International Journal of Behavioral Medicine Copyright © 2006 by

2006, Vol. 13, No. 4, 286–294 Lawrence Erlbaum Associates, Inc.

Benefits of the Uncertainty Management Intervention for African

American and White Older Breast Cancer Survivors:
20-Month Outcomes
Karen M. Gil, Merle H. Mishel, Michael Belyea, Barbara Germino,
Laura S. Porter, and Margaret Clayton
In a 2 × 2 randomized block repeated measure design, this study evaluated the fol-
low-up efficacy of the uncertainty management intervention at 20 months. The sample
included 483 recurrence-free women (342 White, 141 African American women;
mean age = 64 years) who were 5–9 years posttreatment for breast cancer. Women
were randomly assigned to either the intervention or usual care control condition.
The intervention was delivered during 4 weekly telephone sessions in which survivors
were guided in the use of audiotaped cognitive-behavioral strategies and a self-help
manual. Repeated measures MANOVAs evaluating treatment group, ethnic group,
and treatment by ethnic interaction effects at 20 months indicated that training in un-
certainty management resulted in improvements in cognitive reframing, cancer
knowledge, and a variety of coping skills. Importantly, the 20-month outcomes also
demonstrated benefits for women in the intervention condition in terms of declines in
illness uncertainty and stable effects in personal growth over time.

Key words: breast cancer, cancer survivorship, uncertainty management, personal

growth

There is a growing body of knowledge regarding the
factors affecting the quality of life of breast cancer sur-
vivors (Helgeson & Tomich, 2005). Older women who
have survived breast cancer continue to experience ill-
ness uncertainty, fears about cancer recurrence, and
symptoms from treatment side effects (Gil et al.,
2004). Health complaints such as enduring fatigue,
lymphedema, and pain or discomfort are common
(Hull, 2000; Lickley, 1997). Many older women will
continue to experience uncertainty about how to inter-
pret and manage long-term treatment-related side
Karen M. Gil, Department of Psychology, Margaret Clayton,
Merle H. Mishel, Michael Belyea, and Barbara Germino, School of
Nursing, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina; Laura S. Porter, Department of Psychiatry and Be-
havioral Sciences, Duke University Medical Center, Durham, North
Carolina. Michael Belyea is now at the College of Nursing, Arizona
State University and Margaret Clayton is now at the College of
Nursing, University of Utah.
This research was supported by a grant from the National Insti-
tute of Health, National Cancer Institute 1R01 CA78955, M. Mishel,
principal investigator. We would like to thank the nurse follow-up
callers Kay Gruninger, Joanne Held, Colleen Glair-Gajewski, and
Patricia Plummer, as well as the data collectors for this study.
Correspondence concerning this article should be addressed to
Karen M. Gil, Department of Psychology, CB #3270, University of
North Carolina at Chapel Hill, Chapel Hill, NC 27599. E-mail:
kgil@email.unc.edu or Merle Mishel, School of Nursing, CB# 7460,
University of North Carolina at Chapel Hill, Chapel Hill,
NC 27599. E-mail: mishel@email.unc.edu
effects along with the continuing uncertainty about
recurrence and secondary cancer. Various events that
occur regularly in women’s daily lives—such as hear-
ing about someone else’s cancer, new aches and pains,
and information seen in the media about cancer—can
trigger feelings of uncertainty about cancer recurrence.
In our own research (Gil et al., 2004), we have shown
that triggers of illness uncertainty occurred on a regular
basis, an average of two per month. Older women may
be particularly vulnerable to feelings of uncertainty
about cancer recurrence, as they are more likely to be
experiencing other health problems and may have
more difficulty discerning whether physical symptoms
indicate recurrence, are related to comorbid medical
conditions, or are part of the normal aging process.
Recent reviews of the psychological interventions
for cancer patients indicate that there is growing inter-
est in evaluating the efficacy of social support, health
behavior, and educational interventions (Andersen,
2002; Graves, 2003). Despite the empirical support for
the benefits of these interventions for women with
breast cancer, the majority of this research has focused
on evaluating the benefits of interventions for women
who have recently been diagnosed, those currently un-
dergoing treatment, or those with metastatic disease
(Antoni et al., 2001; Cunningham, Edmonds, & Wil-
liams, 1999; Edelman, Bell, & Kidman, 1999). With
only a few exceptions (Helgeson, Cohen, Schulz, &

