ARTICLES

Marital Stability After Breast Cancer

Michel Dorval, Elizabeth Maunsell, Jill Taylor-Brown, Marilyn Kilpatrick

Affiliations of authors: M. Dorval, E. Maunsell, Groupe de Recherche en Épidémiologie, Département de Médecine Sociale et Préventive, Université Laval, Québec, QC, Canada; J. Taylor-Brown, Department of Psychosocial Oncology, Manitoba Cancer Treatment and Research Foundation, St. Boniface Unit, Winnipeg, MB, Canada; M. Kilpatrick, Cancer Nursing Research Group, St. Boniface General Hospital Research Centre, Winnipeg.

Correspondence to: Elizabeth Maunsell, Ph.D., Groupe de Recherche en Épidémiologie de l'Université Laval, Centre Hospitalier Affilié Universitaire de Québec, Pavillon St-Sacrement, 1050 Chemin Ste-Foy, Québec, QC, Canada G1S 4L8.


    ABSTRACT
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
BACKGROUND: The belief that husbands desert wives who have breast cancer is not uncommon and may be a source of stress for women confronting this disease. To assess the validity of this belief, we examined the role of breast cancer as a determinant of marital breakdown by comparing the frequencies of marital breakdown among women with breast cancer and among control women from Quebec City and surrounding regions. METHODS: Secondary analyses were performed on data collected from women who were newly diagnosed with nonmetastatic breast cancer in 1984 or during the period from 1990 through 1992 and then interviewed 3 months, 18 months, and 8 years after diagnosis (1984 cohort) or interviewed 2 weeks, 3 months, and 12 months after diagnosis (1990-1992 cohort). Population-based control subjects (four groups) were recruited through random-digit dialing and from participants in the Quebec Health Surveys for 1987 and 1992. Eligible subjects were those who were living with a spouse at the time of interview and those who reported divorce or separation in the time periods examined. Marital breakdown in the past 12 months and 5 years and current marital satisfaction and adjustment were assessed. All P values are two-sided. RESULTS: Marital breakdown was never higher in women with breast cancer than in control women. Among women with breast cancer, low marital satisfaction within 3 months of diagnosis predicted further marital difficulties (a breakdown—P = .02 at 12-month interview and P = .01 at 18-month interview; low marital satisfaction—P<.0001 at 12-month interview and P = .005 at 18-month interview). CONCLUSIONS: For the times studied, breast cancer does not appear to be associated with marital breakdown among Quebec women. Marital difficulties occurred mainly among the small proportion of women who probably already had marital difficulties when diagnosed.



    INTRODUCTION
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The belief that husbands desert their wives who have breast cancer is not uncommon. Headlines in popular women's magazines give the reader a negative impression of the impact of breast cancer surgery on the marital relationship and may lead women to believe that many husbands leave their wives as a result of a breast cancer diagnosis (1-5). Such comments may raise anxiety, may feed the fear of abandonment, and may contribute to the psychosocial distress experienced by women diagnosed with breast cancer. In contrast, clinical experience, qualitative research, and anecdotal reports suggest competing beliefs that couples facing breast cancer are no more likely to divorce than are couples in the general population and that marital breakdown after breast cancer usually occurs because of pre-existing marital problems (6-10).

We found little quantitative evidence in the published literature to support either belief about the impact of breast cancer on marital relationships. No study has focused specifically on the incidence of divorce or separation for women after a diagnosis of breast cancer, and only a few studies (10-12) have reported the prevalence of being divorced or separated or living alone at various times during the course of the disease. However, none of these studies used comparison groups of women from the general population who have never been diagnosed with breast cancer. Because of this, it is impossible to determine whether women with breast cancer have an excess of marital breakdown compared with women who have never confronted this disease. Thus, we have no evidence on breast cancer as a determinant of marital breakdown.

The aim of this paper is to examine evidence that might support one or the other of these beliefs about the effect of breast cancer on marital breakdown. This was done by the use of data from previously conducted studies of patients with breast cancer and from population-based health surveys. First, we compared the frequency of marital breakdown among patients with breast cancer with the frequency of marital breakdown among similarly aged women from the general population. Second, we compared the degree of marital satisfaction in each group. Finally, among patients with breast cancer only, we evaluated the association of marital satisfaction, assessed after diagnosis, with the occurrence of further marital breakdown, low marital satisfaction, and emotional difficulties with the spouse.


