Understanding the impact of cancer on relationships is important because cancer occurs in an interpersonal context. The diagnosis and treatment of cancer affect not only the patient, but also their significant others, including family and friends. Partners of cancer patients may experience significant decrements in physical, emotional, and social functioning that appear to parallel the patient's own response to their cancer.6,14 Levels of adjustment in cancer patients and their partners also tend to be moderately positively correlated, suggesting that couples may have a mutual influence on one another6,8,15 [for an exception, see ref. 16, where an inverse relationship between patient and partner adjustment was observed]. In addition to affecting individual components of quality of life and adjustment in each member of the dyad, cancer may affect role patterns and responsibilities, social activities, and the general emotional equilibrium of the couple.14,17,18 These changes have potential ramifications for relationship adjustment and the ways in which members of the dyad relate to and support one another throughout the illness trajectory.14,19
Relationships and interpersonal processes are also important to examine because the cancer survivor's social environment plays a crucial role in their psychological adjustment to cancer. Relationships provide opportunities for individuals to receive both emotional and instrumental support, which are associated with better adjustment to cancer.20-23 Although individuals with cancer may receive support from multiple categories of significant others, family members, particularly life partners, are their primary source of empathic support.20,24 In fact, the presence of a positive partner relationship seems to be a key component of successful adaptation to virtually all aspects of the cancer experience.20,24-26 Finally, interpersonal relationships form the basis for social functioning, which is widely regarded to be a critical minimum component of health-related quality of life assessments.27-29
Studies addressing the influence of cancer on relationships can crudely be categorized as falling into one of four methodological categories: (1) cross-sectional studies that compare relationship quality in cancer survivors and non-cancer controls,
(2) longitudinal studies that examine changes in relationship quality over time in cancer survivors, (3) studies documenting the overall level of relationship quality in cancer survivors, and (4) studies that retrospectively assess the perceived impact of cancer on relationship quality.
2.1. Relationship Quality in Cancer Survivors Compared to Healthy Controls
Several studies have compared relationship quality in cancer survivors to various control groups, both population-based and other. With few exceptions, the outcome of focus has been the partner relationship. In one of the earliest studies of this type, no differences in satisfaction with relationships with family or friends, or marital status were found between a mixed sample of 339 long-term (more than 3 years post-treatment), disease-free cancer survivors compared to national age-adjusted data.30 In a more recent study specific to long-term testicular cancer survivors, no differences were found in separation or divorce rates compared to matched controls, and cancer survivors reported fewer negative changes in friendships compared to controls.31 In an older study, also conducted with testicular cancer survivors, levels of satisfaction with the partner relationship were higher in survivors compared to age-matched controls.32 Breast cancer survivors (between 6 and 57 months posttreatment) also have been found to report greater increases in their love for their partner compared to women with benign breast disease (BBD).33 Data obtained from a sample of 5-year disease-free breast cancer survivors uncovered no differences between survivors and age-matched healthy women, or between women who sustained a recurrence and disease-free survivors, in the quality of the marital relationship.34
One of the prevailing myths about the impact of breast cancer on the marital relationship is that husbands desert their wives following treatment.35 In a study designed explicitly to test this notion, secondary analyses were conducted comparing rates of marital breakdown and satisfaction in breast cancer cohorts and population-based controls.36 For both survivors and controls, divorce and separation occurred infrequently (range: 1.6—11.5% of participants across cohorts of survivors and controls) and rates of marital dissatisfaction were low (range: 7.1-14.3% of participants across cohorts of survivors and controls). Marital breakdown was not higher in survivors compared to the controls. With regards to the satisfaction data, a similar percentage of women endorsed marital dissatisfaction across all cohorts of survivors and controls, with one exception: breast cancer survivors assessed 18 months following treatment reported higher levels of marital dissatisfaction (14.3%) compared to controls (7.8%). It should be noted that approximately 90% of the population in the study area were French-speaking and Catholic, which may have implications for the acceptability of divorce in this sample and constrain the generalizability of study findings.
One of the few studies to identify poorer dyadic adjustment in cancer survivors compared to controls comes from a sample of hematopoetic stem cell transplant (HSCT) survivors measured at least 12 months posttransplant (median = 6.6 years).37 This is a unique population characterized by a high level of need for ongoing care that may extend for many years beyond treatment, and ultimately tax the dyadic relationship. Other studies with this population suggest that cancer patients report more positive changes in their partnered relationship than controls, but not in other relationship categories.38
2.2. Longitudinal Assessments of Relationship Quality After Cancer
Longitudinal investigations provide mixed findings regarding the influence of cancer on relationship quality. Declines in marital and family functioning from 60 days to 1 year postdiagnosis that were not observed in couples facing benign breast disease have been documented in women treated for breast cancer and their husbands.15 We observed significant, but small, decrements in relationship quality over the first year following prostate cancer surgery for survivors, but not their partners.6 Research conducted with long-term breast cancer survivors (at least 5 years postdiagnosis) also suggests that there may be small, but statistically significant decreases in the quality of the partner relationship over time; however marital status did not change from baseline to follow-up (time between assessments varied).5
However, other longitudinal data suggest that dyadic adjustment remains fairly constant over the first year following the diagnosis of breast cancer39 and colon cancer11 for both patients and their spouses, although family functioning in colon cancer patients appears to decline.11 Data obtained from HSCT survivors and their caregivers suggest that relationship satisfaction is stable for survivors over the first year posttreatment; however, their partners may be at risk for worsened relationship quality at 6 months and 1 year posttransplant.40 Analysis of change scores revealed that changes in relationship satisfaction were in the positive direction for 48% of HSCT survivors, but only 37% of their partners, who were also their primary care-givers. As suggested previously, the posttransplant course is known to place a high level of demand upon the caregiver for a sustained period following transplant that may uniquely place the partners of these survivors at risk for relationship strain.