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 CANCER UNCERTAINTY MANAGEMENT
Yasko, 2001), there has been very little attention to
long-term survivors, in general, and even less to older
long-term and ethnic minority survivors. This is some-
what surprising in that advances in early detection and
medical treatment of breast cancer have improved the
survival of women such that women are living beyond
diagnosis and treatment to an older age (Andersen &
Urban, 1999).
Recently, we developed an uncertainty manage-
ment intervention for older long-term breast cancer
survivors based on the theory of uncertainty in illness
(Mishel, 1988, 1997). According to this theory, when
symptoms derived from cancer treatment are not un-
derstood because they are unexpected, or because pa-
tients lack information, uncertainty is generated. Un-
certainty during cancer survivorship is an enduring
experience that is associated with emotional distress
and fears of cancer recurrence (McKinley, 2000). Pro-
viding information about the onset and trajectory of
symptoms will result in better understanding about
symptoms, thus less uncertainty. When uncertainty oc-
curs unpredictably, as it often does when a woman is
exposed to an event triggering thoughts of cancer re-
currence, coping strategies to manage the uncertainty
about recurrence will result in improved outcomes.
The survivor intervention combined training in cogni-
tive-behavioral skills for coping with uncertainty about
recurrence with manualized information for the man-
agement of symptoms resulting from treatment side ef-
fects.
In the first study on the evaluation of the efficacy of
the intervention, the outcomes for 509 recurrence-free
women (360 White, 149 African American women)
who were 5–9 years posttreatment for breast cancer
were reported. Women were randomly assigned to ei-
ther the survivor intervention or usual care control con-
dition. The postintervention results at 10 months
(Mishel et al., 2005) indicated that, in comparison to
the control condition, the survivor intervention re-
sulted in improvements in cognitive reframing, cancer
knowledge, doctor–patient communication, knowl-
edge of symptoms and side effects, and other coping
skills when compared to a randomly assigned control
condition.
The purpose of this article is to report on the longer
term effects for the 483 women remaining in the study
at 20 months’ follow-up. This focus on the longer term
effects of the intervention is especially important be-
cause very few intervention studies with cancer survi-
vors have examined whether benefits of interventions
maintain or dissipate over time. To accomplish this
aim, we utilized data from three time points: Baseline
and 10-month and 20-month follow-up. Given that the
outcome data at 10 months have already been reported
(Mishel et al., 2005), this article will present the find-
ings at 20 months postintervention and will highlight
benefits in illness uncertainty and personal growth.
Specifically, we hypothesized that women in the inter-
vention would experience benefits of the intervention
and that these benefits would maintain over 20 months
as compared to a usual care control group.
Methods
Design, Recruitment, and Procedures
The follow-up evaluation of the survivor interven-
tion employed a 2 × 2 randomized block, repeated
measures design with two levels of intervention (inter-
vention and control condition) crossed with two levels
of ethnicity (White and African American). The proce-
dures used to identify and recruit eligible breast cancer
survivors into the study included identifying eligible
women through several hospital tumor registries in
North Carolina. A total of 1,053 eligible women were
mailed a letter explaining the study and then called to
determine their interest; 575 or 55% agreed to partici-
pate in the study. This participation rate is comparable
to other studies using tumor registries for recruitment
(e.g., 31%; Morris, Johnson, Homer, & Walts, 2000).
Women who chose not to participate cited reasons such
as lack of interest (50%), not enough time (26%), other
health problems (10%), not wanting to be reminded of
their breast cancer experience (5%), other reasons
(3%), or no reason specified (6%). Analyses were con-
ducted in order to compare those who chose to partici-
pate versus those who declined (see Gil et al., 2004).
These analyses revealed that those who participated
were significantly younger, and the participation rate
for African American women was higher than for
White women. Regarding time since diagnosis, there
was no significant difference in those who participated
versus those who declined.
Women who participated in the baseline evaluation
were blocked on ethnicity and randomly assigned from
the block to either the experimental (intervention) or
control condition. For women in the control condition,
no specialized treatment was provided. For women in
the intervention, data collectors delivered the interven-
tion materials to women immediately following base-
line data collection, then a nurse contacted them to
schedule the first training call. Measurement occurred
at three points in the women’s homes: Baseline (T1)
immediately after entry into the study, 10 months
postbaseline (T2), and 20 months postbaseline (T3). At
T2, 89% of those who entered the study was retained (n
= 509 of the 575 who agreed to participate). At T3,
95% of the sample that completed the intervention was
retained (n = 483 of the 509 who completed the inter-
vention). At T3, all of the measures administered at T2
were repeated.
Variables included in the analysis for this article
were the same as in our prior report of the T1 to T2 ef-
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 GIL ET AL.

