Research Proposal For A Literature Review - The Impact on Marital Relationship of Mastectomised Breast Cancer Patient

THE IMPACT ON MARITAL RELATIONSHIP OF MASTECTOMISED BREAST CANCER PATIENTS

 

Title

            The working title of the study is initially drafted as – The Impact on Marital Relationship of Mastectomised Breast Cancer Patient. Specifically, there are two issues that will be explored: marital relationship and breast cancer patient who undergone mastectomy. Marital relationship simply refers to the relationship between wife and husband while mastectomised is the patient status post mastectomy.

Question

            The key question that will be explored in this study is: how mastectomy affects the marital relationship of the breast cancer patients with their respective spouses?

Aims  

            The main aim of the study is to determine the effects of mastectomy on the marital relationship of the breast cancer patient involved. This means that the study will deal with the changes – affirmative or unconstructive – pre- and post-mastectomy. Likewise, it would be plausible to distinguish the effects of these marital changes with the coping situation of the breast cancer patients. Other aims of the study include:

·         To determine the perceptions of the breast cancer patients about undergoing mastectomy pre and post

·         To determine the perceptions of the breast cancer patients on how the process will affect their married life

Introduction

            According to the World Health Organization (WHO, 2009), cancer is a leading cause of death worldwide; it is accounted for 7.4 million deaths in 2004. Most cancer deaths each year are caused by lung, stomach, colon and breast cancer. Breast cancer, more specifically, is accounted for 519,000 deaths. Early detection of breast cancer is through mammography. Further, treatment aims to cure, prolong life and improve quality of life for patients. Specific way of improving the quality of life of breast cancer patients is by means of a strong, stable emotional support which comes from the family particularly from the spouses. It is in this sense that cancer becomes a family affair. This is more so for breast cancer patients who undergone mastectomy as this requires a supportive environment onwards survival.

            Breast cancer is a serious malignant disease and treatment is more often than not by surgery. The surgical removal of the affected breast is known as mastectomy. Mastectomy refers to the medical term which refers to the surgical removal of one or both breasts, partially or completely. Mastectomy is usually performed to treat breast cancer and in some instances to prevent cancer rather than treat it (Brown, Freeman and Platt, 2006, p. 82). Moreover, a fact of life is that many marriages fail and there is certainly are several reasons why breast cancer and mastectomy could affect and lead to marital problems. Brown, Freeman and Platt (2006, p. 202) also noted that how a breast cancer patient and probably the spouse respond to the crisis in marriage depends on two factors: first is how much of an emotional investment one has for the marriage and second is what actions are needed to maintain both emotional and physical wellbeing.      

            Weiner et al (2003, p. 83) made mention that the most important close personal relationship is the marital relationship. Although healthy marital relationships afford health benefits, disruptions in the marital relationship are associated with health risks. One of the critical events for the couple is learning about the breast cancer and its inherent emotional shock. Two other events that can have a major impact on the women’s sexual identity and her self-concept may also adversely affect the marital relationship (Pedderson and Trigg, p. 76). Following breast removal, sexual adjustment is perhaps the most critical time for spouses. It may also be the most difficult adjustment for the couple since much of the adjustment will depend on how the woman feels about her femininity after a mastectomy and on the quality of their relationship prior to the illness (Pedderson and Trigg, p. 78).   

            The question now is how do these critical events affect the marital relationship? Mastectomised women tend to think of themselves as less sexually attractive thus withdraw from intimacy for fear of rejection. Withdrawal could be responded with counter withdrawal which may be mistaken as rejection from both sides. Another reason for a woman’s withdrawal may be treatment regimen which causes discomfort and fatigue and which may result to hormonal imbalance. These and other factors may affect the sexual relationship that had been satisfactory prior to mastectomy. Functioning sexually would be deemed as a burden hence the importance she places on her marital-sexual relationship and the quality of such relationship may have a bearing on her sexual adjustment.

            By exploring the effects on the marital relationship of mastectomy, the study could contribute through recommending the proper coping mechanism for the couples. It is of my best belief that the study will lead to various emotional, psychological and physical effects of mastectomy. Sustaining the quality of lives of both persons involved and the quality of the marriage itself nonetheless should be comprehensively addressed. The study will be important in situating mastectomised breast cancer patients in a context wherein their best interests are protected and upheld. Having said this, it would be plausible to explore more deeply the effects of mastectomy on the quality of lives of the couples and their marital relations.    

