1. Coping Strategies and Mental Disorders among Patients
with Recurrent Breast Cancer
Presented by: Hani Hamed Dessoki
Prof. of Psychiatry
Chairman of Psychiatry Department
Beni-Suef University
Authors: Fatma Moussa*, Hani Hamed**, Akmal Moustafa ***, Noha Abdel Shafi****
*Prof. of Psychiatry- Cairo Universitv, **Assist. Prof. of Psychiatry- Beni-Suef University- Beni-SuefEgypt, ***Assist. Prof. of Psychiatry- Cairo University, ****Assist. Prof. of Radiodiagnosis- National
Cancer Institute-Cairo Universityt
Vienna,
WPA
October, 2013

2. Disclosure

I have no significant financial or other relationship with the
manufacturer of any product or service I intend to discuss.

The following information dose not contain clinical trial.

3. Introduction

Coping has been defined as "constantly changing cognitive
and behavioral efforts to manage specific external and/or
internal demands that are appraised as taxing or
"exceeding the resources of the person (Lazarus and
Folkman, 1984).

Coping may be positive (adaptive or constructive coping)
or negative.

4. Introduction

One positive coping strategy, "anticipating a problem is known as
proactive coping." It "reduce[s] the stress of some difficult challenge
by anticipating what it will be like and preparing for how [one is] going
to cope with it (Giuliano et al., 2011).

While adaptive coping methods improve functioning, a maladaptive
coping technique will just reduce symptoms while maintaining and
strengthening the disorder.

5. .Introduction cont

Cancer survivors may experience a battery of sequelae in their
survivorship, including physical discomfort and psychological
concerns, such as uncertainty over the future and persistent
fear of recurrence (Vickberg 2001).

In fact, one of the most frequently mentioned components of
distress among cancer survivors is fear of recurrence, even though
there are no signs of disease and it is one of the greatest
psychosocial stressors confronting survivors and families
(MacBride and Whyte 1998).

6. .Introduction cont

All the patients reported fear of the future, particularly in relation
to death and knowing that cancer had returned was devastating
because they were not prepared for this shock, although they
knew the chances of recurrence.

However, those with previous recurrence were not surprised by
the diagnosis and were optimistic about a remission.

Thus, there is evidence that recurrence is a critical point in that it
means that the cancer has not been controlled and may be
uncontrollable in the future (Mahon et al.,1990).

7. .Introduction cont

Thus, depression can be a complicating problem for a substantial
minority of people with chronic medical illnesses, including
cancer (Hegel et al., 2008).

The relationship between cancer and depression is bi-directional.

More rapid progression and increased symptoms of cancer are
associated with more severe depression, (Van et al., 2008),
while comorbid depression is associated with increased
functional impairment and poorer quality of life over the course
of chronic illness (Van et al., 2008).

8. .Introduction cont

As cancer treatment improves, the disease is being
converted from a terminal to a chronic illness.

Half of all people diagnosed with cancer will live to die of
something else, so more people are living to cope with the
disease, its treatment, the threat of recurrence and complicating
psychiatric disorders.

9. 
To assess the relation between mental disorder and recurrence of
breast cancer including mood symptoms and anxiety symptoms.

To detect the effect of coping strategies on recurrence of breast
cancer.

To detect the impact of disturbed body image due to the
recurrence of breast cancer.

To study the impact of recurrence on the quality of life containing
its different aspects.

11. 
This study is a comparative case-control study aiming
at assessment of the psychiatric co-morbidities in
patients suffering from recurrent breast cancer.
Subjects:

Subjects included in the study are 100 female patients;
all
are
recruited
consecutively
from
diagnostic
radiology department (mammogram and ultrasound
unite) in the National Cancer Institute Cairo University.
Divided into 2 groups: Group A and B.

12. Group A:

Consists of 30 patients who previously have diagnosed as
recurrent breast cancer and coming to radiology department
for follow up.
Group B:

Consists of 70 patients who are referred for diagnostic
radiology department (mammogram and ultrasound unite)
follow up after radical mastectomy. These 70 patients will be
assessed before having the radiology results.
After
completing the battery included in this study subjects in
group B will have their mammogram and ultrasound,
subsequently they will be divided into 2 groups

13. Group B1:

18 patients who were discovered that they have a recurrent
breast cancer on follow up with radiology.
Group B2:

52 patients who didn't have a recurrent breast cancer on
follow up with radiology.

