[[alternative]]Longitudinal Study on Physiological, Psychological and Social Coping Responses and Holistic Adjustment Among Breast Cancer Patients

[[abstract]]現今乳癌的診斷與治療有所進展，幫助病人存活期延長，也使癌症逐漸轉變成慢性疾病的一類，醫療照護的目標不僅著重存活率的追蹤，還須強調病人與癌症共存的適應及罹癌後的生活品質。癌症疾病具隱晦不明的特性，乳癌患者在各治療階段皆會面臨身心壓力，影響疾病適應與生活品質。 本研究採用質性與量性研究，探討乳癌病人從診斷罹患癌症，經過治療的歷程追蹤了解病人之生活與癌症適應經驗；並分別探討心理健康狀態、害怕癌症復發感受、自我調適對癌症生活品質之中介影響因素及預測因素。研究分二階段進行，第一階段採用質性研究，訪談乳癌病人(N=17位)之罹病與治療歷程的生活經驗。第二階段進行縱貫性重複測量，收集北部某醫學中心門診及住院的乳癌病人，分別於確立診斷為乳癌到治療前(Time 1)、接受治療的第六個月(Time 2)、接受治療第十二個月(Time 3)，以結構性問卷收集資料，包括人口學資料、華人健康量表(Chinese health questionnaire-12, CHQ-12)、癌症存活者顧慮量表(Assessment of Survivor Concern, ASC)、自我調適量表(Self-Regulation；SR)及乳癌生活品質量表(Functional Assessment of Cancer Therapy: Breast Cancer, FACT-B)。 第一階段質性研究結果，有三個範疇包含六個主題，範疇一掙扎乳癌的命定，包含覺察被傷害和不合理的處境、轉換疾病與生命角色二個主題；範疇二尋找力量渡過治療的苦煉，包含伴隨疾病的生存磨難、產生突破困境能量二個主題；範疇三與癌症銳變共存，包含癌症復發的擔憂、重新理解與聯結二個主題。第二階段縱貫性重複測量，在三個時間點病人數分別為98位、90位、及82位婦女。首先，以多元階層迴歸分析，呈現Time 1的自我調適變項可部分中介心理健康問題對乳癌後生活品質的負面影響，但自我調適變項無法中介降低害怕癌症復發對生活品質影響。再繼續以廣義估計方程式(Generalized estimating equation, GEE)進行資料分析，同時分析個人基本資料【病人年齡(M=54.4歲，SD＝12.39)、教育程度(49%為專科及以上程度)、就業狀況(53.1%無工作)、婚姻狀況(61.2%已婚)、居住狀況(88.8%與親友同住)、宗教信仰(74.5%有信仰)、經濟狀況(82.7%不須協助)、乳癌家族史、乳癌診斷期別、治療方式】，同時分析三次追蹤時間變項及心理健康、害怕癌症復發、及自我調適變項，以探討乳癌病人癌後生活品質之預測因素。 量性研究結果發現三個時間點均有近五成的乳癌病人有潛在情緒精神障礙，多會出現身體不適、睡眠不好、憂鬱及家庭關係不良等問題。害怕癌症復發呈現有一點擔心癌症復發且隨三時間點有顯著逐漸下降的反應。罹患乳癌後生活品質隨著三個時間點略有增加，但三時間點並未達顯著差異；其中，社交家庭、功能及情緒的生活品質在Time 2有顯著下降的趨勢。病人心理健康狀態、害怕癌症復發與乳癌後生活品質有顯著的負相關，但自我調適與乳癌後生活品質有顯著正相關。癌後病人生活品質的預測因子為教育程度、診斷期別、治療方式，心理健康及其身體症狀、焦慮及擔心、睡眠狀況、憂鬱及家庭關係不良向度，自我調適及其達到滿意與幸福感構面，以及害怕癌症復發。不同治療時間點對癌後生活品質不具顯著預測力。 由以上質量性結果，反應癌症病人罹癌後之生活品質不具明確的時間階段軌跡，病人承受癌症隱晦不明的疾病特性，乳癌病人在各治療階段皆會面臨身心壓力，影響疾病適應與生活品質。質量性研究結果可作為臨床照護乳癌病人之參考，提醒專業人員提供醫療照護時，應評估病人面對罹癌壓力所導致心理健康改變，及對疾病歷程之不同的適應經驗，病人在不同治療階段中，均會經驗新的心理壓力而需協助，因此以乳癌病人經驗發展關懷與照護，協助其建立因應疾病治療歷程的自我調適策略，使其調節癌後生活品質與功能。[[abstract]]Advances in the diagnosis and treatment of breast cancer have helped prolong the survival of patients, and have gradually transformed it into a type of chronic disease. The goal of medical care is not only to monitor survival rates but also to strengthen the patient’s adaptation to coexisting with cancer and improve their quality of life after diagnosis. Cancer has obscure characteristics, and breast cancer patients face physical and psychological stress at various stages of treatment, affecting their adaptation to the disease and quality of life. This study adopted qualitative and quantitative research methods to explore breast cancer patients’ experience of adaptation to life and the disease from cancer diagnosis through the treatment process. This study also evaluated mediating and predictive factors of cancer patients’ quality of life from the perspective of physical and psychological distress, fear of cancer recurrence, and self-adjustment. The study was conducted in two phases. The first phase was the qualitative study, in which breast cancer patients (N = 17) were interviewed about their life experiences during the course of the disease and treatment. In the second phase, longitudinal repeated measures were carried out by collecting data from breast cancer outpatients and inpatients at a medical center in northern Taiwan at three time points: after diagnosed with breast cancer, but before received treatment (Time 1), at 6th month of starting treatment (Time 2), and at one year of treatment (Time 3). Structured questionnaires were used to collect data, including a demographics questionnaire, Chinese Health Questionnaire, Assessment of Survivor Concern, Self-Adjustment Scale, and Breast Cancer Quality of Life Scale. From the first phase of qualitative research, three categories with six themes were identified. Category One was the struggle with the fate of breast cancer, consisting of two themes: (1) awareness of hurt feelings and unbearable situations, and (2) changing roles in response to illness and life transitions. Category Two was finding patient empowering ones' strength to overcome weaknesses and suffering during treatment, which included two themes: (1) surviving