Theoretical Perspective

The theoretical framework I have chosen to utilize in conjunction with this research is an interpretivist one. Interpretivism is the necessary research philosophy for this study because it allows searching the ‘details of the situation to understand the reality or perhaps a reality working behind them’. Limitations inherent with this type of framework would include a susceptibility to projecting my subjectivities on to the healthcare schema in the context of the research study. I would tend to think that the emotional adjustment in light of mastectomy is vested more on the woman and no support structure is established this may not be the case from the research’s perspective, and I would need to remain vigilant when engaging in interpreting data in this research study with regard to my own subjectivities.

I would hope to use this theoretical framework to expound on the health structure and institution applications inherent in this research study by analyzing the position of the mastectomised patients and how the whole process had affected their marital lives. There are two reasons for situating myself in this type of theoretical framework. First, I am interested in conducting my research in a qualitative manner because I want to place myself in the position of viewing the value of marriage as a fortress for all persons involved. Secondly, the research questions that I want to answer fit the Interpretivist framework. I want to gain evidence-based knowledge about the issue and the resulting data analysis will hopefully shed new light (be it positive or negative) on how both men and women view breast cancer and mastectomy.

Current Literature Review

Quality of life of mastectomees

El-Sharkawi et al (1997) noted that quality of life is subjective in nature wherein each individual has a slightly different view of what is important to his or her quality of life. The authors argued that for breast cancer patients who undergone mastectomy alone, surgery plus radiotherapy, surgery plus chemotherapy and hormonal therapy, which comprise the standard armamentarium of breast cancer either alone or in combination, conform to varying quality of life. It would be therefore necessary to include physical functioning, social interactions, psychoemotional well-being and disease- or treatment-related symptoms as the critical domains of their quality of life. 

El-Sharkawi et al (1997) discovered that the physical functioning and the social and pscyhoemotional wellbeing of mastectomised breast cancer patient are greatly impaired. Threats facing each woman facing mastectomy include possible loss of femininity, self-esteem, health and role in life have profound impact on their quality of life. This means that the psychoemotional well-being of women is the most affected aspect of their quality of life. Three months after mastectomy, women also experience moderate social and psychological distress and disruption in their everyday lives and that this level of distress continued for over a year thereafter. 

Mastectomy and marital and sexual relationships

            Haber (1994) maintains that breast cancer will strike a sizable percentage of women during the child-rearing years impacting not only the women but also the significant others in her life. Breast cancer impacts the patient’s life partner, parents and children. Intervention therefore should also focus these people. Following breast cancer, Kalaitzi et al (2007) is one with saying that mastectomy poses a severe threat to body image and sexuality which interferes with the psychological wellbeing of both the patient and her partner, more importantly. The authors acknowledged the fact that although several psychotherapeutic approaches have been assessed and found effective in such patients, few studies have assessed couple or sex therapy in mastectomy patients.

In their study, they reported on a structured combination of brief couples and sex therapy (CBPI) used in 20 women with in situ breast cancer and mastectomy and their partners and an equal number of mastectomy patients were used as controls. The result of the study is that CBPI patients showed significant improvement in depression and state anxiety scores, as well as in body image, satisfaction with relationship, presumed attractiveness to their partner, orgasm frequency and communicating their desire. This means that CBPI can be utilized as an effective alternative to individual or group psychotherapy for mastectomy patients (Kalaitzi et al, 2007).

Same with Kalaitzi et al, Hoga, Mello and Dias (2008) also explored the psychosocial perspectives of mastectomy and breast cancer though qualitatively. They made mentioned that the family members of cancer patients play a central role as caregivers specifically the spouses. Through their report on the perspectives of men whose wives underwent a mastectomy because of breast cancer, they found out that initial reactions to the diagnosis, involvement in caregiving, support received, influence of breast cancer on the couples' relationships, and evaluation of care provided by the institution are the critical events. Emotional demands and care needs are their primary concerns. 

            Mahapatro and Parkar (2005) explore the various concerns associated with mastectomised patients including the level of anxiety and depression among them. The authors offered six important concerns such as recurrence or relapse, sexual role and performance, body image or disfigurement, the future, feeling upset or distressed and current illness. Sexual role and performance showed statistical significance among the patients which when not resolved could lead to sexual problems. Further, levels of anxiety and distress likely interfered with the attention to bodily cues and cognitive responses as sexual arousal. This reflects the women’s perception regarding feelings of sexual attractiveness and desire.

