The Effects of Breast Cancer on the Family: The Essentiality of Medical Family Therapy Interventions
The National Cancer Institute estimated that in 2006 approximately 2.5 women with a history of breast cancer were living (American Cancer Society, 2009). While in 2009, an estimated 254,650 new cases of breast cancer was diagnosed among women and about 1,910 cases were expected to occur among men according to the American Cancer Society. Increased survivorship has changed the disease to a chronic condition with biopsychosocial aftereffects with multiple challenges beyond the acute phase of medical treatment (Naaman, Radwan, & Johnson, 2009).
Although morbidity rates for breast cancer have declined and the majority of
women treated for the disease survive, more women are also being diagnosed and treated for breast cancer (Figueiredo, Fries, & Ingram, 2004). A diagnosis of breast cancer not only affects the life of the woman, but also the lives of those closest to the patient, including partners and children (Campbell, 2003; Faulkner & Davey, 2002; Heiny, Hermann, Bruss, & Fincannon, 2001; Kershaw, Mood, & Schaefnacker, 2005; Manne & Badr, 2008; Wagner, Bigatti, & Storniolo, 2006).
Breast cancer diagnoses and experiences present considerable challenges such as altering family roles, future plans, changing physical appearance, coping with treatment side effects and psychological distress (Figueiredo, et al., 2004; Manne, Ostroff, Sherman, Heyman, Ross, & Fox, 2004; Petersen, Kruczek, & Shaffer, 2003; Scott, Halford, & Ward, 2004). Cancer impacts all families, even those with good coping skills and adaptation abilities (Faulkner & Davey, 2002).
The purpose of this review is to identify the affected relational aspects and the unmet psychosocial needs of the patients and families, as well as some family interventions that have been studied for coping with breast cancer. With females being 99% of those affected by breast cancer, this review will focus on this population. Some of the most common psychosocial concerns reported by women with breast cancer are: fear of recurrence, physical symptoms, body image, sexual dysfunction, treatment-related anxieties, intrusive thoughts, marital or partner communication, feelings of vulnerability and existential concerns (Hewitt, Herdman, & Simone, 2004).
Such concerns and psychological distress extend beyond the patient and can negatively impact the quality of life of the family and caregivers as well(Feldman & Broussard, 2006; Kershaw, Northouse, Kritpracha, & Mood, 2004; Northouse, et al., 2005; Wagner, et al., 2006). Breast cancer
has been described as a “family affair” and as a “biopsychosocial problem that occurs in the context of an intense personal relationship that affects, and is affected by, the disease process in a circular reciprocity,” (Naaman, et al., 2009), thus family support is crucial for patients’ well-being (Shields &
Rousseau, 2004). While over the last 20 years, researchers and oncology
clinicians have recognized the importance of treating breast cancer in the
family context and Medical Family Therapy growing as a valuable specialty in the field, the literature suggests there is still a great need for collaborative oncology teams consisting of a family therapist and implementation of psychosocial family programs within oncology departments (Anllo, 2000; Campbell, 2003; Faulkner & Davey, 2002; Manne & Badr, 2008).
Impact of Breast Cancer on Marital
and Intimate Relationships
It has been well documented that the marital relationship is the most important source of support for patients during breast cancer diagnosis and treatment, (Figueiredo, et al., 2004; Manne, et al., 2004), as well as the most influential family relationship on health (Campbell, 2003). Research shows that both partners affect the others’ coping styles and that distress by both partners was linked to their coping efforts (Feldman & Broussard, 2006). In a qualitative study examining the core concerns of couples facing breast cancer who were seeking psychosocial support it was found that the core concerns were tension in the relationship, not knowing how to respond to her, wanting him to understand, needing to know what it is like to be touched, needing to be together and without the children, tired of listening
to worries, wondering about the children, and managing the threat of breast
cancer and fearing reoccurrence (Shands, Lewis, Sinsheimer, & Cochrane,
2006). Marriage is definitely stressed by breast cancer (Dorval, et al., 2005),
and couples have reported ineffective communication as their biggest concern (Hodgson, Shields, & Rousseau, 2003).
