The International Journal of Psychosocial Rehabilitation

The Incidence of Anxiety among
Spouses of Breast Cancer Patients.

Akhtar Iqbal
Senior Clinical Psychologist
Psychosocial Services, Department of Medical Oncology
Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.

Akhtar Qureshi
Head, Department of Psychology.
Government College of Science, Lahore, Pakistan.

Khawer Saeed Siddiqui
Data Control Manager
Data Management and Process Department
Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.

Citation:
Iqbal, A., Qureshi, A., Saeed Siddiqui, K.  (2001)  The incidence of anxiety among spouses of
breast cancer patients.  International Journal of Psychosocial Rehabilitation6, 13-20


For Correspondence: Akhtar Iqbal, Senior Clinical Psychologist, Psychosocial Services, Department of Medical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Joher Town, Lahore, Pakistan.  E Mail: iakhtar@brain.net.pk or akhter@skm.org.pk

Abstract:
The diagnosis of breast cancer may provoke various emotional disturbances in patient’s spouses and anxiety is one of them. Objective: To observe the incidence of anxiety in spouses of breast cancer patients. Subjects: The spouses of 100 breast cancer patients, who have gone through mastectomy and were receiving curative chemotherapy, were interviewed. Design: Tailor Manifest Anxiety Scale was used to observe the incidence of anxiety. The patients were also assessed to record their performance status by using Karnofsky Performance Status Scale. Results: 64% spouses of breast cancer patients were presented with anxiety. Anxiety was more common among spouses belonging to lower socioeconomic status (43.8%) and among those having schooling of ten years or less (46.9%). It was also observed that 50% of spouses with anxiety belonged to the blue-collar jobs. Conclusion: It is concluded that factors like educational and socioeconomic status of spouses need to be taken into consideration when planning care for women and their spouses.

Background:
Research surveys show that depression and anxiety are almost as common among patients’ partners as among patients themselves. This means that about half the partners will have some symptoms, and in up to a quarter these will be severe. There tends to be concordance between patient and partner; that is, if one is emotionally distressed, the other is likely to be so too. However, this distress has often not been shared because each partner is trying so hard not to upset the other 1,8.

The partner’s emotional response may be complicated by anger or guilt, often indicating some past conflict in the relationship. Sometimes cancer acts as the catalyst for resolution of longstanding marital problems, but sometimes a shaky marriage breaks down completely under the extra strain 3.

If emotional problems in patients themselves are frequently not recognized, this is even more likely to be so for those in their carers, who often feel obliged to keep cheerful and put on a brave face. It is helpful if carers can be seen alone from time to time, perhaps by the family doctor, asked how they are coping and invited to talk over any emotional distress.

The presence of anxiety in family members especially in spouses of breast cancer patients is natural, as they are more close to the patients. It is not strange for spouses to feel anxious because other than hospitalization they have to carry out other responsibilities and there is also the question of their self-satisfaction which involves sexual relationship 6. The most common causes of anxiety in spouses may include inadequate knowledge about disease, outcome of the therapy, financial problems, family problems like illness in other family members, family conflicts, etc. 4.

The aim of the study was to observe the incidence of anxiety in spouses of breast cancer patients in relation to their age, education, occupation, chemotherapy cycles, number of children and performance status their patients.

Methodology:
The spouses of 100 breast cancer patients who have gone through mastectomy and were receiving curative chemotherapy were interviewed. Spouses with previous history of psychiatric illness or spouses of those patients receiving palliative chemotherapy were excluded from the study. Tailor Manifest Anxiety Scale was used to identify the spouses with anxiety (A score of 19 or above was used to determine the presence of anxiety). The patients were also assessed to record their performance status using Karnofsky Performance Status Scale. Data regarding socioeconomic variables was recorded on data capture form.

Statistical Issues:
Categorical data was analyzed using chi square test for independence of variables. 5% level of significance was set to test hypotheses.

Results:
Data on one hundred female cancer patients diagnosed with Breast Cancer stage I or II was recorded for the anxiety among their spouses. Median age for the patients was 45 years (Mean±SEM: 44.310±1.118) while same recorded for the spouses was 36 years (Mean±SEM: 37.040±1.2222). Spouses were evaluated for the anxiety against their age, performance status of their patient, number of children, chemotherapy cycles already administered to the patient and non-illness related concerns. All patients were on chemotherapy.

