Avenues - Winter 2004

Social Support, Stress, and Serum Cortisol

In this issue's Becoming Your Own Advocate article, we discuss the relationship between social support and a woman's ability to cope with breast cancer. As presented in the study reviewed, the psychological aspects of this relationship are straightforward and can be clearly demonstrated. But what physiological processes may be happening in the body that can help explain this phenomenon?

One possible link is cortisol, a stress hormone produced in the adrenal gland. Cortisol is secreted as a response to both acute and chronic stress; the levels of cortisol in the blood and saliva correlate well with the amount of perceived stress a person experiences.6, 15, 1 Higher cortisol levels also lead to lower immune functioning.14

WHAT IS THE RELATIONSHIP BETWEEN CORTISOL AND CANCER?
Women who have breast cancer have been shown to have elevated levels of cortisol in their blood.11 It is not known,however, whether these higher cortisol levels increase the risk of cancer or are simply a byproduct of the stress of a cancer diagnosis and subsequent treatment.

The newly emerging field of chronobiology may illuminate this issue examines the rhythmic cycling between day and night of various functions and biologically active compounds in the body. It has been observed that women with breast cancer tend to be more likely to have a disturbance in the circadian rhythm of their cortisol levels.14 In women with breast cancer, there was a "flattening" of the normally expected day and night fluctuation of cortisol levels, meaning that levels were low when they were expected to be high and high when they were expected to be low.The degree to which this day and night rhythm of cortisol levels follows its normal wave-shaped curve can be a predictor of longevity in women with breast cancer.10

What specific role this disturbance of the day and night rhythm of cortisol levels plays in the development of cancer is not specifically known, but it does suggest a loss of balance in the normal cycles of activity and rest between day and night. One way to help promote healthy day-night variation in cortisol can be to alternate between a low-stress daytime schedule, including exercise that can lower your levels of stress hormones, complemented by high quality sleep at night. A balance between healthy activity by day and good sleep at night can also bring better quality of life, better treatment response, and greater longevity.7

It is hoped that future research that follows patients over a long period of time may help determine which comes first: the stress or the cancer.

WHAT IS THE PRACTICAL BENEFIT OF THIS?
It is important to explore 1) whether there is a connection between a person's cortisol levels and their level of social support and 2) whether cortisol levels can also serve as a monitoring tool to determine the effectiveness of various stress reduction techniques.

There appears to be evidence supporting both questions. The link between cortisol and levels of social support is best studied in observational research, which studies the health of groups of people without offering any specific treatment.omen with breast cancer who report higher levels of social support tend to have lower levels of cortisol concentration.12

The effects of stress management training or group support are best studied in clinical research, which studies the health effect of a specific treatment. In studies of the effects on stress of group support (a kind of social support by design), women who participate in such groups had cortisol levels lower than in women who did not participate. This effect has been reported in several well-designed randomized studies.2, 3

Thus, it appears that whether lower stress levels are the result of support from one's community of family and friends or the result of finding and participating in a support group, a test of cortisol levels can demonstrate the physiological benefits of lowered stress.

HOW MIGHT HAVING GOOD SOCIAL SUPPORT OR PARTICIPATING IN A SUPPORT GROUP HELP LOWER MY CORTISOL LEVELS?
An innovative study conducted at the University of Miami demonstrated that women with breast cancer participating in a group support program were not only able to lower their levels of the stress marker, serum cortisol, but they were also able to improve their personal coping skills, felt a stronger sense of spirituality, and were more effective at taking advantage of their own personal support network of family and friends.3 Furthermore, they report that only the women who were able to achieve these positive personal growth changes during their participation in the support group were able to achieve the physiological benefit of lower serum cortisol; women who didn't achieve these positive changes didn't have lower cortisol levels.

In this program of weekly meetings, women were taught stress management (coping skills training, anger management, social support utilization skills, cognitive restructuring, and assertiveness training) and relaxation techniques (meditation, guided imagery, abdominal breathing, and progressive muscle relaxation). The goal of the program was to help women find ways to adjust to their breast cancer diagnosis by reducing the distress associated with the diagnosis and to help find positive aspects of living with breast cancer (called "benefit finding" by the study authors). The women involved had either Stage I or II breast cancer and were treated with various combinations of lumpectomy, mastectomy, chemotherapy, and tamoxifen. They had their serum cortisol levels measured before and after support group sessions and were asked questions to determine their level of personal distress. Women participating in the weekly sessions reported lower levels of distress, higher levels of benefit finding, and had lower serum cortisol. There was no significant change in any of these three parameters in the control group.

While this University of Miami study does not specifically identify how practicing stress reduction leads to lower cortisol levels, the findings do make an important point: when a person practicing stress reduction techniques feels the positive changes working in their body, there will likely be a measurable change on an objective test such as serum cortisol.