fects (Mishel et al., 2005), with the addition of a mea-
sure of illness uncertainty and a measure of personal
growth; variables were uncertainty, uncertainty man-
agement (cancer knowledge, patient–provider commu-
nication, social support, and cognitive reframing/prob-
lem solving), coping (coping strategies, total
information received, and helpfulness of information),
personal growth, and negative mood state. In order to
evaluate the use of the intervention, women in the in-
tervention condition were called monthly between T2
and T3; there was no contact with women in the control
condition between T2 and T3. Retention procedures
through the 20 months included mailings of bimonthly
letters, special occasion cards, and gasoline cards
($20) given at each data collection point.
Sample
The sample for the follow-up analysis included 483
recurrence-free women (342 White, 141 African
American women) with a mean age of 64 years who
were 5–9 years posttreatment for breast cancer (see Ta-
ble 1). In order to determine if there were any signifi-
cant differences in the intervention versus control
group on any of the baseline demographic or disease
variables, t tests and chi-square analyses were calcu-
lated. There were no significant differences on any of
the variables. As already mentioned, the 20-month fol-
low-up sample represented 95% (n = 483) of the 509
women who were the sample reported in the Mishel et
al. (2005) article. Five percent of women (n = 15 in in-
tervention; n = 11 controls) were not included at
follow-up due to dropout, unable to contact, and so on.
In order to determine if there were any significant dif-
ferences in demographic and disease variables for
those retained versus the original sample, t test and
Pearson correlation coefficients were calculated. The
results indicated that African American women (χ2 =
20.0, p < .0001), women with lower income (χ2 = 13.9,
p < .01), and women with lower education (t = 2.28, p <
.02) were more likely to be lost at 20 months.
Description of the Intervention
The intervention had two main components: a cog-
nitive-behavioral component delivered via audiotapes
and a self-help manual (see Gil et al., 2005). Using a
structured protocol, nurses guided women through the
intervention over the course of four weekly 30-min
telephone calls. Each telephone session focused on one
of four skills—relaxation, pleasant imagery, calming
self-talk, and distraction. During the third and fourth
sessions, nurses also guided the women through the
use of the self-help manual using a specific outline that
could be individualized for each woman’s concerns.
The manual contained educational material and re-
sources about long-term treatment side effects includ-
ing lymphedema, pain, stiffness, and other health con-
cerns. Application was emphasized in that women
were encouraged to use the skills when dealing with

Table 1. Demographic Characteristics of the Breast Cancer Survivors by Treatment and Ethnicity Groups for T1–T3
Treatmenta Controlb

Whitec African Americand Whitee African Americanf

M SD M SD M SD M SD

Mean age 64.47 8.48 64.52 8.52 64.24 8.77 65.19 10.41
Mean years of education 14.16 2.65 13.25 3.05 14.04 2.74 12.21 3.04
Baseline health problems 3.59 2.52 4.26 2.49 3.70 2.61 4.33 3.06

n % n % n % n %

Income (monthly)
Less than $500 2 1.25 2 2.90 1 0.55 1 1.39
$500–$1,000 11 6.88 16 23.19 17 9.34 22 30.56
$1,001–$2,000 30 18.75 25 36.23 41 22.53 19 26.39
$2,001–$4,000 55 34.38 16 23.19 50 27.47 15 20.83
More than $4,000 54 33.75 9 13.04 64 35.16 12 16.67
Missing 8 5.00 1 1.45 9 4.95 3 4.17
Marital status
Married 108 67.50 26 37.68 114 62.64 35 48.61
Other 52 32.50 43 62.32 68 37.36 37 51.39
Tumor stage
In Situ 9 5.63 7 10.14 11 6.04 6 8.33
1 82 51.25 27 39.13 96 52.75 44 61.11
2 52 32.50 25 36.23 50 27.47 9 12.50
3 12 7.50 5 7.25 10 5.49 6 8.33
Missing 5 3.13 5 7.25 15 8.24 7 9.72
aN = 229. bN = 254. cN = 160. dN = 69. eN = 182. fN = 72.

