The coping process of patients with cancer
Article Outline
- Abstract
- Introduction
- Methods
- Results
- Discussion
- Limitations
- Conclusion
- Funding
- Conflicts of interest
- References
- Copyright
Abstract
Purpose
The aim of this study was to investigate the implications of the alterations to lifestyle of cancer patients, from the onset of abnormal symptoms, followed by diagnosis and treatment, and then subsequent acceptance of the condition. Seven cancer patients from medical centers in Taiwan participated in the study.
Method
Exploratory, qualitative study based on grounded theory methods. Each participated in a semi-structured interview with open-ended questions. All interviews were audio recorded and transcribed. Qualitative content analysis was used for the data.
Results
Three themes emerged from the data analysis to exhibit the critical coping processes of the cancer patients. These included negative feelings, self-adjustment and self-reinterpretation.
Conclusion
According to the results this study concluded that the coping processes used by some cancer sufferers enables them to draw upon various strengths and strategies to develop particular attitudes and skills to assist them to live with cancer. Overall, the findings tend to support the developmental interpretation, although the contextual interpretation also applies.
Keywords: Cancer patients, Coping process
Introduction
Half of all men and one-third of all women in the United States will be diagnosed with invasive cancer at some point in their lives (Cancer facts and figures, 2004). In Europe, in 2009, there were about 2,457,610 cancer cases diagnosed and 1,231,220 deaths from cancer (Ferlay et al., 2010). In Taiwan, in 2005, 42% of men and 31% of women in the population were diagnosed with invasive cancer and 37,998 per 100,000 population died of cancer in 2005 (Bureau of Health Promotion Department of Health the Executive Yuan Taiwan, 2009, http://www.mc.ntu.edu.tw/CRS/uploadimages/Y95-ALL.pdf). Birgegard and Glimelius (1998) pointed out that serious illness such as cancer often places patients in crises of varying degrees. For instance, the diagnosis and treatment of cancer often resulted in psychological distress.
The longstanding interest of psychologists and health care professionals in life-course changes in patterns of stress and coping (Hannon et al., 2010) has been heightened in recent years by the dramatic growth in the numbers of people who are living with cancer. In a study of cancer patients’ quality of life (QOL), MacDonald (2001) reported that the disease affected patients in four different dimensions: the psychological dimension, the social dimension, the physical dimension and the spiritual dimension. During each intensive treatment course, patients experience many physical and emotional changes, often with long-lasting after-effects on quality of life (Foley et al., 2006, Hammerlid and Taft, 2001).
The conceptualizations and measurement of hassles and coping are based on a cognitive-phenomenological theory of stress and coping, which is described at length elsewhere. Briefly, stressful events are person-environment transactions. They are appraised by the person as relevant to well-being, and, as taxing or exceeding coping resources. Hassles as noted previously refers to the ordinary stressful transactions of day-to-day living, as opposed to major life events. According to Hammerlid and Taft (2001) coping is not only a mechanism to regulate emotions, but also a stage of problem-solving, such as praying, avoiding being friends with negative thinking people, maintaining a positive attitude, seeking support from family, friends and others in a similar situation, diet control, and exercise therapies. Or, alternately, trying to ignore the cancer (Henderson et al., 2003, Link et al., 2005).
Coping processes may be aimed at problem-solving; such as doing something to alter the illness threat, self-management of the illness, seeking advice and accepting treatment, or at the management of the emotional distress that is associated with the illness. The coping process begins with the diagnosis of cancer and ends when cancer survivors achieve a new balance. Patients with cancer in the clinical trial have consented to participate with a hope to improve, or to realize stability with, the disease as a result of the treatment.
