psychological influences on disease progression, although an interactive or mediational influence was not established.
Likewise, the initial uterine cancer sample was followed for at least 5 years, with similar findings ( Roberts & Andersen, 1990). The probability of recurrence was not predicted by immunological or psychological variables. However, higher levels of self-reported emotional distress at diagnosis predicted a lowered probability of survival as well as shorter survival time. These associations remained even after accounting for the influence of other established prognostic indicators (e.g., stage, cell histopathology). The covariation between emotional distress and disease progression was documented, although serial linkages indicating direct psychoneuroimmunologic mediation of cancer progression could not be supported. Taken together, this series of studies suggests indirect support for psychoimmunological mediation of disease progression, and supports efforts toward continued, refined investigation. However, it also demonstrates the difficulty in establishing the clinical significance of psychoimmunological covariation within a complex model of disease progression. In light of these findings, it continues to be important to stress that biological factors (tumor type, site, stage, and biological treatments) are the major determinants of cancer progression and outcome. Until the conditions outlined in this chapter are empirically documented, the impact of a psychoimmunological mechanism on cancer progression remains a question awaiting answer.
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