Coping Strategies being Practiced by the Breast Cancer Survivors before Receiving First Cycle of Chemotherapy

Breast cancer is the number one cancer among Indian females and chemotherapy is most often used modality to treat breast cancer [1-2]. India is facing a challenging situation with increase in mortality due to breast cancer. Available treatment options are surgery; chemotherapy; hormonal therapy; biological therapy and radiation therapy [3]. Chemotherapy can improve prospects for long term survival but is also associated with long term toxicity including possibility of physical, emotional and cognitive impairments [4]. Abstract


Introduction
Breast cancer is the number one cancer among Indian females and chemotherapy is most often used modality to treat breast cancer [1][2]. India is facing a challenging situation with increase in mortality due to breast cancer. Available treatment options are surgery; chemotherapy; hormonal therapy; biological therapy and radiation therapy [3]. Chemotherapy can improve prospects for long term survival but is also associated with long term toxicity including possibility of physical, emotional and cognitive impairments [4].
Factors like family involvement, social support, self belief and determination encourage patients to come out of this tragic phase and motivate to use positive coping strategies. Many myths and misconceptions are prevalent regarding chemotherapy like permanent hair loss, reoccurrence risks, and used only when the cancer is in advance stages. Chemotherapy has both direct and indirect psychological impacts. The psychologically active paraneoplastic hormones can affect the coping abilities directly whereas emotional reaction related to chemotherapy associated bodily symptoms can influence coping mechanism indirectly [6]. It is well documented in some literatures that in the face of stress and trauma people start using coping mechanisms to maintain psychological equilibrium. Coping strategies used by BCS can be positive or negative, positive use is always associated with better outcomes in terms of handling stressful situation and good QOL.
As per evidences, several factors influence the coping strategies of BCS including demographic characteristics; educational status; family and social support and psychological support [7]. Although there are many studies on how BCS overcome diagnosis by using positive and negative coping strategies. This will be the first study to show how BCS deal with chemotherapy experience after diagnosis. Therefore, the objective of this study was to assess the coping strategies practiced by BCS before receiving first cycle of chemotherapy.

Study Design and Setting
This descriptive study was conducted in Radiation Oncology and General Surgery OPD, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh from July 2018 to December 2019. PGIMER, is one of the leading medical Institute of India. It was established in 1962 and has been functioning as an autonomous body under Ministry of Health and family welfare, Government of India since 1967 through the parliament act of institute of National importance. The source population was all BCS attending Radiation Oncology and General Surgery OPD, PGIMER Chandigarh before chemotherapy during the study period.

Sample size and sampling techniques
The total sample size was calculated on the basis of the pilot study i.e. average number of patients starting first chemotherapy cycle at Radiation Oncology and General Surgery OPD, PGIMER, Chandigarh. Purposive sampling technique was used to enroll sixty two participants who were fulfilling the preset inclusion criteria.

Study Criteria
Inclusion criteria: (1) Breast cancer patients scheduled for first cycle of chemotherapy, before or after breast surgery, (2) Patients who were able to read write and to understand Hindi language. Exclusion criteria: (1) Having previous history of cancer, (2) Patients having neurological and mental health disorders, (3) Not willing to participate.

Data collection tools and techniques
Data was collected using Interview Schedule and Folkman and Lazarus questionnaire.
1. Interview Schedule -It is divided into two parts: A. Socio-demographic profile sheet -To obtain socio -demographic information of the participants such as name, age in years, religion, habitat, educational status, occupation, marital status, family type, number of family members, total family income (in rupees), and socio-economic status (as per modified B.G Prasad scale 2019).
B. Clinical profile sheet-To collect information pertaining to menstrual history, parity, history of truncal obesity, BMI (Kg/m 2 ), co-morbidities, family history, laterality, stage (TNM), grade, quadrant and lymph node involvement and surgical treatment.
2. Folkman and Lazarus questionnaire to assess coping mechanisms.
The questionnaire used to assess coping mechanisms contains 46 items that is adopted from Folkman and Lazarus tool (1988). The tool contains eight major components of coping namely confrontive; distancing; self-controlling; seeking social support; accepting responsibilities; escape avoidance; plan full problem solving and positive appraisal, which further comprises of various coping activities with similar concepts. Participant's responses were assessed as Yes or No for the use of positive and negative coping strategies. Negative and uncertain responses for the given activity were categorized as unpracticed or unused responses. The response's such as 'quite a bit' and 'a great deal' were categorized as positive responses since both responses indicated that the respondent used the activities [5].

