Personality Traits and Health-Related Quality of Life Among Adolescent and Young Adult Cancer Patients: The Role of Psychological Distress

Abstract

Personality may affect the way adolescents and young adults (AYAs) with cancer report health-related quality of life (HRQoL). Patients aged 15–39 years (n = 165) completed a survey at 12–16 months postdiagnosis. The survey included questions on HRQoL (SF-36), distress Brief Symptom Inventory-18, and personality (NEO-Five-Factor Inventory). Personality traits were not associated with physical HRQoL. The personality trait neuroticism was negatively associated with mental HRQoL (β = −0.37; p < 0.001) and positively with psychological distress (β = 0.47; p < 0.001). Hierarchical regression and mediation analyses indicated that psychological distress fully mediated the association between neuroticism and mental HRQoL. Findings emphasize the importance of psychosocial intervention for distress in AYAs with cancer.

Introduction

As developmental life stages, adolescence and young adulthood are often characterized by psychological and social transformations such as developing autonomy and independence from parents, completing formal education, pursuing gainful employment, forming intimate emotional relationships outside the family, and having children.^1,2 Furthermore, these developmental changes occur within a global social and historical context that involves precarious labor conditions, changing timetables and priorities for achieving developmental tasks, public acknowledgment of sexual and gender plurality, and expanding cultural diversity.³

The challenges associated with these developmental tasks and 21st century social conditions are compounded when a young person is diagnosed with a life-threatening disease such as cancer and frequently lead to distress and diminished health-related quality of life (HRQoL).^4–7

Emergent literature identifies a set of sociodemographic, clinical, and psychosocial risk factors for reduced HRQoL in adolescents and young adults (AYAs) diagnosed with cancer, including younger age, lower educational attainment, current physical complaints, lack of health insurance, female gender, and elevated levels of psychological distress.^4,5,7 Other studies suggest that one's subjective appraisal of how cancer and its treatment impinge on one's life is a more substantial predictor of HRQoL than are objective clinical factors such as type or severity of cancer and prognosis for survival.^8,9

Neuroticism is reportedly the most consistent personality trait associated with health outcomes among cancer patients, while inconsistent findings are found regarding the roles of extraversion, agreeableness, conscientiousness, and openness.^10,11 The term neuroticism describes a person's reactivity and emotional stability, with high neuroticism indicating high emotional instability and low neuroticism indicating more emotional stability.

In general, people scoring high in neuroticism have the tendency to experience more negative affect¹² and to focus on and report more somatic symptoms.¹³ They are prone to experience more negative appraisals of cancer on their lives and are less flexible in changing their own standards, values, and conceptualization.¹⁴ Furthermore, these persons tend to use nonadaptive coping strategies when confronted with stress,¹³ making it more difficult for them to adapt to cancer. Moreover, because persons scoring high in neuroticism are more likely to be nervous and sensitive,¹² others might be less willing to support them, which is also reflected in the complex interactions of persons scoring high on neuroticism with their environment.¹⁴

Due to these factors, AYAs with cancer scoring high in neuroticism may also experience more psychological distress, as reflected in prior research, suggesting that high neuroticism is associated with greater exposure and reactivity to stressful events.¹⁵

Investigations comprising older adult cancer patients have demonstrated that HRQoL may be, in part, a function of one's personality^10,11,14; however, little is known about how personality might influence HRQoL in AYAs. In this brief report, we examine the extent to which personality traits are independently associated with HRQoL in AYAs with cancer, after controlling for the effect of sociodemographic and clinical characteristics and psychological distress.

Materials and Methods

Study design and recruitment procedure

A prospective, longitudinal, multisite study examined HRQoL outcomes over 2 years in AYA patients recently diagnosed with cancer. Baseline data were collected within the first 4 months of diagnosis and subsequently at 6 and 12 months after the baseline survey. The analysis reported here focuses on assessments of HRQoL administered at 12 months following baseline recruitment (N = 165), when a standardized instrument measuring personality traits was also included in the survey. Study eligibility criteria included patients aged 14–39 years (and anticipated to turn 15 years old during treatment), first diagnosis of any invasive cancer, and ability to read and understand English or Spanish.

