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Psychosomatics 45:58-68, February 2004
© 2004 The Academy of Psychosomatic Medicine

Changes in Psychological Distress of Women With Breast Cancer in Long-Term Remission and Their Husbands

Lea Baider, Ph.D., Elisabeth Andritsch, Ph.D., Gil Goldzweig, Ph.D., Beatrice Uziely, M.D., Paulina Ever-Hadani, M.P.H., Günter Hofman, M.D., Gerhil Krenn, M.A., and Hellmut Samonigg, M.D.

Received Nov. 5, 2002; revision received April 14, 2003; accepted April 28, 2003. From Sharett Institute of Oncology, Hadassah University Hospital, Jerusalem, Israel; the Division of Oncology, Department of Internal Medicine, Karl-Franzens University of Graz, Graz, Austria; the Department of Psychology, Hebrew University of Jerusalem, Jerusalem, Israel; and the Braun School of Public Health, The Hebrew University—Hadassah Medical School, Jerusalem, Israel. Address reprint requests to Dr. Baider, Sharett Institute of Oncology, Hadassah University Hospital, 91120 Jerusalem, Israel; rnlobel{at}bezqint.net (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The purpose of this randomized, prospective study was to identify factors influencing the psychological distress of breast cancer patients and their husbands during remission. Background variables and distress levels of 172 couples in two locations (Graz, Austria, and Jerusalem, Israel) were assessed by using three standardized instruments in two interviews conducted 6–8 months apart. In both geographic-cultural groups, women whose partners refused to participate in the interview reported significantly less perceived family support. The global severity index (measuring total psychological distress) reflected minor changes in psychological distress of both patients and their husbands over time.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Breast cancer is the most common malignant disease among women in Western countries, with an estimated 5-year survival rate of 75%, and it is the first cause of death in women age 30–60 years.1

In Austria and in Israel, breast cancer accounts for 15% and 18%, respectively, of all cancers and, in particular, 30% of all cancers in women. Between 1985 and 1997, the age-standardized breast cancer rate increased by 37.5% among Jewish women in Israel and by 35% among all women in Austria. In 1995, the crude rate of breast cancer patients per 100,000 population was 102.2 for Jewish women in Israel and 89.7 for women in Austria.2,3

The treatment of breast cancer has increasingly focused on patients' quality of life, not only length of life, through identification of the women's psychosocial needs and coping abilities. As a result of earlier detection and improved treatment, more women, now and in the future, will be living with the disease and adjusting to its aftermath.4–6

Notwithstanding the relevance of quality of life, most studies report on levels of psychological distress at the time of a diagnosis of breast cancer or 1 year after the diagnosis. Psychological distress and coping styles in women with breast cancer have attracted substantial clinical and research attention over the last few decades, with some contradictory findings. About 20%–38% of women who receive a diagnosis of breast cancer experience high levels of psychological distress within the first year after diagnosis.7–9 Such psychological morbidity, if undetected, may be prolonged and disabling, with deleterious effects on the quality of life.10,11 Less is known about these effects in long-term survivors of breast cancer, although the results of previous studies have suggested that, despite the absence of disease, a minority of these women continue to experience psychological distress.12,13

In a prospective study by Bleiker et al.,14 the authors found that from 2 months to 2 years after breast cancer diagnosis, one in five women reported a significantly high level of distress about their cancer. One type of distressful response includes involuntary intrusive thoughts about cancer and efforts to suppress or avoid these thoughts.15 In addition, high levels of intrusive thoughts and avoidance are typically reported at the time of diagnosis and, for some patients, may persist over a period of years after the initial diagnosis.16

McCaul and colleagues17 examined the possible predictors of adjustment to breast cancer stages I and II. The most consistent predictor of psychological distress at 1 and 4 months after diagnosis was avoidant coping: women who reported more avoidant coping were more distressed. However, some authors have suggested that avoidant coping facilitates adjustment and decreased emotional distress. For example, Glanz and Lerman18 reviewed the literature and concluded that avoidant coping can be especially beneficial during active treatment. Greer19 suggested that avoidant thinking after active treatment would also facilitate coping. Vinokur et al.20 analyzed the time course of recovery and concluded that anxiety and depression peak rapidly after breast cancer diagnosis and then decline gradually and significantly over a 1–2-year period.

