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Abstract
Introduction Relationships are a significant dimension of illness experience. At the couple level, partners will respond to illness as an interpersonal unit rather than individuals in isolation. Research adopting a relational perspective have focused on communication, relational coping and relationship functioning and satisfaction. To our knowledge, there is no published systematic review of literature that reports associations between a couple's relationship and psychological outcomes of patients and partners affected by breast cancer.
Aim To review studies that examine the impact of relational mechanisms on psychological outcomes in couples affected by breast cancer and thereby improve understanding of the connections between patient, disease and family.
Methods A systematic search for literature was conducted, which was followed by a thematic analysis of study findings and a narrative synthesis.
Results Sixteen papers were included. Papers were published relatively recently between 1988 and 2010. Three relational components were identified: (i) couple coping, (ii) relationship functioning and satisfaction, (iii) communication. While the literature indicates associations between relational and psychological variables, with such a small evidence base, the use of different terminology and different theoretical frameworks makes it almost impossible to draw definitive conclusions about which relational component holds greatest potential for effecting change on psychological well-being.
Conclusions While there remain many opportunities for contributing to the theoretical and empirical work in this field, there is sufficient evidence to propose a relational approach to supporting people affected by cancer.
- Cancer
- Family management
- Psychological care
- Supportive care
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Introduction
Breast cancer can be considered an illness which affects individuals. Early coping research examined individual stress and individual coping patterns1 of patients and partners as separate entities.2–4 Partners have been defined as people who are cohabiting, married or in a long-term relationship. Such work has examined how each partner is uniquely impacted by illness and there is a voluminous literature indicating the effects of breast cancer on partners, focusing on, for example, anxiety, depression, sexuality and intimacy distress, difficulties in sleeping, difficulties at work, a general sense of helplessness and fear of cancer.5–10 Research suggests that between 5% and 20% of male partners of women with early stage breast cancer have psychosocial difficulties10–12 with the impact of secondary breast cancer being slightly higher at 30%.13 This well-established body of work describes the impact of illness on people as individuals but falls short of examining the connections between patient and partner psychosocial outcomes.
There is a corpus of research which has focused on the connections between patient and partner.14 ,15 For example, studies report that increasing anxiety in patients correlates with increasing anxiety in partners,16–18 and the strategies one person uses to cope with illness have been shown to affect the strategies used by their partner.15 Thus, research suggests that breast cancer impacts on each partner in similar ways, resulting in concordant rates of psychological distress within the couple. Other research however, indicates there is a complementary pattern of distress with only one partner exhibiting distress at any one period in time.19 ,20 This work improves understandings of the impact of cancer on others at an individualistic level by describing connections between patients and partners, but does not explain the nature of the interaction.
By contrast, work which has focused on couple relationship dynamics does offer explanatory potential for understanding connections between patient and partner. Several key themes are emergent in the literature, focusing on communication, relational coping and relationship functioning and satisfaction. These studies describe and explain the impact of illness systemically, that is as a shared experience impacting on the couple as an interactive unit.
Ineffective communication has been reported by couples coping with cancer as their primary relational concern.21 Researchers of couples’ communication have explored what types of communication patterns between partners positively or negatively impact their ability to adapt to a breast cancer diagnosis.22 Studies of communication and cancer indicate an association between closed communication patterns such as disengaging, withdrawing or avoiding open communication about feelings and poorer psychological adjustment.23 ,24 Open communication in contrast, defined as the level of personal disclosure25 is related to lower levels of psychological distress in breast cancer patients.26
Dyadic coping, as opposed to individual coping, describes couples’ efforts to cope conjointly with a common or shared stressor.16 Stress is conceptualised as dyadic if it affects both partners and where the stress signals of one partner influence the coping reactions of the other partner to these stress signals.27 Dyadic coping has drawn on the Systemic-Transactional Model as an explanatory framework for partners coping both individually and collectively as a unit to a shared stressor.27 It incorporates the degree to which both partners communicate their own stress to each other (ie, stress communication), the degree to which both partners respond to each other's’ stress (supportive or unsupportive coping), and the degree to which both partners work together to manage dyadic stress (ie, common positive or negative dyadic coping).20
Researchers have also examined relationship functioning and satisfaction. Spanier28 defines marital satisfaction as the degree of cohesion, consensus and affection reported by couples. Research indicates that the severity of anxiety and depression may be influenced by a patient's appraisal of their marital relationship and perception of support available from the partner.29 Research has also shown that breast cancer impacts on marital functioning,30 thereby illustrating how a stressor (in this case breast cancer) impacts on the couple's relationship.