288
 CANCER UNCERTAINTY MANAGEMENT
their own personal triggers of uncertainty such as go-
ing for a medical check-up. Sample vignettes were
used for this purpose. For example, “when you antici-
pate fear and anxiety as you wait for a mammography,
you can think about using relaxation to handle the
emotional reactions.” Information in the manual also
emphasized application to the woman’s personal situa-
tion. For each symptom such as fatigue, there were
strategies for prevention, tips for management, and
suggestions for when to call the doctor, as well as a list
of resources.
Instruments
Uncertainty was defined as the inability to deter-
mine the meaning of illness-related events, which is re-
lated to fear of cancer recurrence. Uncertainty was
measured using the 22-item Mishel Uncertainty in Ill-
ness Scale-Survivor (MUIS-S) Version. The core
MUIS scale (Mishel, 1981) has been used extensively
with cancer patients including older women with
breast cancer. Significant correlations with trouble-
some thoughts and symptom bother supported the con-
struct validity; alpha coefficients reported in our previ-
ous study ranged from .78 for African American older
breast cancer survivors to .84 for White survivors
(Mishel et al., 2005).
Uncertainty management variables. Cancer
knowledge was measured using the Cancer Survivor
Knowledge Scale, a 16-item true/false questionnaire
that is scored by summing the total number correct.
The scale demonstrated internal consistency (KR20) of
.58 with White survivors and .58 with African Ameri-
can survivors. The relatively low internal consistencies
have been consistent across studies and are attributed
to the broad sampling of knowledge domains related to
living with long-term treatment side effects and fears
of recurrence. Social support satisfaction was mea-
sured by the 6-item satisfaction subscale of the short
form of the Social Support Questionnaire (Sarason,
Levine, Basham, & Sarason, 1983). The 12-item scale
measures the number of supports in specific areas (6
items), and the degree of satisfaction with the available
support in each area (6 items) of the individual’s net-
work. High correlations have been reported between
the short and long forms of the instrument, supporting
construct validity (Sarason et al., 1983). In this study,
Cronbach’s alphas were .90 for Whites and .89 for Af-
rican Americans. Patient–provider communication
was rated from 1 (nothing at all) to 5 (a great deal) on 5
items—for example, how much the doctor (or nurse)
usually tells you about your illness and treatment, how
much you tell the doctor (or nurse) about problems you
might be having, and how much you help with the
planning of your treatment. In this study, the total score
was used (Cronbach’s alphas: .76 for Whites and .78
for African Americans; Mishel et al., 2005).
Two subscales from the Self-Control Schedule
(Rosenbaum & Jaffe, 1983) were used to measure
other components of uncertainty management. The
cognitive reframing subscale has 10 items with a re-
sponse format ranging from 1 (not true about me) to 10
(true about me). Cronbach’s alphas were .86 for White
survivors and .84 for African American survivors. The
problem-solving subscale has 10 items and the same
response format. Alpha levels for survivors in this
study were .86 for Whites and .84 for African Ameri-
cans. The validity of both subscales is supported by
their correlation with emotional distress in the pre-
dicted direction.
Coping (variables) strategies were measured using
a modified version of the Coping Strategies Question-
naire (CSQ; Rosenstiel & Keefe, 1983). The CSQ has
6 subscales: coping self-statements, praying/hoping,
ignoring, increasing behavioral activities,
catastrophizing, and diversion of attention. Cronbach’s
alphas for African Americans ranged from .71 to .87
and for Whites, from .74 to .89. Moreover, an investi-
gator-developed information checklist measured total
information received, and helpfulness of information
was measured on three factors (Mishel et al., 2005)—
information about cognitive coping strategies (e.g.,
how to handle my fears about recurrence of breast can-
cer), symptoms related to long-term treatment effects
(e.g., managing skin changes), and information about
causes, prevention, and management of lymphedema.
For each type of information, the woman also rated the
helpfulness of the information on a scale of 1 (not at all
helpful) to 4 (very helpful). Cronbach’s alpha for total
amount of information was .94 for African Americans
and .92 for Whites. Reliabilities for the helpfulness of
information ranged from .82 to .89.
Negative mood state was measured using the Profile
of Mood States–Short Form (POMS–SF), developed
from the 65-item original Profile of Mood States
(Curran, Andrykowski, & Studts, 1995) by Shacham
(Shacham, 1983), and highly correlated (r > .95) with
the original measure. Internal consistency (Cronbach’s
alpha) for the POMS–SF total score was .95 for White
survivors and .94 for African Americans. Alpha coeffi-
