© Borgis - New Medicine 3/2013, s. 91-96
A study assesing the efficiency of treating emotional distress in women with malignant breast tumour
Faculty of Health Sciences, Semmelweis University, Budapest
Head of Faculty: Prof. Dr. Nagy Zoltán Zsolt
Aim. The aim of the study is to examine the change of emotional distress and fatigue influenced by a psychosocial intervention programme in women with non metastatic breast cancer.
Material and methods. The research was carried out in Budapest at the Department of Radiodiagnostics of the National Institute of Oncology. The sample: n=173, (intervention group = 86, control = 87) (34 women have participated in the study), control = 87. The Shortened Beck Depression Inventory, the Spielberger’s State-Trait Anxiety Inventory and the EORTC QLQ C30 quality of life questionnaire have been used for the research.
Results. There was a significant improvement in patients in all three assessed outcome variables. Depression symptoms: F(1.72) = 4.347 p = 0.041; anxiety: F(1.65) = 6.021 p = 0.017; fatigue: F(1.78) = 15.060 p = 0.000.
Conclusions. The early recognition of the presence of anxiety and depression, and their medical and psychological support are crucial. The psychosocial intervention efficiently helped the reduction of emotional distress and fatigue.
According to the 2008 statistics of the World Health Organization, there were 34 million people diagnosed with cancer. There are about 12.5 million registered new cases, and 7.6 million people die of cancer every year around the world. Caring for patients with malignant tumours is causing more and more difficulties for health services. According to John Seffrin, the chief executive officer of the American Cancer Society, cancerous diseases have to be treated as global epidemic (1). By 2030 the number of new cancer patients is estimated to rise to 26 million, and 11.5 million people will die of malignant tumours. In Hungary, during the last 60 years, the number of cancer cases has also gradually risen, and in this respect we are at the top of the statistics among the EU state members (1, 2). Breast cancer is the most common malignant disease in women worldwide. As a result of early recognition and treatment, in the developed countries, including Hungary, the relative 5-year-survival rate is about 80% (1, 3). The diagnosis of breast cancer usually comes as a shock, accompanied by feelings of a threat to life and uncertainty. The state of anxiety and hopelessness has been proved to cause a decline in the health-related quality of life (4). The most common symptoms, such as depression, anxiety and vital exhaustion, can persist for years after the diagnosis (5, 6).
The number of cases affected by clinical anxiety and depression is much smaller, but reserches suggest that the presence of symptoms of subclinical anxiety and depression adversely affects everyday life management and the experience of quality of life. Most authors suggest that the presence of psychological distress is 50%; these are mainly adjustment difficulties accompanied by anxiety and depression. Derogatis found psychological disorders in 47% of the cases (7). In a large sample research (4496 patients), the prevalence of depression showed 52% (8). Hopwood found close correlation between depression and anxiety; 35% of the patients were characterised by this score, and he did not register any significant improvement at the 5-year follow up either (9).
Concerning the subject, only a few studies have been conducted in Hungary.There has been a national representative study carried out by Hungarostudy 2002, surveying the physical and mental health of the adult population of Hungary, and the relationship between health indicators and the environmental, social and economic background. According to their research results, the incidence of clinically significant depression rate in women affected with cancer was 28.5%, while in men it was 27.4% (10). According to the results of a recent study (11), one tenth of women with breast cancer showed depression reaching the clinical border, and nearly two thirds of them had mild depression symptoms. The symptoms of anxiety were shown in one third of the patients, and 20% of these had severe state-trait anxiety. These results confirm the clinical experiences published by Riskó (12), and are also related to the sources of similar studies (13).
Beside distress, one of the most common side-effects of conventional oncology treatments is vital exhaustion, with its defining characteristics: feelings of excessive fatigue and lack of energy and increasing irritability. Normally, there is a strong correlation between these symptoms and depression (14, 6).
Nowadays it is more and more important that the patients are provided with psychological and emotional support, and there is more emphasis put on promoting the ability for spiritual and emotional adjustment, encouraging coping, and improving psychosocial quality of life. During this process, psychosocial interventions have outstanding significance; in complex therapies for cancerous afflictions, the role of onco-psychology and integrated psychosocial care has become increasingly important (15).