Descriptive data regarding overall levels of relationship quality in cancer survivors consistently indicate that functioning in this domain is excellent. The majority of women with breast cancer measured a year or more after diagnosis describe high levels of relationship satisfaction16,39,41,42 as do patients actively in treatment.43 Moderate-to-high levels of relationship quality have also been reported in women with recurrent breast cancer.44 Even in those studies that reveal small decrements in relationship quality over time, overall marital adjustment tends to be high.15 In our own research with prostate cancer survivors and their partners, we noted that overall relationship quality was excellent across the first year posttreatment for patients and partners,6 echoing findings of other investigators working with this population.45 Marital satisfaction also was high, and rates of marital distress were relatively low, in a sample of HSCT survivors measured a year posttreatment (14% of female patients and 7% of male spouse caregivers were distressed).40
2.4. Retrospective Evaluations of the Impact of Cancer on Interpersonal Relationships
Cancer survivors who are asked to reflect on the impact of cancer on their significant relationships report that the changes associated with the cancer experience are largely positive rather than negative.46 In fact, positive changes in relationships with others is one of the most frequently cited domains of benefit-finding by cancer survivors across virtually all cancer diagnoses, with between 50 and 85% of cancer survivors endorsing this change.46-48
In an early study of breast cancer survivors 2.5 years posttreatment and their husbands, 89% of survivors and 85% of husbands described the impact of cancer on their marriage in positive terms.49 In addition, 81% of survivors and 65% of patients described the impact of breast cancer on relationships with children as positive; and 68% of survivors and 63% of husbands regarded the impact on relationships with friends as positive.49 Although nearly half of women who had breast cancer in another study reported no changes in their relationships with their children, 73% of the women who endorsed some degree ofrelationship change regarded the changes as positive, citing increased closeness and understanding.50 In a sample of breast cancer survivors and their husbands assessed 1 year following diagnosis, 42% of couples (N = 282) were in agreement that breast cancer had brought them closer, 16% regarded cancer as having no impact on relationship closeness, 34% were discordant (i.e., only one member of the couple reported a sense of increased closeness), and only 7% of couples were characterized by perceived distancing in one or both members.51 Likewise, the overwhelming majority of long-term testicular cancer survivors (82%) and their wives (85%) reported that their experience with cancer drew them closer as a couple.52 Although reports of growth in the relationship domain are ubiquitous, some data suggest that strengthening of intimate relationships may be more prevalent in married than nonmarried cancer survivors.53,54
Approximately half of patients undergoing evaluation for bone marrow transplantation reported that their cancer had led to improved relationships with their spouse or partner (57%), children (49%), or friends (43%), and 68% described experiencing more love for their spouse/partner after diagnosis.38 In another study of bone marrow transplantation survivors who ranged from 6 to 149 months posttrans-plant, significantly more positive than negative changes in relationships with various categories of family members, including siblings, parents, children, and spouse were reported.55 It also should be noted, however, that examination of frequency data for reports of no change were generally comparable to or higher than either the positive or negative category.
Data acquired via various methodologies suggest that the overwhelming majority of people diagnosed with cancer report high levels of relationship quality over the course of survivorship. Most studies have focused on the partner relationship, however the few studies conducted with other categories of family and friends are also indicative of high-quality relationships. In fact, survivors themselves tend to recall their interpersonal relationships as having been changed for the better, if at all, by the cancer experience.
A few longitudinal studies suggest that there may be small decrements in the quality of the partner relationship over time, particularly over the first year postdiagnosis, however reported declines are generally small and of questionable clinical significance. In addition, global relationship quality remains excellent, making it difficult to formulate strong conclusions about the meaning of these data. Although longitudinal data generally represent our best source of information about how functioning in a given area changes over time, the fact that we are precluded from measuring relationship quality prior to the cancer diagnosis further limits interpretations about the impact of cancer on relationship functioning. Observed decrements in relationship quality over time may reflect a trend observed in the broader marital literature,13 and may not be attributable to the cancer experience.
Although global relationship quality is good for the majority of cancer survivors, it is possible that measures of overall relationship satisfaction fail to capture or obscure subtle areas of strain experienced by cancer survivors in the relationship domain. One component of relationship quality that has received some attention is the quality of communication between the survivor and their partner. We turn to this next.
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