Keywords
breast cancer survivors - posttraumatic growth - psychological distress - depression
- anxiety - women - body image disturbances
Introduction
Breast cancer (BC) is the most common malignancy affecting millions of individuals
worldwide.[1] Various therapeutic modalities are used to cure BC over an extended period.[2] Many psychiatric disorders are associated as a result of the diagnosis of BC.[3]
[4] This journey of the entire treatment procedure is difficult as it brings financial
burden, disruption of family routine, disfigurement in the body, fear of recurrence
(FORC), and death.[3]
[4]
[5]
Despite all the adverse outcomes, positive changes have been observed in survivors
after BC's frightening and traumatic journey.[6] Different individuals use different coping mechanisms to deal with additional adversity
of life like BC. A growing literature suggests the development of positive changes
resulting from traumatic events known as posttraumatic growth (PTG). PTG is defined
as “positive change in the individual's previous level of functioning aftermath a
traumatic experience.”[7] According to Tedeschi and Calhoun, PTG encompasses five domains of positive growth:
more significant appreciation of life and a changed sense of priority; increased sense
of personal strength; closer relationships with others; recognition of new possibilities
for one's life; and spiritual growth.[7]
[8] Evidence from western literature suggests the development of PTG is associated with
various demographic and clinical variables.[7]
[9]
[10] In the current study, we aimed to know the outcome of PTG among breast cancer survivors
(BCS) and the relationship between PTG, psychological distress, body image disturbances,
and demographic and clinical variables among women who have survived BC in Indian
demography.
Methods and Materials
Sample and Procedure
A cross-sectional study was conducted during January to April 2021 in a tertiary care
teaching hospital in North India. We have approached (matching the study population)
700 BCS for the study, treated in the institution from January 2016 to June 2020.
We reviewed the patients' medical records to confirm the diagnosis, time of diagnosis,
treatment method, and stage of cancer. The final study sample was selected based on
inclusion and exclusion criteria ([Fig. 1]). Patients were recruited using purposive sampling during their follow-up visits,
and some patients were contacted using the telephone. We explained the purpose of
the study to participants in their local language. Women between 18 and 60 years of
age, diagnosed and treated for BC, and who have completed their active treatment for
at least 3 months (surgery, chemotherapy, and radiotherapy) were included in the study.
Patients with metastasis, recurrent cancer, and receiving treatment for any psychiatric
comorbidities were excluded from the study. To ensure anonymity, we included no names
or other identifying information in the questionnaires or database.
Fig. 1 Recruitment process of the samples. BIS, Body image scale; DASS-21, Depression, Anxiety,
and Stress Scale; PTGI, Posttraumatic Growth Inventory Short Form.
Measure
Patients were assessed using a semi-structured proforma for socio-demographic and
clinical details. PTG was measured using posttraumatic growth inventory (PTGI-10 item).[11] Psychological distress was measured using the depression, anxiety, and stress scale
(DASS-21) comprising 21 articles.[12] Body image disturbances were measured using a 10-item body image scale.[13] All the tools were administered by the interviewer (mental health professional).
Patients found to be positive for any psychiatric morbidity were referred to the department
of psychiatry for further consultation.
Depression, Anxiety, and Stress Scale (DASS-21)
The DASS-21 is a self-report questionnaire consisting of three dimensions of negative
emotional states: depression, anxiety, and stress/tension (Lovibond and Lovibond,
1995; Page et al., 2007).[41] Seven items measure each dimension, and each item is calculated using a 4-point
Likert-type scale, ranging from 0 (“did not apply to me at all”) to 3 (“applied to
me very much, or most of the time”). Scores of at least 10 for depression, 8 for anxiety,
and 15 for stress indicate clinical levels of distress for each subscale, respectively.
