Post-Traumatic Stress Disorder and Health-Related Quality of Life in Patients and Their Significant Others Facing Lung Cancer Diagnosis: Intrusive Thoughts as Key Factors

doi:10.4236/psych.2013.46A1001

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Psychology

2013. Vol.4, No.6A1, 1-7

Published Online June 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.46A1001

Post-Traumatic Stress Disorder and Health-Related Quality of

Life in Patients and Their Significant Others Facing Lung

Cancer Diagnosis: Intrusive Thoughts as Key Factors

Jean-Louis Pujol1,2, Carine Plassot1, Jean-Pierre Mérel1, Elodie Arnaud1,

Michel Launay2, Jean-Pierre Daurès1, Isabelle Boulze2

1Thoracic Oncology Unit, Montpellier Academic Hospital, Montpellier, France

2Epsylon. University Laboratory Dynamics of Human Abilities and Health Behaviours

EA 4556, University of Montpellier 3, Montpellier, France

Email: [email protected]

Received February 20th, 2013; revised March 20th, 2013; accepted April 20th, 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

Purpose: 1) to determine the level of post-traumatic stress disorder (PTSD) by means of impact of event

scale (IES) in patients for whom lung cancer has been diagnosed for the first time and compare this level

in patients having learnt that they affected by chronic obstructive pulmonary disease (COPD); 2) to com-

pare PTSD in patients and their significant others facing a diagnosis of lung cancer; 3) to determine

whether or not IES and General Health Questionnaire 28 (GHQ-28) correlate. Methods: This prospective

survey-study included 41 consecutive patients who learnt that they were afflicted by primary lung cancer.

IES and GHQ-28 were answered once between four and five weeks following medical appointment. The

significant others (n = 16) who were present during the lung cancer diagnostic appointment were also in-

vited to complete similar questionnaires. Control group consisted of 19 patients with chronic asthma or

COPD. Results: Following a lung cancer diagnosis, patients and their significant others are indistinctly

affected by a high level of PTSD. These two groups had a higher frequency of high IES total score when

compared with COPD patients. The IES intrusion subscale score significantly differed among groups:

median [IR] values: 20 [12 - 26]; 15 [9 - 22]; 7 [5 - 15] for significant others, cancer patients and COPD

patients respectively; P = 0.02). IES and GHQ-28 inversely correlated. Conclusion: Patients and signifi-

cant others facing a diagnosis of lung cancer are at high risk of PTSD. The level of IES intrusion in per-

sons facing lung cancer increases emotional distress that in turn affects quality of life.

Keywords: Trauma; PTSD; Cancer Diagnosis; Lung Cancer; Significant Others

Introduction

Post-traumatic stress disorder (PTSD) is commonly observed

in patients facing cancer (McBride et al., 2000; McCaul et al.,

1998). Patients affected by cancer are considered to be affected

by a potential traumatic event inasmuch as life-threatening ill-

nesses are included as PTSD-leading stressor according to the

DSM-IV. The first evidence classifying cancer as a stressor is

that stigma and stereotypes surrounding the word “cancer” lead

to the development of stressful reaction and anxiety (Themes et

al., 2001; Lloyd et al., 1996). However, patients are also ex-

posed to other stressors such as treatment consequences, major

style-life changes, fears of future, family impact. The latter im-

pact has been only partially analyzed and the detection of PTSD

in patients and their relatives might be an important psycho-

logical dimension of quality of life. Among the different tools

developed in order to evaluate PTSD, the impact of event scale

(IES), developed by Horowitz et al. (1979) is considered as a

reliable screening method. This instrument has been shown to

efficiently measure avoidance and intrusion cognitions follow-

ing any traumatic event. In the past, several studies have used

IES in order to evaluate PTSD incidence among different popu-

lations of cancer patients (Jacobsen & Holland, 1991; Norum &

Wist, 1996; Kaasa et al., 1993).