Persons who receive a diagnosis of cancer do not live in a social vacuum. The trajectory of patients' experiences invades every segment of their milieu but chiefly the spouse relationship. It is not surprising, then, that the severity of depressive symptoms experienced by a woman with breast cancer may be influenced by her appraisal of the adequacy of support available from her partner. Yet, the available data on psychological factors affecting distress levels of the spouse within the marital context have yielded inconclusive, contradictory, and controversial results.21–24

In a large study by Hann et al.,25 the results confirmed that increased social support, larger network size, and higher perceived adequacy of support from partners are associated with less depression in breast cancer patients. It is believed that the perception of the availability of emotional and instrumental support is more important than the actual use of such support.26

Ell et al.27 and Kaye and Gracely28 reported an increase in psychological distress over time in breast cancer patients but not in their spouses. In contrast, Keitel et al.29 found that spouses were more distressed than patients and that the distress of both partners decreased significantly over time. Hannun et al.30 reported a negative correlation between the distress of the patient and the spouse, whereas no such correlation was found by Dar et al.31 No significant differences in psychological distress between women with breast cancer and their spouses were detected by Northouse et al.32 In contrast, a study by Hoskins33 indicated that the psychological distress of breast cancer patients was greater than that of their spouses. Adding to the confusion are the results of a large study by Baider et al.,34 in which no correlation between patient distress and spouse distress was found.

Previous research has strongly suggested that the partner relationship is unique and that additional social support cannot overcome the negative effect of a distant husband on the female patient's emotional well-being.35 Male partners may often have a different idea about the type of support they should be providing. They might hide their feelings while adopting a "protective" role that is perceived as supportive. However, their wives may interpret this approach as insensitive and as a rebuff, and it may subsequently serve as an obstacle to any possible communication between them about the illness. Furthermore, some of the results reported earlier are consistent with other findings showing that a partner's avoidance of open discussion about the cancer experience is associated with increased distress in the patient.36–38

Although findings on the relative distress of healthy partners and patients are not always consistent and are mostly restricted to the first years after diagnosis, the majority of studies support a consistent tendency in the relative but similar psychological distress levels of the patient and the spouse.39

This analysis is part of an ongoing large longitudinal study being conducted in two different cultural settings (Graz, Austria, and Jerusalem, Israel) and in which psychological distress and perceived family support are assessed in women with a diagnosis of breast cancer at stages I or II currently in remission. The present research was designed as a randomized, prospective study, with assessments at two time points: time 1 (1–5 years after termination of any medical treatment) and time 2 (6–8 months after time 1). The main purpose was to gain a better understanding of the factors influencing the psychological distress of patients and their spouses during a remission period when there is no evidence of active disease.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
This randomized, prospective study was conducted at two oncology centers, one in Graz and the other in Jerusalem. We describe the levels of psychological distress and the sociodemographic and medical variables of married breast cancer patients (N=172 couples) at time 1 and time 2. The study subjects were drawn from a larger group of randomly selected women who were disease-free and still in remission at the beginning of the study. The final study groups comprised 71 couples in Graz and 101 couples in Jerusalem at time 1 and 55 and 65 couples, respectively, at time 2. Interviews were conducted between June 2000 and July 2001 for time 1 and between January 2001 and February 2002 for time 2.

