Daily assessment of stressful events and coping amongpost-menopausal women with breast cancer treated withadjuvant chemotherapyecc_994 507..516

M. BROWALL, mnsc, doctoral student, The Sahlgrenska Academy at Göteborg University, Institute of Healthand Care Sciences, Göteborg, L.-O. PERSSON, associate professor, The Sahlgrenska Academy at GöteborgUniversity, Institute of Health and Care Sciences, Göteborg, K. AHLBERG, rn, phd, senior lecturer, TheSahlgrenska Academy at Göteborg University, Institute of Health and Care Sciences, Göteborg, and Departmentof Oncology, Sahlgrenska University Hospital, Division of Selected Clinical Specialties, Göteborg, P. KARLSSON,md, associate professor, Department of Oncology, Sahlgrenska University Hospital, Division of Selected ClinicalSpecialties, Göteborg, and Department of Oncology, Southern Älvsborg Hospital, Borås, & E. DANIELSON, phd,professor, The Sahlgrenska Academy at Göteborg University, Institute of Health and Care Sciences, Göteborg,and Department of Health Science, Mid Sweden University, Östersund, Sweden

BROWALL M., PERSSON L.-O., AHLBERG K., KARLSSON P. & DANIELSON E. (2009) European Journal ofCancer Care 18, 507–516Daily assessment of stressful events and coping among post-menopausal women with breast cancer treatedwith adjuvant chemotherapy

The purpose of the study was twofold: to examine what type of daily stressful events post-menopausal womanwith breast cancer experience during adjuvant chemotherapy and how bothersome these are and to identifycoping strategies used by these women used to manage such stressful events. The patient group comprised 75consecutively invited women (�55 years of age) at two university hospitals and one county hospital in Sweden.The Daily Coping Assessment was used to collect data over time. Data were analysed both qualitatively andquantitatively. Six categories of stressful events were identified: ‘nausea and vomiting’, ‘fatigue’, ‘othersymptoms’, ‘isolation and alienation’, ‘fear of the unknown’ and ‘being controlled by the treatment’. The firstthree categories were subsumed under the domain physical problems and the latter three under psychosocialproblems. Almost 30% of the diary entries recorded no stressful event. Physical problems were three times asfrequent as psychosocial problems. ‘Nausea/vomiting’ was the most frequently observed stressful event (21.6%).‘Isolation and alienation’ and ‘fear of the unknown’ were less frequent, but when they occurred they were ratedas the most distressing. Several coping strategies were used to manage each stressful event. The most commonstrategies were acceptance, relaxation and distraction. Religion was rarely used as a coping strategy.

Keywords: stressful events, coping, coping strategies, breast cancer, post-menopausal women.

INTRODUCTION

Approximately 6900 women developed breast cancer inSweden in 2004. About 65% of these women were post-menopausal and about 30% were aged 70 or older(National Board of Health and Welfare 2004). Adjuvantchemotherapy (CT) protocols used to treat women withbreast cancer have evolved over the last decade and have

Correspondence address: Maria Browall, The Sahlgrenska Academyat Göteborg University, Institute of Health and Care Sciences, Box 457,SE 405 30 Göteborg, Sweden (e-mail: maria.browall@vgregion.se).

Accepted 23 June 2008DOI: 10.1111/j.1365-2354.2008.00994.x

European Journal of Cancer Care, 2009, 18, 507–516

Original article

© 2009 The AuthorsJournal compilation © 2009 Blackwell Publishing Ltd

extended survival for these women; however, such treat-ments and the disease itself may cause symptoms(Schreier & Williams 2004; Boehmke & Dickerson 2005;Miaskowski et al. 2006; Wood et al. 2006) and reducequality of life (QoL) (Given et al. 2001; Kurtz et al. 2001;De Jong et al. 2002; Ganz et al. 2003, 2004). Demographic,individual and disease characteristics are other factorsthat can influence patient experiences (Armstrong 2003;Kim et al. 2005). Although it is known that assessingsymptom distress helps to identify patients’ perceptions oftheir needs and problems (Rhodes et al. 2000), there is stilla lack of research that has explored the experience ofsymptom distress over time in breast cancer patientsundergoing treatment with chemotherapy (Cooley et al.2003).

