Prostate cancer is a leading malignancy in men, and prostatectomy is widely used for its treatment. Psychological distress and pain are commonly experienced in the perioperative period, and both can contribute to suppression of the immune response to cancer. This study evaluated perioperative pain, psychological distress, and immune function in men undergoing prostatectomy. Men were evaluated prior to surgery, 1 and 2 days postoperatively and 4—6 weeks postoperatively. Compared to cancer-free men, the prostatectomy group reported increased perceived stress, depression, confusion, and anxiety prior to surgery. During the 2 postoperative days, mood disturbance and anxiety persisted and were accompanied by mild elevations in pain and reduced vigor. At 4—6 weeks postoperative, mood, pain, and immune function were similar to those of the cancer-free group; however, the prostatectomy group continued to report significant elevations in anxiety. Natural killer cell activity (NKCA) was significantly reduced on Day 1 after prostatectomy, but by postoperative Day 2, NKCA returned to a level similar to that of the cancer-free group. The reduction in NKCA was not accompanied by changes in circulating immune cells, demonstrating that this reduction represented a functional change in NKCA. No correlations between immune variables and pain or psychological variables were found, suggesting that the postoperative reduction in NKCA was likely the result of the physical stress of the surgical experience. Suppression of immune defenses during the critical postoperative period can place cancer patients at risk for nascent tumor seeding. Additional interventions are needed to reduce this risk.
Andersen, B.L., Farrar, W.B., Golden-Kreutz, D.M., Glaser, R., Emery, C.F., Crespin, T.R., et al. (2004). Psychological, behavioral, and immune changes after a psychological intervention: A clinical trial. Journal of Clinical Oncology, 22, 3570-3580.
4.
Andersen, B.L., Farrar, W.B., Golden-Kreutz, D., Kutz, L.A., MacCallum, R., Courtney, M.E., et al. (1998). Stress and immune responses after surgical treatment for regional breast cancer. Journal of the National Cancer Institute, 90, 30-36.
5.
Avraham, R., & Ben-Eliyahu, S. (2007). Neuroendocrine regulation of cancer progression: II. Immunological mechanisms, clinical relevance, and prophylactic measures. In R. Ader (Ed.), PsychoneuroimmunologyVol. 1 (4th ed., pp. 251-265). Burlington, MA: Elsevier Academic Press.
6.
Awsare, N.S., Green, J.S., Aldwinckle, B., Hanbury, D.C., Boustead, G.B., & McNicholas, T.A. (2008). The measurement of psychological distress in men being investigated for the presence of prostate cancer. Prostate Cancer and Prostatic Diseases, 11, 384-389.
7.
Ben-Eliyahu, S. ( 2003). The promotion of tumor metastasis by surgery and stress: Immunological basis and implications for psychoneuroimmunology. Brain Behavior and Immunity, 17, 27-36.
8.
Ben-Eliyahu, S., Page, G.G., Yirmiya, R., & Shakhar, G. ( 1999). Evidence that stress and surgical interventions promote tumor development by suppressing natural killer cell activity. International Journal of Cancer, 80, 880-888.
9.
Benish, M., Bartal, I., Goldfarb, Y., Levi, B., Avraham, R., Raz, A., et al. (2008). Perioperative use of beta-blockers and COX-2 inhibitors may improve immune competence and reduce the risk of tumor metastasis. Annals of Surgical Oncology, 15, 2042-2052.
10.
Biondi, M. ( 2001). Effects of stress on immune functions: An overview . In R. Ader & N. Cohen (Eds.), Psychoneuroimmunology (3rd ed., pp. 189-226). New York: Academic Press.
11.
Bisson, J.I., Chubb, H.L., Bennett, S., Mason, M., Jones, D., & Kynaston, H. ( 2002). The prevalence and predictors of psychological distress in patients with early localized prostate cancer. British Journal of Urology International, 90, 56-61.
12.
Bloch, S., Love, A., Macvean, M., Duchesne, G., Couper, J., & Kissane, D. ( 2007). Psychological adjustment of men with prostate cancer: A review of the literature. BioPsychoSocial Medicine , 1, 1-14.
