- Email: [email protected]
Coping and the outcome of stoma surgery
Journalof Psychosomatic Printed in Great Britain.
Research,
Vol. 32. Nos415. pp. 457-467,
1988.
0022-3999/88 $3.00 + .OO 01988 PergamonPress plc
COPING AND THE OUTCOME OF STOMA SURGERY CHRIS THOMAS.* PETER TURNER and FELICITY MADDEN (Received 15 March 1988; accepted in revised form 26 May 1988) Abstract-A prospective 12 month study of 106 subjects who underwent stoma surgery was conducted and has been described previously. Coping responses to the underlying diagnosis and to the stoma itself were assessed at 3 and 12 months post operatively and are related to,the outcome 3 years after the operation. Difficulty coping with the stoma itself was a greater determinant of later psychiatric disturbance than difficulty in coping with the illness. Physical outcome, in those with colorectal carcinoma, was influenced by coping strategies only in the males, denial over diagnosis was significantly associated with poor outcome whereas fighting spirit over the stoma was associated with a good outcome.
INTRODUCTION FOR COLORECTAL carcinoma it has Geen suggested that a number of variables are associated with survival [l-3]. These include the site of the tumour, mode of presentation, duration of symptoms, pathological staging and sex. Of these the most important, by far, is staging. No such predictors of outcome are known in inflammatory bowel disease. The influence of coping strategies on physical outcome in carcinoma of the breast has been reported by Greer et al. [4,5]. Recurrence free survival was commoner in patients who had reacted to cancer by denial or fighting spirit than amongst those patients who had responded with stoic acceptance or feelings of helplessness or hopelessness. We have reported the results of a prospective 12 month study of 106 subjects who underwent stoma surgery [6, 71. They consisted of 74 patients with cancer, 17 with colitis and 1.5 with diverticular disease. At the 3 month follow-up, 87 patients were still alive and available and 18% had moderate/severe psychiatric disturbance. Sixty-eight patients were alive and seen 12 months after surgery and 22% had moderate/severe psychiatric problems. At neither of the follow-up assessments did the diagnosis appear to influence psychiatric outcome. This group of patients provided a further opportunity to look at the effect of coping strategies on the physical and psychiatric outcome of people with physical illness. There has been a longstanding debate, in cancer surgery, concerning the relative influences on psychological outcome of such factors as: the knowledge of the diagnosis compared to the self image distortion aspects of the surgery itself. This argument is best exemplified in research on breast cancer and mastectomy [8, 91. Stoma surgery is a fitting further example of such debate. It would appear that the stoma itself can certainly cause distress and could affect outcome. This has been illustrated by Druss et al. IlO, 111, who found distress in
Department of Psychiatry, Leicester General Hospital, *Author to whom correspondence should be addressed. 457
Leicester,
U.K.
458
CHRIS THOMAS et al
post operative patients with colostomies, whether the underlying diagnosis was cancer or inflammatory bowel disease. Another study [12] showed that, in a follow up of anorectal cancer patients, there was a considerably greater amount of ‘psychological disturbance’ found in those patients with stomas compared to those that had undergone restorative surgery. For these reasons we considered it important, therefore, to differentiate the coping strategies adopted in relation to the underlying diagnosis from those relating to the stoma itself.
METHOD This study was designed to assess the psychological and social outcome of patients undergoing stoma surgery. These aspects of the study have been described in previous papers [6, 71. Patients between the ages of 21 and 70 who had been consecutively admitted to the Leicester Royal Infirmary for stoma surgery were considered for inclusion in the study, providing they spoke English and were physically and mentally capable of participating. Patients who did not give consent were obviously excluded. The patients were seen at 3 stages by the research nurse, (F.M.), firstly in the post operative period whilst still on the surgical ward (usually between 5-8 days after surgery) and then 3 and 12 months after surgery in their own homes. During these assessments, as well as formal psychiatric questionnaires, a semi-structured interview was conducted that allowed an assessment of a variety of physical, social and psychological factors. The interviews on average lasted 1h and much of this time was spent on discussing the symptoms, the diagnosis, the treatment and the functioning of the stoma. The patient’s own feelings and attitude to these issues were also sought. During the interview a variety of questions were asked and from the responses to these, as well as from spontaneous responses, the style of coping that the patient was using was judged, again by the research nurse, (F.M.). It was decided to use the same four major coping strategies described by Greer and his colleague in breast cancer patients [4]. These are:(1) denial, (2) stoic acceptance, (3) fighting spirit, (4) helplessness/hopelessness. After the first few patients had been seen it became apparent that coping strategies had to he assessed separately for the illness and for the stoma itself, as they were potentially different. The way a patient approached his illness was often at variance to the way he approached the reality of having a stoma. (See Appendix I.) Nursing staff claimed that nearly all the patients in the study had been told of their diagnoses whilst on the surgical ward. Obviously most of the patients with colitis had been suffering with their disease for some time and were well aware of the diagnosis. About one third of the cancer and some of the diverticulitis patients were admitted as acute emergencies and may not heve been aware of the diagnosis pre-operatively. Although staff felt patients had been told, there was no way to actually check on this, and whether the actual diagnosis of cancer or a euphemistic term had been given to the patient. For this reason, when coping with illness was assessed, much more was taken into account than just knowledge of diagnosis. Obviously all the patients were aware they had a stoma and all were seen by the stoma nurse therapist before and/or soon after operation for discussion of its working and implications. The four types of coping strategy for both illness and the stoma are given in Appendix I. Physical outcome During the 12 months of the study the general practitioners of all patients were contacted to find out whether the patients were alive and able to be interviewed at home. All patients who had died during this 12 month period were therefore known. Two years after the last patient had been interviewed the medical notes of all patients in the study were collected. All the patients still alive were having regular contact with the surgical team and had been seen within the previous 6 months. From the notes the following information was obtained:(1) diagnosis - if cancer, the site of cancer was noted (2) operation - if cancer. had excision been total or not (3) histology - was the tumour well or poorly differentiated (4) present State of the Patient - if alive any evidence of spread or recurrence of cancer. If dead what was the cause of death, was it cancer related or other.
