Couples Who Get Closer After Breast Cancer: Frequency and Predictors in a Prospective Investigation
http://www.100md.com
《临床肿瘤学》
the Unite de recherche en sante des populations, Centre de recherche du Centre Hospitalier Affile Universitaire de Quebec
Universite Laval
Centre des maladies du sein Deschênes-Fabia, Hpital du Saint-Sacrement, Quebec
Centre de recherche Fernand-Seguin de l'Hpital Louis-H. Lafontaine
Universite de Montreal
Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
Fred Hutchinson Cancer Research Center, Seattle, WA
ABSTRACT
PURPOSE: Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this.
PATIENTS AND METHODS: This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect.
RESULTS: Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer.
CONCLUSION: Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.
INTRODUCTION
Although the marital relationship is undoubtedly stressed by a diagnosis of breast cancer, many couples seem to have the resources to meet this challenge, to acquire the appropriate support to do so, or both.1 Clinical experience and some research suggest that some couples facing cancer perceive that their marital relationship improved since the cancer episode.2 Although there are reports of spouse and/or patient assessments of marital adjustment and the importance of social support from the spouse for adjustment generally in this situation,3-8 these studies still consider each partner separately. None has taken into account the views of both partners simultaneously or prediagnosis predictors of marital adjustment in the evaluation of effects on the marital relation. Thus we do not know the extent to which both partners consider that they have come through the first year after breast cancer with a closer relationship. Nor do we know which sociodemographic, psychosocial, illness, and treatment characteristics contribute to this positive outcome. A better understanding of characteristics involved may suggest avenues for improving psychosocial care of patients and their spouses and possibly their quality of life. If it turns out that the couple relation is relatively unaffected or even made closer afterwards, such information could be empowering to women and men facing this disease and help dedramatize the effects of breast cancer on the couple relationship.
We undertook a large, prospective study to assess quality of life of patients and their spouses in the first year after diagnosis of nonmetastatic breast cancer. Family systems theory, which provided the general conceptual framework for this study, starts with the postulate that illness in one family member influences the entire family.9,10 A life-threatening illness like cancer may cause considerable distress among couple members and change their communication patterns, roles, and relationships.11 These changes occur through a process of interaction. The patient’s reactions to cancer affect her spouse, just as spouse’s reactions affect the patient. Also, changes in family patterns are part of a process influenced by events both inside and outside the family unit. Thus members of families where one individual has cancer may change over time as a result of new information, new ways of coping, treatments, and the illness course itself. Two crucial points emerge from this conceptual framework. First, to better understand the impact of breast cancer diagnosis and initial treatment on couples, the perspective of both members should be assessed. Second, a longitudinal design is required to understand changes occurring over time and to identify factors that may influence such changes.12
In this article, we present information on the extent to which both couple members report that breast cancer brought them closer and on characteristics related to couple interactions after diagnosis that are associated with both partners’ reporting a closer marital relationship 1 year after diagnosis. At the time we planned this study, we incorporated information from multiple sources to select the variables that could potentially be associated with the quality of life of both couple members, including relevant qualitative and quantitative literature then available on couples or spouses and marital adjustment after breast cancer,13-29 data from our own research program on psychosocial aspects of breast cancer, survivor experience and concerns, and clinical observations from surgeons, social workers, and nurses involved in breast cancer research and clinical care. In this study, we wanted to explore the effects of a wide variety of potential predictors from the perspective of both couple members at two time points after diagnosis.
PATIENTS AND METHODS
Consecutive series of newly diagnosed patients with breast cancer with histologically confirmed, localized, or regional-stage disease who were first treated in one of four hospitals in Quebec (Hpital du Saint-Sacrement, Htel-Dieu de Levis, Centre Hospitalier de l’Universite de Montreal campus Notre-Dame, and campus Htel-Dieu) between January 1996 and May 1997 and who met study eligibility criteria were invited to participate in a study of quality of life among couples facing breast cancer. Women with previous treatment for cancer, distant metastasis at diagnosis, not living with a spouse, or for whom a telephone interview was impossible (ie, without a telephone, insufficient fluency in French, and those with hearing problems or other health problems so severe that a telephone interview was unfeasible) were ineligible. Eligible patients were identified by a research nurse through weekly operating lists for breast surgery and pathology reports at each hospital. The nurse verified pathologic confirmation of the cancer and medical files for previous cancer treatment or evidence of metastatic disease at diagnosis. Physicians in each hospital either agreed to make patients aware of the study and seek their consent to be contacted by a research nurse about the study or had previously given their consent for a specially trained clinic nurse to contact all potentially eligible patients.
The nurse then contacted potentially eligible patients. At this first contact, the nurse ascertained whether the woman was currently living with a spouse (including both legally married and common-law couples) and provided explanation of the overall objectives and procedures of the study. Women were also informed that the study interviewer would contact them within the week to schedule the first interview. To maximize participation, women were recruited independently of knowing whether the spouse would also agree to participate.
Several paths were used for spouse recruitment. For a fairly large number of women, the spouse was present at the clinic when the nurse first met with the woman. In such cases, the nurse could explain what was required from both couple members if they consented to participate. If the spouse was not present, the woman was then asked to give permission to contact her spouse about the study. Among these women, some preferred to present the study to the spouse themselves. In such cases, the woman was recontacted by telephone within a couple of days to determine whether the spouse could now be approached by study personnel about the study. Spouses were eligible if their wives were participating. Additionally, like patients, spouses unable to give interviews in French or with severe health problems precluding a telephone interview were ineligible. Female spouses were excluded because of known differences in psychological distress levels in men and women in our population and small numbers that would have precluded stratifying on spouse sex in the analyses.