13.
Brand, J.M., Frohn, C., Luhm, J., Kirchner, H., & Schmucker, P. ( 2003). Early alterations in the number of circulating lymphocyte subpopulations and enhanced proinflammatory immune response during opioid-based general anesthesia. Shock, 20, 213-217.
14.
Cannon, G.B., Dean, J.H., Herberman, R.B., Perlin, E., Reid, J., Miller, C., et al. (1980). Association of depressed postoperative lymphoproliferative responses to alloantigens with poor prognosis in patients with stage I lung cancer. International Journal of Cancer , 25, 9-17.
15.
Carapella, J.S. ( 1994). Radical prostatectomy: A case study. Journal of Post Anesthesia Nursing, 9, 344-349.
16.
Cella, D.F.S., Tross, J.E., Orav, J.C., Holland, P.M., Silberfarb, J., & Rafla, S. ( 1989). Mood states of patients after the diagnosis of cancer . Journal of Psychosocial Oncology, 7, 45-54.
17.
Chambrier, C., Chassard, D., Bienvenu, J., Saudin, F., Paturel, B., Garrigue, C., et al. (1996). Cytokine and hormonal changes after cholecystectomy. Effect of ibuprofen pretreatment. Annals of Surgery, 224, 178-182.
18.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396.
19.
Colacchio, T.A., Yeager, M.P., & Hildebrandt, L.W. (1994). Perioperative immunomodulation in cancer surgery. American Journal of Surgery, 167, 174-179.
20.
DaCosta, M.L., Redmond, H.R., & Bouchier-Hayes, D.J. (1998). The effect of laparotomy and laparoscopy on the establishment of spontaneous tumor metastases. Surgery, 124, 516-525.
21.
da Silva, F.C. ( 1993). Quality of life in prostatic cancer patients. Cancer, 72, 3803-3806.
22.
De Cosmo, G., Congedo, E., Lai, C., Primieri, P., Dottarelli, A., & Aceto, P. ( 2008). Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia. Clinical Journal of Pain, 24, 399-405.
23.
Deguchi, M., Isobe, Y., Matsukawa, S., Yamaguchi, A., & Nakagawara, G. (1998). Usefulness of metyrapone treatment to suppress cancer metastasis facilitated by surgical stress. Surgery, 123, 440-449.
24.
Dhabhar, F.S., & McEwen, B.S. (2007). Bi-directional effects of stress on immune function: Possible explanations for salubrious as well as harmful effects. In R. Ader (Ed.), Psychoneuroimmunology (Vol. 2, pp. 723-760). Burlington, MA: Elsevier Academic Press .
25.
Dighe, A.S., Richards, E., Old, L.J., & Schreiber, R.D. (1994). Enhanced in vivo growth and resistance to rejection of tumor cells expressing dominant negative IFN gamma receptors. Immunity, 1, 447-456.
26.
Elenkov, I.J., Wilder, R.L., Chrousos, G.P., & Vizi, E.S. ( 2000). The sympathetic nerve-an integrative interface between two supersystems: The brain and the immune system. Pharmacological Review, 52, 595-638.
27.
Esterling, B.A., Kiecolt-Glaser, J.K., Bodnar, J.C., & Glaser, R. ( 1994). Chronic stress, social support, and persistent alterations in the natural killer cell response to cytokines in older adults . Health Psychology, 13, 291-298.
28.
Esterling, B.A., Kiecolt-Glaser, J.K., & Glaser, R. ( 1996). Psychosocial modulation of cytokine-induced natural killer cell activity in older adults. Psychosomatic Medicine , 58, 264-272.
29.
Faist, E., Ertel, W., Cohnert, T., Huber, P., Inthorn, D., & Heberer, G. ( 1990). Immunoprotective effects of cyclooxygenase inhibition in patients with major surgical trauma. Journal of Trauma , 30, 8-17.
30.
Fitch, M.I., Gray, R., Franssen, E., & Johnson, B. ( 2000). Men’s perspectives on the impact of prostate cancer: Implications for oncology nurses. Oncology Nursing Forum, 27, 1255-1263.