Outcome of stoma surgery
359
RESULTS
122 patients were considered for this study. However, three refused to cooperate, three could not speak English and 10 were too physically ill to be able to participate. These people were not followed up further. 106 patients were seen in the study but the first five did not have coping for illness and stoma assessed separately and were therefore excluded from the analyses. A total of 101 patients were seen in the immediate post-operative period following stoma surgery to assess which coping style they were using for both their illness and the stoma itself. Of these patients 68 (67.3%) had cancer, 17 (16.8%) colitis, and 16 (15.8%) diverticular disease. Fewer patients were seen at 3 months (n = 83) and at 12 months (n = 66) after surgery. The reason for the reduction in numbers of subjects was due to the deaths of 30 people (all from the cancer group), and 5 who declined further interviews (two with cancer, two with colitis and one with diverticular disease). On each occasion a small number of patients could not be classified as to coping style. Coping styles At all times denial and stoic acceptance predominate as the coping style used in physical illness. There is a gradual lessening of the use of denial over the 12 month period but this was not statistically significant. There is much less use of denial for the stoma than for the illness at all assessments and there is a reduction in the use of denial in the stoma after the immediate post-operative period. Coping and diagnosis At none of the three different assessments was any significant difference found in the coping styles used by the patients with colitis and diverticular disease, and therefore the patients with these diagnoses are combined into a total non-cancer group. Table I shows the illness coping styles used by the cancer and non-cancer patients. At all times, the cancer patients use denial more and stoic acceptance less than the non-cancer patients. This difference is most marked immediately after surgery (denial vs stoic acceptance vs rest x2 = 20.33; df = 2; p = < 0.005), still present at 3 months h2 = 9.74; p = < 0.01) but much less and not significant at 12 months. The coping over the stoma itself for men and women in the cancer and noncancer groups is shown in Table II. There are no significant differences in coping styles with the stoma between the cancer and the non-cancer groups. It can be seen that the non-significant increase in denial immediately after surgery compared with the later assessments is found only in the cancer patients. Coping and sociodemographic factors Age. The average age of all 101 patients was 59.5 yr (range 26-70). The average age of the cancer patients (64.1 yr) and diverticulitis patients (61.5 yr) was greater than those with colitis (41.5 yr). There was no significant difference in the ages of patients with different coping styles for illness in either the cancer or non-cancer group at any of the three assessments.
*Corrected
percentages
Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain Replaced
Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
after excluding
IO 34 16 7 1
patients
(14.7%) (50%) (23.5%) (10.3%) (1.8%) -
cancer(n68) (3%) (42.4%) (36.4%) (15.2%) (3%) -
with replaced
1 14 12 5 1
non-cancer 27 14 7 3
(51.Y%) (26.9%) (13.5%) (5.8%) -
1 (1.9%)
(n52)
22 (42.3%) 19 (34.5%) 6 (11.5%) I (1.9%) 4 i7.7%)
cancer
DIAGNOSIS
0 14 9 7 1 (45.2%) (29%) (22.6%) (3.2%) -
(n31)
12 I 4 1 12
0 (33.3%) (19.4%) (11.1%) (2.8%) (33.3%)
cancer
3 (9.7%) 17 (54.8%) 6 (19.4%) 2 (6.S%) 3 (9.7%)
non-cancer
3112
non-cancer(n31)
3112
ANDDIAGNOSIS
(n52)
COPING
cancer
stomas.
(n33)
TABLE IL-STOMA Time 0
(n33)
COPING AND
3 (Y.l%) 20 (60.6%) 7 (21.2%) 2 (6.1%) 1 (3%)
non-cancer
Time 0 (n68)
37 (54.4%) 17 (25%) 9 (13.2%) 3 (4.4%) 2 12.9%)
cancer
TABLE I.-ILLNESS
non-cancer (36.7%) (20%) (3.3%) (6.7%) (30%)
I (3.3%) 11 6 1 2 9
12112
4 17 6 1 2
(n30)
(4.8%)* (52.4%)* (28.6%)* (4x%)* (9.5%)*
(~30)
(13.3%) (56.7%) (20%) (3.3%) (6.7%)
non-cancer
12112 (~~36)
(33.3%) (47.2%) (11.1%) (5.6%) (2.8%)
(50%)” (29.2%)* (16.7%)* (4.2%)*
(n36)
12 17 4 2 1
cancer
?
yl 2
s
9
Outcome
of stoma
surgery
461
When coping with the stoma is examined there is a significantly younger group of patients who use fighting spirit at all 3 times following surgery. For example, immediately post operatively, the average ages of the different coping styles was denial 64.1 yr, stoic acceptance 60.5 yr, fighting spirit 44.9 yr and helplessness/ hopelessness 63.4 yr (p = < 0.05). Sex. Coping style over illness showed no significant differences between men and women at any of the assessments. A reduction in the use of denial over the one year period was, however, found to be present only in the men. Men using denial: post operatively 39.6%, at 3 months 23.7% and at 12 months 20.7%. Women using denial: post operatively 39.6%) at 3 months 35.6% and at 12 months 35.1%. At all 3 times, the coping over the stoma was more likely to be helplessness/ hopelessness in women compared with men, although this difference was only significant at the 3 and 12 month assessments. (Helplessness/hopelessness: pre operatively, men 6.3%) women 17.0% ; at 3 months, men 7.9%) women 24.4%) p = < 0.03; and at 12 months, 0% men, women 20.8%, p = < 0.03.) Marital status. Coping styles for both illness and the stoma were not different at any stage between the married and unmarried patients. Occupational status. Again, no differences in coping style was found between those patients who were employed and those who were not. Coping and psychiatric outcome A previous publication [7] discussed the psychiatric outcome of these patients over the 12 months after the stoma surgery. Of the 66 patients in this study, who were seen at 12 months, a total of 14 (21.2%) had significant levels of anxiety and/ or depression. The results were analysed to see whether coping styles used by patients immediately after surgery or 3 months later were associated with this psychiatric outcome. Coping style for illness showed a non-significant tendency for those with fighting spirit, both immediately and 3 months after surgery, to be less depressed. There was a very highly significant association between the coping with the stoma and psychiatric outcome. At the post operative assessment, 6 of the 14 patients (42.8%) who had significant psychiatric disturbance over the 12 months were using helplessness/hopelessness as a coping strategy, compared with 2 of the 52 patients (3.8%) psychiatrically well (Fishers p = < 0.001). This difference was more marked when stoma coping was assessed at 3 months with its effect on psychiatric symptoms at 12 months - 3 out of 52 (5.8%) psychiatrically well and 10 out of 14 (71.4%) with disturbance used helplessness/hopelessness (Fishers p = < 0.00001). Coping and physical outcome All of the patients with colitis or diverticular disease were alive 2 yr after stoma surgery. The slight drop in numbers of patients assessed over the 12 months was due to refusal to participate further in the study. To look at the effect coping may have on physical survival, only the patients with cancer will therefore be considered. The coping styles used immediately after and 3 months after surgery were examined to see whether they were associated with physical survival. Surveying the medical notes of the 68 cancer patients showed that at 36 months after surgery 39 (57.4%) were dead, 7 (10.3%) alive with recurrence and 22
CHRISTHOMAS~~
462
al.