Lung cancer is known to rapidly impair quality of life (Gralla

& Thatcher, 2004), and usually requires intensive therapy re-

sulting in the daily involvement of significant others with re-

gards to everyday care and living with the disease (Ostlund et

al., 2010). The distress that affects significant others, particu-

larly spouses, is probably underestimated (Gaugler et al., 2008).

The diagnosis of lung cancer is a highly traumatic event, given

the social presuppositions of both incurable and self-inflicted

disease that are conveyed by this diagnosis (Chapple et al.,

2004) and therefore may differ from other cancers (LoConte et

al., 2008; Pujol & Quantin, 2009). We hypothesized that both

patients and significant others are at high risk of PTSD follow-

ing a lung cancer diagnosis.

The herein study was designed in order 1) to determine the

level of PTSD by means of impact of event scale (IES) in pa-

tients for whom lung cancer has been diagnosed for the first

time and compare this level in patients having learnt that they

affected by (chronic obstructive pulmonary disease (COPD); 2)

J.-L. PUJOL ET AL.

to compare PTSD in patients and their significant others facing

a diagnosis of lung cancer; 3) to determine whether or not there

is any correlation between IES and General Health Question-

naire 28 (GHQ-28, QoL scale measuring emotional distress in

medical settings).

Participants and Methods

Study Design

This is a prospective survey-study. The survey was designed

to take 20 minutes to complete, and included validated tools,

demographic data and disease characteristics. Lung cancer pa-

tients and their significant others were consecutive participants

seen during a chest medical oncology consultation with one of

our team members. During this consultation, the lung cancer

was diagnosed to the patient in presence of his/her relative.

Then, a delay of at least four weeks (and no more than 5 weeks)

elapsed before the different questionnaires were administered.

During the period of this survey-study, patients with chronic

respiratory symptoms who attended a preplanned consultation

with the same physician in the outpatient unit were invited to

participate once the diagnosis of their benign obstructive lung

disease (asthma or COPD) had been established. The question-

naires were collected by an administrative representative who

was responsible for keeping the records anonymous and who

managed a clinical research technical assistant, the latter re-

sponsible for recording the data. The database was frozen on

March 5th, 2012. The questionnaires were completed by the

patients either in a quiet room of the unit or at home for those

preferring not to answer immediately. The questionnaires were

answered once between four and five weeks following medical

appointment. None of the patients were asked to answer in

presence of a physician, nurse or psychologist. All participants

spoke and wrote French fluently. Written informed consent in-

dicating the purpose of the research and guarantying the ano-

nymous evaluation of their answers was given by all partici-

pants. The study was approved by the Montpellier Ethical Com-

mittee.

Patients

Consecutive patients of both sexes, aged over 18 and who

were seen for the first time at the Montpellier Academic Hos-

pital chest oncology consultation unit were prospectively ac-

crued on the basis that lung cancer diagnosis was announced for

the first time during this first consultation. The eligibility crite-

ria consisted of: 1) histologically- or cytologically-proven lung

cancer of any stage (usually incompletely known at that time)

and any histology (both small cell and non-small cell lung can-

cer), 2) performance status equal to or less than 2 according to

the Eastern Cooperative Oncology Group (ECOG), 3) no pre-

vious history of malignant disease (except well-controlled basal

cell skin cancer or in situ cervix carcinoma).

Significant Others

Those who took part as “significant others” during the diag-

nostic consultation were invited to participate in the study,

whatever the degree of relation (generally the patient’s spouse

but occasionally a parent, adult child or sibling). The eligibility

criteria consisted of being aged 18 years or above.