31.
Fujisawa, T., & Yamaguchi, Y. ( 1997). Autologous tumor killing activity as a prognostic factor in primary resected nonsmall cell carcinoma of the lung. Cancer, 79, 474-481.
32.
Gotay, C.C., & Stern, J.D. ( 1995). Assessment of psychological functioning in cancer patients . Journal of Psychosocial Oncology, 13, 123-160.
33.
Grass, J.A., Sakima, N.T., Valley, M., Fischer, K., Jackson, C., Walsh, P., et al. (1993). Assessment of ketorolac as an adjuvant to fentanyl patient-controlled epidural analgesia after radical retro-pubic prostatectomy. Anesthesiology, 78, 642-648.
34.
Greenwald, H.P., Bonica, J.J., & Bergner, M. ( 1987). The prevalence of pain in four cancers. Cancer, 60, 2563-2569.
35.
Gutman, H., Risin, D., Pollock, R.E., & Pellis, N.R. ( 1993). Effect of surgery on peripheral blood lymphocyte locomotion through type I collagen. Cancer, 71, 2833-2837.
36.
Held, J.L., Osborne, D.M., Volpe, H., & Waldman, A.R. ( 1994). Cancer of the prostate: Treatment and nursing implications . Oncology Nursing Forum, 21, 1517-1529.
37.
Herbert, T.B., & Cohen, S. ( 1993a). Depression and immunity: A meta-analytic review . Psychological Bulletin, 113, 472-486.
38.
Herbert, T.B., & Cohen, S. ( 1993b). Stress and immunity in humans: A meta-analytic review . Psychosomatic Medicine, 55, 364-379.
39.
Herbert, T.B., Cohen, S., Marsland, A.L., Bachen, E.A., Rabin, B.S., Muldoon, M.F., et al. (1994). Cardiovascular reactivity and the course of immune response to an acute psychological stressor. Psychosomatic Medicine, 56, 337-344.
40.
Hogevold, H.E., Lyberg, T., Kahler, H., Haug, E., & Reikeras, O. ( 2000). Changes in plasma IL-1beta, TNF-alpha and IL-6 after total hip replacement surgery in general or regional anaesthesia. Cytokine, 12, 1156-1159.
41.
Homburger, J.A., & Meiler, S.E. ( 2006). Anesthesia drugs, immunity, and long-term outcome . Current Opinion in Anaesthesiology, 19, 423-428.
42.
Jacobs, R., Karst, M., Scheinichen, D., Bevilacqua, C., Schneider, U., Heine, J., et al. (1999). Effects of fentanyl on cellular immune functions in man. International Journal of Immunopharmacology , 21, 445-454.
43.
Jameson, P., Desborough, J.P., Bryant, A.E., & Hall, G.M. ( 1997). The effect of cortisol suppression on interleukin-6 and white blood cell responses to surgery. Acta Anaesthesiology Scandinavia, 41, 304-308.
44.
Kagi, D., Ledermann, B., Burki, K., Seiler, P., Odermatt, B., Olsen, K.J., et al. (1994). Cytotoxicity mediated by T cells and natural killer cells is greatly impaired in perforin-deficient mice. Nature, 369, 31-37.
45.
Kajantie, E., & Phillips, D.I. (2006). The effects of sex and hormonal status on the physiological response to acute psychosocial stress . Psychoneuroendocrinology, 31, 151-178.
46.
Kaplan, D.H., Shankaran, V., Dighe, A.S., Stockert, E., Aguet, M., Old, L.J., et al. (1998). Demonstration of an interferon gamma-dependent tumor surveillance system in immunocompetent mice. Proceedings of the National Academy of Science, USA, 95, 7556-7561.
47.
Kemeny, M.E. ( 2007). Emotions and the immune system. In R. Ader (Ed.), PsychoneuroimmunologyVol. 1 (4th ed., pp. 619-629). Burlington, MA: Elsevier Academic Press.
48.