(32.4%) alive with no evidence of recurrence. None of the deaths were due to illnesses other than the cancer itself. Further analyses will be made between those patients dead or alive with recurrence and those alive with no recurrence. The coping styles were examined to see whether there was any association with other factors that may determine physical outcome. There were no differences in age or sex between the patients with good outcome and those dead or with recurrence. Not surprisingly, those patients who, at the time of operation, had tumours which were incompletely excised or were poorly differentiated histologically, were much more likely to be dead or have recurrence. This was also the case for those whose tumours were of Duke’s classification C,, Czz, or who showed evidence of metastatic spread. There were no significant differences in the coping styles for either illness or the stoma immediately after surgery or 3 months later in patients with total/incomplete surgical removal or good/poor histological differentiation. There was a tendency for patients with Duke’s A or B classification to show fighting spirit in coping with their illness at both times but this only reached significance at the 3 month assessment. TAME
III.-COPING
WI-IHILLNLSSAND DLJKF'S(‘LASSIF-KAI-ION AI 3 MONIHS Duke’s
Time 3112 Denial Stoic acceptance Fighting spirit Helplessnessihopelessncss
A/B (32)
13 IO 6 0
Duke’s C,/CJor with mctastases (20) 9 9 0
I
Fisher p = 0.04
It can be seen that of the 32 patients with Duke’s A or B, 6 (18.8%) showed fighting spirit whereas none of the 20 patients with Duke’s C,, CT. or with metastases, showed this coping strategy (Fisher I_’= 0.04). Coping with the stoma showed no differences between patients with different Duke’s classifications. Table IV shows the coping styles over illness used by men and women with different physical outcome. It can be seen that patients who use denial over illness have a worse physical outcome. This is only statistically significant immediately after surgery (denial vs stoic acceptance vs rest xz = 6.8; df = 2; p = < 0.05). If the outcome is broken down into the sexes there is a marked difference between men and women. For women, there is no difference in coping styles, either over the illness or with the stoma, between those with good and those with poor physical outcome. Table V shows coping styles over illness and physical outcome in men. A poor outcome with denial is found in men. Sixteen of the 18 men (88.9%) who used denial in the post operative period either died or had recurrence, compared with only 6 of the 15 (40%) of those using other coping strategies with regard to illness, (x2 = 8.8; df = 1; p = < 0.005). Six of the 8 men (7.5%) alive at 3 months
Outcome TABLE W.-COPING
of stoma
surgery
463
WITH ILLNESSAND PHYSICALOUTCOMEAT 24-36 Dead and alive with
recurrence Time 0 Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
Alive -
Dead and alive with recurrence (30)* 15 12 1 0 2
no recurrence
(22)
(46)
30 (65.2%) 9 (19.6%) 4 (8.7%) 2 (4.3%) 1 (2.2%)
Time 3112 Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
MONTHS
7 (31.8%) 8 (36.4%) 5 (22.7%) 1 (4.5%) 1 (4.5%) ,$ = 6.8 df r = 2p = 0.05 Alive -
(50%) (40%) (3.3%)
no recurrence
7 7 5 1 2
( 6.7%)
(22)
(31.8%) (31.8%) (22.7%) (4.5%) (9.1%) NS
*16 patients
died before
the 3 month
TABLE V.-COPING
assessment.
WITH ILLNESSAND PHYSICALOUTCOMEIN MALES Dead and alive with
recurrence Time 0 Denial Other coping
styles
16 (72.7%) 6 (27.3%)
Dead and alive with recurrence (13) Time 3/12 Denial Other styles
Alive -
no recurrence
(11)
(22) 2 (18.2%) 9 (81.8%) x2 = 8.8 df = 1 p = < 0.005 Alive -
6 (46.2%) 7 (53.8%)
no recurrence
(11)
2 (18.2%) 9 (81.8%) Fisher p = 0.08
who were then using denial either died or had recurrence at follow-up, compared with 7 of the 16 (43.8%) who used other strategies (Fishers p = 0.08). Table VI shows coping styles with the stoma and physical outcome in men. The use of fighting spirit to cope with the stoma is associated with better physical outcome. Four of the 7 (57.1%) using this post operatively were alive and well, compared with only 7 of the 26 (26.9%) using other strategies. This just failed to reach significance. At 3 months, the difference is significant, 8 of 9 (88.9%) men alive at this time who used fighting spirit did well, compared with only 3 of the 15 (20%) with other forms of coping with the stoma (p = < 0.002). DISCUSSION
Although this was a prospective study, it was unfortunately patients prior to the stoma formation. Many such procedures
not possible to assess had been undertaken
464
CHRISTHOMAS~~
al.
TABLEVI.-COPINGWITHSTOMASANDPHYSICALOUTCOMEINMALES Dead and alive with recurrence (22) Time 0 Fighting spirit Other styles
3 (13.6%) 19 (86.4%)
Dead and alive with recurrence (13) Time 3/12 Fighting spirit Other styles
Alive -
1 (7.7%) 12 (92.3%)
Alive -
no recurrence
(11)
4 (36.4%) 7 (63.6%) Fishers
p = 0.09
no recurrence
(11)
8 (72.7%) 3 (27.3%) Fishers
p = 0.002
as emergencies. A pre operative assessment of coping styles would have, nevertheless, been desirable methodologically. The original coping strategies as described by Greer et al. [4] are, in the passage of time, being modified and superseded. A greater level of sophistication and definition in the description and assessment of coping strategies is being developed. It is hoped that this will lead to a more accurate assessment of the psychological impact of surgery [13]. We opted to use the original four classes of ‘coping style’ as described by Greer because, despite the criticisms about their temporal stability, they are simple to use and easily understood. It was originally expected that an overall coping style could be made for each individual patient. It quickly became apparent, however, that the same patients might adopt quite different strategies for dealing with the illness and for dealing coping style was assessed with the fact of having a stoma. For this reason, separately for the illness and the stoma. There are many stresses to be faced by patients with illness and it is quite feasible that there may be different strategies adopted for each of them. In assessing outcome of physical illness it will be important in future studies to assess the coping style used by patients with different aspects of the illness. The assessment of coping styles was made during interviews with the patients in the few days after operation and 3 months later. The psychological outcome was also assessed at interviews with patients one year following surgery. In assessing the physical outcome 3 yr after diagnosis, reliance was placed on surgical case notes and the patients were not re-interviewed. It is possible that further recurrence of cancer or even death had occurred since the last entry in the case notes. As the case note review in all cases had been within a few weeks of the last entry it was hoped this would not be a significant error. The results show that with the illness itself there were two major coping styles adopted; denial and stoic acceptance. With the stoma itself the most common styles were stoic acceptance or fighting spirit. Denial is less often seen with the stoma as it is presumably more difficult to deny a physical reality that is visibly present than an Although the staff claimed all underlying bodily lesion such as a carcinoma. patients had been told the diagnosis, this was difficult to verify. It is possible that if a diagnosis had not been communicated, either at all or in very euphemistic terms,
Outcome
of stoma surgery
465
then this could lead to the development of denial. Another factor that may influence the use of denial is that surgical staff might discourage patients asking questions or seeking information about their diagnoses and this could lead to the development of denial as a coping strategy. It cannot be definitely concluded therefore that, as a coping style, denial must purely be determined by personal factors. Denial over illness was more commonly seen in the cancer group compared with the non-cancer sufferers. It is possible that this style of coping is more rarely provoked by non-cancerous illnesses, as they carry less personal threat to the individual than cancer and the need to deny is thus less. Also the staff are perhaps more likely to give full information and encourage questions in non-cancerous disorders. A further explanation may be that the non-cancerous illnesses are more likely to have been present for a longer time prior to surgery than the cancers, and that adjustment to the illness would have occurred over this period. Therefore in the non-cancerous group any initial use of denial as a way of coping with their illness would have passed. Over the period of the study there was a gradual reduction of denial in the cancer group. Although at first sight this would seem to confirm the fact that denial may lessen over time since diagnosis, further analysis provides a different explanation. The results show that the reduction of denial was only seen in the males and that it was due to the fact that the males who use denial as a coping strategy had considerably increased chances of dying of their illness. The reduction of denial is thus not due to its reduced use, but to the fact that those men are no longer alive. The coping strategies used for the stoma remained largely consistent over time and there was no major difference between cancer and non-cancer patients. One significant finding was that females were more likely than males to show a helpless/ hopeless coping strategy. This perhaps indicates that women find it more difficult to tolerate body image disturbances than men. Psychiatric outcome was related more to the ability to cope with the stoma itself than the illness. Patients who had adopted the helpless/hopeless strategy, both immediately post operatively and 3 months after surgery, were much more likely to have serious psychiatric symptoms one year after surgery. It is impossible to be certain as to whether it is the coping style that influences psychiatric outcome or vice versa. It is possible that if someone is depressed then they are much more likely to view their stoma in very pessimistic terms. There is certainly evidence from our previous work [7] to suggest that people with psychiatric disturbance at 12 months had suffered their symptoms from an early stage post operatively. Thus at the time the coping style was assessed they may already have had psychiatric disturbance. When physical outcome is considered it is only the males where associations were found. Denial of the illness predicted a poor outcome, particularly immediately following surgery. There was also an association between fighting spirit with the stoma as a better physical prognosis. It is difficult to explain why there should be a sex difference in physical outcome and coping strategies. It is possible that this is a spurious finding and that a larger study with more patients might show no difference. It could be suggested that patients with the most serious cancers and poor prognosis were more likely to receive communications from the surgical staff
466
CHRIS THOMAS et al.
