Embodying Identity Experienced By Breast Cancer Patients Survivals Undergoing Chemotherapy .

https://doi.org/10.33698/NRF0234-Narinder Kaur , Jasbir Kaur, Amit K Dhiman

Introduction: Breast cancer is a malignant growth in the tissues of the breast. It is one of the commonest causes of deaths in middle aged women. Chemotherapy is one of the treatment modalities to treat breast cancer. The adverse effects associated with chemotherapy lead to physiological and psychological impact on the patients and ultimately on their embodying identity. Objective: To assess the embodying identity perceived by breast cancer patients undergoing chemotherapy. Methodology: An exploratory study was undertaken on 520 breast cancer patients receiving second cycle of chemotherapy by adopting purposive sampling technique from four cancer treatment hospitals of punjab fullling dened inclusion and exclusion criteria. Interview was scheduled using Dr. P Hopwood’s body image scale to assess embodying identity of the patients. Data was analyzed using descriptive and inferential statistics. Results: Most of the breast cancer patients were in age group of 56 years & above. 88% were married with maximum having 21-40 years of duration of marriage. Two third of (65.5%) females were having 1-2 children and 58.3% breastfed last child for a period of 13-18 months. Two third of patients (64.2%) had good level of perceived embodying identity followed by 33.5% with satisfactory level and very few had poor perception. The study showed signicant association of body image and intimacy with marital status, duration of marriage, number of children and history of breast fed to the last child. Conclusion: Most of the patients had good level of perceived embodying identity while receiving chemotherapy. An information Education Communication (IEC) protocol was also developed to improve the embodying identity of breast cancer patients and to make their perception to the highest level of satisfaction.

Key words: Breast cancer; chemotherapy; embodying identity; information.

Correspondence at

Prof. (Mrs.) Narinder Kaur Walia

Principal

Saraswati Professional & Higher education  College of Nursing

Village -Gharuan,  Mohali M. No: 9988839676

E-mail: narinder_120kaur@hotmail.com

INTRODUCTION

Cancer is an iceberg which aficts a l l c o m m u n i t i e s w o r l d w i d e . Approximately 10 million people are diagnosed with cancer and more than 9.6 million deaths in 2018 (WHO). Breast cancer is the most common cancer amongst women, accounting for 25% of all new cancer cases. It causes 14% of women’s cancer deaths and more than 370,000 deaths per year around the world. Incidence of breast cancer in India varies from 7.2 to 33.4/100,000 (annual age adjusted rate). Among Indian women, cancer of breast, cervix and ovary accounts for nearly 60% all cancers. According to National Cancer Registry Program projections, breast cancer has overtaken cervical cancer to become the leading cancer in metro cities like Delhi, Bangalore, Mumbai, Chennai, Bhopal, and Kolkata with relative proportion ranging 21.7% to 28 %.1,2 The Malwa belt in Punjab has recorded high incidence of breast cancer in the state. According to a study by the United Kingdom based non- governmental organization, “Roko Cancer,” which has worked with collaboration with the state health department, while 92 cases were detected in 12 districts through 86 camps, in which a total 5,670 mammography tests were conducted from 2006 to 2009, as cancer cells. Because of this, there may be many side effects during treatment, including alopecia, nausea, vomiting, taste and appetite changes, diarrhea, constipation etc.4

Among all adverse effects alopecia is the main symptom to be enlightened, because especially in women hair is a part of identity and sense of self. Loss of hair due to chemotherapy has been proven to alter patient’s body image and self-concept resulting in an altered socio behavioral, depression and anxiety.5 It places a signicant burden on the patient and could have a psychological and physiological impact on the them. Patients with breast cancer have more impact on their embodying identity. The embodying identity is a process in which individuals come to understand, dene their changing self and to arrive at a new understanding of who they are. Embodying identity address the in-between movements when patients are seeking to understand either acute changes or those which slowly occurs over many as 131 suspected cases were detected time.6