Several studies have examined and studied communication and engagement in couples coping with breast cancer and it has been supported that open disclosure and relationship talk is related to relational satisfaction, feelings of intimacy and greater emotional well-being, and avoidant coping is associated with partner distress (Badr & Acitelli, 2005; Figueiredo, et al., 2004; Hodgson, et al., 2003; Manne, et al., 2004; Manne, Ostroff, Rini, Fox, Goldstein, & Grana, 2004; Manne, Ostroff, Winkel, Grana & Fox, 2005). A study was conducted on couples who reported breast cancer brought them closer and it was found that the spouse accompanied the patient to treatments, they reported they were confidants, and the patient gave advice to the spouse on how to cope with her breast cancer, which also supports the benefits of open disclosure and may suggest that the couple relationship is not fundamentally threatened by breast cancer (Dorval, et al., 2005). Studies conducted on the effectiveness of couple-interventions in coping with breast cancer have proven to be effective in reducing psychological distress and improving relationship functioning, however many have been pilot studies or have been conducted with the use of focus groups (Baucom, et al., 2009; Northouse, et al., 2005; Scott, et al., 2004; Shields & Rousseau, 2004). It is proposed that Emotion-Focused therapy may benefit couples following treatment for breast cancer to focus on reducing avoidance and may enhance open communication and self-disclosure (Manne, Ostroff, Norton, Fox, Goldstein & Grana, 2006; Naaman, et al., 2009)
Impact of Breast Cancer on Partners
The literature also shows that husbands or intimate partners are often the primary caregivers for their spouses during breast cancer treatments (Feldman & Broussard, 2006; Northouse, et al., 2005; Wagner, et al., 2006). Male partners are assuming fundamental roles in the patient and family care; however, literature suggests that they are in a high-risk group because they tend to be disregarded or neglected while health care professionals focus on the patients’ concerns (Feldman & Broussard, 2006; Wagner, et al., 2006). A breast cancer diagnosis in a partner is associated with considerable psychological distress for husbands, typically shown as anxiety and depression (Wagner, et al., 2006) which affects other aspects of their lives such as sleep, work, aspects of their relationship, sex lives, and relationships with others (Feldman & Broussard , 2006).
In a study on men’s adjustment to their partners’ breast cancer it was found that patients’ physical well-being was negatively associated to men’s negative coping. However, longer relationship length was correlated with less illness intrusiveness, lowered occurrence of depression and higher levels of their partner’s physical well-being (Feldman & Broussard, 2006). Being such an important figure and at high-risk, partners should be included in psychosocial interventions for the patient, including couples-coping techniques to assist with dyadic coping skills.
Impact of Breast Cancer on Sexual Relations
There is a growing body of evidence to suggest that changes in body image after breast cancer and its treatments may have direct effects on sexuality, sexual response, sexual roles and intimate relationships (Anllo, 2000; Pelusi, 2006). However, responses to changes or importance placed on these issues may vary culturally, because one study found that Asian American women did not place value on their body image, they opted for a mastectomy more often so they would not be away too long from family duties (Kagawa-Singer & Wellisch, 2003).Traditional health care providers do not typically address these issues. The effects on cancer and its treatment on sexuality are not usually included in the assessments or plans of care for the patients (Anllo, 2000). Psychotherapy interventions have been suggested to help with understanding the potential impact on sexuality, help with sexual dysfunctions and enhance body image or self-esteem, specifically with Medical Family Therapists who may be more comfortable handling sex and relational issues regarding breast cancer (Anllo, 2000; Pelusi, 2006).
Impact of Couples’ Age on Diagnosis
In a study examining the role of reconstructive surgery, younger age was found to be more of an important risk factor for distress and sexual dysfunction than the type of surgery received (Rowland, Desmond, Meyerowitz, Belin, Wyatt, & Ganz, 2000). 68% of young women reported feeling self-conscious and had sexual problems since their treatments (Walsh, Manuel, & Avis, 2005). Breast cancer in young women usually means these women have small children to care for while battling a life-threatening disease. While for younger women who have not yet had their children, the diagnosis and treatment of breast cancer can lead to possibilities of death, infertility, toxicities, or premature menopause, all which contribute to the risk of greater psychological distress in young women and their young husbands (Hewitt, et al., 2004). Also the study on men’s adjustment to their partners’ breast cancer found that the impact can be more severe for young couples in the child rearing years and also because they have not had the opportunity to grow and develop their relationship over time, which was found to be a source of strength for partners (Feldman & Broussard, 2006).
