ANXIETY IN BREAST CANCER PATIENTS, UNDERGOING SURGERY AS A PRIMARY TREATMENT MODALITY Mrs. Shejila.C.H 1, Dr.Mamatha Shivananda Pai 2, Dr.Donald J Fernandes 3, Dr. Anice George 4, Dr. Baby S Nayak 5, Dr. Elsa Sanatombi Devi 6, Dr. Jyothi R.K 7, Dr. Stanley Mathew 8 1 PhD Scholar, 2 Professor, 4 Dean, 5, 6 Professor, 7 Associate Professor, Manipal College of Nursing Manipal, Manipal University,Karnataka,India.. 3 Professor& HOD, Department of Radiotherapy & Oncology, KMC, Manipal University,. Karnataka, India. 8 Professor, Department of Surgery, KMC, Manipal University, Karnataka, India. Corresponding author: Dr.Mamatha Shivananda Pai,Professor,Department of Child Health Nursing,Manipal College of Nursing Manipal,Maniapl University,Madhav Nagar,Manipal- 5761,Karnataka,India, ABSTRACT Breast cancer is the most common cancer and main cause of cancer death in females worldwide. Anxiety and psychological distress are most common sequelae seen in patients with cancer. Prolonged anxiety can influence a person s response to treatment, decision making and overall quality of life. The main objective of the study was to assess the level of anxiety experienced by breast cancer patients awaiting surgery. A descriptive, cross-sectional study among 30 breast cancer patients undergoing surgery by purposive sampling was used to assess the level of anxiety prior to surgery. The study was conducted in general surgery and oncology wards of a tertiary care hospital in Karnataka. Data for this study was collected through State Trait Anxiety Inventory (STAI). The findings of this study show that 80% of women were in the age group of 41-60years,80% were in stage II of cancer and 67% were planned to have modified radical mastectomy(mrm).majority of the samples (80%) exhibited moderate level of anxiety, whereas 7% had severe anxiety. Study found that none of the demographic and clinical variables were associated with anxiety level. The findings of the study indicate the magnitude of the problem and need for appropriate interventions to alleviate anxiety among these patients Key words: Anxiety, Breast Cancer Patients, Surgery, Quality Of Life www.apjor.com Page 17
Introduction Breast cancer is the most common cancer and main cause of cancer death in females worldwide (Jemal et al, 21). Women s anxiety increases after diagnosis of breast cancer, as breast is considered as a symbol of womanhood & women s sexuality. Having breast cancer & undergoing surgery is a traumatic experience due to its impacts on their self-image and sexual relationship (Yankaskas B.C, 25). The most prevalent psychological conditions seen in breast cancer patients are anxiety and depression. One study found that prevalence of depression was 19.1% where as anxiety prevalence was 24.1% (Saria. A.R & Zainal.N.Z, 20).Most of the patients experience anxiety prior to treatment whereas depression emerges during post treatment phase. Despite of improvements in health care, patients continue to experience anxiety due to fragmented care, difficulty in understanding information and misinterpretation of treatment plans. In addition to that nursing barriers in assessing anxiety include lack of time, lack of knowledge of screening tools, reluctance in exploring patients upsetting issues. Prolonged anxiety has immunosuppressive effects, compromise patient and impairs their recovery. With this background the present study is carried out to assess the level of anxiety experienced by breast cancer patients prior to surgery. Objectives The objectives of the study were to 1. Assess the level of anxiety in breast cancer patients undergoing surgery. 2. Find out the association between level of anxiety and selected demographic and clinical variables. Materials and methods A descriptive cross sectional design was used for the present study. The study was conducted in surgical oncology and general surgery wards of Kasturba Hospital, Manipal. A total of 30 women diagnosed with breast cancer undergoing surgery were recruited by purposive sampling technique. The inclusion criteria used to select subjects were women who are operable cases of breast cancer, who are undergoing Modified Radical Mastectomy or Breast conserving surgeries, women in the age group of 25-75 years, who are undergoing breast cancer surgery for the first time. Women with stage IV cancer and metastasis to brain or bone, women with concurrent malignancies, who have received neoadjuvant chemotherapy, women with severe cognitive impairment or psychiatric illnesses were excluded from the study. Study was undertaken after the approval by the Institutional Ethical Committee and obtaining consent from the study participants. Data collection procedure Data was collected using