Kiecolt-Glaser, J.K., Dura, J.R., Speicher, C.E., Trask, O.J., & Glaser, R. ( 1991). Spousal caregivers of dementia victims: Longitudinal changes in immunity and health. Psychosomatic Medicine, 53, 345-362.
49.
Kiecolt-Glaser, J.K., Glaser, R., Shuttleworth, E.C., Dyer, C.S., Ogrocki, P., & Speicher, C.E. (1987). Chronic stress and immunity in family caregivers of Alzheimer’s disease victims. Psychosomatic Medicine, 49, 523-535.
50.
Kiss, A., & Meryn, S. ( 2001). Effects of sex and gender on psychosocial aspects of prostate and breast cancer. British Medical Journal, 323, 1055-1058.
51.
Koda, K., Saito, N., Takiguchi, N., Oda, K., Nunomura, M., & Nakajima, N. ( 1997). Preoperative natural killer cell activity: Correlation with distant metastases in curatively research colorectal carcinomas. International Journal of Surgery, 82, 190-193.
52.
Koltun, W.A., Bloomer, M.M., Tilberg, A.F., Seaton, J.F., Ilahi, O., Rung, G., et al. (1996). Awake epidural anesthesia is associated with improved natural killer cell cytotoxicity and a reduced stress response . American Journal of Surgery, 171, 68-72.
53.
Kurosawa, S., & Kato, M. ( 2008). Anesthetics, immune cells, and immune responses . Journal of Anesthesia, 22, 263-277.
54.
Kutza, J., Gratz, I., Afshar, M., & Murasko, D.M. ( 1997). The effects of general anesthesia and surgery on basal and interferon stimulated natural killer cell activity of humans . Anesthesia and Analgesia, 85, 918-923.
55.
Larsen, B., Hoff, G., Wilhelm, W., Buchinger, H., Wanner, G.A., & Bauer, M. ( 1998). Effect of intravenous anesthetics on spontaneous and endotoxin-stimulated cytokine response in cultured human whole blood. Anesthesiology, 89, 1218-1227.
56.
Levy, B.S., & Carpenter, R. ( 1995). Perioperative pain management. Journal of the American Association of Gynecological Laparoscopy, 2, 381-387.
57.
Lewis, J.W., Shavit, Y., Terman, G.W., Nelson, L.R., Gale, R.P., & Liebeskind, J.C. (1983). Apparent involvement of opioid peptides in stress-induced enhancement of tumor growth. Peptides, 4, 635-638.
58.
Love, A.W., Scealy, M., Bloch, S., Duchesne, G., Couper, J., Macvean, M., et al. (2008). Psychosocial adjustment in newly diagnosed prostate cancer. Australian and New Zealand Journal of Psychiatry , 42, 423-429.
59.
Lutgendorf, S., Costanzo, E., & Siegel, S. ( 2007). Psychosocial influences in oncology: An expanded model of biobehavioral mechanisms. In R. Ader (Ed.), PsychoneuroimmunologyVol. 2 (4th ed., pp. 869-895). Burlington , MA: Elsevier Academic Press.
60.
Maliski, S.L., Kwan, L., Elashoff, D., & Litwin, M.S. ( 2008). Symptom clusters related to treatment for prostate cancer . Oncology Nursing Forum, 35, 786-793.
61.
McNair, D.M., Lorr, M.M., & Droppleman, L.F. (1992). Manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Service.
62.
Mehnert, A., Lehmann, C., Schulte, T., & Koch, U. ( 2007). Presence of symptom distress and prostate cancer-related anxiety in patients at the beginning of cancer rehabilitation. Onkologie, 30, 551-556.
63.
Melamed, R., Bar-Yosef, S., Shakhar, G., Shakhar, K., & Ben-Eliyahu, S. (2003). Suppression of natural killer cell activity and promotion of tumor metastasis by ketamine, thiopental, and halothane, but not by propofol: Mediating mechanisms and prophylactic measures. Anesthesia and Analgesia, 97, 1331-1339.
64.
Melzack, R. ( 1987). The short-form McGill Pain Questionnaire. Pain, 30, 191-197.
65.