According to Kornblith et al. (2001), the more stressbreast cancer patients must endure, the more likely theyare to have difficulty adjusting. The authors highlight theimportance of finding a link between the stressful eventsand the degree of distress they induce, and the need forthese women to have support systems in place before theevent occurs in order to facilitate adjustment. Hence, it isimportant that healthcare providers identify patients’particular stressors at an early stage, in order to be ableto target support needs early on and thereby help patientsto achieve optimal adjustment.

Lazarus and Folkman (1984) define coping as ‘constantlychanging cognitive and behavioral efforts to manage spe-cific external or internal demands that are appraised astaxing or exceeding the resources of a person’ (p. 141).Coping strategies have been shown to be associatedwith adjustment and QoL after breast cancer diagnosis(Epping-Jordan et al. 1999; Stanton et al. 2000; Avis et al.2005). A study by Manuel et al. (2007) found that effectiveadjustment may require that different coping strategies beimplemented for specific stressors and in relation to dif-ferent interventions. Some researchers have concludedthat different coping strategies are associated with differ-ent stressors, that is, symptom distress (Kuo & Ma 2002),age (Schnoll et al. 1998) or the diagnosis of cancer, whichin itself produces a great amount of distress (Shapiro et al.2001). A variety of determinants of coping strategies havebeen identified, or at least theorized in cancer patients.Nevertheless, according to Link et al. (2005), little isknown from the cancer patients’ own perspective regard-ing what factors contribute to the patients’ choice ofcoping strategy.

To be able to provide self-care management education,healthcare providers must have more knowledge abouthow well the patient is able to manage these stressfulevents (i.e. coping). In line with Lazarus’ definition of

coping, repeated assessments and a specification of thedemands are important to gain a more complete under-standing of the adjustment process (Stone & Neale 1984;Lazarus 1993). The Daily Coping Assessment (DCA)(Stone & Neale 1984; Porter & Stone 1996) was developedin accordance with these notions to enable detailedrecording of coping responses on a daily basis. The instru-ment is useful for eliciting stressful events as specifiedand described by the patient, as well as information aboutthe use of coping strategies in relation to those events.

The overall aim of the present study was to describestressful events experienced by post-menopausal womenwith breast cancer receiving adjuvant CT and how thesewomen handle these stressful events or situations. Thefollowing research questions were posed:

1 What types of daily stressful events (related or not to thecancer) do post-menopausal women with breast cancerexperience during adjuvant CT treatment and howbothersome are these?

2 What types of coping strategies do these women use tohandle these stressful events?

METHODS

Sample and setting

A consecutive series of newly-operated-upon, post-menopausal breast cancer patients scheduled for adjuvantCT at two university hospitals and one county hospital inSweden between November 2003 and November 2005were invited to participate. The inclusion criteria wereaged 55 years and older, newly diagnosed with histologicalconfirmed stage I to III a breast carcinomas, and able togive informed consent, to read and speak Swedish and tounderstand the purpose of the study. Age 55 years andabove was used to ensure that the women participatingin the study were homogeneous with respect to post-menopause.

The exclusion criteria were evidence of dementia,known history of psychiatric disorder and history of othercancers within the previous 5 years. Of 80 eligiblepatients, 75 patients agreed to participate. The age rangewas 55–77 years.

