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Indian Journal of Cancer, Vol. 47, No. 3, July-September, 2010, pp. 296-303 Original Article Psychosocial disorders in women undergoing postoperative radiation and chemotherapy for breast cancer in India Khan MA, Bahadur AK1, Agarwal PN2, Sehgal A, Das BC Institute of Cytology and Preventive Oncology (ICPO) ICMR, Noida, 1 Department of Radiotherapy, Maulana Azad Medical College, New Delhi, 2 Department of Surgery, Maulana Azad Medical College and LN Hospital, Delhi, India Code Number: cn10072 PMID: 20587906 DOI: 10.4103/0019-509X.64729 Abstract Background: Breast cancer is the most common cancer in urban India, but no study has been carried out on psychosocial disorders in breast cancer patients. Aims: The present study has been undertaken to evaluate behavioural and psychosocial impacts before and after treatment of women with breast cancer. Settings and Design: The study was carried out in a reputed hospital in Delhi. Patients and Methods: A total of 97 breast cancer patients matched for age and economic status were divided into group A (66) and group B (31) on the basis of treatment modalities offered to the patient. These women were interviewed, before and after the treatment, and the observations were recorded in a pre-tested structured questionnaire. Statistical Analysis: Chi-square test and Fisher's exact test were used to calculate statistical significance. Results: Although the extent of sociobehavioral disorders were higher in patients on postoperative adjuvant chemotherapy and radiotherapy when compared with those on postoperative adjuvant chemotherapy alone, the difference was, however, not statistically significant. Psychological reactions were observed in 31% of patients but after intervention, 65% showed adjustment within 4 to 12 weeks, whereas the rest showed late adjustments. Conclusions: Breast disfigurement and sexuality were found to be least important, but psychological and social support appears to significantly influence the treatment outcome and rehabilitation of breast cancer patients in India. Keywords: Breast cancer, breast surgery, chemotherapy, psychosocial impact, quality of life, radiotherapy Introduction Breast cancer is the most common cancer in women in India. [1] The incidence of breast cancer in India, as reported in the National Cancer Registry Programme, Indian Council of Medical Research (Annual Report 2005), varied from 23 to 32 per 100,000 women. [2] It is likely to emerge as a major malignancy among females because of recent changes in lifestyle, food habits, and industrialization. In 2009, American Cancer Society estimated that about 200,000 new cases of breast cancer were diagnosed in the United States. In India, the major burden of breast cancer is due to its early onset, whereas it is mostly a postmenopausal disease in the western population. Therefore, although the incidence of breast cancer is relatively very high in the west (90.7 vs 23.5), there is not much difference in the incidence of early onset of breast cancer, which varies between 12 and 33 cases per 100,000 women. [3] Mastectomy leads to a significant cause of psychological morbidity and mortality among women aged between 35 and 54 years. [4] Breast cancer has been the most extensively studied human tumor site not only from clinicoepidemiologic, experimental, and molecular angle, but also from a psychological point of view. Because breast is an emotional symbol of a woman′s pride and personality, including sexuality and motherhood, any threat to breast is to shake the very core of her mind and feminine orientation. [5] It is also intimately associated with a woman′s self-image, self-esteem, femininity, and reproductive and nurturing capacity. Breast cancer in women causes extreme mental stress leading to many emotional disorders, such as anxiety, tension, depression, grief, anger, hopelessness, helplessness, and a high degree of passivity. [4],[5] Breast cancer survivors often encounter physiological and psychological problems related to their diagnosis and treatment that can influence long-term prognosis. [6] It is widely accepted that the quality of life is impaired by persistent depression or anxiety. [7] It is important to evaluate the behavior of breast cancer patients so that appropriate counseling and rehabilitation strategies can be offered. In the absence of information on the psychosocial aspect of breast cancer patients in India, the present study was designed and is the first such attempt in India. Objectives
Materials and Methods It is a pilot study to understand the possible role of supportive counseling for rehabilitation of breast cancer patients. Thus, 97 consecutive breast cancer patients in the age range of 21 to 70 years (mean age = 42.5 years) with biopsy-proven breast carcinoma (ie, TNM stage II and III) were recruited from the surgical outpatient department of a reputed teaching hospital in Delhi. The patients were randomized and recruited in 2 groups: group A comprised 66 patients who received both postoperative adjuvant chemotherapy and radiotherapy, whereas group B comprising 31 patients received postoperative chemotherapy alone. Patients with cancer of other regions of the body and those with multiple disorders were excluded from the study. The study was ethically and scientifically approved by the Institutional Ethical Committee. Demographic