The findings of past studies have expanded the body of knowledge on coping with cancer. However, limitations exist and hinder their contribution to a comprehensive understanding of coping. These include: the limitation in the use of self-reporting questionnaires to detect contextual and personal beliefs that affect coping with different stressors at different stages, and relevant outcomes. Thus this study uses semi-structured interviews as a more sensitive method to elicit cancer patients’ experiences. Hwang (1977) studied the patterns of the coping process among the Chinese living in Taiwan. He found that Confucian beliefs in forbearance and striving for a goal by working hard, the Taoist concept of stoic acquiescence to fate by doing nothing, and concepts of dynamic harmony between the individual and the environment were cited as characteristics of coping of the Chinese people. Moreover, a majority of Chinese women with ovarian cancer in Hong Kong had little motivation to seek information from their physicians, but faithfully relied on their physicians. They also tended towards self-control to deal with physical, psychological and social concerns (Ngan et al., 1994, Wu et al., 2009). Similarly, a study on psychological adjustment of Chinese Women at the beginning of breast cancer experience found that for Chinese women interviewees, even the fighters, a sense of control did not equate to mastery of the situation. All the women had great trust and depended on their health care providers for decision making and advice, which demonstrates the great authority of the doctor and the patient, will follow the doctor’s advice without questioning the decisions made (Ching et al., 2009). Since the coping process is highly specific to the person, their culture and their social factors, existing theories developed in western countries do not explain the coping of Chinese people with cancer (Zeidner and Saklofske, 1996).
Comparatively little research is available on the coping of Chinese cancer patients. Specifically, few research studies have been focused on Chinese patients who have been diagnosed with cancer and have coped with the progression of the disease, and have received one or more treatment sessions without a recurrence, even when they were aware of the possibility of a recurrence. The literature on psychological reactions and coping during the progression of the illness in this situation is sparse. Therefore, further study is needed.
The study aimed to explore the process of how these cancer survivors coped with their illness from the onset, and after one or more complete courses of treatment, with an awareness of the possibility of a recurrence of their illness. In depth interviews were focused on their daily experiences of the illness and how they cope with it.
Methods
A qualitative study was used to investigate coping process used by Chinese people with cancer. Seven cancer patients from medical centers in Taiwan participated in the study. The use of grounded theory facilitates the exploration of social process in their culture context (Strauss and Corbin, 1998). Grounded theory methods have been used in other qualitative studies of patient with cancer (Hamilton and Sandelowski, 2004).
Sampling
The study was conducted in the hospital outpatient’s department in Taiwan. We recruited interviewees who had undergone or were undergoing the experience and were willing to share their feelings, and who were articulate about their coping process. In order to control the effect on generality for both the scope of the population and the conceptual level of the theory, the study employs specific criteria (Minichiello et al., 1995), the criteria is as follows: (1) being diagnosed with any type of cancer, (2) who had received one or more complete courses of treatments such as surgery, chemotherapy or radiation, (3) were 18 years or older, (4) were fluent in Chinese, (5) agreed to participate in one-on-one interviews. All interviews took place between September and December in 2007. This research was approved by The University of Chang Gung Human Research Ethics Committee and conducted without any funding or grant aid from any funding agency in the public, commercial or not-for-profit sectors.
Procedure
This study was first introduced to primary investigators’ social networks. Persons who were willing to participate in this study were referred to the principal investigator by friends. Patients were contacted by telephone to determine their willingness to participate in this study. Once they agreed to meet with the primary investigator, a date of interview would be scheduled in the week following the first contact. Interview participants were given both written and verbal information about the purpose of the study and its procedures before signing the consent form at the time of interview. Semi-structured interviews were employed with open-ended questions to guide them. Each interview lasted for 60–90 min and was audio recorded. The principal investigator transcribed all the recorded interviews and added notes taken from the interviews.
Analysis
The process of data analyses started immediately after the first interview and remained as a concurrent maneuver while the interviews were in progress. In fact, two of the seven participants were contacted for a follow-up interview. Although the interviews had originally intended to be a single event, the two interviewees who raised new issues were contacted for a follow-up interview. In order to explore the issues they raised more widely more questions were subsequently added for the rest of interviewees, also the two interviewees were contacted approximately one month after their initial interviews to discuss the new emerging issues. Data were analyzed with the constant comparison method to identify the repetitive themes in every transcript (Miles and Huberman, 1994). Each transcript was analyzed line by line to generate open codes. After all the transcripts were analyzed, those open codes with similar meanings were linked together to form a theme. The principal investigator completed the data analysis process alone. Another researcher was consulted to assist the principal investigator in examining the logic of sorting open codes into themes. Once a theme was agreed by both researchers, patient statements were then organized into each established theme of cancer patients’ coping processes to provide rich descriptions of each theme.