Control Group

Consecutive patients suffering from chronic or recurrent res-

piratory symptoms, who learnt that they were afflicted with a

diagnosis of disabling chronic asthma or COPD entered the

study as part of the control group. Diagnoses were established

according to current international guidelines and took into ac-

count duration/characteristics of respiratory symptoms prior to

visit in the unit, and results of respiratory functions tests per-

formed in the outpatient unit of the chest department of the

Montpellier Academic Hospital. The eligibility criteria con-

sisted of the following: 1) aged 18 years or above, 2) suffering

from chronic asthma with a Global Initiative for Asthma

(GINA) score of 3 - 4 or COPD with a Chronic Obstructive

Lung Disease (GOLD) score ≥ 2, 3) symptoms of dyspnoea or

wheezing, interfering with activity and requiring daily treat-

ment, 4) no previous history of cancer at any site.

Questionnaires

Putative predictive variables to be tested: The participants’

demography and social position questionnaire consisted of the

following items: sex, age, marital status (single, divorced, mar-

ried), smoking habits (never smoker, former smoker [at least

one year since stopping], active smoker), employment, educa-

tional degree, knowledge of cancer (having been affected him/

herself, being a relative of an affected person or having been

informed by the general media).

Impact of event scale: The IES has been elaborated to assess

psychological stress reactions after any major life event and has

been validated in any kind of stressful event including cancer

over the past three decades (Horowitz et al., 1979; Koopman et

al., 2004; Steinglass & Gerrity, 1990; Tibben et al., 1994). In

this study, it has been anchored to the date of the event: i.e. the

date of the cancer diagnosis for the lung cancer patients and

their significant others; the date of diagnosis of COPD or chro-

nic asthma for the control group. The IES consists of 15 items

that measure intrusive re-experiences of the trauma (seven

questions) and avoidance of trauma-related stimuli (eight ques-

tions). Participants are invited by each of the 15 questions to

report the frequency of symptoms during the past seven days on

a four-point scale: 0 indicating not at all, 1 indicating rarely, 3

indicating sometimes, and 5 indicating often. By combining the

15 items, the IES total score, ranging from 0 to 75, can be cal-

culated for each participant. The IES enables a separate analysis

of intrusion and avoidance subscale scores (with a possible

range of 0 - 35 and 0 - 40, respectively). The original IES ques-

tionnaire was used in its validated French translated form.

Global Health Questionnaire 28: The GHQ-28 is a measure

of generalized psychological distress and has been validated for

a wide range of populations and a variety of settings (Goldberg

& Hillier, 1979). This 28-item health-related quality of life ins-

trument is mainly devoted to measure emotional distress in

medical settings. A score of above 10 indicates that the psy-

chological distress level is consistent with a need for psycho-

logical intervention. The GHQ comprises 28 items, seven of

which are formulated in a positive manner (e.g. Do you feel

perfectly well and in good health?) and 21 in a negative manner

(e.g. Do you feel sick?). The four subscales of the GHQ-28 are

severe depression, social dysfunction, anxiety and insomnia,

and somatization. These were calculated separately and then

pooled in the total GHQ-28 score. The original GHQ-28 ques-

tionnaire was used in its validated French translated form (Bo-

J.-L. PUJOL ET AL.

lognini et al., 1989).

Statistics

Comparisons between groups were carried out as follows: the

distribution of qualitative variables (such as gender, employ-

ment, educational degree, etc) between groups was compared

using the ² test. When the calculated frequency of the cate-

gorical data of the contingency table did not allow the use of

the ² test, the Fisher’s exact test was used. The normal (Gaus-

sian) distributions of the IES scores and GHQ-28 scores were

tested using the non-parametric Kolmogorov-Smirnov test (K-S

test) for the equality of continuous, one-dimensional probability

distribution: Regarding the GHQ-28 total scores, in each of the

three tested populations, the P value was >0.10, indicating a

normal distribution. Therefore, the expression of GHQ-28 scores

as mean ± S.D. was allowed. Regarding IES total and subscale

scores, the tests were significant, thereby rejecting the H0 hy-

pothesis (i.e. demonstrating that IES scores were not distributed

according to the Gaussian law). Therefore, in order to analyze

the distribution of variables such as IES scores among groups,

results were expressed as median, and variation was expressed

as interquartile range [IR]. Non-parametric statistical analyses

were uniformly used: differences between two independent

groups were determined by means of the Mann Whitney U test;

differences between more than two groups were determined by

the Kruskal Wallis one-way analysis of variance.