Participating hospitals included three pediatric care institutions and two university-affiliated adult care medical institutions. Research staff at each institution monitored clinic rosters and subsequently identified and approached a total of 286 eligible patients between March, 2008, and April, 2010. Fifty-eight patients did not provide consent, either because they refused participation or because physicians denied access to patients who were too sick to participate. An additional 12 AYAs did not return a completed survey after providing consent, and one died. Overall participation rate was 75% (n = 215). Patients who did not complete the 12-month follow-up assessment (n = 50, of which 17 died during follow-up) were excluded for analyses, resulting in a total sample size of 165.

Institutional review board approval was obtained from each participating site and coordinating center. Informed consent and/or assent were obtained from patients and parents.

Measures

Health-related quality of life

HRQoL was measured by the Medical Outcomes Study Short Form-36 Health Survey (SF-36). The SF-36 is a widely used and well-validated instrument that assesses generic HRQoL.¹⁶ Two higher order component scores were calculated, one for physical health (physical component score [PCS]) and one for mental health (mental component score [MCS]). Raw scores for MCS and PCS were transformed into T scores ranging from 0 to 100, with higher scores representing better HRQoL. The SF-36 is validated among adolescents aged 14 years and older, Cronbach's alpha coefficients were high (range 0.82–0.91).¹⁷

Psychological distress

Psychological distress was measured by the Brief Symptom Inventory-18 (BSI-18).¹⁸ A Global Symptom Index (GSI) was calculated, with higher scores indicating greater psychological distress. The BSI-18 has demonstrated reliability and validity in more than 400 research studies, including samples of healthy adolescents aged 13 years and older.¹⁸ Cronbach's alpha coefficient of the GSI was 0.91.

Personality

Personality was assessed with the NEO Five-Factor Inventory short form.¹⁹ This psychometrically validated clinical assessment tool consists of 60 items designed to measure 5 personality traits on a continuous scale: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. This well-validated and reliable instrument was used in several studies on adolescents, and Cronbach's alpha coefficients were high (range 0.68–0.83).¹³

Self-reported sociodemographic information included age, sex, race, employment/school status, and relationship/marital status. Clinical data obtained from medical charts included type of cancer, types of treatment (chemotherapy, radiation, and surgery), and treatment status (on vs. off treatment). Surveillance, Epidemiology, and End Results codes were used to categorize cancer type into severity of disease: diseases with expected 5-year survival rates greater than 80%; diseases with expected 5-year survival rates between 50% and 80%; and all other invasive malignancies with expected 5-year survival rates less than 50%.²⁰

Statistical analyses

All statistical analyses were performed using SPSS software, version 22.0 (SPSS, Inc., Chicago, IL), and two-sided p-values of <0.05 were considered statistically significant.

Differences in demographic and clinical characteristics between respondents and nonrespondents were compared using chi-square and t-tests, where appropriate.

Hierarchical linear regression models were constructed to assess the unique variance in HRQoL explained by personality traits and psychological distress separately and total variance (entering personality and psychological distress together in the model). The variables were entered to the model as follows: sociodemographic and clinical covariates determined a priori (step 1); covariates + personality traits (step 2); covariates + psychological distress (step 3); and covariates + personality traits + psychological distress (step 4). Partial mediation is indicated if the relationship between personality traits and HRQoL is significant in step 2, and smaller, but still significant, in step 4 when psychological distress is added. Full mediation is indicated when the relationship between personality traits and HRQoL is significant in step 2, and not significant in step 4 where psychological distress is added.²¹ The Sobel test was also conducted to provide statistical evidence for mediation.²⁰

Results

The demographic and clinical characteristics of 165 participants who completed surveys at 12-month follow-up are summarized in Table 1. Respondents were significantly younger at diagnosis (22.8 vs. 26.9 years), there was a higher incidence of leukemia, a brain tumor, or soft tissue sarcoma, and more often received chemotherapy (91% vs. 63%) compared to nonrespondents (all p < 0.01).

Table 1.