Results
Characteristics of participants
Table 1 shows the characteristics of the seven participants in this study, including demographic backgrounds, types of diagnoses, types of treatment received, and the employment status. Participants were all female cancer survivors, aged from 34 to 67 with a mean age of 49.57. Only one of them was single and the others were married. Two of the patients worked part-time, one worked full-time, two were unemployed, and two had retired.
Table 1. Sample Characteristics (N = 7).
| Demographic data | N |
|---|---|
| Married status | |
| Married | 6 |
| Single | 1 |
| Work status | |
| Full-time | 1 |
| Part-time | 2 |
| unemployed | 2 |
| Retired | 2 |
| Diagnosis | |
| Breast cancer | 5 |
| Endometrial cancer | 1 |
| CML | 1 |
| Type of treatment | |
| OP | 1 |
| OP + C/T | 4 |
| OP + R/T | 1 |
| C/T | 1 |
| Age range (mean) | 34–67 (49.57) |
Balance process of life fluctuations
Using inductive analysis of the broad topic areas introduced during the interviews, a core concept and three key themes were identified. These themes, which were determined by using content analysis, have been drawn together to correspond to the concept of the “balance process of life fluctuation” which was used to create the core concept. The concept and these themes emerged from data analysis of the interviews with the cancer patients and are detailed as follows.
The framework applied in this study was derived from extensive research conducted on coping responses to the diagnosis and treatment of cancer and facilitates identifying and categorizing of the known coping process of cancer patients. Most research conducted tended to explore the coping and psychological adjustment among cancer patients, but only a few drew it together as framework. Since the coping process is highly specific to the person, their culture, and their social factors, applying the existing theories developed in western countries do not explain the coping process of Chinese people with cancer. Moreover, there is little agreement on what the coping process is in general and there is a lack of study of coping process of the Chinese people. Consideration of the basic elements of the coping process is the crucial first step to take if the coping process of the Chinese people is to be understood. Thus this study formed the framework of the coping process. A core concept, “balance process of life fluctuations” emerged from the data analysis. The “balance process of life fluctuations” included all the psychological distress Chinese patients encounter and how they adjust to live with the disease. Also included is the internal impact of the changes they face, from diagnosis of the disease to completion of treatments, and the anxiety of waiting for the possible recurrence of their disease. This concept, “balance process of life fluctuations” — a framework for guiding the coping process — is introduced as the conceptual framework for this study.
All participants expressed no expectation of experiencing cancer. They viewed their diagnosis of cancer as an accident; one that introduced sudden changes to their lives. When diagnosed, they experienced unexpected complicated emotions and feelings. After treatment was administered, they endured a decline in physical strength, increased fatigue, sleeplessness, and other physical or mental challenges. Moreover, the effects of the disease forced some to leave their jobs.
Four participants stated that they coped with the disease by self-reinterpretation and readjustment. They reinterpreted their values and beliefs in order to adjust to the changes brought about by their diagnosis. These patients gained strength from encouragement they received from family, friends, colleagues and medical professionals. Participants reinforced their personal values by working for others in need, disregarding their own pain and suffering. They became volunteers and participated in cancer patient support groups or worked in charitable organizations. These measures enabled adjustment to their new life.
Thus, after an extensive literature review and a rigorous psychometric process, this study concludes that coping process can be conceptualized as having three steps. The three steps corresponded to the time period following one or more treatment sessions and prior to being informed of the progression or recurrence of their disease. These steps are negative feelings, self-adjustment and self-reinterpretation and are consistent with the core concept “balance process of life fluctuations”. These three themes are related to each other and may be interchangeable. To protect confidentiality I have put a participant number after each quote. These pseudonyms are used in this section.
Negative feelingsNegative feeling is one of the core categories of “balance process of life fluctuations”. This occurred when the patients became aware of the changes in their regular life, and related to the negative feelings experienced from dealing with their symptoms, the diagnosis, and the treatments. The negative feelings included two sub-themes: mental distress and loss of physical control.