Tool 1:Sociodemographic Proforma and Clinical Proforma, Tool 2:Speilberger state trait anxiety inventory (STAI).Tool 1 consisted of Sociodemographic proforma which include variables like age,religion,marital status, education, occupation, income, friends and family support and clinical proforma consisted of variables like stage of cancer, duration of diagnosis, type of surgery and nodal status. Tool 2 Speilberger state trait anxiety inventory (STAI) is a standardized questionnaire, which presents 20 statements describing anxiety. Patients were asked to record one of the four descriptors which best indicated their degree of emotion. (Scores 1-4). The minimum score was 20 and maximum score was 80. The scores www.apjor.com Page 18
were arbitrarily classified as mild anxiety (21-40), moderate level of anxiety (41-60) and severe level of anxiety (61-80). Tool has an already established validity and reliability. Internal consistency coefficients for the scale have ranged from0.86 to0.95; test-retest reliability coefficients have ranged from0.65 to0.75.the data collected were analyzed using the descriptive and inferential statistics with the help of SPSS 16.0 version. Results The findings of the present study are organized under the following headings: Section 1: Description of sample characteristics Frequency and percentage distribution of sample characteristics is given in the following tables. Table 1: Distribution of samples according to demographic characteristics n=30 Demographic characteristics Frequency (f) Percentage (%) 1. Age (in years) 26-40 13 41-60 24 80 61-75 07 2. Religion Hindu 23 77 Muslim 13 Christian 10 3. Marital status Married 30 1 Unmarried 4. Education Primary& secondary 07 23 Higher secondary 22 74 Graduate and above 5. Occupation Employed 06 20 House wife 24 80 6. Income < 50 07 51-1 12 40 1-150 11 37 >150 05 16 7. Friends/family support Yes 30 1 No It is evident from the table that most of the subjects belong to the age group of 41-60 (80%).Majority of the samples belongs to Hindu religion (77%).All the samples were married.97% of the samples had primary,secondary or higher secondary education whereas only 3% were graduated. Majority of the samples (80%) were housewives. Most of the samples (40%) belong to the income group of Rs. 51-1.It is important to note that 7% of the samples were earning less than Rs.50/month. All the samples were getting family and friends support during illness. www.apjor.com Page 19
Table 2: Distribution of samples according to clinical variables n=30 Clinical variables Frequency (f) Percentage (%) 1. Stage of cancer Stage I 13 Stage II 24 80 Stage III 07 2. Duration of diagnosis 1-2 weeks 09 30 3-4 weeks 21 70 3. Type of surgery Breast conservation surgery 10 33 Modified Radical Mastectomy 20 67 4. Nodal status Positive 20 67 Negative 10 33 Data presented in table 2 shows that 80% of the samples were in stage II of breast cancer. 70% of the subjects were having duration of diagnosis between 3-4 weeks. Majority of samples (67%) were planned to have modified radical mastectomy rather than breast conservation surgery.67% of the samples were positive for nodal involvement. Section 2: Distribution of sample based on anxiety scores Anxiety scores were categorized as mild level of anxiety (21-40),moderate level of anxiety (41-60) and severe level of anxiety (61-80). Percentage 1 80 60 40 20 0 80 13 7 Mild Moderate Severe Level of Anxiety Figure1: Percentage distribution of samples based on anxiety scores www.apjor.com Page 20
Data depicted in figure1 shows that majority (80%) of the subjects had moderate level of anxiety and 07% had severe anxiety. Section 3: Association between anxiety scores and selected demographic and clinical variables Analysis of association between anxiety scores and selected demographic and clinical variables were performed in order to identify whether anxiety scores are associated with any of the selected demographic variables like age, educational status, occupation and income and clinical variables like stage of cancer, duration of diagnosis and type of surgery.it was found that none of the demographic or clinical variables are associated with anxiety scores. (Table.3) Table 3: Association between quality of life and demographic and clinical variables n=30 Variables Anxiety categories Chi p value Significance square Mild Moderate Severe value Age 26-40 41-60 61-75 18 1.79 0.32 NS* Educational status Primary & secondary Higher secondary Graduate and above Income 50 5-1 1-150 150 Occupational status Employed House wife Stage of cancer Stage I Stage II Stage III Type of surgery Breast conservation MRM Duration diagnosis 1-2 weeks 3-4 weeks of 07 16 10 07 05 05 09 19 08 16 22 3.41 0.60 NS* 7.09 0.90 NS* 0.63 1. NS* 2.14 0.77 NS* 1.31 0.63 NS* 2.76 0.72 NS* NS*-Not Significant p<0.05 www.apjor.com Page 21
