Psychological adaptation to cancer and strategies for coping with pain in patients with cervical cancer

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1 Archives of Perinatal Medicine 22(1), 59-65, 2016 ORIGINAL PAPER Psychological adaptation to cancer and strategies for coping with pain in patients with cervical cancer DOROTA ROGALA 1, ALEKSANDRA MAZUR 1,2, MARIOLA MAŚLIŃSKA 1,3, KRZYSZTOF KOPER 1,3, MARTA STANISZEWSKA 4 Abstract Introduction: Pain of different origins associated with cancer occurs in approximately 90% of patients. Scientists distinguish two attitudes that are accepted by patients facing cancer diagnosis. Active approach is characterized by taking the fight for their own health and life as well as general mobilization, and passive, manifested in anxiety and the patient's general resignation to the existing problem. Depending on the chosen strategy, patients cope differently with pain and its control. Aim: Evaluation of the relationship between mental adaptation to cancer and strategies for coping with pain in women with cervical cancer. Material and methods: The research involved 30 women with cervical cancer. The following arrangement questionnaire were used: The Questionnaire of Strategy for Coping with Pain CSQ, The Scale of and Mental Adjustment to Cancer MINI-MAC. The relation between mental adaptation to disease and chosen strategies of coping with pain, pain control and the ability to reduce it were analized. Results: 1) Women with cervical cancer choose two constructive strategies to adapt to cancer: the Fighting spirit and Positive revaluation and four predominant strategies for coping with pain: Declaring to cope Increased behavioral activity, Praying/deep hope and Divert attention from the disease. 2) Women choosing constructive strategies cope with pain better, are more active, they can control the pain. Conclusions: 1) Women with cancer of the reproductive organs are adapting well to the disease. 2) The active attitude towards the disease gives strength to fight the pain. Key words: pain, psychological adjustment, cervical cancer Introduction Cervical cancer is one of the most common malignant tumor in the world. It is the sixth most common after breast, colorectal, lung, endometrial and ovarian cancers [1]. In the early stage of tumor invasion typically no symptoms are seen. Usually it gives symptoms when its character becomes invasive and invades neighboring tissue. Sick women present with vaginal discharge, spotting, contact bleeding or bleeding after exercise, pain in the lower abdomen and radiating pain in the pelvis [2]. The pain of various origins associated with cancer occurs in approximately 90% of patients. It may be associated with tumor growth or metastasis to distant tissues [3]. Strenght of pain and discomfort depend on the chosen form and methods of cancer pain treatment. In the case of chemotherapy, pain symptoms are caused by: inflammation of the mucous membranes, muscle pain, articular pain, gastrointestinal disorders, cardiomyopathy, and general destruction of chemotherapeutic agents. In radiotherapy pain is caused by skin burns, inflammation of the mucous membranes, inflammatory reactions, a disorder of the gastrointestinal tract and itching. However, in case of surgical procedures the patient face postoperative pain in the area of a scar. In addition, pain can cause occlusion, colic, urinary retention [4]. In most patients the pain intensity ranges from moderate to very strong. According to the WHO analgesic ladder, analgesia should be used appropriately for the degree of pain, and then increased until its eradication. Depending on the severity of pain the pharmacological agents used are non-opioid drugs, non-steroidal antiinflammatory drugs, weak and strong opioids used. Nonpharmacological methods may include radiation therapy, physiotherapy and psychotherapy. The purpose of the latter is to provide the patient with strategy relying adversity [5, 6]. According to psychologists, the ways to cope with pain, which patients use are based on three factors: the cognitive coping, diver attention/taking steps substitutes 1 Chair of Oncology, Radiotherapy and Oncological Gynaecology, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Toruń 2 Clinic of Oncological Gynecology, Lukaszczyk Oncological Center, Bydgoszcz 3 Department of Chemotherapy, Lukaszczyk Oncological Center, Bydgoszcz 4 Student, BSc Midwifery, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Toruń

