1. Background
Advances and improvements have been done in diagnosis and treatment of cancer, and have increased survival of breast cancer patients to focus more on health care, quality of life (QOL) of these patients. Therefore, assessment of QOL is now one of the most important issues in studies of oncology. Health related quality of life (HRQoL) is a subjective concept of health-related quality of life consisting of the physical, mental, and social health dimensions (1). This concept is one of the most important issues in the field of cancer research, particularly in breast cancer in women. Factors such as social features, demographic, medical, public health, and life style can influence HRQoL in women with breast cancer. Coping and mental adjustment are important factors in HRQoL in cancer patients (2). Mental adjustment to cancer (MAC) was defined as ‘the cognitive and behavioral responses the patient makes to the diagnosis of cancer (3). This definition includes the emotional reactions to cancer, too (4).
Studies have shown the mental adjustment of cancer patients associated with QOL and psychological distress (5, 6). In addition, some studies have shown that psychological adjustment to cancer may affect patients’ health outcomes. Watson et al. (3) developed the mental adjustment to cancer (MAC) scale to measure cognitive and behavioral responses of patients suffering from cancer. This MAC scale has been widely used as a tool to measure the coping response in cancer patients and contain five dimensions. spirit spirit (FS) was characterized by a determinant of fight to the illness and adopting an optimistic attitude with a realistic appraisal of the illness. Fatalism (FA) is the acknowledgment of the illness without seeking further information unless new symptoms are developed. It is a tendency to put oneself in the hands of God. Helplessness-hopelessness (HH) relate to the tendency to adopt a pessimistic attitude about the illness. Anxious preoccupation (AP) is characterized by constant preoccupation with cancer as an event source of feelings of devastation, anxiety, fear, apprehension, and cognitive avoidance (CA) is tendency to avoidance of direct thinking about the disease (3, 7).
In most studies on coping styles conducted in the East, the fighting spirit and fatalism are classified as positive attitudes (8, 9). In addition, some researches show that anxious reoccupation and helplessness/hopelessness strategies must be as negative emotion factor combined (9). According to the studies by Watson (10), Bredal (11) and Hulbert-Williams (12), and Wang (13), helplessness/hopelessness and anxious preoccupation, and cognitive avoidance are specified as a maladaptive coping styles. According to researches, avoidance response or helplessness/hopelessness was related with higher level of anxiety and depression while active or coping styles have been related with better adaptation (14, 15).
The positive relation between anxiety and depression in patients with breast cancer and anxiety preoccupation, fatalism and helplessness/hopelessness have been reported, while the style of fighting spirit is negatively correlated with anxiety and depression (16). Finding of another study showed that the hopelessness coping response a negative determinant of perceived social support of patients (17). In Johansson’s study (18) which was conducted on laryngeal cancer patients, helpless-hopeless and anxious reoccupation responses were associated with mood disorder and HRQoL. Also helpless/hopeless and anxious preoccupation responses that were significantly had a negative effect on well-being, irrespective of phase of illness. The results of Lampic et al. (19) also showed that high level of fighting spirit is related with high levels of psychosocial well-being and mood with less concerns related to cancer, while the preoccupation anxiety and helplessness/hopelessness styles are related to the less psycho-social well-being, more situation anxiety, and more concerns related to cancer. Jacobsen and Jim (2) studied the relation between mental adjustment styles and QoL in Chinese patients with cancer. They showed that the QoL has a positive relation with fighting spirit and a negative relation with fatalism. Also, high fighting spirit has a positive relation with more positive affect which in turn is related with better QOL but higher fatalism is related to less positive affect and more negative emotion, which in return related to worse QoL. There is no significant correlation between fighting spirit and the QoL in other studies. Because of the relation between fatalism and QOL, some studies showed that it was a negative relation (20, 21), while others showed a positive relation (22, 23) or no significant correlation (24).
According to the findings, the relation between adjustment with cancer between patients and HRQoL is varied and inconsistent. Not much research has been done in this regard. The research questions are “what is the relation between these variables in Iranian breast cancer patients?”, and “which styles of adjustment impact greatly in the HRQoL of breast cancer patients?”
2. Methods
The study is a cross sectional and correlational one. The correlation and regression methods have been applied to answer the study questions.
