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Local Literature

According to National Breast Cancer Foundation, 2005 it is a disease in which malignant (cancer) cells form in the tissues of the breast. It is considered a heterogeneous diseasediffering by individual, age group, and even the kinds of cells within the tumors themselves. It is a cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare (National Cancer Institute, 2010).

Foreign Literature

Breast cancer is an uninvited and life altering event frequently associated with a rapid entry into a challenging treatment regimen and a long process of learning to cope







challenges (Boehmke and Dickerson, 2006). In addition, the breast cancer experience has several distinct phases, each characterized by a unique set of psychosocial concerns. These phases coincide with the aspects of the clinical course of the illness and related treatments. Special issues related to breast cancer are completing the treatment and re-entry to usual living, survivorship, recurrence and palliation for advanced cancer. The psychosocial impact of breast cancer must also be understood in the context of other issues that affect womens coping, quality of life and well being, such as socioeconomic factors and cultural factors, the availability of social support, access to health care and the presence of other chronic illness or life crises (Institute of Medicine and National Research Council of the National Academies, 2002).

Many fears emerge with breast cancer such as fear of pain, mutilation and loss of sexual attractiveness; concern about inability to care for ones self and ones family; concern about taking time off from work and coping with an uncertain future (Brunner and Suddarth 2010).

Assessing the factors that contribute to resilience, effective coping with cancer, and positive psychological outcomes associated with the cancer experience is of increasing interest to researchers (Brennan, 2001;

Cordova et al., 2001; Tomich and Helgeson, 2002), and some of these studies show reductions in the need for medical visits with benefit finding (Stanton et al., 2002). Stanton et al. (2000) found that for women, the emotional approach coping scales were correlated positively with hope, a construct reflecting a sense of goal-directed determination, and ability to generate plans to achieve goals.

Acceptance of

the diagnosis,

treatment decisions,

emotional distress associated with physical change and loss, alterations in lifestyle, uncertainty and existential concerns create a need for information and support that persist during all phase of breast cancer experience. (Badger, Braden, Mishel and Longman 2004; Ganz 2002). The importance of the significant others support is well documented, Han et. Al, 2005 by positive support, the women meant no differentiation in the conduct of others toward them. Social support for the woman with breast cancer includes instrumental support, such as transportation to appointments, preparation of meals, help with activities of daily living and emotional support, meaning the availability of someone to share ones fears, feelings and concerns (Maria Hewitt et. al, 2002). Social support has been documented to help in

adjustment and coping with breast cancer and to impact

positively on the survivor's health. For breast cancer survivors, access to a supportive environment can prevent long-term psychological difficulties and positively impact general well-being (Yoo, G. J., Aviv, C. and Levine, E. G., 2004).Moreover, social support can reduce stress by helping the person to appropriately cope with the situation through the provision and of emotional positively and practical the




reappraisal of the event (Elenice Dias Ribeiro de Paula Lima, 2010). Providers can take several of the following steps to help individuals cope with normal level of distress these are as follows: clarify diagnosis, treatment options and side effects and ensure that the patients understands the disease and her treatment options, acknowledge that distress is normal and expected and inform patients that points of transition can increase distress, build trust, mobilize resources and direct patient to appropriate educational material and local resources, consider

medication to manage symptoms such as analgesics, hypnotics and ensure continuity of care. (NCDDN Distress Management Guidelines, 2003). Assisting the patient in identifying and mobilizing her support systems can be beneficial to her well being. The patients spouse or partner may also need guidance, support and education (Brunner and Suddarth 2010). According to Brunner and Suddarth (2010) encouraging the patients to discuss issues and concerns with other patients who have had breast cancer may help her understand that her feelings were normal and that other women who have had breast cancer can provide invaluable support and understanding.

Support groups have become central to psychosocial interventions for cancer patients because they provide a confidential atmosphere where cancer patients can discuss their challenges and insights with each other (Classen et. al 2001). Group therapy offers three unique

advantages compared to individual therapy: (1) Social support. Participants can find a comradeship that they may experience nowhere else. In fact, many patients participate in support groups because of the benefits of seeing and talking with others experiencing the same problem; (2) the helper-therapy principle. Patients gain benefits from giving and receiving support; (3) Costeffectiveness.

African American women, report receiving insufficient information from their health care providers regarding how to cope with their breast cancer. Furthermore, African American women state that some breast cancer support groups lack cultural sensitivity and do not provide them with the information and emotional support they need to cope with breast cancer. These experiences of African American women with traditional health care services may place them at risk for inadequate adjustment to their breast cancer. (Phyllis Henderson, 2003).

Foreign Studies

The diagnosis of any disease in someones life is a fragile moment and the way of facing it depends on the individuality of every person. After being aware of the disease, the person suffers implications in her daily life, as well as in her social context. Both the woman and her family are a target of affliction and uncertainties regarding the future. Women diagnosed with breast cancer experience a wide array of physical, psychological and support needs (Ganz 2002, Rawl 2002). Partners often experience difficulty helping the cancer survivor cope with the emotional impact of the illness because of their own psychological distress, and may subjugate their own needs to assist the cancer survivor. One consequence of dealing with ones own psychological distress is a decreased communication between the cancer patient and other family members

about important issues (Carlson, Bultz, Speca and St. Piere, 2000). Women with breast cancer routinely describe the negative consequences of the illness on themselves and their family members (Manne, 2003). Segrin 2005, had found that spouses or partners often

experience higher distress than the cancer patient and that there is a high concordance between the patients and partners emotional distress. In addition breast cancer survivors and their partners were on similar trajectories during the cancer experience; that if the survivor became more depressed or anxious so too did her partner, making it more difficult to cope with her illness. Decreased communication can lead to increased psychological distress and decrease quality of life for both the person with cancer and the partner (Segrin, 2001).