    METHODS
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Subjects

We analyzed data from previously conducted studies of patients with breast cancer and population-based health surveys. For each study, subjects retained for these analyses were those living with a spouse at the time of their interview and those not living with a spouse who reported divorce or separation in any of the relevant time periods examined immediately before their interview.

Breast cancer patients. We analyzed data on patients with breast cancer from two prospective quality-of-life studies of newly diagnosed patients (12-14). Data from two different cohorts were studied, the first diagnosed in 1984 (the 1984 cohort) and the second diagnosed during the period from 1990 through 1992 (the 1990-1992 cohort). In both cohorts, all women had newly diagnosed, histologically confirmed localized or regional stage breast cancer that was first treated in Quebec City hospitals. The methodology of each of these studies has been reported in detail (12-15). Informed consent was obtained from all subjects, and these studies were approved by the Saint-Sacrement Hospital Ethics Review Committee. The 1984 cohort included women who had participated in a study of their short-term and long-term quality of life. Overall, study participation was more than 95% at each time period. In that study, women were interviewed 3 months (n = 224), 18 months (n = 204), and 8 years (n = 124) after diagnosis. Among the 224 patients interviewed at 3 months, 89 had died or were too ill to be interviewed at 8 years, and only 11 participants who were interviewed at 3 months refused one or another of the subsequent interviews (16). Thus, in this cohort, the ultimate sample size was primarily determined by attrition through death. These analyses are based on 137 women who were interviewed 3 months after diagnosis, 128 women who were interviewed 18 months after diagnosis, and 80 women who were interviewed 8 years after diagnosis. These numbers represent women who were living with a spouse at the time of the interview and women who reported that they had divorced or separated in the relevant time period. In the 1990-1992 cohort, subjects were patients who consented to participate in a randomized trial that assessed the effects of a psychological distress screening program on quality of life (12). In that trial, 89% of the 282 eligible women completed study interviews within 2 weeks, 3 months, and 12 months of initial treatment (n = 250). Data used herein came from the 158 trial participants who at 12 months were living with a spouse or who reported divorce or separation since initial treatment.

Control subjects. For our control subjects, we used data on women from the general population who were recruited specifically for one of the breast cancer studies (13) and also data on women from two population-based health surveys (17,18) conducted during approximately the same period as the breast cancer studies. A total of four control groups were used. In each group, control subjects were selected if they had the same age distribution and came from the same residential regions as one or the other of the breast cancer cohorts and if their data had been collected within 1.5 years of the data from the patients with breast cancer. As was the case for patients with breast cancer, control subjects retained for analyses were those living with a spouse at the time of their interview and those not living with a spouse who reported divorce or separation in the relevant time periods. The first control group was composed of women identified through random-digit dialing as the comparison group for 8-year survivors who were diagnosed in 1984 (the 1984 cohort). Overall participation among eligible control subjects was 61% (262 participants of 427 potentially eligible women) (13). From a total of 262 women identified through random-digit dialing, 174 who were living with a spouse or who had divorced or separated in the relevant time period were retained for these analyses. Three other control groups were drawn from women who had participated in two population-based health surveys carried out in Quebec in 1987 (18) and in 1992 (17). These studies were based on random samples of noninstitutionalized women from the general population and were conducted among 11 323 and 13 266 households, respectively. The household response rate was 87% in both surveys. In each participating household, data were then requested from all persons older than 15 years of age. Among eligible persons at this stage, response rates of more than 80% were obtained in each survey. Of these latter three control groups, two different groups were drawn from the 1992 survey: one group (n = 2491) as a second comparison group for 8-year survivors of women diagnosed in 1984 (the 1984 cohort) and one group (n = 3056) for 1-year survivors among patients diagnosed during the period from 1990 through 1992 (the 1990-1992 cohort). This was necessary because distributions of age and areas of residence differed somewhat for these patient groups. Finally, the third group (n = 2948) was drawn from the 1987 survey as a comparison group for 18-month survivors of women diagnosed in 1984 (the 1984 cohort).