Each participating hospital’s ethics review committee approved this study. All patients provided signed informed consent to participate. In some cases, this was obtained at the hospital at the time of presentation of the study. For women who wanted more time to consider the study or speak to their spouse about it, consent forms were mailed back to the research team. Only two hospitals required signed consent to participate from spouses.
For both partners, data on quality of life and the marital relationship were assessed at 2 weeks and were obtained from telephone interviews carried out individually within 2 weeks of initiation of the woman’s definitive treatment (either surgery or preoperative chemotherapy) and then again 3 and 12 months later. Information on participants’ sociodemographic and psychosocial characteristics before diagnosis was obtained at the 2-week interview. All interviews were conducted by specially trained, experienced interviewers. The interviews mainly comprised validated instruments, questions used in our previous work, and some developed specifically for this study.30-35 Interview questions had been tested in a pilot study among 42 patients and 34 spouses (Dorval et al, unpublished data). Information on the women’s disease and treatment characteristics was abstracted from medical records and included extent of disease at diagnosis and other prognostic factors, initial surgical and adjuvant treatments, disease recurrence, and associated treatments.
Information about the effect of the disease and its treatment on closeness of the relationship was obtained at the 12-month interview using a single question: "Up to now, would you say that your (your wife’s) breast cancer and its treatment has been an experience that: (1) brought you closer to your partner, (2) distanced you from your partner, or (3) had no effect on your relationship with your partner" Interviews also provided information on several psychosocial characteristics measured 2 weeks and 3 months after start of treatment. Instruments and questions used and score reliability (where applicable) are summarized in Table 1.
In this study, the unit of analysis is the couple. A couple was classified as being closer after breast cancer when both couple members reported the disease had brought them closer. For any other combination of patient and spouse answers to the question about the effect of breast cancer on their relationship, the couple was considered as not being closer.
Multivariate analysis of characteristics potentially associated with increased closeness was performed using hierarchical logistic regression. Before carrying out the regression analysis, we examined whether there was collinearity between all the potential predictors using the procedure described in the SAS REG procedure (SAS Institute, Cary, NC).36 After considering the condition indices, the proportion of variance of the estimate accounted for by each principal component, and the variance inflation factors, we concluded that collinearity was not a problem in this data set.
The regression model was built in five steps. The first three steps were carried out using variables identified a priori to take into account the possible influence of characteristics that couples bring to the situation and that are not modifiable. Sociodemographic (step 1), prediagnosis psychosocial (step 2), and disease and treatment characteristics (step 3) were all block entered in the model. Because of the high correlation between patient and spouse age (r = 0.92), the mean age of the partners was used. In steps 4 and 5, stepwise regressions were performed to identify postdiagnosis characteristics associated with the likelihood of both couple members saying they were closer. The characteristics considered for inclusion in steps 4 and 5 were assessed at the 2-week and the 3-month interviews, respectively. Specifically, all Table 1 characteristics for which the reference period was after the diagnosis were candidates for stepwise selection, using an inclusion criterion of P = .10 and a removal criterion of P = .05. In all, 16 characteristics were considered for inclusion in step 4 and 12 in step 5, and these can be identified in Table 1 by the asterisk () and dagger (), respectively. Ordinal and continuous variables were categorized because most were not linearly associated with the study outcome. All significance levels are two-sided.
At each step, the percentage of variance explained (R2) so far in the proportion of couples who got closer was calculated using the maximum adjusted R2.37 Increments in R2 from one step to the next were also calculated. Likelihood ratio rests were used to obtain P values testing overall significance of each characteristic entered in each step and the significance of the model obtained after each step. Finally, odds ratios and their corresponding P values are reported for the final hierarchical model, obtained once all five steps were completed. All P values are two-sided.
RESULTS
During the study period, 863 women with newly diagnosed breast cancer were identified, of whom 464 were ineligible (previous cancer, 147 patients; distant disease at diagnosis, 11 patients; not living with a male spouse, 278 patients; non-French speaking, 11 patients; other severe health problems making a telephone interview impossible, 15 patients; and no home telephone, two patients).
Of the 399 eligible women, 349 (87%) consented to participate in the study and completed the first interview. Reasons for nonparticipation were refusal (38 patients) and other (nine women missed because of no or short hospitalization, and three women did not return written consent despite having verbally consented). Subsequently, 345 and 341 women completed the second and third interviews, respectively. At 3 months, losses to follow-up resulted from four refusals, and at 12 months, losses to follow-up resulted from two refusals and two deaths. Thus 98% (341 of 349) of those women who initially consented completed all study interviews.
Among the 349 spouses of participating women, 12 were ineligible for the following reasons: inability to complete an interview in French (two men) and other health problems making a telephone interview impossible (10 men). Among eligible spouses of participating patients, 308 (91%) of 337 spouses consented to participate. When considered relative to the total eligible population of 399 women while taking into account the 12 ineligible spouses, 80% (308 of 387) of eligible men consented. Second and third interviews were completed with 296 and 282 spouses, respectively, with losses resulting from 12 refusals at 3 months and from nine refusals, two patient deaths, and three spouse deaths at 12 months. Thus overall, 92% (282 of 308) of initial spouse participants completed all study interviews. Therefore, data from 282 couples were available for analyses.
