Journal of the National Cancer Institute Advance Access originally published online on January 29, 2008
JNCI Journal of the National Cancer Institute 2008 100(3):213-218; doi:10.1093/jnci/djm280
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© The Author 2008. Published by Oxford University Press.
Personality Factors and Breast Cancer Risk: A 13-Year Follow-up
Affiliations of authors: Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands (EMAB, HMvdP); National Expert and Training Center for Breast Cancer Screening, Nijmegen, The Netherlands (JHCLH, ALMV); Department of Epidemiology and Biostatistics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands (JDMO, ALMV)
Correspondence to: Eveline M. A. Bleiker, PhD, Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands (e-mail: e.bleiker{at}nki.nl).
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Consistent scientific evidence on the possible relationship between psychologic variables and breast cancer development is lacking. In 1996, our group first reported on the present prospective, longitudinal study. We found a weak association between a high score on the antiemotionality scale (indicating an absence of emotional behavior or a lack of trust in one’s own feelings) and the development of breast cancer. No associations were found between any of the other 10 studied personality traits and breast cancer development. However, the study had a relatively short follow-up and did not investigate interaction effects between various personality traits. Therefore, the current follow-up study was conducted with the same cohort, which included the 9705 women who attended a biennial population surveillance program for breast cancer and completed a self-report personality questionnaire between January 1, 1989, and December 31, 1990. Women who developed breast cancer during the period from May 17, 1995, through January 1, 2003, formed the case group (n = 217) and were compared with age-matched women without breast cancer who formed the control group (n = 868) with regard to personality traits and medical risk factors for breast cancer. None of the personality factors were statistically significantly associated with an increased risk of breast cancer, with or without adjusting for the medical risk factors. Also, the occurrence of a combination of various personality traits (eg, a so-called cancer-prone personality) was not related to breast cancer development.
Prior knowledge Associations between personality factors and breast cancer risk have been inconsistent between studies and remain the subject of debate. Study design This is a follow-up report of a prospective study that included 9705 women, of whom 217 were diagnosed with breast cancer between 5 and 13 years after the completion of a personality questionnaire. Possible psychologic and medical risk factors were compared between the 217 case patients and 868 age-matched control subjects. Contribution Personality factors, including the so-called cancer-prone personality risk profile, did not appear to be related to breast cancer incidence. Implications Physicians can use these results to reassure patients that their personality factors (eg, optimism, emotional expression, or depression) do not appear to be associated with the development of breast cancer. Limitations The low response rate to the initial questionnaire may have introduced self-selection bias.
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The possibility that certain psychosocial factors may be added to the list of risk factors for breast cancer remains a topic of interest (1–6). The results of prospective longitudinal studies focusing specifically on breast cancer have ranged from no association of psychosocial factors with breast cancer incidence (7–19) to an inverse association (20,21) and to a positive association (22–24).
In 1996, our group reported (9) a weak association between a high score on the antiemotionality scale (indicating an absence of emotional behavior or a lack of trust in one's own feelings) and the development of breast cancer. We used a prospective longitudinal design to compare 131 breast cancer patients with 771 age-matched control subjects. No statistical significant differences were found for any other measured personality trait, such as optimism and the expression and control of emotions. One limitation of that study, however, was the relatively short follow-up period in which breast cancer was diagnosed (ie, between 2 weeks and 5 years after the psychologic assessment). Gerits (25) suggested that it may take more than 5 years for breast cancer to develop into a detectable lump. A relatively short follow-up period may therefore assess subclinical effects of tumor growth (eg, fatigue) that influence the self-reported psychologic traits (eg, depression scores); it is therefore important to assess personality factors some years before the detection of breast cancer (26). A second limitation of our 1996 paper (9) was that we did not investigate statistical interactions between various personality traits, such as "high emotional control" in the presence of "little social support," in the prediction of breast cancer (5). In this follow-up analysis, we investigated the extent to which each personality factor contributed to the risk of developing breast cancer, especially in women who were diagnosed with breast cancer at least 5 years after they completed a personality questionnaire. We also explored other possible statistical interactions between personality traits and the development of breast cancer.