that encouraged denial. It is difficult, however, to see why this should occur in men and not women. An alternative suggestion might be that surgical staff assume that men are more able to take bad news and therefore could possibly have informed the men of their poor prognosis at a very early stage. A sudden awareness of likely death could then lead to the use of denial in the early stages. It is of interest that in Greer’s study with women with breast cancer [4] denial had quite the opposite effect than in our males and predicted recurrence free survival. It is therefore possible that coping strategies may influence different illnesses in different ways. There is a considerable interest in the effect on cancer of various psychological states at the current time, but before any definite conclusions can be drawn considerably more research needs to be conducted in this area with different illnesses and perhaps larger numbers of patients. Acknowledgements-This research was carried out with a grant from the Trent Regional Research Committee. Our thanks must be expressed to all the Consultant Surgeons and the nursing staff who allowed us access to their patients. Thanks to Dr Stephen Greer for his helpful comments on the preparation of this paper.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
POLISSAR L, SIM D, PHIL M, FRANCIS A. Survival of colorectal cancer patients in relation to duration of symptoms and other prognostic factors. Dis Colon Rectum 1981; 24: 364-369. PESCATORI M, MARIA G, BELTRANI B, MATTANA C. Site, emergency, and duration of symptoms in the prognosis of colorectal cancer. Dis Colon Rectum 1982; 25: 3330. CHUNG CK, ZANINO RJ, STRYKER JA. Colorectal carcinoma: evaluation of histologic grade and factors influencing prognosis. J Surg Uncol 1982; 21: 143-148. GREER S, MORRIS T, PETUNGALE KW. Psychological response to breast cancer: effect on outcome. Lancet 1979; ii: 785-787. PE~INGALE KW. Coping and cancer prognosis. J psychosom Res 1984; 28: 363-364. THOMAS C, MADDEN F, JEHU D. Psychosocial morbidity in the first three months following stoma surgery. J psychosom Res 1984; 2% 251-257. THOMASC. MADDEN F. JEHU D. Psychosocial morbidity . one year after stoma surgery. Jpsychosom . -. Res 1987; il: 311-316. STEINBERG MD, JULIANO MA, WISE L. Psychological outcome of lumpectomy versus mastectomy in the treatment of breast cancer. Am J Psychiat 1985; 142: 34-39. STEHLIN JS, EVANS RA, GUTIERREZ AE, COWLES J, DE IPOLYI PD, GREEFE PJ. Treatment of carcinoma of the breast. Surg Gynaec Obstet 1979; 149: 912-97.2. DRUSS RG, O’CONNOR JF, PR~JDDEN JF, STERN IO. Psychologic response to colectomy. Archs gen Psychiat 1968; 18: 53-59. DRUSS RG. O’CONNOR JF. PRUDDEN JF, STERN IO. Psychologic response to colectomy-II Adjustmen; to a permanent colostomy. Archs gen Psychia; 1969;20: 419427. DEVLIN HB. PLANT JA. GRIFFIN M. Aftermath of surgery I _ for anorectal cancer. Br med J 1971; 3: 413-418. MORRIS T, BUCKLEY M, BLAKE SM. Defining psychological responses to a diagnosis of cancer. In Psychological Aspects of Cancer (Edited by WATSON M, MORRIS T). Oxford: Pergamon Press, 1984.
APPENDIX
1: COPING
STRATEGIES
Coping with illness Denial. Patients in this group showed a reluctance to gain knowledge of their illness, whatever it was. A few had been told the diagnosis and refused to accept it, believing the doctor had made a mistake. Other patients claimed there was no possibility the illness was serious and they were completely cured.
Outcome
of stoma surgery
467
They had the general attitude of not wanting to be involved with their illness and were happy to leave it in other people’s hands. Stoic acceptance. Patients with this strategy accepted the diagnosis or at least potential seriousness of their condition. They were generally fatalistic believing that there was little they could do about it now it was present and only time would tell as to whether they would recover or not. There was a general belief in taking each day as it comes and not thinking too far into the future. They were happy to be provided with information but did not actively seek more for themselves. Fighting spirit. These patients believed they had some personal control over the cause of their illness and could potentially ‘master it’. They wanted to know the diagnosis and prognosis so that they knew what they had to fight. They often sought further information by asking questions of surgical staff or through written material. Helplessness/hopelessness. These patients felt that recovery was highly unlikely. They were often greatly distressed by their illness and felt that the disease was almost certain to progress. They felt that neither they nor the medical staff had any control over it and that it would progress whatever was done to them. Coping with the stoma Denial. These patients did not wish to discuss their stomas - feeling that it would only be present for a very short period and could be left entirely to be managed by the staff, they felt they would never need to know anything about it. Stoic acceptance. As with illness there was a sense of fatalism about the stoma. It was there now and they just had to manage as best they could. Often they did not wish to think about it, or talk about it, and tried to forget it as much as possible, but they did expect to look after it and learn to live with it, and they accepted that the stoma would be part of their life. Fighting spirit. Again these patients had a feeling of personal control and mastery. They felt they would eventually train their stoma to work when they wanted it to. They often wanted information and asked about stoma associations or to see other sufferers. They saw the stoma as not interfering with other aspects of their life and felt they would carry on all their usual normal activities. Helplessness/hopelessness. Patients in this category saw the stoma as a devastating blow to their existence. They felt that it would greatly restrict their activities and that they would never be able to learn to live with it. They predicted endless problems and felt the stoma would ruin their lives.