Studies which have reported communication, relational coping and relational functioning satisfaction have therefore begun to crystallise theories and explanatory frameworks regarding the mechanisms which underpin cancer's psychological impact on people beyond solely the patient.
Fuller understanding of the psychological impact of cancer may be gained by examining its impact systemically. The purpose of this paper is to provide a narrative review of studies examining the associations between relationship and psychological variables in patients and partners affected by breast cancer. In doing so, we aim to contribute towards theorising and modelling connections between patient, partner and disease. The paper does not include literature about other kinds of family relationships such as between mother and daughter or siblings since these have different relational dynamics.31 ,32 We also address methodological and conceptual limitations of this body of research and propose ways in which the field of enquiry about couples can be developed in the future.
Methods
A systematic search for literature was conducted, which was followed by a thematic analysis of study findings and a narrative summary.33
Systematic search
The initial search strategy developed by the reviewers aimed to identify all papers about breast cancer and families published in the English language. MEDLINE, EMBASE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index, Applied Social Sciences Index and Abstracts, Social Sciences Citation Index, the Psychological Information Database and COCHRANE LIBRARY electronic databases were searched on 18 April 2011 by one of the reviewers (FH). No date restriction was imposed. Search terms related to ‘family,’ ‘couple,’ ‘spouse’ and ‘breast cancer’. The full electronic search of MEDLINE, including search terms and number of hits, is presented in appendix 1.
The initial search identified 10 603 titles and abstracts. After removing duplicates 6513 abstracts were screened by two reviewers who referred to a third reviewer if agreement about inclusion could not be reached. If two different papers reported identical results but in different journals this was defined as a duplicate and the most recent paper was included (see online supplementary flow diagram S1).
Inclusion and exclusion criteria
An article was included if it reported a study which was about patients and breast cancer and their partners, included the perspectives of the partner and/or patient about their relationship, examined associations between relational variables and psychological outcomes of the partner, used a cross-sectional or prospective design using validated instruments, measured the couple's relationship and was published in the English language and no date restrictions were applied (see online supplementary box S1).
Assessment of quality
The reasons for not conducting quality appraisal are because there is a paucity of research about correlations between couple relationship and variables and we wished to include as many articles as possible and we were mindful of controversies surrounding critical appraisal.34 Nevertheless, only studies using at least one validated relational measure were included (see table 1) and limitations of each study are described (see online supplementary table S1) so that the reader can make an informed and independent assessment of quality.
Relational measures
Data processing and narrative synthesis
Given the heterogeneity of studies, a narrative approach was identified as the most appropriate method of reporting the findings of the review. The process of comparing and contrasting associations between relational and psychological variables between papers was facilitated by one of the reviewers (GH) collating and tabulating the following extracted data: author, title, study design and sample, relational and psychological variables, validated instruments used, study limitations and study findings. The main focus of the analysis was to identify couple relational dynamics to develop our understanding of dyadic and inter-individual models of psychological well-being in couples affected by breast cancer. Finally, an assessment of the robustness of the analysis was reached by another reviewer (LF) who reviewed the primary data against the proposed narrative summary.
Findings
Sixteen papers were included (see online supplementary table S1). Regression analyses are reported in order that only couple relationship variables which explain variance in patient and partner psychological state (for example, anxiety and depression) are described. However, if no regression analyses were conducted simple correlations between variables are shown.
The papers were all published between 1988 and 2010. Eight studies used a longitudinal design enabling researchers to describe changes in couples’ relational dynamics and patient and partner psychological well-being. Eight studies used a cross-sectional design to report correlations between relationship and psychological variables. Two studies included couples affected by metastatic breast cancer.45 ,36 Only three studies38 ,46 ,47 were conducted outside of North America and Europe and in cultures that arguably have different values towards marital relationships.38
All studies used self-report to examine correlations between relational variables and psychological outcomes, which are listed in table 1. Psychological variables included cancer-related distress, anxiety, depression, emotional well-being, neuroticism, illness intrusiveness and post-traumatic growth.
Studies are listed and described according to the main relational dynamic being reported: (i) couple coping, (ii) relationship functioning and satisfaction, and (iii) communication.
Couple coping
Feldman and Broussard48 in a cross-sectional study investigated associations between five dyadic coping patterns (i) dyadic stress communication, (ii) common dyadic coping, (iii) positive dyadic coping, (iv) hostile dyadic coping, and (v) avoidance of dyadic coping, in a cross-sectional study. They examined associations between dyadic coping and emotional well-being and perceptions of illness intrusiveness, which were self-reported by male partners of newly diagnosed breast cancer patients. Multivariate analyses indicate that when high levels of hostile dyadic coping are used (defined as when the stress signals of one partner generate hostile responses from the other such as, distancing, ridicule, sarcasm, obvious disinterest or minimising the level of the partner's stress) this was associated with greater illness intrusiveness.