Moene, M., Bergbom, I., & Skott, C. ( 2006). Patients’ existential situation prior to colorectal surgery. Journal of Advanced Nursing, 54, 199-207.
66.
Monroe, S., & Kelley, J. ( 1995). Measuring stress: A guide for health and social scientist . In R. K. S. Cohen & L. Gordon (Eds.), Measurement of stress appraisal (pp. 122-147). New York: Oxford University Press.
67.
Nagabhushan, M., Mathews, H.L., & Witek-Janusek, L. (2001). Aberrant nuclear expression of ap-1 and nfkb in lymphocytes of women stressed by the experience of breast biopsy. Brain Behavior and Immunity, 15, 78-84.
68.
Namiki, S., Saito, S., Tochigi, T., Numata, I., Ioritani, N., & Arai, Y. ( 2007). Psychological distress in Japanese men with localized prostate cancer. International Journal of Urology, 14, 924-929.
69.
Northouse, L.L., Mood, D.W., Montie, J.E., Sandleer, H.M., Forman, J.D., Hussain, M., et al. (2007). Living with prostate cancer: Patients’ and spouses’ psychosocial status and quality of life. Journal Clinical Oncology, 25, 4171-4177.
70.
Olff, M., Langeland, W., Draijer, N., & Gersons, B.P. ( 2007). Gender differences in posttraumatic stress disorder . Psychological Bulletin, 133, 183-204.
71.
Page, G.G., & Ben-Eliyahu, S. (1997). The immune-suppressive nature of pain. Seminars in Oncology Nursing, 13, 10-15.
72.
Page, G.G., Ben-Eliyahu, S., & Liebeskind, J.C. (1994). The role of LGL/NK cells in surgery-induced promotion of metastasis and its attenuation by morphine . Brain Behavior and Immunity, 8, 241-250.
73.
Page, G.G., Ben-Eliyahu, S., Yirmiya, R., & Liebeskind, J.C. (1993). Morphine attenuates surgery-induced enhancement of metastatic colonization in rats. Pain, 54, 21-28.
74.
Page, G.G., Blakely, W.P., & Ben-Eliyahu, S. (2001). Evidence that postoperative pain is a mediator of the tumor-promoting effects of surgery in rats. Pain, 90, 191-199.
75.
Page, G.G., McDonald, J.S., & Ben-Eliyahu, S. (1998). Pre-operative versus postoperative administration of morphine: Impact on the neuroendocrine, behavioral, and metastatic-enhancing effects of surgery. British Journal of Anaesthesia, 81, 216-223.
76.
Pollock, R.E., Babcock, G.F., Romsdahl, M.M., & Nishioka, K. ( 1984). Surgical stress-mediated suppression of murine natural killer cell cytotoxicity. Cancer Research, 44, 3888-3891.
77.
Pollock, R.E., & Lotzova, E. ( 1987). Surgical-stress-related suppression of natural killer cell activity: A possible role in tumor metastasis. Natural Immunity and Cell Gowth Regulation, 6, 269-278.
78.
Pollock, R.E., Lotzova, E., & Stanford, S.D. (1991). Mechanism of surgical stress impairment of human perioperative natural killer cell cytotoxicity . Archives of Surgery, 126, 338-342.
79.
Pollock, R.E., Lotzova, E., & Stanford, S.D. (1992). Surgical stress impairs natural killer cell programming of tumor for lysis in patients with sarcomas and other solid tumors. Cancer, 70, 2192-2202.
80.
Rosen, S., Svensson, M., & Nilsson, U. ( 2008). Calm or not calm: The question of anxiety in the perianesthesia patient. Journal of Perianesthesia Nursing , 23, 237-246.
81.
Sacerdote, P., Manfredi, B., Bianchi, M., & Panerai, A.E. ( 1994). Intermittent but not continuous inescapable footshock stress affects immune responses and immunocyte beta-endorphin concentrations in the rat. Brain Behavior and Immunity, 8, 251-260.
82.
Sandoval, B.A., Robinson, A.V., Sulaiman, T.T., Shenk, R.R., & Stellato, T.A. (1996). Open versus laparoscopic surgery: A comparison of natural antitumoral cellular immunity in a small animal model. American Surgeon, 62, 625-630; discussion 630-631.