Mental distress
Mental distress means the negative emotions and feelings the patients experienced from their diagnosis to the acceptance of cancer treatments. A cancer diagnosis led to mental distress, including worries and fear, bad anticipations, shock, hopelessness, anger, a sense of unfairness, and denial
Worries and fear
Experience of worries and fear began with waiting for the diagnosis, which when confirmed as cancer, resembled the announcement of a life sentence. Most of the patient thoughts were then dominated by what might happen next. For example, one participant stated:
“My menses did not come from March to June 2004.When I was waiting for the diagnostic checks at the obstetrics and gynecology department in Hsin Chu Armed Force Hospital, I felt quite nervous and worried that something might have happened. However, I hoped that it would be good. Once the endometrium is clearly scraped everything will be ok.” (patient 3)
Bad anticipations
Despite the reported experiences of worry and fear, the participants said that they were aware that the illness could be cancer, and this was something they had to learn to live with. Three participants described that they felt nervous when visiting the physician who was doing the examination and would inform them of the result. Two of them experienced bad anticipations. This, in turn, inspired a premonition of cancer.
“The doctor told me when he did the palpation, he felt the shape was irregular. He also asked me if I felt pain. I said, ‘No.’ Then he told me not to worry. There was 60% of possibility that the result would be benign. After I heard the percentage, I was mentally prepared. I thought it also might be malignant.” (patient 2)
“I lay on the surgical table and my upper body was locally anesthetized. After surgery, my doctor said he observed calcification in my breast. According to the word ‘calcification’ from the doctor, I thought to myself that the cancer must be malignant.” (patient 1)
Shock, hopelessness, anger, stigma and unfairness
When participants first heard the diagnosis of cancer, their level of shock resembled having just had a severe blow to the head or some other sudden “accident”. There was no easy acceptance of the diagnosis, which was accompanied by reactions of anger, a sense of unfairness, stigma and even a complete loss of hope.
“When I heard the bad news from the doctor, I burst into tears right away. My daughter kept trying to comfort me, but I thought it was hopeless.” (patient 7)
“I had worked so hard throughout my whole life, why did I still get cancer? I did not want to have my breast removed, I will not to be a woman anymore, my husband will leave me” (patient 5)
“My immediate thought was why was me that had acute myelogenous leukemia? Why me? Why on earth it was me? I cried and cried. I couldn’t control my fury. I thought of the fact that I had taken care of my grandmother and parents for such a long time, being such a nice daughter, doing things with all my strength, but why had God treated me like that?” (patient 4)
“Suddenly I felt that it was like a bomb thrown to me from nowhere, and I was too shocked to react. I acted mechanically, not knowing what to do.” (patient 2)
Loss of physical control
Loss of physical control refers to the physical discomfort that cancer patients experienced from the time they started feeling ill to the period following their treatment courses. These discomforts are subjective feelings and include loss of sleep, deteriorating physical strength, and loss of appetite.
Four participants claimed that they had suffered from loss of sleep from the confirmation of diagnosis and throughout the entire treatment course. Some continued to suffer insomnia after the treatment was completed. This caused tremendous anxiety and discomfort in patients’ daily lives. In addition, the participants also reported deteriorating physical strength, and loss of appetite after onset of symptoms or during chemotherapy.
“I didn’t have any sleeping problems before. It’s weird. I don’t know why. I seemed to have gotten sleeping problems since I took hormonal medicine, and now I have to lie in bed for a long time before finally falling asleep.” (patient 2)
“I used to be quite optimistic and talkative before. But after falling ill I have no vigor, and less strength and vitality.” (patient 5)
“After completing the chemotherapy and coming home, I’ve got less strength than before. It’s really exhausting. I want to lie down to take a rest more often.” (patient 6)
“During the course of chemotherapy, I just kept feeling like vomiting. I was so uncomfortable and there seemed to be puffiness both in my head and stomach.” (patient 1)
Self-adjustmentSelf-adjustment refers to the ways patients adjusted their personal beliefs and lifestyles in order to cope with the stress of the diagnosis, all the related physical examinations and treatments. The self-adjustment included two sub-themes: adjustment of personal belief and adjustment of lifestyle.