From January 1, 1989, through December 31, 1990, 28940 women who were residents of the Dutch city of Nijmegen and were at least 43 years old received a personality questionnaire. This questionnaire was sent with an invitation to participate in a population-based breast cancer screening program. In total, 9705 women completed the questionnaire. The psychologic questionnaire consisted of 11 well-known measures used to assess personality traits. These traits reflect relatively enduring dispositions of an individual. The following dispositions were assessed: anxiety (27,28), anger (29,30), depression (31,32), rationality (33,34), antiemotionality (33,34), understanding (ie, understanding others in spite of negative feelings) (33,34), optimism (35,36), social support (37), emotional expression–in (ie, feelings are held in or suppressed) (34,38,39), emotional expression–out (ie, feelings are directed toward other people or objects) (34,38,39), and emotional control (ie, control of outward expression of feelings) (34,38,39). Information on possible medical risk factors (including having a first-degree relative [mother or sister] with breast cancer, nulliparity or the first parity at age 30 years or older, ever using estrogen, being overweight [body mass index 
27.5 kg/m2], or having an early age at menarche [
12 years]) for breast cancer was also collected by self-reported questionnaires that were sent at each breast cancer screening round to all invited women. Information on whether or not a respondent had developed breast cancer was retrieved from the central registry of the population screening program. The study was approved by the institutional review board and the board of the population surveillance program for breast cancer.
Case patients were women diagnosed with a primary breast cancer from May 17, 1995, through January 1, 2003. For each case patient, four age-matched control subjects without breast cancer were selected from all women who completed the questionnaire from January 1, 1989, through December 31, 1990. Power calculations for estimating sample size requirements were performed before the start of the study and were based on the following criteria for defining a substantively meaningful statistical association: 1) a minimal product-moment r of 0.35 or 2) a minimal effect size (d statistic) of 0.50. With r = 0.35 and alpha = 0.05, 46 cases of breast cancer were needed to achieve a power (1 – beta) of 0.80. With d = 0.50 and alpha = 0.05, 50 cases of breast cancer were needed to achieve power of 0.80 when undertaking a Student's t test to identify those personality traits that were statistically significantly associated with a cancer diagnosis (40,41). Univariate statistics (Student's t test for continuous variables and chi-square tests for categorical variables) were used to investigate possible differences between the case patients with breast cancer and control subjects for the 11 personality traits and five medical risk factors. Data were first screened for acceptable skewness (symmetry of the distribution) and kurtosis (peakedness of the distribution), after which t tests were applied. Conditional logistic regression analysis was used to investigate whether the psychologic variables were associated with breast cancer incidence after adjustment for the medical risk factors. To explore the interaction of the personality traits (see Table 3), the 25% and 50% cutoff scores were used to define "high" and "low" scores, respectively, on the personality traits assessed (see Appendix). The percentages of case patients and control subjects fulfilling specific criteria for a psychologic risk profile (eg, high depression scores in the presence of little social support) were compared by use of chi-square tests. All reported P values are two-sided.
Of the 9705 women who returned the self-assessment questionnaire, 217 were diagnosed with primary breast cancer during the 5- to 13-year period after they completed the 1989–1990 questionnaire (Fig. 1). When we compared the mean scores for the 11 personality scales of the 217 case patients with those of the 868 control subjects, no statistically significant differences between the groups were found (Table 1). In addition, the prevalence of all five medical risk factors was similar in case patients and control subjects (Table 2); in conditional logistic regression analyses that adjusted for medical risk factors, personality factors were not associated with the development of breast cancer.