The medical records of women who had received a diagnosis of stage I or stage II breast cancer between August 1995 and August 1999 and who showed no evidence of active disease at the time of the study were identified and randomly selected from the Division of Oncology in the Department of Internal Medicine of the University of Graz and the Institute of Oncology at Hadassah University Hospital in Jerusalem. Inclusion criteria were age between 30 and 80 years, a time lapse of 1–5 years after the initial breast cancer diagnosis, no local or systemic adjuvant cancer therapy received for at least 6 months, no current disease, no current cancer therapy other than tamoxifen, no prior diagnosis of other cancers, no other current or previous chronic or psychiatric conditions, ability to complete questionnaires independently, permanent residence in Austria or Israel for at least 10 years (to control for immigration and acculturation), and residence in the areas of Graz or Jerusalem. In the present study, we enrolled only married patients who had been living with their husbands in a stable relationship for at least 10 years. Each patient's medical suitability for inclusion was confirmed by the treating physician. Approval for the study was obtained from the Ethical Review Board of both institutions

Of the patients meeting the inclusion criteria for the larger longitudinal study, 300 of approximately 820 women were randomly selected in Graz and 300 of 650 women were randomly selected in Jerusalem. A total of 210 women in Graz (70%) and 214 in Jerusalem (71%) agreed to participate in the study. Of these, 144 of the patients in Graz (69%) and 148 (69%) in Jerusalem were married and therefore were eligible for enrollment in the present study. Each eligible couple received a letter signed by the physician that briefly described the study. The research coordinator contacted each patient and her husband to secure their agreement. Trained psychologists conducted home interviews with each woman and separately with her husband. Each participant was required to give written informed consent.

Among the Graz husbands, 71 (49%) agreed to be interviewed at time 1, and, of these, 55 (77%) agreed to be interviewed again at time 2. Among the husbands in Jerusalem, 101 (69%) were interviewed at time 1, and 65 of them (65%) were interviewed again at time 2. Thus, the total numbers of couples participating at time 2 in the present study were 55 in Graz and 65 in Jerusalem. None of the married women in either location had a local recurrence or any manifestation of active disease between the time-1 and time-2 interviews.

Assessments
The patients and their husbands were interviewed separately in their homes by psychologists using a semistructured interview schedule designed to elicit detailed information about sociodemographic and medical variables. To control for any possible language-related misconceptions, the medical and sociodemographic data were translated from Hebrew into German and from German into Hebrew. Sociodemographic and background data were first compiled from a pilot group and reviewed by independent language experts to control for bias and ambiguity. The three standardized instruments used in this report had already been used extensively in Austria and in Israel. They are the Brief Symptom Inventory, the Impact of Event Scale, and Perceived Family Support.

Sociodemographic and medical variables. The sociodemographic semistructured interview gathered information on the age and education of the patients and their husbands. Patients' medical information, relating mainly to the breast cancer diagnosis, types of surgical procedures, staging, time since diagnosis, treatment, and Karnofsky index value,40 was obtained by reviewing the medical chart of each participant. The data were analyzed by categorizing patients according to cancer stage and prognostic factors by using the TNM (tumor, node, metastasis) staging system.41

Standardized instruments. The Brief Symptom Inventory42 is a 53-item assessment tool used extensively to assess global psychological distress, which is determined by the individual's score on a global severity index. The global severity index for each subject is obtained by averaging the 53 symptom ratings. The test-retest reliability of the global severity index is 0.90. The measure has nine specific subscales (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). The raw scores are converted to T scores. The accepted cutoff point for psychopathology is a global severity index of 63 or scores of 63 on three of the subscales. The internal reliability (Cronbach's alpha) of the global severity index was 0.96 for the patients and 0.92 for the husbands.

The Impact of Event Scale43 is a 15-item measure used extensively to assess the intrusion (seven items) and the avoidance (eight items) of an event (cancer in this study). Its internal reliability was good (intrusion: Cronbach's alpha=0.89 for patients and 0.89 for husbands; avoidance: Cronbach's alpha=0.78 for patients and 0.79 for husbands). A score of 20 or higher usually suggests a high level of psychological distress.

