Berta Varela Lic. Psyc, Ana Inés Galain Lic. Psyc
Department of Medical Psychology, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
The health-related quality of life (HRQL) of patients with breast cancer can be affected by a variety of factors, including ways of coping with the disease. Coping, as well as quality of life, depends upon the subjective evaluation of events that are health related. Coping plays an important role in adjustment to disease and has a great impact on the person’s ability to function and maintain a positive quality of life.
The person’s evaluation of his/her possibilities to manage the illness is the key concept regarding the adaptation process.1 R.S. Lazarus gave an important impulse to the studies on coping, the mechanisms by which individuals face stressful situations. The appraisal of a stimulus as being threatening triggers the processes of coping that involves a complex psycho- physiological reaction that characterizes stress. Coping was defined as “ongoing cognitive and behavioral efforts to manage specific external/or internal demands that are appraised as taxing or exceeding the resources of the person.”2 It refers to the attempt to reduce an external demand, actual or potential, that may represent a threat or challenge, by means of an intra- psychical (cognitive or emotional) effort or by means of actions.3
Health-related quality of life was defined as a multidimensional construct referring to the patient’s subjective perception of the illness and its treatment that provides information about the appraisal of physical, functional, and emotional well-being.4
Few studies have reported on the association of coping mechanisms and HRQL. The relationship between coping and HRQL, as well as their reciprocal influences, will help one better understand patient reports.
This pilot study aimed at exploring prevalent coping strategies in relation to the stage of the disease and type of surgery. It was also focused on evaluating how coping strategies might influence the HRQL of women after breast-cancer surgery.
The design was descriptive and prospective with measurement prior to and after surgery. Only data on the post-treatment assessments will be presented here. A set of patient self-reported instruments were applied after breast cancer surgery:
- The short version of the Mental Adjustment to Cancer (Mini- MAC)5 is a standardized, valid, and reliable measure that assesses the specific psychological response to cancer (coping). It consists in a scale of 29 items, with separate scores for five types of psychological responses: Fighting Spirit (FS), Hopelessness/Helplessness (HH), Anxious Worrying (AW), Fatalism (F), and Cognitive Avoidance (CA).
- The Medical Outcomes Study Health Survey Short Form (SF- 36)6,7 was used as a generic measure designed to examine perceived health status. The eight dimensions of the scale were introduced in the analyses: Physical Function (PF), Role Physical (RP), Bodily Pain (BP), Vitality (V), General Health (GH), Social Function (SF-36), Role Emotional (RE), and Mental Health (MH).
Descriptive statistics and non-parametric Spearman correlations were used to analyze the data.
The study was conducted in the Mastology Unit of the Hospital de Clínicas, Facultad de Medicina, Universidad de la República, in Montevideo, Uruguay.
The sample included 71 women, mean age of 62 years (SD 12.8). Thirty-five (49%) of the patients were at Stage I, and 27 (38%) at Stage II; in nine patients (13%) the data was not available. Conservative surgery with axillary lymph node dissection (CS+ALND) was performed in 39 (55%) of the patients, while modified radical mastectomy (MRM) in 32 (45%) of them. Informed consent was provided. Ethical approval from the institutional review board was obtained. The questionnaires were easy to apply and understand, and they were not excessively time consuming.
Anxious preoccupation was the prevalent coping strategy observed in both groups (Figure 1). The analysis of coping did not show differences between Stage I and Stage II of the disease. Although Role Physical and Role Emotional showed lower values in women undergoing MRM, no significant differences in HRQL were found between types of surgery performed (Figure 2).
Table 1 shows the correlations between the coping strategies as assessed by the Mini-MAC and the eight dimensions of the SF-36. Several coping strategies were associated with HRQL, but the size and direction of the correlations varied according to the coping strategy involved. Two avoidance- oriented mechanisms (Helplessness-Hopelessness, and Anxious-Worrying) showed moderate- to high-negative correlations with GH and the four emotional subscales of the SF-36 (V, SF, RE, and MH) meaning that the more helplessness and anxiety worrying, the lower reported HRQL. Inversely, one problem-solving- oriented coping strategy (Fighting Spirit) was positively correlated with PF, GH, V, SF, and MH. As for Fatalism, it showed positive correlations with GH, V, and SF.
Our results are aligned with the prevalent hypothesis that the sort of coping mechanisms the subject uses in dealing with the stress in the context of cancer diagnosis and treatment may have an impact in the assessment of his/her HRQL. Problem-oriented coping strategies showed the best outcome in terms of physical and psychological well-being after surgery. In turn, coping mechanisms might be related to the subject’s psychological features, like mood state, personality traits, system of beliefs, but this hypothesis was not part of this study.
As for Fatalism, it is defined in the Mini-MAC as stoic acceptance. It refers to the active effort of thinking how things would be in the worst possible scenario as a way of preparing oneself in advance for bad news but not necessarily implying resignation or withdrawal. In our opinion, this concept might include instrumental aspects of coping that may represent an active approach more than the passive acceptance usually related to the term fatalism.
We did not find differences in the prevalence of the type of mechanisms depending on the type of surgery. Additional multivariate analyses would help to depict the relative importance of biological (tumor stage and type of surgery), psychological (mood state, personality traits, spiritual well- being, including coping strategies), and social factors as possible determinants of HRQL.
In this study, coping strategies were related with the patients’ assessments of HRQL. Significant positive and negative associations were found depending on the type of coping mechanism with patients using predominantly problem- solving-coping styles having the better perception of the HRQL in comparison to patients using avoidance-oriented approaches. Questions for future studies are related with how coping mechanisms can interact with other multiple biological, psychological, and social factors impact on HRQL assessments.
1. Lazarus R, Folkman S: Estrés y procesos cognitivos. Barcelona: Martinez Roca Ed.; 1986.
2. Lazarus R: Coping Theory and Research: Past, Present, and Future. Psychosom. Med 1993, 55:234-247.
3. Lazarus R: Stress and emotion. A new synthesis. New York: Springer Publishing Co.; 1999.
4. Carr AJ, Gibson B, Robinson PG: Measuring Quality of Life: Is Quality of Life Determined by Expectations or Experience? BMJ 2001, 322:1240-1243.
5. Greer S, Moorey S, Watson M: Patients’ adjustment to cancer: the Mental Adjustment to Cancer (MAC) scale vs. clinical ratings. J Psychosom Res 1989, 33(3):373-377.
6. Ware, JE, Sherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36), I: Conceptual framework and item selection. Med Care 1992, 30(6):473-483.
7. Ware, JE, Gandek B & the IQOLA Project Group: The IQOLA Project Group. The SF-36 Health Survey: Development and Use in Mental Health Research and the IQOLA Project. International Journal of Mental Health 1994;23:49-73.