Discussion The present study findings shows that 80% of patients were in age group 41-60 years and 77% of them have educational status above higher secondary level, which shows consistent findings with a descriptive study conducted by Lueboonthavatchai P (27) to identify prevalence and psychosocial factors of anxiety and depression among 3 breast cancer patients. The study revealed that 64.3% were in the age group of 41-60 years, 80% of the women had educational status above secondary school level. In current study 80% of samples were in stage II of cancer whereas a study conducted among 176 cancer patients by Schwarz R et al, (21) to detect the psychological distress in woman scheduled for surgery, showed that 63% of samples were in stage 1 of cancer. The results of the present study revealed that 80% of samples exhibited moderate level of anxiety, 13% had mild level of anxiety and 7% exhibited severe level of anxiety. This is supported by a study conducted by Miller K et al, (25) that 25% of samples exhibited mild anxiety, 7% exhibited severe anxiety and 68% showed moderate level of anxiety. The present study proved that any of the demographic or clinical variables were not associated with level of anxiety. But Studies conducted by Stark et al,(22) and Fallowfield L.J, (24) revealed that type of surgery and onset of cancer, younger age and lower socioeconomic status, has got association with levels of anxiety. Recommendations for future research However because of small sample size, more studies examining relationship between age, stage of cancer, type of surgery and other related clinical and demographic variables are needed. More researches are needed to explore specific nursing roles and nurse led programmes to alleviate anxiety and distress among breast cancer patients. Increased attention is required in the area of psychosocial intervention research and use of complimentary therapies for individuals and groups. Further studies exploring the informative and supportive needs of patients can be conducted to relieve their anxiety and distress. Conclusion Recent research has reiterated the prevalence of anxiety in breast cancer patients before surgery. Nurses should use screening and assessment protocols to identify patients with anxiety prior to surgery. By providing anxiety screening at numerous points along breast cancer trajectory nurses can plan specific psychologic and psychosocial interventions. Recognizing anxiety and intervening it on time is pivotal to improve treatment outcomes of women with breast cancer. References 1. Aass, N., Fossa, S.D., Dahl, A. A., Moe, T.J.(27) Prevalence of anxiety and depression in cancer patients. European Journal Of Cancer, 33,pp.1597-16 2. Baqutayan S.M.S.(22) Managing anxiety among Breast cancer patients. Advances in Psychology Study,1(1),pp.4-7 www.apjor.com Page 22
3. Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (23). Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med, 65(4),pp. 571-581. 4. Corporate Research Associates.(24) cancer patient navigation evaluation.retrieved fromhttp://www.cancercare.ns.ca/media/cancercare/patientnavigationevaluationfindings.pdf 5. Fallowfield,L.J., Hall, A., Maguire, P., Baum, M., A Hern,R.P. (24) Psychological effects of being offered choice of surgery for breast cancer. BMJ,309.pp. 448 448 6. Jemal, A., Bray, F., Center M.M., Ferlay, J., Ward, E., Forman,D. (21).Global cancer statistics. CA: a cancer journal for clinicians, 61(2), pp.69-90. 7. Lueboonthavatchai, P. (27).Prevalence and psychosocial Factors of anxiety and Depression in Breast Cancer Patients, Journal of Medical Association Thailand,90(10),pp.2164-2173. 8. Madden, J. (26). The problem of distress in patients with cancer: More effective assessment. Clinical Journal of Oncology Nursing, 10(5), pp.615 619. 9. Millar, K., Jelicic,M., Bonke, B., Asbury,J.(25).Assessment of preoperative anxiety:comparison of measures in patients awaiting surgery for breast cancer.british Journal of Anaesthesia,74,pp.180-183 10. Sariah A.R, Zainal N.Z. (20). Anxiety, depression and coping strategies in breast cancer patients on chemotherapy. Malays J Psychiatr.;19(2).pp.213-217 11. Stark D.P, House A. (20). Anxiety in cancer patients. Br J Cancer 83:pp.1261-1267 12. Yankaskas B,C.(25) Epidemiology of breast cancer in young women. Breast Disease, 23,pp.3-8. 13. Zabora, J. R., Blanchard, C. G., Smith, E. D., Roberts, C.S., Glajchen, M., Sharp, J. W., et al. (1997). The prevalence of psychosocial distress among cancer patients across the disease continuum. Journal of Psychosocial Oncology, 15, pp.73-87. www.apjor.com Page 23