cients on the subscales ranged from .80 to .93 for
White women and from .73 to .90 for African Ameri-
can women.
The Growth Through Uncertainty Scale (GTUS;
Bailey, Mishel, Belyea, Stewart, & Mohler, 2004;
Mast, 1998) is a 39-item scale that measures positive
life change or personal growth as a result of serious ill-
ness on dimensions such as a new view of life and
greater flexibility. Alpha coefficients for older breast
cancer survivors were .95 for Whites and .94 for Afri-
can Americans. Construct validity of the instrument is
supported by an inverse relationship found between the
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 GIL ET AL.
GTUS and the Profile of Mood States scale (POMS), a
measure of mood disturbance (Mast, 1998).
The demographic data collected included age, eth-
nicity, family income, years of formal education, and
other relevant demographics. Also, medical informa-
tion from the medical record included date of diagnosis
(from the pathology report), initial staging, current dis-
ease status, type of treatment, and timing and symp-
toms or problems related to the breast cancer or treat-
ment.
Data Analysis
Repeated measure MANOVAs were conducted for
uncertainty management (uncertainty, cognitive
reframing, problem solving, cancer knowledge, pa-
tient–provider communication, social support) and
coping (CSQ subscales, amount and helpfulness of in-
formation) as a function of treatment group, ethnic
group, and treatment by ethnic interaction effects.
When the MANOVA was significant, follow-up re-
peated measures analyses with planned contrasts were
used to test the hypotheses for the individual variables.
For the POMS and GTUS, repeated measure analyses
with planned contrasts were done in a similar way.
Planned contrasts between T1 and T3 were constructed
in order to test for impact of the intervention over the
20-month period. Contrasts for these time differences
were also tested for within ethnic groups to see if dif-
ferences existed for only one ethnic group. Because
most of the scale scores were created as means rather
than summated scores, a change of .5 corresponds to a
half-step on the scale. In order to compare the magni-
tude of our findings to those of similar studies, partial
eta squares for the Wilks’s lambda F and Cohen’s d for
the planned contrasts are included in the findings.
Results
Uncertainty Management
The MANOVA for uncertainty management vari-
ables (uncertainty, cognitive reframing, problem solv-
ing, cancer knowledge, social support, patient–pro-
vider communication) revealed significant differences
over time for the intervention groups (Wilks’s lambda
F[12, 468] = 3.84, p = .0003). Follow-up analyses re-
vealed that there were significant time-by-intervention
group interactions for uncertainty, cognitive reframing,
and cancer knowledge (Wilks’s lambda F[2, 478] =
2.91, p = .05, η2 = .012; Wilks’s lambda F[2, 478] =
3.32, p < .04, η2 = .014; Wilks’s lambda F[2, 478] =
12.54, p < .0001, η2 = .050, respectively). There were
no significant time-by-intervention group effects for
problem solving, social support, or overall pa-
tient–provider communication.
290
The specific T1–T3 contrast tests for uncertainty in-
dicated that there was a significant difference over time
(F[1, 479] = 4.85, p < .03, d = .09, η2 = .010). (Cohen’s
d was calculated as d = µT2 - µT1/s.) Women in the inter-
vention group reported a decrease in illness uncer-
tainty, whereas there was no change for the women in
the control group from baseline to 20 months (see Fig-
ure 1). Examination of the ethnic differences in treat-
ment response at 20-month follow-up indicated that
the effects were mostly due to decreases in uncertainty
for the White women (F[[1, 479] = 6.32, p < .01, d =
.10, η2 = .013).
The T1–T3 specific contrast tests for cognitive
reframing indicated that there was a significant differ-
ence (F[1, 479]= 3.94, p < .05, d = .06, η2 = .008).
Women in the intervention group reported an increase
in cognitive reframing, whereas there was a slight de-
cline in cognitive reframing for women in the control
group from baseline to 20-month follow-up (see Figure
2). Examination of the ethnic differences in cognitive
reframing indicated that while the increase in cognitive
reframing was most pronounced for African American
women from T1 to T2 and remained significant at T3,
there was a slight decline in the gains made by African
American women over the follow-up period.
The T1–T3 specific contrast tests for cancer knowl-
edge indicated that there was a significant difference
(F[1, 479] = 17.85, p < .0001, d = .15, η2 = .036).
Women in the intervention group reported an increase
in cancer knowledge over time, and this increase was
evident for both White and African American women.
The pattern of effects shows that the increase in cancer
knowledge that occurred for African American and
Figure 1. Uncertainty intervention versus control (T1–T3).
Figure 2. Cognitive reframing intervention versus control
(T1–T3).
 CANCER UNCERTAINTY MANAGEMENT