2.1. Participants
The study sample was recruited from the cancer clinic in Kermanshah and Shiraz cities. Inclusion criteria of the study included diagnosis of breast cancer in women, who were 18 or older (with confirmed breast cancer diagnosis) with no sever physical or cognitive impairment. After the patients had been informed of the purpose of the study, their consent was obtained. 100 patients participated voluntarily through a non-random convenient sampling procedure from hospitals and oncology clinics in Kermanshah and Shiraz, Iran.
Information on the sample group is shown in Table 1. It should be mentioned that many patients were not aware of the stage of the disease; therefore, questions related to the stage of the disease were eliminated.
Table 1.Demographic and Medical Data (n = 100)
| Characteristics | N |
|---|---|
| Mean Age | 43.8 |
| Rang Age | 24 - 70 |
| Marital status | |
| Married | 85 |
| Single | 4 |
| Divorced | 3 |
| Widowed | 4 |
| Unclear | 4 |
| Education | |
| Diploma | 47 |
| diploma degree | 37 |
| Undergraduate | 13 |
| Graduate | 2 |
| Unclear | 1 |
| Occupation | |
| Employed | 31 |
| Unemployed/ Retired | 59 |
| Unknown | 10 |
| Treatment | |
| Surgery | 65 |
| Surgery-Chemotherapy | 25 |
| Surgery-Chemotherapy-Radiotherapy | 10 |
2.2. Measures
Demographic questionnaire: This questionnaire includes patient characteristics, such as gender, age, education, marital status and the treatment carried out in the past and in the present.
2.3. Persian Version of the Mini-MAC
The 29-item Mini-MAC (10) was used in its Persian version. The original factor structure was used to obtain scores on the five sub-scales identified in the Watson et al. (10) study namely; fighting spirit (4 items), hopelessness (8 items), anxious preoccupation (8 items), fatalism (5 items) and cognitive avoidance (4 items). It should be noted that the items have been scored based on a 4-point scale from 1 (Definitely does not apply to me) to 4 (Definitely applies to me). A higher score represents a higher level of the respective adjustment style. The Persian version was done by the following standard translation method. To translate the Mini-MAC from English into Persian, the ‘forward-backward’ procedure was applied. The scale was translated from English into Persian by an expert in English and a PhD student in psychology, and next revised by a professor of psychology after obtaining copyright permission from the original author. To be compared with the original, another language expert translated it back to English. The final version obtained made the content valid and provided to another psychology professor to evaluate the scale from content and partial clarity that led to reforms in some items. Alpha coefficients are helplessness/hopelessness 0.94, cognitive avoidance 0.76, anxious preoccupation 0.90, fatalism 0.77, the fighting spirit 0.80 for the subscales and the total scale is 0.84 respectively (25). The findings show that the Mini-MAC can be used as a valid and reliable tool to measure adjustment and coping with cancer.
2.4. Persian Version of the FACT-B
The functional assessment of cancer therapy-breast (FACT-B) is a HRQoL instrument that is specifically developed for breast cancer patients. The FACT-B (V4.0) has two parts: the general subscale on cancer (FACT-G) and the additional concerns on breast cancer as a specific subscale (BCS) with nine items. This scale includes physical well-being (PWB) with seven items, social/family well-being (SFWB) with seven items, the emotional well-being (EWB) with six items, the functional well-being (FWB) with seven items and the BCS with nine items. Each item is rated on a 5-point Likert scale. The total score of the FACT-B is the score sum of all five subscales which can range from 0 to 144. A higher score shows the better QoL of the patient (26, 27). To translate the FACT-B from English into Persian, the ‘forward-backward’ procedure was applied. The scale was translated from English into Persian by an expert in English and a PhD student in psychology, and next revised by a professor of psychology. To be compared with the original, another language expert translated it back to English. The final version obtained made the content valid and was provided to another psychology professor to evaluate the scale from content and partial clarity that led to reforms in some items (28). Cronbach’s alpha coefficients are 0.71, 0.91, 0.78, 0.93, 0.63, and 0.92 for PWB, SFWB, EWB, FWB, BCS and FACT-B total respectively.
In sum, the results show that this scale can be used in research and clinical settings to assess HRQoL in Iranian patients with breast cancer.
3. Results
Information about the correlation between variables of variables study is presented in Table 2.