83.
Schantz, S.P., Brown, B.W., Lira, E., Taylor, D.L., & Beddingfield, N. (1987). Evidence for the role of natural immunity in the control of metastatic spread of head and neck cancer . Cancer Immunology Immunotherapy, 25, 141-148.
84.
Schantz, S.P., Savage, H.E., Racz, T., Taylor, D.L., & Sacks, P.G. ( 1989). Natural killer cells and metastases from pharyngeal carcinoma . American Journal of Surgery, 158, 361-366.
85.
Schedlowski, M., Jacobs, R., Stratmann, G., Richter, S., Hadicke, A., Tewes, U., et al. (1993). Changes of natural killer cells during acute psychological stress. Journal of Clinical Immunology , 13, 119-126.
86.
Schmaus, B.J., Laubmeier, K.K., Boquiren, V.M., Herzer, M., & Zakowski, S.G. (2008). Gender and stress: Differential psychophysiological reactivity to stress reexposure in the laboratory. International Journal of Psychophysiology, 69, 101-106.
87.
Schnur, J.B., Montgomery, G.H., Hallquist, M.N., Goldfarb, A.B., Silverstein, J.H., Weltz, C.R., et al. (2008). Anticipatory psychological distress in women scheduled for diagnostic and curative breast cancer surgery. International Journal of Behavioral Medicine, 15, 21-28.
88.
Seki, N., Hayakawa, Y., Brooks, A.D., Wine, J., Wiltrout, R.H., Yagita, H., et al. (2003). Tumor necrosis factor-related apoptosis-inducing ligand-mediated apoptosis is an important endogenous mechanism for resistance to liver metastases in murine renal cancer. Cancer Research , 63, 207-213.
89.
Shaha, M., Cox, C.L., Talman, K., & Kelly, D. ( 2008). Uncertainty in breast, prostate, and colorectal cancer: Implications for supportive care. Journal of Nursing Scholarship , 40, 60-67.
90.
Shakhar, G., & Ben-Eliyahu, S. (2003). Potential prophylactic measures against postoperative immunosuppression: Could they reduce recurrence rates in oncological patients? Annals of Surgical Oncology , 10, 972-992.
91.
Shakhar, G., & Blumenfeld, B. (2003). Glucocorticoid involvement in suppression of NK activity following surgery in rats. Journal of Neuroimmunology, 138, 83-91.
92.
Shavit, Y., Martin, F.C., Yirmiya, R., Ben-Eliyahu, S., Terman, G.W., Weiner, H., et al. (1987). Effects of a single administration of morphine or footshock stress on natural killer cell cytotoxicity. Brain, Behavior, and Immunity, 1, 318-328.
93.
Smyth, M.J., Kelly, J.M., Baxter, A.G., Korner, H., & Sedgwick, J.D. (1998). An essential role for tumor necrosis factor in natural killer cell-mediated tumor rejection in the peritoneum . Journal of Experimental Medicine, 188, 1611-1619.
94.
Smyth, M.J., Thia, K.Y., Cretney, E., Kelly, J.M., Snook, M.B., Forbes, C.A., et al. (1999). Perforin is a major contributor to NK cell control of tumor metastasis. Journal of Immunology, 162, 6658-6662.
95.
Smyth, M.J., Wallace, M.E., Nutt, S.L., Yagita, H., Godfrey, D.I., & Hayakawa, Y. ( 2005). Sequential activation of NKT cells and NK cells provides effective innate immunotherapy of cancer. Journal of Experimental Medicine, 201, 1973-1985.
96.
Spielberger, C.D., Gorsuch, R.C., & Lushene, R.E. ( 1970). Manual for the State Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists .
97.
Steginga, S.K., Occhipinti, S., Gardiner, R.A., Yaxley, J., & Heathcote, P. ( 2004). Prospective study of men’s psychological and decision-related adjustment after treatment for localized prostate cancer . Urology, 63, 751-756.
98.