Measures

The occurrence of marital breakdown was assessed by use of questions from stressful life event scales administered in these studies. Among 8-year survivors and their control subjects who were selected by random-digit dialing, two questions from the Life Experiences Survey (15,19) were used, one asking about divorce and the other asking about separation. In both Quebec Health Surveys, a single question assessed whether divorce or separation had occurred. Occurrence of such events was assessed in the previous 12 months among all subjects, both patients with breast cancer and control subjects. As well, among 8-year survivors and their control subjects selected by random-digit dialing, divorce and separation in the preceding 5 years were assessed. The frequency of marital breakdown over a given period was estimated as the number of women reporting the event divided by the total number of women living with a spouse at the time of their interview plus the number of women who were divorced or separated during that period, whether or not they were cohabiting when interviewed.

For participants living with a spouse at a given interview, marital satisfaction was also assessed in each study by use of a one-item indicator. Although item formulation and number of response options differed slightly across studies, we considered that degree of marital satisfaction could be compared across various samples after grouping positive assessments into one group and negative or neutral assessments into another (Table 1).Go The Locke-Wallace Marital Adjustment Test (20), a multi-item scale, was also used among 8-year survivors of the 1984 cohort and their control subjects who were selected by random-digit dialing and at all interviews with the 1990-1992 cohort. In these groups, Pearson correlation coefficients between the one-item indicator and the total Locke-Wallace Marital Adjustment Test score averaged .80 (range, .74-.86). When we used the criterion of a Locke-Wallace Marital Adjustment Test score of less than 90 for identifying women with low marital satisfaction (21), the dichotomized one-item indicator had an average sensitivity of 91% (range, 81%-100%) and specificity of 89% (range, 88%-90%) to detect marital dissatisfaction.


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Table 1. One-item indicators of marital satisfaction across studies

 
Finally, for the 1990-1992 cohort, the proportion of women reporting emotional problems with spouse was also examined as an indicator of marital adjustment. These data were collected by use of a standardized data collection form by social workers responsible for the psychosocial care of these women for the first year after their initial treatment (12).

Analysis

Data from Quebec Health Surveys were weighted to adjust for sample design and nonresponse with weights supplied by the Bureau de la Statistique du Québec. Specifically, responses from subjects in strata underrepresented with respect to sex, age, and area of residence were given more weight, and those from subjects in overrepresented strata were given less weight. To compare control groups drawn from the two Quebec Health Surveys to patients with breast cancer, the survey data then were standardized to reflect the age and residential distributions of corresponding groups of patients. Percentages and 95% confidence intervals were used to describe the experiences of patients with breast cancer and population control subjects with respect to marital breakdown and marital satisfaction. Among patients with breast cancer, associations of marital satisfaction assessed soon after diagnosis with the occurrence of further marital breakdown, low marital satisfaction, and emotional difficulties with the spouse were evaluated by means of Fisher's exact test. All significance levels reported are two-sided.


    RESULTS
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
As a result of our standardization, age was similar among patients with breast cancer and corresponding control subjects (Table 2).Go In the areas of the province of Quebec from which study participants came, more than 90% of the population is French speaking and has a Catholic religious background. Patients and control subjects were not compared with respect to other sociodemographic variables because of considerable variation in question formulations across studies (e.g., questions relating to education and income) or because such information was not collected in these datasets (e.g., duration of the relationship with the spouse or number of children).


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Table 2. Age (mean ± standard deviation) of women available for analyses among breast cancer cohorts and control groups*

 
Eight-year survivors represent about 40% of the cohort initially recruited and interviewed 3 months after diagnosis. Because of this, we explored whether nonparticipation, which in this study was mainly due to death or being too ill to be interviewed, in the 18-month and 8-year interviews was related to 3-month marital satisfaction. This analysis was done by using 116 of the 137 women from the 1984 cohort for whom marital satisfaction was assessed at the 3-month interview. For 21 women, marital satisfaction was not assessed 3 months after breast cancer diagnosis because the spouse was present when the woman was interviewed at home. In our analysis, we observed very little difference in percent of participants and nonparticipants in the 18-month interview who reported low marital dissatisfaction at the 3-month interview (Table 3).Go Among participants in the 8-year interview, low marital satisfaction at the 3-month interview was a bit more frequent in nonparticipants (15.7%) than in participants (10.8%). However, neither of these levels appears to differ greatly from the 12.9% of women who reported low marital satisfaction overall at the 3-month interview.