The DASS-21 has good reliability and validity, and we found it to be moderately sensitive
to change (Page et al., 2007).[41]
Posttraumatic Growth Inventory Short Form (PTGI-SF)
The PTGI (Steffens and Andrykowski, 2014; Tedeschi and Calhoun, 1996[8]) assesses personal growth that can arise from the experience of cancer. While the
original PTGI scale has 26 items, the PTGI short form (PTGI-SF[11]) consists of 10 items to measure 5 subscales: new possibilities, relating to others,
personal strength, appreciation of life, and spiritual change. Each item is scored
on a 6-point Likert scale on the basis of the degree of change that has occurred for
the participants concerning that item, ranging from 0, “No change,” to 5, “Change
to a very great degree.” The total score ranges from 0 to 50, with a higher score
indicating a higher level of PTG. The PTGI-SF has been found to have good internal
reliability (α = 0.72–0.89), and the adjusted correlations between the PTGI and PTGI-SF total scores
were consistently near or above 0.90.
Body Image
The 10-item body image scale was developed as a unitary measure to measure body image
distress, including influence, actions, and cognition, and has been commonly used
in oncology contexts. Participants assessed the degree to which they agreed with statements
on a 4-point Likert scale, such as “Did you feel self-conscious about your appearance?”
(0, not at all, to 3, very much). The total summary scores will range from 0 (no distress)
to 30 (high body image distress). This scale demonstrates high reliability (α = 0.93) of the item and strong clinical validity and alteration sensitivity. In the
current analysis, the item reliability of this scale was high (α = 0.94).
Statistical Analysis
Statistical analysis was performed using SPSS-20 software. The continuous variables
were compared using the t-test, and the ordinal and nominal variables of the two groups were compared using
the Chi-square test. We studied the relationship between various domains of PTG and
body image and other variables using the Pearson correlation coefficient.
Ethics
The procedures followed were as per the ethical standards of the responsible committee
on human experimentation and with the Helsinki Declaration of 1964, as revised in
2013. The present study was approved by the Institutional Ethics Committee of King
George's Medical University, Lucknow, Uttar Pradesh, India, dated January 22, 2021
(Ref code: 104th ECM IIA/P14). Informed consent has been obtained from the patients.
Results
Total 700 BCS were selected for the study. We applied inclusion and exclusion criteria
to the subjects. Final analyses were used on 182 BCS. The recruitment process is presented
in [Fig. 1].
Socio-Demographic and Clinical Details of the Study Sample
The mean (standard deviation [SD]) age of the patients was 43.14 (8.53) years. The
majority of the patients in the study were housewives 175 (96.2%), not literate 56
(30.8%). The majority (180, 98.9%) of the patients were married and belonging to Hindu
religion (142, 78%), living in a joint family (127, 69.8%), from an urban and semi-urban
background (118, 69.7%), and with monthly family income ranging between 5,000 and
10,000 Indian rupee (127, 69.8%).
The mean (SD) duration of completion of treatment was 13.05 (10.54) months, with a
median of 12 ranging from 4 to 64 months. We found family history negative for cancer
and other psychiatric morbidities in 175 (96.2%) and 164 (90.01%) of subjects, respectively.
The majority of the patients were diagnosed at the third stage of malignancy (99,
54.4%). More than half of the women, 105 (57.7%), were in premenopausal status. The
majority, 168 (92.3%), of the patients expressed FORC of BC.
Prevalence of Depression, Anxiety, and Stress and Body Image Disturbances
The prevalence of depression, anxiety, and stress in our study (29.11%, 33.5%, 25.25%,
respectively) in majority of the patients was with mild severity ([Table 2]). The mean (SD) body image score was 20.30 (6.48).
Table 1
Clinical characteristics of breast cancer survivors (n = 182)
|
Variables
|
Mean (SD)
|
|
Posttraumatic growth/subdomain
|
37.00 (11.38)
|
|
1. Relating to other
|
8.56 (2.45)
|
|
2. New possibilities
|
6.71 (2.68)
|
|
3. Personal strength
|
8.67 (2.36)
|
|
4. Spiritual change
|
8.43 (2.18)
|
|
5. Appreciation of life
|
8.62 (2.30)
|
|
Psychological distress
|
Depression
|
10.43 (9.76)
|
|
Anxiety
|
6.06 (5.43)
|
|
Stress
|
9.97 (6.06)
|
|
Body image score
|
Body image score among MRM + BCS patients
|
18.40 (8.52)
|
|
Body image score among MRM patients
|
20.34 (6.48)
|
Abbreviations: BCS, breast conservative surgery; MRM, modified radical mastectomy;
SD, standard deviation.