Adjustment of personal belief
The adjustment of personal belief means the adjustments cancer patients took to prepare themselves to face the impact of the disease. The participants described many different positive adjustments to accept the diagnosis. These included: constructive thoughts, acceptance of the fact, self-encouragement, self-comfort and praying for peace of mind.
Constructive thoughts
Not long after receiving their diagnosis, two participants traversed through shock stages fairly quickly and adjusted to confront the disease constructively. Some patients displayed a dramatic shift in attitude.
“Right after I got home from the hospital with tears and told my family that I had cancer and wrote my will, I told myself to face the fact bravely.” (patient 2)
“I told myself that I must be really strong and brave to help myself recover to how I was before getting the disease. I’ve kept such an attitude all the time since then.” (patient 5)
Accepting the fact
Once it was understood that the cancer diagnosis was unalterable, two participants accepted the fact and held the belief that the suggested treatments provided their only chance of survival.
“I realized very soon that no matter what I do, nothing can ever change the fact that I’ve got cancer. And I think the most important thing for the moment is to accept treatment and prepare for the operation.” (patient 4)
“The only thing in my mind was that by finishing the chemotherapy, without interruptions, I could possibly get through this difficult situation?” (patient 1)
Self-encouragement
Having accepted the need for treatment, some participants gained strength from the actual improvement in their condition at the hospital. Physical improvement increased positive thought processes and demonstrated a particular example of self-encouragement. Two participants reported that they felt sure they would experience recovery following treatment.
“I told my daughter to help me up on my feet the day after surgery, and I could get off the bed by myself on the third day. I felt that I seemed to recover quite well, so I thought there shouldn’t be any big problems.” (patient 6)
“My weight, which was 60.5 kilogram, hadn’t changed after the operation. I tried hard to eat a lot, and felt that I would recover quite well. By cooperating with the doctors, I felt that I had a new hope.” (patient 7)
Self-comfort
When comparing the seriousness of their conditions with those less fortunate, three participants acquired a different perspective of their own situations. Moreover, they learned to adjust their attitude toward the disease and realized it wasn’t as bad as they’d first imagined.
“Later on, I felt I was quite lucky. At least the disease was discovered right after I took the health examination, and it was only at the initial stage. It reminded me that I had seen other, less fortunate cases, as I work as a nurse. Compared with others, I was really much luckier.” (patient 3)
“The doctor said that my disease was the most dangerous type. Some people didn’t accept treatment and passed away very soon. I felt lucky that I had listened to the doctor and finished all the treatment without interruptions.” (patient 6)
Consolation from religion
Religious beliefs and prayer to their God guided three participants towards peace of mind. They felt they would be given guidance throughout their illness. Not all women in this study informed their family about their cancer. In some cases, women received support from peers (religion of Buddhism) who provided women with recitations from the Buddhist Scripture to assist their emotional and personal well-being. Other women preferred to visit a naturopath to receive herbal medicine rather than western medicine.
“I pray every day. I pray every morning. I pray to God and Buddha and hope they can help me through this difficulty. I felt that they really hear my prayers.” (patient 6)
“I went to see a naturopath to get herbal medicine and my friends took me to pray to Buddha” (patient 4)
Adjustment of lifestyles
Adjustments to lifestyle involved changes to diet, exercise, work schedule, and workload.
Most participants changed their dietary habits after the cancer diagnosis. They had not previously considered diet as a significant issue but chose to follow a healthy and balanced diet regime in order to enhance their well-being. For example, one participant described the change in attitude:
“Now I eat lighter food. I used to prefer fish or meat when eating, and didn’t like vegetables. Now I try not to eat meat, and, instead, consume more vegetables. Polished rice used to be my choice for meals, but now I choose unpolished rice. Every morning, I drink a glass of soybean milk with fibers made by myself. Some foods are on my forbidden food list.” (patient 1)
Regular exercise had not been a habit for participants with very busy work schedules, but they have since adapted. For example, one participants stated:
“I used to be busy working, and had no time for exercise or leisure activities. Now I go to yoga everyday, trying to exercise as much as I can. It’s rather good for me to adjust to such things now. It helps me build a habit of taking exercise regularly.” (patient 2)
Lifestyle change was essential. The importance of moderate work schedules with more rest and less responsibility, particularly after illness, was a necessary adjustment for the participants who had worked long hours consistently.
