الفهرس 
Introduction and Aim of the studyOnly 14 pages are availabe for public view
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Abstract
Cancer is the leading cause of death in economically developed countries and the second leading cause of death in developing countries.
Cancer represents one of the most feared diseases by people because at some point in their lives, they have been in contact or have heard of someone who has suffered from it and therefore know some of its features such as pain, the imminence of death, or the most common side effects caused by the medical treatments; all this knowledge helps in forming beliefs to guide their behavior towards the disease.
Living with chronic medical conditions is largely associated with psychological disorders and cancer is a typical example of increased need for psychosocial support. For those patients in whom psychosocial distress does not decrease over time, psychosocial interventions may be appropriate and it is important to identify these patients as soon as possible.
The MAC scale is one of the tools widely used to assess the patients’ psychological dimensions of adjustment to cancer since it is not specific to any one cancer type.
National Cancer Control Programme proposed by the WHO is a public health program designed to reduce the number of cancer cases and deaths and improve quality of life of cancer patients through implementing systematic, equitable, and evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation using available resources.
Aim of the work
To investigate the psychological adjustment of cancer patients to the disease and to explore the phenomenon of response shift using the MAC scale among Egyptian cancer patients using the mental adjustment to cancer scale, Alexandria, Egypt.
Materials and Methods
A longitudinal descriptive study was used for the implementation of the study which was conducted in the Clinical Oncology and Nuclear Medicine Department, Alexandria Main University Hospital, Alexandria, Egypt. The program StatsDirect was used to calculate the sample size based on the acceptable absolute deviation of sample from population rate to be set at 5% with 95% confidence interval. The sample required for this study was 182 cancer patients with DROP outs of approximately 10% of the cancer patients.
Cancer patients with a recent diagnosis of any type of cancer presenting to the Clinical Oncology and Nuclear Medicine Department were recruited consecutively till the required sample was attained. Follow up with the cancer patients was done during their visits to the Clinical Oncology and Nuclear Medicine Department for receiving their scheduled treatment.
Informed consent was taken from all study participants.
Data collection methods and tools:
- Data collection forms were designed to include the following socio-demographic data and risk factors: age, gender, residence, marital status, presence of children, occupation, level of education, and smoking.
- Clinical review sheet which included: the type of cancer, staging, treatment, response to treatment, and duration of follow up; in addition to the reviewing of patients’ records for any further information such as determining the patients’ response to treatment by monitoring the disease progression all through the study period.
- Pre-designed self-administered questionnaire: MAC scale which is one of the important tools used to assess the psychological adaptation of cancer patients towards the disease was used.
After data was collected it was revised, coded, and fed to statistical software SPSS version 24, then it was analyzed using appropriate statistical techniques.
Results
The following were the main results
Socio-demographic characteristics of the studied cancer patients:
Age: The age of the studied cancer patients ranged from 19-85 years with a mean of 50.08 (±SD 2.84) years. Patients aging 40 years and above (79.5%) were almost 4 times more than those aging less than 40 years (20.5%).
Gender: Females (68%) were almost 2 times more than males (32%) with a sex ratio of 2.12.
Marital status: The percentage of cancer patients who were married was more than 5 times higher than the widowed, divorced, or single combined.
Residence: The majority of the cancer patients were living in urban areas (68%), followed by the semi-urban and rural inhabitants (28.5% and 3.5%, respectively).
Occupation: Most patients were housewives (64%) who represented in addition to those with no work (17.5%) more than twice those who had either professional or non-professional jobs (18.5%).
Smoking: Non-smoker cancer patients (86.5%) were more than 6 times higher than the smokers (13.5%).
Clinical characteristics of the studied cancer patients:
Type of cancer: The study revealed that about one third of the studied patients had breast cancer (28.5%), followed by colorectal cancers and lymphomas (19.5% and 13.5%, respectively), while gastrointestinal, Gynecological, head and neck, and lung cancers amounted for (28%) combined.
