumor necrosis factor alpha)
- Perceived stress decreased with time.
- Older women were more likely to have lower stress levels.
- Other factors, including body mass index (BMI, a measure of weight), education level and chemotherapy treatment were not associated with perceived stress.
Women with satisfying relationships had less stress, and women with less stress had lower inflammation. But does a woman's relationship satisfaction directly lead to lower inflammation? Do relationships affect stress, which in turn impacts inflammation? Or does stress affect relationships, which affects inflammation?
- Statistical analyses showed that relationship satisfaction indirectly affected inflammation. How much stress a woman perceived was associated with her level of inflammation.
- Statistical models supported the idea that satisfying relationships lead to lower stress, not that lower stress leads to relationship satisfaction.
- The group as a whole showed the same overall result: that relationships affected stress, which in turn affected inflammation. This result was also seen in individual women. Women who were more satisfied with their relationships during one one visit had lower stress and inflammation during that particular visit compared to other visits.
While these results show a correlation of relationship satisfaction, stress and inflammation, they do not necessarily indicate cause and effect. Whether this correlation indicates that relationship satisfaction leads to differences in stress levels will require additional testing (e.g., testing whether an intervention to improve relationship satisfaction leads to decreased stress).
- This study followed women before and after breast cancer treatment. This approach was a strength of this study.
- This study lacked a control group of women without breast cancer. While this was a limitation, related studies suggest that relationship satisfaction is linked to stress and inflammation in healthy women. Tracking data for each participant individually provided internal controls: the change of a particular woman's relationship satisfaction, stress and inflammation could be compared between visits. Women who were highly satisfied and less satisfied in their relationships were compared for the overall findings. These internal controls helped to support the study conclusions in the absence of a true control group.
- The lack of diversity among the participants was a limitation. The findings may not be representative of the population as a whole. The majority of women were White. Seven percent of participants were Black, but this isn’t significant representation. No Hispanic or Asian American women participated.
- Another impact of the lack of diversity pointed out by the researchers is factors that may be associated with stress and inflammation levels (other diseases, BMI, education level, cancer treatment) were similar among all of the participants. While researchers did control statistically for whether these factors might account for their observations, the lack of differences would obscure impacts that these factors may have. These factors may also impact inflammation, stress and/or relationship satisfaction.
- The number of participants was sufficient for the main point of the study, but it was too small to say anything about the impact of cancer subtype or .
- This study found correlations between satisfying relationships, stress and inflammation. These correlations may or may not be causal. These correlations must be tested with an intervention to determine if they cause the correlations observed. For example, whether interventions that improve relationship satisfaction directly decrease stress is unknown.
These findings fit well with prior research showing that relationships affect inflammation in healthy people. Similarly, this work confirms that relationships of breast cancer survivors affect inflammation. This work also shows that the relationships of breast cancer survivors impact their perceived stress, and that in turn affects inflammation. Other research connects high inflammation to an increased risk of recurrence, other diseases and earlier death. This work suggests that interventions that lower stress may be beneficial in lowering inflammation and its physiological effects.
Women who were more satisfied with their romantic relationships experienced less stress and lower inflammation.
The National Comprehensive Cancer Network (NCCN) recommends screening and treatment of distress as part of the recommended standard of care.
These recommendations include:
- Healthcare providers should inform patients, families and treatment teams that distress management is a key part of their medical care, and they should provide information about psychosocial services.
- Ideally, healthcare providers should screen patients for distress at every medical visit— minimally at a patient’s initial visit and then as clinically indicated, especially with changes in disease status (i.e., remission, recurrence, progression or treatment-related complications).
- Healthcare providers should assess and manage distress according to clinical practice guidelines.
- Experts in psychosocial aspects of cancer should be readily available, either as staff members or by referral.
- Assessments should include psychosocial issues (e.g., quality of life and patient and family satisfaction).
Patients should expect to receive distress screening and help at your doctor visits. If your distress isn’t addressed, ask for help. NCCN provides a "Distress During Cancer Care" pamphlet that provides more information.
The American Society for Clinical Oncology (ASCO) points out several therapies for anxiety and stress for patients to consider during or after cancer treatment:
- meditation, particularly mindfulness stress-reduction programs
- music therapy
- stress management therapy.
- Is my symptom(s) part of being distressed?
- What emotional or psychological support is available for me?