Perceived Family Support44 is a 20-item questionnaire that assesses the patient's perception of emotional and moral support by the family. The possible answers are 1, yes; 2, no; and 3, don't know. Higher scores are indicative of the respondent's sense that the family is supportive. Scores range from 0 to 20 and are obtained by counting the number of items for which the patient indicates a perception of family support. Cronbach's alpha was 0.75 for patients and 0.82 for partners.

Statistical Analysis
The background characteristics of patients whose husbands refused to be interviewed were compared to those of patients whose husbands agreed to be interviewed at least at time 1 by using nonpaired t tests for continuous variables and chi-square tests for categorical variables. A paired t test was used to compare the global severity index at time 1 with that at time 2, for patients and husbands separately, in each study group. In addition, two multiple regression analyses were conducted for the patients and husbands separately in each location to analyze the level of change in psychological distress from time 1 to time 2 and the determinants of that change. The global severity index at time 2 was the dependent variable. To predict the change in the global severity index we controlled the relevant global severity index at time 1, forcing it to enter the regression equation as the first independent variable. All other variables were selectively entered by using the stepwise forward method.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Analysis of Refusals
Of the 210 breast cancer patients interviewed in Graz, 144 (69%) were married. In this group, 71 husbands (49%) agreed to be interviewed at time 1 and 55 of them (77%) agreed to be interviewed again 6 to 8 months after the first interview (time 2).

One-way analysis of variance was used to compare the background, medical, and psychological variables of women whose husbands refused the first interview with those of women whose husbands participated at least in the first interview.

In Graz, the women whose husbands refused to be interviewed at time 1 showed significantly higher levels of intrusion and avoidance, as measured by the Impact of Events Scale, and significantly lower levels of perceived family support than the women whose husbands agreed to be interviewed (Table 1). The background characteristics of the husbands in the two groups could not be compared, since no information was available for husbands who were not interviewed. Similar comparisons between the women whose husbands were interviewed at both times and the women whose husbands refused to be interviewed at the second interview yielded significantly higher levels of intrusion and avoidance in the latter group. The intrusion level for women whose husbands refused to be interviewed at time 2 was significantly higher than that of women whose husbands consented (mean=8.3, SD=7.8, compared to mean=4.2, SD=5.4) (p<0.05). The corresponding values for avoidance were mean=10.1, SD=7.8, and mean=6.0, SD=6.2 (p<0.05).


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TABLE 1. Characteristics of Women With Breast Cancer in Long-Term Remission in a Study of Psychological Distress and Perception of Support in Patients' Families in Two Geographic-Cultural Settings, by Whether Their Husbands Agreed to be Interviewed at Study Time 1a



Thus, for patients whose husbands refused to be interviewed, scores on intrusion and avoidance were significantly higher and Perceived Family Support scores were significantly lower than for patients whose husbands consented to be interviewed.

Of the 214 women with breast cancer interviewed in Jerusalem, 148 (69%) were married. Among the married couples, 101 husbands (69%) were interviewed at time 1, and of these 65 (65%) were interviewed again at time 2.

In Jerusalem, the Perceived Family Support for the women whose husbands refused to be interviewed at time 1 was significantly lower than for women whose husbands consented (mean=16.1, SD=4.2, compared to mean=17.4, SD=3.2, respectively) (p<0.05) (Table 1). A similar comparison between women whose husbands were interviewed at both times and women whose husbands refused the second interview yielded no significant results. Thus, among the subjects in Jerusalem, as among those in Graz, the patient's perception of family support was related to the husband's agreement to be an active participant in the study.

Characteristics of Participants
Table 2 reports descriptive statistics for patients whose husbands were interviewed at both time 1 and time 2. A number of significant differences between the Graz patients (N=55) and the Jerusalem patients (N=66) were found. The Jerusalem patients had a significantly higher level of education (p<0.001), a higher likelihood of working (p<0.001), and a longer time since receiving their diagnosis (p<0.02), compared with the Graz patients. The mean global severity index, as well as the mean Impact of Event Scale intrusion and avoidance scores, were significantly higher for the Jerusalem patients than for the Graz patients (p<0.001 for the three variables).


