Breast cancer is one of the most common cancers encountered throughout the world; it is the second most common cancer diagnosed worldwide after lung cancer as well as the most frequent cancer that affects the psychological condition of women 1,2. In Egypt, it accounts for 35.1% of female cancers 3. Besides the worries related to prognosis and survival, impaired body image and breast loss have negative effects on the patients; these negative effects may in turn cause anxiety and depression that may require psychotherapy and medical treatment 4. Anxiety and depression are the most common psychological problems encountered in patients with cancer. Anxiety is mainly related to uncertainty about the diagnosis, the side effects of chemotherapy or radiotherapy treatment, lack of social or personal control, progressive physical deterioration, and thoughts of impending death 5. It is known that the prevalence of depression among cancer patients is often underestimated, partly because many symptoms of depression, such as fatigue, weight loss, loss of appetite, or sleep disruption, closely mirror the psychological effects of cancer 6. The prevalence of depression varies between 8 and 36% depending on the site of cancer, the diagnostic criteria, and the rating scales used 7. Coping strategies represent behavioral and cognitive efforts to deal with stressful encounters 8. Coping has also been found to predict long-term psychological adjustment and quality of life in patients with breast cancer 9. It is defined as ongoing cognitive and/or behavioral efforts to manage external and/or internal demands that are considered as taxing or exceeding the resources of the individual 10. In patients with breast cancer, the ability to cope with the problems caused by the disease is related to various variables, such as age, education, personal characteristics, career, marriage, and children, stage and treatment, degree of change in quality of life, and the social support network available 11. Coping strategies are classified either as problem-focused or emotion-focused, delineating the function of coping as dealing with the problem or with its emotional and physiological outcomes, respectively 8,10. Taken collectively, the findings indicate that engagement-type coping strategies, namely problem solving, information seeking, cognitive restructuring, and emotional ventilation are positively associated with better long-term outcomes and quality of life 9,12,13. In addition to problem-focused coping, women often use distraction methods, turning to social support and faith or religion 14. However, disengagement-type coping strategies or coping through behavioral or cognitive avoidance such as denial, self-criticism, and social withdrawal are inversely associated with health-related quality of life 15,16. Consistent evidences have indicated that coping styles play an important role in the survival of patients with breast cancer, and they should be encouraged to adopt particular coping styles to improve survival, lifestyle, and reduce rates of recurrence of cancer 14.
Hypothesis and aim
Coping strategies with such a dangerous, chronic and disfiguring disease as breast cancer greatly influenced its recurrence, survival years and lifestyle of those patients. Thus, our aim was to study the clinical variables and life stresses associated with the coping patterns used by Egyptian female patients with breast cancer.
Patients and methods
This study was carried out at the weekly breast cancer follow-up clinic at Ain Shams University Hospitals (Cairo, Egypt), after the approval of the Research and Ethics Committee at the Ain Shams University.
The study included Egyptian female patients aged between 30 and 65 years who were diagnosed with breast cancer (stages I and II) and treated surgically by modified radical mastectomy or lumpectomy; patients with local or regional recurrence were also included. We excluded patients with metastasis, hepatic, or renal dysfunction, and also those receiving intensive chemotherapy and radiotherapy, as the side effects of such treatments might transiently affect adjustment and coping. A total of 120 patients who fulfilled the inclusion criteria agreed to participate in the study and signed a printed consent form. However, two patients (1.6%) withdrew consent, 13 (10.8%) did not attend the second visit for assessment, and five (4.2%) started extensive chemotherapy or radiotherapy before the second visit and were thus excluded; therefore, the rate of dropout was 16.6% (20 patients). The remaining 100 patients were enrolled in the study.
All participants in the study were evaluated in two sessions by experienced and trained research investigators and were subjected to the following:
- A Structured Psychiatric Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) Axis-I – clinical version was used for diagnosis on the basis of the DSM-IV criteria 17.
- The Beck Depression Inventory (BDI), a 21-item self-reported measure of the severity of depression state that is specifically geared to measure the behavioral, emotional, somatic and cognitive manifestations of depression, was used 18. The Arabic version 19 was used with the following culturally validated cut-off scores for the Egyptian population: normal (0–20), mild (21–31), moderate (32–41), and severe (≥42).
- The Taylor Manifest Anxiety Scale 20, which consists of 50 self-reported items to assess the anxiety state, was used. The Arabic version 21 was used with the following culturally validated cut-off scores: normal (0–16), mild (17–24), moderate (25–35), and severe (≥36).
- The Dealing with Illness Coping Inventory 22 is a self-administered questionnaire with 47 statements on a Likert scale aimed at measuring three main coping methods (active cognitive, active behavioral, and avoidance coping). Further, they are categorized into eight specific coping strategies (e.g. active positive involvement, active experience information, active reliance on others, cognitive positive understanding, cognitive passive rumination, distraction, passive resignation, and avoidance solitary-passive behavior). The Arabic version 23 was used in the current study.
