Electronic ISSN 2287-0237

VOLUME

RELATIONSHIPS BETWEEN SELECTED VARIABLES AND ADAPTATION INWOMEN AFTER BREAST SURGERY

SEPTEMBER 2019 - VOL.15 | ORIGINAL ARTICLE

Breast cancer is one of the most life-threatening cancers among womenworldwide. The incidence of breast cancer has increased in both developedand developing countries. In 2018, the World Health Organization reportedthat there were more than 2 million new cases of breast cancer patients or24.2 % of all newly diagnosed cancers among women around the world.1Approximately a quarter of total breast cancer cases was diagnosed in theAsia-Pacific region.2 In Thailand in 2017, the Bureau of Health Policy andStrategy reported that the estimated number of Thai women with breastcancer death was 4,177.3 Surgery is usually the primary treatment and thecornerstone for the early stage of breast cancer women. The modified radicalmastectomy (MRM) has been performed as the standard of traditionaltherapy for breast cancer surgery over the past few decades.4 However, thecurrent surgical technique has become more developed with a less invasiveprocedures.

Breast conserving surgery followed by radiation has been more broadlyperformed.5 Moreover, sentinel lymph node biopsy (SLNB) has become astandard of care to examine the nodal staging of breast cancer. Women withbreast cancer who undergo SLNB are more likely to have less incidence oflymphedema, stiffness of shoulder, numbness, and wound seroma comparedwith axillary lymph node dissection.6 Furthermore, breast reconstruction hasbecome an available option leading to an improvement of body image,sexuality, and quality of life in women with breast cancer.7

Although breast surgery has benefits in terms of enhancing overallsurvival and improving aesthetic outcome after treatment, its adverse outcomealso affects both physical and psychological integrity of women with breastcancer. After breast surgery, women with breast cancer are at risk to possiblydevelop complications such as wound infection, seroma formation, hemorrhage or hematoma, and lymphedema.8 In addition, they oftenreported high anxiety.9 The breast is the organ that representsthe femininity of women. Appearance changes because ofbreast surgery leads women with breast cancer to face distressand body dissatisfaction.10 Women who lost their breast oftenreport sexual problems adversely affecting their physical andemotional well-being especially women having a sexualpartner.11 The relationship with their spouses had changed andthey abstained from social participation.12

In Thailand, few researchers have assessed the adaptationafter breast surgery in the past ten years. At that time, MRMwas performed in almost every patient regardless themetastatic of axillary lymph node. Most of the adaptationstudies examine the relationships of adaptation with personalcharacteristics including age13-15, educational level13,16,income13,16; clinical characteristic including time after surgery;and social support.13,17 However, some variables had a positiverelationship, negative relationship, or even no relationship withadaptation. Furthermore, women with breast cancer hadreceived various types of surgery and additional treatmentafter breast surgery, which might affect their adaptation differently.

According to Roy’s Adaptation Model, Roy views peopleas an adaptive system, consisting of input, process, and output,always interacting with the changing environment. Theenvironment input (the stimuli) has an influence on personalbehavior. However, people can adapt themselves dependingon the focal and contextual stimuli and their adaptive level.When each person confronts stimuli, they will use specificcoping mechanisms to handle these changes and expressindividual’s adaptation through four modes of behavior includingphysiological mode, self-concept mode, role function mode,and interdependence mode.18 When people have an effectiveresponse, they will adapt themselves effectively.

Women with breast surgery will be confronted withstimuli that threatens the equilibrium of their lives and theywill need to adapt themselves to a changing environment.Breast surgery (including, type of breast surgery, currenttreatment, time after breast surgery) is a focal stimulus. Socialsupport is a contextual stimuli, and personal characteristics(e.g. age, educational level, and income) is an adaptive levelfor an individual’s adaptation in this study. There are twopossible ways to promote personal adaptation based on Roy’sAdaptation Model, which are: managing the stimuli or increasingone’s personal ability. Nurses play an important role to promotepersonal adaptive level, helping breast cancer women to adaptthemselves to new challenges after breast surgery.