In order to determine the sensitivity-specificity relationship

of IES total score, IES intrusion structure score and IES avoid-

ance score in detecting PTSD following lung cancer diagnosis,

receiver Operating Characteristic (ROC) curves were con-

structed: sensitivity was considered as a true positive (i.e. high

IES score or subscores) in lung cancer patients and specificity

was considered as a true negative (i.e. low IES score or sub-

scores) in patients suffering from chronic asthma or COPD.

Areas under the ROC curves (AUC-ROC) were calculated. The

Z statistic (two-tailed test) was applied for comparing each

AUC-ROC and non-information line. Correlations between

total GHQ-28 and IES were made as follows: Separate scatter-

plots of IES total score, IES intrusion score and IES avoidance

score, by GHQ-28 score, were tested using Spearman rank-

order correlation coefficients. Internal consistency was tested

across subscales and for the total IES in all participants: item

total correlation coefficients and Chronbach’s α coefficient for

the intrusion and avoidance subscales of the IES were calcu-

lated. A P level of less than 0.05 was considered as significant.

SAS software was used for all analyses (version 9.2, Copyright

Results

The herein reported results suggest that patients facing a lung

cancer diagnosis together with their significant others have

been affected by a high level of intrusive thoughts.

Description of Samples

Between July 2011 and March 2012, a total of 95 partici-

pants were invited to take part in this survey-study (Table 1).

Among them, 19 (20%) withdrew their agreement to participate

(five in the control group, ten in the patients group and four in

the significant others group). The herein study describes the

Table 1.

Participants’ demographic and social positioning.

Lung cancer

pts n (%)

Relatives

n (%)

COPD

n (%) P†

N 41 16 19

Age (median) 59 60.5 57 0.54

Women 18 (43.90) 12 (75.00) 9 (47.37)0.69

Marital status 0.39

Single 4 (9.76) 3 (15.79)

Divorced 6 (14.63) 3 (15.79)

Married 31 (75.61) 16 (100) 13 (68.42)

Employment 0.39

Working 15 (36.59) 5 (31.25) 9 (47.37)

Retired 18 (43.90) 8 (50.00) 10 (52.63)

Unemployed 7 (17.07) 3 (18.75)

Missing data 1 (2.44)

Knowledge of cancer 0.004

Personal experience31 (75.61) 1 (6.25) 1 (5.26)*

Relative affected 8 (19.51) 13 (81.25) 11 (57.89)

None of the above2 (4.88) 2 (12.50) 5 (26.32)

Smoking habits 0.004

Never smoker 3 (7.32) 6 (37.50) 10 (52.63)

Former smoker 30 (73.17) 5 (31.25) 8 (42.11)

Active smoker 8 (19.51) 5 (31.25) 1 (5.26)

Educational degree 0.18

A level or less 24 (58.54) 6 (37.50) 8 (42.11)

Bachelor or higher16 (39.02) 10 (62.50) 11 (57.89)

Missing data 1 (2.44)

†Statistical comparison between the three groups: Mann and Whitney U test for

age; comparisons using ² tests for all others; *protocol violation.

survey of the remaining 76 participants: 41 lung cancer patients,

16 significant others and 19 COPD/chronic asthmatic patients.

Knowledge of cancer from the participants’ point of view had

different origins depending on the groups and as a consequence

of the group definitions themselves (e.g. most of the partici-

pants in the significant others group had a knowledge of cancer

from being the spouse of a patient with lung cancer). Smoking

habits significantly differed within the groups. Other variables

tested did not significantly differ among groups. In particular,

subscales of the GHQ-28 detected a comparable level of these

dimensions among patients with lung cancer and patients with

COPD, suggesting that groups did not differ in terms of burden

of symptoms. There were five missing items among the 76 IES

questionnaires (0.04% missing data) and four missing subscales

among the 76 GHQ-28 questionnaires (1.32% missing data).