The majority of women had partial mastectomy (84%) and radiotherapy (80%), whereas 40% received adjuvant chemotherapy and 51% received adjuvant hormone therapy (Table 2). At diagnosis, most couples were legally married (83%), 81% had been living together for more than 15 years, and 29% had children younger than 18 years of age living at home.
When considering both members, 42% (118 of 282) of the couples said that breast cancer and its treatments had brought them closer (Table 3). Both partners of only two couples (1%) reported breast cancer had distanced them, and only 18 couples in all (6%) had one or other member reporting this. In the rest, only the patient or the spouse reported getting closer, with no effect in the other partner (14% and 20%, respectively), or both reported no effect (16%). The global agreement between the patients and their spouse (ie, when both gave the same answer) about the effect of the disease on their relationship was 59% (165 of 282 couples). Both patients’ and spouses’ 12-month marital satisfaction scores were significantly higher among couples where both partners reported individually that breast cancer had brought them closer (patient mean, 37.7; spouse mean, 37.7) than among couples not closer (patient mean, 34.8; spouse mean, 35.6; P < .0001 and P = .0002 for comparisons of patients and spouses, respectively).
Characteristics predicting couples’ getting closer 1 year after breast cancer are presented in Table 4. Sample size for this analysis is just slightly lower (n = 278) than that presented earlier (n = 282) because of some missing data. All five blocks of characteristics simultaneously explained 31% of the variance in the proportions of couples who got closer (P < .0001). Globally, the control characteristics block entered in the first three steps accounted for 15% of the variance (P = .12). The patient having received chemotherapy (P = .021) and partners having lived together for 25 to 34 years (P = .007) were the only control characteristics associated with increased closeness after breast cancer once all characteristics were considered. In step 4, three characteristics of couple interactions in the 2 weeks after diagnosis accounted for 13% of the variance (P < .0001). Specifically, the spouse reporting the patient as a confidant (P = .003) or getting advice from her about coping with breast cancer (P = .03) and his accompanying the patient to surgery (P = .057) all increased the likelihood of both couple members saying the disease brought them closer. In the final step, the patient’s reporting at 3 months of more demonstrations of tenderness and affection from her spouse since diagnosis was significantly associated with an increased couple perception of closeness (P = .003).
DISCUSSION
Using a clear and simple question, we found a considerable proportion of couples (42%) facing nonmetastatic breast cancer reporting that the experience of the illness and its treatments had brought them closer 1 year after diagnosis. In addition, we have identified four characteristics, all related to short-term interactions connected with breast cancer, that are associated with an increased sense of marital closeness in both partners. Two weeks after diagnosis, the patient’s giving advice to the spouse about coping with breast cancer, the spouse’s accompanying the patient to surgery, and the spouse reporting the patient as a confidant were all independently associated with a greater likelihood of getting closer. At 3 months, the patient’s reporting more demonstrations of tenderness and affection from her spouse since diagnosis also emerged as a characteristic that predicted getting closer. Of the 28 characteristics related to patients’ and spouses’ postdiagnosis experiences that we considered, these are the only four that emerged as significant predictors. Characteristics not associated included several related to partners’ reports of psychological and physical effects of the disease and communication with the physician.
To our knowledge, this longitudinal study is the first to estimate the proportion of couples facing breast cancer that come through the first year with a closer relationship and identify potentially modifiable characteristics contributing to this positive outcome. Overall, our results support findings from the only other quantitative study showing that breast cancer is not associated with marital breakdown.38 They are also consistent with results from two other studies that suggested that partners who support each other in a reciprocal manner early after breast cancer diagnosis each individually tended to be more satisfied with their couple relationship 12 months later.6,39 The current study goes further by providing insight into the characteristics of the couples who became closer after this stressful life experience.
The design and methods of this study have several strengths and increase confidence in our findings. First, the study was based on an unselected, consecutive series of women with nonmetastatic breast cancer and their spouses. These women are representative of women being treated for breast cancer now: a high proportion had breast-conserving surgery and radiotherapy and either adjuvant chemotherapy or hormone therapy, depending on prognostic characteristics. Participation was high among patients and spouses alike, as was retention over time. Thus couples in this study are likely to be representative of couples facing breast cancer. Second, we used a prospective design that enabled us to measure a number of key characteristics related to each partner early on after diagnosis but before the assessment of marital closeness at 12 months. Third, we used a stringent criterion for rating couples as closer. To be considered as having gotten closer, both partners had to agree. As well, patients and spouses who individually reported getting closer had higher marital satisfaction than those who did not. Fourth, the study was large enough to assess a wide range of characteristics potentially influencing couples’ getting closer. Finally, our results are independent of differences in sociodemographic, prediagnosis marital satisfaction and the other psychosocial characteristics and key treatment and disease characteristics that were also included in our analyses. Although it may seem surprising at first glance that marital satisfaction before diagnosis was not predictive of getting closer, it does highlight the fact that, under certain conditions, couples at all levels of prediagnosis marital satisfaction can get closer after breast cancer.