Research,
Vol. 32. Nos415. pp. 457-467,
1988.
0022-3999/88 $3.00 + .OO 01988 PergamonPress plc
COPING AND THE OUTCOME OF STOMA SURGERY CHRIS THOMAS.* PETER TURNER and FELICITY MADDEN (Received 15 March 1988; accepted in revised form 26 May 1988) Abstract-A prospective 12 month study of 106 subjects who underwent stoma surgery was conducted and has been described previously. Coping responses to the underlying diagnosis and to the stoma itself were assessed at 3 and 12 months post operatively and are related to,the outcome 3 years after the operation. Difficulty coping with the stoma itself was a greater determinant of later psychiatric disturbance than difficulty in coping with the illness. Physical outcome, in those with colorectal carcinoma, was influenced by coping strategies only in the males, denial over diagnosis was significantly associated with poor outcome whereas fighting spirit over the stoma was associated with a good outcome.
INTRODUCTION FOR COLORECTAL carcinoma it has Geen suggested that a number of variables are associated with survival [l-3]. These include the site of the tumour, mode of presentation, duration of symptoms, pathological staging and sex. Of these the most important, by far, is staging. No such predictors of outcome are known in inflammatory bowel disease. The influence of coping strategies on physical outcome in carcinoma of the breast has been reported by Greer et al. [4,5]. Recurrence free survival was commoner in patients who had reacted to cancer by denial or fighting spirit than amongst those patients who had responded with stoic acceptance or feelings of helplessness or hopelessness. We have reported the results of a prospective 12 month study of 106 subjects who underwent stoma surgery [6, 71. They consisted of 74 patients with cancer, 17 with colitis and 1.5 with diverticular disease. At the 3 month follow-up, 87 patients were still alive and available and 18% had moderate/severe psychiatric disturbance. Sixty-eight patients were alive and seen 12 months after surgery and 22% had moderate/severe psychiatric problems. At neither of the follow-up assessments did the diagnosis appear to influence psychiatric outcome. This group of patients provided a further opportunity to look at the effect of coping strategies on the physical and psychiatric outcome of people with physical illness. There has been a longstanding debate, in cancer surgery, concerning the relative influences on psychological outcome of such factors as: the knowledge of the diagnosis compared to the self image distortion aspects of the surgery itself. This argument is best exemplified in research on breast cancer and mastectomy [8, 91. Stoma surgery is a fitting further example of such debate. It would appear that the stoma itself can certainly cause distress and could affect outcome. This has been illustrated by Druss et al. IlO, 111, who found distress in
Department of Psychiatry, Leicester General Hospital, *Author to whom correspondence should be addressed. 457
Leicester,
U.K.
458
CHRIS THOMAS et al
post operative patients with colostomies, whether the underlying diagnosis was cancer or inflammatory bowel disease. Another study [12] showed that, in a follow up of anorectal cancer patients, there was a considerably greater amount of ‘psychological disturbance’ found in those patients with stomas compared to those that had undergone restorative surgery. For these reasons we considered it important, therefore, to differentiate the coping strategies adopted in relation to the underlying diagnosis from those relating to the stoma itself.
METHOD This study was designed to assess the psychological and social outcome of patients undergoing stoma surgery. These aspects of the study have been described in previous papers [6, 71. Patients between the ages of 21 and 70 who had been consecutively admitted to the Leicester Royal Infirmary for stoma surgery were considered for inclusion in the study, providing they spoke English and were physically and mentally capable of participating. Patients who did not give consent were obviously excluded. The patients were seen at 3 stages by the research nurse, (F.M.), firstly in the post operative period whilst still on the surgical ward (usually between 5-8 days after surgery) and then 3 and 12 months after surgery in their own homes. During these assessments, as well as formal psychiatric questionnaires, a semi-structured interview was conducted that allowed an assessment of a variety of physical, social and psychological factors. The interviews on average lasted 1h and much of this time was spent on discussing the symptoms, the diagnosis, the treatment and the functioning of the stoma. The patient’s own feelings and attitude to these issues were also sought. During the interview a variety of questions were asked and from the responses to these, as well as from spontaneous responses, the style of coping that the patient was using was judged, again by the research nurse, (F.M.). It was decided to use the same four major coping strategies described by Greer and his colleague in breast cancer patients [4]. These are:(1) denial, (2) stoic acceptance, (3) fighting spirit, (4) helplessness/hopelessness. After the first few patients had been seen it became apparent that coping strategies had to he assessed separately for the illness and for the stoma itself, as they were potentially different. The way a patient approached his illness was often at variance to the way he approached the reality of having a stoma. (See Appendix I.) Nursing staff claimed that nearly all the patients in the study had been told of their diagnoses whilst on the surgical ward. Obviously most of the patients with colitis had been suffering with their disease for some time and were well aware of the diagnosis. About one third of the cancer and some of the diverticulitis patients were admitted as acute emergencies and may not heve been aware of the diagnosis pre-operatively. Although staff felt patients had been told, there was no way to actually check on this, and whether the actual diagnosis of cancer or a euphemistic term had been given to the patient. For this reason, when coping with illness was assessed, much more was taken into account than just knowledge of diagnosis. Obviously all the patients were aware they had a stoma and all were seen by the stoma nurse therapist before and/or soon after operation for discussion of its working and implications. The four types of coping strategy for both illness and the stoma are given in Appendix I. Physical outcome During the 12 months of the study the general practitioners of all patients were contacted to find out whether the patients were alive and able to be interviewed at home. All patients who had died during this 12 month period were therefore known. Two years after the last patient had been interviewed the medical notes of all patients in the study were collected. All the patients still alive were having regular contact with the surgical team and had been seen within the previous 6 months. From the notes the following information was obtained:(1) diagnosis - if cancer, the site of cancer was noted (2) operation - if cancer. had excision been total or not (3) histology - was the tumour well or poorly differentiated (4) present State of the Patient - if alive any evidence of spread or recurrence of cancer. If dead what was the cause of death, was it cancer related or other.
