Perceived stress moderates the effects of a randomized trial of dance movement therapy on diurnal cortisol slopes in breast cancer patients
Introduction
Breast cancer is the most prevalent cancer among women worldwide (K. D. Miller et al., 2016). Radiotherapy is an integral part of treatment to reduce the risk of loco-regional recurrence in breast cancer patients (Fisher and Rabinovitch, 2014). Patients often suffer from various side effects such as fatigue, sleep disturbance, pain, and psychological distress during or after the course of radiotherapy (Sjövall et al., 2010, Noal et al., 2011, Ho et al., 2014). These comorbid symptoms are associated with not only poorer quality of life (Luutonen et al., 2014), but also disrupted activities in the hypothalamic-pituitary-adrenal (HPA) axis (Roscoe et al., 2002). HPA axis activity refers to the neuroendocrine response to stress that is reflected in the secretion of cortisol, a glucocorticoid hormone, from the adrenal gland (Gunnar and Quevedo, 2007). In normal individuals, cortisol levels follow a typical circadian rhythm, with an early morning peak upon awakening and a gradual decline throughout the day (Turner-Cobb, 2005). The diurnal cortisol slope represents the diurnal fluctuation of cortisol and is indicative of HPA axis reactivity (Smyth et al., 1997).
Schmidt et al. (2016) recently linked greater physical fatigue with increased evening cortisol levels and higher overall cortisol secretion and Tell et al. (2014) found that sleep disturbance and fatigue were associated with disrupted cortisol rhythms in breast cancer patients. Prolonged exposure to stress disturbs the regulatory feedback system of the HPA axis and leads to flatter diurnal cortisol slopes. Costanzo et al. (2012) found that cancer survivors tend to perceive everyday stressors as more severe and disruptive than do healthy controls. Breast cancer patients undergoing radiotherapy are at risk of psychosocial distress that may alter their HPA-axis activity, thus increasing the risk of neuroendocrine dysfunction and aberrant diurnal cortisol rhythms. Perceived stress and stressful daily events have been linked to flatter diurnal cortisol slopes (Lovell et al., 2011) and increased cortisol secretion (van Eck et al., 1996), respectively. These findings suggest a potential link between subjective perceived stress and disturbed diurnal cortisol rhythm as a physiological indicator.
Apart from the genetic and environmental factors, psychosocial factors may play a role in dysregulation of the HPA axis (Glaser and Kiecolt-Glaser, 2005). According to the bio-psycho-social model (Lutgendorf and Costanzo, 2003), the way patients respond to the environment determines their health behavior and contributes to their neuroendocrine response. Psychosocial and biological factors might have an interactive influence on health outcomes. For instance, research has linked psychological factors such as stress and depression with cancer progression (Lutgendorf et al., 2010). Circadian regulation has been advocated as a prerequisite for maintaining proper host defense against cancer (Sephton and Spiegel, 2003). The past decade has seen an increasing number of studies on the effects of non-pharmacological interventions such as qigong (Chen et al., 2013) and yoga (Chandwani et al., 2014) on the neuroendocrine system. A large randomized controlled trial by Carlson et al. (2013) showed that both mindfulness-based cancer recovery and supportive-expressive therapy resulted in more normative diurnal cortisol profiles.
Dance movement therapy (DMT) is an integrated movement-based form of psychotherapy that incorporates exercise, artistic, and recreational components (Sandel et al., 2005). The use of verbal and non-verbal approaches facilitates participants to freely express themselves through guided and self-initiated body movements (Chaiklin and Wengrower, 2009). DMT enhances participants’ self-expression, acceptance, and reconnection with their bodies. The mind-body reconnection helps strengthen their personal resources, rebuild their self-confidence, and better cope with feelings of depression and fear. The group approach allows patients to share their emotions, concerns, and coping strategies with others and establish mutual social support (Ho, 2005). Previous small-sample, non-randomized studies have suggested positive results for the use of DMT in cancer patients (Dibbell-Hope, 2000, Ho, 2005, Sandel et al., 2005). A recent Cochrane review (Bradt et al., 2015) suggested that DMT had beneficial effects on the patients’ quality of life, somatization, and vigor.
Our previous randomized controlled trial (Ho et al., 2016) showed that DMT provided significant benefits on symptom clusters such as perceived stress and pain in breast cancer patients. A novel examination of the physiological effects of DMT on the neuroendocrine response would provide further grounds for evidence-based research along the line of mind-body medicine. In the present study, we aimed to investigate the effectiveness of DMT on the HPA axis activity in women with breast cancer undergoing radiotherapy. To explore the potential interactions between psychological and physiological symptoms, we examined the role of perceived stress as a potential moderator and mediator of the intervention effect. The findings of this study would contribute to a better understanding of the health benefits of DMT and potential mechanisms of the intervention effects. We hypothesized that breast cancer patients would benefit from a brief DMT intervention over the course of radiotherapy by improving their HPA axis functioning.
Section snippets
Study sample
The study consisted of a secondary data analysis of a randomized controlled trial of DMT to improve symptoms among women with breast cancer. The recruitment procedures, inclusion criteria, and exclusion criteria of the study participants were described in detail in a previous paper (Ho et al., 2016). The original study sample comprised 139 breast cancer patients undergoing adjuvant radiotherapy in Hong Kong, who were randomized into either the DMT group (n = 69) or the control group (n = 70).
Demographic and clinical profiles of participants
The participants had a mean age of 49.4 years (SD = 8.1) and the mean cancer duration was 21.6 months (SD = 7.3). They received an average of 9.1 days (SD = 8.1) of radiotherapy sessions at the start of the study. The majority of the sample attained a secondary education level (65%), were married (65%), and had undergone breast conserving surgery (58%) and chemotherapy treatment (79%). Table 1 presents the profiles of the participants by treatment group. The demographic and clinical variables of the
Intervention effects of DMT on cortisol slopes
This is the first study to investigate the physiological effects of DMT on diurnal cortisol slopes in breast cancer patients undergoing radiotherapy. Participants in both groups displayed significantly steeper diurnal cortisol slopes over the 3-week interval. The overall improvement in endocrine functioning might be associated with the radiotherapy treatment in two ways. First, the treatment course of adjuvant radiotherapy likely induces a cluster of short-term side effects such as fatigue,
Conflict of interest
None, the authors declared no conflict of interests related to this study. There are no financial disclosures from any of the authors.
Role of the funding source
This study was funded by the Research Grants Council of Hong Kong under the General Research Fund (HKU745110H). The Research Grants Council was not involved in the study design, the collection, analysis, or interpretation of the data, the writing of the article, or the decision to submit the article for publication.
Acknowledgements
This study was funded by the General Research Fund (HKU745110H) of the Research Grants Council of Hong Kong. We would like to express our thanks to Dr. Lam Mei-yuk for her help in patient recruitment, Ms. Irene Cheung for her coordination of the project and extraction of the cortisol data, Ms. Angela Leung for her effort in leading the DMT groups, and last but not least, the participating patients and centers for their invaluable support.
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Rainbow T. H. Ho and Ted C. T. Fong have contributed equally to this work.