Stage of caner: More than one third of the cancer patients (40%) were detected on stage II followed by stages III and IV with 26.5% each, while stage I was represented by a very low proportion (7%).
Treatment: Forty percent of the patients had chemotherapy and surgery, 33% had chemotherapy treatment only, while those who had chemotherapy and radiotherapy or all of the three treatment modalities (chemotherapy, radiotherapy and surgery) combined had lower percentages (10.5% and 16.5%, respectively).
Response to treatment: Among the studied cancer patients, 53% had partial remission, 14.5% had complete remission, while 32.5% had either progressive or stable disease.
Stage of cancer and Residence: Rural areas had the least number of patients who presented to the study (3.5%), but none of them got the disease detected on stage I; however the disease was fairly detected on stage II (57.1%), while later stages had 42.9% of the patients. About half of the patients were diagnosed in urban areas (68%) where a proportion of them presented on stage I (7.4%), while stages III and IV constituted about quarter of the studied patients with percentages of 25% and 27.2% respectively. Almost quarter of the patients presented from semi-urban areas (57%) where about two thirds of them had stages II and III diagnoses (36.8% and 31.6%, respectively).
Response to treatment and Gender: More than half of the studied female cancer patients had partial disease remission (57.4%) and a good proportion of them had complete disease remission (16.9%); whereas amongst the males, about half of them had partial disease remission (43.8%) and a fairly low proportion of them had complete disease remission (9.4%). Almost half of male cancer patients had the disease progress (43.8%) compared to nearly quarter of the female patients (25.7%).
Description of the MAC scale profile:
Fighting spirit subscale: The mean result was 48.36 (SD ±4.63) with minimum score 32, maximum score 64, and median 47 at baseline. Three months later, the mean result was 48.72 (SD ±4.31) with minimum score 32, maximum score 63, and median 48. After 6 months, the mean result was 47.50 (SD ±4.06) with minimum score 35, maximum score 60, and median 47. The IQR was 5 for the three time points.
Helpless/Hopelessness subscale: The mean result was 14.04 (SD ±2.61) with minimum score 6 and maximum score 22 at baseline. Three months later, the mean result was 13.46 (SD ±2.46) with minimum score 6 and maximum score 21. Six months afterwards, the mean result was 13.98 (SD ±2.51) with minimum score 7 and maximum score 22. The median and IQR values were 14 and 3 respectively for the three time points.
Anxious preoccupation subscale: The mean result was 23.42 (SD ±3.24) with minimum score 14, maximum score 34, median 24, and IQR 4 at baseline. Three months later, the mean result was 22.88 (SD ±2.82) with minimum score 14, maximum score 32, median 23, and IQR 4. After 6 months, the mean result was 22.48 (SD ±2.41) with minimum score 14, maximum score 32, median 23, and IQR 3.
Fatalism subscale: The mean result was 23.34 (SD ±2.03) with minimum score 16, maximum score 32, median 23, and IQR 2. Three months afterwards, the mean result was 23.46 (SD ±1.51) with minimum score 21, maximum score 30, median 23, and IQR of 2. Six months later, the mean result was 23.65 (SD ±1.35) with minimum score 21, maximum score 30, median 24, and IQR 1.
Avoidance subscale: The mean result was 2.67 (SD ±0.74) with minimum score 1, maximum score 4, median 3, and IQR 1. Three months later, the mean result was 2.41 (SD ±0.71) with minimum score 1, maximum score 4, median 2, and IQR 1. After 6 months, the mean result was 2.03 (SD ±0.61) with minimum score 1, maximum score 4, median 2, and IQR 0.
Questionnaire’s validity and reliability:
Validity and reliability: The results revealed that the MAC scale is a valid questionnaire (Mann-Whitney p=0.000) and a reliable one as well since the alpha coefficients for the five subscales varied from 0.44 to 0.83 and Pearson’s correlation coefficients ranged from 0.76 to 1.