We have also considered potential limitations that could have affected our findings. First, questions pertaining to psychosocial characteristics before diagnosis were asked retrospectively. However, when questioned all study participants were dealing with breast cancer diagnosis and treatment, and all were interviewed at similar periods since the start of treatment. Thus any effect of retrospective reporting, the only kind possible in this situation, would be nondifferential. Second, the use of a single item to measure the impact of breast cancer on the relationship is a potential limitation. This simple question was not intended to provide an in-depth assessment of the couples’ relationship. Rather, it was developed to summarize a dynamic process that involves both individual and couple dimensions. Moreover, we know from clinical experience that it corresponds to the way patients and spouses talk about the impact of breast cancer on their relationship,1 and to our knowledge, no validated instrument currently exists to measure this. Thus we believe the measure to be adequate to quantitatively assess the proportion of couples who explicitly linked the experience of breast cancer to getting closer, a phenomenon different from marital satisfaction. Third, we cannot exclude the possibility that social desirability may have affected the evaluation of the effect of breast cancer on closeness of the relationship. For example, some spouses might have been reluctant to say that their wife’s cancer distanced them. However, it seems less plausible that social desirability would lead to reporting that breast cancer had brought the couple closer when it in reality it had no effect. By merging the "no effect" and the "distanced us" categories of the outcome measure, we think that we may have limited any effect of social desirability.
Our findings are in line with a growing body of literature that emphasizes the importance of mutual social support in the couple relationship in general,40 and most likely in relation with breast cancer.41 In this study, we have gained some insight into the specific type of support provided within the first 2 weeks after treatment start by patients and spouses who felt closer 12 months later. The couples where the spouse reported confiding in the patient early after diagnosis, and where he got advice from her about coping with breast cancer, were better off. However, our results also suggest that spouses do not have to engage in extensive disclosure of their feelings and reactions to breast cancer. We assessed this characteristic, and the extent to which the spouse disclosed his feelings was not one that predicted getting closer. This in itself may be information of value to spouses, many of whom may not feel at ease initiating a discussion about the disease and prefer to avoid talking extensively about the cancer for fear of distressing the patient.41 In addition, despite the fact that the final odds ratios do not suggest a linear relationship, it does appear that some advice from the patient to spouse is helpful. Although the use of only two items to measure this characteristic precludes an in-depth understanding of this finding, one may speculate that the patient may have more information overall about the disease and its effects than the spouse and thus be in a good position to advise him about his coping with the disease and its treatments. This finding has been reported previously39 and points to the importance of mutuality in the support process. Further studies are needed to identify the specific kinds of advice that patients give their spouses in the short term after breast cancer diagnosis if we are to translate these findings into concrete clinical recommendations that can be tested experimentally to determine their effect on marital closeness. Finally, the simple act of accompanying the patient when she went for surgery also contributed to getting closer. This behavior can be interpreted as an effective form of both emotional and tangible support occurring at a critical moment for the patient.42 Thus spouses might be informed that involvement at this step may be important for helping the patient at a stressful stage of treatment.
Women in couples who got closer also reported increased demonstrations of tenderness and affection from their spouse during the first 3 months after diagnosis. It is difficult to speculate about this association because the specific manifestations of tenderness and affection in each couple are unknown to us. Nevertheless, from the woman’s viewpoint, it seems that it might be the right type of support given the needs elicited by this particularly stressful life event.43-45 Such demonstrations may provide tangible evidence to the patient that the couple relationship is not fundamentally threatened by breast cancer and thus contribute to countering the fear of abandonment reported among women facing breast cancer.1 It may also reassure the patient about the spouse’s acceptance of any changes in body image. We have already found that women in this study were much more preoccupied by the possible physical effects of the disease than spouses as a group.46 It is known that among individuals in the social network generally, intimate others are the most highly valued in terms of providing esteem and emotional support.8 Our results are consistent with the view that an increase in manifestations of tenderness and affection by the spouse can contribute to fostering intimacy and closeness and hold the couple together through this difficult time.40
A first implication of our results is that they may reassure newly diagnosed patients and their spouses. They provide further evidence that, under certain conditions, breast cancer can be a growth experience for many couples affected by this disease, just as it can be with other types of cancer.2 In some ways, then, this finding presents a much less dire image of the effect of breast cancer on a couple than might be feared.47
Second, our results suggest that attention should be given to the ways partners support each other during the first weeks after the start of treatment. Others have shown that the spouse is seen as the most important source of support among women with breast cancer,31,48 and that helping from other network members fails to substitute for spouse support.7 Thus both patients and their spouses may benefit from a psychoeducational intervention aimed to help them with basic interactions about the disease. This intervention could target simple ground rules that do not involve a formal skills training given by professionals and could be implemented at relatively low cost. From a public health viewpoint, such an intervention timed to coincide with the period when treatments are decided and initiated could be particularly efficient in reaching many patients with breast cancer who are living with a spouse.
Finally, promoting increased closeness within the couple could conceivably also have health benefits for women facing breast cancer. Quality of the marital relationship has been positively associated with immune and endocrine function.49 From a bio-behavioral perspective, positive emotions resulting from a closer relationship with the spouse can affect health either indirectly through better health behaviors or compliance with medical regimens, or directly, through lesser alterations in the functioning of the CNS and immune, endocrine, and cardiovascular systems.50,51
The characteristics identified here that predict getting closer after breast cancer are all potentially modifiable. Taken together, our findings suggest that it may be important to develop a brief psychoeducational intervention for delivery early after diagnosis of breast cancer to help couples with basic interactions about the disease and evaluate whether such an intervention can increase the likelihood that more couples will experience favorable marital outcomes after the stress of dealing with breast cancer.
Authors' Disclosures of Potential Conflicts of Interest
The authors indicated no potential conflicts of interest.