WHAT ABOUT THE RELATIONSHIP BETWEEN STRESS AND THE IMMUNE SYSTEM?
The same University of Miami research group recently published a follow-up study in which the authors tested the same stress reduction methods in women following surgery for breast cancer.5 They found that in the women who achieved higher levels of benefit finding, there were significantly higher levels of immune function as measured by increases in lymphocyte count. Lymphocytes are one of the five kinds of white blood cells (leukocytes) circulating in the blood.

The authors suggest that by participating in a support group and intentionally developing and practicing skills to help themselves respond to stressful experiences, a person can learn to perceive stressful circumstances less as a threat and more as a challenge. This difference in a person’s response seems to make a significant difference in their physiology.

DOES PARTICIPATING IN GROUP SUPPORT TO LOWER CORTISOL HELP YOU LIVE LONGER?
According to a new study, perhaps not.4 In a trial of 303 women with Stage I and II breast cancer, women attending weekly sessions of group therapy did not liver longer than women who did not. However, as the study authors point out, they did report lower levels of anxiety and fear along with better family relationships. So while they may not be living longer, they may be living better.

WHAT IF I DON'T WANT A SUPPORT GROUP? ARE THERE OTHER WAYS TO LOWER CORTISOL LEVELS?
Support groups and training in psychological coping have been shown to be effective tools for reducing stress and lowering cortisol levels. But such groups and training are not for everyone. Other ways to reduce cortisol levels include exercise and meditation (see Exercise and Health and Meditation and Health).

For more on this topic, see Saliva Tests for Cortisol and Other Hormones: Questions and Resources.

References:
1. Aardal, E. and A. C. Holm (1995). "Cortisol in saliva--reference ranges and relation to cortisol in serum." Eur J Clin Chem Clin Biochem 33(12): 927-32.
2. Andersen, B. L., W. B. Farrar, et al. (2004). "Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial." J Clin Oncol 22(17): 3570-80.
3. Cruess, D. G., M. H. Antoni, et al. (2000). "Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer." Psychosom Med 62(3): 304-8.
4. Kissane, D. W., A. Love, et al. (2004). "Effect of Cognitive-Existential Group Therapy on Survival in Early-Stage Breast Cancer." J Clin Oncol.
5. McGregor, B. A., M. H. Antoni, et al. (2004). "Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer." J Psychosom Res 56(1): 1-8.
6. Morgan, C. A., 3rd, A. M. Rasmusson, et al. (2002). "Neuropeptide-Y, cortisol, and subjective distress in humans exposed to acute stress: replication and extension of previous report." Biol Psychiatry 52(2): 136-42.
7. Mormont, M. C., J. Waterhouse, et al. (2000). "Marked 24-h rest/activity rhythms are associated with better quality of life, better response, and longer survival in patients with metastatic colorectal cancer and good performance status." Clin Cancer Res 6(8): 3038-45.
8. Neary, J. P., L. Malbon, et al. (2002). "Relationship between serum, saliva and urinary cortisol and its implication during recovery from training." J Sci Med Sport 5(2): 108-14.
9. Obminski, Z. and R. Stupnicki (1997). "Comparison of the testosterone-to-cortisol ratio values obtained from hormonal assays in saliva and serum." J Sports Med Phys Fitness 37(1): 50-5.
10. Sephton, S. E., R. M. Sapolsky, et al. (2000). "Diurnal cortisol rhythm as a predictor of breast cancer survival." J Natl Cancer Inst 92(12): 994-1000.
11. Touitou, Y., A. Bogdan, et al. (1996). "Disruption of the circadian patterns of serum cortisol in breast and ovarian cancer patients: relationships with tumour marker antigens." Br J Cancer 74(8): 1248-52.
12. Turner-Cobb, J. M., S. E. Sephton, et al. (2000). "Social support and salivary cortisol in women with metastatic breast cancer." Psychosom Med 62(3): 337-45.
13. van der Pompe, G., M. H. Antoni, et al. (1996). "Elevated basal cortisol levels and attenuated ACTH and cortisol responses to a behavioral challenge in women with metastatic breast cancer." Psychoneuroendocrinology 21(4): 361-74.
14. van der Pompe, G., N. Bernards, et al. (2001). "An exploratory study into the effect of exhausting bicycle exercise on endocrine and immune responses in post-menopausal women: relationships between vigour and plasma cortisol concentrations and lymphocyte proliferation following exercise." Int J Sports Med 22(6): 447-53.
15. Wust, S., I. Federenko, et al. (2000). "Genetic factors, perceived chronic stress, and the free cortisol response to awakening." Psychoneuroendocrinology 25(7): 707-20.

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