Procedure

This study was part of a larger study with the aim toinvestigate health-related QoL among post-menopausalwomen treated for breast cancer. Chemotherapy wasoffered to all patients with hormone receptor-negativebreast cancer and to high-risk hormone receptor-positive

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patients (i.e. tumour size > 50 mm and/or more than threepositive lymph nodes). The CT regimes were either flur-ouracil 600 mg/m2 intravenously, epirubicin 75 mg/m2

intravenously and cyclophosphamide 600 mg/m2 intrave-nously (FEC) every third week in a course of six treat-ments (n = 72) or cyclophosphamide 100 mg/m2 p.o. ondays 1–14 and methothrexate 40 mg/m2 intravenously andflurouracil 600 mg/m2 intravenously on days 1 and 8(CMF) in a course of six treatments (n = 3). Anti-emetictreatment was administered in accordance with localpractice. Generally, betametson 8 mg ¥ 1 intravenouslyand ondnsetron 8 mg ¥ 1 intravenously were given beforethe CT started. Subsequently, during days 1–4 ondanetron8 mg p.o. ¥ 2 was used together with a suppository meto-clopramid 20 mg on demand.

The first author contacted each woman interested inparticipating in the study. The women who agreed toparticipate were asked to complete a DCA diary for fiveconsecutive days starting on the treatment day of cycle 1(day 1) and after the third and last cycle of CT. Thus, eachpatient was requested to complete a total of 15 days. Theywere instructed to record all stressful events, the intensityof those events and the coping strategy used to managethem. The diary entries were mailed to the patients,together with a prepaid envelope and a letter explainingthe procedures and providing the telephone number of thefirst author.

A total of seven patients withdrew from adjuvant CTduring the six cycles due to various medical problems(diverticulitis, neutropenia, relapse, pulmonary embo-lism, neutropenia and heart conditions).

Measures

The DCA by Stone and Neale (1984) was developed spe-cifically for the daily recording of coping with everydaystressful events. Questions regarding the most stressfulevent of the day are completed once a day during fiveconsecutive days, where day 1 is the first day of treat-ment. The DCA contains four sections. The first sectionis a question to which the patients respond by describingthe most stressful event (illness related or not) in theirown words. The second section assesses the distressoccasioned by the stressful event. Scores range from 1(not at all bothersome) to 7 (extremely bothersome). Thethird section includes two questions concerning reac-tions to the stressful event: (1) how much control didyou have over its occurrence? (no control, some, quite alot); and (2) was it an expected stressful event or situa-tion? (completely unexpected, somewhat unexpected,somewhat anticipated, completely anticipated). The

fourth part includes eight categories of strategies formanaging the stressful event: distraction (thought aboutsomething else), situation redefinition (looked at theproblem in a different way), direct action (did somethingabout it), catharsis (expressed emotions), acceptance(accepted the problem), seeking social support (soughtsupport from others), relaxation (relaxed) and religion(sought spiritual support). The patients report whether ornot they use each of the strategies as a means of han-dling their recorded stressor for that day. The Swedishversion of the DCA was developed by Wasteson et al.(2002) and used for assessing patients with gastrointesti-nal cancer.

Analysis and reduction of qualitative data

A combination of qualitative and quantitative contentanalyses was conducted (Weber 1995). Qualitativecontent analysis was used to code and categorize patientresponses to the first question in the DCA, that is,descriptions of the most stressful events of the day. Alldiary entries were first read several times by the firstauthor (MB). The last author (ED) read a sample of thediary entries to obtain a sense of the whole. Texts thatwere relevant to the research question was then takenand compiled into a single text document. This textwas subsequently divided into units of meaning, whichwere then condensed into codes of stressful events.Identified codes were labelled to reflect the content ofthe categories.

All codes were cross-checked several times against theunits of meaning and entire diary text, and some wererevised. The codes were also compared for differencesand similarities with other codes, and tentative catego-ries were discussed and revised several times by three ofthe authors (MB, LP and ED), before they were finallysorted into six categories (Weber 1995). The categorieswere labelled ‘nausea and vomiting’, ‘fatigue’, ‘othersymptoms’, ‘isolation and alienation’, ‘fear of theunknown’ and ‘being controlled by the treatment’ andillustrated how the participants experienced the first 5days of adjuvant CT treatment at cycles 1, 3 and 6. Fromthese categories two major domains were observed:physical problems and psychosocial problems. Thedomain physical problems subsumed the categories‘nausea and vomiting’, ‘fatigue’ and ‘other symptoms’and the domain psychosocial problems consisted of ‘iso-lation and alienation’, ‘fear of the unknown’ and ‘beingcontrolled by the treatment’. Table 1 presents thederived categories and domains together with citationsfrom the diary to exemplify the categories.