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Table 3. Low marital satisfaction at the 3-mo interview according to participation status at subsequent interviews for 1984 cohort

 
In all cohorts of patients with breast cancer and corresponding control groups, divorce or separation in the last 12 months were relatively infrequent events, which varied between 1.6% and 5.5% (Table 4).Go In all groups compared, the percent of patients with breast cancer reporting a marital breakdown in the past 12 months or in the past 5 years was never higher than the corresponding percent of women in the general population reporting a marital breakdown. The percent of women reporting dissatisfaction with the current marital relationship was quite low, between 7.1% and 14.3%, and was generally similar in survivors and control subjects (Table 4).Go The largest difference in marital dissatisfaction between patients with breast cancer and their corresponding control subjects was observed at 18 months after initial treatment for breast cancer. Patients (14.3%) more frequently reported low marital satisfaction than control subjects (7.8%). At 8 years, the percent of breast cancer survivors reporting dissatisfaction (10.8%) was a bit higher than the percent of the control group selected by random-digit dialing (7.1%) but was slightly lower than the percent of control subjects from the 1992 Quebec Health Survey (11.6%).


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Table 4. Marital outcomes among breast cancer patients and control subjects

 
Among patients with breast cancer, women who reported low marital satisfaction (assessed by a single question) within 3 months of diagnosis were consistently at higher risk for further marital difficulties compared with women reporting high satisfaction (Table 5).Go Marital breakdown mainly occurred among women who initially reported low marital satisfaction (P = .02 at 12-month interview; P = .01 at 18-month interview). In addition, the percent of women who reported marital dissatisfaction 12 and 18 months after diagnosis was much higher among women with low marital satisfaction at the first interview (P<.0001 at 12-month interview; P = .005 at 18-month interview). Results were similar when the Locke-Wallace Marital Adjustment Test, a validated scale measuring marital adjustment, was used in the 1990-1992 cohort that was assessed 12 months after diagnosis (P<.0001). Finally among this same cohort, more women with low marital satisfaction at initial treatment reported emotional problems with their spouse to social worker compared with women with high marital satisfaction. The difference between groups was most evident in the first 2 weeks after the initial treatment. During this period, more than half the patients in the low-satisfaction group mentioned such difficulties to their social worker (P = .0001).


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Table 5. Marital outcomes among breast cancer patients by marital satisfaction reported within 3 months of initial treatment

 

    DISCUSSION
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Our results for different breast cancer cohorts and assessment times suggest that marital breakdown is not more frequent among breast cancer survivors in Quebec City and surrounding regions in the first 18 months or in the 3-8 years after diagnosis than among women from the general population. Comparisons of survivors and control subjects seem to indicate that breast cancer per se does not result in lower marital satisfaction in either the short term or the long term. These results are generally consistent with previous studies (6-10) based on fewer patients with breast cancer and without control subjects, in which women reported that marital adjustment is generally unaffected by breast cancer. Finally, we observed that breast cancer survivors who had poor marital adjustment at the time of diagnosis are the women who are most likely to experience further marital difficulties. This observation supports the view that marital problems after breast cancer occur mainly among couples already experiencing difficulties. Overall, confidence in our results is supported by the fact that the breast cancer cohorts used in these analyses do not seem to be highly selected groups. They came from consecutive series of women identified early after diagnosis, and no patient was lost to follow-up. Participation was uniformly high. For the 1984 cohort, ratings of marital satisfaction at the 3-month interview were not strongly associated with the likelihood of participating in successive interviews.