2 60 D. Rogala, A. Mazur, M. Maślińska, K. Koper, M. Staniszewska and catastrophing and the search for hope [7]. Their strategies are related to three basic styles of coping with stress: concentrated on the task at avoiding and emotions. It is believed that the best is to use a strategy focused on the task, though, if this is not possible, more effective can be escaped strategies. It is also important to match their own ability to cope with the pain with preferred strategies [8]. Patients suffering from oncological diseases cope with the disease differently. Psychologists distinguish two general styles: constructive, comprising strategies of fighting spirit and a positive revaluation and destructive, including preoccupation with anxiety and feeling of helplessness-hopelessness. The fighting spirit leads the sick to treat the disease as a personal challenge and take measures to combat the disease. Positive revaluation is a reorganization of their disease problem, and with full awareness of its severity find hope and satisfaction with the already antiquated years. Preoccupation with anxiety expresses concern at the disease, which is mainly perceived as a threat causing fear, over which you cannot control. Helplessness-hopelessness provides a sense of helplessness, confusion, passive submission to illness. Finally the adopted attitude towards the disease most affects the quality of life and can be decisive in the long-term effects of treatment [9]. Rating of preferred strategy is useful at every stage of treatment and rehabilitation. The test results show that better prognosis considering the length of survival, no relapse and a better quality of life are associated with the choice of active strategies [7]. Material and methods Patients The analysis covered 47 women with cervical cancer after surgery treatment in the Clinic of Oncological Gynaecology, Lukaszczyk Oncological Center in Bydgoszcz. Finally, the research involved 30 women, as 15 women refused to participate in the study, 2 withdrew from participation in the process of completing questionnaires. The researched group was varied by age, place of residence, education, marital status and material conditions. Among 30 studied women, 20 cases were diagnosed with primary cervical cancer (67%), and 10 cases with the recurrence (33%). Patients were treated with the following procedures: simple hysterectomy with bilateral salpingo-oophorectomy 5 (17%), radical hysterectomy 16 (53%), in 4 same cases made relaparotomy was needed (13%), 2 amputations of the cervix (7%), 2 cervical conizations (7%), 1 (3%) patient refused to MPE (modified posterior exenteration). 4 (13%) patients developed complications which required emergency stomy. After discharge all patients were recommended to report to the Commission's Interdisciplinary to determine further way of treatment method. Age of the patients was in the range of years (mean 55.4 years). Among the respondents, the largest group were women aged years (46.7%), followed by (20%), (13.3%), years old (10%) and 70 years + (10%). 11 women lived in large cities (36.7%), 10 in small towns (33.3%) and 9 (30%) in the countryside. Among the respondents, most had secondary education 12 (40%), followed by professional 7 (23.3%), higher 6 (20%) and basic 5 (16.7%). The largest group of patients were married 18 (60%), following by single women 10 (33.3%) and in a partnership 2 (6.7%). The socioeconomic condition of the patients was as follow: good 15 women (50%), average 9 (30%), very good 4 (13.3%), bad 2 (6.7%). Methods The study used: a questionnaire describing a group of women in terms of socio-demographics, standardized tool Scale Mental Adjustment to Cancer Watson et al. from 1988 (Polish adaptation Juczyński 1997 Cronbach " coefficients for the different strategies ) and Questionnaire Strategy of Dealing with Pain Rosentiel and Keefe of 1983 (Polish adaptation Juczyński- Cronbach " coefficients for the different strategies ). The Scale of Mental Adjustment to Cancer MINI MAC (Mental Adjustment is Cancer) measures four strategies for coping with the disease: two constructive the fighting spirit and positive reevaluation and two destructive preoccupation with anxiety and helplessness-hopelessness. Results are calculated separately for each of the four strategies. The range of possible results is in the range of 7-28 points. The overall rate, when converted into standardized units is open to interpretation according to the properties characterizing sten scores. Results within 1-4 sten (10-24 pts.) is taken as the results of low and within 7-10 sten (30-40 pts.) as high. The results between 5 and 6 sten (25-29 pts.) is considered as mediocre. The higher the score, the greater the severity of behaviors that are characteristic for the method of struggle with cancer [7]. The questionnaire Strategy for Coping with Pain CSQ (The Pain Coping Strategies Questionnaire) consists of 42 statements that describe the seven strategies to cope with the pain and two questions concerning the