Pretest
Content validity of the tools was ensured and modifications were done after the pilot study on 10% of BCS in Radiation Oncology OPD. For flawless administration tool was written in clear and easily understandable Hindi language.

Ethical consideration
Ethical approval for the study was obtained from the Institute Ethics Committee of PGIMER, Chandigarh and complete autonomy was given to the participants in the study. After informing them about the study written informed consent was taken. Confidentiality was ensured.

Data analysis
Descriptive and inferential statistics were used to analyze the data. Calculations were carried out manually along with Microsoft excel and Statistically Package for Social Science (SPSS) program version 23. Frequencies, percentage, mean, range, SD, were used to describe the study population in relation to different variables. Analyzed data was presented in the form of tables and figures. distancing; self-controlling; seeking social support; accepting responsibility; escape avoidance; plan full problem solving and positive appraisal. Out of these, distancing and escape avoidance were the only negative coping styles whereas others were positive. It is evident from the ( Table 4) that out of 46 coping activities participants responded positively for 31 whereas negative

Socio demographic Characteristics
Out of 62 BCS, more than half of participants (51.7%) were above the age of 50 years and Hindu (51%) by religion. Majority of the participants belonged to rural area (62.9%) and were illiterate or educated up to primary level (54.8%). Most of the participants were married (83.9%) and 72.6% were unemployed. More than half (54.8%) of the participants were from nuclear families. Around half (48.4%) belonged to the middle and lower middle class of socio-economic status (as per modified B.G Prasad scale 2018) (Table1).

Clinical Characteristics
Majority of the participants (74.2%) had a history of irregular menstrual cycle. Most of the BCS were multiparous (98.4%). Only 14.5% had truncal obesity and 32.3% participants were overweight. Co-morbidities were present in 30.6% of the participants and hypertension was the most common co-morbidity found among BCS i.e. 89.4%. Only 4.8% of BCS had a positive family history of breast cancer. More than half (56.5%) of the participants had left side breast involvement.53.2% of the participants had early stage as per TNM classification. Around (58%) of the BCS had grade III breast cancer. Majority of the BCS had upper outer quadrant (79%), and lymph node (72.6%) involvement ( Table 2).

Treatment profile
More than half (62.9%) of the BCS were on neo-adjuvant chemotherapy (Table 3). Only chemotherapy as a treatment modality was used in 56.5% of BCS and 53.2% participants were receiving anthracyclins drugs.

Surgical intervention profile
Surgical interventions were done in 48.3% of participants. Majority (27.4%) of them had undergone surgical procedure i.e. TMAC. None of the participants had reported any complication associated with surgery (Figure1).

Coping Mechanisms
This questionnaire consists of 46 items designed to measure eight different coping styles namely confrontive;  response was noticed for 13 activities. For the remaining two activities half of the participants responded in a positive way whereas remaining half had a negative response. Escape avoidance is one of the major predictor of negative coping among all the coping strategies, under its subparts "hoped a miracle would happen"; "Wished that the situation would go away or somehow be over with" were used by all the participants in this study. Although the negative coping activities were not predominant but were still used by the participants up to some extent.