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TABLE 2. Characteristics of Women With Breast Cancer in Long-Term Remission Whose Husbands Agreed to be Interviewed at Time 1 and Time 2 in a Study of Psychological Distress and Perception of Support in Patients' Families in Two Geographic-Cultural Settingsa



Changes in Psychological Distress With Time
To measure the effect of time on psychological distress, we analyzed changes in the psychological distress (global severity index) of patients and their husbands in each study group (Table 3). A paired t test comparing the global severity index at time 1 and time 2 for both patients and husbands revealed a significant decrease in the mean levels of distress between the two time points for the Graz patients (from 50.5 to 48.6) and for the Jerusalem husbands (from 58.1 to 53.9).


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TABLE 3. Global Severity Index Values of Women With Breast Cancer in Long-Term Remission and Their Husbands at Time 1 and Time 2 in a Study of Psychological Distress and Perception of Support in Patients' Families in Two Geographic-Cultural Settingsa



To identify the determinants of the level of change in psychological distress from time 1 to time 2 for the patients, we conducted a multiple regression analysis for each group using the global severity index values of patients at time 2 as the dependent variable. To predict the change in the global severity index, we controlled for the global severity index at time 1 by forcing it to enter the regression equation as the first independent variable. All other variables (husband's global severity index at time 1; patient's age, education, Karnofsky index value, and stage of illness; whether the patient underwent mastectomy; patient's time since diagnosis; and patient's Impact of Event Scale intrusion and avoidance scores and Perceived Family Support score) were selectively entered by using the stepwise forward method to determine whether they contributed significantly to the prediction of global severity index values at time 2.

A similar analysis was conducted for the partners by using their global severity index values at time 2 as the dependent variable and forced entry of their global severity index values at time 1.

Among the Graz subjects, the patients' global severity index at time 1 explained 59% of the variance in patients' global severity index at time 2 (F=69.18, df=1, 48, p<=0.001). None of the other variables added significantly to this prediction. The husbands' global severity index at time 1 explained 54% of the variance in the husbands' global severity index at time 2 (F=62.05, df=1, 53, p<=0.001). No other variable added significantly to this prediction.

Among the Jerusalem subjects, the patients' global severity index at time 1 explained 67% of the variance in patients' global severity index at time 2 (F=93.22, df=1, 45, p<=0.001). No other variable added significantly to this prediction. The husbands' global severity index at time 1 explained 58% of the variance in the husbands' global severity index at time 2 (F=84.46, df=1, 60, p<=0.001). The only variable that added significantly to the latter prediction was the husband's Perceived Family Support score, which was negatively correlated with the global severity index at time 2 and which accounted for 3.4% of the explained variance (F=5.27, df=1, 60, p<0.03).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The onset of a life-threatening illness such as breast cancer presents a complex challenge to the emotional stability and physical behavioral patterns within a couple's relationship. What was once routine becomes unpredictable, and spouses fluctuate between high and moderate levels of psychological distress as they learn to cope with and adjust to the illness trajectory.

In this study of subjects from two geographic-cultural regions (Graz, Austria, and Jerusalem, Israel), we compared the changes in psychological distress of women in remission from breast cancer and their husbands over time. We selected two time points: from 1 to 5 years after diagnosis (time 1) and from 6 to 8 months after time 1 (time 2) and compared the psychological distress of patients and their husbands. At time 1, participants included 71 couples in Graz and 101 couples in Jerusalem. At time 2, there were 55 couples in Graz and 65 in Jerusalem.