3 Psychological adaptation to cancer and strategies for coping with pain in patients with cervical cancer 61 assessment of their own abilities to cope and reduce pain. Ways of dealing with pain reflect the six cognitive strategies: divert attention, reevaluation of pain sensations, catastrophing, ignoring sensations, praying/deep hope, declaring of deal and one behavioral increased behavioral activity. The results are calculated for each strategy, the value of which is within the range 0-36 pts. The higher the score the greater importance of ascribed way of dealing with pain. The questionnaire used a sevenpoint Likert scale. There are additional two questions related to pain control and the ability to reduce it [7]. In the statistical analysis we used one-way analysis of variance (ANOVA), a one-way multivariate analysis of variance (MANOVA), ANOVA Kruskal-Wallis test, Mann- Whitney U, the correlation coefficient r Pearson s (r ) and Kendall's Tau (J ). The level of significance was set at p # Results The first stage of the study included the analysis of the Mental adaptation strategy to cancer that select women with cervical cancer. Analyses show that among patients with cervical cancer outweigh constructive strategies: the fighting spirit and a positive revaluation. After standardization, the results for constructive policies have a value of 6 stena, which corresponds to the average results obtained by the population, on which we created the Polish standards. Destructive strategies in relation to Polish norms, have a value of 4 stena, which should be considered as the results below the average. For measuring the relationship between the age of patients and strategies to adapt the disease linear correlation coefficients were calculated (r Pearson's). None of calculated the Pearson correlation coefficient does not exceed the level of statistical significance age of patients is not associated with the use of a specific strategy. To check whether there is relationship between place of residence and used strategies for coping with the disease, we conducted multivariate analysis of variance MANOVA. The test results are not statistically significant, 8 (8, 48) = 1.28; p = Place of residence did not affect the strategies used to cope with the disease. The analyzed result of the relationship between education (ANOVA rank Kruskal-Wallis), marital status (U Mann-Whitney test) and financial situation (ANOVA rank Kruskal-Wallis) and the choice of a particular strategy are presented below. Table 1. Descriptive statistics for indicators strategy for coping with the disease Strategy for coping with disease N M SD Minimum Maximum Preoccupation with anxiety Fighting spirit Helplessness-hopelessness Positive revaluation N group size; M median; SD standard variation Table 2. Age and adaptation strategies to the disease Strategy for coping with disease Age Preoccupation with anxiety 0.10 Fighting spirit 0.08 Helplessness-hopelessness 0.22 Positive revaluation 0.22 Table 3. Strategies for coping with the disease, depending on education (p 1 ), marital status (p 2 ), financial situation (p 3 ) Strategy for coping with disease N p 1 p 2 p 3 Preoccupation with anxiety * Fighting spirit Helplessness-hopelessness * 0.07* Positive revaluation * 0.36 *p # 0.10

4 62 D. Rogala, A. Mazur, M. Maślińska, K. Koper, M. Staniszewska Table 4. Strategies for coping with pain among women with cervical cancer Strategy for coping with pain N M SD Minimum Maximum Divert attention Revaluation of pain sensations Catastrophizing Ignoring sensations Praying/deep hope Declaring deal Increased behavioral activity Pain control The ability to reduce pain N group size; M median; SD standard variation Table 5. Correlations between strategies for coping with pain and age Strategy for coping with pain Age Divert attention 0.28 Revaluation of pain sensations 0.28 Catastrophizing!0.10 Ignoring sensations 0.25 Praying/deep hope 0.12 Declaring Deal 0.20 Increased behavioral activity 0.11 Pain control 0.12 The ability to reduce pain 0.06 Table 6. Strategies for coping with pain depending on education (p 1 ), marital status (p 2 ), financial situation (p 3 ) Strategy for coping with pain N p 1 p 2 p 3 Divert attention Revaluation of pain sensations Catastrophizing Ignoring sensations * Praying/deep hope Declaring deal * Increased behavioral activity Pain control The ability to reduce pain * * *p # 0.10 Table 7. Correlations between strategies of coping with the pain and strategies for coping with the disease Strategy for coping with the disease Strategy for coping with pain Preoccupation Fighting Helplessnesshopelessness revaluation Positive with anxiety spirit Divert attention ! Revaluation of pain sensations * Catastrophizing 0.37* -0.44* 0.19!0.28 Ignoring sensations *! * Praying/deep hope ! Declaring deal! *!0.35* 0.49* Increased behavioral activity! *! * Pain control!0.25* 0.40*!0.24* 0.32 The ability to reduce pain!0.22* 0.37*!.39* 0.25* *p # 0.10