J.-L. PUJOL ET AL.

Sensitivity-Specificity Relationship of IES

Specificity was calculated using the results of the IES scores

in the control group, and sensitivity was measured in the pa-

tients with lung cancer. AUC-ROC curves [95% confidence

interval] and Z statistics were 0.65 [0.52 - 0.79], P = 0.04; 0.69

[0.56 - 0.81], P = 0.01; and 0.60 [0.46 - 0.74], P = 0.18 for the

IES total score, IES intrusion subscale score and IES avoidance

subscale score respectively (Figure 1). Therefore, the IES total

score and intrusion subscale score AUC-ROC curves signifi-

cantly differed from the non-information line, whereas the IES

avoidance subscale score did not. The IES total score threshold

of 35 was used throughout the following steps of this study; this

threshold is characterizing stress-response to major traumatiz-

ing events as published in the literature (Sundin & Horowitz,

2003).

IES Distribution According to Group s

Taking into account the threshold, the patients with lung

cancer and the cancer-patient significant others had a higher

frequency of high IES total score when compared with patients

with COPD or chronic asthma (49% versus 21%; 2 test, P =

0.04; 1 degree of freedom).

The IES intrusion subscale score significantly differed

among groups inasmuch as the highest median [IR] values were

observed in the significant others group and the lowest in the

control group, (20 [12 - 26]; 15 [9 - 22]; 7 [5 - 15] for signifi-

cant others, patients with lung cancer and control group respec-

tively; Kruskal Wallis, P = 0.02; Figure 2(a)). The IES intru-

sion subscale score was significantly lower in the latter group

when compared with the patients with lung cancer group (Mann

and Whitney U test, P = 0.04) and the significant others group

(Mann and Whitney U test, P = 0.01). The IES intrusion sub-

scale score in the significant others group was higher than that

observed in the patients with lung cancer group, although the

difference did not reach the level of statistical significance

(Mann and Whitney U test, P = 0.14).

The IES avoidance subscale score did not significantly differ

among the groups, with median [IR] values of 9 [4.5 - 15]; 14

[7 - 22]; 8 [3 - 18] for significant others, patients with lung

cancer and control group respectively (Kruskal Wallis, P = 0.17

Figure 2(b)).

Figure 1.

Receiver operating characteristic constructed using the sensitivity-

specificity relationship of IES scale and subscales to discriminate

COPD/chronic asthmatic patients and persons facing lung cancer.

GHQ-28 and IE S Relations hi p

The GHQ-28 total score did not significantly differ among

the groups with mean ± SD: 8.13 ± 4.94, 7.59 ± 5.18 and 7.05 ±

5.03 for significant others, patients with lung cancer and control

group respectively (Kruskal Wallis, P = 0.77). The four sub-

scales of the GHQ-28 did not significantly vary among the

different groups (data not shown). There was a significant rela-

tionship of IES total score and GHQ-28 total score with a

Spearman rank-order correlation coefficient Rs = 0.51 (P <

0.0001; Figure 3).

(a)

(b)

Figure 2.

Impact of event scale score distribution according to groups.

Horizontal bar = median value; columns = interquartile range. (a)

Intrusion subscale (Kruskal-Wallis Test: P = 0.02); (b) Avoid-

ance subscale (Kruskal-Wallis Test: P = 0.17).

Figure 3.

Relationship of IES total score and GHQ-28 total score in per-

sons facing lung cancer. Spearman rank-order correlation coeffi-

cient Rs = 0.51 (P < 0.0001).

J.-L. PUJOL ET AL.