information, including age, marital status, number of children, relation of people living in the household, education, and monthly income, and others are given in [Table - 1]. Medical information about the year of diagnosis, stage of the disease, details of surgery, chemotherapy, and radiotherapy, including detailed clinical, reproductive, and family history was obtained from the medical records. Findings of general physical examination, hematological, blood chemistry, and cyto- and histopathologic investigations were also recorded. Psychological testing was conducted in a well-structured and pre-tested questionnaire, which was filled in by a trained and professional clinical psychologist/interviewer from January 2005 to June 2007 at the time of recruitment of patients, thus minimizing the chance of bias. Informed consent was obtained from each patient. The main components of psychological questionnaires were fear of pain and malignancy, breast disfigurement, obsessive thoughts, worry about family and treatment cost, sexual and professional adjustment, anxiety, stress, depression, and others. These were evaluated and recorded at the time of recruitment. The names and other information were kept confidential. Thus, the following behavioral aspects were evaluated. All the subjects included in the study were available to us only after they underwent necessary chemotherapy/surgery and were subjected to anxiety, stress, and depression tests. Anxiety was measured by a Comprehensive Anxiety Test. The test has as many as 90 items written in local Hindi language and were relating to the "Overt" and "Covert" symptoms of anxiety, stress, and so on with ′Yes′ and ′No′ type responses. The reliability coefficient by split-half method (Gutman′s formula) of the test has been found to be 0.94, and the coefficient of validity was determined by computing the correlation between scores of the test and with Spiel Berger′s state and Trait Anxiety scale. Stress was evaluated by a ′Personal Stress Inventory′ with 35 questions in a local language. [8] The item marked as ′Seldom′ was assigned a score of 1 and the higher the score, the greater was the magnitude of personal stress. The test-retest reliability was found to be 0.792 and possessed a sufficient degree of content validity. Symptoms of depression were measured by ′Beck′s Depression Inventory (BDI), [9] which was adopted in a local language using a 21-item self-report rating inventory measuring characteristic attitudes and symptoms of depression. The items were rated on a scale of 0, 1, 2, and 3. The total score on each item was an aggregate of the categories on the items. Information was collected during the assessment of response to treatment and a standard intervention strategy/package was designed. All the women received educational, medical, or psychosocial care that was deemed necessary. For this information, education, and communication (IEC) systems such as brochures, pictorial charts, leaflets, audiovisual aids, and others were used for both literate and illiterate women to bring about awareness on the quality of life in breast cancer patients. The subjects were primarily treated for breast cancer with surgery by carrying out simple or modified mastectomy or modified radical mastectomy followed by adjuvant chemotherapy plus hormonal therapy depending on the case. Some of the patients received neo-adjuvant chemotherapy. Patients having positive hormonal receptors received hormonal therapy. Surgery, radiation therapy, chemotherapy, and hormonal therapy makeup the standard armamentarium of breast cancer therapy either alone or in combination. The excised tumor lump was always shown to the patient to have psychological satisfaction about the elimination of the diseased part. The drugs most commonly used for chemotherapy were cyclophosphamide, methotrexate, and 5-fluorouracil. The treatment cycle was repeated every 28 days and each patient received a total of 6 such cycles. Both the groups (A and B) received identical postoperative adjuvant chemotherapy. Telecobalt radiotherapy was given to the chest wall, regional lymphatic area of the operated breast, and the lymph nodes involved. Breast cone was often used during chest wall irradiation. A dose of 5000 rads was given over a period of 5 weeks. Special care was taken in the management of treatment-related toxicities through conservative symptomatic treatment and counseling. The first follow-up was scheduled after 1 month of the patients′ recruitment for assessing the treatment response and giving counseling related to psychological disorders, if any. The interview was conducted on a single occasion for each patient. The second follow-up was after 3 months and subsequently at 6 months intervals. Evaluation of postintervention counseling was carried out at the conclusion of the study. The time interval between the first presentation of the case and the last interview with the patients ranged up to 12 months. Statistical analysis The results obtained in the 2 groups of patients were compared and validation/testing was done using standard statistical methods to find the statistical significance. Chi-square test and Fisher′s exact test were used wherever applicable. Results A significant proportion (75%) of women were in the age range of 21-50 years. Only 23% had achieved a high school or higher education levels. Most of the patients were from Hindu community (53%); nearly