Groups B1 and B2 will be compared statistically with group A
for evidence of anxiety and depression revealed by the study
tools.
Informed consent:

A written informed consent was taken from patients after
discussing with them the aim of the study.

14. Procedure

The patient’s interviews were done twice per week
(from November 2010 till November 2011).

Each patient was interviewed twice in the same week.

15. All participants were subjected to the following:
I-Present State Examination: (Wing et al., 1974)

Clinical
assessment
using
the
semi-structured
interview of Present State Examination (PSE) which is
useful for clinicians and researchers in

screening the subjects with psychiatric disorders and
those who present with subclinical morbidity

16. II-Psychometric tools:
1- Hamilton depression rating scale (HDRS)
(Hamilton, 1960)
(Arabic version, Futtaim ,1998):
2-Hamilton anxiety rating scale (HAM-A)
(Hamilton, 1959)
(Arabic version Futtaim ,1998):
3- Body Images Scale (Shoukaire, 2002):
This scale is self rated, formed of 26 items every one of
the subject answers in 3 grades from totally accepting
to totally not accepting with score from 0 to 2 for each
item. Normal range for males is (14 + 6) and for females
(16 + 6) above which the body image is considered
disturbed.

17. 4- Coping Processes Scale (Ibrahim, 1994):

This scale is self rated, every one of the subjects
answers in four grades to each phrase from totally
accepting to totally not accepting. Each one of the 11
coping processes has certain phrases and each phrase
take score from 1 to 4 then the total score for each
process is calculated.

18. 5-European Organization for Research and Treatment of Cancer 30-item core
quality of life questionnaire (EORTC QLQ C-30) (Aaronson et al., 1993)
Arabic version (Manal et al, 2008).
The QLQ-C30 is a 30-item self-report questionnaire covering functional and
symptom related aspects of QOL for cancer patients. It is grouped into five
functional subscales (role, physical, cognitive, emotional and social
functioning). In addition, there are three multi-item symptom scales
(fatigue, pain, and nausea and vomiting), There are three versions 1.0, 2.0 and
3.0.

19. V - Radiology Study (mammography and ultrasound) :
Statistical analysis

All collected questions will be revised for completeness
and logical consistency. Results were evaluated
statistically by the Statistical Package for the Social
Sciences (SPSS) version 20. Data were entered in a
master table and categorical data were coded.

21. Results

There were no statistically significant differences between the
three groups as regards the sociodemographic data including
age, marital status and education, but there were statistically
significant difference as regard the occupation which means
good matching for the groups.

22. 1) Comparison between the three groups A, B1 and B2
as regards Hamilton depression rating scale (HDRS)
Hamilton
Group A
depression rating
n = 30
Group B
B2
n = 18
scale (HDRS)
B1
n = 52
P
>0.000*
Mean
43.00
27.11
23.96
Standard deviation
+ 8.00
+ 5.87
+7.41

23. The degree of severity of Hamilton Depression rating
scale in the three groups
Hamilton
depression rating
scale
Group A
n = 30
Group B
Group B1
no=18
Group B2
no=52
No.
%
No.
%
No
0
.0
0
.0
4
7.7
Mild
0
.0
1
5.6
12
23.1
Moderate
0
.0
3
16.7
4
7.7
Severe
30
100.0
14
77.7
32
61.5
Total
30
100.0
18
100.0
52
100.0
P
%
Normal
Chisquare
20.672
0.002*

24. 2) Comparison between the three groups A, B1 and B2
as regards Hamilton Anxiety rating scale (HARS)
Hamilton anxiety
Group A
rating scale
Group B
B1
n = 18
(HARS)
B2
n = 52
P
>0.000*
n = 30
Mean
39.13
32.22
31.44
Standard deviation
+7.19
+ 6.68
+7.91

25. 3) Comparison between the three groups A, B1, B2 as regard
the Coping Processes Scale
Coping process scale
Group A
n = 30
Group B
Group B1
n = 18
Group B2
n = 52
No.
%
No.
%
Low
0
0.0
0
0.0
0
0.0
1
3.3
8
44.4
19
36.5
High
29
96.7
10
55.6
33
63.5
Total
Mental
disengagement
No.
Normal
Helplessness
%
30
100.0
18
100.0
52
100.0
Low
0
0.0
0
0.0
0
0.0
Normal
1
3.3
8
44.4
13
25.0
High
29
96.7
10
55.6
39
75.0
Total
30
100.0
18
100.0
52
100.0
P
0.001*
0.003*