Although there is evidence in the through 894 mammography tests in Mansa, Bathinda and Muktsar districts from September 2009 to December 2009.3 Treatment of breast cancer includes surgery, radiotherapy, chemotherapy, and hormonal treatment. Chemotherapy can be quite effective in treating cancer by reaching all parts of the body, not just the literature to strongly suggest the loss of hair is a greater identity issue than we anticipate little is known about the process by which this occurs. We offer embodying identity is a useful concept that has potential stimulate for the study and eventual nursing approaches to supporting patients during this most profound process. If the patients have their positive attitude towards their treatment they recover earlier than others having negative attitude towards treatment of breast cancer. However, adverse effects are difcult to tolerate for the normal human being, but if the patients have strong will power then they can beat by all means and angles.7

Hence, considering the above adverse effects on physical, psychological and social image of women and resulting in psychological stress and lowering quality of life the researchers felt the need to assess embodying identity among the breast cancer patient, so that information education communication (IEC) protocol can be developed to improve their embodying identity. Raising awareness may also empower women to follow healthy behaviors and health promotion activities.

OBJECTIVES

  1. To assess the embodying identity perceived by breast cancer patients receiving
  2. To nd out the association of embodying identity perceived by breast cancer patients receiving chemotherapy with their selected socio demographic
  3. To develop information, education & communication protocol to improve embodying identity among patients receiving

MATERIAL & METHODS

A quantitative research approach and exploratory research design was used to assess perceived embodying identity among breast cancer patients, undergoing chemotherapy in selected hospitals of Punjab. Data was collected from 520 breast cancer patients who attended oncology OPD and admitted in oncology wards in DMCH Ludhiana (83), Mediways Hospital Ludhiana (167), Sandhu Cancer Hospital Ludhiana (97) and Fortis Hospital  Mohali (173) receiving second cycle onwards chemotherapy induced embodying identity and who met with inclusion criteria. Purposive sampling technique was used to select sample. A structured interview schedule was adopted to collect data. Tool A : P e r f o r m a f o r s e l e c t e d s o c i o – demographic characteristics: viz. age, education status, religion, habitat, occupation, type of family, marital status, duration of marriage, number of children, duration of breast feeding to the last child. Tool B: Modied P. Hopwood’s body imager scale includes statements related to body image, feminity, intimacy, emotional & physical, functional well being and coping strategies was used to collect the data from selected subjects. Modied Dr. P. Hopwood’s Body image scale (2001) was 5- point rating scale, marked as 0 – 4. Scale consist of 65 statements with maximum score 260 and minimum score 0. The level of perceived embodying identity categorized as Poor (198-265), Satisfactory (132 – 197), Good (66- 131) and Very good (0 – 65).8 Written permission was taken from Head, department of oncology of Fortis hospital Mohali; Sandhu Cancer Centre Ludhiana; Mediways hospital Ludhiana; DMCH Ludhiana Punjab to conduct the study. An informed consent was taken from the subjects. The subjects were explained about the objectives of the research project. Anonymity and condentiality of information was maintained throughout the study. Data was collected from the patients who fulll the inclusion criteria by interviewing them as per interview schedule. Each interview lasted for 20-30 minutes. Collcted data was coded and analysed by using SPSS 21 version.

RESULTS

Socio demographic variables of the subjects

Nearly half of the subjects (44.8%) were in the age group of 56 years and above followed by 41.5% in the age group of 41- 55 year. Almost one third (36.2%) had education up to secondary, 30.2% were graduate and above and only 11.0% subjects were not literate.More than half of the subjects (51.5%) were from Hindu religion and 61.7% were from urban area. Maximum (83.3%) females were home- makers,  8.8%  employed  in  a  private  or Govt. concern and remaining were self- employed. More than half of the subjects (54.8%) were from nuclear families and the remaining were from joint families. Maximum females (88.1%) were married, 6.3% were widows, 3.3% were divorcees and remaining was unmarried. Furthermore 64.2% were married for a period of 21-40 years and 21.3% were married for more than 20 years. 65.5% of females had 1-2 children, 27.1% had 3-4 children and remaining had 5 or more number of children. More than half of the subjects (58.3%) had breast fed the last child for 13- 18 months, followed by 24.0% breast fed for less than 6 months and 5.8% did not breast fed to the last child.