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509

Tab

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510

Ethics

The study was performed in accordance with the ethicalstandards of the Helsinki Declaration and Good ClinicalPractice guidelines (WMA 2000). The Ethics Committeesat Göteborgs University and Stockholm Universityapproved the study. All patients received oral and writteninformation and gave informed written consent beforeinclusion.

RESULTS

Socio-demographic and clinical characteristics

Socio-demographic characteristics (e.g. marital status,education, work status) were obtained through patientinterviews and clinical variables (e.g. histopathology,surgery, stage) were abstracted from medical records(Table 2).

Stressful events and coping strategies

Stressful events

The frequency of occurrence of the six types of stressfulevents and the two major domains in the diary entries isshown in Table 3. Only one event could be recordedper diary. Of the 75 women participating in the question-naire study 40 patients completed all 15 diary entries(first, third and last treatments), 11 patients completed 10diary entries (first and third treatments), nine patientscompleted five diary entries (first treatment), and finally,15 did not complete any diary entries. A total of 755 diaryentries were completed, which constitute the data baseand observation units in the study.

Almost 30% (217 diary entries) recorded no stressfulevent during treatment (cycle 1, 3 and 6). Only one eventcould be recorded per diary entry and thus a total of 538diary entries (755–217) recorded some kind of stressfulevent. The most frequently mentioned stressful event was‘nausea and vomiting’ (21.6%) and the least mentionedwas ‘fear of the unknown’ (5.7%). Events associated withthe domain physical problems were almost three times asfrequent as those subsumed under psychosocial problems(34% vs. 14%).

In addition to describing an event, patients also ratedits intensity (scores 1–7), that is, how bothersome it wasperceived. These ratings were added up and divided bythe number of recordings for each specific category,yielding a mean level of distress for each category.Although the experiences of ‘isolation and alienation’and ‘fear of the unknown’ were relatively rare, they were

associated with the highest mean of distress (4.80 and4.60 respectively). In contrast, ‘being controlled by thetreatment’, also rarely mentioned, was associated withthe lowest mean level of distress (4.08). All events wereassociated with low mean levels of control, that is, theywere all experienced as difficult to manage. The event‘being controlled by the treatment’ was associated withthe lowest level of control (2.48), whereas, the event‘nausea and vomiting’ was rated easiest to control (2.18).The latter event that was also the most expectedsymptom (3.15), and the event ‘other symptoms’ wasthe least anticipated (2.58).

Table 2. Socio-demographic and clinical characteristics of thesample

Variable

Chemotherapytreatment(n = 75) N (%)

Age (years)55–64 36 (48)65–70 26 (35)>70 13 (17)

Mean 65Demographic data

Single/divorced/widowed 35 (47)University/graduate degree 38 (51)Employed, full or part time 28 (37)Old age retirement 42 (56)Swedish born 60 (80)

HistopathologyInvasive ductal 55 (73)Invasive lobular 11 (15)Other 8 (11)Data missing 1 (1.3)

SurgeryTotal mastectomy 43 (57)Sector resection 31 (41)Data missing 1 (1.3)

Axillary explorationAxillary clearance 56 (75)Sentinel node biopsy 23 (31)

Positive receptor status 34 (45)Positive lymph nodes 46 (61)Tumour size (mm)

1–20 31 (41)21–50 30 (40)>51 13 (17)Data missing 1 (1.3)

TreatmentCT 12 (16)CT + RT 26 (35)CT + RT + Endocrine 33 (44)CT + Endocrine 4 (5)

Tumour StageStage I 23 (31)Stage II 22 (29)Stage III 27 (36)Data missing 3 (4)

CT, chemotherapy; RT, radiotherapy.