NOTES
Supported by a research grant from the Canadian Breast Cancer Research Alliance (grant No. 006426). M.D. currently holds a Chercheur-boursier award from the Fonds de la Recherche en Sante du Quebec. A.R. is Chairholder of the Scotiabank Chair in Diagnosis and Treatment of Breast Cancer. E.M. is a Canadian Institutes for Health Research Investigator.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
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Universite Laval
Centre des maladies du sein Deschênes-Fabia, Hpital du Saint-Sacrement, Quebec
Centre de recherche Fernand-Seguin de l'Hpital Louis-H. Lafontaine
Universite de Montreal
Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
Fred Hutchinson Cancer Research Center, Seattle, WA
ABSTRACT
PURPOSE: Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this.
PATIENTS AND METHODS: This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect.
RESULTS: Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer.
CONCLUSION: Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.
INTRODUCTION
Although the marital relationship is undoubtedly stressed by a diagnosis of breast cancer, many couples seem to have the resources to meet this challenge, to acquire the appropriate support to do so, or both.1 Clinical experience and some research suggest that some couples facing cancer perceive that their marital relationship improved since the cancer episode.2 Although there are reports of spouse and/or patient assessments of marital adjustment and the importance of social support from the spouse for adjustment generally in this situation,3-8 these studies still consider each partner separately. None has taken into account the views of both partners simultaneously or prediagnosis predictors of marital adjustment in the evaluation of effects on the marital relation. Thus we do not know the extent to which both partners consider that they have come through the first year after breast cancer with a closer relationship. Nor do we know which sociodemographic, psychosocial, illness, and treatment characteristics contribute to this positive outcome. A better understanding of characteristics involved may suggest avenues for improving psychosocial care of patients and their spouses and possibly their quality of life. If it turns out that the couple relation is relatively unaffected or even made closer afterwards, such information could be empowering to women and men facing this disease and help dedramatize the effects of breast cancer on the couple relationship.
We undertook a large, prospective study to assess quality of life of patients and their spouses in the first year after diagnosis of nonmetastatic breast cancer. Family systems theory, which provided the general conceptual framework for this study, starts with the postulate that illness in one family member influences the entire family.9,10 A life-threatening illness like cancer may cause considerable distress among couple members and change their communication patterns, roles, and relationships.11 These changes occur through a process of interaction. The patient’s reactions to cancer affect her spouse, just as spouse’s reactions affect the patient. Also, changes in family patterns are part of a process influenced by events both inside and outside the family unit. Thus members of families where one individual has cancer may change over time as a result of new information, new ways of coping, treatments, and the illness course itself. Two crucial points emerge from this conceptual framework. First, to better understand the impact of breast cancer diagnosis and initial treatment on couples, the perspective of both members should be assessed. Second, a longitudinal design is required to understand changes occurring over time and to identify factors that may influence such changes.12
In this article, we present information on the extent to which both couple members report that breast cancer brought them closer and on characteristics related to couple interactions after diagnosis that are associated with both partners’ reporting a closer marital relationship 1 year after diagnosis. At the time we planned this study, we incorporated information from multiple sources to select the variables that could potentially be associated with the quality of life of both couple members, including relevant qualitative and quantitative literature then available on couples or spouses and marital adjustment after breast cancer,13-29 data from our own research program on psychosocial aspects of breast cancer, survivor experience and concerns, and clinical observations from surgeons, social workers, and nurses involved in breast cancer research and clinical care. In this study, we wanted to explore the effects of a wide variety of potential predictors from the perspective of both couple members at two time points after diagnosis.
PATIENTS AND METHODS
Consecutive series of newly diagnosed patients with breast cancer with histologically confirmed, localized, or regional-stage disease who were first treated in one of four hospitals in Quebec (Hpital du Saint-Sacrement, Htel-Dieu de Levis, Centre Hospitalier de l’Universite de Montreal campus Notre-Dame, and campus Htel-Dieu) between January 1996 and May 1997 and who met study eligibility criteria were invited to participate in a study of quality of life among couples facing breast cancer. Women with previous treatment for cancer, distant metastasis at diagnosis, not living with a spouse, or for whom a telephone interview was impossible (ie, without a telephone, insufficient fluency in French, and those with hearing problems or other health problems so severe that a telephone interview was unfeasible) were ineligible. Eligible patients were identified by a research nurse through weekly operating lists for breast surgery and pathology reports at each hospital. The nurse verified pathologic confirmation of the cancer and medical files for previous cancer treatment or evidence of metastatic disease at diagnosis. Physicians in each hospital either agreed to make patients aware of the study and seek their consent to be contacted by a research nurse about the study or had previously given their consent for a specially trained clinic nurse to contact all potentially eligible patients.
The nurse then contacted potentially eligible patients. At this first contact, the nurse ascertained whether the woman was currently living with a spouse (including both legally married and common-law couples) and provided explanation of the overall objectives and procedures of the study. Women were also informed that the study interviewer would contact them within the week to schedule the first interview. To maximize participation, women were recruited independently of knowing whether the spouse would also agree to participate.
Several paths were used for spouse recruitment. For a fairly large number of women, the spouse was present at the clinic when the nurse first met with the woman. In such cases, the nurse could explain what was required from both couple members if they consented to participate. If the spouse was not present, the woman was then asked to give permission to contact her spouse about the study. Among these women, some preferred to present the study to the spouse themselves. In such cases, the woman was recontacted by telephone within a couple of days to determine whether the spouse could now be approached by study personnel about the study. Spouses were eligible if their wives were participating. Additionally, like patients, spouses unable to give interviews in French or with severe health problems precluding a telephone interview were ineligible. Female spouses were excluded because of known differences in psychological distress levels in men and women in our population and small numbers that would have precluded stratifying on spouse sex in the analyses.
