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.
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ABSTRACT |
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INTRODUCTION |
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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.
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METHODS |
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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). 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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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.
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RESULTS |
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DISCUSSION |
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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.
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NOTES |
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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.
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Manuscript received May 26, 1998; revised July 24, 1998; accepted October 29, 1998.
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