26. 3) Comparison between the three groups A, B1, B2 as
regard the Coping Processes Scale (cont.)
Coping process scale
Group A
n=
30
Group B
Group B1
n = 18
Group B2
n = 52
P
No.
%
No.
%
Low
0
0.0
0
0.0
0
0.0
Norm
al
8
26.7
4
22.2
17
32.7
22
73.3
14
77.8
35
67.3
Total
Positive
reinterpretation
No.
High
Information
& social
support
%
30
100.0
18
100.0
52
100.0
Low
0
0.0
0
0.0
0
0.0
Norm
0
0.0
0
0.0
3
5.8
0.662
0.240

27. 3) Comparison between the three groups A, B1, B2 as regard the
Coping Processes Scale (Cont.)
Coping process scale
Group A
n = 30
Group B
Group B1
n = 18
Group B2
n = 52
No.
%
No.
%
Low
0
0.0
0
0.0
1
1.9
Normal
13
43.3
13
72.2
42
80.8
17
56.7
5
27.8
9
17.3
Total
Turning
To religion
No.
High
Wishful
thinking
%
30
100.0
18
100.0
52
100.0
Low
0
0.0
0
0.0
0
0.0
Normal
9
30.0
5
27.8
10
19.2
High
21
70.0
13
72.2
42
80.8
Total
30
18
100.0
52
100.0
P
0.006*
0.501

28. 3) Comparison between the three groups A, B1, B2 as regard the
Coping Processes Scale (cont.)
Coping process scale
Group A
n = 30
Group B
Group B1
n = 18
Group B2
n = 52
No.
%
No.
%
Low
0
0.0
0
0.0
0
0.0
Normal
5
16.7
4
22.2
30
57.7
25
83.3
14
77.8
22
42.3
Total
Acceptance
No.
High
Emotional
discharge
%
30
100.0
18
100.0
52
100.0
Low
0
0.0
0
0.0
0
0.0
Normal
9
30.0
7
38.9
29
55.8
High
21
70.0
11
61.1
23
44.2
Total
30
100.0
18
100.0
52
100.0
P
0.000*
0.066

29. 3) Comparison between the three groups A, B1, B2 as regard the
Coping Processes Scale (cont.)
Coping process scale
Group A
n = 30
Exercite
restrain
Denial
Active
coping
Low
Normal
High
Total
Low
Normal
High
Total
Low
Normal
High
Total
No.
8
15
7
30
0
3
27
30
0
8
22
30
%
26.7
50.0
23.3
100.0
0.0
10.0
90.0
100.0
0.0
26.7
73.3
100.0
Group B
Group B1
Group B2
n = 18
n = 52
No.
3
12
3
18
0
1
17
18
0
6
12
18
%
16.7
66.7
16.7
100.0
0.0
5.6
94.4
100.0
0.0
33.3
66.7
100.0
No.
4
39
9
52
0
16
36
52
0
43
9
52
%
7.7
75.0
17.3
100.0
0.0
30.8
69.2
100.0
0.0
82.7
17.3
100.0
P
0.145
0.018*
0.000*

30. Quality of Life Scale in Three Groups

There are no statistically significant differences
regarding all domains of quality of life scale
between the three groups.

31. Positive Correlation
Hamilton anxiety and
depression rating scale
emotional
discharge

32. Conclusion

There is high frequency of psychiatric co-morbidities
(especially anxiety) in recurrent breast cancer patients.

The presence of psychiatric co-morbidities increases the
impairment in quality of life in recurrent breast cancer
patients.

The breast cancer patients used certain strategies to cope
with their illness and the presence of anxiety and
depression modifies the coping mechanisms used by them.

33. Recommendation

Adequate referral system which ensures prompt referral of
recurrent breast cancer patients in oncology inpatient and
outpatient clinics to the liaison psychiatry clinic for early detection
of psychiatric manifestations and proper management.

Implementation of educational programs for the working staffs
(Doctors and nurses) in oncology to enhance the importance of
screening for psychiatric disorders using simplified assessment
scales.

34. Limitations

Longitudinal study is needed for assessment of the psychological
state of the patients when they knew to have cancer breast.

Larger sample is needed for better comparison after subdivision of
the groups.