The level of perceived body image has been found to be ‘good’ in 334 (64.2%) subjects and ‘satisfactory’ in 174 (33.4%) cases. As per different aspects of body image the level of perceived feminity was ‘good’ in 46.3% subjects, ‘very good’ in 24.0%, satisfactory for 22.8% and 6.9% for ‘poor’. Good and very good level of perceived intimacy was expressed by 348 (66.7%) of the subjects. The level was satisfactory for 109 (21.0%) and it was poor only for 63(12.3%) of the breast cancer patients. Almost equal number of cases perceived the level of physical well being as satisfactory (50.8%) and good (47.7%). The remaining 8 (1.5%) subjects perceived the level to be ‘very good’. In none of    the level was poor.

The level of emotional wellbeing was perceived to be good and very good by 412 (79.2%) respondents and   ‘satisfactory’ by 108 (20.8%) respondents. The level of perceived functional well being was found to be satisfactory in the case of 294 (56.5%) respondents and ‘good’ in 167 (32.1%), and very good in 28 (5.4%) respondents. The level was found to be poor only in the case of 31(6.0%) of the respondents. The level of coping strategies was found to be good or very good in all the subjects leaving only ‘one’ in whose case the level was poor. The level of perceived embodying identity in all the categories among breast cancer patients was found to be poor in very small number of cases. In most of the categories of embodying identity the level was either satisfactory or good. However in the case of feminity and coping strategies, quite a few expressed the level as very good also.

Table 2 presents the ranking of different categories according to mean percentage of respondents which depicts coping strategies ranked 1st with highest mean percentage 70.8% , feminity ranked 2nd with mean percentage 63.3% , emotional wellbeing ranked 3rd and mean percentage 59.5% , intimacy ranked 4th with 54.6% mean percentage , body image and physical wellbeing ranked 5th and 6th with mean percentage 53.6% and 52% respectively and functional wellbeing ranked 7th with lowest mean percentage 50.22%.

Association of the level of perceived body image among breast cancer patients with socio demographic variables:

The level of perceived body image among breast cancer patients was signicantly related with age, occupation, type of family, duration of marriage, the number of children and history of breast feeding. The perception improved with increase in age. Housewives have shown better perception as compare to the self- employed and working women. Patients from the joint families have expressed a better level of perception. With the increase in the duration of period of marriage the perception changes from satisfactory to good. The more the number of children and with increased duration of breast had led to better level of perception.

Association of demographic variables with different aspect of perceived body image:

The variables age, educational status, duration of marriage were signicantly associated with the levels of perceived feminity. As the age increases, the level of perceived feminity shifts from poor to very good. Similarly, the education status has a positive relation with the levels of perceived feminity i.e.as the educational status increases the levels also change from, poor to satisfactory, then to good and from good to very good. About duration of marriage the maximum number of subjects mentioned the level to be good, followed by very good and then satisfactory. Very few respondents had poor level of perception.

The association of the level of perceived intimacy among breast cancer patients with age, education, habitat, duration of marriage and history of breast feeding have been found to have a highly signicant. Similarly in the case of educational status, it has been shown that better the education, the better was the level of perceived intimacy. However the maximum numbers of subjects have expressed the level as good. In the case of rural and urban habitat although the level of perceived intimacy is not much different. Since the level of perceived intimacy relates to the married subjects only, the relative questions were asked to only married patients. Out of these a total of 62% of the married subjects expressed the level of perceived intimacy to be good, followed by 22% as satisfactory,12% as very good and the remaining 4.0% as poor. Regarding the association of duration of marriage with levels of perceived intimacy, The percentage of subjects who expressed the level as good for the duration of 21 to 40 years decreased from 61%, where as 33% are those who were married for 41 to 60 years expressed the level as poor and 40% were those who were married for 60 years and above expressed the level as satisfactory. More than 50.0% of all the subjects perceived the level of intimacy to be ‘good’ followed by about 20.0% who expressed the level as satisfactory, about 14.0% as poor and the remaining 10.0% as very good.