Among 64 (64%) spouses of the patients anxiety was found beyond the cut-off point of 19 on Manifest Anxiety Scale. Anxiety was more common among the spouses having schooling for ten years or less (46.9%) than those who were illiterate (29.7%, p value: 0.017). Least number of spouses (3.1%) was found exhibiting anxiety beyond cut-off point among those who had post graduate level of education.

We subdivided our population of spouses among four occupational categories viz. White Collar, Blue Collar, Service and Farm Workers. Fifty percent of the spouses (32 individuals) with clinically significant level of anxiety belonged to the blue-collar professions (45 individuals) with p – value = 0.01035.

Although 64% of the patients belonged to the families categorized as lower middle class or poor, anxiety was more common among Lower Middle Class (43.8%) compared to those who were poor (P value: 0.0168). Only two families could be categorized as either belonging to Upper Class or Upper Middle Class.

No significant interdependence was observed among the observed anxiety and age, performance status of their patient, number of children, chemotherapy cycles already administered and non-illness related concerns. The multivariate analysis of data was also carried out. No significant interaction for any other variable explained in multivariate analysis was observed.

Discussion:
The diagnosis and treatment of breast cancer in women may provoke various emotional disturbances in their husbands; the feeling of anxiety during investigation period and during the course of treatment is very common among spouses of breast cancer patients. Omne – Ponten, Holmberg, Bergstrom, & Sjoden (1993) have reported emotional disturbances in 48% of husbands during investigation period. In our study, 64% of spouses were presented with anxiety. This rate of is high when compared to Omne – Ponten et. al. (1993) because all patients in our study were receiving chemotherapy which is thought to be a major source of tension and anxiety in patients and their family members 9.

The onset of a life threatening disease results in significant changes in role and responsibilities of patients’ spouses due to which they may become over concerned about the financial condition and their families’ well-being. In our society domestic affairs like raising children, house-keeping etc. is considered to be the job of female partners whereas husbands govern the responsibilities outside the house. The diagnosis and treatment of breast cancer increases the responsibilities of male spouses. In these circumstances they have to take care of the children, house keeping and other domestic chores along with their own responsibilities like earning bread and butter for the family. This burden becomes multifold when they also have to attend their partners diagnosed with a disease they know not very much about it 4,10.

This anxiety is understandable as the onset of a life threatening disease may jeopardize emotional stability, emotional associations and physical boundaries of a couple’s relationship 2,3.

The uncertainty of treatment outcome and side effects of chemotherapy could be another source of anxiety among spouses as majority of our sample population attributed their anxiety to the uncertainty about treatment outcome and side effects of chemotherapy.

Among spouses with anxiety, 31.25% of them were belonging to the age group of 30 – 40 years whereas 25% were falling in age range of 20 – 30 years. But overall we observed no significant interdependence between anxiety in spouses and their age (Table: 1).
 
 
 
Table I Anxiety in spouses and their age, number of children, chemotherapy cycles and performance status of patient. Values are numbers (percentages)
   
(n = 64)
(n = 36)
Age      
  Below 20
2 (40%)
3 (60%)
  20 – 30
8 (33%)
16 (67%)
  30 – 40
12 (37%)
20 (63%)
  40 – 50
6 (35%)
11 (65%)
  50 – 60
7 (39%)
11 (61%)
  Above 60
1 (25%)
3 (75%)
Performance Status      
  Till 50
1 (20%)
4 (80%)
  Above 50
35 (37%)
60 (63%)
Number of children      
  Issueless
3 (30%)
7 (70%)
  Single
5 (45%)
6 (55%)
  Two to six
22 (36%)
39 (64%)
  Six and above
6 (33%)
12 (67%)
Chemocycle      
  One to four
22 (36%)
39 (64%)
  Five to eight
11 (33%)
22 (67%)
  Nine and above
3 (50%)
3 (50%)

Footnote Table 1:
Table 1 is showing no significant interdependence between anxiety in spouses and age, number of children, chemotherapy cycles and performance status of patient.