5 Psychological adaptation to cancer and strategies for coping with pain in patients with cervical cancer 63 In order to analyze the status of the woman two categories were defined: 1) person in a partnership or marriage; 2) single person. Statistical analysis showed that: 1) the education of patients is not associated with any strategy for coping with the disease; 2) women living in relationships reach an average higher scores in applying the strategy helplessness-hopelessness and a positive revaluation than single women; 3) people with poor and average financial situation exhibit a higher propensity for the use of destructive strategies. The next stage of the study included analysis of selected strategies to cope with pain in patients with cervical cancer. The conducted calculations show that among patients with cervical cancer 4 prevailing strategies for coping with pain can be extracted: declaring coping, increased behavioral activity, praying/deep hope and divert attention. The other three strategies, ie. ignoring sensations, catastrophizing and reassessment sensations of pain, the patient clearly ascribe less importance. For measuring the relationship between the age of patients and strategies for coping with pain, the correlation coefficient Pearson was used. In the case of pain control and the ability to reduce pain, the nonparametric correlation coefficient Kendall Tau was used. None of the calculated correlation coefficients reached the level of statistical significance no association between age of patients and the use of strategies to cope with pain, pain control and the ability to reduce it. To check that between place of residence and used strategies for coping with pain there is a relationship, we conducted multivariate analysis of variance MANOVA. The test results were not statistically significant, 8 (14, 42) = 0.39; p = Place of residence does not affect the strategies used to cope with pain. In case of indicators measuring the ability of the control and reduction of pain, ANOVA Kruskal-Wallis Rank was used. Also in this case, the results give no reason to believe that there is a relationship between variables (pain control, p = 0.69; ability to reduce pain, p = 0.46). The results of the analysis of the relationship between education (ANOVA rank Kruskal-Wallis), marital status (U Mann-Whitney test) and financial situation (ANOVA rank Kruskal-Wallis) and the choice of a particular strategy are presented below. The results of the analysis indicate that: 1) women with secondary and higher education have a greater ability to reduce pain than women with primary education and vocational; 2) a woman with a very good financial status have the highest propensity to use the strategies ignoring sensations, declare to deal better with pain and have a greater ability to reduce pain. The last stage of the study consisted of finding a connection between the choice of a specific strategy for the adaptation to cancer and the way to deal with pain (correlation coefficient r Pearson's), pain control and the ability to reduce it (Kendall Tau correlation coefficient). Conducted analysis revealed the existence of a number of dependencies: along with the use of strategies preoccupation with anxiety increases the tendency to apply the strategy of catastrophizing. along with the use of strategies fighting spirit falls tend to be used catastrophizing strategy, and rises to the strategy ignoring sensations, declaring deal and ncreased behavioral activity, along with the application of the strategy helplessness-hopelessness falls tend to be used to declaring deal, along with the application of the strategy a positive revaluation tend to increase the use of revaluation of pain sensations, ignoring sensations, declaring deal and increased behavioral activity, with an increase of pain control and ability to reduce pain decreases the tendency to apply strategies preoccupation with anxiety and helplessnesshopelessness and increasing the use of strategies fighting spirit and a positive revaluation. Discussion MINI-MAC In the light of the survey which were carried out among 30 studied patients in the Clinic of Oncological Gynaecology Oncological Center prevailed constructive strategies to adapt to the disease ( fighting spirit (22.6) and positive revaluation (21.1)). In contrast, destructive forms preoccupation with anxiety (16.1) and helplessness/hopelessness (12.6) occurred much less frequently. Other studies which analyzed women with tumors also indicated that dominant group chose constructive strategies to cope with the disease [10, 11]. Different results were obtained by Malicka. She also indicates that women with breast cancer much more often chose the strategies of fighting spirit and a positive revaluation than women with cancer of reproductive organs [9]. Kozak compared group of patients with different types of cancers and observed that women with cancers