Thus, the purpose of this study was aimed to investigatethe adaptation of married women after breast surgery and todetermine the relationships among selected variables includingage, educational level, and income, type of breast surgery,current treatment, social support, and adaptation. The findingsfrom this study would be useful for health care providers tobetter understand adaptation among married women withbreast cancer after breast surgery.

This study was a descriptive correlational design. Thesample size was calculated using the G* power softwareprogram.19 The effect size of 0.26 from previous study wasused,14 as well as the power of 0.80, and the level ofsignificance (α) of 0.05. After performing this G*powercalculation, it was found that the estimated proper sample sizewas 90. In order to allow for the loss of participants due tounexpected situations, a total of 100 participants wererecruited from one university hospital in Bangkok.

The inclusion criteria were as follows:

  1. Thai women aged 18 and over.
  2. Those with newly diagnosed with breast cancer at stageI, II, or III, and undergoing breast surgery between threemonths and one year.
  3. Those who were married and stayed with their spouses.
  4. Those who understood, and were able to communicatein the Thai language.
  5. Participants aged 60 or over who were cognitive intactassessed by the set test and whose score was equal toor higher than 25
  6. Those who were willing to participate in this study.

Instrumentations

The following three instruments were used to collect datain this study:

The Demographic Questionnaire and Clinical Data Form was developed by the researcher to assess the personalcharacteristics and clinical information of the participants. Theform was composed of two main parts:

  • Part 1: to collect the demographic and socioeconomicinformation about women with breast cancer. The itemscovered the following: (a) age; (b) number of children; (c)child care; (d) educational level; (e) occupation; (f) income;(g) income sufficiency; (h) medical payment methods; (i)right- or left-handedness; (j) caregivers; and (1) careactivities.
  • Part 2: to assess the clinical information from the medicalrecords of the participants. This information included thefollowing: (a) time after breast surgery; (b) cancer stage;(c) cancer type; (d) side of breast surgery; (e) type of breastsurgery; and (f) current treatment.

The Adaptation of Breast Cancer Questionnaire(ABCQ) was employed to evaluate adaptation by women withbreast cancer. It was developed by Samranrat18 and modifiedfrom the adaptation questionnaire based on Roy’s AdaptationModel. This questionnaire consisted of 46 items covering fourmodes of adaptation including physiological mode, self-conceptmode, role-function mode, and interdependence mode. All ofthe items were scored using a five-point Likert scale (1 =absolutely disagree; 5 = absolutely agree). There are 20positive items and 26 negative items (with the score reversed) in the scale. The total possible score ranges from 46 to 230. Ahigher score on this questionnaire indicated higher levels ofadaptation after breast surgery. The adaptation scores aredivided into three levels, representing low (46-107), moderate(108-169), and high (170-230) levels of adaptation. TheCronbach’s alpha coefficient of ABCQ of a pilot study withten participants, who had similar demographic characteristicsto the participants in the main study, was 0.81. The Cronbach’salpha coefficient for the main study was 0.83.

The Social Support Scale was employed to evaluate thesocial support of women with breast cancer. It was originallydeveloped by Toljamo and Hentinen,20 based on the conceptof social support, as defined by House. This questionnaire wastranslated into the Thai language with minor modifications byLeelacharas.21 This questionnaire consists of 12 items with afive-point Likert scale (1 = strongly disagree; 5 = stronglyagree). The negative questions had reversed scores. The totalpossible scores ranged from 12 to 60. Higher scores indicatedthat participants had higher levels of social support. The Cronbach’salpha coefficient of the Social Support Scale in a pilot studywith ten participants, who had similar demographiccharacteristics to the participants in the main study, was 0.73.The Cronbach’s alpha coefficient for the main study was 0.87.

Ethical considerations: This study was approved by theEthical Review Committee for Research on Humans of theFaculty of Medicine of Ramathibodi Hospital of MahidolUniversity (No. 09-60-19).