Coping has been defined as the way in which people respond and behave to stressful events. After the period of the breast cancer discovery, the treatment stage also offers factors that may break the biological and cognitive balance, which is often changed by the disease and/or the impact of the diagnosis. That happens because the patient has to face deep changes in the performance of her daily activities, in the social interaction and, especially, the woman who has breast cancer will need to adjust herself to significant changes in her body and to the reappraisal of her self-concept (Andolhe R, Guido LA, Bianchi RF, 2009). Coping strategies mediate the relationship between challenging situations and their impact on psychosocial outcomes (John Wiley, 2010). Coping with an advanced cancer is a challenge. Many patients need guidance and support to encounter difficulties associated with unfamiliar illness (http://online, 2009).The coping strategies is frequently studied by their efficacy. Effective

active coping alleviates the problem

and reduces

emotional distress. Ineffective passive coping, however, exacerbates and intensifies the problem. Different coping strategies were found to have different impacts on the participants lives and morale. Multitude factors including the motivational and hindering factors for coping with breast cancer must be identified by health care workers. Coping strategies were considered best in response to different stressful aspects dealing with cancer. (Myrna Aa et. Al 2008). Saniah Ar, Zainal Nz, 2010 proposed that coping style with a fighting spirit has been observed to associate with a greater adherence to the chemotherapy regimen. Coping strategies refer to the specific efforts both behavioural and event. Coping dimension can be divided into two major categories: these are Problem Focused (active coping, planning, using instrumental support) and the other is the Emotion Focused which involves positive reframing, acceptance, religion, using emotional support and denial.

According to Dr. Elanur Y Karabulutlu, 2010 coping has two important functions including the handling of the problematic issue (problem-focused strategies) and

arrangement of emotions (emotion-focused strategies). Effective coping strategies are to necessitate treatment and disease related psychological problem. Patients with cancer recruit different coping strategies. Because coping is a multidimensional concept on which individual perception can be affected by the persons individual beliefs and values, the effect of cultural context on the coping strategy use of individuals with certain ethnic heritage may not be wholly excluded .

In the study of Myrna Aa et. al 2008 has been concluded that Iranian women used a religious approach for coping. The use of religious coping strategies may be particularly prevalent when dealing with stress cancer diagnosis. They used positive suggestions, hope and intentional

forgetfulness as coping mechanisms

Another study conducted by Phylis Henderson et. al 2003 suggested that African American women coped by relying on prayer, avoiding negative people, developing a positive attitude, having a will to live and receiving support from the family friends and support groups. Manual et. Al (2008), reported, that the most frequently used coping strategies were positive cognitive restructuring, wishful thinking, making changes, social support engaging in physical activity using medication and resting. On the other hand Hack and Degner in 2004 proclaimed that women who respond to their breast cancer diagnosis with passive acceptance and resignation are at a significant risk for poor long term psychological

adjustment. Saniah Ar, Zainal Nz, 2010 added that behavioural disengagement is a dimension that reduces ones effort to deal with a stressor, even giving up the effort to accomplish objectives with which stressor is interfering.

Facilitating coping factors were identified by Myrna Aa et. Al 2008, this includes to the belief that cancer is something from God. Patients dealt with cancer as something coming from God that they had to accept because they had no power to change the situation. Cancer is not different or more dangerous than other diseases, and they specifically named diabetes. They all compared cancer to diabetes in terms of chronicity and complications. Positive support from work environment, family, and husband helped the women diagnosed as having breast cancer to cope with their diagnosis and disease. All the participants of the study wanted to survive for the sake of their children; for the sake of seeing them growing and enjoying life with them. This attitude is well explained within the Lebanese culture, where the mother plays an important and central role in the family. These results are in line with other studies conducted by Henderson et al and Ashing et al, in which the primary concern of women

was to survive and combat the disease for the sake of their children (Myrna et al, 2008). Sharing information with other people who lived the same experience was considered as a helping factor. Benefiting from others' experiences and also sharing one's own experience were considered as important factors for coping with breast cancer (Myrna Aa et. Al 2008). . Myrna et al, 2008 reported that a sort of interaction and mutual communication were reported to be very beneficial and useful by the participants. So that breast cancer boosted the participants' morale and gave them the feeling that they were still useful and strong. According to Dr. Elanur Y Karabulutlu, 2010 the

recognition of coping strategies, by health team, may enable appropriate information and interventions to be provided at optimal times for each individual. Recent studies have shown that the main reason for oncological outpatients not to participate in psychosocial

support was sufficient support from the family, friends or doctors (Eakin & Strycker, 2001; Plass & Koch, 2001).