This study aimed to identify the differences in the psychological and physical impact of patients with breast cancer according to the principal treatment received. Hence, role functioning and QoL among patients were analysed according to the main treatment they received. In addition, the study aimed to determine if symptomatology, such as fatigue and nausea, could predict the effects in role functioning and QoL of these women.
Regarding the psychological impact of the disease in the initial phase of medical treatment, it was observed that there were significant differences among women who received chemotherapy compared with women who received hormone treatment. Previous research has confirmed that there are differences in the symptoms experienced at a physical and emotional level between groups that received chemotherapy and radiotherapy as independent treatments27. The results of our study provided new results when compared with the information gathered from the hormonal treatment group and studying the elements of discomfort experienced by this group of women. To our knowledge, no studies have so far compared both types of treatment and compared their physical and psychological impact. The major question of clinical practice is to discover the relationship that may exist between the medical treatment phase and the impact on the QoL of patients [5-6,27]. According to these studies, the level of QoL fluctuates over time according to medical treatment. In terms of the fluctuation of QoL found in previous studies, the possibility arises that some psychological constructs, such as coping strategies, act as mediators between emotional state and QoL [7]. The present study has not been able to confirm the mediating role of coping strategies in patients who are in the active phase of treatment; however, significant differences found in important maladaptive strategies reflected the importance of coping and its impact on QoL. Despite the inconsistencies found in QoL over time, there appears to be a consensus that the group most affected is the one receiving chemotherapy. One plausible explanation for this result is the effect of radiotherapy as an adjunctive treatment. As confirmed by previous literature, adverse symptoms caused by chemotherapy increase its intensity in patients undergoing adjuvant radiotherapy [12].
The coping mechanisms used by patients with breast cancer receiving chemotherapy appear to be focused on how they perceive situations as a potent threat that generates anxiety, the feeling of being helpless when coping with the impossibility of controlling the progress of the disease, as well as feeling hopeless in the face of the disease [7-8]. Studies have been shown that this type of strategy leads women to anticipate situations that involve decision-making (go to medical consultations, deliberate decisions about treatment with your doctor, and so forth), which can generate high levels of anxiety [28]. Our study offers consistent results regarding the feeling of helplessness in relation to the medical treatment to which patients are subjected, responding to the study that also made this comparison by evaluating coping strategies, without finding significant differences depending on the treatment [29]. The methodology employed by previous studies to explore the comparison between patients usually focused on the division of the participating sample based on the main medical treatment. Generally, the main cancer treatments are usually chemotherapy and radiation [5,30]. However, it is important to note that radiotherapy is often prescribed as an adjunct to chemotherapy in a high percentage of patients [12]. According to the data provided on the adjuvant of medical treatment, we have verified that more than 50% of participants who completed their chemotherapy sessions as their main treatment also have radiotherapy prescribed as the next treatment that they must complete to slow the progress of breast cancer. In addition, we have verified that another of the main treatments, in addition to chemotherapy, is hormone therapy. Despite the lack of knowledge about the impact of hormonal cancer treatment on QoL, our results emphasise the emotional distress of patients who comply with this treatment. It has been shown that the trend in the use of coping strategies focused on the feeling of hopelessness is prevalent both in the chemotherapy and hormone therapy groups.
This study yields results regarding coping mechanisms that are used by women who receive hormonal treatment to prevent recurrences. Our results support those found by previous studies that confirm that patients on hormone therapy perceive the disease as a threat and visualise their prognosis negatively, preventing them from performing some control over it [31-32]. This lack of control to deal with stressful situations linked to the disease is called helplessness. Helplessness feeds on concerns about certain issues that surround the disease (secondary symptoms of treatment, prognosis, and so forth) and causes women to feel unable to make decisions to improve their health [8,16].
Regarding alexithymia, we also observed significant differences between both groups, with higher scores in the group treated with chemotherapy. These results offer new information regarding the role of alexithymia, clarify some questions raised in previous studies [21,23], and support the idea that difficulty in emotional recognition is fed by anxiety in adverse situations, such as treatment sessions [21-23]. Our results showed a tendency in women receiving chemotherapy to focus their thinking towards that which is external to them, preventing an internalisation of the emotions they are experiencing. The tendency to focus thinking towards concrete situations is related to the confrontation that these women activate during their treatment, focusing on the avoidance of situations that cause them to suffer [34-35]. These data address some of the limitations found in previous studies, such as that proposed by Gritti et al. [23] and Gutiérrez et al. [33], in which conclusive results on the difficulty of emotional identification in the active phase of treatment was found.