The distribution of IES did not significantly vary according

to the age, family status, smoking habit, employment, degree of

education. However, women proved to have a higher IES total

score when compared with men (median [IR]: 36.5 [29 - 45]

versus 22 [12 - 39]; Mann and Whitney U test: = 0.03).

Internal Co nsistency

In Table 2, Cronbach’s α and item total correlation coeffi-

cients are shown. Internal consistency coefficients proved to be

uniformly high across subscales and for the total IES in the

herein whole population. Cronbach’s α were 0.88, 0.90 and

0.81 for IES total score, intrusion subscale and avoidance sub-

scale respectively. Each subscale was found to be homogeneous

with satisfactory correlations between each item and subscale

total scores.

Discussion

Three different data sets emerging from this survey-study

would merit discussion as they might be of importance to clini-

cians proposing best therapy and psychological support to lung

cancer patients: 1) Post-traumatic stress disorders following the

diagnosis of lung cancer are extremely high, 2) the significant

other is consistently affected, having co-experienced the same

Table 2.

Item total correlation coefficients and Cronbach’s α coefficients for the

intrusion and avoidance subscales of the IES participants’ demographic

and social positioning.

Item

intrusion items Item-total correlation coefficient Cronbach’s α

1 0.71 0.88

4 0.68 0.88

5 0.78 0.87

6 0.57 0.89

10 0.81 0.87

11 0.62 0.89

14 0.72 0.88

Subscale total Cronbach’s α = 0.90

Avoidance items

2 0.40 0.81

3 0.58 0.78

7 0.46 0.80

8 0.34 0.82

9 0.55 0.79

12 0.71 0.77

13 0.68 0.77

15 0.52 0.79

Subscale total Cronbach’s α = 0.81

Total IES scale

Total score Cronbach’s α = 0.88

trauma, 3) intrusive re-experiences are the main stress reactions

and might explain the high values of observed IES.

In the herein study, an IES value greater than or equal to 35

is very common and affects most of the patients with lung can-

cer following the event (diagnosis). This is in accordance with

several studies that have noted that patients with lung cancer

are affected by a much greater stigma than patients with cancer

emerging in other sites (Bell et al., 2010; Burris, 2006). This is

due to the widespread social representations that constantly

consider lung cancer as a self-inflicted disease, even if this

social thinking is disconnected from scientific reality. Indeed,

over the last two decades, there has been an epidemiological

rise of lung cancer among non-smoker (or light former smoker)

patients. According to qualitative psychological studies, non-

smoker patients suffer from similar stereotypes and stigmas and

must constantly defend themselves as having no responsibility

in their disease (Chapple et al., 2004).

In an article by LoConte et al. (2008), a group of patients

with non-small cell lung cancer (NSCLC) was compared to a

group of patients with either breast cancer or prostate cancer.

This study is interesting because the social representations of

these diseases are quite distinct. Patients with prostate cancer,

like patients with breast cancer, are not generally considered

responsible for their illness. Moreover, the social representation

of these diseases does not systematically link them with a poor

prognosis. These authors have shown that NSCLC patients had

high levels of perceived stigma related to cancer and that they

were much higher than those of patients with prostate or breast

cancer. Their smoking status might have significantly corre-

lated with high levels of guilt and shame (Bell et al., 2010). In a

classic paper, Sundin and Horowitz (2003) performed a meta-

analysis of the use of IES during two decades. They demon-

strated that it was possible to rank the events by type, according

to the mean IES levels observed in different studies: the group

of subjects facing an illness or injury is usually part of the

lower hierarchical levels and this could be the case in our study

of patients with COPD or chronic asthma.