Each participating hospital’s ethics review committee approved this study. All patients provided signed informed consent to participate. In some cases, this was obtained at the hospital at the time of presentation of the study. For women who wanted more time to consider the study or speak to their spouse about it, consent forms were mailed back to the research team. Only two hospitals required signed consent to participate from spouses.
For both partners, data on quality of life and the marital relationship were assessed at 2 weeks and were obtained from telephone interviews carried out individually within 2 weeks of initiation of the woman’s definitive treatment (either surgery or preoperative chemotherapy) and then again 3 and 12 months later. Information on participants’ sociodemographic and psychosocial characteristics before diagnosis was obtained at the 2-week interview. All interviews were conducted by specially trained, experienced interviewers. The interviews mainly comprised validated instruments, questions used in our previous work, and some developed specifically for this study.30-35 Interview questions had been tested in a pilot study among 42 patients and 34 spouses (Dorval et al, unpublished data). Information on the women’s disease and treatment characteristics was abstracted from medical records and included extent of disease at diagnosis and other prognostic factors, initial surgical and adjuvant treatments, disease recurrence, and associated treatments.
Information about the effect of the disease and its treatment on closeness of the relationship was obtained at the 12-month interview using a single question: "Up to now, would you say that your (your wife’s) breast cancer and its treatment has been an experience that: (1) brought you closer to your partner, (2) distanced you from your partner, or (3) had no effect on your relationship with your partner" Interviews also provided information on several psychosocial characteristics measured 2 weeks and 3 months after start of treatment. Instruments and questions used and score reliability (where applicable) are summarized in Table 1.
In this study, the unit of analysis is the couple. A couple was classified as being closer after breast cancer when both couple members reported the disease had brought them closer. For any other combination of patient and spouse answers to the question about the effect of breast cancer on their relationship, the couple was considered as not being closer.
Multivariate analysis of characteristics potentially associated with increased closeness was performed using hierarchical logistic regression. Before carrying out the regression analysis, we examined whether there was collinearity between all the potential predictors using the procedure described in the SAS REG procedure (SAS Institute, Cary, NC).36 After considering the condition indices, the proportion of variance of the estimate accounted for by each principal component, and the variance inflation factors, we concluded that collinearity was not a problem in this data set.
The regression model was built in five steps. The first three steps were carried out using variables identified a priori to take into account the possible influence of characteristics that couples bring to the situation and that are not modifiable. Sociodemographic (step 1), prediagnosis psychosocial (step 2), and disease and treatment characteristics (step 3) were all block entered in the model. Because of the high correlation between patient and spouse age (r = 0.92), the mean age of the partners was used. In steps 4 and 5, stepwise regressions were performed to identify postdiagnosis characteristics associated with the likelihood of both couple members saying they were closer. The characteristics considered for inclusion in steps 4 and 5 were assessed at the 2-week and the 3-month interviews, respectively. Specifically, all Table 1 characteristics for which the reference period was after the diagnosis were candidates for stepwise selection, using an inclusion criterion of P = .10 and a removal criterion of P = .05. In all, 16 characteristics were considered for inclusion in step 4 and 12 in step 5, and these can be identified in Table 1 by the asterisk () and dagger (), respectively. Ordinal and continuous variables were categorized because most were not linearly associated with the study outcome. All significance levels are two-sided.
At each step, the percentage of variance explained (R2) so far in the proportion of couples who got closer was calculated using the maximum adjusted R2.37 Increments in R2 from one step to the next were also calculated. Likelihood ratio rests were used to obtain P values testing overall significance of each characteristic entered in each step and the significance of the model obtained after each step. Finally, odds ratios and their corresponding P values are reported for the final hierarchical model, obtained once all five steps were completed. All P values are two-sided.
RESULTS
During the study period, 863 women with newly diagnosed breast cancer were identified, of whom 464 were ineligible (previous cancer, 147 patients; distant disease at diagnosis, 11 patients; not living with a male spouse, 278 patients; non-French speaking, 11 patients; other severe health problems making a telephone interview impossible, 15 patients; and no home telephone, two patients).
Of the 399 eligible women, 349 (87%) consented to participate in the study and completed the first interview. Reasons for nonparticipation were refusal (38 patients) and other (nine women missed because of no or short hospitalization, and three women did not return written consent despite having verbally consented). Subsequently, 345 and 341 women completed the second and third interviews, respectively. At 3 months, losses to follow-up resulted from four refusals, and at 12 months, losses to follow-up resulted from two refusals and two deaths. Thus 98% (341 of 349) of those women who initially consented completed all study interviews.
Among the 349 spouses of participating women, 12 were ineligible for the following reasons: inability to complete an interview in French (two men) and other health problems making a telephone interview impossible (10 men). Among eligible spouses of participating patients, 308 (91%) of 337 spouses consented to participate. When considered relative to the total eligible population of 399 women while taking into account the 12 ineligible spouses, 80% (308 of 387) of eligible men consented. Second and third interviews were completed with 296 and 282 spouses, respectively, with losses resulting from 12 refusals at 3 months and from nine refusals, two patient deaths, and three spouse deaths at 12 months. Thus overall, 92% (282 of 308) of initial spouse participants completed all study interviews. Therefore, data from 282 couples were available for analyses.
The majority of women had partial mastectomy (84%) and radiotherapy (80%), whereas 40% received adjuvant chemotherapy and 51% received adjuvant hormone therapy (Table 2). At diagnosis, most couples were legally married (83%), 81% had been living together for more than 15 years, and 29% had children younger than 18 years of age living at home.
