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Gender differences in psychosocial responses to lung cancer
GENDER MEDICINE/VOL. 7, NO. 2, 2010
Gender Differences in Psychosocial Responses to Lung Cancer Joy M. Jacobs-Lawson, PhD1; Mitzi M. Schumacher, PhD2; Travonia Hughes, PhD3; and Susanne Arnold, MD4 1Graduate
Center for Gerontology, University of Kentucky, Lexington, Kentucky; 2Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky; 3Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 4Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
ABSTRACT Background: Although biologically based sex differences in the smoking patterns, epidemiology, biomedical markers, and survival rates associated with lung cancer are well documented, examinations of psychosocial gender differences are scarce. Objective: This cross-sectional study examined gender differences in psychosocial factors that are important in the medical management of lung cancer. Methods: A convenience sample of patients who were attending a multidisciplinary lung cancer treatment center (Markey Cancer Center, Lexington, Kentucky) were invited to complete a psychosocial needs assessment. Eligibility criteria included primary diagnosis of lung cancer, age ≥18 years, and being cognitively intact. Measures focused on psychosocial resources, treatment decision-making, social consequences of treatments, and treatment outcomes. Data were collected between the fall of 2005 and the summer of 2006. Results: A total of 47 women and 53 men (mean [SD] age, 62.81 [12.01] years; 95% white) completed the needs assessment. Gender was not found to be associated with demographic characteristics, time until diagnosis, treatment, or survival rate. Smoking histories differed significantly in the proportion of women and men who smoked or were former smokers (P = 0.01) as well as the age when they began to smoke (P = 0.02). There were no significant gender differences in social support networks, general coping, information needs, treatment decision satisfaction, functional health, life satisfaction, financial impact, or service needs. However, significant gender differences did indicate that women favored spiritual practices (P = 0.02) and religious coping (P = 0.04), and were more likely to endorse having a life mission (P = 0.03) and being part of a divine plan (P = 0.01). Conclusions: Previous research has found that religiousness and spirituality improved depressive symptoms and may ease end-of-life despair. In the present study of patients with lung cancer, gender differences in religiousness and spirituality suggest that this may be especially true for women, and that interventions should be directed toward their religious practices and coping. (Gend Med. 2010;7:137–148) © 2010 Excerpta Medica Inc. Key words: lung cancer, gender, psychosocial, religion, spirituality. Accepted for publication December 14, 2009. © 2010 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.genm.2010.03.002 1550-8579/$ - see front matter
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INTRODUCTION Examinations of sex differences in lung cancer have focused on the biomedical aspects of the disease. For example, Rivera and Stover1 reviewed literature on gender and lung cancer, and characterized those differences as epidemiologic, biological, hormonal, and genetic. Furthermore, sex differences have been observed in susceptibility,2,3 survival rates,4–6 and treatment.7 Little is known, however, about gender differences in the psychosocial aspects of lung cancer. To provide optimal care to patients, multidisciplinary lung cancer treatment teams— including physicians, nurses, social workers, and case managers—need as complete a picture of biomedically based sex and psychosocially based gender differences as possible. Researchers and health care professionals have called for greater attention to the psychological aspects of cancer.8–10 The goal of the present study was to examine gender differences in psychosocial reactions to lung cancer, so that we are better able to meet the needs of patients and their families. Based on the gender effects observed in literature with respect to other cancers, we focused on psychological resources, treatment decision-making, financial impact and service needs, and treatment outcomes.
Psychosocial Resources The most effective means of treating cancer patients not only focuses on medical treatment, but also addresses psychosocial distress and concerns.8–10 Studies of cancer patients and survivors have shown that women often experience higher levels of distress, depression, and anxiety.9,11–14 In an investigation of predictive factors of psychological distress in 87 lung cancer patients, utilizing questionnaire and interview-based data, Akechi et al15 reported that women were significantly more likely than men to experience 6 emotional states (ie, tension-anxiety, depression-dejection, angerhostility, vigor, fatigue, confusion) characterizing mood disturbances (P = 0.01). In a more general exploration of gender differences in psychological adjustment to cancer using data from self-report questionnaires from 34 women and 15 men, PelegOren et al16 reported that, on average, men were significantly more likely than women to experience
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paranoid ideation (P = 0.05), but in the second stage of cancer, women had significantly higher mean somatization scores than did men (P = 0.05). In a larger study (n = 4496) examining distress by cancer site, including lung cancer, Zabora et al17 failed to find gender differences in distress for the sample. Understanding how men and women cope with distress is critical to being able to provide optimal treatment. Most research on cancer and social support has reported significant gender differences. Several studies have found that women were more likely to seek support than were men.18–20 Women may more actively seek social resources because men believe that their current level of support is sufficient. For instance, in a study of 82 head and neck cancer patients, men reported significantly higher levels of perceived social support than did women (P = 0.01),12 but a study of 150 cancer patients aged ≥75 years found that women were significantly more likely to report having felt lonely compared with men (68.0% vs 56.0%, respectively; P = 0.01).21 Although Peleg-Oren et al16 failed to find gender differences in cancer patients’ social resources, McIllmurray et al22 found significant gender differences in the types of resources desired (N = 402; P < 0.05). It has been reported that both relying on religion and finding meaning in chronic illnesses,23 including cancer, are beneficial. In a study of 276 patients with advanced cancer, McClain-Jacobson et al24 found that belief in an afterlife was associated with significantly lower levels of hopelessness (P < 0.01), suicide ideation (P = 0.03), and desire for a hastened death (P = 0.03). However, once spiritual well-being was taken into account, these relationships were no longer significant, which suggests the importance of spirituality in coping with cancer. Religion has also been found to serve as a buffer from depression among women diagnosed with breast cancer,25 and furthermore, women were more likely than men to utilize it as a resource for coping with cancer.19
Treatment Decision-Making One area of research that has recently received increased attention is patients’ preferences regard-
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ing treatment decision-making. Studies of both breast and prostate cancer patients have reported that patients were most satisfied when their actual level of involvement matched their desired level of involvement in the treatment decision.26,27 In a gender-based study of colorectal cancer patients, men (n = 102) and women (n = 73) did not differ in terms of how important they believed the decision process was; however, women indicated that they wanted to be more involved with their treatment decisions (27% of women vs 24% of men), whereas men preferred to have the surgeon make the decision (32% of men vs 19% of women).28 Gender differences have also emerged in terms of the amount and type of information sought regarding cancer and cancer treatments.18,22,29,30 Other research has found that gender was related to fears about cancer and outcomes,30 but not to how worried long-term cancer survivors were about the cancer returning.11
Social Consequences of Treatment Relative to other areas of adjustment and coping, the social consequences of treatment, in particular, the financial impact and service needs of lung cancer patients, have received less attention. A study examining the lasting effects of treatment on employment found that during treatment, colon and lung cancer patients were the most likely to reduce their workload, women with lung cancer were less likely than their male counterparts to be working after treatment, and gender was related to spouses’ employment status.31 In addition, male lung cancer survivors’ spouses were more likely to be employed than were female survivors’ spouses. Onakoya et al32 found that, regardless of gender, most head and neck cancer patients (96.2%) had to stop working during treatment. Other studies have reported that 17% to 30% of terminal cancer patients used all their savings in managing their illness,33 and that women aged ≥75 years with cancer had fewer economic resources than did older men with cancer.21 Although cancer can have a profound impact on financial resources, it is not clear whether this differs for women and men with lung cancer. Several studies have suggested that one means of reducing the financial expenses associated with
cancer is for patients and their families to utilize more of the services and resources available.10,34 Most cancer patients and their families do not use these resources,35 and those who do are more likely to be women8 or to have breast or prostate cancer.9
Treatment Outcomes as Measured by Quality of Life and Health Two cancer studies reported that women and men were similar in terms of general life satisfaction, overall life satisfaction, and health-related quality of life (QoL).12,36 However, Thomé and Hallberg21 found that among adults aged ≥75 years with cancer, women (n = 74) reported a significantly lower QoL than did men (n = 76) (P < 0.01). Gender differences have also emerged with respect to the impact that cancer and its treatment have on patients’ QoL: whereas women tended to focus more on psychological well-being, men were more often concerned about physical functioning.37 Much of the current literature on psychosocial aspects of adjustment and outcomes associated with cancer is limited in that the studies focus on a gendered cancer (eg, breast or prostate25,26), lack sufficient sample sizes within each type of cancer to conduct gender-based cancer-site analyses, or do not report findings based on gender and site.9,19 Of those that have examined gender differences in psychosocial adjustment by cancer site, most have focused on colorectal cancer,28,30 not lung cancer. Given the severity of this disease and the devastating impact that it can have on individuals,38 as well as our awareness of gender differences in the biomedical aspects and treatment and in coping with respect to other types of cancer, we would be remiss if we did not examine the role of gender in lung cancer. Doing so will offer insights for physicians and health care professionals as to how we can develop the means to most effectively meet the psychosocial needs of women and men with lung cancer.