Data collection

After the approval of the Institutional Review Board,participants who met the inclusion criteria were approached.They were informed of the purpose of the study, as well as theconfidentiality of their responses and their right to refuse toparticipate at any time without any effect on their care ortreatments they would receive from the hospital. If each personagreed to participate in the study, they were asked to sign theinformed consent form prior to collection data.

Data analysis

All data obtained were analyzed using a program ofstatistical software. Descriptive statistics, including frequency,percentage, range of score, mean, and standard deviation (SD),were used to analyze the demographic and clinicalcharacteristics of the participants, as well as their levels ofadaptation and social support. Chi-square test was used todetermine the relationships of adaptation for categoricalvariables including educational level, income, type of breastsurgery, and current treatment. Pearson product-momentcorrelation coefficient was used to determine the relationshipsof adaptation and age, social support, and time after breastsurgery.

mostly of participants (65%) in middle adulthood age, withages ranging from 33 to 75 years. More than half of theparticipants (52%) did not take care of their children becausethey were now grown up. Nearly half of the participants (46%)were well educated, with a Bachelor’s degree or higher.Approximately 20% of participants were working as governmentofficers. In terms of income, almost half of participants (45%)earned between 10,001 and 30,000 Thai Baht per month. Morethan half of the participants (52%) reimbursed their medicalpayments through government welfare. After their breastsurgery, most of them (90%) had family caregivers taking careof them. Most family caregivers were husbands (45.76%)followed by their children (33.90%). The details of thedemographic data are shown in Table 1.

Table 1: The demographic characteristics of participants (n = 100)

 

Almost half of the participants (49%) had been diagnosedwith stage II of breast cancer. The average time after breast surgerywas seven months (SD = 3.26). Most participants (66%) hadundergone mastectomy, followed by breast conserving surgery(18%). Approximately 35% of the participants had receivedchemotherapy after breast surgery, as showed in the Table 2.

From one-hundred participants who met all inclusioncriteria, seven participants could not respond to the part of thequestionnaire regarding the parental role of role-function modeof ABCQ due to not having children and some children alreadyhaving grown up. However, these seven participants stillresponded to all other parts of the questionnaire. The meanscore of overall adaptation was 180.31 (SD = 17.02), indicatingthat the participants had a high level of adaptation. Amongfour modes of adaptation, the mean scores of the physiologicalmode (52.89 ± 5.51) and role-function mode (56.99 ± 6.73)were at high levels, whereas the mean scores of self-conceptmode (40.53 ± 6.90) and the interdependence mode (30.19 ±3.41) were at moderate levels, as shown in Table 3.

In this current study, the actual scores for Social SupportQuestionnaire ranged from 38 to 59. The results showed that theaverage score for social support was 49.96 (SD = 5.30). Morethan half of the participants (56 %) had a social support scorehigher than the mean score. The highest mean score of socialsupport scale was “Follow-up visits in breast cancer clinic are very important for getting information.” (4.63 ± 0.58)” whereasthe lowest mean score was “Whenever I need help for breastcancer, I get help from other people with breast cancer.” (3.54 ±1.096).

Chi-square test used to examine the correlation betweenwomen’s adaptation after breast surgery and the categoricalvariables: (1) education level; (2) income; (3) type of breastsurgery; and (4) current treatment. As showed in Table 4, therewas no significant association of adaptation with any categoricalvariables examined (p > 0.05).

 

Table 2: The clinical characteristics of participants (n = 100)

 

Table 3: Adaptation of women after breast surgery (n = 100)

 

Table 4: Relationships between educational level, income, type of breast surgery, current treatment andadaptation (n = 93).