Discussion
The results of this study highlighted that the use of positive coping strategies was predominant among BCS to overcome the stress and fear related to diagnosis and chemotherapy. In present study, out of the 46 coping activities participants retorted positive action for 31 whereas it was negative for 13 activities. Remaining two activities had equal number of positive and negative responses. Thus, in order to discourage the use of negative coping behaviors efforts are required on behalf of nursing professionals to make their patients aware about negative coping activities and at the same time encouraging them to use more of the positive coping strategies. Role of family and society cannot be ignored during this stressful period of life so both the family as well as society can be involved by nurses in nudging the BCS towards adopting positive coping styles.
Escape avoidance is one of the major predictor of negative coping among all the coping strategies. Out of its nine components participants showed a positive reaction towards six of them. It was astonishing that all the participants resorted to the negative strategies "hoped that a miracle would happen" and "wished that the situation would go away or somehow be over with" as a measure to cope. These findings were contrary to another study where wishful thinking was the least commonly used coping strategy six months after the diagnosis [8]. 88.7% participants of current study "accepted the situation, since nothing could be done". This is consistent with the results reported by Chen et al. [9] where acceptance was one of the most common types of coping reactions and it can be directly linked to lower distress.
Helplessness and hopelessness are two factors responsible for the use of escape avoidance coping style by the patients instead of facing the situation. Therefore, escape-avoidance coping style strongly predicts a worse    psychological well-being [5]. It has been recommended that medical professionals should be well versed in identifying the coping styles and treat accordingly [10]. It is good to see that in the current study out of nine coping activities under escape avoidance coping style, only three were used by the participants and majority of the BCS didn't use six negative coping activities which reflects a good state of their psychological health. Counseling sessions can be provided including information regarding coping strategies to make them aware about positive coping styles and discourage the use of negative coping activities.
Seeking social support is one of the major components of positive coping strategies. The result of the current study showed that majority of the participants took positive initiative for seeking social support. This reflects their readiness to seek help from family, friends, society and health care professionals which can contribute towards better treatment outcome. This is in agreement with the study where instead of religion and spirituality, social support has more significant association in coping [11]. Therefore, in order to make the patient strong at the emotional level, it is imperative that family, society and professionals participate actively in patient care. Therefore seeking social support can be an important aspect to improve QOL and deal with present situation by effective use of coping style.
Planful problem solving is another part of positive coping strategies. Out of ten coping activities under this component, participants responded positively for six activities and in a negative way for three activities. For 'I went over in my mind what I would say or do' equal number of participants responded in positive and negative way. The more effectively patients use planful problem solving, the more it helps them to cope positively with the situation. By using planful problem solving as a coping strategy a person can focus their efforts on planning and positive reframing that would help them to take action towards resolving their problems and help them better adjust to chemotherapy experience [12]. It has been documented that planful problem solving was frequently used coping strategy by breast cancer patients who were anxious [12].
Exercise is one of the major component of planful problem solving activities [5]. In the present study 79% of the participants did not jog or exercise. These findings were contrary to a study where physical exercise was identified as one of the coping strategies among cancer patients [13]. Exercises are required for healthy behavior change in patients in terms of adopting positive strategies to deal with the situation [14][15]. So keeping in mind the current study findings a need was felt to guide the BCS. They were encouraged and informed about the benefits of exercise in this traumatic phase of illness.
Positive appraisal is one of the major positive coping strategies, which has a greater influence on patient's coping style. In the present study majority of participants 'prayed' (88.7%), 'found new faith' (88.7%) and 'came out of the experience better than went in' (90.3%). Religious coping is one of the alternatives for making psychological adjustment [16]. Prayer and other religious practices helped the current study subjects to calm down mentally and at the same time provided courage to deal with the challenges in life. These results are consistent with the study conducted by Ahmad et al [17] where majority of participants used religious faith and practices as a coping style.
Self controlling, a positive coping strategy, was used by majority of participants to cope with the stressful situations. 98.4% of participants 'tried to keep their feelings from interfering with other things too much'. Therefore by keeping themselves busy or distracted in other activities they were able to avoid thinking too much about their problem. That's why self controlling is a good way to cope with this situation. These findings are supported by a study conducted by Burger [18] where self controlling as a coping strategy can positively influence the outcome of stressful event.
In the present study, majority of participants responded in a positive way to cope by confronting the situation. 91.9% of participants responded to positive coping strategies 'let their feeling out somehow' and 88.7% 'stood their ground and fought for what they wanted'. This suggested that acceptance of a situation is very important. Once the acceptance is there then only a person starts looking for alternatives, contrary to this chances of adopting negative coping styles are more when one runs away from the situation. Similar findings were also reported by Amare et al [5], where most of BCS had used confrontive as a coping strategy to cope up with breast cancer.
Distancing represents a major part of negative coping strategies. In the present study, for this component majority of the participants responded in a positive way. Similar findings were reported in a study by Amare et al [5] where distancing was the least used negative coping strategy. Distancing can be one of the reasons to have negative opinion about chemotherapy and thus delaying the early interventions. This highlights the importance of encouraging patients for the use of positive coping styles. The encouraging attitude of health care professionals can facilitate the process of problem solving rather than distancing from the actual scenario.
Accepting responsibilities is one of the positive coping styles. In the present study, majority of the participants responded negatively for this component. Wonghongkul et al. [19] supported the current findings that 'acceptance of responsibilities' was least used coping strategy among BCS.
In conclusion, the present study revealed that the use of positive coping activities was predominant among BCS to overcome the stress and fear related to diagnosis and chemotherapy. In spite of being lesser in number, negative coping strategies were still used by some of the participants to deal with stressful situations. After completion of the study all participants using negative coping strategies were contacted and counseled to encourage the use of positive coping styles.

Limitations
Limited data collection period and lesser number of patients, meeting our inclusion criteria, visiting OPDs per day resulted in a small sample size for this study. This sample size cannot capture the diversity of the country. Thus there is a scope for the future studies being done with a larger and more diverse sample size.