METHODS Study Design A cross-sectional design required participants to answer questions in a one-time individual interview at their convenience during a scheduled clinic
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visit at the Markey Cancer Center, Lexington, Kentucky, between the fall of 2005 and the summer of 2006. The study was approved by the University of Kentucky Medical Institutional Review Board.
Participants Patients attending a multidisciplinary treatment team clinic for lung cancer were asked if they might be interested in talking to a researcher about the needs of lung cancer patients. Patients were comfortable with refusing to participate, and not all met the inclusion criteria, which comprised a primary diagnosis of lung cancer, age ≥18 years, and being cognitively intact as determined by the nursing staff. Those interested were introduced to an investigator who explained the nature of the study, answered questions, and obtained written informed consent. One hundred and thirty-six consecutive patients who arrived at their appointment on time were approached, and 100 patients subsequently participated (~74% recruitment rate). Of those who did not participate, 20 were ineligible due to having a cancer other than lung, 6 declined, and 10 stated they were too ill to participate.
Assessment Instrument Demographic questions assessed age, sex, race, marital status, number of living children, education, income, employment status, and occupation. Treatment history questions inquired when patients first suspected a problem, made their first appointment with a general practitioner or specialist, made their first appointment at a cancer center, and began treatment, as well as what type of treatment they underwent. After responding whether they currently, previously, or never smoked, the current and previous smokers were asked how much they smoked, the age when they began to smoke, and whether they had quit and at what age. Psychosocial measures assessed social support, religiousness and spirituality, coping, information needs, treatment decision satisfaction, worries, financial impact and social service needs, functional health, well-being, life satisfaction, and perspectives on a “good death.” Psychosocial resources for managing treatment included social network, religious and spiritual
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coping, religious support, and effective coping. The Lubben Social Network Scale was used to assess the number and frequency of contacts with others, as well as the nature of relationships with relatives and friends.39 A score (a higher score represents a greater social network) was derived from a mean of the 6-point response scales for 9 items (coefficient α = 0.71). The Social Network Scale is commonly used as a screening tool for older adults at risk for social isolation. The Coping Effectiveness Scale, developed by Gottlieb and Rooney,40 measured respondents’ perceptions of the effectiveness of their coping with challenging health situations. The score (a higher score represents more effective coping) was a mean of 5-point ratings for 7 items (coefficient α = 0.45). Scores on this measure predict scores on the mental health subscale of the RAND measure of QoL (also known as the 36-item Short Form Health Survey).41 Aspects of religiousness and spirituality most likely to be related to the course of treatment for lung cancer were assessed using 3 subscales of the Fetzer/National Institute on Aging Brief Multidimensional Measure of Religiousness/Spirituality42: daily spiritual experiences, religious and spiritual coping, and religious support. Daily spiritual experiences were assessed using 6 items rated on a 6-point scale (1 = never or almost never and 6 = many times a day) (coefficient α = 0.90), for example, “Do you find strength and comfort in your religion?” The religious and spiritual coping subscale consisted of 6 items rated with a 4-point scale (1 = not at all and 4 = a great deal) (coefficient α = 0.70), for example, “Do you think about how your life is part of a larger spiritual force?” Four items with 4-point scales (1 = never and 4 = a great deal), which indicated how much people in their congregation provided help to them, assessed respondents’ religious support (coefficient α = 0.50), for example, “If you were ill, how much would the people in your congregation help you out?” Two additional items were included to address religious meaning with 4-point scales (1 = strongly disagree and 4 = strongly agree). These items addressed whether participants believed that the events of their life unfolded according to a divine plan and whether they had a strong sense of a mission or calling in their life.
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Psychosocial factors surrounding treatment decision-making included information needs, decision satisfaction, and worries during treatment. An information needs scale, adapted from the work of Ljungman et al43 with families of children with cancer, assessed the importance of information needs and whether they had been met. Respondents were asked how important the information was for them and then asked whether the health professionals taking care of them had met those information needs. Two scores were derived: a perceived importance of information needs score and a frequency of needs met score. The importance of information score was the mean of a 10-point rating scale for 20 items and could range from 1 to 10, with 10 being extremely important. The needs met score was a count ranging from 0 to 20, with 20 meaning that all needs were met. Satisfaction with their treatment was measured using the Satisfaction With Decision Scale developed by Holmes-Rovner et al,44 which gauged participants’ perceptions about their treatment decision. Respondents rated their agreement with 6 statements on a 5-point agreement scale (1 = strongly disagree and 5 = strongly agree); scores are the means across the items (coefficient B = 0.63). A separate item asked respondents to indicate whether they worried too much, worried about important things, or hardly ever worried. An additional openended question asked respondents to describe up to 3 particular things that they worried about most often. These responses were coded as first mentioned, second mentioned, and third mentioned. Social consequences of treatment included the impact of patients’ finances on their own or their spouse’s job, as well as the need for social services. A measure of financial impact assessed any potential job-related consequences for the participants or their spouses and the financial circumstances of the household. Respondents who still worked or whose spouses still worked rated their agreement on 5 statements regarding their job performance on a 4-point scale anchored with disagree/agree. The score was the mean across items and ranged from 1 to 4, with higher scores indicating more agreement (coefficient α = 0.60). All respondents, regardless of their or their spouses’ employment
status, rated their agreement on 5 statements about their financial circumstances on a 5-point scale. This score, also a mean, ranged from 1 to 5, with higher scores indicating more agreement (coefficient α = 0.87). Social service needs were assessed using a 12-item checklist with the question, “Which of these services do you think lung cancer patients like yourself might need?” The services included transportation, nursing care, mental health care, hospice care, relocation/placement services, administrative/legal assistance, meal preparation, personal care, homemaker/household help, social/ recreational or companion services, employment disability assistance, and care coordination/referral services. A total score indicated the number of services endorsed, although percentages for each service were also examined. Finally, treatment outcomes included the physical and mental aspects of QoL, life satisfaction, and perceptions of what comprises a “good death.” QoL was measured with the RAND-36, which assesses patients’ health subsequent to their cancer treatment.41 It consists of 36 items grouped into 8 subscales that include general health perception, mental health, pain, physical functioning, role functioning—emotional and physical, social functioning, and vitality. Scale percentiles are calculated and 4 subscales are combined to indicate physical health (general health perception, pain, physical functioning, and physical role functioning). The 4 remaining scales are combined to indicate mental health. Life satisfaction was assessed using the scale developed by Diener et al.45 Respondents indicated the extent of their agreement with each of 5 statements on a 5-point rating scale (1 = strongly disagree and 5 = strongly agree). Scores are the means across the statements (coefficient α = 0.75). Finally, patients’ perceptions of a “good death” were elicited using an open-ended question, asking respondents what they thought would be a good death. Up to 3 descriptors were coded as first mentioned, second mentioned, and third mentioned.
Procedure After obtaining informed consent, one of the investigators read questions to obtain responses
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from individual participants. The investigator recorded participants’ responses on a paper copy of the survey instrument. The interview lasted ~40 minutes. No respondents complained of fatigue or discontinued the interview before completing all the measures. Data were subsequently entered in a data file and coded using SPSS v13 (SPSS Inc., Chicago, Illinois).
Statistical Analyses SPSS v13 was used for all analyses. Women’s and men’s categorical responses were compared using χ2 analyses. Scaled scores were compared using independent group t tests. A probability level of 0.05 was adopted as the criterion for significance. Measures of interest are presented as means (SD).
