A Descriptive Comparative Study of Marital Satisfaction among Healthy Women and Women with Breast Cancer

Introduction                             

Today, cancer is one of the most important health problems worldwide (1).  Among cancers, breast cancer is the most common known cancer among women (2).About 23% of newly diagnosed cancers are breast cancers (3). In 2013, 232,340 new cases of breast cancer have been diagnosed in the United States, in the same year about 39,620 women died of breast cancer (2). Over the past 20 years, the prevalence of breast cancer and its mortality rate has increased rapidly in developing countries (3). It is estimated that one per eight women develops cancer in their lifetime. Every year, more than one million and one hundred thousand women in the world are diagnosed with breast cancer (4). According to the Ministry of Health National Cancer Registration Program, 98% to 99% of breast cancers occur in women. The average age of people with cancer in Iran is 50 years, and since the age pyramid of our population is slightly younger than other countries, the proportion of young people is higher than the number of elderly people (5). Breast cancer with a rate of 21.4 % ranks first among all malignant diseases in Iranian women.

Cancer as a stressful event can affect various aspects of a person's life (6). On the other hand, breast cancer has a great impact on the daily activities of the individuals and family. The physical, psychological, and spiritual effects of cancer and the related therapies include nausea, fatigue, insomnia, pain, worry, anger, rage, loneliness, feelings of emptiness, meaninglessness, jealousy, resentment, and psychological stress; so, breast cancer poses many challenges for affected women. In addition, patients suffer from the initial disclosure of their disease, the side effects, surgery or combination therapies, getting rid of the disease or fearing of its recurrence, and they are worried about their physical abilities (7).

Besides the physical problems, diagnosis and treatment of breast cancer is also associated with many psychological problems and imposes considerable stress on patients. Among these, the most important issues are sexual problems and marital satisfaction.  Husbands of women with breast cancer experience many problems in their marital and sexual relationships (8). When the women are diagnosed with cancer, care providers should understand how these men perceive the problems and how they react to changes in their marital relationships and thus can help patients and their spouses. Since the sexual relationship is an important factor in marital satisfaction, in addition to treating patients, they also should be helped to solve their sexual problems and maintain their mental health and marital satisfaction (9).

Marital satisfaction refers to the individual's assessment of the marital status and can be positive or negative (10). Bahmani et al. showed that since each couple's maladaptive responses to the consequences of this disease may present them with a major challenge in their marital relationships, this issue has led to breast cancer being referred to as relational cancer (11). However, some studies showed that despite many negative changes that breast cancer may have on the relationship of some couples, most of them maintained satisfaction in their relationship and even surgery has no effect on their marital relationships (12).

With regard to the high prevalence of breast cancer among women and a lack of studies on the marital relationships which is the important aspect of women's lives, this study was performed to compare marital satisfaction in women with breast cancer and healthy women in Iran. It is hoped that the results of this study could be helpful to identify the dimensions of marital satisfaction in women with breast cancer.

Materials and Methods

This descriptive-comparative study was performed on 95 women with breast cancer and 95 healthy women. Inclusion criteria for breast cancer group were the diagnosis of breast cancer by the medical record and stage I, II, IIIa of cancer with mastectomy and no other cancer according to the patient's statements. Other inclusion criteria for both cancer and healthy groups were: no physical and mental illness according to the patient's medical record and their statement, no alcohol and drug addiction, no history of psychotropic and psychiatric drug abuse, no history of hospitalization in a psychiatric ward, the ability to communicate verbally, and willingness to cooperate in the study. The statistical populations were healthy women referring to health centers to receive medical care and breast cancer women referring to the health centers and the breast cancer clinics in Ilam city in 2019. Sampling in this study was done through convenience sampling. The study was approved by the University Ethics Committee with code No. After obtaining permission from the Vice-Chancellor of the Health Department, the researcher referred to the selected study settings to conduct the research. The health centers of Ilam city were divided into three groups according to the social, economic, and cultural situation based on the experts' opinion of the health deputy of Ilam city. The study settings            were three health centers, which were randomly selected by lottery among low, medium, and high socio-economic and cultural levels. Then, the necessary coordination was done with the officials of these centers, and one of the center staff was selected as a member of research team to conduct the research. The method of conducting the study was explained for the subjects during a separate meeting with each member involved in the research. Also, the tools for data collection were reviewed. 

The subjects were randomly selected from each cluster according to the population covered by the relevant areas and centers, and a total of 95 healthy women referring to the health centers who had the inclusion criteria were randomly selected from these centers (preparing a list of eligible people in each center and doing lottery and selection of individuals for control group). After recruitment the subjects, the researcher introduced himself to the subjects through phone call and after clarifying the goals and methods of the study, the person was invited to participate in the study. The subjects who verbally expressed a willingness to take part in the study, were asked to complete the questionnaires. If necessary, the questionnaire was completed with the help of the researcher.