            Barni and Mondin (1997) explore more specifically the effect of mastectomy on women’s sexuality. Ninety percent (90%) of the 50 subject had continued sexual activity after treatment but there was an increase in the incidence of sexual problems that resulted in slight reduction in the quality of their sex lives. Sexual problems include absence of sexual desire, low sexual desire, dyspareunia, frigidity and lubrication problems. Others are vaginismus, brief intercourse and female orgasmic disorder. About 50% also experienced changes in the relationship with their partner. These sexual problems are found to be easier to discuss with doctors and psychologists than their husbands.

Treatment and coping strategies for mastectomees

Amicetti and Caffo (2003) contend that conservative breast surgery is perceived to be a surgical technique that improves the psychophysical outcome of women who underwent surgery for breast cancer. Similar to that observed after mastectomy, this type of surgery has clearly improved the impact of local treatment on postoperative body image adjustment and its subsequent effect on the patient’s quality of life. Insufficient adjustment may be related to the fact that pain produces negative effect on patient’s quality of life. Pain is a consequence of treatment as noted and it generally affects the patient’s physical and psychological wellbeing, physical autonomy and relationships particularly of partners and children. This therefore limits the patient adaptation and reducing the beneficial effect of the conservative breast surgery on body image.

It was also discovered, nevertheless, that coping strategies are either effective or ineffective in resolving such concerns. However, helplessness which is the most frequently used coping strategy for concern regarding body image was ineffective in resolving the concern. A concern about recurrence or relapse was also not effectively resolved but the frequent coping strategy used was talking to others such as the professionals. Coping mechanisms intended for sexual role and performance is discovered as temporary acceptance. Their orgasmic capacity, sexuality practices including caressing, and the attitude of the partner are the associated concerns of the mastectomised patients (Mahapatro and Parkar, 2005).

Methodology

             The study will be conducted in a qualitative manner. I want to place myself in the position wherein I could provide new orders of thinking applicable to incumbent and posterity. The qualitative research refers to that discipline of inquiry on different subject matters and phenomenon. Qualitative research provides an in-depth understanding of human behaviors as well as the reasons that guides such behaviors.

In lieu with this, the majority of the research will incorporate secondary data. Secondary data review and analysis will be the main data collating technique. It refers to the evaluation of data and information gathered for the purpose of the research. A cost-efficient gathering technique, secondary data review and analysis could provide broader understanding of specific occurrences (Holloway, 1997). The content of secondary materials will be subjected to content analysis in order to digest and extract the most relevant information.

Sample

            Basically, there are three that would be accessed: Pub Med Central, British Medical Journal (BMJ) and Elsevier Health Sciences. These databases will be used since there would be a wealth of literatures about mastectomised breast cancer patients and their respective relationships with their spouses. Research papers, case studies, empirical studies, policy papers, article and general review are most likely sources that I am going to use for this literature review.

Access to Data/Sample

As already mentioned, Pub Med Central, British Medical Journal (BMJ) and Elsevier Health Sciences are the databases to be used. The keywords to be used are marital relationship, mastectomy and breast cancer. Boolean tools will be also used: NOT, AND OR. I will search for effects of mastectomy and marital relationship and breast cancer and marital relationship.

Data Collection

Majority of the research will be library-based, drawing on the contents from published articles. Sources of data will be medical books and journals, theses and related studies, official statistics, and magazines and newspapers. Basically, interpretation will be conducted which can account as qualitative in nature.

Data Analysis

After gathering empirical data, contextual or thematic content analysis of the literatures will be adopted. Contextual analysis refers to the method of analyzing the contents of literature and research and identifies how the themes relate to the study. Qualitative data analysis will be used to collect relevant themes from the analyzed data and categorize them accordingly. From those themes, the study will develop insights regarding the subject. This type of analysis is highly inductive as the themes emerge from data and are not imposed by the researcher or evaluator. Background reading can form part of the analysis process. Thematic analysis is always accompanied by comparative analysis. For the qualitative analysis of the responses, content analysis will be used, a process which is more mechanical where analysis takes places after data has been collected.

Further, the study will be presented in written form and with the addition of data charts which will illustrate the project’s results and findings. The study will be presented in five chapters: first chapter will present the background of the study, the objectives, research problems, the study’s scope and limitation and its significance; second chapter will discuss literatures relating to the study, third chapter will tackle the methodologies used in the study; fourth chapter will discuss the results of the conducted survey. The fifth chapter, finally, will summarize the findings and provides recommendations based on the conclusions.