The majority of the studies assesing patients with breast-cancer confirms the beneficial effects of psychosocial interventions in reducing emotional distress and also in impoving quality of life (16-20).
MATERIAL AND METHODS
In 2009-2010, a comprehensive psycho-oncology research was conducted, intending to develop a complex, complementary rehabilitation programme in addition to the conventional medical cancer treatment, in order to improve health and quality of life, strengthen coping abilities, and increase the life expectancy of patients suffering from cancer. As first steps of this research, cross-sectional studies were carried out, then a randomized sample was introduced to a complex, psychosocial intervention programme.
Our present study explores the variation of three commonly characteristicsymptoms of breast cancer following a psychosocial intervention programme:
1. Variation of depression and anxiety affected by the programme.
2. Variation of vital exhaustion, fatigue affected by the programme.
The assessed sample and methodologies
173 women agreed to participate in our research, all suffering from malignant breast cancer (C50) and who were currently undergoing medical treatment because of their illness. The research was carried out in Budapest at the Department of Radiodiagnostics of the National Institute of Oncology, with the permission of the Institute’s Ethical Committee. During the assessments an eight-page self-assessment form was used that took 50 minutes to be completed. The sample (n = 173) was randomly divided into treatment (n = 86) and control group (n = 87).Patients assigned to the experimental group were sent a letter of information, followed by telephone contact. 36 patients agreed to participate in the programme. All participants attended the first interview. The 36 patients were divided into two groups; between September and December 2009 (group 1) and between February and June 2010 (group 2). Two patients left the intervention; hence the final number of the participants was 34. Two measurements were carried out: one before the programme (1st measurement – T1) and one after the programme (2nd measurement – T2). The first questionnaires were completed during mammographic investigation, and then the participants received the other packages by post. 51 participants of the control-group (out of 87) returned the questionnaire. Social-demographic characteristics of the sample are shown in table 1.
Table 1. Demographic characteristics of study sample by groups at T1.
| ||Treatment group (N = 36)||Control group (N = 87)||p|
|Age (mean and SD)||53.17 (7.66)||52.09 (9.15)||t = 0.61 ns.|
|Duration of the disease (mean and SD)||2.47 (0.47)||2.55 (0.86)||t = 0.45 ns.|
|Time spent since surgery (mean and SD) ||2.30 (0.74)||2.30 (0.79)||t = 0.04 ns.|
|Education: N (%)|
primary or vocational school
secondary school or higher
p = 0.007*
|Marital status: N (%)|
lack of stable relationship
χ2 = 2.72
|Having Children: N (%)|
χ2 = 2.76
|Economic activity: N (%)|
χ2 = 0.01
|History of family cancer N (%)|
χ2 = 7.16
p < 0.01
SD – Standard Deviation; ns.= non-significant; *Fisher’s exact test
Concerning the demographic characteristics of the treatment and the control group, there were differences in education (the treatment group had more patients with at least secondary school); concerning the family medical history, there was a difference in the occurrence of cancerous affections (the control group had higher number of family members affected by tumours) (tab. 1).
The psychosocial intervention programme consisted of three main parts: a five-day residential life-style camp, where the patients received theoretical and a practical training related to healthy living, the incorporation of the acquired knowledge into everyday life-management, and finally a 14-week group psychotherapy, 5 hours a week.
Shortened Beck Depression Inventory BDI
The Shortened Beck Depression Inventory BDI was used to determine severity, and explore and follow up depression (21). The shortened version has nine items, that are related to social withdrawal, indecisiveness, change of sleep pattern, fatigue, hypochondria, inability towork, pessimism, lack of contentment and joy, and feelings of self-reproach. They can be scored by the patient between 1 and 4 (from ‘not at all characteristic’ to ‘totally characteristic’). High correlation (r = 0.92) between the total scores of the Shortened and the Full version confirms the reliability and applicability of the Shortened version. Concerning the severity of the depression, the Shortened Beck Inventory has the following categories: 0-9: not depressed,
10-18: mild depression, 19-25: moderate depression, above 26 points: severe depression. According to clinical validity, the borderline for clinical depression is 19 points. The reliability of the questionnaire on the sample proved adequate (Cronbach-alpha = 0.86) (22).
Spielberger’s State-Trait Anxiety Inventory (STAI-T)
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