The levels of physical wellbeing was signicantly related to women who breast fed the last child for longer duration. The levels of physical wellbeing increased with increase in duration of breast feeding the last child. The association of perceived level of emotional wellbeing with age and ‘type of family’ was highly signicant. For all the age groups the percentage of the subjects who expressed the perceived level as good or very good was much more as compare to the percentage for the satisfactory level. This difference in percentage increased with the increase in age. In the case of type of family, more subjects from joint families expressed level as good or very good as compared to the subjects coming from nuclear families.

The duration of marriage has been found to have a highly signicant relation with the perceived level of coping strategies. Almost all the subjects categorized the perceived level as good. Only one out of the total 520 subjects mentioned the perceived level of coping strategies to be poor.

DISCUSSION

Breast cancer is a malignant growth in the tissues of the breast. It is one of the commonest causes of deaths in middle aged women. The chemotherapy is one of the treatment modalities to treat breast cancer but it has adverse effects which have physiological and psychological impact on the patients and ultimately on their embodying identity. The ndings of the current study based on age showed that nearly half of the subjects (44.8%) were in the age group of 56 years & above and mean age of the study participants is 53.8 years. In contrast to this study conducted by Saleh S.B et. al. at Lahore Pakistan (2010) the ndings showed that the mean age of study participants was 45.5 years.9 T h e p r e s e n t s t u d y d e p i c t s embodying identity perceived by breast cancer patients receiving chemotherapy was good in two third of (64.2%) breast cancer patients. Level of perception regarding feminity was observed to be good among 46.3% of subjects followed by perception of intimacy was recorded to be good among 56.3% of breast cancer patients involved in study. Perception regarding physical wellbeing was observed to be satisfactory among nearly half of subjects. Level of perception related to emotional wellbeing was good in majority (73.7%) of breast cancer patients and none had poor perception. Satisfactory perception related to functional wellbeing was recorded amongst more than half (56.5%) of the patients. Perception regarding coping strategies adopted by patients proved to be good among 74.8% of subjects. The ndings of the present study are contradictory with the study done by Baxley et. al. (1984) on Alopecia. Effect on cancer patient’s body image, showed that there was low body image of patients with alopecia than the patients without alopecia.10 Hunt and McHale (2005)showed the perceived body image including self image and shame feeling has a strong negative impact due to alopecia, means the body image was lower in patient with alopecia. All patients think that appearance is important and they were not well prepared for alopecia and experienced substantial physical, psychological and social distress.11 Furthermore Margaret M. P r e s t o n e t . a l , ( 2 0 11 ) p r e s e n t e d contradictory ndings that appearance related changes to body were most devastating after having chemotherapy. Researcher described that losing hair on   b o t h t h e i r h e a d a n d b o d y l e f t unrecognizable to subjects. These personal changes resulting from breast cancer treatment were described as being traumatic to the women established sense of self and self esteem often causing it to plummet.12 The present study depicted the highly signicant association of the level of perception of body image with age, occupation, type of family, duration of marriage, the number of children and history of breast feeding. The level of perception improved with increase in age. A study was conducted by Rani Ruchika et.al. to assess perceived body image among Breast Cancer Patients with Alopecia, undergoing Chemotherapy and result were shown that more than half of the patients had satisfactory perception for their body image followed by less than half of the patients had good perception and only few had poor perception for their body image. There was no signicant association of age with perceived body image.13 The Present study reported that perception regarding feminity was signicantly related with age, educational status and duration of marriage. Age, education, habitat, duration of marriage and history of breast feeding had signicantly associated with the level of perceived intimacy. Intimacy increased with the increase of age. Study conducted by Patricia A, Ganj et.al reported that overall, 65.5% of the breast cancer survivors (BCS)reported they were sexually active at the time of their cancer diagnosis. For those who were inactive, in more than half (55%), inactivity was due to not having a partner and for the remainder a variety of reasons were endorsed. Approximately71% of the sample reported having attempted sexual activity since the breast cancer diagnosis, and 60% reported having been active with a partner in the past6 months. CARES sex dysfunction subscale show a trend for worsening of sexual functioning with increasing age.14 Another study done by Joseph Andrew Shatley et. al 2011 show that the 40.5% of women had an unfavorable to regular SQ-F (Sexual Quotient – Female Version) score. A signicant positive correlation (p < 0.05) was found between the SQ-F score and years of education (p = 0.03). A signicant negative correlation was found between SQ-F score and the age of the partners (p = 0.03).15