Multilevel analyses conducted as part of a longitudinal study by Badr et al20 indicate patients and partners who perceived their spouses as being more unsupportive experienced greater distress. Further, individuals who used more common negative dyadic coping (common refers to conjoint avoidance and mutual withdrawal) experienced greater cancer-related distress. These analyses also indicate that patients and partners who used common positive dyadic coping more frequently (defined as joint problem solving, coordinating everyday demands, relaxing together, mutual calming, sharing and expressions of solidarity) experienced greater dyadic adjustment (defined as relationship functioning and marital satisfaction).
Hannum et al49 used patient and partner self-report questionnaires, interviews and observations in a cross-sectional study to examine partners’ coping styles (defined as an individual's coping style which is rational-logical, denying-distracting, minimising, seeking support, optimism, external control-resignation and confrontation). Individual coping styles were correlated with marital satisfaction and marital cohesion. Stepwise regression indicates that husbands’ self-reported marital cohesion, self-reported external control-resignation (a coping strategy) and the researcher's observation of his level of supportiveness correlated with patient psychological distress. Stepwise regression also indicates that a husband's denial as reported by his wife and the researcher's observation of his confronting behaviour correlated with husband psychological distress.
A couple of studies examined protective buffering, which is a specific type of relationship-focused coping strategy. Coyne and Smith50 define protective buffering as efforts to protect one's partner from upset and burden by concealing worries, hiding concerns and yielding to the partner to avoid disagreement. While the intention of protective buffering used by a partner may be to minimise distress its use may in fact inadvertently have adverse psychological consequences.51 The purpose of Hinnen et al's52 longitudinal study was to examine if the most distressed and neurotic partners would use more protective buffering and less active engagement (characterised as involving their partner in discussions, asking how the partner feels and other problem-focused and emotion-focused strategies). Their study indicates that higher levels of partner distress and neuroticism were associated with the use of more protective buffering strategies at 3, 9 and 15 months after diagnosis and less distress was associated with more active engagement but only at 3 months after diagnosis. They conclude that distress and neuroticism appear as robust and strong explanatory factors for the use of more protective buffering strategies.
In a longitudinal study, Manne et al51 hypothesised that protective buffering would result in greater distress among patients and partners reporting higher relationship satisfaction. A mixed linear models repeated-measures approach for analyses indicate that patients’ protective buffering predicted greater distress among patients rating their relationship as highly satisfactory, whereas patients’ protective buffering did not predict distress among patients rating their relationships as less satisfactory. Further, increases in partner protective buffering were associated with increases in patient distress. For partners, they found that patient protective buffering was marginally associated with higher partner distress among partners reporting higher relationship satisfaction.
Relationship functioning and satisfaction
In a prospective study of couples affected by benign and malignant breast disease, Northouse et al41 examined, (i) marital satisfaction (defined as dyadic consensus, satisfaction, expression and cohesion), (ii) family functioning (defined as participant's satisfaction with their family's ability to communicate, assist one another, respond to change and spend time together) and (iii) social support (defined as the degree of emotional support that participants perceived from their spouse, family and friends). Associations between these three relational variables and psychosocial adjustment (defined as emotional distress and role problems related to work, family and social interactions) were examined. Structural equation modelling indicated that the strongest predictor of patient role adjustment problems was the severity of the illness and the strongest predictor of patient emotional distress was hopelessness (ie, not relational factors). The strongest predictor of husband's role adjustment problems at 1 year was husbands’ own baseline level of role problems that were reported approximately 1 week post diagnosis. Marital satisfaction had an indirect effect on role adjustment that was mediated by his feelings of uncertainty about the nature and course of the illness. The strongest predictor of husband's emotional distress was his own baseline level of distress.
Only one of the studies was conducted with Chinese breast cancer patients and their partners who arguably may hold different values towards marriage than for example, their European counterparts. In a cross-sectional study, Ming38 examined associations between, (i) self-perspective-taking (defined as a person's perception of their ability to put themselves in their partner's place), (ii) other-perspective-taking (defined as a person's perception of their partner's ability to put themselves in their shoes), and (iii) husbands’ perception towards patient physical appearance, (iv) psychological distress, and (v) marital adjustment (defined as satisfaction with their relationship). Regression analyses indicate that patients’ self-perspective-taking and other-perspective-taking contributed significantly to the prediction of patient marital adjustment. Husband marital adjustment was explained by his reported self-perspective taking and his psychological distress.