“I didn’t go to bed until 12 midnight. Now I regret that I always went to bed so late. Since I got this disease, I have set a rule for myself that I must go to bed no later than 9:30pm to 11:00pm.” (patient 1)
“I thought it was time to get away from work, so I handed in my application. Therefore, now I don’t have so much work to do. I feel quite relaxed.” (patient 4)
“I worked as a salesperson before, and had to use a computer quite often. Now I have few things to do. I take my father to the hospital for dialysis or help my company with simple things like going to the bank. I just try to do some easier things with less pressure.” (patient 6)
Self-reinterpretationParticipants deduced that changes in old value systems were now necessary. Despite negative feelings, they realized the importance of informed, realistic expectations regarding their illness that would require self-adjustment, leading to re-evaluation, of their lives.
Re-evaluation of the meaning of life
As human beings, the participants viewed life and their values differently. For example, acceptance of death as a normal process allowed them to view the remainder of their life in a more positive perspective.
One participant said that everyone eventually has to face death and as long as they were aware of the progress of their cancer, facing death was not too difficult.
“I view things with a broader mind, not caring about it too much. Since I have got cancer, I think back and realise that there also seemed to be a kind of uncertainty in life before. What I want to say is that to die of cancer as the final result has become quite clear to me.” (patient 1)
Life before cancer had been full of expectations for the participants, and were seldom questioned. Since diagnosis for example, one participant stated that fear of recurrence and exhaustion from treatments contributed to his feeling of loss of control. With the fear that life could end at any moment he refrained from forming expectations and lived one day at a time to avoid disappointment.
“I have no special intentions for the future. Nothing is waiting for me to do. Yeah, nothing. Anyway, I just live day by day. I feel that I don’t know when this kind of disease will come back again. Once it comes back again, I shall just pass. Yeah, I have no further thoughts for the future. I just walk step by step with nothing to look forward to.” (patient 5)
Life is short and fragile. This vivid realization compelled the participants to change rigid attitudes and give weight to their right to cherish themselves.
“I just feel that I must live for myself. Only when I live a healthy life can I truly enjoy it.” (patient 2)
“I just feel that I am not so eager to get things that I want anymore. That is to say, that I let go of things more easily.” (patient 4)
“Now, being not so strict with myself, I don’t fee regret about anything…I should let go of things. Being well is already a blessing.” (patient 5)
Future perspective
Despite their serious situation, most of the participants chose to view the future positively. They made plans for vacations and travel, visiting relatives, and performing volunteer jobs. They could even, to some extent, look forward to these events. They felt that it was necessary to maintain a fighting spirit and to keep their hope alive. One participant expressed increased hope by planning and considering potential accomplishment:
“I do my best to be a volunteer in the hospital in the day time, or to take some related lessons, trying to arrange a fulfilling life for myself. And I also join in a breast-cancer-patient support group. It feels quite fulfilling and happy for me to devote myself and rearrange my life with things like sharing experiences with the group and listening to other patients’ feelings and thoughts. Thus, I can realize more about the meaning of life, which is just like a saying of Christ, ’Love never gives up.”(patient 1)
Discussion
The core concept “balance process of life fluctuations” proved to be comprehensive in exploring issues related to the coping process of patients with cancer after one or more complete courses of treatment. The three themes of this core concept— “balance process of life fluctuations” —negative feelings, self-adjustment and self-reinterpretation, are fundamental to the discussion of the findings. Furthermore, it would be of value to explore the questions and implications that have emerged from this study in future research.