The fact that the diagnosis of COPD, a disease with a se-

verely disabling health condition, induced a PTSD with IES

scores that ranked in the group of diseases or injury according

to the meta-analysis by Horowitz is congruent. A lot more sur-

prising is the fact that the diagnosis of lung cancer is, for the

person who receives this diagnosis, a traumatic event whose

consequences in terms of post-traumatic stress are within the

values reported by Horowitz that affect survivors of scenes of

war (Sundin & Horowitz, 2003). The reality of post-traumatic

stress disorder is evidenced by the internal consistency coeffi-

cients of all of the items of the IES scale and subscales together

with the correlation of the IES scores and quality of life GHQ-

28 scores in persons facing lung cancer (Haagsma et al., 2012).

An increased amount of literature suggests that the psycho-

logical distress of the significant others interacting with the

person suffering from cancer could have been underestimated

(Ostlund et al., 2010). In this setting, there are specificities

regarding significant others, and here again they are in link with

the unique characteristics of the lung cancer itself. Significant

others are as exposed to the representations of this illness as are

the patients themselves (the characteristics included in this re-

presentation, such as almost incurable disease and/or self-in-

flicted disease, are generalized in occidental countries). An-

other feature is due to the high level of symptoms. Gralla (2012)

J.-L. PUJOL ET AL.

noted that over 80% of patients with lung cancer are affected by

at least three symptoms (including the most common such as

pain, dyspnea and fatigue). This explains the patient’s social

function impairment. Therapeutic weight by itself also contrib-

utes to this impairment and consequently increases the impact

in the significant other’s life, with possible changes in family

and social status. Caught between the social representations of

illness and the burden of patient support, the significant other’s

room for expression is restricted during or subsequent to the

diagnosis.

From the significant other’s point of view, the herein study

suggests that the trauma is equivalent to that affecting the pa-

tients, as long as the IES total scores and IES intrusion subscale

scores are considered. Here again, internal consistency coeffi-

cients of all items of the IES scale and subscales together with

the correlation of the IES scores and quality of life GHQ-28

scores attest the reality of the observation (Ganz et al., 1991;

Dancey et al., 1997). Therefore, this study suggests that the

diagnosis-induced trauma had as much impact (and maybe nu-

merically more) on the significant other’s experience as on the

patient’s, and that the GHQ-28 is essentially a health-related

quality of life instrument. Considering the intrusion subscale

score, the high median value in asymptomatic significant others

and the low median value in COPD patients (although suffering

from symptoms requiring daily treatment) demonstrated that

there was no link between clinical burden and a high IES.

The intrusive re-experiences are more important than the

avoidance cognitions after the specific event of lung cancer

diagnosis. We hypothesize that avoidance type behaviors are

inhibited because of the current circumstances of diagnosis and

treatment of lung cancer. Indeed, the majority of patients who

participated in this survey-study were then supported by ther-

apy, mainly with chemotherapy regimens given every three

weeks. The repetitive admissions did not allow favorable con-

ditions for avoidance cognitions. As a matter of fact, several

studies having evaluated PTSD prevalence in various malignant

diseases, suggested that avoidance behavior is difficult to de-

fine in cancer patients insofar as therapy imply a continuous

confrontation with putative stressors (Mehnert & Koch, 2007).

Intrusive re-experiences are high (some patients’ questionnaires

having indicated the 35 maximum subscale score); this could be

interpreted as an indicator of a particularly intense break at the

time of the diagnosis. This study has two main limitations: the

follow up is not sufficiently long to assess possible change

along time of the PTSD level. Comparison with other cancers

that are not linked with self-inflicted social representations

should be useful. However, the herein reported results deserve

further researches.

Psychological intervention should be considered in any pa-

tient with an IES score equal to or greater than 35 and/or a high

level of intrusive re-experiences. A similar intervention should

also be offered to significant others as they experience the same

type of PTSD.

Acknowledgements

Authors thank Mrs. Sylvia Motsch and Mrs. Odile Flohic for

technical assistance. Pr Gregory Ninot; Pr Claude Guy Bruère

Dawson for helpful discussions. Study supported by grants

from the French League against Cancer (national and Hérault

committee), from Roche Company and from Chugaï Company.

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