Outcome of stoma surgery
359
RESULTS
122 patients were considered for this study. However, three refused to cooperate, three could not speak English and 10 were too physically ill to be able to participate. These people were not followed up further. 106 patients were seen in the study but the first five did not have coping for illness and stoma assessed separately and were therefore excluded from the analyses. A total of 101 patients were seen in the immediate post-operative period following stoma surgery to assess which coping style they were using for both their illness and the stoma itself. Of these patients 68 (67.3%) had cancer, 17 (16.8%) colitis, and 16 (15.8%) diverticular disease. Fewer patients were seen at 3 months (n = 83) and at 12 months (n = 66) after surgery. The reason for the reduction in numbers of subjects was due to the deaths of 30 people (all from the cancer group), and 5 who declined further interviews (two with cancer, two with colitis and one with diverticular disease). On each occasion a small number of patients could not be classified as to coping style. Coping styles At all times denial and stoic acceptance predominate as the coping style used in physical illness. There is a gradual lessening of the use of denial over the 12 month period but this was not statistically significant. There is much less use of denial for the stoma than for the illness at all assessments and there is a reduction in the use of denial in the stoma after the immediate post-operative period. Coping and diagnosis At none of the three different assessments was any significant difference found in the coping styles used by the patients with colitis and diverticular disease, and therefore the patients with these diagnoses are combined into a total non-cancer group. Table I shows the illness coping styles used by the cancer and non-cancer patients. At all times, the cancer patients use denial more and stoic acceptance less than the non-cancer patients. This difference is most marked immediately after surgery (denial vs stoic acceptance vs rest x2 = 20.33; df = 2; p = < 0.005), still present at 3 months h2 = 9.74; p = < 0.01) but much less and not significant at 12 months. The coping over the stoma itself for men and women in the cancer and noncancer groups is shown in Table II. There are no significant differences in coping styles with the stoma between the cancer and the non-cancer groups. It can be seen that the non-significant increase in denial immediately after surgery compared with the later assessments is found only in the cancer patients. Coping and sociodemographic factors Age. The average age of all 101 patients was 59.5 yr (range 26-70). The average age of the cancer patients (64.1 yr) and diverticulitis patients (61.5 yr) was greater than those with colitis (41.5 yr). There was no significant difference in the ages of patients with different coping styles for illness in either the cancer or non-cancer group at any of the three assessments.
*Corrected
percentages
Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain Replaced
Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
after excluding
IO 34 16 7 1
patients
(14.7%) (50%) (23.5%) (10.3%) (1.8%) -
cancer(n68) (3%) (42.4%) (36.4%) (15.2%) (3%) -
with replaced
1 14 12 5 1
non-cancer 27 14 7 3
(51.Y%) (26.9%) (13.5%) (5.8%) -
1 (1.9%)
(n52)
22 (42.3%) 19 (34.5%) 6 (11.5%) I (1.9%) 4 i7.7%)
cancer
DIAGNOSIS
0 14 9 7 1 (45.2%) (29%) (22.6%) (3.2%) -
(n31)
12 I 4 1 12
0 (33.3%) (19.4%) (11.1%) (2.8%) (33.3%)
cancer
3 (9.7%) 17 (54.8%) 6 (19.4%) 2 (6.S%) 3 (9.7%)
non-cancer
3112
non-cancer(n31)
3112
ANDDIAGNOSIS
(n52)
COPING
cancer
stomas.
(n33)
TABLE IL-STOMA Time 0
(n33)
COPING AND
3 (Y.l%) 20 (60.6%) 7 (21.2%) 2 (6.1%) 1 (3%)
non-cancer
Time 0 (n68)
37 (54.4%) 17 (25%) 9 (13.2%) 3 (4.4%) 2 12.9%)
cancer
TABLE I.-ILLNESS
non-cancer (36.7%) (20%) (3.3%) (6.7%) (30%)
I (3.3%) 11 6 1 2 9
12112
4 17 6 1 2
(n30)
(4.8%)* (52.4%)* (28.6%)* (4x%)* (9.5%)*
(~30)
(13.3%) (56.7%) (20%) (3.3%) (6.7%)
non-cancer
12112 (~~36)
(33.3%) (47.2%) (11.1%) (5.6%) (2.8%)
(50%)” (29.2%)* (16.7%)* (4.2%)*
(n36)
12 17 4 2 1
cancer
?
yl 2
s
9
Outcome
of stoma
surgery
461
When coping with the stoma is examined there is a significantly younger group of patients who use fighting spirit at all 3 times following surgery. For example, immediately post operatively, the average ages of the different coping styles was denial 64.1 yr, stoic acceptance 60.5 yr, fighting spirit 44.9 yr and helplessness/ hopelessness 63.4 yr (p = < 0.05). Sex. Coping style over illness showed no significant differences between men and women at any of the assessments. A reduction in the use of denial over the one year period was, however, found to be present only in the men. Men using denial: post operatively 39.6%, at 3 months 23.7% and at 12 months 20.7%. Women using denial: post operatively 39.6%) at 3 months 35.6% and at 12 months 35.1%. At all 3 times, the coping over the stoma was more likely to be helplessness/ hopelessness in women compared with men, although this difference was only significant at the 3 and 12 month assessments. (Helplessness/hopelessness: pre operatively, men 6.3%) women 17.0% ; at 3 months, men 7.9%) women 24.4%) p = < 0.03; and at 12 months, 0% men, women 20.8%, p = < 0.03.) Marital status. Coping styles for both illness and the stoma were not different at any stage between the married and unmarried patients. Occupational status. Again, no differences in coping style was found between those patients who were employed and those who were not. Coping and psychiatric outcome A previous publication [7] discussed the psychiatric outcome of these patients over the 12 months after the stoma surgery. Of the 66 patients in this study, who were seen at 12 months, a total of 14 (21.2%) had significant levels of anxiety and/ or depression. The results were analysed to see whether coping styles used by patients immediately after surgery or 3 months later were associated with this psychiatric outcome. Coping style for illness showed a non-significant tendency for those with fighting spirit, both immediately and 3 months after surgery, to be less depressed. There was a very highly significant association between the coping with the stoma and psychiatric outcome. At the post operative assessment, 6 of the 14 patients (42.8%) who had significant psychiatric disturbance over the 12 months were using helplessness/hopelessness as a coping strategy, compared with 2 of the 52 patients (3.8%) psychiatrically well (Fishers p = < 0.001). This difference was more marked when stoma coping was assessed at 3 months with its effect on psychiatric symptoms at 12 months - 3 out of 52 (5.8%) psychiatrically well and 10 out of 14 (71.4%) with disturbance used helplessness/hopelessness (Fishers p = < 0.00001). Coping and physical outcome All of the patients with colitis or diverticular disease were alive 2 yr after stoma surgery. The slight drop in numbers of patients assessed over the 12 months was due to refusal to participate further in the study. To look at the effect coping may have on physical survival, only the patients with cancer will therefore be considered. The coping styles used immediately after and 3 months after surgery were examined to see whether they were associated with physical survival. Surveying the medical notes of the 68 cancer patients showed that at 36 months after surgery 39 (57.4%) were dead, 7 (10.3%) alive with recurrence and 22
CHRISTHOMAS~~
462
al.