6 64 D. Rogala, A. Mazur, M. Maślińska, K. Koper, M. Staniszewska of reproductive organs most often choose constructive strategies [12]. Juczyński obtained similar results by examining 266 patients with tumors of breast, reproductive organ, prostate, stomach, intestines, pancreas, and larynx. In hormone-dependent tumors prevailed constructive strategies, and diet-related destructive. He also pointed to the differences between men and women men often tilted and were prone to destructive strategies [7]. Analyzing the obtained results of the study it can be concluded that socio-demographic variables such as age, place of residence and education do not have a significant impact on choosing the strategies of coping with the disease. There is only a correlation between marital status and material conditions. Women living in relationships, reach on average higher scores in applying the strategy helplessness-hopelessness and positive revaluation than single women. In contrast, sick women with a bad and average financial situation show a higher propensity for use destructive strategies of coping with the disease. Kozak said that an elder age correlated with positive revaluation [12]. CSQ Among these patients four predominant strategies for coping with pain were isolated: declaring deal (20. 47), increased behavioral activity (19.77), praying/ deep hope (19.33) and divert attention (17.97). For the other strategies, patients appose less importance. Andruszkiewicz studies conducted on patients with degenerative changes on the hip joint showed similar results. Patients chose two dominant strategies for coping with pain: declaring deal (21.35) and praying/deep hope (21.15) [13]. Rosentiel, Keefe report that higher scores in cognitive factor ( cognitive coping and suppression ) were associated with decreased overall activity and higher results in the medium helplessness were associated with increased anxiety and depression. People with high scores in factor distraction and praying/deep hope revealed greater severity of pain and loss of activity [14]. Juczyński analyzed the results of the three groups of patients hospitalized for chronic pain: back pain, migraine (women) and neuralgia. Patients with a diagnosis of neuralgia differed from other groups by poorer coping with the pain and ignoring the experience and the lack of ability to revalue sensations of pain. Compared with the British patients which often exaggerate catastrophizing strategy [7]. In another study analyzing 138 patients with chronic pain, Juczyński indicated that patients who are not capable to control their pain, describe the pain as a crush of their life to have no value ( catastrophizing ), while those who control the pain, associate it with their own skills ( declaring deal ) [15]. Socio-demographic variables such as age, place of residence and marital status did not correlate with the choice of strategies to cope with pain. Only education had an influence on the ability to reduce pain. Patients after graduating secondary school and high school have a greater ability to reduce pain. In contrast, women with good material conditions have a tendency to use the ignoring strategy sensations. Andruszkiewicz study showed that socio-demographic variables such as age and education had little impact on the strategies for coping with the pain. Only those living in rural areas were more tilted to catastrophizing strategies than those who live in the city [13]. The test results showed by Zielazny indicate that the elder the age, the patients are more often coping with pain by using activities behavioral strategies, and the higher the education, the less tendency to catastrophism [16]. Differences between own and other authors research may result from the structure of gender subjects and different disease entities. MINI-MAC and CSQ The study also showed that there are dependencies between strategies of coping with the pain and mental adaptation to disease. In women declaring constructive strategies, we observed decrease tendency to catastrophizing and increased use of revaluation of pain sensations, increased behavioral activity, declaring