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Coping strategies

In total, 1790 coping strategies were reported in relation tothe 538 stressful events. Hence, several different copingstrategies were used to manage each stressful event, witha mean of 3.33 coping strategies per stressful event (1790/538). Table 4 presents the frequencies of reported copingstrategies. The most commonly used strategies wereacceptance (17.5%), relaxation (16.6%) and distraction(16.4%). The least used strategy was religion (1.7%).

Coping strategies in relation to stressful events

Table 5 shows the daily occurrence of each coping strategyfor each type of stressful event. Acceptance, relaxation,distraction and direct actions were commonly usedcoping strategies for all types of stress. Acceptance andrelaxation were particularly frequent in relation to theevents ‘fatigue’, ‘nausea and vomiting’ and ‘being con-trolled by the treatment’. Social support and situationredefinition were most commonly used to handle ‘fear ofthe unknown’. Situation redefinition was also commonly

used for ‘isolation and alienation’, ‘being controlled by thetreatment’ and ‘fatigue’. Religion was rarely used asa coping strategy, except in relation to ‘fear of theunknown’. Catharsis and social support also tended to beused in connection with this event. The greatest meannumber of coping strategies was used in relation to ‘fear ofthe unknown’ (3.95) and the least (2.80) for ‘other symp-toms’ (data not shown). Acceptance was the most fre-quently used coping strategy in the stress event domain‘physical problems’, whereas distraction was the mostfrequently used in the domain psychosocial problems.

DISCUSSION

Stressful events

Content analysis of a total of the 755 diary entries frompost-menopausal women undergoing adjuvant CT forbreast cancer yielded six categories of stressful eventswere over the treatment period.

A surprisingly high proportion (30%) of the diary entriesin this study recorded no stressful events during the adju-vant CT, which may suggest that the everyday life of thewomen in this study was not dominated by concerns,either related to the disease or unrelated to it. Among thewomen who experienced stressful events, more of theseevents were related to physical problems (34%) than topsychosocial problems (14%).

Nausea and vomiting was among the most frequentlyrecorded stressful events and also the most expected one.Many breast cancer studies report that despite advances inthe prevention and treatment of emesis, nausea and vom-iting is still considered to be among the most severe,feared and distressing symptoms of CT (Grunberg et al.2005; Lee et al. 2005; Booth et al. 2007), despite the wide-spread use of 5-HT3 antagonists (Lee et al. 2005). Most of

Table 3. Frequency of stressful events, mean levels of perceived distress, perceived control and perceived expectations

Stressful eventFrequency(%)

Level of distressM (SD)*

Level of controlM (SD)†

Level of expectationM (SD)‡

No stressful event 217 (28.7) – – –Nausea and vomiting 164 (21.6) 4.14 (1.8) 2.18 (0.6) 3.15 (0.8)Other symptoms 117 (15.5) 4.34 (1.7) 2.40 (0.6) 2.58 (1.1)Fatigue 99 (13.1) 4.30 (1.6) 2.37 (0.7) 2.92 (0.8)Isolation and alienation 66 (8.7) 4.80 (1.8) 2.29 (0.7) 2.64 (1.0)Being controlled by the treatment 49 (6.5) 4.08 (1.8) 2.48 (0.9) 2.65 (1.0)Fear of the unknown 43 (5.7) 4.60 (1.7) 2.26 (0.6) 2.95 (1.0)Physical problems 380 (33.8) 4.24 (1.7) 2.30 (0.6) 2.92 (0.9)Psychosocial problems 158 (14.0) 4.53 (1.8) 2.34 (0.7) 2.73 (1.0)Total (across all stressful events) 755 (100) 4.33 (1.8) 2.31 (0.7) 2.86 (0.9)

*High levels correspond to high distress (range 1–7).†High levels correspond to low control (range 1–3).‡High levels correspond to high expectation (range 1–4).

