تاثیرات روانی بر روی قبول واقعیت درمان بعد از جراحی در بیماران مبتلا به سرطان

Abstract Objective: Many cancer patients fail to complete treatment for reasons that are unclear in previous research which, nevertheless, suggested hypotheses for this study about the characteristics of the patients and their consultations. Method: 158 adults with breast cancer or other cancers who had been chosen for postsurgical treatment in the Lister Hospital or the Mount Vernon Hospital had completed published questionnaires to assess either (n=74) personal attributes or circumstances viz. locus of health control, health habits, support, affiliative drive, anxiety, depression, or (n=84) their attitudes to cancer or their consultations, viz. the Mental Attitudes to Cancer Scales, Trust in Physicians, Perceived Empathy, and Satisfaction With Recent and Diagnostic Consultations. Results: 32% then failed to complete treatment. In logistic multiple regression analyses, only diagnosis (P=.0001), gender (P=.005), and treatment center (P=.0002) predicted this although the effect of gender was not significant among patients without breast cancer. Among the patients without breast cancer intended for the Mount Vernon Hospital, a National Cancer Centre, fewer completed treatment than those did not complete. Conclusion: The breast cancer patients, unlike women with other cancers, and patients referred to the local hospital rather than the regional cancer center, were more likely to complete treatment. Thus, uptake of treatment may be favored by accessibility and familiarity of its source and by the unique impact in women of breast cancer and the wider public attention given to that illness. Research on patients' expectations, fears, and corresponding experiences of treatment, rather than personal attributes, should clarify failure to complete cancer treatment especially in patients without breast pathology.

Introduction It has been concluded that, in cancer patients, adjuvant radiotherapy and chemotherapy improve survival rates, enhance the quality of life, and reduce the rate of recurrence [1], [2] and [3]. In spite of that, many patients refuse or fail to complete treatment [4]. Although noncompliance has long been recognized in medicine, few studies have examined this in cancer [4]. Research has suggested, as hypotheses for our study, that the following favor the acceptance and or completion of treatment by patients: good social support [5], being reconciled to a diagnosis of cancer [5], low levels of depression and anxiety [6], high self-confidence [7], tolerance of side effects [8], determination to fight the illness [6], enthusiastic recommendations by the physician [9], satisfaction with the diagnostic consultation and with information given about the illness [9] and [10], and low ‘barriers’ plus good ‘support’ [11]. However, because studies have had one or more deficiencies, the effects on compliance are unclear. Studies have relied on the patients' reports of attendance [11], which can be unreliable or biased [12], or they have examined only the completion of treatment once accepted [9], or have given few details of their measures [8], or no evidence of the psychometric properties of those measures [9], or have conducted several simultaneous statistical tests of their data without regard for risk of Type I error [8], or have been retrospective [5] and [6], so that the cause and effect relationships of variables with compliance are indeterminate. All studies but one [11] have examined only one illness in spite of the large differences in care and publicity given to different cancers and their treatment [13]. Therefore, the present study relied on hospital records of treatment to examine the effect of different cancers, patient characteristics, and perceptions of care, as measured by scales of proven validity, on the uptake and completion of postsurgical treatment.