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Various combinations of personality traits have been hypothesized to be associated with the development of breast cancer. These traits include abnormal release of anger (42); repression (43); a tendency to control anger (44); non-assertiveness, calmness and easy going, and keeping anger inside (45); commitment to social norms (46); depression (47); a repressive coping style (48); and a so-called cancer-prone (type C) personality that is characterized by 1) personality traits of stoicism, niceness, perfectionism, sociability, conventionality, and more rigid defensive controls; 2) difficulties in expressing emotions; and 3) an attitude or tendency toward helplessness or hopelessness (49,50). We investigated eight of these risk profiles and found that none of them were associated with the development of breast cancer (Table 3). Specifically, the risk profile "high emotional control" plus "low social support" was identified in approximately the same percentage of both groups—in 16 (7.4%) of the 217 case patients and 62 (7.1%) of control subjects—and so this risk profile was not associated with the development of breast cancer (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.59 to 1.83; P = .91). Comparable results were found for other combinations of traits, such as the type C personality (49,50), which was identified in 39 (18.0%) of the 217 cases and 183 (21.1%) of the 868 control subjects (OR = 0.85, 95% CI = 0.62 to 1.17; P = .31).
Personality traits alone, in combination with medical risk factors, or in combination with other personality factors were not associated with breast cancer incidence in this prospective study, which included a follow-up of 5–13 years after the assessment of personality traits. These results largely support our previous findings that were based on women diagnosed with breast cancer during the first 5 years after they completed the self-assessment personality questionnaire. In our previous study sample (9), the only personality factor that was statistically significantly associated with breast cancer incidence was antiemotionality (OR = 1.19; 95% CI = 1.05 to 1.35; P = 006); however, the association between this factor and breast cancer incidence was not found in the follow-up of 5–13 years. One possible explanation as to why this association disappeared is that an increased antiemotionality score may be a consequence of subclinical personality symptoms caused by the cancer, which was present in the first 5 years of follow-up but absent in the next 5–13 years of follow-up, as noted previously by Nakaya et al. (26). Alternatively, the finding in our previous study (9) that only one of the 11 (related) personality traits was associated with breast cancer risk might have been only a chance finding.
Our study had several limitations. We found no association between any medical risk factor and the development of breast cancer, which was unexpected. However, epidemiologic studies have shown that the associations between known risk factors and development of breast cancer are relatively small, with the relative risks ranging between 1.2 and 2.5 (52). Furthermore, only one-third of the participants returned the initial questionnaire, and so we cannot rule out the possibility that only a selected group (eg, those with specific risk profile) responded to the initial questionnaire, which would introduce selection bias and possibly less variance in at least one trait studied. In an additional analysis, however, no statistically significant differences were found between the respondents in our study and a normative group of the Dutch population with regard to anxiety (28) and anger (30), indicating that these personality traits may not have played an important role in which individuals returned our questionnaire.
In conclusion, in this prospective, longitudinal cohort study, we found no evidence of an association between the incidence of breast cancer and personality traits such as anxiety, depression, optimism, and the expression of emotions. In particular, we could not confirm our previously reported association between antiemotionality and breast cancer (9). Our finding that no psychologic risk profile was associated with the incidence of breast cancer may help oncologists to reassure patients that their personality appears to have played no role in the development of their breast cancer.
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Dutch Cancer Society (IKW 92-133).
Appendix. The 25%, 50%, and 75% cutoff points of each scale that assessed a personality trait on the basis of the mean sum scores of the total sample of the 9705 women in this study*
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* Because there are no guidelines about values that constitute a high or low score on the personality traits assessed, we chose a 25% cutoff score on these scales that was based on the mean sum scores of the total sample of 9705 women when investigating a risk profile that included two personality traits and a 50% cutoff score when investigating a risk profile with three personality traits (eg, a cancer-prone personality). CI = confidence interval.
The hypothesized direction of the risk for each personality trait, obtained from the literature, is indicated with a + (indicating that a trait with a high score is a risk factor) or – (indicating that a trait with a low score is a risk factor). That is, a mean score of 42 or higher on the depression scale or a mean score of 20 or lower on the optimism scale was assumed to be a risk factor for breast cancer (usually in combination with another factor).
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J. H. C. L. Hendriks is deceased.
The authors had full responsibility for the design of the study, the collection of the data, the analysis and interpretation of the data, the decision to submit the manuscript for publication, and the writing of the manuscript.
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Manuscript received July 20, 2007; revised November 15, 2007; accepted November 19, 2007.
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