Posttraumatic Growth and Its Correlate
The mean PTG score of our study population was 37.0 (11.38). The mean scores of the
subdomains of the PTG were as follows: appreciation of life, 8.56 ± 2.30; relating
to other, 8.56 ± 2.45; spiritual strength, 8.43 ± 2.18; personal strength, 8.67 ± 2.36;
and new possibilities in life, 6.71 ± 2.68 ([Table 1]).
Table 2
Frequency and percentage of severity of anxiety, depression, and stress
|
Clinical variable/severity (n = 182)
|
Depression:
n (%)
|
Anxiety:
n (%)
|
Stress:
n (%)
|
|
Normal
|
129 (70.09)
|
121 (66.05)
|
136 (74.07)
|
|
Mild
|
33 (18.01)
|
31 (17.0)
|
39 (21.04)
|
|
Moderate
|
8 (4.04)
|
23 (12.06)
|
6 (3.03)
|
|
Severe + very severe
|
9 + 3 (6.05)
|
6 + 1 (3.08)
|
1 (0.5)
|
PTG score was found to be positively associated with treatment completion time and
negatively correlated with anxiety, depression, and stress. PTG was not found to correlate
with age and body image score ([Table 3]).
Table 3
Correlation between posttraumatic growth and different clinical variables
|
Variable
|
r, p
|
|
Posttraumatic growth
|
Treatment completion time
|
r = 2.260, p = 0.02
|
|
Depression
|
r = –0.145, p = 0.05
|
|
Anxiety
|
r = –0.152, p = 0.04
|
|
Stress
|
r = –0.162, p = 0.02
|
Note: Significant at 0.05 (only significant values depicted).
Discussion
This study was performed to observe PTG and the subdomains of the PTG (appreciation
of life, spiritual change, personal strength, new possibilities, and relating with
others) and its relationship with different demographic and clinical variables among
BCS, and how psychological distress and body image disturbances are associated with
PTG.
Demographic and Clinical Variables
The mean (SD) age of the patients was 43.25 (8.53) years. This could be due to the
higher incidence of BC in this age group.[1] The demographic characteristics of our study population are similar to the demographic
details of studies conducted in North India.[3]
[14] The mean duration of the completion of treatment in this study group was 13.05 ± 10.54
months. This could be due to predefined selection criteria, according to which we
had only included patients whose active treatment was completed at least 3 months
before data collection time. The majority of the patients were diagnosed in third
stage of malignancy (54.04%). Late presentation of the patients at treatment care
facilities generally attributed to the following reasons, as represented by the previous
research studies: poor financial status, lack of awareness, and lack of resources
in nearby treatment facilities; this can be the possible reason for the majority of
the patients being in third stage of malignancy.[1]
[15] More than half (57.7%) of the women in our study were in premenopausal status. This
can be because the mean age of menopause among Indian women ranges between 41.9 and
49.4 years.[16] The majority of the patients expressed fear of recurrence (FORC) of BC. It has been
a significant finding in our study, which shows that survivors have many underlying
concerns such as FORC, resulting in psychological disturbances and decreased quality
of life.[17] Literature suggests cancer patients considered FORC as one of their most frequent
unmet supportive care needs, and FORC is present at a higher level in 40 to 60% of
patients and at lower levels in almost all the patients.[17]
[18]
[19]
Posttraumatic Growth
The mean PTG score of our population was 37 (SD: 11.38). The mean score was higher
compared with previous literature.[20]
[21]
[22] The higher score can be a reasonable adjustment with the illness over a while as
our posttreatment population ranges from 4 to 64 months. Research suggests better
PTG over a longer period.[23]
[24]
[25] Further, most of the studies have reported a positive association of marriage with
PTG and marital status as a predictor for PTG.[9]
[10] Since most of the participants in our study were married, this can be the reason
for higher scores in the PTG domain.