When considering both members, 42% (118 of 282) of the couples said that breast cancer and its treatments had brought them closer (Table 3). Both partners of only two couples (1%) reported breast cancer had distanced them, and only 18 couples in all (6%) had one or other member reporting this. In the rest, only the patient or the spouse reported getting closer, with no effect in the other partner (14% and 20%, respectively), or both reported no effect (16%). The global agreement between the patients and their spouse (ie, when both gave the same answer) about the effect of the disease on their relationship was 59% (165 of 282 couples). Both patients’ and spouses’ 12-month marital satisfaction scores were significantly higher among couples where both partners reported individually that breast cancer had brought them closer (patient mean, 37.7; spouse mean, 37.7) than among couples not closer (patient mean, 34.8; spouse mean, 35.6; P < .0001 and P = .0002 for comparisons of patients and spouses, respectively).
Characteristics predicting couples’ getting closer 1 year after breast cancer are presented in Table 4. Sample size for this analysis is just slightly lower (n = 278) than that presented earlier (n = 282) because of some missing data. All five blocks of characteristics simultaneously explained 31% of the variance in the proportions of couples who got closer (P < .0001). Globally, the control characteristics block entered in the first three steps accounted for 15% of the variance (P = .12). The patient having received chemotherapy (P = .021) and partners having lived together for 25 to 34 years (P = .007) were the only control characteristics associated with increased closeness after breast cancer once all characteristics were considered. In step 4, three characteristics of couple interactions in the 2 weeks after diagnosis accounted for 13% of the variance (P < .0001). Specifically, the spouse reporting the patient as a confidant (P = .003) or getting advice from her about coping with breast cancer (P = .03) and his accompanying the patient to surgery (P = .057) all increased the likelihood of both couple members saying the disease brought them closer. In the final step, the patient’s reporting at 3 months of more demonstrations of tenderness and affection from her spouse since diagnosis was significantly associated with an increased couple perception of closeness (P = .003).
DISCUSSION
Using a clear and simple question, we found a considerable proportion of couples (42%) facing nonmetastatic breast cancer reporting that the experience of the illness and its treatments had brought them closer 1 year after diagnosis. In addition, we have identified four characteristics, all related to short-term interactions connected with breast cancer, that are associated with an increased sense of marital closeness in both partners. Two weeks after diagnosis, the patient’s giving advice to the spouse about coping with breast cancer, the spouse’s accompanying the patient to surgery, and the spouse reporting the patient as a confidant were all independently associated with a greater likelihood of getting closer. At 3 months, the patient’s reporting more demonstrations of tenderness and affection from her spouse since diagnosis also emerged as a characteristic that predicted getting closer. Of the 28 characteristics related to patients’ and spouses’ postdiagnosis experiences that we considered, these are the only four that emerged as significant predictors. Characteristics not associated included several related to partners’ reports of psychological and physical effects of the disease and communication with the physician.
To our knowledge, this longitudinal study is the first to estimate the proportion of couples facing breast cancer that come through the first year with a closer relationship and identify potentially modifiable characteristics contributing to this positive outcome. Overall, our results support findings from the only other quantitative study showing that breast cancer is not associated with marital breakdown.38 They are also consistent with results from two other studies that suggested that partners who support each other in a reciprocal manner early after breast cancer diagnosis each individually tended to be more satisfied with their couple relationship 12 months later.6,39 The current study goes further by providing insight into the characteristics of the couples who became closer after this stressful life experience.
The design and methods of this study have several strengths and increase confidence in our findings. First, the study was based on an unselected, consecutive series of women with nonmetastatic breast cancer and their spouses. These women are representative of women being treated for breast cancer now: a high proportion had breast-conserving surgery and radiotherapy and either adjuvant chemotherapy or hormone therapy, depending on prognostic characteristics. Participation was high among patients and spouses alike, as was retention over time. Thus couples in this study are likely to be representative of couples facing breast cancer. Second, we used a prospective design that enabled us to measure a number of key characteristics related to each partner early on after diagnosis but before the assessment of marital closeness at 12 months. Third, we used a stringent criterion for rating couples as closer. To be considered as having gotten closer, both partners had to agree. As well, patients and spouses who individually reported getting closer had higher marital satisfaction than those who did not. Fourth, the study was large enough to assess a wide range of characteristics potentially influencing couples’ getting closer. Finally, our results are independent of differences in sociodemographic, prediagnosis marital satisfaction and the other psychosocial characteristics and key treatment and disease characteristics that were also included in our analyses. Although it may seem surprising at first glance that marital satisfaction before diagnosis was not predictive of getting closer, it does highlight the fact that, under certain conditions, couples at all levels of prediagnosis marital satisfaction can get closer after breast cancer.
We have also considered potential limitations that could have affected our findings. First, questions pertaining to psychosocial characteristics before diagnosis were asked retrospectively. However, when questioned all study participants were dealing with breast cancer diagnosis and treatment, and all were interviewed at similar periods since the start of treatment. Thus any effect of retrospective reporting, the only kind possible in this situation, would be nondifferential. Second, the use of a single item to measure the impact of breast cancer on the relationship is a potential limitation. This simple question was not intended to provide an in-depth assessment of the couples’ relationship. Rather, it was developed to summarize a dynamic process that involves both individual and couple dimensions. Moreover, we know from clinical experience that it corresponds to the way patients and spouses talk about the impact of breast cancer on their relationship,1 and to our knowledge, no validated instrument currently exists to measure this. Thus we believe the measure to be adequate to quantitatively assess the proportion of couples who explicitly linked the experience of breast cancer to getting closer, a phenomenon different from marital satisfaction. Third, we cannot exclude the possibility that social desirability may have affected the evaluation of the effect of breast cancer on closeness of the relationship. For example, some spouses might have been reluctant to say that their wife’s cancer distanced them. However, it seems less plausible that social desirability would lead to reporting that breast cancer had brought the couple closer when it in reality it had no effect. By merging the "no effect" and the "distanced us" categories of the outcome measure, we think that we may have limited any effect of social desirability.