(32.4%) alive with no evidence of recurrence. None of the deaths were due to illnesses other than the cancer itself. Further analyses will be made between those patients dead or alive with recurrence and those alive with no recurrence. The coping styles were examined to see whether there was any association with other factors that may determine physical outcome. There were no differences in age or sex between the patients with good outcome and those dead or with recurrence. Not surprisingly, those patients who, at the time of operation, had tumours which were incompletely excised or were poorly differentiated histologically, were much more likely to be dead or have recurrence. This was also the case for those whose tumours were of Duke’s classification C,, Czz, or who showed evidence of metastatic spread. There were no significant differences in the coping styles for either illness or the stoma immediately after surgery or 3 months later in patients with total/incomplete surgical removal or good/poor histological differentiation. There was a tendency for patients with Duke’s A or B classification to show fighting spirit in coping with their illness at both times but this only reached significance at the 3 month assessment. TAME
III.-COPING
WI-IHILLNLSSAND DLJKF'S(‘LASSIF-KAI-ION AI 3 MONIHS Duke’s
Time 3112 Denial Stoic acceptance Fighting spirit Helplessnessihopelessncss
A/B (32)
13 IO 6 0
Duke’s C,/CJor with mctastases (20) 9 9 0
I
Fisher p = 0.04
It can be seen that of the 32 patients with Duke’s A or B, 6 (18.8%) showed fighting spirit whereas none of the 20 patients with Duke’s C,, CT. or with metastases, showed this coping strategy (Fisher I_’= 0.04). Coping with the stoma showed no differences between patients with different Duke’s classifications. Table IV shows the coping styles over illness used by men and women with different physical outcome. It can be seen that patients who use denial over illness have a worse physical outcome. This is only statistically significant immediately after surgery (denial vs stoic acceptance vs rest xz = 6.8; df = 2; p = < 0.05). If the outcome is broken down into the sexes there is a marked difference between men and women. For women, there is no difference in coping styles, either over the illness or with the stoma, between those with good and those with poor physical outcome. Table V shows coping styles over illness and physical outcome in men. A poor outcome with denial is found in men. Sixteen of the 18 men (88.9%) who used denial in the post operative period either died or had recurrence, compared with only 6 of the 15 (40%) of those using other coping strategies with regard to illness, (x2 = 8.8; df = 1; p = < 0.005). Six of the 8 men (7.5%) alive at 3 months
Outcome TABLE W.-COPING
of stoma
surgery
463
WITH ILLNESSAND PHYSICALOUTCOMEAT 24-36 Dead and alive with
recurrence Time 0 Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
Alive -
Dead and alive with recurrence (30)* 15 12 1 0 2
no recurrence
(22)
(46)
30 (65.2%) 9 (19.6%) 4 (8.7%) 2 (4.3%) 1 (2.2%)
Time 3112 Denial Stoic acceptance Fighting spirit Helplessness/hopelessness Uncertain
MONTHS
7 (31.8%) 8 (36.4%) 5 (22.7%) 1 (4.5%) 1 (4.5%) ,$ = 6.8 df r = 2p = 0.05 Alive -
(50%) (40%) (3.3%)
no recurrence
7 7 5 1 2
( 6.7%)
(22)
(31.8%) (31.8%) (22.7%) (4.5%) (9.1%) NS
*16 patients
died before
the 3 month
TABLE V.-COPING
assessment.
WITH ILLNESSAND PHYSICALOUTCOMEIN MALES Dead and alive with
recurrence Time 0 Denial Other coping
styles
16 (72.7%) 6 (27.3%)
Dead and alive with recurrence (13) Time 3/12 Denial Other styles
Alive -
no recurrence
(11)
(22) 2 (18.2%) 9 (81.8%) x2 = 8.8 df = 1 p = < 0.005 Alive -
6 (46.2%) 7 (53.8%)
no recurrence
(11)
2 (18.2%) 9 (81.8%) Fisher p = 0.08
who were then using denial either died or had recurrence at follow-up, compared with 7 of the 16 (43.8%) who used other strategies (Fishers p = 0.08). Table VI shows coping styles with the stoma and physical outcome in men. The use of fighting spirit to cope with the stoma is associated with better physical outcome. Four of the 7 (57.1%) using this post operatively were alive and well, compared with only 7 of the 26 (26.9%) using other strategies. This just failed to reach significance. At 3 months, the difference is significant, 8 of 9 (88.9%) men alive at this time who used fighting spirit did well, compared with only 3 of the 15 (20%) with other forms of coping with the stoma (p = < 0.002). DISCUSSION
Although this was a prospective study, it was unfortunately patients prior to the stoma formation. Many such procedures
not possible to assess had been undertaken
464
CHRISTHOMAS~~
al.
TABLEVI.-COPINGWITHSTOMASANDPHYSICALOUTCOMEINMALES Dead and alive with recurrence (22) Time 0 Fighting spirit Other styles
3 (13.6%) 19 (86.4%)
Dead and alive with recurrence (13) Time 3/12 Fighting spirit Other styles
Alive -
1 (7.7%) 12 (92.3%)
Alive -
no recurrence
(11)
4 (36.4%) 7 (63.6%) Fishers
p = 0.09
no recurrence
(11)
8 (72.7%) 3 (27.3%) Fishers
p = 0.002
as emergencies. A pre operative assessment of coping styles would have, nevertheless, been desirable methodologically. The original coping strategies as described by Greer et al. [4] are, in the passage of time, being modified and superseded. A greater level of sophistication and definition in the description and assessment of coping strategies is being developed. It is hoped that this will lead to a more accurate assessment of the psychological impact of surgery [13]. We opted to use the original four classes of ‘coping style’ as described by Greer because, despite the criticisms about their temporal stability, they are simple to use and easily understood. It was originally expected that an overall coping style could be made for each individual patient. It quickly became apparent, however, that the same patients might adopt quite different strategies for dealing with the illness and for dealing coping style was assessed with the fact of having a stoma. For this reason, separately for the illness and the stoma. There are many stresses to be faced by patients with illness and it is quite feasible that there may be different strategies adopted for each of them. In assessing outcome of physical illness it will be important in future studies to assess the coping style used by patients with different aspects of the illness. The assessment of coping styles was made during interviews with the patients in the few days after operation and 3 months later. The psychological outcome was also assessed at interviews with patients one year following surgery. In assessing the physical outcome 3 yr after diagnosis, reliance was placed on surgical case notes and the patients were not re-interviewed. It is possible that further recurrence of cancer or even death had occurred since the last entry in the case notes. As the case note review in all cases had been within a few weeks of the last entry it was hoped this would not be a significant error. The results show that with the illness itself there were two major coping styles adopted; denial and stoic acceptance. With the stoma itself the most common styles were stoic acceptance or fighting spirit. Denial is less often seen with the stoma as it is presumably more difficult to deny a physical reality that is visibly present than an Although the staff claimed all underlying bodily lesion such as a carcinoma. patients had been told the diagnosis, this was difficult to verify. It is possible that if a diagnosis had not been communicated, either at all or in very euphemistic terms,
Outcome
of stoma surgery
465
then this could lead to the development of denial. Another factor that may influence the use of denial is that surgical staff might discourage patients asking questions or seeking information about their diagnoses and this could lead to the development of denial as a coping strategy. It cannot be definitely concluded therefore that, as a coping style, denial must purely be determined by personal factors. Denial over illness was more commonly seen in the cancer group compared with the non-cancer sufferers. It is possible that this style of coping is more rarely provoked by non-cancerous illnesses, as they carry less personal threat to the individual than cancer and the need to deny is thus less. Also the staff are perhaps more likely to give full information and encourage questions in non-cancerous disorders. A further explanation may be that the non-cancerous illnesses are more likely to have been present for a longer time prior to surgery than the cancers, and that adjustment to the illness would have occurred over this period. Therefore in the non-cancerous group any initial use of denial as a way of coping with their illness would have passed. Over the period of the study there was a gradual reduction of denial in the cancer group. Although at first sight this would seem to confirm the fact that denial may lessen over time since diagnosis, further analysis provides a different explanation. The results show that the reduction of denial was only seen in the males and that it was due to the fact that the males who use denial as a coping strategy had considerably increased chances of dying of their illness. The reduction of denial is thus not due to its reduced use, but to the fact that those men are no longer alive. The coping strategies used for the stoma remained largely consistent over time and there was no major difference between cancer and non-cancer patients. One significant finding was that females were more likely than males to show a helpless/ hopeless coping strategy. This perhaps indicates that women find it more difficult to tolerate body image disturbances than men. Psychiatric outcome was related more to the ability to cope with the stoma itself than the illness. Patients who had adopted the helpless/hopeless strategy, both immediately post operatively and 3 months after surgery, were much more likely to have serious psychiatric symptoms one year after surgery. It is impossible to be certain as to whether it is the coping style that influences psychiatric outcome or vice versa. It is possible that if someone is depressed then they are much more likely to view their stoma in very pessimistic terms. There is certainly evidence from our previous work [7] to suggest that people with psychiatric disturbance at 12 months had suffered their symptoms from an early stage post operatively. Thus at the time the coping style was assessed they may already have had psychiatric disturbance. When physical outcome is considered it is only the males where associations were found. Denial of the illness predicted a poor outcome, particularly immediately following surgery. There was also an association between fighting spirit with the stoma as a better physical prognosis. It is difficult to explain why there should be a sex difference in physical outcome and coping strategies. It is possible that this is a spurious finding and that a larger study with more patients might show no difference. It could be suggested that patients with the most serious cancers and poor prognosis were more likely to receive communications from the surgical staff
466
CHRIS THOMAS et al.