ordeals associated with the disease and (2) generating the energy to break through difficulties. Category Three was coexisting with the changing of cancer, which included two themes: (1) fear of cancer recurrence and (2) recognition about cancer and life, and reconstruction life after cancer. In the second phase of longitudinal repeated measures, the number of women participating at the three time points was 98, 90, and 82, respectively. The multi-level regression analysis showed that self-adjustment at Time 1 partially mediated the negative impact of physiological and psychological distress on the quality of life after breast cancer diagnosis. However, self-adjustment could not mediate and lower the effect of fear of cancer recurrence on quality of life. Generalized Estimating Equations (GEE) were used to further analyze the data, and the demographic data were examined. The mean age of the participants was 54.4 years (SD = 12.39), and approximately half of them had an education level of junior college or above (49%) and were unemployed (53.1%). Other participant characteristics included marital status (61.2% married), living conditions (88.8% live with relatives), religious beliefs (74.5% have faith), economic status (82.7% without assistance), breast cancer family history, breast cancer diagnosis stage, and treatment methods. The variables of time, mental health, fear of cancer recurrence, and self-adjustment were analyzed to explore the predictors of breast cancer patients’ quality of life after diagnosis. Quantitative research results showed that nearly 50% of breast cancer patients had potential emotional and psychological disorders, physical discomfort, poor sleep quality, depression, and poor family relations at all three time points. The participants had a slight fear of cancer recurrence in general, and their fear decreased significantly over the three time points. After being diagnosed with breast cancer, patients’ quality of life increased slightly over time, but there was no significant difference among the three time points. Among them, the social, familial, functional, and emotional aspects of quality of life significantly declined at Time 2. Patients’ mental health status and fear of cancer recurrence was significantly negatively correlated with quality of life after diagnosis. The variable of self-adjustment was significantly positively correlated with quality of life after diagnosis. The predictors of breast cancer patients’ quality of life were education level, stage of cancer, treatment method, mental health and physical symptoms, level of anxiety and worrying, sleep quality, depression and poor family relationships, self-adjustment, the dimension of achieving satisfaction and well-being, and fear of cancer recurrence. However, the variable of follow-up month did not exemplify significant estimation in the model. The qualitative and quantitative results showed that cancer patients’ quality of life after diagnosis did not have a clear time and phase trajectory and that they suffered from the obscure and unclear characteristics of cancer. Breast cancer patients face physical and psychological distress at all stages of treatment, which affects their adaptation to the disease and quality of life. The results of this qualitative and quantitative research can be used as a reference for the clinical care of breast cancer patients, and serve as a reminder to healthcare professionals that when providing medical and nursing care, patients should be assessed for physical and psychological health changes caused by cancer and different adaptation experiences to the disease. Patients require assistance when they experience new psychological distress at different stages of treatment. The experience of breast cancer patients can be used to develop patient care programs and establish self-adjustment strategies in response to the disease treatment process so that patients can regulate and reconstruct their quality of life and life functioning after diagnosis