Table 2.Correlation Matrix of the Study Variables
| Physical Well-Being | Social/Family Well-Being | Emotional Well-Being | Functional Well-Being | BCS | FACT-B | |
|---|---|---|---|---|---|---|
| Helplessness/Hopelessness | -0.250a | -0.590b | -0.528b | -0.654b | - 0.237a | - 0.768b |
| Preoccupation Anxiety | -0.353b | -0.333b | -0.545b | -0.392b | -0.319b | -0.577b |
| Cognitive Avoidance | -0.196 | 0.351b | -0.101 | 0.151 | -0.098 | 0.113 |
| Fatalism | -0.254 | 0.655b | 0.332b | 0.490b | 0.141 | 0.427 |
| Fighting Spirit | -0.007 | 0.717b | 0.350b | 0.665b | 0.088 | 0.633b |
aP < 0.05
bP < 0.01.
The results in Table 2 show that helplessness/hopelessness and preoccupation anxiety have significant negative relation with the whole subscales of FACT-B. Cognitive avoidance only has a significant positive relation with social/family well-being. Fatalism and fighting spirit have significant positive relation with social/family well-being, emotional well-being and functional well-being subscales of FACT-B. As it can be seen in the correlation matrix, except cognitive avoidance style, other mental adjustments to cancer have significant relations with HRQoL.
To predict HRQoL by styles of mental adjustment to cancer, regression analysis has been performed (Tables 3 and 4).
Table 3.The Results of Regression Analysis to Explain Health Related Quality of Life (HRQoL) Through Mental Adjustment to Cancer Styles
| Sum of Squares | df | Mean of Square | F | Sig. | R | R2 | Std.standard Error of the Estimate | ||
|---|---|---|---|---|---|---|---|---|---|
| Helplessness/Hopelessness | Regression | 21548.751 | 1 | 21548.751 | 111.843 | 0.001 | 0.768 | 0.589 | 13.880 |
| 15028.237 | 79 | 192.670 | |||||||
| Preoccupation Anxiety | Regression | 12874.362 | 1 | 12874.362 | 38.829 | 0.001 | 0.577 | 0332 | 18.208 |
| 25861.838 | 79 | 331.562 | |||||||
| Cognitive avoidance | Regression | 492.292 | 1 | 492.292 | 1.004 | 0.113 | 0.113 | 0.013 | 22.143 |
| 38243.908 | 79 | 490.307 | |||||||
| Fatalism | Regression | 15517.585 | 1 | 15517.585 | 52.082 | 0.001 | 0.633 | 0.400 | 17.261 |
| 23239.615 | 79 | 297.944 | |||||||
| Fighting Spirit | Regression | 6783.312 | 1 | 6783.312 | 16.935 | 0.001 | 0.427 | 0.182 | 20.014 |
| 30442.483 | 79 | 400.559 |
Table 4.Statistical Indicators and the Coefficients of the Predictive Variables of Mental Adjustment to Cancer in Regression Analysis of Health Related Quality of Life (HRQoL)
| Unstandardized Coefficients B | Std. Error | Standardized Coefficients Beta | T | Sig. | |
|---|---|---|---|---|---|
| Helplessness/Hopelessness | -0.768 | 0.212 | -2.245 | -10.576 | 0.001 |
| Preoccupation Anxiety | -2.854 | 0.458 | -0.577 | -6.231 | 0.001 |
| Cognitive Avoidance | 0.929 | 0.928 | 0.113 | 1.002 | 0.319 |
| Fatalism | 3.868 | 0.536 | 0.633 | 7.212 | 0.001 |
| Fighting Spirit | 2.847 | 0.692 | 0.427 | 4.115 | 0.001 |
4. Discussion
Few studies have explained why mental adjustment styles affect health. Therefore, the present study aimed to investigate the relation between psychological adjustment and HRQoL in women with breast cancer.
According to the findings, helplessness/hopelessness and anxiety preoccupation styles have significant negative relation with all subscales of FACT-B. Also helplessness/hopelessness (58%) and anxiety preoccupation (33%) explain variance of HRQoL. These findings are coordinate with researches done by Anagnostopoulos et al. (23), Grassi et al. (29) and Akechi et al. (30) that identified helplessness/hopelessness and anxiety preoccupation styles as maladaptive coping styles. Also, it coordinate with Cayrou’s study (31) that explains helplessness/hopelessness and anxiety preoccupation as negative coping styles and Kang (9) that suggests the combination of these styles as negative emotion subscales. Given the large role of helplessness/hopelessness coping style in explaining the variance in HRQoL, it can be said that the feeling of helplessness, lack of disease control and knock off the face of the disease play important roles in determining the physical and mental health of patients.