RESULTS Sample Characteristics A total of 47 women and 53 men with a primary diagnosis of lung cancer participated in this study. Women and men with lung cancer did not differ significantly on their demographic characteristics. Overall, the mean (SD) age of the 100 participating lung cancer patients was 62.81 (12.01) years, with 52% above the national retirement age of 65 years. Nearly two thirds were married (64%), education level attained ranged from less than high school (45%), to high school (28%), and some college (27%). The participants generally had low incomes (<$30,000; 69%), and were white (95%). There were also no significant gender differences in patients’ diagnostic or treatment histories. All had had lung cancer for <10 years. Most (73%) had been diagnosed in the past 2 years. Most had also started or finished treatment, although some (11%) had not yet started. More than half (60%) had received some combination of chemotherapy, radiation, and/or surgical treatment, although almost a third (29%) had had only one type of treatment (6% chemotherapy, 3% radiation, and 20% surgery). There were significant gender differences in smoking history. Women were much more likely than men to have never smoked (21.3% vs 1.9%, respectively; χ2 [1, N = 100] = 9.58; P = 0.01). Although men had smoked more packs per day than women
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had (1.4 vs 1.1 packs, respectively), this difference did not reach significance. Males began smoking at a significantly younger age than did females (14.7 vs 16.7 years, t[87] = 2.3; P = 0.02).
Psychosocial Resources There were several gender differences in patients’ psychosocial resources for managing the treatment of lung cancer. Comparing the means listed in the table, the social networks of men and women were nearly identical; however, women’s and men’s reliance on religion and spirituality differed significantly. Men and women were equally likely to be a member or affiliate of a church (52.8% vs 68.1%, respectively). However, women had significantly more frequent daily spiritual experiences (t[98] = 2.37; P = 0.02), and used significantly more religious coping (t[98] = 2.10; P = 0.04). Women were also significantly more likely to believe in a divine plan (t[98] = 2.91; P = 0.01) and to believe they had a life mission (t[98] = 2.28; P = 0.03). There was no significant gender difference in the religious support that patients derived from their congregations. Finally, there were no significant gender differences in patients’ perceptions of the effectiveness of their general (ie, nonreligious) coping.
Treatment Decision-Making There were no significant gender differences in either the respondents’ ratings of the importance of information or whether their information needs were met. Of note, for both women and men, the means for these 2 measures were very close to the highest scores possible—9.66 and 9.85 out of a possible 10, respectively, and 19.49 and 19.60 out of a possible 20, which could indicate a ceiling effect. Similarly, respondents were highly satisfied with their treatment decision-making, scoring 4.29 out of a possible 5. There were gender differences in the extent to which respondents worried. Men were significantly more likely to report never worrying compared with women (28.3% vs 10.6%, respectively), and women were significantly more likely to report worrying too much compared with men (48.9% vs 30.2%, respectively) (χ2 [2, N = 100] = 6.14; P = 0.05). The table shows the per-
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Table. Mean (SD) of psychosocial measures of patients with lung cancer, by gender. Women (n = 47)
Measure Psychosocial resources Social network (6-pt scale)a Coping effectiveness (5-pt scale)b Daily spiritual experiences (6-pt scale)c Religious and spiritual coping (4-pt scale)d Religious support (4-pt scale)e Religious meaning Belief in a divine plan (4-pt scale)f Belief in a life mission (4-pt scale)g
4.54 3.11 3.84 3.42 3.67
Treatment decision-making Importance of information (10-pt scale)h Information needs met (20 needs)i Satisfaction with decision (5-pt scale)j Worries Health, % Family, % Finances, % Social consequences of treatment Still employed, % of patients Still employed, % of spouses Work impact on self or spouse (4-pt scale)k Financial impact (5-pt scale)l Service needs (12 needs)m Treatment outcomes Functional healthn Well-beingo Life satisfaction (5-pt scale)p Higher scores reflect/indicate: a Higher social network.39 b More effective coping.40 c Increased frequency of spiritual experiences.42 d Increased use of religious and spiritual coping.42 e Increased support from congregation.42 f Increased belief in a divine plan. g Increased belief in a life mission. h Increased importance of knowing information.43
(0.85) (0.54) (0.79) (0.40) (0.40)
Men (n = 53)
4.55 3.20 3.38 3.22 3.62
P
(0.78) (0.54) (1.09) (0.53) (0.46)
0.93 0.40 0.02 0.04 0.64
3.47 (0.50) 3.19 (0.61)
3.09 (0.74) 2.87 (0.78)
0.01 0.03
9.66 (0.70) 19.49 (1.64) 4.29 (0.48)
9.85 (0.87) 19.60 (1.47) 4.28 (0.50)
0.24 0.71 0.89
29.8 25.5 17.0
34.0 24.5 30.2
– – –
6.4 25.9 2.37 (0.57) 2.53 (1.12) 3.23 (2.90)
13.2 24.3 2.40 (0.65) 2.42 (0.99) 3.89 (3.06)
0.33 1.00 0.89 0.62 0.35
32.23 (25.21) 35.11 (13.32) 3.49 (0.75)
39.69 (27.63) 38.77 (20.60) 3.66 (0.65)
0.16 0.30 0.25
i More
needs being met.43 satisfaction with the decision.44 k Greater impact on work performance. l That having lung cancer has had a greater impact on their financial situation. m A larger number of services needed. n Greater functional health.41 o Greater mental health/well-being.41 p Greater life satisfaction.45 j Greater
centage of respondents who cited their health, family, or finances, indicating who or what they worried about. In addition, many more women than men worried about their children (21.7% vs 3.8%, respectively). Other worries cited by only 1 or 2 respondents included the weather (2.1% of women), whether their house was clean (2.1% of women), work (3.8% of men), their life or accomplishments (3.8% of men), their grandchildren (3.8% of men), and their spouse’s future (1.9% of
men). Although these percentages are low, there appear to be some gender differences in the worries mentioned by men and not women (and vice versa).
Social Consequences of Treatment There were no significant gender differences in measures of the financial impact, service use, or work impact of lung cancer on respondents. Overall, participants reported that they had experi-
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enced a moderate change in their financial status. Almost all the respondents reported having health insurance (89.4% of women and 98.1% of men) and for the majority, health insurance covered all their bills (63.8% of women and 69.8% of men). About half (52%) were eligible for Medicare because they were aged ≥65 years; others may have been receiving disability or retained their insurance coverage from their employers. On average, respondents selected 3 to 4 services as potentially needed by lung cancer patients from the list of 12 possible. The most frequently selected services included coordination/referral services (37%), hospice care (34%), nursing care (33%), transportation (32%), and employment/disability services (22%). Between 10% and 20% of respondents endorsed the rest of the services. Some respondents (13.2% of men and 6.4% of women) still worked. Of those who were married, respondents also reported that some of their spouses still worked (24.3% of men’s and 25.9% of women’s spouses). Of those respondents who worked or who had spouses who were employed, all reported moderate work impact.
Treatment Outcomes There were no significant gender differences in respondents’ reports of their QoL or life satisfaction. Although functional health and well-being were low (between the 30th and 40th percentiles), life satisfaction was moderately high (3.49 and 3.66 on a 5-point scale). Not quite a third of the respondents had advanced directives (29.8% of women and 30.2% of men). When asked what would constitute a “good death,” 63.8% of women cited dying in one’s sleep, compared with 69.8% of men. The next most frequently mentioned first option was a quick death for women (14.9%) and a pain-free death for men (11.3%). After first mentioning dying in one’s sleep, the most frequently mentioned second option was a pain-free death (68.1% of women and 64.2% of men).