The majority of breast cancer patients were enjoying better performance status as 95% of them had above 50 score on Karnofsky Performance Status Scale. As far as anxiety in spouses of breast cancer patients with better performance status is concerned 63.25% showed anxiety whereas 36.75% had no features of anxiety. There was no significant relationship between patients’ performance status and anxiety in their spouses (Table: 1).

It has also been observed that number of children and chemotherapy cycles patients have already received had no significance in relation to anxiety in spouses (Table: 1). Our findings regarding age, performance status of patients and number of chemotherapy cycles (Treatment) are in agreement with earlier findings of Glasdam, Jensen, Madsen, Rose (1996) who reported no significant difference between anxiety in spouses and age, patients’ diagnosis, treatment and performance status of patients 5.

Among spouses presented with anxiety, 29.7% were illiterate, 46.9% had schooling for 10 years or less. Least number of spouses with anxiety (3.1%) was found among those who had schooling for more than 14 years. We found significant interdependence between anxiety in spouses and their educational status. It seems that educated spouses have better communication with physicians and are better able to understand the physicians’ briefings regarding patient’s disease, treatment and any other matter relating to the patient management during the course of illness and treatment. Secondly, the educated spouses, of course, can handle their day-today affairs (changes in role and responsibilities) better and can manage their patients more effectively when compared with less educated spouses. Because of that, they feel less anxious than the other spouses do (Table: 2). A significant interdependence between spouses’ anxiety and their occupation was also observed as 50% of spouses with anxiety belonged to the blue-collar professions like machine operators, assemblers, inspectors, equipment cleaners, helpers and laborers. 25.56% were doing white-collar jobs i.e. executive, administrative, and managerial, and professional specialty occupations and 23.44% were farm workers whereas no spouse with service providing job was found with anxiety. This can be attributed towards the fact that persons with schooling for less than 14 years can hardly find a white-collar job in Pakistan (Table: 2). This fact can also be related to the spouses’ socioeconomic status because there is an obvious relationship between person’s education, profession and socioeconomic status. In our study majority of patients were belonging to poor or lower socioeconomic class. 31.25% were poor and 43.75% were from lower socioeconomic class whereas only 23.44% were belonging to the middle class and 1.56% to the upper class (Table: 2). Here we can not ignore the fact that this is a medical centre based study and has obvious limitations in terms of patient selection because majority of patients being treated in this hospital are from lower socioeconomic class. The anxiety in spouse resulting from breast cancer in wife was more common among people from lower socioeconomic class, as they are more prone to develop emotional disturbances 11. In all we have observed that majority of the spouses with anxiety were from lower socioeconomic class; with schooling for less than 10 years and were belonging to the blue-collar professions.
 
Table 2 Educational background, occupation and socio-economic status of the patients with clinical manifestation of anxiety. Values are numbers (percentages)
   
(n = 64)
(n = 36)
Educational Status *      
  Illiterate
19 (29.7%)
3 (8.3%)
  Till Grade 10
30 (46.9%)
16 (44.4%)
  Graduation
13 (20.3%)
12 (33.3%)
  Post Graduation
2 (3.1%)
5 (13.9%)
Occupation **      
  White Collar
17 (26.6%)
20 (55.6%)
  Blue Collar
32 (50.0%)
13 (36.1%)
  Farm Workers
15 (23.4%)
3 (8.3%)
Socio-economic Status ***      
  Upper Class
1 (1.6%)
0
  Upper Middle Class
0
1 (2.8%)
  Middle Class
15 (23.4%)
19 (52.8%)
  Lower Middle Class
28 (43.8%)
9 (25.0%)
  Poor
20 (31.3%)
7 (19.4%)
* p = 0.01709
** p = 0.01035
*** p = 0.02101

Conclusion:
It is concluded that anxiety is common among spouses of breast cancer patients belonging to blue collar jobs and lower socioeconomic status. They need special attention of physicians to take care of their emotional and informational needs and to refer them for professional help at proper time.

Acknowledgement:
The authors thank all of the healthcare professionals and support groups who were involved in this study, especially Ms. Kiran Intekhab and Ms. Asma Maqsood for their help in finding patients, spouses and in literature
search.


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