Ethical Issues

The research will abide by the regulations outlined in the University’s ethical approval process as well as those will be imposed by the libraries and online databases. This means that terms and conditions of accessing, utilizing and publishing contents of specific literatures will be followed. Copyrighted materials will be also carefully managed. I will establish with the data providers the use of my data and will ask their permission in case of publishing data. In this way, I can ensure the providers that literatures provided or accessed will be used according to the purpose of the study. I will save the findings of the research in Thumbnail retrievable only by me and my instructor and after 6 months all materials that are borrowed will be returned to the rightful owners and materials made will be destroyed.

Rigors

            Breast cancer is one of the leading causes of death among women worldwide. Needless to say, it is also one of the most researched medical conditions. Mastectomy, in addition, has received a considerable attention in the medical research, focusing on specific issues of emotional adjustment, coping and quality of life.

Limitations

            A study that will investigate the effects of mastectomy on the spousal relationship of the breast cancer patients, this study might provide new results that can be further explored in future studies. This type of study will allow seeing the importance of providing quality of life not just to the patients themselves but also to all the family members while in the process of post mastectomy. Comparison of these views may lead to the development of new hypotheses or theories that may contribute to breast cancer research. However, like any other study, this research also has various limitations that may affect the credibility of its results. One of the limitations is that data will only be acquired through empirical study.

Timeframe

TASK

Weeks

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Read preliminary literatures

Finalize objectives

Draft preliminary literature review

Devise conceptual frameworks/mind maps

Organize and collect literatures

Conduct actual literature review

Evaluate literature review

Develop comprehensive literature review

Draft findings chapter

Complete remaining chapters

Submit to tutor and await feedback

Revise draft and format for submission

Print, bind and submit

 

Dissemination

I will feed back the findings of the research to the necessary people, unit and organization. There are two ways by which results will be communicated. First is through written reports. This may take the form of a summary report at the end of the project. The research is planned to be disseminated to universities across Hong Kong as well as to international medical journals such as CHEST, Blackwell-Synergy, and MEDLINE as well, disseminating my findings through dedicated websites. The final written report will be published in medical journals accessible to users and electronically via putting the findings on a database or dissemination network accessible to both users and other stakeholders. There will be also informal discussions of the findings with relevant stakeholders.  

References

Amicetti, M & Caffo, O 2003, ‘Pain after Quadrantectomy and Radiotheraphy for Early Stage Breast Cancer: Incidence, Characteristics and Influence on Quality of Life,’ Oncology, vol. 65, no1, pp. 23-28.

Barni, S ^ Mondin, R 1997, ‘Sexual dysfunction in treated breast cancer patients,’ Annals of Oncology, vol. 8, pp. 149-153.

Brown, Z K, Freeman, H & Platt, E 2006, 100 Questions & Answers about Breast Cancer, Jones & Bartlett Publishers. 

El-Sharkawi, M, Sakr, M F, Atta, H Y & Ghanem, H M 1997, ‘Effect of different modalities of treatment on the quality of life of breast cancer patients in Egypt,’ Eastern Mediterranean Health Journal, vol. 3, no.1, pp. 68-81.  

Haber, S 1994, ‘Psychological impact of breast cancer on the patient and the family: A clinical perspective,’ Journal of Clinical Psychology in Medical Settings, vol. 1, no. 4, pp. 331-338.

Hoga, L A K, Mello, D & Dias, A F 2008, ‘Psychosocial Perspectives of the Partners of Breast Cancer Patients Treated With a Mastectomy: An Analysis of Personal Narratives,’ Cancer Nursing: An International Journal for Cancer Care, vol. 31, no. 4, pp. 318-325.

Holloway, I 1997, Basic concepts for qualitative research, Iowa State University, Iowa.

Kalaitzi, C, Papadopolous, V P, Michas, K, Vlasias, K, Skandalakis, P & Filippou, D 2007, ‘Combined brief psychosexual intervention after mastectomy: Effects on sexuality, body image and psychological well-being,’ Journal of Surgical Oncology, vol. 96, no. 3, pp. 235-240. 

Mahapatro, F & Parkar, S R 2005, ‘A comparative study of coping skills and body image: Mastectomized vs. lumpectomized patients with breast carcinoma,’ Indian Journal of Psychiatry, vol. 47, no. 4, pp. 198-204. 

Pedderson, L M & Trigg, J M 1995, Breast Cancer: A Family Survival Guide, Greenwood Publishing Group.

Weiner, I B, Freedheim, D K, Nezu, A M, Schinka, J A, Nezu, C M & Geller, P A 2003, Handbook of Psychology: health psychology, John Wiley and Sons, New York.

WHO 2009, Cancer, retrieved on 21 December 2009, from http://www.who.int.

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