deal and ignore sensations. In contrast, patients who used destructive ways of coping with the disease inverse dependence can be observed. A tendency of catastrophizing is growing and the use of declaring deal is reducing. The ability to control pain and ability to reduce it goes hand in hand with a tendency to use constructive strategies. Kofta, Szustrowa shows that patients who approach the disease in an active way better cope with the disease, relate to their situation realistically, want to learn as much as possible about the disease, they talk about their feelings and are looking for people who can provide support without inducing negative emotions. The patient trust the doctors, is aware of the adverse effects of their illness, does not resign from his/her activity and social role, believe that she/he is able to overcome the disease [17]. Payne, Haines indicate that patients choosing constructive strategies to cope with the disease are more

7 Psychological adaptation to cancer and strategies for coping with pain in patients with cervical cancer 65 active and are considered to have better prognosis than those using strategies considered not adaptive. In the process of the disease and treatment we should have in mind that the quality of life of the patient is often not commensurate with the real patient's condition, and that the duration of the disease in patients adaptive strategies may be a subject to change [18]. Conclusions 1) Women with cancer of the reproductive organs are adapting well to the disease; among all the groups surveyed cancer patients show the most active attitude. 2) Women in relationships often feel helpless in the face of illness, but are trying to find hope and satisfaction from the years of live they spent with their spouse. 3) An active attitude towards the disease and better material status gives strength to fight the pain. References [1] Krajowy Rejestr Nowotworów [dostęp: ]. [2] Spaczyński M., Nowak-Markwitz E., Kędzia W. (2012) Praktyczna ginekologia. Wielkopolskie Towarzystwo Onkologii Ginekologicznej, Poznań. [3] Kotlińska-Lemieszek A., Bączyk E., Deskur-Śmielecka E. et al. (2011) Ból u pacjenta z chorobą nowotworową diagnoza kliniczna jako warunek prawidłowego postępowania. Now. Lek. 80 (1): [4] Żylicz Z., Krajnik M. (2013) Ból u chorych na nowotwór. Wydawnictwo Lekarskie PZWL, Warszawa. [5] Diener Ch.H., Maier Ch. (2005) Leczenie bólu metody leki psychologia. Wydawnictwo Medyczne Urban & Partner, Wrocław. [6] Oxenham D. (2009) Opieka paliatywna i leczenie bólu. [In]: Boon N.A., Colledge N.R., Walker B.R., red. Choroby wewnętrzne. Wydawnictwo Medyczne Urban & Partner, Wrocław. [7] Juczyński Z. (2001) Narzędzia pomiaru w promocji i psychologii zdrowia. Pracownia Testów Psychologicznych Polskiego Towarzystwa Psychologicznego, Warszawa. [8] Heszen-Niejodek I. (2000) Teoria stresu psychologicznego i radzenia sobie. [In:] Strelau J. (ed.) Psychologia. Podręcznik akademicki. Gdańskie Wydawnictwo Psychologiczne, Gdańsk. [9] Malicka I., Szczepańska J., Anioł K. et al. (2009) Zaburzenia nastroju i strategie przystosowania do choroby u kobiet leczonych operacyjnie z powodu nowotworu piersi i narządów rodnych. Współcz. Onkol. 13 (1): [10] Michałowska-Wieczorek I. (2006) Rola wsparcia w zmaganiu się z chorobą nowotworową. Psychoonkologia 10 (2): [11] Szczepańska-Gieracha J., Malicka I., Rymaszewska J. et al. (2010) Przystosowanie psychologiczne kobiet bezpośrednio po operacji onkologicznej i po zakończeniu leczenia. Współcz. Onkol. 14 (6): [12] Kozak G. (2012) Zróżnicowanie strategii radzenia sobie nowotworem chorych w przebiegu wybranych nowotworów złośliwych. Anest Ratow. 6: [13] Andruszkiewicz A., Wróbel B., Marzec A. et al. (2008) Strategie radzenia sobie z bólem u pacjentów ze zmianami zwyrodnieniowymi stawu biodrowego. Probl. Pielęg. 16 (3): [14] Rosentiel A., Keefe F.J. (1983) The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 17: [15] Juczyński Z. (2002) Zmaganie się z przewlekłym bólem. [In:] Heszen-Niejodek I., (ed.) Teoretyczne i praktyczne problemy radzenia sobie ze stresem. Wydawnictwo Naukowe SPA, Poznań. [16] Zielazny P., Biedrowski P., Lezner M. et al. (2013) Stopień akceptacji choroby, przekonania na temat kontroli bólu oraz strategie radzenia sobie z bólem wśród pacjentów zakwalifikowanych do zabiegu z powodu choroby zwyrodnieniowej kręgosłupa. Post. Psychiatr. Neurol. 22: [17] Kofta M., Szustrowa T. (2001) Złudzenia, które pozwalają żyć. PWN, Warszawa. [18] Payne S., Haines R. (2002) The Contribution of psychologists to specialist palliative care. Int. J. Palliat. Nurs. 8: J Dorota Rogala Clinic of Oncological Gynecology Łukaszczyk Oncological Centery Romanowskiej 2, Bydgoszcz drogala@cm.umk.pl