that encouraged denial. It is difficult, however, to see why this should occur in men and not women. An alternative suggestion might be that surgical staff assume that men are more able to take bad news and therefore could possibly have informed the men of their poor prognosis at a very early stage. A sudden awareness of likely death could then lead to the use of denial in the early stages. It is of interest that in Greer’s study with women with breast cancer [4] denial had quite the opposite effect than in our males and predicted recurrence free survival. It is therefore possible that coping strategies may influence different illnesses in different ways. There is a considerable interest in the effect on cancer of various psychological states at the current time, but before any definite conclusions can be drawn considerably more research needs to be conducted in this area with different illnesses and perhaps larger numbers of patients. Acknowledgements-This research was carried out with a grant from the Trent Regional Research Committee. Our thanks must be expressed to all the Consultant Surgeons and the nursing staff who allowed us access to their patients. Thanks to Dr Stephen Greer for his helpful comments on the preparation of this paper.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
POLISSAR L, SIM D, PHIL M, FRANCIS A. Survival of colorectal cancer patients in relation to duration of symptoms and other prognostic factors. Dis Colon Rectum 1981; 24: 364-369. PESCATORI M, MARIA G, BELTRANI B, MATTANA C. Site, emergency, and duration of symptoms in the prognosis of colorectal cancer. Dis Colon Rectum 1982; 25: 3330. CHUNG CK, ZANINO RJ, STRYKER JA. Colorectal carcinoma: evaluation of histologic grade and factors influencing prognosis. J Surg Uncol 1982; 21: 143-148. GREER S, MORRIS T, PETUNGALE KW. Psychological response to breast cancer: effect on outcome. Lancet 1979; ii: 785-787. PE~INGALE KW. Coping and cancer prognosis. J psychosom Res 1984; 28: 363-364. THOMAS C, MADDEN F, JEHU D. Psychosocial morbidity in the first three months following stoma surgery. J psychosom Res 1984; 2% 251-257. THOMASC. MADDEN F. JEHU D. Psychosocial morbidity . one year after stoma surgery. Jpsychosom . -. Res 1987; il: 311-316. STEINBERG MD, JULIANO MA, WISE L. Psychological outcome of lumpectomy versus mastectomy in the treatment of breast cancer. Am J Psychiat 1985; 142: 34-39. STEHLIN JS, EVANS RA, GUTIERREZ AE, COWLES J, DE IPOLYI PD, GREEFE PJ. Treatment of carcinoma of the breast. Surg Gynaec Obstet 1979; 149: 912-97.2. DRUSS RG, O’CONNOR JF, PR~JDDEN JF, STERN IO. Psychologic response to colectomy. Archs gen Psychiat 1968; 18: 53-59. DRUSS RG. O’CONNOR JF. PRUDDEN JF, STERN IO. Psychologic response to colectomy-II Adjustmen; to a permanent colostomy. Archs gen Psychia; 1969;20: 419427. DEVLIN HB. PLANT JA. GRIFFIN M. Aftermath of surgery I _ for anorectal cancer. Br med J 1971; 3: 413-418. MORRIS T, BUCKLEY M, BLAKE SM. Defining psychological responses to a diagnosis of cancer. In Psychological Aspects of Cancer (Edited by WATSON M, MORRIS T). Oxford: Pergamon Press, 1984.
APPENDIX
1: COPING
STRATEGIES
Coping with illness Denial. Patients in this group showed a reluctance to gain knowledge of their illness, whatever it was. A few had been told the diagnosis and refused to accept it, believing the doctor had made a mistake. Other patients claimed there was no possibility the illness was serious and they were completely cured.
Outcome
of stoma surgery
467
They had the general attitude of not wanting to be involved with their illness and were happy to leave it in other people’s hands. Stoic acceptance. Patients with this strategy accepted the diagnosis or at least potential seriousness of their condition. They were generally fatalistic believing that there was little they could do about it now it was present and only time would tell as to whether they would recover or not. There was a general belief in taking each day as it comes and not thinking too far into the future. They were happy to be provided with information but did not actively seek more for themselves. Fighting spirit. These patients believed they had some personal control over the cause of their illness and could potentially ‘master it’. They wanted to know the diagnosis and prognosis so that they knew what they had to fight. They often sought further information by asking questions of surgical staff or through written material. Helplessness/hopelessness. These patients felt that recovery was highly unlikely. They were often greatly distressed by their illness and felt that the disease was almost certain to progress. They felt that neither they nor the medical staff had any control over it and that it would progress whatever was done to them. Coping with the stoma Denial. These patients did not wish to discuss their stomas - feeling that it would only be present for a very short period and could be left entirely to be managed by the staff, they felt they would never need to know anything about it. Stoic acceptance. As with illness there was a sense of fatalism about the stoma. It was there now and they just had to manage as best they could. Often they did not wish to think about it, or talk about it, and tried to forget it as much as possible, but they did expect to look after it and learn to live with it, and they accepted that the stoma would be part of their life. Fighting spirit. Again these patients had a feeling of personal control and mastery. They felt they would eventually train their stoma to work when they wanted it to. They often wanted information and asked about stoma associations or to see other sufferers. They saw the stoma as not interfering with other aspects of their life and felt they would carry on all their usual normal activities. Helplessness/hopelessness. Patients in this category saw the stoma as a devastating blow to their existence. They felt that it would greatly restrict their activities and that they would never be able to learn to live with it. They predicted endless problems and felt the stoma would ruin their lives.