Table 4. Frequency (%) of use of the eight pre-defined copingstrategies

Coping strategies Frequency (%)

Acceptance 313 (17.5)Relaxation 297 (16.6)Distraction 293 (16.4)Direct action 279 (15.6)Situation redefinition 250 (14.0)Social support 186 (10.4)Catharsis 141 (7.9)Religion 31 (1.7)Total 1790 (100)

The patients could respond with more than one coping strategyfor each reported stressful event.

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the functional changes described in QoL studies have beenfound to be attributable to CT-induced nausea and vom-iting (Rusthoven et al. 1998; Bloechl-Daum et al. 2006). Arecent study by Dibble et al. (2003) reported that delayednausea is a significant problem in women with breastcancer that receive CT and experience nausea in stressfulsituations.

The fact that nausea and vomiting was the mostexpected stressful event in the present study reflects theinformation that is given by healthcare providers beforetreatment and what the general public knows about CTand its side effects. This finding also indicates that health-care providers still do not seem to know which pharma-cologic or non-pharmacologic treatments offer best relieffrom CT-induced nausea and vomiting. It also suggeststhe need for more research on this well-known symptom.

The patients’ experiences of isolation and alienationand fear of the unknown were rated as highly distressing,even though they were relatively rare. These stressfulevents may be likened to psychological distress (depres-sion and anxiety), which is a common symptom in rela-tion to the diagnosis of cancer and its treatment (Starket al. 2002; Kissane et al. 2004; Trask 2004; Sharpley &Christie 2007). Women with substantial symptoms ofdepression and anxiety often experience increased physi-cal side effects, as well as difficulty in managing these sideeffects. The symptoms may also lead to an experience ofoverall reduced QoL (De Jong et al. 2002; Badger et al.2004; Massie 2004; Schreier & Williams 2004). Symptomsof depression and anxiety also decrease the breast cancervictims’ ability to mobilize critical support when the needfor it is greatest (Manne et al. 2004). An interview studyby Browall et al. (2006) among women in breast cancerwith adjuvant treatment found that the treatment gavedistressing experiences with affect on both body andmind. The women received some positive support from

healthcare professionals. However, the women alsodescribed variations in professionals’ attitudes, knowledgeand empathy, and they were in need of more time forinformation including support. Healthcare providers needto learn more about these symptoms and how to best be ofhelp to the women.

Coping strategies

Acceptance, relaxation and distraction were the mostcommon coping strategies for managing all stressfulevents in this study. Correspondingly, they were also themost frequently used strategies to handle stressful eventsin patients with gastrointestinal cancer in a study byWasteson et al. (2002). The benefits of using these copingstrategies is also consistent with a recent study by Cohenand Fried (2007) in which relaxation and guided imageryshowed benefits in reducing fatigue. Relaxation therapyhas also been shown to improve QoL (Walker et al. 1999)and to reduce depressed mood, anxiety and pain(Hernandez-Reif et al. 2005) in women with breast cancer.Also, non-pharmacologic interventions such as self-hypnosis, relaxation and distraction have been shownto relieve CT-induced nausea (Roscoe et al. 2003; DeCarvalho et al. 2007).

The participants in this study recorded the use of avariety of coping strategies and used an average of 3.33different coping strategies per reported stressful event(1790/538). In other words, the women did not rely on asingle coping strategy but rather employed many differentcoping strategies to deal with the same stressful event.This has been confirmed by other studies of patients withdifferent cancer diagnoses. For example, Miedema et al.(2007) reported that young adults use various coping strat-egies to come to terms with the disease and its treatment.In an interview study by Link et al. (2005), it was found

Table 5. Coping strategies in relation to stressful events (per cent diary entries recording the use of the pre-defined coping strategies foreach of the ‘stressful events’)

Coping strategies

Nauseaandvomiting% (n)

