Illness Related Variables

Disease and treatment severity. Characteristics of the illness, including disease stage, treatment, and time since diagnosis predict psychological adjustment and quality of life in cancer patients.2,5,12 Given this, one might anticipate that these variables would have implications for relationship functioning as well. However, few studies have investigated the impact of illness- or treatment-related variables on relationship functioning specifically. In a cross-sectional study, no differences were found in relationship satisfaction, the expression of affection, or cohesiveness in partners of patients at four stages of the illness trajectory, including initial diagnosis, first remission, first recurrence, and metastatic disease.76 Other data suggest that women with recurrent breast cancer report equivalent levels of relationship satisfaction to disease-free survivors and matched controls without cancer.34,44

There are, however, a few exceptions to these findings. In one of the only studies that explored the role of illness severity on relationship problems between mothers with breast cancer and their children, relationship problems and poorer prognosis were significantly correlated.50 However, this study did not tease apart the unique contributions of illness-severity (prognosis) and treatment-severity (surgery), which was also linked to relationship problems. Treatments that are more severe and physically debilitating may be associated with a higher degree of disruption to interpersonal relationships because they cause more role limitations.77

More invasive surgery (mastectomy versus lumpectomy) has been linked to poorer marital adjustment in breast cancer patients and their husbands61 and more relationship problems between breast cancer patients and their children.50 Results of a meta-analysis that examined the impact of breast conserving surgery versus mastectomy on marital and sexual functioning suggest that mastectomy may be associated with worse functioning, however the effect size was small.78 Higher levels of marital dissatisfaction have also been observed in the spousal caregivers of patients who underwent more intensive HSCT regimens (allogeneic versus autologous transplants).40

Treatment regimens that are more physically debilitating, or are associated with prolonged caregiving (such as stem cell transplant) may be more disruptive to the couple's relationship as roles and responsibilities are altered for extended periods of time. Data indicate that patient functional impairment may restrict the spouse's ability to participate in their usual activities, which can lead to higher levels of negative mood in the spouse.43 Impairments in patient physical functioning79 and illness-related demands80 also are associated with lower levels of marital satisfaction in cancer patients and their spouses.

The severity of the illness also may exert its impact on relationship functioning via patients' and family members' perceptions about the cancer, and the effects of these perceptions on patient and partner distress. For instance, the relationship between illness severity and poorer psychological adjustment in cancer patients appears to be mediated by cognitive variables such as hopelessness.77 Perceptions about illness severity are related not only to patient distress, but also to distress in their spouse and children.1,81,82 Other study results support these findings, concluding that it is not entirely physical symptoms related to the cancer or medical factors per se that contribute to psychosocial problems in patients and partners, but also appraisals about the illness can have a significant impact on adjustment.83

In summary, although illness-severity variables such as disease prognosis and recurrence do not appear to account for large portions of the variance in relationship functioning, more severe treatments may place patients and partners at risk for relationship distress. Possible mechanisms for the association between treatment severity and dyadic adjustment include increased disruption to patients' physical functioning, illness-related demands that tax the partner's resources, and perceptions about the severity of the illness and treatment, all of which may contribute to psychological, and ultimately, couple distress.

Time since diagnosis or treatment. A sizeable literature suggests that the period surrounding diagnosis and treatment is particularly challenging and stressful for cancer patients.84,85 Presumably then, the impact of cancer on relationship functioning may also be most pronounced during this period of time, as patients and their loved ones adjust to and cope with changes in health status and role functioning. Time since completing treatment was moderately positively correlated with marital satisfaction in one small sample of breast cancer survivors.86 In general, however, time since diagnosis or treatment has not been included as a predictor of relationship quality. Also, as discussed above, longitudinal data do not support the idea that relationship satisfaction improves over time.

Several investigators have examined patterns of communication and support in cancer survivors over time. Consistent with our clinical experience, the data suggest that some cancer survivors have an ongoing desire to communicate about their experience with cancer that persists long after treatment has been completed.58,61 In one of the few studies to examine the evolution of cancer-related communication over time, patterns of communicating about cancer were stable over the first year or so following cancer treatment, suggesting that the transition to survivorship may require ongoing communication within the couple.60 Alternatively, the stability of communication may simply have been a by-product of the fact that most participants were in highly satisfied, stable relationships that were likely characterized by stable and adaptive communication patterns.

Although survivors may have a need for ongoing support related to the cancer experience, research indicates that supportive behaviors from members of one's social network may decline as the patient moves further from treatment.20,87 In addition, increases in patient emotional distress over time may lead to the erosion, rather than provision, of support.87 Cancer survivors who are distressed and/or have ongoing needs to communicate and receive support about the cancer experience seem likely to be at risk for relationship disruption. Also, couples may have a tendency to avoid addressing relationship problems during the initial phases of the illness, such that relationship problems may accumulate over time, and only emerge once the acute stress associated with diagnosis and treatment subsides.88 Finally, cancer treatments with ramifications for intimate aspects of the couple's relationship (such as radical prostatectomy) or those requiring ongoing caregiv-ing (such as HSCT) may be associated with longer term reductions in marital satisfaction.6,12,40

To summarize, few investigators have examined time since treatment or diagnosis as a predictor of relationship functioning after cancer. However, existing data suggest that survivors who experience prolonged psychosocial impairments or have ongoing caregiving needs may be at risk for relationship distress.