The present study showed that history of breast feeding has been found to have a signicant association with the levels of perceived physical wellbeing. Age and ‘type of family’ have a highly signicant relation with perceived level of emotional well  being  and  functional wellbeing. The ndings of the present study are supported by a study conducted by Byeong-Woo Park among 1,250 eligible patients, show that younger women (age <50 years) showed signicantly higher QOL scores than older women (age ≥50 years) in all of the QOL subscales including functional, physical and  emotional  wellbeing.16    The  present study showed that duration of marriage (21- 40 years) has been found to have a highly signicant relation with the perceived level of coping strategies. A co-relational survey was carried out by Athar Javeth on 100 female cancer patients with chemotherapy induced alopecia supported the present study. Coping strategies were signicantly associated with economic status (χ2 = 10.38),  frequency  of  chemotherapy  (χ2 =17.28) and cycles of chemotherapy (χ2 = 12.72). On the other hand, the rest of the variables like age, marital status, education status, occupation etc were found non- signicant with coping strategies of cancer patients. Another familiar study was done on relationships among stage of disease, age, coping, and psychological adjustment in women with breast cancer by Robert A. Schnoll (1998).17 In particular, the model showed that younger women and women with an earlier disease stage used greater levels of the coping strategy characterized as a ghting spirit and lower levels of the coping strategies characterized as hopelessness/ helplessness, anxious preoccupation, and fatalism which, in turn, were related to better psychological adjustment. Overall, these ndings may offer  an  explanation  for  the conicting ndings regarding the relationship between age, stage of disease, and psychological adjustment to breast cancer by illustrating that coping strategies may be an essential mediating factor; in turn, a mediating model of psychological adaptation may offer useful information for clinicians as they implement interventions designed to improve patients coping efforts.

The present study itself stands unique in terms of detailed ndings upon Indian females’ perceptions regarding their embodying identity. The perceived physical appearance almost equally affected in account of body image, feminity, intimacy, functional, emotional wellbeing, coping strategies among breast cancer patients. It was observed that most of women were perceived good and satisfactory level of perception in all the categories of embodying identity. The embodying identity among breast cancer patients can be improved by acceptance of illness, compliance with the treatment, positive attitude and trying to minimize adverse effects by reducing anxiety, doing yoga, light exercises, meditation and follow healthy foods habits. Hence present study c o n t r i b u t e s s i g n i  c a n t l y i n t h e advancement of phenomena by preparing  t h e i n f o r m a t i o n e d u c a t i o n a n d communication (IEC) protocol. It will assist patients in minimizing adverse effects and improve embodying identity. It is written according to Indian culture and it will help the breast cancer patients in effective coping and improving their quality of life. Very simple measures are emphasized to manage day to day problems. Adverse effects such as alopecia can be managed by use of wigs, scarf’s and improving blood circulation by frequent scalp massage. Nausea and vomiting could be minimized using intake of proteins and vitamin C rich diet. By doing light exercises and diversional therapy stress and anxiety can be handled which furthermore boost the physical well being, emotional stability, functional well being and ways to cope up with effects. Use of this booklet is recommended for breast cancer patients in different settings.

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