- What support is available for my partner and family?
- How do I find a therapist?
- What help for distress will my insurance cover?
- Are there resources for couples counseling?
- What strategies are most helpful for maintaining healthy relationships during this time?
- What approaches do you recommend for decreasing stress?
The following studies on the emotional effects of cancer are enrolling patients:
- NCT04739696: Developing a Virtual Stress Management Intervention for Spousal/Partnered Caregivers of Solid Tumor Cancer Patients. This study will look at the ability of a stress management program for employed caregivers to improve psychological distress in spouses or partners who are caregivers for people diagnosis with a solid tumor cancer of any .
- NCT03581357: Mobile Mindfulness Meditation Intervention for Cancer Survivors. This will study the impact and satisfaction of Mobile Mindfulness Meditation on anxiety, pain, fatigue, trauma, and sleep in cancer survivors.
- NCT03611309: Perioperative Surrounding Cancer Surgery for Patients & Their Family Members (PERIOP-PC). The study goal is to compare surgeon-palliative care team co-management, versus surgeon alone management, of patients and family members preparing for major upper gastrointestinal cancer surgery.
- NCT04604158: Evaluating the Effect of a Mobile Audio Companion (Elly) to Reduce Anxiety in Cancer Patients. This is a study in cancer patients to examine the feasibility of a mobile health application, Elly (Elly Health Inc.), to reduce levels of anxiety, stress, loneliness, and social isolation.
- NCT03344757: Health Gatherings - For Your Health After Cancer. look at the effects of a 10-week stress management in-person group program. The program will study emotions, stress, and stress management techniques (such as relaxation and coping techniques) on quality of life, distress, depression, and physical health in Spanish- speaking, Hispanic/Latino men diagnosed with Cancer (PC).
- NCT05364450: Studying Types of Therapy for Coping With Fear of Recurrence Among Breast Cancer Survivors. Fear of breast cancer recurrence (FCR) is common. This study will test three types of online, group therapy for breast cancer survivors with FCR.
- NCT04583891: Mobile Apps to Reduce Distress in Breast Cancer Survivors Using an Adaptive Design. This project will look at using a mobile health app to address emotional distress in women with breast cancer, and test the impact of coaching as a way to increase engagement with the app.
- NCT02871752: Reducing the Effects of Active Surveillance Stress, Uncertainty and Rumination Thru Engagement in Mindfulness Education (REASSUREME). This study examines how well a couples-based mindfulness-based stress reduction (MBSR) works on positive and negative psychological responses to active surveillance (AS) and AS adherence.
- NCT03344757: Health Gatherings - For Your Health After Cancer. This study will look at the effects of a 10-week stress management in-person group program. The program will study the effects of stress, and stress management techniques on quality of life, distress, depression, and physical health in Spanish- speaking, Hispanic/Latino men diagnosed with cancer.
Finding mental health experts
Support for severe distress
If you are experiencing severe distress and cannot wait for a referral to a mental health care professional, please call the experts at the National Suicide Prevention Helpline.
- The National Suicide Prevention Helpline is a network of crisis centers that provide free and confidential emotional support for people in suicidal crisis or extreme distress. Dial 988.
Finding professional support related to cancer distress
The following resources can help you locate a mental health expert in your area.
- Association of Oncology Social Workers: Database for finding a social worker by location
- National Alliance on Mental Illness: Tips for finding a mental health professional
- The Anxiety and Depression Association of America: Database of licensed professionals who provide telehealth services
- Mental Health America: Tool for finding a mental health care professional based on people's current needs
Other ways to find experts
- Register for the FORCE Message Boards and post on the Find a Specialist board to connect with other people who share your situation.
- The National Cancer Institute (NCI)-designated comprehensive cancer centers have specialists to manage the symptoms and side effects from cancer prevention or treatment.
- Cancercare is a nonprofit organization that provides support through their trained oncology social workers, or call 800-813-HOPE.
- Livestrong has helpful information and tips for finding mental health care professionals.
Who covered this study?
Can satisfying romantic relationships lead to better health for breast cancer survivors? This article rates 4.5 out of 5 stars
A satisfying romantic relationship may improve breast cancer survivors' health This article rates 3.0 out of 5 stars
Breast cancer survivors with romantic relationships could have better health outcomes This article rates 2.0 out of 5 stars