4.2. Demographic Variables

Clinical experience suggests that some demographic characteristics may have implications for how couples maneuver through the cancer experience. In this section we focus on a few specific demographic variables that have been linked to relationship functioning in cancer survivors including gender, role status, age, and length of relationship.

Gender and role status. Although most researchers have focused their attention on the influence of gender on psychological adjustment in response to cancer, a few studies have examined the impact of gender on relationship functioning specifically. Existing data suggest that women report lower levels of marital satisfaction and more role problems than men, regardless of whether they are the patient or spouse.11 Levels of marital satisfaction following HSCT also are lower in female compared to male partners.40 These findings are consistent with the larger literature regarding the impact of chronic illness on marital functioning which suggests that women may be more likely than men to experience worsened marital satisfaction when their spouse suffers from chronic illness.18

The relation between female gender and poorer relationship quality may be partly attributable to the differential impact of cancer on the psychological adjustment of women versus men. Several studies suggest that women are more vulnerable to psychological distress than men following cancer.8,11,76,89 In addition, women's distress appears to be independent of their role as patient or partner/caregiver.8,11,76,90 Data on the relationship between gender and distress are not entirely consistent, however. Higher levels of distress have been reported in male spouses of colon cancer patients compared to their (female) partners and male patients9; and male spouses of melanoma patients compared to female spouses.89 Other research suggests that male patients are at higher risk for distress than male partners.90

Although very few studies have examined the relationship between gender and relationship quality as an outcome variable, available data are suggestive of lower levels of relationship satisfaction in women compared to men, which may be related to their higher levels of emotional distress. However, gender and role are frequently confounded, which further complicates the interpretation of study findings. Consideration of role (patient or partner) as well as gender may be important in the context of understanding relationship functioning and psychological adjustment to cancer.

Age and length of relationship. Data linking age to global relationship adjustment following cancer are inconclusive. Although the trend in the literature is to assume that younger patients are at risk for relationship problems, the data are not consistent. Some investigators have found no relationship between age and marital satisfaction40 or problems with role adjustment83; while still others have reported an inverse relation between age and marital satisfaction.61

Several other studies have identified younger age as a risk factor for specific relationship problems, however. For instance, younger female cancer patients report poorer partner communication than older patients.42 In a tri-ethnic sample of early-stage breast cancer patients, younger age was associated with more partner-related concerns (e.g., concern about arguing with partner or being rejected).91 Perceptions of spouse criticism and spouse avoidance are also higher in younger than older cancer patients.74 Younger cancer patients also tend to report poorer quality of life,92 more psychosocial problems,91 and greater impact of cancer on life plans and activities5 which may partly explain their apparently higher levels of disruption in some components of relationship functioning.

The inconsistencies in the literature regarding the association between age and relationship adjustment highlight the importance of considering third variables that may explain the conflicting findings. On a related note, age and length of relationship are usually confounded, making it unclear to which variable any observable relationship should be attributed. Thus, future research should also examine the impact of cancer on the marriages of younger versus older couples.

4.3. Psychological Distress

Psychological distress has been linked to relationship quality in cancer survivors and their partners.16,39,79,93 Not surprisingly, cancer patients who are in less satisfying relationships endorse higher levels of psychological distress.43 Distress in one member of the dyad also may be related to the level of marital satisfaction reported by their partner.16,79 Negative behaviors from one's partner, including social withdrawal and other kinds of unsupportive behaviors, have been found to predict patient psychological distress.74,75 Available data suggest that patients' perceptions about relationship processes such as communication are more strongly linked to both patient and partner distress and relationship satisfaction than partners' perceptions.16,60

Although few data address distress as a predictor of relationship quality, a growing literature supports the idea that relationship quality may play a role in attenuating psychological distress in cancer survivors. The relationship between avoidant and intrusive stress symptoms and negative mood appears to be less pronounced for prostate cancer patients who endorse higher levels of relationship satisfaction.94 Other data suggest that the mechanisms accounting for the relationship between patient functional impairment and partner distress or partner negative behaviors may differ in high versus low satisfaction marriages.43

Although psychological adjustment and relationship functioning are clearly correlated, the direction of the relationship remains unclear. Most available research emphasizes the role of relationship functioning in predicting psychological distress rather than vice versa, however the cross-sectional nature of the bulk of the data precludes establishing the direction of the relationship. Furthermore, it seems quite likely that the relationship between these variables is bidirectional. Data suggest that psychological distress and maladjustment may be more prevalent in relationships that are low in satisfaction, and that the presence of a good quality partner relationship may buffer against psychological distress.

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