three-fourths of them were residing in urban areas. Over 84% had family income of less than 5000/- Rupees per month and belonged to low socioeconomic status and had financial burden. Of the total number of women studied, a majority of them, that is, 52 (53.6%), were married and 45 (46.4%) were either unmarried, divorced, or widowed [Table - 1]. When the patients were categorized according to their food habits, 50% were vegetarian and the other 50% were nonvegetarian. Diet was found to be significantly associated with religion (P < 0.001, Fisher′s exact test). All Muslims were nonvegetarian, whereas among Hindus 71.4% were vegetarian and the remaining 28.6% were nonvegetarian. Rest of the parameters did not correlate with the diet. All the patients were nonalcoholics and nonsmokers. Nearly half of the women were premenopausal (52%), whereas the remaining (48%) were postmenopausal. The menopausal age ranged from 48 to 51 years. Menopausal status did not show correlation with the other parameters. The size of the lump was about 0.5 cm 2 in 55% of the patients, between 6 and 10 cm 2 in 37% of the patients, and> 10 cm 2 in 8.3% of the patients. There was no statistically significant difference in the size of the lump in the breast in the 2 groups [Table - 2]. In 66 (68%) cases, tumor was located in the left breast, whereas in 31 (approx 32%) cases, tumor was located in the right breast. All patients had unilateral tumors. The diameter of the tumor was measured in 2 perpendicular directions and the maximum tumor diameter ranged between 2 and 10 cm with a mean diameter of 5.4 cm. The tumor size and side did not correlate with other parameters. In all the patients, MRM was performed followed by adjuvant chemotherapy plus hormonal therapy depending on the case. Some of the patients received neoadjuvant chemotherapy. Patients having positive hormonal receptors received hormonal therapy. Group A patients experienced mild to moderate esophagitis (36.4%) that was attributed to radiation therapy. One patient experienced severe esophagitis during the course of subsequent chemotherapy. Skin reactions in the form of pigmentation and dry or wet desquamation were encountered in 40% of the patients in group A compared with 54.6% in the patients belonging to group B. Most of these reactions were transient and did not require prolonged interruption of treatment. Side effects common to both the groups included nausea and vomiting (5.7%), diarrhea (4.6), stomatitis (3.4), and alopecia (6.8); and psychological fatigue was found to be the most common side effect of radiotherapy. Following are the observations made to identify psycho- and sociobehavioral disorder(s), if any, before, during, and after the treatment among the 2 groups. [Table - 3] indicates that 30 patients (31%) reacted strongly psychologically with the diagnosis, whereas 67 (69%) had positive attitude toward the treating physicians and the therapeutic treatment. There is no significant difference with respect to the parameter of the manifestation of fear of pain and malignancy between the patients of group A and group B. Adjustment was evaluated psychologically with the help of a structured and pre-tested proforma. Supportive counseling through empathetic listening and encouragement was given and psychological reaction toward therapeutic treatment was found among patients in the 2 treatment groups. Counseling was effective for the quality of life of the women. But there was not much difference in pre- and postcounseling of the patients either in group A or group B. Psychosexual disorders were judged by problems of sexual maladjustment experienced by the patients. Findings suggest that psychosexual problem is not a major problem because 45 (46.4%) women were single and the rest (53.6%) were married and belonged to a monogamous society. Sexual maladjustment was due to indifference to sex and non-cooperation from their spouse (P > 0.05). The rest of the patients did not feel any difference and had normal sexual desires. Six percent of the patients showed symptoms of social withdrawal in group A, whereas social withdrawal was not observed in group B [Table - 3]. The findings of behavioral disorders, such as anxiety, stress, and depression, on the basis of the anxiety/depression scale suggest that a majority of the patients, that is, 43 (65.15%) in group A and 17 (54.84%) in group B had very high levels of anxiety; 45 (68.18%) in group A and 25 (80.64%), in group B had moderate levels of stress; and 26 (39%) in group A and 12 (39%) in group B had borderline levels of depression [Table - 4]. The patients were called after 3 months for a repeat questionnaire and also for counseling purposes; 94.9% patients turned up for the second follow-up, which was meant to find out their positive attitude toward the therapeutic treatment/intervention counseling along with the time taken for adjustment. Sixty-five percent of the patients have shown satisfactory adjustment in various areas, such as home/family, social, health and emotional and marital adjustment in 4 to 12 weeks. As shown in [Table - 4], no significant difference emerged before and after treatment, in both the therapeutic treatment groups, indicating the ineffectiveness of the intervention for psychological morbidities. Majority of the patients presented symptoms of breast cancer of late stage. Most of the patients had multiple symptoms as shown in [Table - 5]. Discussion This study indicates that most of the patients enrolled for the study were from low socioeconomic status and breast cancer treatment was a financial burden that leads to an additional psychological stress. [10] Prevalence of breast cancer in India and in the West differs on several counts, especially with regard to age of onset and stage of diagnosis. In India, most breast cancers occur a decade early, especially in the premenopausal phase as compared with those in the western countries [11] where due to mammography-based screening program, cancer is detected at a very early stage. This facilitates a limited surgery and a much better prognosis as compared with those for Indian women, the majority of whom are detected at late stages. This is mainly due to a lack of awareness and the absence of early detection programs. Because of these differences, the sociopsychological adjustment differs between western and Indian women. [12],[13] In this present study, 43% of the patients were younger than 40 years and 51.6% were premenopausal. In addition, about 45% of the patients had a lump size of more than 6 cm, and more than 40% had symptoms of advanced disease, such as loss of appetite and loss of weight. A sexual maladjustment was not a major problem in the current study. This is in sharp contrast to that in the West. [14] In rural areas, social taboos are higher and sex is least important for women and that′s why breast disfigurement is not a problem for sex rather than social and cultural factors. In contrast, in the West, sexual and reproductive functions are given much importance till late in life. [15],[16] In the present study, the main factors responsible for the delayed adjustment were due to nonacceptance by the patient′s husband and family. Because fear of disfigurement and alopecia, and patients′ consciousness about their image influence recovery efforts, they express their desire for breast implants/prosthesis or reconstructive plastic surgery, and also request doctors to keep the fact that they have an artificial breast, a secret. The breast reconstruction is a procedure that enhances self-esteem, restores body image, and a sense of hope and purpose. This may be the reason why women often opt for breast reconstruction surgery and prefer the saree, an Indian traditional dress, as their costume of choice. Women who have undergone mastectomy without breast reconstruction are more likely to report low satisfaction. [17] Among postoperated breast cancer patients, subjective feelings of uncertainty, such as fears of treatment, count among traumatic stressors. [18] However, in the present study, the emotional stress among women in each group was normally occasional and of short duration as they resumed normal activities quickly. In India, marriage provides a strong personal and social security. In the present study, 57% of patients were older than 40 years and had completed their families. This helped patients to overcome psychological reactions relating to breast disfigurement and so on. After surgery for breast cancer, many women experience anxiety relating to cancer that can adversely affect the quality of life and emotional functioning. [19] Anxiety and depression [20] are the 2 main psychological complaints of women with breast cancer. In this study, it was observed [Table - 4] that most of the patients (65.2% in group A and 54.9% in group B) suffer from very high levels of anxiety , but moderate levels of stress and borderline depression were observed in group A and group B (39.4% and 38.7%, respectively). This finding is consistent with the others in the literature, which shows that anxiety and depression are major problems in women with breast cancer. [21],[22] It is said that the experience of the adjuvant chemotherapy of breast cancer is a stressful event in women′s life and causes a range of distressing symptoms, such as anxiety, stress, and depression. Although these symptoms are likely to be transient, they may pose various demands and difficulties. [23] Manifestation of fear of pain and malignancy were mainly psychological morbidities in group A and group B (21% and 23%, respectively), not doing any work, inability to concentrate, anorexia, and looking for somebody′s support. Therefore, discussion with the patient′s husband is always useful to meet his wife′s real needs, her emotional problems, treatment, and rehabilitation plan. [24],[25] Some investigators [26],[27],[28],[29],[30] have demonstrated the efficacy of counseling in improving psychosocial morbidity. However, in the present study, counseling does not seem to have an impact on the ability to provide reassurance, and also it failed to demonstrate any improvement in psychosocial morbidity. This may be due to a small sample size of the study. Its efficacy, however, needs to be explored in a larger sample size with longer duration counseling. Although supportive-expressive counseling revealed a positive impact on the duration of adjustment, the finding suggests that an appropriate intervention, including psychoeducation and emotional support are needed for patients with breast cancer in order to detect and manage psychological distress. References
Copyright 2010 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn10072t4.jpg] [cn10072t1.jpg] [cn10072t5.jpg] [cn10072t2.jpg] [cn10072t3.jpg] |
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