The number of husbands who refused to participate in this prospective study was significantly higher in Graz (73 of 144, 50.7%) than in Jerusalem (47 of 148, 31.7%) (p<0.001). In both groups, women whose husbands refused the first interview (at time 1) were found to have significantly lower Perceived Family Support scores than women whose husbands agreed to be interviewed (p<0.01 for Graz and p<0.05 for Jerusalem). In the Graz couples, women whose husbands refused the first interview also had significantly higher scores for intrusion (p<0.01) and avoidance (p<0.01), as measured by the Impact of Events Scale, than women whose husbands consented. However, a similar comparison for the Jerusalem couples yielded no significant results.

In accordance with some of our results, Giese-Davis et al.45 reported that women whose healthy husbands had participated in their research study indicated less mood disturbances, more family support, and less psychological distress than women whose husbands had refused to participate.

Furthermore, we found that patients whose partners refused to participate reported lower levels of family support in both the Graz and Jerusalem groups (Table 1). It might be suggested that partner participation serves as an indication of how patients appraise their own perception of family support. Although there were no statistically significant differences in the patients' perceived levels of family support in either the Graz or Jerusalem groups, it is interesting to note that the partners' refusal rate was significantly higher in the Graz group. This difference may be related to the major role that family support and partner participation play in Israel, whereby patients require more support from their partners (lower refusal rate) in order to achieve a level of perceived family support that is the same as that for the Graz patients.34,46

This idea is consistent with our findings that the only variable in the Jerusalem group that predicted change in the global severity index over time (time 1 versus time 2) was Perceived Family Support (the significant predictors of the global severity index at time 2 were the global severity index at time 1 and the Perceived Family Support score). Conversely, in the Graz group, the only variable that predicted the global severity index value at time 2 was the global severity index value at time 1.

In general, the global severity index values of both patients and partners were not high, and the change in the psychological distress levels was either not statistically significant or not clinically significant. Moreover, the most dominant factor in determining global severity index values at time 2 for both patients and partners was the initial global severity index value at time 1. These findings may indicate that, from a psychological point of view, women with breast cancer in remission a year or more after diagnosis and their partners cannot be treated as patients with severe disease. Factors such as medical condition and psychological coping style, which had a significant effect during the period immediately after diagnosis, may no longer be relevant.47

A possible cause for the relatively low scores obtained for psychological distress in the present study might be that our patients were all at an early stage of their illness at the time of diagnosis and were in complete remission and good physical condition at the time of the study (only one patient in the Graz group and one in the Jerusalem group scored below 90 on the Karnofsky index). These findings support the observation that patients who are in good physical condition who achieve a Karnofsky index of 90 or more, whose illness is at stage I or II, and who have higher levels of perceived family support experience normal processes of adaptation to their illness, as expected in a healthy population.48

Similarly, Vinokur et al.49 found that the extent of anxiety and depression among long-term survivors did not differ significantly from normal levels of anxiety and depression in an asymptomatic healthy comparison group. Furthermore, patients with breast cancer in remission for 2–5 years from the time of the initial treatment enjoy a high quality of life, similar to that of healthy women.

It should be noted that at time 1, intrusion and avoidance, as measured by the Impact of Events Scale, and the global severity index values of both patients and their partners were significantly higher for the Jerusalem group than for the Graz group (Table 2). This outcome is surprising, since the longer mean time from diagnosis for the Jerusalem patients should have yielded lower values for the global severity index. A possible rationale is that differences in the global severity index may reflect general cultural differences between the two groups and are not specifically related to the cancer illness. It may be suggested that the "extroverted" and "open" nature of the Israeli culture reflects a lower behavioral inhibition to report higher levels of psychological distress than might occur in the Graz group, whose behavior could be characterized as more "introverted" and "reserved." Another possible rationale might be that the higher global severity index values in the Jerusalem group reflect conflictive tensions permeating all of Israeli society.