According to the role that symptomatology plays in relation to the effects of the treatment received, the results of our study showed that physical symptoms were closely related to a decrease in QoL in patients with chemotherapy and adjuvant radiotherapy. Research suggests that chemotherapy increase the chances of negative physical and emotional symptoms, leading to a decrease in QoL [36]. In the studies that contemplated the transition from chemotherapy to radiotherapy, it has been shown that QoL fluctuates over time, being the worst after finishing radiotherapy [37-38] and that physical symptoms are closely related to a decrease in QoL in patients receiving chemotherapy and adjuvant radiotherapy [10]. In research dedicated to the study of women in hormonal treatment, they suggest that this type of treatment improves QoL, although long-term benefits are not guaranteed because there is still a probability that new recurrences may appear- [31-32,39].
Among women who receive a hormonal treatment, it has also been observed that changes in their physical condition noticeably affected their QoL; however, the appearance of emotional problems caused by oestrogen receptors was also common [18]. A single study conducted in Egypt, which compared the three types of treatment separately, identified chemotherapy as the most aversive treatment, while hormone therapy did not significantly affect QoL. In addition to confirming the existence of an inverse relationship between fatigue and QoL, as indicated by previous studies on chemotherapy in breast cancer, this study also provides more information highlighting fatigue as the physical symptom that plays the most relevant predictive role in explaining low QoL in patients who are undergoing chemotherapy with adjuvant radiotherapy and hormone therapy. Furthermore, fatigue and nausea tend to be very harsh symptoms for patients and exacerbate fear before the beginning of any cancer treatment, especially in chemotherapy, impacting how women perceive a decline in their health and QoL [40].
In addition to QoL, this study considers treatment as a factor in the decrease of patients’ physical functioning in their daily tasks due to fatigue [40-41]. Other studies highlight fatigue as a symptom that better explains the results in physical functioning, QoL, and emotional state [38]. Our results support the importance of fatigue in the prediction of physical functioning, considering those women who are under hormonal treatment, as they also report high levels of fatigue similar to the group of women with chemotherapy.
Study limitations
The present study had several methodological limitations to consider. The most important limitation is its transversal design, which does not allow for making causal inferences. It should be considered that the physical and psychological conditions vary from the beginning to the end of treatment, so it would be interesting to collect these measures at several time points, as previous studies consider chemotherapy as the main treatment. Another limitation was related to the fact that the sample comprised of adult female breast cancer patients who were Hispanic and was limited to a specific geographic area, which could also affect the generalizability of the results. Furthermore, it should be noted that for the generalisation of results, it is advisable to increase the number of participants and to compare different types of chemotherapy and hormonal treatments. It is further recommended to opt for the recollection of qualitative data that would complement the information collected by self-reports during the evaluation sessions, which allows us to understand how the experimentation of these symptoms affects patients as the medical treatment sessions progress.
Clinical implications
The results of this study aim to be an impetus for future research in the study of psychological and physical variables that can affect women receiving hormone therapy for breast cancer. We have been able to confirm that hormonal therapy also affects patients at the psychological and physical levels; thus, research dedicated to the design of intervention programmes could verify whether people who undergo this type of hormonal treatment require a special psychological approach that would reduce their impact.
Our study aims to motivate future lines of research in the design of therapies that include components such as physical activity that favour the QoL of patients within a multidisciplinary framework. It is evident in existing studies that the implementation of physical exercises adapted to Oncology benefits the experimentation of pleasant emotions that allow patients to endure the treatment process. Furthermore, physical exercise can also reduce symptoms such as pain and fatigue. However, medical treatment is a factor that can interfere with the effectiveness of physical exercise as a therapeutic component, and it is important to consider the adversity of treatment within the biopsychosocial approach to health in patients with breast cancer. Thus, the present study emphasises the multidisciplinary nature of Oncology and the role of psychological therapy as an essential component for improving patients’ physical condition and QoL.