To recruit subjects with breast cancer, the researcher first referred to the breast cancer clinic at Hospital. Cooperation was made through a brief session with the director of the special diseases medical center and explaining the research method and reviewing the tools of the research. A total of 124 breast cancer patients referred to the breast cancer clinic during the study period from whom 95 women who met the inclusion criteria were selectd. Sampling was done as a full census, and they were considered as a case group. 

The tools included the Enrich Inventory Satisfaction Marital Questionnaire and a questionnaire of demographic characteristics and disease-related data (for women with breast cancer). In this questionnaire, data about age, education, socio-economic status, and obstetric records were asked. The Marital Satisfaction Questionnaire had 35 Persian questions with four subscales including marital satisfaction, communication, conflict resolution and ideal distortion. The answers to the questions were in the form of 5 points: strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree. A high score in this questionnaire indicated more satisfaction and a low score indicated dissatisfaction with the marital relationship. In study by Rajabi (2010), the reliability of the scale by using Cronbach's alpha coefficient was 0.86 and the retest coefficient was 0.7 (13). In the present study, the reliability of the questionnaire was assessed by calculating the Cronbach's alpha coefficient, which was 0.89.

Data were analyzed by SPSS software (version 22) and descriptive and analytical statistical methods. The Chi-square test was used to compare qualitative variables and Independent t-test was used to compare quantitative variables between the healthy and patient groups. P<0.05 was considered statistically significant.

Results

A total of 95 women with breast cancer and 95 healthy women were studied. In the cancer group, 26 women were in the stage I, 33 in the stage II and 36 in the stage IIIa, all of whom underwent mastectomy (mostly radical mastectomy). In the patient group, 36% received radiotherapy and 78% received chemotherapy. Demographic information of the both groups, including age, education, number of children, economic status and living conditions was presented in Table 1.

Table 2 showed the comparison of mean scores of marital satisfaction and its four dimensions between the healthy and patient groups. According to the table 2, the two groups had significant difference in terms of the total score of marital satisfaction and its four dimensions (P˂0.001).

Discussion

The aim of the present study was to compare the marital satisfaction and to examine the possible differences between the two groups of women with breast cancer and healthy women in order to understand the relationship between breast cancer and marital satisfaction of women. The findings of this study indicated that there is a significant difference between marital satisfaction of women with breast cancer and healthy women.  In addition, a significant difference was observed between the two groups in terms of marital satisfaction, communication, conflict resolution, and ideal distortion. The findings of this study were consistent with the results of some other studies (11,14-19). 

Women's sexual relationship, sexual and body image, are damaged after breast cancer; therefore, providing appropriate psychological therapies help women with cancer and their spouses to increase their sexual satisfaction and life satisfaction (20). According to another study by Anderson et al. on marital satisfaction in women with breast cancer, low quality marital satisfaction was observed in women with breast cancer, which confirms the results of the present study  (21).

Many studies have shown that while complementary therapies for cancer, such as chemotherapy or radiation therapy, can increase life expectancy or even eliminate the risk of death altogether, they can be deforming, painful, and have permanent side effects, leading to reduced patient's social communication (22). Complications such as nausea, vomiting, weakness and fatigue, hair loss, skin burns and skin lesions can have severe negative effects on body image of women with cancer and thus decrease their self-confidence (23). Breast cancer women are worried about their spouses' impressions and thoughts about their status and changes in their appearance, which can lead them to have negative and hopeless thoughts about their marital relationships. Factors such as the desire to limit social communications, and loss of some individual activities and perception of the disease affect the patient's quality of  life (24). These consequences has direct or indirect negative effects on the level of marital satisfaction of women at least for a while(25). So, during the critical period of cancer, providing counseling and couple therapy services is important in reducing the individual and interpersonal psychological harassment and preventing the aggravation of marital problems (26,27).

The limitation of this research was that sampling was not possible to be done in multiple breast cancer centers, so the research results cannot be generalized. However, the center which was used as study setting in this research was the only referral breast cancer center in Ilam city.

Conclusion

Based on the findings of this research, breast cancer can affect marital satisfaction in different dimensions and reduce it compared to non-affected women. Therefore, providing appropriate psychological counselling help women with cancer and their spouses to enhance their marital satisfaction.

Acknowledgements

This article is derived from a master dissertation in Midwifery, Faculty of Nursing and Midwifery, Shahid Beheshti University, Iran                                                . The authors would like to appreciate and thank the cooperation and financial support of this faculty, as well as the cooperation of the Vice Chancellor of Health department of Shahid Beheshti University of Medical Sciences and the participants who cooperated us to perform this study.

Conflicts of interest

Authors declared no conflicts of interest.