DISCUSSION The sample in the present study had some interesting characteristics. First, it was characterized by lower education and income levels, in contrast
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to a study with more highly educated subjects.15 Second, in contrast to studies of patients with other types of cancer,11,25,28,31 many of this study’s participants had cancer for a shorter period of time, and some had not even begun treatment. This is largely due to the rapid clinical course of lung cancer and the poor survival rate associated with it. Third, the female patients were less likely to have smoked, started smoking at a later age, and smoked fewer cigarettes than did the male patients. Gender differences did emerge with respect to the psychosocial variables investigated. Specifically, there were gender differences in religiousness and spirituality such that women with lung cancer reported more spiritual experiences, used more religious coping, and had greater faith in the meaningfulness of life than did their male counterparts. This suggests that compared with men, women may have the potential to use greater religious coping resources when confronted with this life-threatening disease. Women also reported worrying more than men did and were more likely to be worried about their children. Their worries may lead to distraction from treatment decisionmaking and/or the implementation of their decisions. There were no other significant gender differences in the social consequences of treatment or in treatment outcomes. Of the gender differences in patients’ psychosocial characteristics, the differences in religiousness and spirituality were the most robust. These findings contribute to the growing body of literature on the spiritual and religious practices of cancer patients. Current research on religion and spirituality and cancer is based on single-sex samples25,46 or general cancer patient samples that do not differentiate between types of cancer24,47 or the terminally ill.48 One research study specifically reporting gender differences in religiousness and spirituality, similar to the present study, used a sample of mixed patients, of which half were cancer patients,49 to establish the reliability and validity of a recently developed measure. Other research has linked cancer patients’ religiousness and spirituality to declines in depression,25,48 reduced end-of-life despair,24 and increased optimism.50 Gender differences in the role of religion and spirituality in the
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well-being of lung cancer patients suggest that women may have a naturally existing buffer against depression and end-of-life despair. Taylor47 reported that those patients for whom spiritual needs were most important were also most desirous of nursing assistance. Finally, ancillary analyses from the present study indicated that religious coping was associated with significantly better mental health functioning for women (r = 0.47; P = 0.01) but not for men (r = –0.08; P = NS). However, for both women and men, religious coping was significantly associated with higher life satisfaction, but the effect was stronger for women (r = 0.42; P = 0.01) than for men (r = 0.29; P = 0.04). Religious coping, particularly for women, may be one means of helping patients adjust psychologically to lung cancer. Women’s increased focus on religion and spirituality could be used in the treatment setting to help them more effectively cope with cancer. They could be encouraged to utilize resources that offer more religious or spiritual messages. This is not to say that men would not benefit from such programs. In light of men’s lesser use of religion and spirituality as a coping mechanism, perhaps the goal should be to first raise their awareness of the benefits of using such coping techniques, and then to encourage them to use those resources. Combined with recent findings of the benefits of treating not only the physical aspects of cancer but also the psychosocial aspects of the disease,8–10 the present findings suggest that religious and spiritual coping should be assessed. This could help health care professionals to better meet the needs of lung cancer patients. For instance, as a means of helping patients cope with the disease, health care workers could provide lists of resources, such as books and printed materials, and assist patients and their families in finding support groups that are aligned with the patients’ religious and spiritual choices. Measures of religiousness and spirituality are relatively brief and very easy to administer. This helps health care professionals with assessing patients and finding appropriate resources as quickly as possible, which is critical, given the rapid course of lung cancer and the amount of distress that it causes. From a practical
standpoint, such measures may reduce both the emotional and financial costs associated with lung cancer. However, future studies are warranted to determine the effectiveness of tailoring resources based on religious/spiritual coping. Our findings indicate the men and women do not differ with respect to many of the psychosocial aspects of cancer. For example, gender was not related to social network, which is consistent with Peleg-Oren et al’s findings.16 However, numerous other studies have shown the gender does influence social resources.18–21 Furthermore, differences were not found in terms of the financial impact of lung cancer, which also contradicts other cancer research.31 Similar to previous research, gender differences were not found in terms of lung cancer, patients’ QoL, or well-being.12,36 As a final example, we did not find gender differences in terms of the importance of information, because all the patients believed that the information was important. There are several possible explanations for the lack of gender differences in our study. First, it may be that the nature of lung cancer reduces gender differences that are often found in other types of cancer, as both women and men with lung cancer have been found to experience greater amounts of distress than have patients with most other types of cancer.9,17 It may also be that unlike many other studies, we limited our investigation to a single cancer site, whereas others have combined various cancer sites to examine gender effects (ie, grouping all women regardless of specific cancer diagnosis). Overall, the role of gender in psychosocial adjustment to cancer may be dependent on the type of cancer. It is also possible that gender differences in terms of psychosocial adjustment are rare. For example, based on data from a large number of cancer patients, both Zabora et al17 and Carlson et al9 (N = 4496 and 3095, respectively) reported few if any gender differences in psychosocial adjustment to cancer. Finally, it is possible that low reliability scores on some measures may help explain some of the null findings. Although all measures were established, the distress associated with lung cancer or the characteristics of our sample may have influenced their responses on the measures. Regardless of the ex-
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planation for these findings, health care professionals can benefit from them. With the exception of religious coping, it appears that psychosocial adjustment to lung cancer, unlike many of the other cancers, is not gender based, which has implications for communication, service recommendations, and QoL. This study has several limitations. First, the psychosocial aspects of treatments and outcomes were limited in scope. Other psychosocial resources could include characteristics such as hope or coping styles; social consequences and psychosocial outcomes could include the impact on families. Second, this was a convenience sample from a single clinic. Although all patients had a primary diagnosis of lung cancer, the sample was not characterized by the type or stage of cancer. As noted earlier, the income and education levels of this sample are intriguingly different from those in other studies. The lower levels of income and education in the present sample are likely related to psychological resources as well as to treatment decision-making and the social consequences of treatment. For instance, Jacobs-Lawson et al51 found that education influenced the types of information lung cancer patients wanted. Future studies should continue to explore the role of these 2 individual difference variables (income and education level) in how patients cope with lung cancer and how health care professionals can modify their interactions to meet the needs of patients with various backgrounds. Finally, the nature of lung cancer itself may limit the generalizability of this study’s findings. Its rapid clinical course makes the importance of some psychosocial characteristics, such as religion and spirituality, more immediate to QoL issues. Although more research has been conducted on the psychosocial aspects of breast or prostate cancers, those cancers lack comparable groups for analyses of potential gender differences.
CONCLUSIONS Research has reported that religiousness and spirituality improved depressive symptoms and may ease end-of-life despair. In this study of patients with lung cancer, gender differences in religious-
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ness and spirituality suggest this may be especially true for women, and that interventions should be directed toward their religious practices and coping. The psychosocial gender differences and biomedical sex differences noted in patients with lung cancer suggest that additional research is needed to map the boundaries of these differences. Implications for clinicians include incorporating religious support in the care of patients as well as addressing the worries of women.
ACKNOWLEDGMENTS The authors thank the Kentucky Lung Cancer Research Program for their grant support of The Comprehensive Support Protocol: Providing Psychosocial Assistance to Lung Cancer Patients and Their Families. The authors have indicated that they have no other conflicts of interest regarding the content of this article.
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21. Thomé B, Hallberg IR. Quality of life in older people with cancer—a gender perspective. Eur J Cancer Care (Engl). 2004;13:454–463. 22. McIllmurray MB, Thomas C, Francis B, et al. The psychosocial needs of cancer patients: Findings from an observational study. Eur J Cancer Care (Engl). 2001;10:261–219. 23. Stanton AL, Revenson TA, Tennen H. Health psychology: Psychological adjustment to chronic disease. Annu Rev Psychol. 2007;58:565–592. 24. McClain-Jacobson C, Rosenfeld B, Kosinski A, et al. Belief in an afterlife, spiritual well-being and end-of-life despair in patients with advanced cancer. Gen Hosp Psychiatry. 2004;26:484– 486. 25. Aukst-Margetic B, Jakovljevic M, Margetic B, et al. Religiosity, depression and pain in patients with breast cancer. Gen Hosp Psychiatry. 2005;27:250– 255. 26. Fischer M, Visser A, Voerman B, et al. Treatment decision making in prostate cancer: Patients’ participation in complex decisions. Patient Educ Couns. 2006;63:308–313. 27. Lantz PM, Janz NK, Fagerlin A, et al. Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer. Health Serv Res. 2005;40:745– 767. 28. Salkeld G, Solomon M, Short L, Butow PN. A matter of trust—patient's views on decision-making in colorectal cancer. Health Expect. 2004;7:104–114. 29. Rutten LJ, Squiers L, Hesse B. Cancer-related information seeking: Hints from the 2003 health information national trends survey (HINTS). J Health Commun. 2006;11(Suppl 1):147–156. 30. Friedemann-Sánchez G, Griffin JM, Partin MR. Gender differences in colorectal cancer screening barriers and information needs. Health Expect. 2007;10:148–160. 31. Bradley CJ, Bednarek HL. Employment patterns of long-term cancer survivors. Psychooncology. 2002;11:188–198. 32. Onakoya PA, Nwaorgu OG, Adenipekun AO, et al. Quality of life in patients with head and neck cancers. J Natl Med Assoc. 2006;98:765–770. 33. Hanratty B, Holland P, Jacoby A, Whitehead M. Financial stress and strain associated with terminal
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cancer—a review of the evidence. Palliat Med. 2007; 21:595–607. Simpson JS, Carlson LE, Trew ME. Effect of group therapy for breast cancer on healthcare utilization. Cancer Pract. 2001;9:19–26. Alter CL. Predictors of referral for psychosocial services: Recommendations from the Institute of Medicine report—cancer care for the whole patient. J Clin Oncol. 2009;27:659–660. Keller M, Henrich G. Illness-related distress: Does it mean the same for men and women? Gender aspects in cancer patients’ distress and adjustment. Acta Oncol. 1999;38:747–755. Derdiarian AK. Informational needs of recently diagnosed cancer patients. Nurs Res. 1986;35:276– 281. American Cancer Society. Cancer facts & figures 2006. http://www.cancer.org/downloads/stt/caff 2006pwsecured.pdf. Accessed February 22, 2010. Lubben JE. Assessing social networks among elderly populations. Fam Community Health. 1988; 11:45–52. Gottlieb BH, Rooney JA. Coping effectiveness: Determinants and relevance to the mental health and affect of family caregivers of persons with dementia. Aging Ment Health. 2004;8:364–373. Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med. 2001;33: 350–357. Fetzer Institute, National Institute on Aging Working Group. Multidimensional measurement of religiousness/spirituality for use in health research: A report. October 1999.