Sample Characteristics

	Respondents N = 165 (76.7%)^a	Nonrespondents N = 50 (23.3%)^b	p
Sociodemographic characteristics
Sex			0.63
Female	76 (46.1)	25 (50)
Male	89 (53.9)	25 (50)
Race			0.43
White	74 (45.4)	21 (42)
Hispanic/Latino	71 (43.6)	20 (40)
Other	18 (11.0)	9 (18)
Relationship status at 12-month follow-up^c
No	101 (62.7)	NA	NA
Yes	60 (37.3)
Educational level baseline			0.13
Less than high school	84 (51.5)	18 (36)
High school graduate	21 (12.9)	10 (20)
Some college	35 (21.5)	10 (20)
College graduate or above	23 (14.1)	12 (24)
Employment/school status at 12-month follow-up
Not occupied^d	58 (35.6)	NA	NA
Occupied^e	105 (64.4)
Clinical characteristics
Age at diagnosis, years
Mean (SD)	22.8 (8.8)	26.9 (8.4)	0.003
14–17	78 (47.3)	10 (20)	0.001
18–25	32 (19.4)	11 (22)
26–39	55 (33.3)	29 (58)
Type of cancer			0.014
Breast carcinoma	13 (7.9)	6 (12)
Hodgkin lymphoma	19 (11.5)	4 (8)
Non-Hodgkin lymphoma	12 (7.3)	5 (10)
Testicular carcinoma	8 (4.8)	6 (12)
Female reproductive	4 (2.4)	4 (8)
Soft tissue sarcoma	19 (11.5)	2 (4)
Brain	13 (7.9)	1 (2)
Leukemia	43 (26.1)	7 (14)
Bone tumors	21 (12.7)	5 (10)
Other carcinomas^f	13 (7.9)	10 (20)
Severity of cancer by survival rate			0.19
<50%	52 (31.5)	11 (22)
50%–80%	68 (41.2)	19 (38)
>80%	45 (27.3)	20 (40)
Type of treatment
Chemotherapy	150 (90.9)	31 (63.3)	<0.001
Radiation	32 (19.4)	9 (18.4)	0.87
Surgery	65 (39.4)	18 (36.7)	0.74
Treatment status		NA	NA
Off treatment	85 (51.5)
On treatment	80 (48.5)
Psychological distress (caseness)		NA	NA
No	116 (76.8)
Yes	35 (23.2)
Personality traits—mean (SD)
Neuroticism	18.2 (7.7)	NA	NA
Extraversion	30.0 (6.3)	NA	NA
Openness	27.3 (6.3)	NA	NA
Agreeableness	33.4 (6.8)	NA	NA
Conscientiousness	32.3 (7.9)	NA	NA

For some variables, the sum of number is not 165 because of missing data.

Seventeen patients (34%) were deceased.

Question was worded as follows: “Are you currently married, living together, or in a significant committed relationship?”

Response categories included the following: on temporary medical leave/disability; unemployed; and permanently unable to work.

Response categories included the following: employed full time; employed part time; full-time homemaker; and full-time student.

Other carcinomas included thyroid, melanoma, adrenocortical carcinoma, hepatic carcinoma, and other sarcomas.

NA, not applicable.

Relationship between personality, MCS, PCS, and psychological distress

Personality traits were not associated with physical HRQoL (Table 2). Physical HRQoL was associated with occupational status (β = −0.32; p < 0.001) and psychological distress (β = 0.25; p < 0.001), explaining 31% of the variance. Neuroticism was negatively associated with mental HRQoL (β = −0.37; p < 0.001) and positively with psychological distress (β = 0.47; p < 0.001; Table 2). None of the other personality traits (extraversion, agreeableness, conscientiousness, and openness) was associated with mental HRQoL or with psychological distress (Table 2).

Table 2.