Before running the correlational analysis, a one-sampleKolmogorov-Smirnov test was used for testing normality. Theresults showed “age,” “social support,” and “adaptation” werenormally distributed. However, “time after breast surgery” wasnot normally distributed. Kurtosis (-1.56) and skewness (0.097)were further examined for this variable and the kurtosis andskewness were in the acceptable ranges, considering close tonormal distribution. The linearity of each pair of variable wasalso examined. They all met the assumptions before runningPearson’s Product-Moment Correlation. The results were thatsocial support was positively related to adaptation (r = 0.437,p < 0.05). However, there was no relationship between age(r = 0.085, p > 0.05) and time after breast surgery (r = 0.018,p > 0.05) with adaptation, as showed in Table 5.

 

Table 5 : Relationships between age, time after breast surgery,social support, and adaptation (n = 93)

The majority of the participants were married women ofworking age. The findings support that the incidence of breastcancer in women aged 40 and above was very high. Mostparticipants had completed higher education. Although themonthly income was varied, most of them did not reportfinancial problems. It is possible that they used the universalhealth insurance covering some curative treatments of cancercare. During the seven months after surgery, all participantshad adapted themselves to their breast surgery. However, mostof them still had to adapt themselves to adjuvant therapy ofcancer treatment.

Women with breast cancer reported high levels of adaptationreferring to good adaptation, and from a previous study it wasreported that the adaptation in women with breast cancerundergoing chemotherapy were at moderate levels.13 Onepossible explanation could be that the current study recruitedonly non-metastasis women with breast cancer. Most of themwere diagnosed in the early stage. In this current study,participants did not suffer from severe pain and distress symptomsthat could affect the personal ability of adaptation. Additionally,most participants were married and had their family memberssuch as spouses, their children or relatives taking care of them.They might help them in confronting with the difficultsituations of adaptation. Moreover, this study was conductedin a university hospital with professionals who were expertsin special care. All participants received health informationregarding disease, prognosis, details of treatment, and specificcare instructions. These might be useful for them to betteradapt to both the disease and treatment.Among four modes of adaptation, the mean scores of thephysiological mode and role-function mode were at highlevels, whereas the mean scores of self-concept mode and theinterdependence mode were at moderate levels. When analyzingadaptation by item, the highest mean scores item belonged torole-function mode that was “teaching their children”. Atseven months after breast surgery, most participants stillworked. They could perform daily activities and their tasksindependently. Nearly a hundred percent of participants hadchildren. Although breast cancer affected their mother roles,all participants had their spouse to assist them in a role ofparenting. Furthermore, more than half of participants did nottake care for their children because they were already grownup. As they were growing up, children became more independent,resulting in reducing some of the burdens of child care for theparticipants.

The lowest mean score item belonged to the interdependencemode which was “feeling uncomfortable to ask for help”. Theparticipants were working age people who accumulated bothknowledge and life skills. Well-educated people tend to havea better understanding in managing their health. However, they arefrequently faced with psychological problems. Surgery is anaggressive treatment that contributed to anxiety amongwomen with breast cancer. Additionally, women with breastcancer were also worried about the cancer recurrence. Eventhough the participants had some consequences (limitation ofarm function) after having breast surgery despite helpingthemselves, they sometimes still needed assistance.

For the physiological mode, the early complications afterhaving breast surgery such as seroma formation, woundinfection, and hematoma could happen in a short period oftime. At seven months post-operative breast surgery, thesesymptoms may disappear and would not have an effect on theadaptation of women with breast cancer. For the self-conceptmode, more than three-fifths of participants had undergonemastectomy. The appearance change from breast cancer andits treatment resulted in the participants experiencing poorbody image. They might have low confidence and difficultyin social activities..

Social support plays an important role to help women withbreast cancer to experience less distress and to cope better withthe disease. In this current study, most participants had highlevels of social support. This finding is congruent with a priorstudy that social support of breast cancer survivor’s ongoingtreatment is available.22 The correlational analysis showed thatsocial support was positively related to adaptation. It could beinterpreted that participants who received support fromavailable resources including family members, friends, healthcare providers, or patients with similar diseases had a goodadaptation. Most participants had family members taking careof them continuously in various aspects of care involvingphysical, psychological, and social well-being after breast