Results Of the 158 patients, the mean age was 59.2 years (±S.D.=12.6), 73.8 were married or cohabiting, 27% had attended higher education, and 21.9% were in occupational Classes 1 and 2, 46.4% had breast cancer, the others (31% of whom were women) had colorectal cancer (30.1%), cancer of the bladder (22.4%), or gastrointestinal cancer (1%), 58% had node-positive disease, 50% had chemotherapy, the others had radiotherapy or radiotherapy plus chemotherapy. The other independent variables are summarized in Table 1. Table 1. Summary of the independent variables and their relationship with adherence Logistic regression analysis of adherence Mean S.D. Beta S.E. Exp (β) Walda P(α) R Psychosocial variables (Group 1, n=84) Chance locus of control 16.99 4.13 −0.12 0.06 0.89 3.83 .05 −.13 Internal locus of control 20.31 3.38 −0.07 0.07 0.93 1.00 .32 .00 Powerful others locus of control 20.80 4.27 −0.05 0.06 0.95 0.93 .33 .00 Health habits 35.87 4.35 −0.05 0.06 0.95 0.75 .39 .00 Extraversion 19.16 3.40 0.04 0.07 1.04 0.40 .53 .00 Emotional support 100.18 47.14 0.01 0.01 1.01 3.27 .23 .11 Practical support 100.19 46.48 0.01 0.01 1.01 2.53 .34 .07 Affiliative drive 23.84 11.55 −0.03 0.02 0.97 1.59 .13 .00 Self-esteem 13.88 2.23 0.03 0.10 1.03 0.11 .74 .00 Depression 4.43 3.44 −0.05 0.07 0.95 0.51 .38b .00 Anxiety 7.09 4.37 −0.02 −0.02 0.98 0.07 .13 .00 Consultation and coping (Group 2, n=74) Trust in physicians 42.39 7.00 −0.06 0.04 0.95 1.76 .18 .00 Empathy 18.18 18.0 70.00 0.01 1.00 0.02 .89b .00 Diagnostic satisfaction 63.20 7.74 0.02 0.03 1.02 0.35 .56 .00 Consultation satisfaction 76.69 10.65 −0.02 0.03 0.98 0.50 .48 .00 Helplessness–hopelessness 9.31 2.71 0.10 0.10 1.10 1.02 .31 .00 Anxious preoccupation 22.36 4.62 0.07 0.06 1.07 1.56 .21 .00 Fatalism 18.25 3.48 0.11 0.08 1.12 1.98 .16 .00 Fighting spirit 50.47 7.52 0.00 0.03 1.00 0.01 .92b .00 Avoidance 1.82 0.80 0.22 0.34 1.25 0.43 .51 .00 Demographic and clinical variables (Groups 1 and 2, n=158) Age – – −0.01 0.01 0.99 0.83 .74 .00 Type of treatment – – −0.09 0.43 0.92 0.04 .84 .00 Treatment center – – 1.06 0.42 0.35 6.49 .01 −.15 Surgeon – – −0.05 0.07 0.57 1.44 .38 .00 Diagnosis – – 0.94 0.36 2.56 6.83 .009 .16 Stage of disease – – −4.38 0.50 0.13 0.24 .75 .00 Social class – – 0.21 0.41 1.24 0.28 .59 .00 a df=1. b Because of non-normal distribution, this was confirmed by χ2 (P>.10). Table options Adherence to postsurgical treatment: the relationship with the independent variables Of the 158 patients, treatment was rejected at the outset by 13%, 19% accepted only some, and 68% had all that was prescribed. For the analyses of each group, because there were too few subjects in the first two categories, they were combined for the variable ‘adherence’: those completing and those failing to complete treatment. For similar reasons, patients in the four diagnostic categories were combined into two, those with breast cancer and those without. Because one oncologist saw all but one of her patients at Mount Vernon, and the other attended all but two of his patients at the Lister Hospital, the variable ‘oncologist’ was omitted from analysis in favor of ‘treatment. center’ Because all the breast cancer patients were women, ‘gender’ was omitted in favor of ‘diagnosis’ from the first analyses. All continuous independent variables, except depression, empathy, and fighting spirit, were normally distributed. The data were analyzed by logistic regression analyses (‘Enter’ procedure) [26]. A separate screening analysis, using a conservative level of α (P=.10) for each independent variable, suggested that only chance locus of control, diagnosis, and treatment center had a significant relationship with adherence (Table 1). A single logistic regression analysis of adherence in Group 1, with those as the independent variables, showed no effect of chance locus of control (Table 2). A similar analysis of all the subjects (n=158) omitting, therefore, that variable, confirmed that diagnosis and treatment center (Table 2) predicted adherence. Seventy-three percent of the patients were correctly predicted by the model. More patients with cancer of the breast and more allocated to the Lister Hospital compared, respectively, with other cancer patients and those intended for Mount Vernon accepted and completed treatment (Table 3). Table 2. Logistic regression analyses of adherence as the dependent variable Sample Independent variable B S.E. Walda P(α) Odds ratio 95% CI R Group 1 (n=84) Diagnosis 1.67 0.58 8.20 .004 5.37 1.69–16.63 .24 Center −2.38 0.74 10.17 .001 0.09 0.02–0.40 −.28 Chance control −0.08 0.07 1.38 .240 0.92 0.80–1.06 .00 Merged sample (n=158) Diagnosis 1.60 0.41 14.95 .0001 4.94 2.20–11.09 .26 Center −1.78 0.47 14.17 .0002 0.17 0.07–0.43 −.25 Merged sample (n=158) Gender −1.52 0.47 10.58 .0011 0.22 0.09–0.54 −.20 Center −1.14 0.41 7.87 .0050 0.22 0.09–0.54 −.21 Merged sample (non-breast cancer) (n=83) Gender −0.93 0.52 0.03 .86 0.91 0.33–2.53 .00 Center −1.66 0.49 11.33 .0008 0.19 0.07–0.50 −.29 a df=1. Table options Table 3. Numbers of patients accepting and completing treatment (percentage of diagnostic group in brackets) Completes treatment Mount Vernon Lister Hospital Yes No Yes No Breast cancer 49 (65.3%) 16 (21.3%) 10 (13.3%) 0 (0%) Other cancers 17 (20%) 25 (30%) 32 (39%) 9 (11%) Percent of those intended for each center 62 38 82 18 Table options Because all the patients with breast cancer were women, diagnosis would have been much confounded with gender. Therefore, the preceding logistic regression analysis was repeated, substituting gender for diagnosis. This showed (Table 2) that treatment center and gender predicted adherence. However, an analysis of the non-breast cancer patients showed that treatment center but not gender did so (Table 2). Therefore, of the non-breast cancer patients, women were no more likely than men to complete treatment. Women were more likely to complete only if they had breast cancer.