43. Ljungman G, McGrath PJ, Cooper E, et al. Psychosocial needs of families with a child with cancer. J Pediatr Hematol Oncol. 2003;25:223–231. 44. Holmes-Rovner M, Kroll J, Schmitt N, et al. Patient satisfaction with health care decisions: The satisfaction with decision scale. Med Decis Making. 1996;16:58–64. 45. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale. J Pers Assess. 1985;49:71–75. 46. Hamrick N, Diefenbach MA. Religion and spirituality among patients with localized prostate cancer. Palliat Support Care. 2006;4:345–355. 47. Taylor EJ. Prevalence and associated factors of spiritual needs among patients with cancer and family caregivers. Oncol Nurs Forum. 2006;33:729–735. 48. Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion, and depression in the terminally ill. Psychosomatics. 2002;43:213–220. 49. Büssing A, Matthiessen PF, Ostermann T. Engagement of patients in religious and spiritual practices: Confirmatory results with the SpREUK-P 1.1 questionnaire as a tool of quality of life research. Health Qual Life Outcomes. 2005;3:53. 50. Sherman AC, Simonton S, Adams DC, et al. Measuring religious faith in cancer patients: Reliability and construct validity of the Santa Clara Strength of Religious Faith questionnaire. Psychooncology. 2001;10:436–443. 51. Jacobs-Lawson JM, Schumacher MM, Hughes T, Arnold Sl. The relationship between lung cancer patients’ educational level and evaluation of their treatment information needs. J Cancer Edu. 2009;24:346–350.
Address correspondence to: Joy M. Jacobs-Lawson, PhD, 306 Wethington Health Sciences, University of Kentucky, Lexington, KY 40536–0200. E-mail: [email protected]
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Gender Differences in Psychosocial Responses to Lung Cancer Joy M. Jacobs-Lawson, PhD1; Mitzi M. Schumacher, PhD2; Travonia Hughes, PhD3; and Susanne Arnold, MD4 1Graduate
Center for Gerontology, University of Kentucky, Lexington, Kentucky; 2Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky; 3Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 4Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
ABSTRACT Background: Although biologically based sex differences in the smoking patterns, epidemiology, biomedical markers, and survival rates associated with lung cancer are well documented, examinations of psychosocial gender differences are scarce. Objective: This cross-sectional study examined gender differences in psychosocial factors that are important in the medical management of lung cancer. Methods: A convenience sample of patients who were attending a multidisciplinary lung cancer treatment center (Markey Cancer Center, Lexington, Kentucky) were invited to complete a psychosocial needs assessment. Eligibility criteria included primary diagnosis of lung cancer, age ≥18 years, and being cognitively intact. Measures focused on psychosocial resources, treatment decision-making, social consequences of treatments, and treatment outcomes. Data were collected between the fall of 2005 and the summer of 2006. Results: A total of 47 women and 53 men (mean [SD] age, 62.81 [12.01] years; 95% white) completed the needs assessment. Gender was not found to be associated with demographic characteristics, time until diagnosis, treatment, or survival rate. Smoking histories differed significantly in the proportion of women and men who smoked or were former smokers (P = 0.01) as well as the age when they began to smoke (P = 0.02). There were no significant gender differences in social support networks, general coping, information needs, treatment decision satisfaction, functional health, life satisfaction, financial impact, or service needs. However, significant gender differences did indicate that women favored spiritual practices (P = 0.02) and religious coping (P = 0.04), and were more likely to endorse having a life mission (P = 0.03) and being part of a divine plan (P = 0.01). Conclusions: Previous research has found that religiousness and spirituality improved depressive symptoms and may ease end-of-life despair. In the present study of patients with lung cancer, gender differences in religiousness and spirituality suggest that this may be especially true for women, and that interventions should be directed toward their religious practices and coping. (Gend Med. 2010;7:137–148) © 2010 Excerpta Medica Inc. Key words: lung cancer, gender, psychosocial, religion, spirituality. Accepted for publication December 14, 2009. © 2010 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.genm.2010.03.002 1550-8579/$ - see front matter
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INTRODUCTION Examinations of sex differences in lung cancer have focused on the biomedical aspects of the disease. For example, Rivera and Stover1 reviewed literature on gender and lung cancer, and characterized those differences as epidemiologic, biological, hormonal, and genetic. Furthermore, sex differences have been observed in susceptibility,2,3 survival rates,4–6 and treatment.7 Little is known, however, about gender differences in the psychosocial aspects of lung cancer. To provide optimal care to patients, multidisciplinary lung cancer treatment teams— including physicians, nurses, social workers, and case managers—need as complete a picture of biomedically based sex and psychosocially based gender differences as possible. Researchers and health care professionals have called for greater attention to the psychological aspects of cancer.8–10 The goal of the present study was to examine gender differences in psychosocial reactions to lung cancer, so that we are better able to meet the needs of patients and their families. Based on the gender effects observed in literature with respect to other cancers, we focused on psychological resources, treatment decision-making, financial impact and service needs, and treatment outcomes.
Psychosocial Resources The most effective means of treating cancer patients not only focuses on medical treatment, but also addresses psychosocial distress and concerns.8–10 Studies of cancer patients and survivors have shown that women often experience higher levels of distress, depression, and anxiety.9,11–14 In an investigation of predictive factors of psychological distress in 87 lung cancer patients, utilizing questionnaire and interview-based data, Akechi et al15 reported that women were significantly more likely than men to experience 6 emotional states (ie, tension-anxiety, depression-dejection, angerhostility, vigor, fatigue, confusion) characterizing mood disturbances (P = 0.01). In a more general exploration of gender differences in psychological adjustment to cancer using data from self-report questionnaires from 34 women and 15 men, PelegOren et al16 reported that, on average, men were significantly more likely than women to experience
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paranoid ideation (P = 0.05), but in the second stage of cancer, women had significantly higher mean somatization scores than did men (P = 0.05). In a larger study (n = 4496) examining distress by cancer site, including lung cancer, Zabora et al17 failed to find gender differences in distress for the sample. Understanding how men and women cope with distress is critical to being able to provide optimal treatment. Most research on cancer and social support has reported significant gender differences. Several studies have found that women were more likely to seek support than were men.18–20 Women may more actively seek social resources because men believe that their current level of support is sufficient. For instance, in a study of 82 head and neck cancer patients, men reported significantly higher levels of perceived social support than did women (P = 0.01),12 but a study of 150 cancer patients aged ≥75 years found that women were significantly more likely to report having felt lonely compared with men (68.0% vs 56.0%, respectively; P = 0.01).21 Although Peleg-Oren et al16 failed to find gender differences in cancer patients’ social resources, McIllmurray et al22 found significant gender differences in the types of resources desired (N = 402; P < 0.05). It has been reported that both relying on religion and finding meaning in chronic illnesses,23 including cancer, are beneficial. In a study of 276 patients with advanced cancer, McClain-Jacobson et al24 found that belief in an afterlife was associated with significantly lower levels of hopelessness (P < 0.01), suicide ideation (P = 0.03), and desire for a hastened death (P = 0.03). However, once spiritual well-being was taken into account, these relationships were no longer significant, which suggests the importance of spirituality in coping with cancer. Religion has also been found to serve as a buffer from depression among women diagnosed with breast cancer,25 and furthermore, women were more likely than men to utilize it as a resource for coping with cancer.19
Treatment Decision-Making One area of research that has recently received increased attention is patients’ preferences regard-
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ing treatment decision-making. Studies of both breast and prostate cancer patients have reported that patients were most satisfied when their actual level of involvement matched their desired level of involvement in the treatment decision.26,27 In a gender-based study of colorectal cancer patients, men (n = 102) and women (n = 73) did not differ in terms of how important they believed the decision process was; however, women indicated that they wanted to be more involved with their treatment decisions (27% of women vs 24% of men), whereas men preferred to have the surgeon make the decision (32% of men vs 19% of women).28 Gender differences have also emerged in terms of the amount and type of information sought regarding cancer and cancer treatments.18,22,29,30 Other research has found that gender was related to fears about cancer and outcomes,30 but not to how worried long-term cancer survivors were about the cancer returning.11
Social Consequences of Treatment Relative to other areas of adjustment and coping, the social consequences of treatment, in particular, the financial impact and service needs of lung cancer patients, have received less attention. A study examining the lasting effects of treatment on employment found that during treatment, colon and lung cancer patients were the most likely to reduce their workload, women with lung cancer were less likely than their male counterparts to be working after treatment, and gender was related to spouses’ employment status.31 In addition, male lung cancer survivors’ spouses were more likely to be employed than were female survivors’ spouses. Onakoya et al32 found that, regardless of gender, most head and neck cancer patients (96.2%) had to stop working during treatment. Other studies have reported that 17% to 30% of terminal cancer patients used all their savings in managing their illness,33 and that women aged ≥75 years with cancer had fewer economic resources than did older men with cancer.21 Although cancer can have a profound impact on financial resources, it is not clear whether this differs for women and men with lung cancer. Several studies have suggested that one means of reducing the financial expenses associated with
