Society-Derived Factors

The society-derived factors are constantly changing, since they reflect society's perceptions and knowledge of cancer at a given time and its attitudes toward cancer and its treatment. Long feared and stigmatized, cancer is somewhat less fearsome today. The diagnosis is more routinely given, and the public is better informed, far more knowledgeable about cancer, and justifiably more optimistic about the outcome. Coupled with current standards of informed consent and legal mandates for patients' knowledge of treatment options, better communication between doctor and patient has been a positive spin-off. This has resulted, however, in an added burden for the patient because of the fuller knowledge of the realistic prognosis associated with each treatment option. In addition, patients who have finished cancer treatment are followed far more carefully today to detect recurrent cancer. Follow-up visits are often the cause of intense anxiety and fears. Uncertainty about the future is still a major burden that accompanies cancer.

An additional burden is the widely popularized but erroneous belief that stress causes cancer. Some patients mistakenly feel that a significant loss or response to a major stressful event caused their cancer. Repeated reassurance that this is pseudoscience is necessary.^17–19

Patient-Derived Factors

The patient-derived factors that affect adaptation come from three sources: the intrapersonal (developmental stage and coping ability); interpersonal (social support from others); and socioeconomic and social class (material resources available).

The developmental stage of the person at the time a cancer develops clinically determines the meaning of an illness or of a treatment-related loss. Infertility or an altered appearance, for example, will affect differently, depending upon the time of life that it occurs. An awareness of the individual's developmental stage, the associated biologic changes at that age, and psychological and social tasks ordinarily expected, helps in understanding the impact of cancer. Successful interventions must be appropriate for each stage. Table 70-4 outlines the developmental stages, the normal tasks that must be achieved at each age, the disruption in achieving expected life goals, and the interventions that can minimize the deleterious effects of illness. It is particularly important in treating childhood and adolescent cancer to assure that normal developmental milestones are reached and maintained as nearly as possible.²⁰ Detailed developmental tables of the life cycle have been published elsewhere.²¹

Table 70-4

Developmental Stages and Cancer.

The intrapersonal resources a person brings to the illness are those derived from personality, level of emotional maturity, coping strategies, and attitudes and beliefs about illness. There are several characteristics of personality that are associated with better adjustment to cancer: being optimistic by nature; facing illness directly as a challenge or problem; using humor; being able to find some positive meaning in the situation, despite its stress; and having a philosophy or belief system that puts the illness in a tolerable perspective.^12,13

The strategies that patients use to cope with cancer must accomplish several goals: (1) to keep distress within manageable levels; (2) to maintain a sense of personal worth; (3) to restore or maintain relations with significant others; (4) to enhance recovery and physical function; and (5) to work out a socially acceptable post-illness status with maximal physical function.¹³ Taken overall, good coping strategies are important in maintaining a sense of control, optimism, and acceptance of the facts while seeking constructive, positive approaches to illness and treatment. Sharing information and obtaining support from others is a helpful coping strategy. For many individuals, spiritual beliefs and religion provide a view of life, death, and illness that helps in coping. In addition, being part of a supportive community of like-minded individuals who share their views is extremely helpful.¹⁵

Prior experience influences behavior. Individuals who develop cancer are at greater risk of distress if they have had a prior psychiatric problem or if they have experienced loss of a beloved family member to cancer earlier in life. The death of a relative from the same cancer adds a particularly heavy burden of painful memories. Individuals who have survived extremely traumatic experiences earlier in life (eg, Holocaust survivors or survivors of physical abuse) are more apt to experience symptoms of posttraumatic stress disorder (PTSD) and may have additional distress in coping with cancer.²² Table 70-5 outlines the major predictors of poor coping that can readily be elicited in taking a history, thus identifying patients who are most vulnerable.²³

Table 70-5

Predictors of Poor Coping with Cancer.

The patient's social environment provides the important interpersonal resources of spouse or partner, family, and friends as social support that materially contribute. Increasing evidence suggests the central role that social support plays in both coping and survival. Isolated individuals have more trouble coping with illness and have a higher age-related mortality.^24–27

A major patient-derived factor is the individual's socioeconomic and social class status. Increasing evidence points to these as important issues that influence both morbidity and mortality, not only through limited access to appropriate care but also because poorer education and fewer resources affect cancer treatment availability and outcome.^28–30 Research points to a social class gradient: Higher mortality correlates with lower social class based on education and income, with a linear gradient across the five social classes.³⁰

Cancer-Derived Factors

The cancer-derived factors that contribute to adaptation are the clinical facts themselves of stage of disease at diagnosis; site; presence of symptoms (especially pain); prognosis; the type(s) of treatment required and their impact on function, both immediate and long-term; and the extent of rehabilitation that is possible. These are the “givens,” but in addition, the psychological interaction with the oncology team is an important variable. The sensitive oncologist and nurse become important sources of psychological support for the patient and family. Concern, compassion, and “caring” in the context of professional ministrations are invaluable aids to the patient's ability to cope with illness.^8–10,31 Absence of such a relationship with key staff is a significant negative factor.⁵