Steineck, G., Helgesen, F., Adolfsson, J., Dickman, P.W., Johansson, J.E., Norlen, B.J., et al. (2002). Quality of life after radical prostatectomy or watchful waiting. New England Journal of Medicine, 347, 790-796.
99.
Street, S.E., Cretney, E., & Smyth, M.J. ( 2001). Perforin and interferon-gamma activities independently control tumor initiation, growth, and metastasis. Blood, 97, 192-197.
100.
Tartter, P.I., Steinberg, B., Barron, D.M., & Martinelli, G. (1987). The prognostic significance of natural killer cytotoxicity with colorectal cancer. Archives of Surgery, 122, 1264-1268.
101.
Tashiro, T., Yamamori, H., Takagi, K., Hayashi, N., Furukawa, K., Nitta, H., et al. (1999). Changes in immune function following surgery for esophageal carcinoma. Nutrition, 15, 760-766.
102.
Tonnesen, E., & Wahlgreen, C. ( 1988). Influence of extradural and general anaesthesia on natural killer cell activity and lymphocyte subpopulations in patients undergoing hysterectomy. British Journal of Anaesthesia, 60, 500-507.
103.
Uchida, A., Kolb, R., & Micksche, M. ( 1982). Generation of suppressor cells for natural killer activity in cancer patients after surgery. Journal of the National Cancer Institute, 68, 735-741.
104.
Vallejo, R., Hord, E.D., Barna, S.A., Santiago-Palma, J., & Ahmed, S. ( 2003). Perioperative immunosuppression in cancer patients. Journal of Environmental Pathology, Toxicology, and Oncology , 22, 139-146.
105.
van den Broek, M.E., Kagi, D., Ossendorp, F., Toes, R., Vamvakas, S., Lutz, W.K., et al. (1996). Decreased tumor surveillance in perforin-deficient mice. Journal of Experimental Medicine, 184, 1781-1790.
106.
van’t Spijker, A., Trijsburg, R.W., & Duivenvoorden, H.J. (1997). Psychological sequelae of cancer diagnosis: A meta-analytical review of 58 studies after 1980. Psychosomatic Medicine, 59, 280-293.
107.
Wallace, M.E., & Smyth, M.J. ( 2005). The role of natural killer cells in tumor control-effectors and regulators of adaptive immunity. Springer Seminars in Immunopathology, 27, 49-64.
108.
Weekes, N.Y., Lewis, R.S., Goto, S.G., Garrison-Jakel, J., Patel, F., & Lupien, S. ( 2008). The effect of an environmental stressor on gender differences on the awakening cortisol response. Psychoneuroendocrinology , 33, 766-772.
109.
Whiteside, T.L., & Herberman, R.B. (1994). Role of human natural killer cells in health and disease. Clinical Diagnostic Laboratory Immunology, 1, 125-133.
110.
Witek-Janusek, L., Albuquerque, K., Chroniak, K.R., Chroniak, C., Durazo-Arvizu, R., & Mathews, H.L. ( 2008). Effect of mindful-ness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, Behavior, and Immunity, 22, 969-981.
111.
Witek-Janusek, L., Gabram, S., & Mathews, H.L. ( 2007). Psychologic stress, reduced NK cell activity, and cytokine dysregulation in women experiencing diagnostic breast biopsy . Psychoneuroendocrinology, 32, 22-35.
112.
Witek-Janusek, L., & Mathews, H. ( 2000). Stress, immunity, and health outcomes. In V. Rice (Ed.), Handbook of stress, coping, and health. implications for nursing research, theory, and practice (pp. 47-67). Thousand Oaks, CA: Sage Publications.
113.
Woiciechowsky, C., Schoning, B., Lanksch, W.R., Volk, H.D., & Docke, W.D. ( 1999). Mechanisms of brain-mediated systemic anti-inflammatory syndrome causing immunodepression. Journal of Molecular Medicine , 77, 769-780.
Yokota, T., Uehara, K., & Nomoto, Y. ( 2000). Intrathecal morphine suppresses NK cell activity following abdominal surgery. Canadian Journal of Anaesthesia , 47, 303-308.