tion (F[1, 479] = 120.93, p < .0001, d = .44, η2 = .202;

F[1, 479] = 41.19, p < .0001, d = .30, η2 = .079, respec-
tively) indicated very similar patterns. Over time,
women in the intervention group increased in amount of
symptom information (see Figure 5) and lymphedema
information (see Figure 6) and reported that both these
types of information were significantly more helpful,
whereas women in the control group reported only
slight increases or no changes in the amount and helpful-
ness of symptom and lymphedema information at 20
Figure 3. Cancer knowledge intervention versus control months. Inspection of the ethnic effects indicated that
(T1–T3). both African American and White women in the inter-
vention group reported significant increases in cogni-
White women in the intervention group from T1 to T2 tive, symptom, and lymphedema information that were
maintained over the follow-up period (see Figure 3). maintained over the follow-up period.
For diverting attention, the T1–T3 planned contrast
showed a significant effect (F[1, 479] = 4.71, p < .03, d
Coping
= .09, η2 = .010). Although diversion scores decreased
The MANOVA for the coping variables (amount somewhat for women in the intervention group from
and helpfulness of information, coping strategies) indi- T2 to T3, there continued to be a significant difference
cated that there were significant differences over time in comparison to the control group over time (see Fig-
between the intervention and control groups (Wilks’s ure 7). Analysis of the ethnic differences indicated that
lambda F[16, 464] =10.68, p = .0001). Follow-up anal- the greatest increases in diverting attention were for
yses for the amount and helpfulness of information re- White women between T1 and T2 (F[1, 479] = 21.80, p
vealed that there was a significant intervention by time < .0001, d = .08, η2 = .044).
interaction for amount and helpfulness of cognitive in-
formation (Wilks’s lambda F[2, 478] = 46.48 p < Personal Growth
.0001, η2 = .168; Wilks’s lambda F[2, 478] = 51.81, p <
The MANOVA test for the total from the growth
.0001, η2 = .178, respectively), amount and helpful-
through uncertainty scale indicated that there was a
ness of symptom information (Wilks’s lambda F[2,
478] = 49.64 p < .0001, η2 = .172; Wilks’s lambda F[2,
478] = 25.84, p < .0001, η2 = .098, respectively), and
amount and helpfulness of lymphedema information
(Wilks’s lambda F[2, 478] = 80.90, p < .0001, η2 =
.253; Wilks’s lambda F[2, 478] = 27.13, p < .0001, η2 =
.102, respectively). Regarding the coping strategies
from the CSQ, although there were no significant over-
all time-by-group effects, there was a significant
time-by-group-by-ethnicity interaction for diverting
attention (Wilks’s lambda F[2, 478] = 9.64, p < .0001,
η2 = .039).
The specific T1–T3 contrast tests for amount and
helpfulness of cognitive information indicated that Figure 4. Cognitive information intervention versus control
(T1–T3).
there were significant differences (F[1, 479] = 81.88, p <
.0001, d = .43, η2 = .146; F = 79.43, p < .0001, d = .43, η2
= .142, respectively). Women in the intervention re-
ported an increase in the amount and helpfulness of cog-
nitive information; this increase was evident for both
African American and White women. The pattern of ef-
fects shows that the increase in amount and helpfulness
of cognitive information that occurred for women in the
intervention group from T1 to T2 maintained at 20
months (see Figure 4). The specific T1–T3 contrast tests
for amount and helpfulness of symptom information
(F[1, 479] = 77.56, p < .0001, d = .38, η2 = .139; F[1,
479] = 41.99, p < .0001, d = .28, η2 = .081, respectively) Figure 5. Symptom information intervention versus control
and amount and helpfulness of lymphedema informa- (T1–T3).