Spearman’s rank correlation coefficient of the MAC subscales:
Spearman’s rank correlation coefficient of the MAC subscales: A moderate positive correlation was found between fighting spirit and fatalism (p=0.000), and anxious preoccupation and avoidance (p=0.000) at baseline; whereas a moderate negative correlation was found between fighting spirit and helplessness/hopelessness (p=0.000) after 6 months of follow up.
Psychological adjustment to cancer results:
Psychological adaptation to cancer: Significance was found between males and females only for fighting spirit (p=0.038) after 3 months of follow up, and for both fatalism (p=0.010) and avoidance (p=0.025) at baseline according to Kruskal Wallis test; while Friedman test was used to show whether significance was present between different time points for each item of each patient characteristic for the five subscales.
Regarding the fighting spirit subscale, a difference of statistical significance was found in patients aging from 40 to less than 60 years, from both genders, and for smokers and non- smokers. It was also found in patients with cancer on stages II and III, who received chemotherapy treatment only, combined with surgery or the three different treatment modalities, and for those who had their disease progress, partially or completely remiss.
With regards to the helplessness/hopelessness subscale, a difference of statistical significance was found in patients aging from 40 to less than 50 years and 60 years and above, for males, and for non-smokers. It was also present in patients with stage III cancer, those receiving chemotherapy with surgery or the three different treatment modalities, and for patients who had partial cancer remission.
As for the anxious preoccupation subscale, a difference of statistical significance was found in patients aging from 40 to less than 60 years, for both sexes, and for non-smokers. It was also found in patients diagnosed with stage II, III or IV cancer, those receiving chemotherapy treatment only or with surgery, and for patients who had partial cancer remission.
Concerning the fatalism subscale, no difference of statistical significance was found for patients in any age group, whereas a significant difference was present for males, for non-smokers, for patients diagnosed with stage III cancer, for those who received chemotherapy treatment only, and for patients who had partial cancer remission.
With respect to the avoidance subscale, a difference of statistical significance was found in patients from all age groups, from both sexes, for smokers and non-smokers, for patients diagnosed with any stage of cancer, for those receiving any type of treatment, and for patients who had their disease progress, partially or, completely remiss.
Response shift results:
Response shift: Response shift was not shown in the cancer patients’ questionnaire responses throughout the 6 months study period for different subscales comprising both positive and negative ones where all of the five subscales (fighting spirit, anxious preoccupation, fatalism, and avoidance) showed a significant difference according to Friedman’s test, which meant that changes occurred throughout the study since all of the subscales showed significance with a p-value of 0.000 each; except for the fatalism subscale which had a p-value of 0.013.
Conclusion
It could be concluded from the study that:
• According to Friedman’s test, a significant difference was found between different time points for all of the five subscales constituting the MAC scale which showed that no response shift phenomenon was present.
• Cancer patients’ psychological adaptation to the disease was shown in the manner through which positive and negative subscales changed over time during the 6 months course of the study.
• The MAC questionnaire showed adequate validity and reliability.
Recommendations
Psycho-social support for those who have been diagnosed with cancer, through-out the treatment and after recovery by healthcare professionals, patients’ families and the community to help in providing a better quality of life for the patients.
Psychosocial care could be achieved by:
o Providing clear and appropriate information about psychosocial service and knowledge about types of psychosocial interventions.
o Offering proper psychosocial support by members of the treatment team and by groups outside of it for cancer patients.
o Providing suitable referral to specialized physical and psychological services for patients experiencing distress as a result of physical symptoms.
o Setting strategies by health professionals for properly informing the cancer patients and their families about their disease, their treatment options, and prognosis.
o Providing information about practical and financial support for patients with cancer particularly those from rural and remote settings.
o Supporting the use of different validated PROMs to help assess the patients’ psychological state and better evaluate any interventions applied.
o Screening for psychosocial healthcare needs should be done for patients and families at their initial visit to a cancer treatment facility and at intervals throughout their cancer care trajectory, particularly with changes in disease status.