Negative feelings
Based on the concluded theme of “negative feelings” in this study, a high proportion of the interviewees reported negative emotions and feelings during the period from diagnosis to conclusion of treatments. The negative feelings related to mental distress and degrees of loss of physical control. All participants had suffered mental distress, such as worries and fear, bad anticipations, shock, hopelessness, anger and feelings of unfairness when diagnosed and faced with the need to accept cancer treatments. The study findings concur with those from the literature investigating the coping process of cancer patients. Holmes and Rahe (1967) reported that what the cancer patients experienced is like a catastrophic event, which causes life changes much more overwhelming than other major life events and daily hassles. Similarly, Cassileth and Deng (2004) stated that immediately after the diagnosis, anxiety and other mood disturbances may occur, and these can fluctuate over time in response to remission, recurrence, and the diagnosis of refractory disease. A study conducted in Asian (Pakistan) found that for all the women the presence of a breast lump was an upsetting, petrifying, threatening and extremely scary experience. Many women cried continually and felt depressed. Further findings were, for unmarried younger women, the diagnosis of breast cancer not only created personal anxieties about life expectancy but also the anxieties related to the prognosis and the associated stigma of post-mastectomy (Banning et al., 2010). Furthermore, these women were worried about the possibility that they may pass down the cancer to their children. They also were anxious about how the spouses’ family would react to the diagnosis and how to break this devastating news to them. Although there have been many research papers focus on coping process, there were no special emphasis on the coping process regarding the disfigurement and stigma post-mastectomy in the western society (Hannon et al., 2010, Foley et al., 2006, Schlegel et al., 2009). In addition to this, there is the widespread belief in Asian culture that if women with breast cancer need to be treated by surgery, then they will lose their femininity and the husband or boyfriend may not love them anymore (Ching et al., 2009). These points are hardly ever discussed in western society. These underlying cultural issues can have a very negative impact on families and their future coping process.
The current study revealed that participants reported physical weakness related to mental distress, such as sleeplessness, deteriorating physical strength and loss of appetite throughout the diagnosis and following treatment period. Even though cancer survivors face most of the mental distress associated with diagnosis and treatment, they still continue to face the uncertainties that survivorship brings. Many also continue to have cancer or treatment related symptoms (Deimling et al., 2006). This finding is consistent with that of Savard et al. (2001), who found that around 30% to 50% of newly diagnosed cancer patients were reported to have sleep difficulties.
Clearly, mental and physical changes are the first step of the “balance process of life fluctuations”. However it is not in itself sufficient to construct this coping process during the treatment period. However, there are other elements involved and these will be discussed in the following section.
Self-adjustment
This study showed that from the diagnosis of cancer and subsequent treatments, participants found ways to adjust to all the accompanying problems. These included the adjustment of personal beliefs and lifestyles which form the second step of “balance process of life fluctuations”.
The lifestyle changes involved work schedules, workload, diet and exercise to assist in management of their life-threatening illness. They also remodeled their personal beliefs and included constructive thoughts, acceptance of the facts, self-encouragement, self-comfort, and gaining consolation from religion. This result concurs with those from the literature which suggest that cancer patients always have mental strategies to enhance their abilities for self-cure and recovery (Towsley et al., 2007). For example, some cases sought spiritual support and advice from peers as a coping strategy and they preferred to seek herbal therapy rather than western medicine. These findings are similar to other studies in which a belief in God was a strong source of support for African American women coping with breast cancer (Henderson et al., 2003). Similarly, other studies have pointed toward religion’s/spirituality’s potential contribution to the development, maintenance or enhancement of an individual’s positive attitude in the face of stress (Gall et al., 2009, Foley et al., 2006). The longitudinal study conducted by Gall et al. (2009) addressed the role of spirituality in women’s response to breast cancer. The results show that women who were less spiritually/religiously involved prior to the onset of breast cancer, and who attempt to mobilize these resources under the stress of diagnosis, may experience a negative process of spiritual struggle and doubt that, in turn, has negative implications for their long-term adjustment. Those who are good at self-adjustment have the ability to get more information and use it to form new strategies, and quickly adapt to their life-threatening disease (Clark and Gong, 2000).