Our findings are in line with a growing body of literature that emphasizes the importance of mutual social support in the couple relationship in general,40 and most likely in relation with breast cancer.41 In this study, we have gained some insight into the specific type of support provided within the first 2 weeks after treatment start by patients and spouses who felt closer 12 months later. The couples where the spouse reported confiding in the patient early after diagnosis, and where he got advice from her about coping with breast cancer, were better off. However, our results also suggest that spouses do not have to engage in extensive disclosure of their feelings and reactions to breast cancer. We assessed this characteristic, and the extent to which the spouse disclosed his feelings was not one that predicted getting closer. This in itself may be information of value to spouses, many of whom may not feel at ease initiating a discussion about the disease and prefer to avoid talking extensively about the cancer for fear of distressing the patient.41 In addition, despite the fact that the final odds ratios do not suggest a linear relationship, it does appear that some advice from the patient to spouse is helpful. Although the use of only two items to measure this characteristic precludes an in-depth understanding of this finding, one may speculate that the patient may have more information overall about the disease and its effects than the spouse and thus be in a good position to advise him about his coping with the disease and its treatments. This finding has been reported previously39 and points to the importance of mutuality in the support process. Further studies are needed to identify the specific kinds of advice that patients give their spouses in the short term after breast cancer diagnosis if we are to translate these findings into concrete clinical recommendations that can be tested experimentally to determine their effect on marital closeness. Finally, the simple act of accompanying the patient when she went for surgery also contributed to getting closer. This behavior can be interpreted as an effective form of both emotional and tangible support occurring at a critical moment for the patient.42 Thus spouses might be informed that involvement at this step may be important for helping the patient at a stressful stage of treatment.
Women in couples who got closer also reported increased demonstrations of tenderness and affection from their spouse during the first 3 months after diagnosis. It is difficult to speculate about this association because the specific manifestations of tenderness and affection in each couple are unknown to us. Nevertheless, from the woman’s viewpoint, it seems that it might be the right type of support given the needs elicited by this particularly stressful life event.43-45 Such demonstrations may provide tangible evidence to the patient that the couple relationship is not fundamentally threatened by breast cancer and thus contribute to countering the fear of abandonment reported among women facing breast cancer.1 It may also reassure the patient about the spouse’s acceptance of any changes in body image. We have already found that women in this study were much more preoccupied by the possible physical effects of the disease than spouses as a group.46 It is known that among individuals in the social network generally, intimate others are the most highly valued in terms of providing esteem and emotional support.8 Our results are consistent with the view that an increase in manifestations of tenderness and affection by the spouse can contribute to fostering intimacy and closeness and hold the couple together through this difficult time.40
A first implication of our results is that they may reassure newly diagnosed patients and their spouses. They provide further evidence that, under certain conditions, breast cancer can be a growth experience for many couples affected by this disease, just as it can be with other types of cancer.2 In some ways, then, this finding presents a much less dire image of the effect of breast cancer on a couple than might be feared.47
Second, our results suggest that attention should be given to the ways partners support each other during the first weeks after the start of treatment. Others have shown that the spouse is seen as the most important source of support among women with breast cancer,31,48 and that helping from other network members fails to substitute for spouse support.7 Thus both patients and their spouses may benefit from a psychoeducational intervention aimed to help them with basic interactions about the disease. This intervention could target simple ground rules that do not involve a formal skills training given by professionals and could be implemented at relatively low cost. From a public health viewpoint, such an intervention timed to coincide with the period when treatments are decided and initiated could be particularly efficient in reaching many patients with breast cancer who are living with a spouse.
Finally, promoting increased closeness within the couple could conceivably also have health benefits for women facing breast cancer. Quality of the marital relationship has been positively associated with immune and endocrine function.49 From a bio-behavioral perspective, positive emotions resulting from a closer relationship with the spouse can affect health either indirectly through better health behaviors or compliance with medical regimens, or directly, through lesser alterations in the functioning of the CNS and immune, endocrine, and cardiovascular systems.50,51
The characteristics identified here that predict getting closer after breast cancer are all potentially modifiable. Taken together, our findings suggest that it may be important to develop a brief psychoeducational intervention for delivery early after diagnosis of breast cancer to help couples with basic interactions about the disease and evaluate whether such an intervention can increase the likelihood that more couples will experience favorable marital outcomes after the stress of dealing with breast cancer.
Authors' Disclosures of Potential Conflicts of Interest
The authors indicated no potential conflicts of interest.
NOTES
Supported by a research grant from the Canadian Breast Cancer Research Alliance (grant No. 006426). M.D. currently holds a Chercheur-boursier award from the Fonds de la Recherche en Sante du Quebec. A.R. is Chairholder of the Scotiabank Chair in Diagnosis and Treatment of Breast Cancer. E.M. is a Canadian Institutes for Health Research Investigator.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
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