- The Social Readjustment Rating Questionnaire 24 is a self-administered questionnaire that consists of 43 happenings (life events); each is assigned a score that indicates the impact of event. From these scores, the life experience of a person is assessed over a period of time by life change units. Okasha et al. 25 had validated the Egyptian version of the Social Readjustment Rating Questionnaire.
- The Medical Outcome Study (MOS) social support survey 26 is a 20-item self-report scale designed to measure four dimensions of perceived functional social support and interaction (emotional/informational, tangible/practical, affectionate, and total support).
Both the ‘Dealing with Illness Coping Inventory’ and the ‘MOS social support survey’ were translated from English into Arabic with the necessary semantic adaption, back translated by two independent bilingual language expert translators, and reviewed by an expert committee for cultural applicability 23.
As both the Dealing with Illness Coping Inventory and the MOS social support survey were self-administrated tools, illiterate patients included in the research were provided assistance by the researchers to fill their forms.
Data analysis was carried out using statistical package for social sciences version-10 (SPSS Inc., Chicago, Illinois, USA). Student’s t-test was used for comparison between the means of the different groups. The Pearson χ2-test was used for comparison between qualitative variables. A P value was used to indicate the level of significance, where P less than or equal to 0.05 was considered as significant, P less than or equal to 0.01 as highly significant, and P less than or equal to 0.001 as very highly significant.
The coping methods and strategies in relation to severity of depression are presented in (Table 1). The avoidance coping method was significantly associated with moderate depression in the studied group, whereas active cognitive and active behavioral coping methods were more evident in those patients who reported no or a milder form of depression but did not reach significance. However, active positive involvement is significantly inversely related to the degree of depression less in the moderate form. Other coping strategies showed an insignificant relation to depression; yet, it is noteworthy that those with no or a milder form of depression scored lower on the maladaptive coping strategies such as distraction and solitary-passive behavior.
In terms of the social support received by the studied group, those patients who received less affectionate social support had a moderate form of depression as indicated by the BDI. Other social support did not reach significance; yet, less total social support received higher scores of BDI for the patients with breast cancer as shown in (Table 2).
Although no significant difference was found on comparing the coping methods and strategies in relation to the severity of anxiety disorders found among cancer patients, the milder form was found among those who used more active coping methods. In contrast, patients who used passive resignation were found to have a moderate form of anxiety that reached significance (P=0.01) (Table 3).
In addition, patients who received higher total social support had a milder form of anxiety compared with those who had moderate anxiety scored by the Taylor Manifest Anxiety Scale (P=0.02) (Table 4).
The impact of life stresses on the coping methods and strategies used by breast cancer patients is presented in (Table 5), which shows that patients who faced moderate life stresses used more active coping methods such as the active behavioral method (P=0.0002), followed by the active cognitive coping method (P=0.001) and less likely the avoidant method (P=0.02). Data showed the importance of the coping methodology of individuals to face different life stresses. Moreover, patients with moderate life stresses used more active strategies with a significant relation in the following order active positive involvement (P=0.002), active reliance on others (P=0.003), active information seeking, and cognitive positive understanding (each with P value=0.04), and solitary-passive behavior (P=0.03), whereas the rest of the coping strategies did not show significant differences, with higher scores among patients with moderate life stresses.
Patients with breast cancer face a variety of stressors including the life-threatening diagnosis itself, and stressful medical procedures and treatment-related side effects 27. In addition, they experience psychological threats such as reduced functioning and role performance, uncertainty about the future, and concerns about body image 28. Thus, the diagnosis and treatment of breast cancer are significant life stressors for women with the disease that often result in psychological disorders 29. Since the advances in early diagnosis as well as surgical and adjuvant treatment of breast cancer, the number of long-term survivors has increased, and there has been growing interest in research on associated psychiatric disorders that affect patterns of coping with the disease and quality of life of these patients 30.