In a longitudinal study, Segrin et al19 examined interdependent anxiety and psychological distress in women with breast cancer and their partners. The analyses used the anxiety of one member of the dyad to predict changes over time in the other member's anxiety. Analyses show no significant partner effects originating from the women with breast cancer to their partners. However, there was a significant partner anxiety affecting patient's anxiety. The study also tested the association between the dyad's relationship quality and their anxiety levels. These analyses included both intrapersonal associations (eg, patient's anxiety and her reported relationship quality) and interpersonal associations (eg, patient's anxiety and her partner's reported relationship quality). Results indicate no intrapersonal associations between women's anxiety and their reported relationship satisfaction. The study however, indicates interpersonal associations between relationship quality and anxiety.
In a longitudinal study, Baider et al47 examined the associations between family support (defined as the perception of emotional and moral support) and psychological distress in two different countries. Multiple regression analyses show that in the Israeli group, perceived family support was associated with psychological distress in partners but not patients; but family support was not associated with psychological distress in partners or patients in the Austrian group.
Hoskins et al53 conducted a longitudinal study of adjustment among husbands of women with breast cancer. Repeated measures analyses of variance indicate that perceived support within the marital relationship was a predictor of both emotional and physical adjustment among husbands.
Mantani et al46 conducted a cross-sectional study involving patients with breast cancer and their partners in Japan. They examined associations between, (i) alexithymia (defined as the degree of difficulty in identifying feelings, difficulty in describing feelings and externally oriented thinking), (ii) family functioning (defined as problem solving, communication, roles, affective responsiveness, affective involvement and behaviour control), (iii) depression and (iv) anxiety. Multiple regression analyses indicate that husband perceptions of inappropriate sharing of roles among family members correlated with higher levels of depression, and patient perceptions of inappropriate affective responses from the spouse correlated with a higher level of depression.
Baider and De-Nour44 conducted a cross-sectional study involving patients with breast cancer and their partners. They examined associations between perceptions of their relationship (defined as cohesion, expressiveness and conflict) and psychological adjustment. They found that self-reported state anxiety was significantly correlated with cohesion in the patient group and the partner group. In the patient group self-reported depression was significantly correlated with expressiveness and in the husband group self-reported depression was significantly correlated with cohesion.
In one of the few studies of couples affected by metastatic breast cancer, Blake-Mortimer et al45 theorised that high levels of dependency and high feelings of ambivalence (defined as conflicted feelings towards one's partner) would make it difficult for the spouse to resolve their loss after bereavement.54 The cross-sectional study found that the husband's reported feelings of dependency were associated with worries about her death. Further, the greater his worry, the more satisfied she felt about their relationship. They concluded that patients with a life-threatening illness may draw comfort from knowing that their partner is dependent on them. They also found that if the husband had ambivalent feelings towards his wife the worse he would evaluate their relationship (in terms of expressiveness, cohesion and conflict).
Weiss55 conducted a cross-sectional study of post-traumatic growth (defined as positive changes in views of self, relationships with others and philosophy of life) in husbands whose wives had breast cancer. Weiss examined associations between post-traumatic growth and husband perceptions of the quality of the relationship with the patient (ie, the spouse). Multiple regression analyses indicate that husbands’ level of post-traumatic growth was positively associated with greater depth-of-commitment to the patient.
Communication
In a prospective study, Manne et al39 examined three marital communication patterns: (i) mutual constructive communication, (ii) mutual avoidance and (iii) demand-withdraw communication. They report associations between these three communication patterns alongside psychological distress and marital satisfaction of patients and their partners. Repeated measures analyses of variance were used to evaluate changes in marital communication patterns over time. Analyses indicate that patients reporting more mutual constructive communication had lower levels of distress; patients reporting more avoidance of discussing problems and stressors and more use of demand-withdraw communication had higher levels of distress. Mutual constructive communication was associated with higher relationship satisfaction, and demand-withdraw communication was associated with lower relationship satisfaction. Similarly, partner-rated marital communication also predicted partner distress.
Walker56 examined three marital communication patterns: (i) mutual constructive communication, (ii) mutual avoidance and (iii) demand-withdraw communication. They report associations between these three communication patterns alongside psychological distress and marital satisfaction of patients and their partners. Repeated measures analysis of variance was used to evaluate changes in marital communication patterns over time. Analyses indicate that patients reporting more mutual constructive communication had lower levels of distress; patients reporting more avoidance of discussing problems and stressors and more use of demand-withdraw communication had higher levels of distress. Mutual constructive communication was associated with higher relationship satisfaction, and demand-withdraw communication was associated with lower relationship satisfaction. Similarly, partner-rated marital communication also predicted partner distress.