A comparison of global severity index values at time 1 and time 2 for the patients and their husbands in both the Graz group and the Jerusalem group revealed only minor changes, despite a significant decrease at time 2 for the Graz patients (p<0.01, compared to time 1) and for the Jerusalem husbands (p<0.01, compared to time 1). Analysis on an individual case basis revealed a tendency toward a decrease in psychological distress for both patients and husbands in both groups (with the exception of the husbands in the Graz group). Global severity index values at time 2 could not be predicted by any other variable besides the corresponding global severity index values at time 1. Furthermore, the tendency toward lower global severity index values at time 2 could not be explained by the background or medical variables or by the differences in psychological stress between the patients and their husbands.

It is interesting to note that perceived family support had a more positive influence on the Jerusalem husbands than on their wives. This might be explained if we assume that, whereas breast cancer patients experience an adaptive process of psychological recovery, their husbands are in need of a great deal of family support.50

Breast cancer patients and spouses who reported greater perceived support also reported fewer adjustment problems and lower levels of psychological distress.51 In a study of women with breast cancer, Northouse et al.52 found that a high level of perceived family support was a predictor of lower psychological distress. Roberts et al.,53 in a cross-sectional study, noted that spousal support was correlated with lower levels of psychological distress, whereas Bolger et al.54 found no such relationship.

Omne-Ponten et al.,55 in one of the few prospective studies in this field, addressed two basic questions: Is there agreement between spouses in their assessments of the experience of breast cancer, and can the husband's assessment be used as a predictor of the patient's psychological distress outcome? The results showed a high rate of agreement on the couple's assessment. The husband's assessments of the marital relationship and support were all significantly related to the patient's psychosocial outcome 13 months later. However, the patient's own assessment at 4 months was a better predictor of her psychosocial outcome after 13 months. These findings are comparable to the results of the present study, in which the best predictor of psychological distress (global severity index) was the patients' and husbands' distress levels at time 1.

It should be pointed out that, in contrast to the authors of previous studies,56 we did not find that the global severity index of the patients or their husbands, either in Graz or in Jerusalem, contributed to change in psychological distress with time in the spouse. The fact that the global severity index was within the normal range (lower than 63) for most of the patients reduced the probability of finding greater decrease and improvement in distress and of identifying contributing variables.

The literature indicates that psychological distress among cancer patients may have a significant effect on quality of life and behavioral and health outcomes.57,58 Notwithstanding the outcome of the present study, we would like to suggest that there is, indeed, a need to implement psychological interventions. Further research is needed to determine appropriate means to integrate and implement psychosocial intervention in a manner that is easily "transportable" into different types of families and to different communal and social settings. Most of the studies to date have focused primarily on young, white, educated, middle-class subjects, and the findings might therefore not be applicable to other sociodemographic and cultural groups.59

It is important to take into account the limitations of our study. Since the findings refer only to women with a single diagnosis of breast cancer at stages I or II who were in good physical condition and in long-term remission with a relatively good prognosis, they should not be generalized to patients with other stages of breast cancer. Furthermore, the subjects constituted a selected group, because the couples who agreed to participate were in somewhat better psychological condition than those who did not participate. Although the study included two time points for observation and more than 302 interviews, it is limited by the relatively small number of couples, and therefore the findings cannot be considered as representative of breast cancer patients and their husbands.

Despite these limitations, the findings of this study provide important information about the psychological distress of couples and their perceived family support. It should be borne in mind, however, that the family context and the marital relationship are sometimes used as indices of positive social support, without knowledge of the extent to which the partners in the relationship perceive their marriage as supportive. The subjective perception of the relationship between family support and the psychological distress of patients or their spouses differs throughout the course of the illness process and within the dynamics of the couple's relationship, their particular cultural norms, and the social context of the family. Maintenance of psychological distress at a normal level and a sense of mutual support should be the guiding principle of any psychological intervention for similar cancer patients in remission.


  ACKNOWLEDGMENTS

 
This study was supported by grants from the Österreichische Nationalbank Jubilümsfonds, Jubilümsfondsprojekt Number 9038 and from Verein für Krebskranke at the Division of Clinical Oncology, Department of Internal Medicine, University of Graz, Graz, Austria.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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