The current study explored the relationship of coping patterns and strategies with depression, anxiety, and exposure to stress. Data obtained from our study indicated that breast cancer creates a multifaceted group of stressors that often exceed the coping abilities women had before becoming ill. In our study, it was found that the avoidance coping method and the active positive involvement strategy were used more frequently by patients with a moderate form of depression, whereas those who suffered from anxiety disorders used the passive resignation coping strategy more frequently. In agreement with other researchers 5,31,32, who reported that the ineffective-passive coping strategy (e.g. avoidance) is correlated with a greater incidence of depression and anxiety, and maladaptive coping styles such as avoidant or negative ‘coping, negative self-coping statements, preoccupation with physical symptoms, and catastrophizing, with higher levels of depression, anxiety, and fatigue symptoms. Meanwhile, Stanton et al.33 have shown that anxiety is lowest when patients who have a sense of personal control over their cancer use active, problem-oriented methods of coping. Recent studies have suggested that women with breast cancer continue to experience significant levels of psychosocial distress, anxiety, hostility, and depression that interrupt daily life and reduce quality of life 34–36. It is noteworthy that social support can strongly affect how individuals deal with challenges and threats; it may offer feedback that enables individuals to alter the way they view and experience the world and to undertake a process of cognitive restructuring 37. A significant difference was found in the studied group regarding their depression and anxiety disorders; the more affectionate social support they received the less likely they suffered from moderate form of depression. However, the total social support they received appeared to be protective against a moderate form of anxiety. Lauver et al.38 reported that the significant majority of their sample of women with breast cancer, at the end of their primary treatment, used emotional support over time and found it helpful. Also, seeking social support was a commonly used coping strategy. Usually, the beneficial effects of social support on stress, well-being, and health are attributed to a buffering function that reflects support as a moderator. However, evidence suggests that there is also a mediator effect. Supporters shape coping attitudes and skills, provide incentives for engagement in beneficial activities, and motivate others by showing that it is possible to overcome difficulties by persistent effort. Therefore, social support also serves an enabling function by enhancing self-efficacy (a mediator) that, in turn, facilitates favorable health outcomes 37,39. Distress after cancer is predicted by a history of multiple life stressors predating the illness. According to the stress-coping model, coping strategies are efforts directed toward managing or dealing with a stressor. The coping strategies of cancer survivors may include logical analysis, positive reappraisal, guidance/support, problem solving, cognitive avoidance, and resigned acceptance 40,41. The current study presents data that strongly suggest that the presence of life event stresses is related to certain types of coping methods and strategies. A high significant difference was found between moderate stressful life events and the use of active behavioral (P=0.0002) and active cognitive (P=0.001) coping strategies, and then the avoidance coping method was the least used coping strategy (P=0.02). It has also been found that the active expressive coping strategy, cognitive positive understanding, and the avoidance/solitary coping strategy were all significantly correlated to life event stresses faced by the studied group, who had higher means for the moderate form of life stresses. In agreement with others, Vickberg and colleagues 42,43 reported greater depressive and post-traumatic symptoms among cancer patients who had experienced other stressful life events in the year before the diagnosis or during the time since diagnosis depending on the maladaptive coping strategies they used. In contrast, Lauver et al. 38 have reported stressors experienced by women cancer survivors at the end of primary cancer treatments and delineated coping strategies that were used and helpful. More than 90% of the participants used acceptance as a coping strategy over time and found it helpful. Acceptance has been associated with reduced negative moods among individuals coping with health stressors. Moreover, Yang et al.44 found that patients were more likely to use disengagement coping strategies (which include three strategies: denial, withdrawal, and avoidance) as their stress level increased. In another domain, Low et al.45 found that life stresses do not have a direct influence on coping in the first year after cancer treatment. Instead, life stresses interacted with cancer-specific coping to predict adjustment, such that the cancer-specific emotional approach of coping was adaptive only under conditions of low life stresses. This lack of agreement may be attributed to the methodological differences among our studies and the earlier studies; our study has a cross-sectional design and we assessed both life stresses and psychological distress simultaneously.
We can conclude that adaptive coping strategies are protective against development of psychological disorders and, thus depression and anxiety disorders. Patients who rely on maladaptive coping methods such as avoidance or passive resignation are more likely to suffer from depression and anxiety. In addition, the life event stressors resulted in the use of more active coping strategies by the group studied. Those who experienced moderate life stressors used more active coping patterns. Psychiatric guidance should be provided to patients suffering from breast cancer to help them to adopt more adaptive coping strategies that would result in better adjustment and consequently better quality of life.
The findings of this study should be interpreted considering the limitation of the cross-sectional design, which could not explain the causal inference of anxiety and depression on coping methods and strategies. A multicenter longitudinal study to assess the impact of the use of more adaptive coping strategies and continuous life stresses on the choice of coping methods and overall outcome among cancer patients would be very helpful. Despite this limitation, the strength of this study is that this is (to our knowledge) the first Egyptian study to examine the clinical variables correlated with the coping patterns of patients with breast cancer, which should be considered as a crucial factor when planning the management of these patients .
The authors are sincerely grateful to Afaf Hamed Khalil, Professor of Psychiatry and former chair of the Institute of Psychiatry, Ain Shams University, for her generous support throughout this work. The authors are very grateful to Professor Ahmed Saad and Professor Gihan AlNahas for their valuable guidance. The authors are also grateful to Assistant Professor Nivert Zaki and the team of the Institute of Psychiatry, Ain Shams University who actively participated and providing training on the tools used in this research. The authors also thank the patients who were willing participants in our research; without them, this work would not have been possible.
Conflicts of interest
There are no conflicts of interest.
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