Impact of Mothers’ Breast Cancer on
Children and Adolescents
Literature on the impact of breast cancer on children and adolescents is sparse and not as extensive as that on the couple dyad; therefore little is known on the effects of their psychosocial development (Faulkner & Davey, 2002). However, some child-related themes are present in the literature including role shifts, emotional distress, increased closeness and the importance of the child’s development stage (Faulkner & Davey, 2002; Heiny, et al., 2001; Petersen, et al., 2003; Walsh, et al., 2005). From a family systems perspective, the stress of parental illness affects the balance of the system (Faulkner & Davey, 2002; Petersen, et al., 2003) and concerns about the effects on the children were present in the qualitative study by Shands, Lewis, Sinsheimer & Cochrane (2006).
Breast cancer can cause mothers to be inaccessible due to treatment demands, suffer depression and be emotionally unavailable, to have marital tension, all which can affect the children in the household (Faulkner & Davey, 2002). In a study evaluating the impact on young women’s relationships with partners and children, it was found that women felt a huge loss in quality time with their child and their maternal role. The shift in family dynamics presented challenges and 61% of mothers reported negative effects on their relationships with their children, while 39% did report a positive impact and increased closeness (Walsh, et al., 2005).
A mother’s breast cancer impacts children differently depending upon the child’s age and developmental stage and should be considered when deciding how to discuss the disease with the child (Heiny, et al., 2001), when behavioral changes related to the breast cancer need to be distinguished from normal developmental changes (Shands, et al., 2006) and when determining how to best clinically intervene (Faulkner & Davey, 2002). Literature suggests that young children do not understand the concept if cancer due to their concrete mode of thinking, but their emotional responses are mainly fear, loneliness, anger and uncertainty. Older school-age children are aware that they have more household responsibilities and chores, but they are more concerned with their own interests and activities, which is appropriate for their egocentric perspective (Faulkner & Davey, 2002; Petersen, et al., 2003). Adolescents however are at greater risk for emotional distress. They report that their lives are complicated by their mothers diagnosis, and they feel torn with struggling for independence and forming a separate identity but they know they are needed at home emotionally and physically (Faulkner & Davey, 2002). They tend to take on more roles and responsibilities which may hinder their progress towards autonomy during their developmental stage (Davey, Gulish, Askew, Godette, & Childs, 2005; Faulkner & Davey, 2002; Petersen, et al., 2003). They are of
age to comprehend the life-threatening disease and thus are more vulnerable to emotional distress (Faulkner & Davey, 2002). There are gender differences in the way adolescents cope with their mothers’ diagnosis (Davey, et al., 2005; Faulkner & Davey, 2002; Petersen, et al., 2003). Daughters are more affected because they want to support their mother but may be resentful of taking on their tasks due to their socialized gender role in the family, as well as being fearful of inheriting the disease which may cause them to withdrawal (Faulkner & Davey, 2002; Petersen, et al., 2003), whereas adolescent sons may just avoid communication about the illness and situation (Faulkner & Davey, 2002).
While studies on family interventions with children are lacking in relation to breast cancer, it has been suggested that they would be beneficial and that family therapists can provide emotional and social support to the family, helping them find ways to tell their children, navigate the stresses of coping with cancer, promote shared family understanding and open communication (Davey, et al., 2005; Faulkner & Davey, 2002; Heiny, et al., 2001).
Conclusion
In aggregate, the literature supports the importance of viewing breast cancer in a family context, noting the negative impact that breast cancer has not only on the patient, but on the couple dyad, and the psychological well-being of the partners and children of women facing breast cancer. Implications suggest that despite the current advances in medical family therapy, interventions are essential in the medical treatment of breast cancer. Family interventions are needed, emphasizing services for partners and caretakers for coping strategies, and working with couples to optimize communication and emotional support, and to help alleviate sexual dysfunction. Research findings suggest that resources targeting younger couples, children and adolescents are in particularly high demand. There is also a growing need to provide therapy for survivors and that adjuvant
models of care should be developed beyond core treatment.
Directions for Future Research
While the literature on female patients of breast cancer is extensive, more research should explore the effects of male patients with breast cancer to examine if there are gender differences on the impact for them and their caregivers. As the literature was predominantly representative of heterogeneous couples; more research should be conducted to examine a variety of dyadic relationships and the unique relational distresses they may experience while facing breast cancer. Diverse cultural populations should also be further examined to increase the generalizability of these findings outside of the American, middle class Caucasian population.
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