291
 GIL ET AL.

There were no significant changes on the other cop-

ing subscales or for mood state on the POMS or any of
the POMS subscales.

Discussion

The long-term effects suggest that women who re-

ceived training in uncertainty management maintained
a range of benefits when compared to women in the
control condition. Specifically, at the 20-month evalua-
Figure 6. Lymphedema information intervention versus con-
trol (T1–T3).
tion, women in the intervention (vs. control condition)
maintained improvements in cognitive reframing, can-
cer knowledge, knowledge of symptoms and side ef-
fects, seeking and using information resources, and use
of distraction as a coping skill. Examination of the fig-
ures shows that most of the improvements from pre- to
posttest maintained at a stable level over time. Also,
over time from baseline, women in the intervention de-
creased in illness uncertainty related to fears of cancer
recurrence and improved in personal growth, particu-
larly in terms of greater flexibility and new view of life.
Thus, these older long-term survivors continued to
benefit from an intervention long after the intervention
ended. Prior psychological intervention research with
Figure 7. Diverting attention intervention versus control cancer survivors has been mostly clinic or office based
(T1–T3). with intensive (and costly) therapeutic contact through
frequent individual or group sessions (e.g., Cun-
significant time-by-intervention group effect (Wilks’s ningham et al., 1998; Edelman et al., 1999). Diffi-
lambda F[2, 478] = 3.30, p < .05, η2 = .014). The spe-
cific T1–T3 contrast tests were significant (F[1, 479] =
5.65, p < .02, d = .06, η2 = .012). Over time, women in
the intervention group reported stable levels of per-
sonal growth, whereas women in the control group re-
ported a decline in growth from T1 to T2 and with a
further decline from T2 to T3. Examination of the eth-
nic differences indicated that the effect was evident for
the African American women in the intervention group
(see Figure 8).
Examination of the subscales of the GTUS indicated
significant time-by-intervention group effects on the
Greater Flexibility subscale (Wilks’s lambda F[2, 478]
= 5.55, p < .004, η2 = .023). The specific T1–T3 con- Figure 8. Growth through uncertainty for African Americans
(T1–T3).
trast tests indicated that women in the intervention
group remained stable in flexibility, whereas women in
the control group declined over time in their flexibility
(F[1, 479] = 9.72, p < .002, d = .09, η2 = .020). This ef-
fect was evident in the African American women, but
not the White women (see Figure 9). For New View of
Life, there was a significant time-by-intervention by
ethnicity interaction (Wilks’s lambda F[2, 478] = 3.62,
p < .03, η2 = .007). The specific T1–T3 contrast tests
indicated that African American women in the inter-
vention group remained stable in their new view of life,
whereas women in the control group declined over
time in their new view of life (F[1, 479] = 5.01, p < .03, Figure 9. Growth through uncertainty: Greater flexibility for
d = .03, η2 = .010; see Figure 10). African Americans (T1–T3).