cancer is for patients and their families to utilize more of the services and resources available.10,34 Most cancer patients and their families do not use these resources,35 and those who do are more likely to be women8 or to have breast or prostate cancer.9
Treatment Outcomes as Measured by Quality of Life and Health Two cancer studies reported that women and men were similar in terms of general life satisfaction, overall life satisfaction, and health-related quality of life (QoL).12,36 However, Thomé and Hallberg21 found that among adults aged ≥75 years with cancer, women (n = 74) reported a significantly lower QoL than did men (n = 76) (P < 0.01). Gender differences have also emerged with respect to the impact that cancer and its treatment have on patients’ QoL: whereas women tended to focus more on psychological well-being, men were more often concerned about physical functioning.37 Much of the current literature on psychosocial aspects of adjustment and outcomes associated with cancer is limited in that the studies focus on a gendered cancer (eg, breast or prostate25,26), lack sufficient sample sizes within each type of cancer to conduct gender-based cancer-site analyses, or do not report findings based on gender and site.9,19 Of those that have examined gender differences in psychosocial adjustment by cancer site, most have focused on colorectal cancer,28,30 not lung cancer. Given the severity of this disease and the devastating impact that it can have on individuals,38 as well as our awareness of gender differences in the biomedical aspects and treatment and in coping with respect to other types of cancer, we would be remiss if we did not examine the role of gender in lung cancer. Doing so will offer insights for physicians and health care professionals as to how we can develop the means to most effectively meet the psychosocial needs of women and men with lung cancer.
METHODS Study Design A cross-sectional design required participants to answer questions in a one-time individual interview at their convenience during a scheduled clinic
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visit at the Markey Cancer Center, Lexington, Kentucky, between the fall of 2005 and the summer of 2006. The study was approved by the University of Kentucky Medical Institutional Review Board.
Participants Patients attending a multidisciplinary treatment team clinic for lung cancer were asked if they might be interested in talking to a researcher about the needs of lung cancer patients. Patients were comfortable with refusing to participate, and not all met the inclusion criteria, which comprised a primary diagnosis of lung cancer, age ≥18 years, and being cognitively intact as determined by the nursing staff. Those interested were introduced to an investigator who explained the nature of the study, answered questions, and obtained written informed consent. One hundred and thirty-six consecutive patients who arrived at their appointment on time were approached, and 100 patients subsequently participated (~74% recruitment rate). Of those who did not participate, 20 were ineligible due to having a cancer other than lung, 6 declined, and 10 stated they were too ill to participate.
Assessment Instrument Demographic questions assessed age, sex, race, marital status, number of living children, education, income, employment status, and occupation. Treatment history questions inquired when patients first suspected a problem, made their first appointment with a general practitioner or specialist, made their first appointment at a cancer center, and began treatment, as well as what type of treatment they underwent. After responding whether they currently, previously, or never smoked, the current and previous smokers were asked how much they smoked, the age when they began to smoke, and whether they had quit and at what age. Psychosocial measures assessed social support, religiousness and spirituality, coping, information needs, treatment decision satisfaction, worries, financial impact and social service needs, functional health, well-being, life satisfaction, and perspectives on a “good death.” Psychosocial resources for managing treatment included social network, religious and spiritual
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coping, religious support, and effective coping. The Lubben Social Network Scale was used to assess the number and frequency of contacts with others, as well as the nature of relationships with relatives and friends.39 A score (a higher score represents a greater social network) was derived from a mean of the 6-point response scales for 9 items (coefficient α = 0.71). The Social Network Scale is commonly used as a screening tool for older adults at risk for social isolation. The Coping Effectiveness Scale, developed by Gottlieb and Rooney,40 measured respondents’ perceptions of the effectiveness of their coping with challenging health situations. The score (a higher score represents more effective coping) was a mean of 5-point ratings for 7 items (coefficient α = 0.45). Scores on this measure predict scores on the mental health subscale of the RAND measure of QoL (also known as the 36-item Short Form Health Survey).41 Aspects of religiousness and spirituality most likely to be related to the course of treatment for lung cancer were assessed using 3 subscales of the Fetzer/National Institute on Aging Brief Multidimensional Measure of Religiousness/Spirituality42: daily spiritual experiences, religious and spiritual coping, and religious support. Daily spiritual experiences were assessed using 6 items rated on a 6-point scale (1 = never or almost never and 6 = many times a day) (coefficient α = 0.90), for example, “Do you find strength and comfort in your religion?” The religious and spiritual coping subscale consisted of 6 items rated with a 4-point scale (1 = not at all and 4 = a great deal) (coefficient α = 0.70), for example, “Do you think about how your life is part of a larger spiritual force?” Four items with 4-point scales (1 = never and 4 = a great deal), which indicated how much people in their congregation provided help to them, assessed respondents’ religious support (coefficient α = 0.50), for example, “If you were ill, how much would the people in your congregation help you out?” Two additional items were included to address religious meaning with 4-point scales (1 = strongly disagree and 4 = strongly agree). These items addressed whether participants believed that the events of their life unfolded according to a divine plan and whether they had a strong sense of a mission or calling in their life.
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Psychosocial factors surrounding treatment decision-making included information needs, decision satisfaction, and worries during treatment. An information needs scale, adapted from the work of Ljungman et al43 with families of children with cancer, assessed the importance of information needs and whether they had been met. Respondents were asked how important the information was for them and then asked whether the health professionals taking care of them had met those information needs. Two scores were derived: a perceived importance of information needs score and a frequency of needs met score. The importance of information score was the mean of a 10-point rating scale for 20 items and could range from 1 to 10, with 10 being extremely important. The needs met score was a count ranging from 0 to 20, with 20 meaning that all needs were met. Satisfaction with their treatment was measured using the Satisfaction With Decision Scale developed by Holmes-Rovner et al,44 which gauged participants’ perceptions about their treatment decision. Respondents rated their agreement with 6 statements on a 5-point agreement scale (1 = strongly disagree and 5 = strongly agree); scores are the means across the items (coefficient B = 0.63). A separate item asked respondents to indicate whether they worried too much, worried about important things, or hardly ever worried. An additional openended question asked respondents to describe up to 3 particular things that they worried about most often. These responses were coded as first mentioned, second mentioned, and third mentioned. Social consequences of treatment included the impact of patients’ finances on their own or their spouse’s job, as well as the need for social services. A measure of financial impact assessed any potential job-related consequences for the participants or their spouses and the financial circumstances of the household. Respondents who still worked or whose spouses still worked rated their agreement on 5 statements regarding their job performance on a 4-point scale anchored with disagree/agree. The score was the mean across items and ranged from 1 to 4, with higher scores indicating more agreement (coefficient α = 0.60). All respondents, regardless of their or their spouses’ employment
status, rated their agreement on 5 statements about their financial circumstances on a 5-point scale. This score, also a mean, ranged from 1 to 5, with higher scores indicating more agreement (coefficient α = 0.87). Social service needs were assessed using a 12-item checklist with the question, “Which of these services do you think lung cancer patients like yourself might need?” The services included transportation, nursing care, mental health care, hospice care, relocation/placement services, administrative/legal assistance, meal preparation, personal care, homemaker/household help, social/ recreational or companion services, employment disability assistance, and care coordination/referral services. A total score indicated the number of services endorsed, although percentages for each service were also examined. Finally, treatment outcomes included the physical and mental aspects of QoL, life satisfaction, and perceptions of what comprises a “good death.” QoL was measured with the RAND-36, which assesses patients’ health subsequent to their cancer treatment.41 It consists of 36 items grouped into 8 subscales that include general health perception, mental health, pain, physical functioning, role functioning—emotional and physical, social functioning, and vitality. Scale percentiles are calculated and 4 subscales are combined to indicate physical health (general health perception, pain, physical functioning, and physical role functioning). The 4 remaining scales are combined to indicate mental health. Life satisfaction was assessed using the scale developed by Diener et al.45 Respondents indicated the extent of their agreement with each of 5 statements on a 5-point rating scale (1 = strongly disagree and 5 = strongly agree). Scores are the means across the statements (coefficient α = 0.75). Finally, patients’ perceptions of a “good death” were elicited using an open-ended question, asking respondents what they thought would be a good death. Up to 3 descriptors were coded as first mentioned, second mentioned, and third mentioned.