Several limitations need to be considered in assessing our findings. First, our datasets did not allow us to compare survivors and control subjects for a complete range of time since diagnosis. Other times could be important with respect to marital breakdown. Second, the statistical power for some comparisons was low. Specifically, the numbers of breast cancer patients available for analyses in the two cohorts were relatively small, marital breakdown and marital dissatisfaction were infrequent events, and observed percents of survivors and control subjects reporting these events were similar. Thus, our interpretation of these results is based on a qualitative assessment. Nonetheless, the observed stability of results across cohorts, times of assessment, and outcomes increases confidence in our interpretation. Third, the participation rate in the one group of control subjects selected through random-digit dialing was moderate. Because of this, we previously compared these control subjects to similarly aged women from the Quebec population with respect to sociodemographic and psychosocial characteristics, including general health perceptions, psychological distress, and social support (13). The observed similarity between the two groups provides some reassurance with respect to the absence of possible selection bias in this control group. Fourth, differences in data collection procedures for survivors and control subjects might have reduced the comparability of information obtained, although the extent and the direction of any bias are difficult to assess. Although information was collected by interview in some groups or by self-administered questionnaire in others, we believe that women would not forget to report events such as divorce or separation. While both control subjects and patients with breast cancer were questioned about events during similar time periods before the interview, control subjects represent cross-sections of the population and were not followed-up over time. However, these differences in data collection methods do not apply to analyses restricted to specific cohorts of patients with breast cancer and comparing survivors with high and low marital satisfaction. These analyses were based on data collected in the same way for all patients with breast cancer.

Despite these potential limitations, this study addresses an important social issue. This study is a first step in answering the question: "Do breast cancer patients face greater marital breakdown when compared to similar women never diagnosed with breast cancer"? One implication of our results is that breast cancer may not be the cause of marital breakdown for women confronting this disease. This may be because the majority of couples experiencing good adjustment at diagnosis manage to cope with the challenge of breast cancer and/or acquire the support to do so. However, this does not mean that the impact of breast cancer on the marital relationship is benign. Couples confronting breast cancer may experience strain and could possibly benefit from psychosocial interventions that help open communication about difficult issues and fears (22-24). In one of our cohorts, about 15% of the women who were in relationships that they rated as satisfying nonetheless mentioned emotional problems with their spouse to the social worker at some point during the year after initial treatment.

Another implication is that it may be helpful for clinicians to ask about marital adjustment as part of the initial assessment to identify those women who are at high risk of difficulties that may further impair quality of life. A simple brief question about marital satisfaction, such as the ones used in the studies we analyzed, may be an easy and effective way to do this in clinical settings. Those individuals who identify difficulties in their relationship with the spouse could then be targeted for referral to psychosocial specialists.

From a public health perspective, it will be important to determine whether our findings also apply to North American women in general. Previously collected data seem to be one feasible and inexpensive source of information about the role of breast cancer in marital breakdown. If our results can be replicated in other cohorts, it would be possible to reassure the great majority of patients that their spouses will not leave them simply because of a diagnosis of breast cancer. Health care practitioners could then participate in dispelling the belief that breast cancer causes marital breakdown. This might alleviate one source of fear and anxiety for women confronting this disease. Finally, if popular women's magazines based their headlines on research findings, they could play a role in reducing distress not only among women who are newly diagnosed with breast cancer but also among healthy women, some of whom will eventually be confronted with a breast cancer diagnosis.


    NOTES
 
Present address: M. Dorval, Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA.

M. Dorval is a Terry Fox Research Fellow (National Cancer Institute of Canada, No. 8640) supported with funds provided by the Terry Fox Run and was the recipient of a Ph.D. Fellowship (No. 6605-4220-47) from the National Health Research and Development Program (NHRDP) of Health Canada when work on this paper started; E. Maunsell is an NHRDP National Health Research Scholar (No. 6605-4277-48). Support for the breast cancer studies contributing data to this paper was provided through research grants from the National Cancer Institute of Canada with funds from the Canadian Cancer Society. These grants were "Randomized trial of a psychological distress screening programme after breast cancer" and "Quality of life in long-term breast cancer survivors."

We thank Santé Québec for providing the 1987 and the 1992-1993 Quebec Social and Health Survey data. We also thank Myrto Mondor, M.Sc., for her help with data management and Dr. Jacques Brisson for his helpful comments on earlier versions of this article.


    REFERENCES
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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Manuscript received May 26, 1998; revised July 24, 1998; accepted October 29, 1998.


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