292
 CANCER UNCERTAINTY MANAGEMENT
Figure 10. Growth through uncertainty: New view of life for
African Americans (T1–T3).
culties with recruitment, absences from sessions, and
high attrition rates at follow-up often accompany these
types of interventions. In this context, the study find-
ings are especially meaningful in that benefits were de-
rived from a home-based, telephone-call intervention
that required minimal therapeutic contact.
An important outcome of the intervention was in
the use of resources to extend women’s information
in the areas of symptoms and lymphedema. This is
especially meaningful for the older African American
women who have sometimes been observed to only
rely on prayer and spirituality to cope with cancer in-
stead of seeking information or using other coping
strategies (Henderson, Gore, Davis, & Condon,
2003). Being proactive and taking responsibility for
health care is also important (Ashing-Giwa & Ganz,
2000).
Some of the intervention effects did dissipate over
time. For distraction, there was a slight decline in mean
values from posttesting to follow-up. Also, for African
American women, improvement in communication
with health care providers (Mishel et al., 2005) disap-
peared over time. Thus, continued encouragement and
reinforcement might be needed for improvements to
maintain; older minority women might benefit from
continued encouragement to be assertive with health
care providers. Even though some improvements did
not persist, these findings add to the growing body of
research documenting the value of psychosocial inter-
ventions with cancer patients (Antoni et al., 2001;
Tomich & Helgeson, 2002). Importantly, the study
contained a number of features that distinguish it from
prior psychological treatment outcome studies of
breast cancer survivors including the inclusion of older
women (beyond 50 years) who were longer term survi-
vors (5- to 9-year survivors), the inclusion of sufficient
numbers of African American women, and the use of
an intervention requiring minimal therapist contact.
Analysis of the ethnic effects of the intervention dem-
onstrated that there were some benefits unique to Afri-
can American or White women; however, as in prior
studies (Culver, Arena, Antoni, & Carver, 2002), there
were also many similarities between the ethnic groups.
The utilization of the minimal therapist contact condi-
tion delivered mostly via telephone enabled us to test
the benefits of a less-intensive intervention that could
reach women in their homes.
Beyond documenting the follow-up effects of the
survivor intervention, this study extends our previous
research (Mishel et al., 2005) in a meaningful way by
expanding the outcome measures to include illness un-
certainty and personal growth. In comparison to
women in the control group, women in the intervention
declined in illness uncertainty from baseline to
posttesting, and these benefits maintained at 20
months. Regarding personal growth, African Ameri-
can women in the intervention reported slight increases
or relatively stable levels of personal growth over time,
whereas African American women in the control con-
dition suffered a steady decline in their levels of per-
sonal growth. These findings are of interest for several
reasons. Helping African American breast cancer sur-
vivors develop a more positive appraisal of their illness
has been identified as crucial for improving their qual-
ity of life (Northouse et al., 1999). It is likely that the
improvement in cognitive reframing (seeing the situa-
tion in a more positive light) found for the women who
received the intervention accounts for the improve-
ment in personal growth. There is an accumulating
body of evidence that individuals who survive cancer
can derive certain positive benefits from the experi-
ence, including developing a new view of life, finding
meaning or purpose in the experience, changing priori-
ties, developing a greater appreciation of relationships,
or developing greater spirituality (Carver & Antoni,
2004; Cordova, Cunningham, Carlson, &
Andrykowski, 2001; Tomich & Helgeson, 2002). Our
findings suggest that the intervention might help Afri-
can American women maintain personal-growth or
benefit-finding experiences. Given the link of benefit
finding to quality of life and psychosocial adjustment
(Carver & Antoni, 2004), these results suggest that in-
terventions may be important in helping women sus-
tain benefit-finding and personal-growth experiences.
Prior studies have shown that cognitive behavioral in-
terventions for early-stage breast cancer patients in
treatment have lead to improvements in benefit finding
for a sample of mostly nonminority women (Antoni et
al., 2001). This study extends the findings of benefit to
older minority women.
A few limitations should be noted. First, the study
used a standard care control condition and therefore did
not control for the potential nonspecific effects of time
spent with the nurse or time spent in a structured activity
at home. As we mentioned previously (Mishel et al.,
2005), future studies might include an attention control
condition in which women are exposed to structured
contact with a health care provider over time. Second,
the study did not include direct measures of health be-
haviors. Others (Antoni et al., 2001) have demonstrated
293
 GIL ET AL.
that cognitive behavioral interventions lead to improve-
ments in these important measures of treatment re-
sponse. Thus, our future studies would be improved by
including measures of specific health behaviors.
In conclusion, there were enduring benefits found
for many of the outcomes, particularly those that re-
flect improvement in knowledge and ability to find and
use information or resources. Given that there was no
contact with the women from the 10- to the 20-month
assessment, the findings imply that these women inte-
grated the cognitive changes and skills into their life.
When we consider that older African American
women had a number of these gains, the result may
suggest that a self-delivered intervention that provides
cognitive and behavioral skills may help African
American women foster a more positive appraisal of
illness (Northouse et al., 1999).
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