Hierarchical Multivariate Linear Regression Models

	Psychological distress	Mental HRQoL	Physical HRQoL
Model 1: sociodemographic and clinical^a
R-square	0.14	0.13	0.23
Model 2: model 1 + personality
Neuroticism	0.47^b	−0.37^b	−0.07
Extraversion	0.01	−0.07	−0.02
Openness	0.05	−0.02	0.11
Agreeableness	−0.09	0.11	−0.02
Conscientiousness	0.04	0.01	−0.06
R-square	0.36	0.27	0.25
Model 3: model 1 + distress
Distress	NA	−0.66^b	−0.25^b
R-square	NA	0.50	0.28
Model 4: model 1 + personality + distress
Neuroticism	NA	−0.09	0.07
Extraversion	NA	−0.06	−0.01
Openness	NA	0.01	0.12
Agreeableness	NA	0.06	−0.05
Conscientiousness	NA	0.04	−0.04
Distress	NA	−0.61^b	−0.31^b
R-square	NA	0.51	0.31

Including gender, age at diagnosis, race, relationship status, educational level, occupational status, severity of cancer, and treatment status.

p < 0.01.

HRQoL, health-related quality of life; NA, not applicable.

Hierarchical regression analyses showed that the association of neuroticism with mental HRQoL became nonsignificant when distress was added to the model, whereas distress continued to show a significant negative association with mental HRQoL (Table 2). The Sobel test indicated that psychological distress significantly mediated the association between neuroticism and mental HRQoL (Sobel test = −4.98; p < 0.001). The full model explained 51% of the variance in MCS, through which MCS was associated with psychological distress (β = −0.61; p < 0.001; Table 2) and gender (β = −0.15; p < 0.03 indicating that females have worse MCS compared to males).

Discussion

As expected, neuroticism was observed to be the only personality trait associated with HRQoL, and only with regard to mental health functioning; however, this relationship was fully mediated by psychological distress, thereby suggesting that personality traits affect HRQoL in AYA cancer patients mainly by affecting the propensity to experience distress. Although neuroticism was not significantly associated with mental HRQoL after adding psychological distress to the model, AYA patients scoring high on neuroticism may still need special attention as they are more vulnerable to experiencing psychological distress.

Personality traits are difficult to change, however, certain behavior patterns influenced by these traits can be modified by interventions.¹⁹ For example, cognitive behavioral therapy aimed at reducing psychological distress can also be used to modify the behavioral tendencies (e.g., rumination) of individuals with high neuroticism.²²

In addition, healthcare providers should approach and communicate with patients in a manner that is sensitive to the individual strengths and weaknesses of a patient. Patients with high neuroticism may experience more treatment anxiety and may have difficulty disclosing their feelings to healthcare providers.²³ Thus, healthcare providers may need to invest more strongly in a trusting and open relationship with patients to facilitate patients' disclosure. In addition, healthcare providers may need to be more attentive to how they provide certain information about cancer and its treatment to patients with high neuroticism to prevent increasing their anxiety. Awareness of neuroticism as a risk factor for psychological distress will help healthcare providers select appropriate ways to approach patients and refer to interventions when necessary.

In addition, more in-depth research is needed to explore the best ways to reduce levels of distress among AYA cancer patients scoring high on neuroticism. Interventions (therapeutic music videos, educational counseling, and video games) aimed at reducing distress among AYAs in general showed only small and nonsignificant effects.²⁴

Although the five-factor personality model (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness) has proven to be a valuable framework in examining linkages between personality and health, it represents only one of several possible frameworks for examining personality and its relationship to health outcomes. Future research should take into account other personality typologies or systems (e.g., type D [distressed] personality). In the present study, personality was assessed at only one time point, and thus, we were unable to determine the degree to which personality actually influenced or was influenced by HRQoL. Although personality is often seen as a basic invariant characteristic, it has also been shown that personality can change up to the age of 30 years.²⁵ In addition, differences in age, tumor type, and treatment were found between respondents and nonrespondents, which somewhat limits the generalizability of our findings.

Not withstanding these limitations, the present study generated important information on the relationship between personality, psychological distress, and HRQoL in AYA cancer patients. Psychological distress was associated with HRQoL independent of sociodemographic and clinical characteristics and personality traits. Nevertheless, AYAs with high scores in neuroticism may be more vulnerable to experiencing distress. Our findings emphasize the importance of psychosocial intervention for distress in AYAs with cancer and suggest that individual differences in personality may represent one factor that influences the need for supportive services in this population.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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