Discussion
Relational, as opposed to individualistic explanations, provide the main thrust of argument in these papers. Taken together, they propose a practical implication, which is that patients with breast cancer should not be treated in isolation but positioned as part of an interdependent relational system. The papers collectively illustrate the importance of couple relationships for understanding the psychological well-being of patients and partners affected by breast cancer. Studies of families affected by other types of cancer have also demonstrated that relational variables mediate the psychological impact of cancer.57 ,58
Relational approaches have adopted a range of diverse theories and measures, such as dyadic coping, marital satisfaction, disengagement and social support. This variety makes evidence synthesis complex and consequently it is difficult to draw definitive conclusions about the inter-connections within couples and the likely effects on their psychological states. The literature does not lend itself well to establishing a unitary theory of how and why breast cancer impacts on couples. This relational subdiscipline of psycho-oncology is at an early developmental stage, which may explain why relational dynamics are under-theorised.
The review suggests that intervening at a relational level is likely to be fruitful, for example, constructive communication, dyadic coping and relationship functioning would be important areas to target. However there is insufficient evidence to identify which of these relational components holds greatest potential for effecting change on psychological well-being. Moreover, further research about how these relational components interact in couples is required.
Approaches with proven efficacy include family systems therapy which takes account of the important role of relationships in how people respond to illness experience14 ,59 ,60 and provides a framework for including family members beyond the couple dyad. An advantage of this framework is its whole systems approach, recognising that the whole (couple psychological adjustment to illness) is greater than the sum of its parts (ie, each relational component, illness, individuals).
Limitations of current evidence and recommendations for future research
Conceptual limitations
Concepts used in the literature over the past couple of decades are not precise and reflect the wide range of disciplines and literature drawn on in studies, for example, counselling, psychotherapy, cognitive psychology and systemic theory. This means that while the research shows that there are associations between relational and psychological variables, with such a small evidence base, the use of different terminology and different theoretical frameworks makes it almost impossible to draw definitive conclusions about relational processes and mechanisms found to be associated with psychological outcomes. Kissane et al 61 ,62 for instance, offer a family functioning typology focusing on family cohesion, expressiveness and conflict while others63 focus on other constructs such as relationship-focused coping. This problem is compounded by disagreement among scholars about instruments to measure relational variables.64 Researchers should aim to develop theoretically-informed frameworks and models to facilitate further research.
Sampling limitations
Most studies have included heterosexual Caucasian couples affected by early stage breast cancer and this sampling limitation confines the generalisability of studies’ findings. The majority of studies have been conducted within north American and western European countries, which may have different normative standards regarding marriage and relationships to other countries. Moreover, the research focuses on couples where the patient is female and partner male. Thus, studies reporting correlations between relational and psychological variables may reflect gender and sexual-orientation differences rather than being generic to all couple dynamics.
A further sampling limitation is people who do not participate in studies have been found to have lower perceived family support than those who were willing to participate,47 ,65 which means that findings may be skewed towards couples that perceive their relationship as good. Future studies should therefore aim for more representative samples.
Design limitations
Finally, as Badr et al20 point out, studies have not evaluated couples’ premorbid relationship before cancer diagnosis and therefore are unable to determine if relational roles and coping strategies are a consequence of the illness or reflective of existing roles and coping behaviours. Only eight of the studies included in the review were longitudinal and thereby able to examine changes to the relationship over time. However, none of these longitudinal studies started prior to breast cancer diagnosis.
Review limitations
For practical reasons only articles in English language were included and therefore the findings of this review may not necessarily be relevant to non-English speaking countries. In addition, only an electronic database search was conducted, hence some studies may have not been identified.
Conclusion
Social policy and healthcare practice to-date, has not taken into account the complexities of how patient, partner, couple and illness interact dynamically to impact on psychological adjustment to illness. However, there is an emerging field of enquiry focused on the psychological well-being of patients and partners affected by breast cancer that utilises a relational perspective rather than an individualistic approach. This research draws attention to the importance of relational dynamics as both a descriptor and explanatory framework for the psychological impact of breast cancer on couples. A relational understanding of psychological adjustment may also apply to different types of illness and to a range of other relationships (such as friendships, work colleagues, families). While there remain many opportunities for contributing to the theoretical and empirical work in this field, there is sufficient evidence to propose a relational approach to supporting people affected by cancer.
Acknowledgments
Breast Cancer Care, a leading UK cancer charity supporting people affected by breast cancer provided funding to conduct this systematic review of literature.
Appendix 1 Medline search strategy
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online box
- Data supplement 2 - Online Flowdiagram
- Data supplement 3 - Online table
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.