Summary of main findings

Many significant associations were reported between demographic factors and variables of interest in this review. Age was inconsistently associated with personality but seemed to be significantly associated with cognitions and

emotions, with older patients tending to report more positive appraisals, but more negative emotional reactions. Although the evidence suggests that younger

patients tend towards poorer psychological adjustment, significance of these effects between study were inconsistent. Female patients were reported to be

both more neurotic and to report higher distress levels. Higher educational level was associated with more positive personality dimensions, but associations with outcome were predominantly non-significant.

Reported associations between clinical variables and psychological variables were inconsistent; many associations were un-corroborated (or, indeed, opposed) by those presented in other studies. No significant correlations were reported between personality and clinical variables. Cognitions and emotions were most consistently and significantly correlated with psychosocial outcomes. The limited evidence seems to suggest that stage of illness, time since diagnosis, and

treatments received are most pertinent.

Where reported, personality seemed stable (as would be expected), despite the major stress and life adjustment that follow a cancer diagnosis. Only

dispositional optimism is significantly associated with anxiety. Many more significant associations were reported between aspects of personality and

depression; between personality and distress; and, between personality and both total, and subscales of, quality of life. The only exceptions were associations between mastery and symptom-related quality of life, and between self-efficacy and social quality of life. Deeper exploration of subscales of quality of life also shows an interesting pattern; personality is more consistently associated with psychosocial dimensions, but not physical and illness dimension of quality of life.

Meta-analysis found the relationship between self-efficacy and distress to be overall significant, but with a low effect size. Medium effect sizes were found for the meta-analyses between optimism and both well-being and distress.

The evidence for associations between personality variables and cognitions seems to imply medium, or highly significant, effect sizes, particularly where optimism and neuroticism are concerned. In multivariate analysis, aspects of personality remained independent predictors of both distress and quality of life in nine separate studies. In seven others, its effect was reported to be mediated by a number of tertiary variables including clinical variables, appraisals, coping, social support, and locus of control (see section 2.7.5.8).

Emotions were also associated with all psychological outcomes, but not with quality of life. Specifically, negative affect was associated with worse psychological outcome (and vice versa for positive affect). Both anger suppression and anger

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expression were significantly related to higher levels of both quality of life and depression. Meta-analyses between the incongruent findings on the CECS and both anxiety and depression yielded small, albeit highly significant, mean effect sizes.

Thought intrusion and avoidance were reported to be significant influences on levels of anxiety, depression, distress and quality of life. Meta-analysis of associations between the Impact of Events Scale and distress yielded highly significant, small effect sizes. Illness perceptions and cognitive appraisals

(including, for example, threat, challenge, perceived severity and so forth) were, on the whole significantly associated with both psychological outcome (four studies p<.05; two studies p>.05) and quality of life (nine studies p<.05). Self blame was significantly associated with both depression and distress: a meta-analysis for the latter revealed a small, but highly significant effect size (p<.001) where self blame leads to poorer outcome. According to Butow et al. (1999) and Brown et al.

(2000), the importance and reported significance of these cognitive variables is that they are not only measures of cognition, but also an indication of positive dimensions of personality.

Confrontational attitudes towards illness were found to be significantly beneficial for both quality of life and anxiety. Meta-analysis of the sub-components of the MAC scale yielded highly significant, small effect sizes between all

components and both anxiety and depression; where better outcome was

associated with lower hopelessness/helplessness, lower anxious preoccupation, lower fatalistic appraisals, and increased levels of fighting spirit Incongruent findings were reported between MAC components and quality of life, but a small effect size (p<.001) was found in meta-analysis of the relationship between fatalism and quality of life.

Of all cognitions, locus of control appeared to be the most inconsistently correlated variable of all with equal evidence for and against significance; the net effect seems to be toward no influence on psychological outcome. However, the role of control may be more complex than apparent in this review: Carver et al, (2000) claim that control perse is not important in terms of correlation or prediction of psychosocial outcome, but that best outcome is dependent on high concordance between illness expectancies and control beliefs. Andrykowski etal.,

(1994) also makes similar claims of variable interaction; control has greatest effect when illness and treatment perceptions are most negative.

In multivariate analysis, only four studies reported a significant independent cognitive predictor of outcome; perceived social support was found to mediate the effects of health perception on quality of life, fatalism mediated between

hopelessness/helplessness and distress, and coping mediated between control and distress.

Whereas the predictive validity of personality seemed stable over time, the predictive validity and significance of association based on cognitive and

emotional factors seemed more changeable. Some of the strongest predictors of longitudinal adjustment identified in these studies are earlier levels of anxiety, depression and quality of life.

Although not specifically analysed in this review, a brief summary must be given for coping due its role in the transactional model. Direct associations between coping and both psychosocial predictors, and psychosocial outcomes, were inconsistently reported both in terms of which strategies were most

beneficial, at different time points of illness, and in terms of statistical significance.

Consistency was reported, however, in the mediating role of coping over numerous cognitions and appraisals (although cognitions also remain independently

significant predictors), and numerous personality variables typically at high levels of effect size and significance. As such, the findings are clearly concordant with the Transactional Model.

A final point about longitudinal analysis. The methodological critique clearly stated that longitudinal designs are superior to cross-sectional designs and

approximately 50% of the included studies, did indeed, collect some follow up data. Yet, it will be obvious from this data synthesis that very few longitudinal analyses are presented or discussed; data was simply not sufficiently analysed to do so within the individual included papers. Longitudinal analysis was largely limited to multivariate tests which were not the main focus of this review.

Correlation analyses were largely limited to cross-sectional data only. The use of cross-lagged correlations may be beneficial in future research.