Procedure After obtaining informed consent, one of the investigators read questions to obtain responses
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from individual participants. The investigator recorded participants’ responses on a paper copy of the survey instrument. The interview lasted ~40 minutes. No respondents complained of fatigue or discontinued the interview before completing all the measures. Data were subsequently entered in a data file and coded using SPSS v13 (SPSS Inc., Chicago, Illinois).
Statistical Analyses SPSS v13 was used for all analyses. Women’s and men’s categorical responses were compared using χ2 analyses. Scaled scores were compared using independent group t tests. A probability level of 0.05 was adopted as the criterion for significance. Measures of interest are presented as means (SD).
RESULTS Sample Characteristics A total of 47 women and 53 men with a primary diagnosis of lung cancer participated in this study. Women and men with lung cancer did not differ significantly on their demographic characteristics. Overall, the mean (SD) age of the 100 participating lung cancer patients was 62.81 (12.01) years, with 52% above the national retirement age of 65 years. Nearly two thirds were married (64%), education level attained ranged from less than high school (45%), to high school (28%), and some college (27%). The participants generally had low incomes (<$30,000; 69%), and were white (95%). There were also no significant gender differences in patients’ diagnostic or treatment histories. All had had lung cancer for <10 years. Most (73%) had been diagnosed in the past 2 years. Most had also started or finished treatment, although some (11%) had not yet started. More than half (60%) had received some combination of chemotherapy, radiation, and/or surgical treatment, although almost a third (29%) had had only one type of treatment (6% chemotherapy, 3% radiation, and 20% surgery). There were significant gender differences in smoking history. Women were much more likely than men to have never smoked (21.3% vs 1.9%, respectively; χ2 [1, N = 100] = 9.58; P = 0.01). Although men had smoked more packs per day than women
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had (1.4 vs 1.1 packs, respectively), this difference did not reach significance. Males began smoking at a significantly younger age than did females (14.7 vs 16.7 years, t[87] = 2.3; P = 0.02).
Psychosocial Resources There were several gender differences in patients’ psychosocial resources for managing the treatment of lung cancer. Comparing the means listed in the table, the social networks of men and women were nearly identical; however, women’s and men’s reliance on religion and spirituality differed significantly. Men and women were equally likely to be a member or affiliate of a church (52.8% vs 68.1%, respectively). However, women had significantly more frequent daily spiritual experiences (t[98] = 2.37; P = 0.02), and used significantly more religious coping (t[98] = 2.10; P = 0.04). Women were also significantly more likely to believe in a divine plan (t[98] = 2.91; P = 0.01) and to believe they had a life mission (t[98] = 2.28; P = 0.03). There was no significant gender difference in the religious support that patients derived from their congregations. Finally, there were no significant gender differences in patients’ perceptions of the effectiveness of their general (ie, nonreligious) coping.
Treatment Decision-Making There were no significant gender differences in either the respondents’ ratings of the importance of information or whether their information needs were met. Of note, for both women and men, the means for these 2 measures were very close to the highest scores possible—9.66 and 9.85 out of a possible 10, respectively, and 19.49 and 19.60 out of a possible 20, which could indicate a ceiling effect. Similarly, respondents were highly satisfied with their treatment decision-making, scoring 4.29 out of a possible 5. There were gender differences in the extent to which respondents worried. Men were significantly more likely to report never worrying compared with women (28.3% vs 10.6%, respectively), and women were significantly more likely to report worrying too much compared with men (48.9% vs 30.2%, respectively) (χ2 [2, N = 100] = 6.14; P = 0.05). The table shows the per-
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Table. Mean (SD) of psychosocial measures of patients with lung cancer, by gender. Women (n = 47)
Measure Psychosocial resources Social network (6-pt scale)a Coping effectiveness (5-pt scale)b Daily spiritual experiences (6-pt scale)c Religious and spiritual coping (4-pt scale)d Religious support (4-pt scale)e Religious meaning Belief in a divine plan (4-pt scale)f Belief in a life mission (4-pt scale)g
4.54 3.11 3.84 3.42 3.67
Treatment decision-making Importance of information (10-pt scale)h Information needs met (20 needs)i Satisfaction with decision (5-pt scale)j Worries Health, % Family, % Finances, % Social consequences of treatment Still employed, % of patients Still employed, % of spouses Work impact on self or spouse (4-pt scale)k Financial impact (5-pt scale)l Service needs (12 needs)m Treatment outcomes Functional healthn Well-beingo Life satisfaction (5-pt scale)p Higher scores reflect/indicate: a Higher social network.39 b More effective coping.40 c Increased frequency of spiritual experiences.42 d Increased use of religious and spiritual coping.42 e Increased support from congregation.42 f Increased belief in a divine plan. g Increased belief in a life mission. h Increased importance of knowing information.43
(0.85) (0.54) (0.79) (0.40) (0.40)
Men (n = 53)
4.55 3.20 3.38 3.22 3.62
P
(0.78) (0.54) (1.09) (0.53) (0.46)
0.93 0.40 0.02 0.04 0.64
3.47 (0.50) 3.19 (0.61)
3.09 (0.74) 2.87 (0.78)
0.01 0.03
9.66 (0.70) 19.49 (1.64) 4.29 (0.48)
9.85 (0.87) 19.60 (1.47) 4.28 (0.50)
0.24 0.71 0.89
29.8 25.5 17.0
34.0 24.5 30.2
– – –
6.4 25.9 2.37 (0.57) 2.53 (1.12) 3.23 (2.90)
13.2 24.3 2.40 (0.65) 2.42 (0.99) 3.89 (3.06)
0.33 1.00 0.89 0.62 0.35
32.23 (25.21) 35.11 (13.32) 3.49 (0.75)
39.69 (27.63) 38.77 (20.60) 3.66 (0.65)
0.16 0.30 0.25
i More
needs being met.43 satisfaction with the decision.44 k Greater impact on work performance. l That having lung cancer has had a greater impact on their financial situation. m A larger number of services needed. n Greater functional health.41 o Greater mental health/well-being.41 p Greater life satisfaction.45 j Greater
centage of respondents who cited their health, family, or finances, indicating who or what they worried about. In addition, many more women than men worried about their children (21.7% vs 3.8%, respectively). Other worries cited by only 1 or 2 respondents included the weather (2.1% of women), whether their house was clean (2.1% of women), work (3.8% of men), their life or accomplishments (3.8% of men), their grandchildren (3.8% of men), and their spouse’s future (1.9% of
men). Although these percentages are low, there appear to be some gender differences in the worries mentioned by men and not women (and vice versa).
Social Consequences of Treatment There were no significant gender differences in measures of the financial impact, service use, or work impact of lung cancer on respondents. Overall, participants reported that they had experi-
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enced a moderate change in their financial status. Almost all the respondents reported having health insurance (89.4% of women and 98.1% of men) and for the majority, health insurance covered all their bills (63.8% of women and 69.8% of men). About half (52%) were eligible for Medicare because they were aged ≥65 years; others may have been receiving disability or retained their insurance coverage from their employers. On average, respondents selected 3 to 4 services as potentially needed by lung cancer patients from the list of 12 possible. The most frequently selected services included coordination/referral services (37%), hospice care (34%), nursing care (33%), transportation (32%), and employment/disability services (22%). Between 10% and 20% of respondents endorsed the rest of the services. Some respondents (13.2% of men and 6.4% of women) still worked. Of those who were married, respondents also reported that some of their spouses still worked (24.3% of men’s and 25.9% of women’s spouses). Of those respondents who worked or who had spouses who were employed, all reported moderate work impact.