However, in the traditional Chinese culture, people tend to seek Chinese herbal medicine to cure cancer, as they consider the negative physical effects of chemotherapy in particular hair loss, vomiting and nausea. Furthermore, as they do not want to be isolated from their family Chinese medicine is the preferred choice. Surgery is the last option considered, as to have a complete body is very important for them especially for people who live in rural areas. This issue is one of the main differences between western and Asian culture.
Such results suggest one of the common coping strategies is successful adjustment. This is found in patients who believe they can control the disease process through changes in lifestyle and personal belief. It is also important to focus on coping and realizing the role of the self, in creating a subjective positive interpretation, which subsequently enhances acceptance of the disease, at the beginning of the cancer experience. Self-reinterpretation is another category of “balance process of life fluctuations” which will be discussed in the following.
Self-reinterpretation
This study found that effective coping strategies may lead to a greater sense of meaning in life, acceptance of death and a positive future perspective, through the reinterpretation of the diagnosis. The participants in this study expressed positive self-reinterpretation in coping with cancer. These findings are similar to previous studies in which positive self-reinterpretation was an effective strategy for cancer patients to assist them throughout the process (Cordova and Andrykowski, 2003, Ching et al., 2009). Foley et al. (2006) found that the majority of cancer survivors in their study reported that they accepted the cancer diagnosis positively, pursued the appropriate course of treatment, and went on with life with minimal disruption. Furthermore, individual reinterpretation of such an event may find it an opportunity for personal growth (Affleck and Tennen, 1996). For example, in one study, women who showed greater acceptance or positive reinterpretation in coping with their diagnosis, later recorded higher scores on the scale of assessing life perspective, purpose and goal. Also individuals who accept difficult circumstances may change life goals more readily, with goals evolving to ones that remain achievable and satisfying (Jim et al., 2006).
Limitations
There were limitations in this study. The cancer diagnoses of the interviewed patients are varied and include CML, breast cancer, and endometrial cancer. The potential for different outcomes with a similar diagnosis may be high, because different cancers have different progress, recurrence and cure rates. The current sample is also limited by the small number of 7 participants. For future studies, researchers can include patients with similar diagnoses to rule out the variables among different forms of the disease. A cross-sectional study to track the progress of recruited cancer survivors will allow comparison between the experience of long-term survivors and those who are diagnosed and facing the possibilities presented.
Conclusion
With the introduction of adjuvant radiotherapy, chemotherapy, and hormonal therapy in the past few decades, there have been increases in both remission and survival rates. Cancer has become a chronic illness that demands patients live with its impact, or under its shadow, for lengthy periods both during and after treatment. Since stress is inevitable, coping makes a difference to a patient’s adaptation to the disease. Besides dealing with treatment issues, cancer patients have to face: changes in perspectives, acceptance of illness, reinterpretation of the self, facing mortality issues, altered financial or occupational status, exploring the meaning of life and changes in self-concept. These all contribute to a psychological reaction and can be defined as the “balance process of life fluctuations” which is identified as the core concept of the adjustment process of Chinese patients with cancer at outset of the cancer experience. The findings support the view that focusing on coping and realizing the role of self in creating a subjective positive reinterpretation, which subsequently enhances acceptance of the disease, is initiated at the outset of the cancer experience. Understanding cancer patients’ interpretation of their situation is important to health care providers who must assess needs, facilitate coping, anticipate potential problems and finally contribute to patients’ overall adjustment to the impacts of cancer. In this study it is acknowledged that cultural and attitude differences exist with respect to cancer. It is including the fear of mastectomy due to the mutilated body and the perceptions of loss of femininity. The options of treatment are different due to the concepts of Chinese culture. People seem to cure disease with Chinese herbal medicine. These findings provide a basis for nursing intervention. It is essential that nurses understand the cultural and religious beliefs of the patients that they are caring for. Throughout the process, a nursing professional can focus on enabling cancer patients to understand the situation, explore their strengths and weaknesses, realize their role in the coping process, and derive a coping formula that meets their needs, instead of prescribing coping strategies for them.
Funding
None.
Conflicts of interest
None
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PII: S1462-3889(11)00006-8
doi:10.1016/j.ejon.2011.01.002
© 2011 Elsevier Ltd. All rights reserved.