According to other studies, cognitive avoidance subscale only has a significant negative relation with social/family well-being. Also, cognitive avoidance cannot explain role in prediction of HRQoL. This coping strategy is related to assessing the patient’s tendency to actively avoid thinking about cancer diagnosis and outcomes (10). Avoiding coping may be adaptive as long as the person has an opportunity to escape from the pressure of this situation. This strategy as an active way of distraction has a positive relation with the fighting spirit. In addition, cognitive avoidance is not necessarily harmful. The result of this study about lack of the relation of cognitive avoidance with the HRQoL is consistent with the findings of Bredal (11) and Johansson et al. (18). It is argued that avoidance is a coping by itself neither positive and helpful, nor negative and harmful, and the value depends on factors such as the cultural sense and disease conditions.
The other finding of this study shows that fatalism has a significant positive relation with social/family well-being, emotional well-being and functional well-being subscales and has a significant negative relation with physical well-being, as well as no significant relation with breast cancer subscale. In addition, the findings show fatalism explains 18% variance of HRQoL. Some studies which examined the relation between coping styles and psychological health outcomes of cancer patients have mainly been performed in Western countries and few empirical studies investigate the relation between fatalism and HRQoL in Asia. In comparison to Asian studies, the findings of this study are concordant with three studies and are uncoordinated with one study. Ho and colleagues (8) and Ho et al. (32) studies showed that the fighting spirit and fatalism have a positive correlation. They believe that both styles of fighting spirit and fatalism are involved in a positive attitude for the Chinese (8, 30). Also, Kang et al. (9) showed that fatalism was negatively related with helplessness/hopelessness style in Korean patients with cancer. But according to Yeung and Lu (33), fatalism is negatively related to QOL in Chinese patients with cancer. According to Yeung and Lu (33), studies of Kang et al. (9), Ho et al. (8) and Ho et al. (32), the short version of mental adjustment to cancer questionnaire (Mini-MAC) was used in fatalism style that has 5 items while in their study the original version was used MAC with 8 items in fatalism. 2 out of 5 items of fatalism style in Mini-MAC have previously been in original MAC which belongs to fighting spirit subscale (items of “counting blessings” and “value of life”). This might be a possible explanation for the difference between these results that how the study had done by Kang et al. (9) and Ho et al. (8) (as well as in the present study) has been achieved positive relation between fatalism and adaptive psychological consequences.
Another research finding is related to fighting spirit that had positive relation with social/family well-being, emotional well-being and functional well-being subscales, but had no significant relation with physical well-being and other concerns about breast cancer subscales. In addition, the results revealed that fighting spirit explains 40% variance of HRQoL. The fighting spirit is defined as an optimistic attitude and an assessment realistic of the disease (34) and included the preservation of hope when faced with difficult conditions (35). As was expected, this coping strategy has positive relation with HRQoL. This finding is consistent with those of Anagnostopoulos et al. (23) and Rottmann et al. (24). Patients with high fighting spirit see cancer diagnosis as a challenge and view the future optimistically, and believe that it is possible to control the disease (7). So, obviously that is a combination of optimism and hope to the future with the ability to control the disease conditions and can be helpful for physical and psychological well-being and HRQoL in cancer patients. Another unexpected finding is that fatalism with fighting spirit has no significant relation with physical well-being subscale. Also both fighting spirit and fatalism styles have no relation to physical well-being subscale. It is possible to say that these coping styles in relation to aspects of HRQoL that are not directly related to physical condition are more influential but on the physical health and status are not. In other words, the physical problems related to cancer are so severe that even having a positive attitude and coping cannot have any role in reducing them.
This study has several limitations. First, the study is cross-sectional and the relation between variables may be different in longitudinal studies. Second, the scale of MAC has originally been developed in Western countries and although in Persian version has good psychometric properties, it is possible that the adaptation of the concepts of this scale (particularly the concept of fatalism) have problems with the Iranian culture. Third, the sampling method was non-random and available, and had its own problems. So, considering the relation between variables in longitudinal studies and using a random sample are suggested as recommendations for further research in this field to researchers.