Treatment Outcomes There were no significant gender differences in respondents’ reports of their QoL or life satisfaction. Although functional health and well-being were low (between the 30th and 40th percentiles), life satisfaction was moderately high (3.49 and 3.66 on a 5-point scale). Not quite a third of the respondents had advanced directives (29.8% of women and 30.2% of men). When asked what would constitute a “good death,” 63.8% of women cited dying in one’s sleep, compared with 69.8% of men. The next most frequently mentioned first option was a quick death for women (14.9%) and a pain-free death for men (11.3%). After first mentioning dying in one’s sleep, the most frequently mentioned second option was a pain-free death (68.1% of women and 64.2% of men).
DISCUSSION The sample in the present study had some interesting characteristics. First, it was characterized by lower education and income levels, in contrast
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to a study with more highly educated subjects.15 Second, in contrast to studies of patients with other types of cancer,11,25,28,31 many of this study’s participants had cancer for a shorter period of time, and some had not even begun treatment. This is largely due to the rapid clinical course of lung cancer and the poor survival rate associated with it. Third, the female patients were less likely to have smoked, started smoking at a later age, and smoked fewer cigarettes than did the male patients. Gender differences did emerge with respect to the psychosocial variables investigated. Specifically, there were gender differences in religiousness and spirituality such that women with lung cancer reported more spiritual experiences, used more religious coping, and had greater faith in the meaningfulness of life than did their male counterparts. This suggests that compared with men, women may have the potential to use greater religious coping resources when confronted with this life-threatening disease. Women also reported worrying more than men did and were more likely to be worried about their children. Their worries may lead to distraction from treatment decisionmaking and/or the implementation of their decisions. There were no other significant gender differences in the social consequences of treatment or in treatment outcomes. Of the gender differences in patients’ psychosocial characteristics, the differences in religiousness and spirituality were the most robust. These findings contribute to the growing body of literature on the spiritual and religious practices of cancer patients. Current research on religion and spirituality and cancer is based on single-sex samples25,46 or general cancer patient samples that do not differentiate between types of cancer24,47 or the terminally ill.48 One research study specifically reporting gender differences in religiousness and spirituality, similar to the present study, used a sample of mixed patients, of which half were cancer patients,49 to establish the reliability and validity of a recently developed measure. Other research has linked cancer patients’ religiousness and spirituality to declines in depression,25,48 reduced end-of-life despair,24 and increased optimism.50 Gender differences in the role of religion and spirituality in the
J.M. Jacobs-Lawson et al.
well-being of lung cancer patients suggest that women may have a naturally existing buffer against depression and end-of-life despair. Taylor47 reported that those patients for whom spiritual needs were most important were also most desirous of nursing assistance. Finally, ancillary analyses from the present study indicated that religious coping was associated with significantly better mental health functioning for women (r = 0.47; P = 0.01) but not for men (r = –0.08; P = NS). However, for both women and men, religious coping was significantly associated with higher life satisfaction, but the effect was stronger for women (r = 0.42; P = 0.01) than for men (r = 0.29; P = 0.04). Religious coping, particularly for women, may be one means of helping patients adjust psychologically to lung cancer. Women’s increased focus on religion and spirituality could be used in the treatment setting to help them more effectively cope with cancer. They could be encouraged to utilize resources that offer more religious or spiritual messages. This is not to say that men would not benefit from such programs. In light of men’s lesser use of religion and spirituality as a coping mechanism, perhaps the goal should be to first raise their awareness of the benefits of using such coping techniques, and then to encourage them to use those resources. Combined with recent findings of the benefits of treating not only the physical aspects of cancer but also the psychosocial aspects of the disease,8–10 the present findings suggest that religious and spiritual coping should be assessed. This could help health care professionals to better meet the needs of lung cancer patients. For instance, as a means of helping patients cope with the disease, health care workers could provide lists of resources, such as books and printed materials, and assist patients and their families in finding support groups that are aligned with the patients’ religious and spiritual choices. Measures of religiousness and spirituality are relatively brief and very easy to administer. This helps health care professionals with assessing patients and finding appropriate resources as quickly as possible, which is critical, given the rapid course of lung cancer and the amount of distress that it causes. From a practical
standpoint, such measures may reduce both the emotional and financial costs associated with lung cancer. However, future studies are warranted to determine the effectiveness of tailoring resources based on religious/spiritual coping. Our findings indicate the men and women do not differ with respect to many of the psychosocial aspects of cancer. For example, gender was not related to social network, which is consistent with Peleg-Oren et al’s findings.16 However, numerous other studies have shown the gender does influence social resources.18–21 Furthermore, differences were not found in terms of the financial impact of lung cancer, which also contradicts other cancer research.31 Similar to previous research, gender differences were not found in terms of lung cancer, patients’ QoL, or well-being.12,36 As a final example, we did not find gender differences in terms of the importance of information, because all the patients believed that the information was important. There are several possible explanations for the lack of gender differences in our study. First, it may be that the nature of lung cancer reduces gender differences that are often found in other types of cancer, as both women and men with lung cancer have been found to experience greater amounts of distress than have patients with most other types of cancer.9,17 It may also be that unlike many other studies, we limited our investigation to a single cancer site, whereas others have combined various cancer sites to examine gender effects (ie, grouping all women regardless of specific cancer diagnosis). Overall, the role of gender in psychosocial adjustment to cancer may be dependent on the type of cancer. It is also possible that gender differences in terms of psychosocial adjustment are rare. For example, based on data from a large number of cancer patients, both Zabora et al17 and Carlson et al9 (N = 4496 and 3095, respectively) reported few if any gender differences in psychosocial adjustment to cancer. Finally, it is possible that low reliability scores on some measures may help explain some of the null findings. Although all measures were established, the distress associated with lung cancer or the characteristics of our sample may have influenced their responses on the measures. Regardless of the ex-
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planation for these findings, health care professionals can benefit from them. With the exception of religious coping, it appears that psychosocial adjustment to lung cancer, unlike many of the other cancers, is not gender based, which has implications for communication, service recommendations, and QoL. This study has several limitations. First, the psychosocial aspects of treatments and outcomes were limited in scope. Other psychosocial resources could include characteristics such as hope or coping styles; social consequences and psychosocial outcomes could include the impact on families. Second, this was a convenience sample from a single clinic. Although all patients had a primary diagnosis of lung cancer, the sample was not characterized by the type or stage of cancer. As noted earlier, the income and education levels of this sample are intriguingly different from those in other studies. The lower levels of income and education in the present sample are likely related to psychological resources as well as to treatment decision-making and the social consequences of treatment. For instance, Jacobs-Lawson et al51 found that education influenced the types of information lung cancer patients wanted. Future studies should continue to explore the role of these 2 individual difference variables (income and education level) in how patients cope with lung cancer and how health care professionals can modify their interactions to meet the needs of patients with various backgrounds. Finally, the nature of lung cancer itself may limit the generalizability of this study’s findings. Its rapid clinical course makes the importance of some psychosocial characteristics, such as religion and spirituality, more immediate to QoL issues. Although more research has been conducted on the psychosocial aspects of breast or prostate cancers, those cancers lack comparable groups for analyses of potential gender differences.
CONCLUSIONS Research has reported that religiousness and spirituality improved depressive symptoms and may ease end-of-life despair. In this study of patients with lung cancer, gender differences in religious-
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ness and spirituality suggest this may be especially true for women, and that interventions should be directed toward their religious practices and coping. The psychosocial gender differences and biomedical sex differences noted in patients with lung cancer suggest that additional research is needed to map the boundaries of these differences. Implications for clinicians include incorporating religious support in the care of patients as well as addressing the worries of women.
ACKNOWLEDGMENTS The authors thank the Kentucky Lung Cancer Research Program for their grant support of The Comprehensive Support Protocol: Providing Psychosocial Assistance to Lung Cancer Patients and Their Families. The authors have indicated that they have no other conflicts of interest regarding the content of this article.
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Address correspondence to: Joy M. Jacobs-Lawson, PhD, 306 Wethington Health Sciences, University of Kentucky, Lexington, KY 40536–0200. E-mail: [email protected]
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