Our synthesis suggests more or almost equal growth in the subdomains of relating to
others, appreciation of life, spiritual changes, and personal strength. Findings are
congruent with previous studies.[25]
[26]
[27]
[28] The mean (SD) score of personal strength was 8.67 (2.36). The personal strength domain explains knowing own strength to cope with adversity.[7]
[8] Ability to cope with stressful situation tends to the development of confidence
in oneself.[29]
[30] The mean (SD) score for appreciation of life was 8.56 (2.30). A possible explanation for the high score in the domain of appreciation of life is that when patients tend to come out of the adversity successfully, they start
appreciating life. After all the ups and downs associated with the treatment process
and illness, people start appreciating the value of life and become extra careful
with how they live now. The mean (SD) score for relating to others was 8.56 (2.45). Relating
to other domain explains the support they receive from the family, friends, and other support
groups while going through the treatment, which might have improved their interpersonal
relationship leading to a high score in the domain representing relations.[8]
[31] The mean (SD) score for spiritual changes was 8.43 (2.18). Previous literature has reported religious beliefs among cancer
patients, showing that religious beliefs help positively cope with adversity, as people
start thinking it is a curse from God or the punishment of their previous life karma.
Only God is the last resort for their problems.[22]
[32]
[33] The growth in these areas is reported to be less in previous research studies.[24]
[34]
[35] We can explain this based on the different demography of the Indian subcontinent
and cultural values, where spiritual beliefs and family support are a crucial part
of the value system leading to positive growth. The mean (SD) score for new possibilities in life is 6.71 (2.68). The mean score was comparatively less in the new possibility domain since older adults are more affected with BC considering the mean age, and
cognitive rigidity and lesser interest in new avenues lead to less growth in this
area.[24]
[34] At the same time, results were contrary to Sharma and Zhang (2017), where new possibility
scores were more.[22]
PTG score was positively associated with treatment completion time, which is consistent
with the theory of Tedeschi and Calhoun (1996)[8] that growth appears with time from the traumatic event.[6]
[7] This means that the longer a woman survives from BC, the higher the chances of developing
PTG. Previous findings suggest higher PTG development in the women who have stayed
for longer than 5 years post treatment comparing women who have survived below 5 years.
As our study also includes the same age group, this can be the reason for the findings.
Another reason can be because the stretch of the year lived post treatment is more
prolonged, where they become confident over a while about the future.[22]
[25]
[36]
[37]
[38] However, the other findings are not supported by the results, which show an inverse
relationship between time since diagnosis and PTG.[22]
[39] PTG is negatively correlated with anxiety, depression, and stress. Results are in
line with previous literature,[22]
[24]
[39] which reveals more scores in PTG are associated with less severity of psychological
distress or chances of having psychological distress. It was evident from earlier
studies that positive coping results in reducing pain, which supports the results.
PTG is the outcome of a positive coping mechanism, which could help minimize distress.[32] Further, multiple reasons cause the stress to be eliminated, such as reduced financial
cost associated with treatment, recovery from cancer, and adjustment with illness
over some time, which also support the synthesis.
PTG was not found to be correlated with age, suggesting a lack of relationship between age and PTG, which is similar to other
data.[25]
[37] However, some findings contradict our current findings where results differ in the
relationship between age and PTG, revealing that the younger generation is correlated
with the amount of PTG than older individuals.[7]
[22]
[24]
[40] Body image score was also not found to be associated with PTG, which suggests no
association between PTG and body image score. These are two different variables independent
of each other.
Since the study was conducted in a single facility with outpatients, the use of a
small sample was one of the limiting factors for the generalization of the results.
Also, some treatment variables like chemotherapy and hormonal therapy may impact the
outcome of PTG, which was not addressed in this study. Further, longitudinal studies
on a larger population are needed to ascertain our findings. Research should be focused
on results predicting the protective factor for PTG and association with demographic
and clinical variables. Considering the socio-cultural background, healthcare workers
should promote positive coping and identify factors that may lessen or enhance PTG.
Conclusion
Taken together, the current study suggests that BC survivors may experience protracted
adverse effects in the form of psychological distress and body image disturbances,
while PTG may also occur at the same time as a positive outcome of a negative experience.
Hence, consistent psychological help should be available/given to all patients irrespective
of their treatment status, that is, after diagnosis, during treatment, and post treatment.