Othersymptoms% (n)

Fatigue% (n)

Isolationandalienation% (n)

Beingcontrolledby thetreatment% (n)

Fearof theunknown% (n)

Physicalproblems% (n)

Psychosocialproblems% (n)

Acceptance 60.5 (98) 51.3 (60) 73.5 (72) 45.5 (30) 68.1 (32) 44.2 (19) 61.1 (231) 52.6 (82)Relaxation 58.6 (95) 45.3 (53) 72.4 (71) 45.5 (30) 57.4 (27) 48.8 (21) 57.9 (219) 50.0 (78)Distraction 59.9 (97) 47.9 (56) 52.6 (51) 57.6 (38) 51.1 (24) 62.8 (27) 53.9 (205) 57.1 (89)Direct action 54.3 (88) 49.6 (58) 54.1 (53) 57.6 (38) 40.4 (19) 53.5 (23) 52.6 (199) 51.3 (80)Situation redefinition 42.6 (69) 39.3 (46) 53.1 (52) 50.0 (33) 53.5 (25) 55.8 (24) 44.9 (168) 52.6 (82)Social support 30.9 (50) 24.8 (29) 39.8 (39) 45.5 (30) 27.7 (13) 55.8 (24) 31.5 (119) 42.9 (67)Catharsis 17.9 (29) 21.4 (25) 29.9 (29) 30.3 (20) 29.8 (14) 53.5 (23) 22.3 (84) 36.5 (57)Religion 6.2 (10) 0.9 (1) 5.2 (5) 6.1 (4) 4.1 (2) 20.9 (9) 4.3 (16) 9.7 (15)

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that cancer patients use many coping strategies and thatthose who thought of them as methods of control wereyounger, more confident of being cured and used moreproactive strategies (e.g. lifestyle changes). In anotherinterview study by Persson and Ryden (2006), it was sug-gested that well-adjusted persons with somatic disabilitiesand/or chronic illness use several types of coping strate-gies that complement each other.

METHODOLOGICAL CONSIDERATIONS

The strengths of the current study are the demographicand diagnostic homogeneity of the sample and the longi-tudinal design. Another strength may be that both quali-tative and quantitative methods were used to capture theexperience of patient-recorded stressful events and copingstrategies since coping processes are frequently assessedby means of quantitative standardized questionnairesalone (Lazarus 2006). Problems and health-related QoL areoften assessed at pre-defined time points, often in connec-tion with a visit at the clinic. Few studies have assessedpatient-reported problems on a daily basis and over time.Standardized questionnaires often ask about the mostcommonly occurring and/or typical problems during thepast week. In analysing such information it is difficult toknow how often the symptom is experienced during thatperiod. We wanted to describe the experiences of stressfulevents and the coping strategies that post-menopausalwomen use during the period of CT. Accordingly, webelieve that it is advantageous to let the patients them-selves specify their primary problems is during treatment.The use of a diary has the advantage of providing informa-tion regarding the frequency of occurrence of symptoms,which in turn gives a more comprehensive picture of howsymptoms change over time.

A weakness of this study may be the fact that the DCAdiary is not a well-known or established instrument. Inthe present study, the unit of observation was each diary.Consequently, individuals who submitted several diarieswere over-represented, while those submitting few wereunder-represented. It is thus possible that some of ourresults may be ‘biased’ due to the fact that a few individu-als may have reported the same stressful event and thesame type of coping in all their diary entries. To checkthis, we performed analyses with each individual as theunit of observation, for example, by examining the pro-portions of stressful events and coping strategies reportedby each individual. These analyses yielded roughly thesame results as those that are presented here.

Finally, there are some limitations to the generalizabil-ity of our findings. It is important to bear in mind that our

results are reported at the group level and cannot bedirectly translated to the level of the individual patient.Furthermore, this study was hospital-based with consecu-tively treated post-menopausal patients and hence we lackinformation about patients who were not referred for ornot offered adjuvant CT, as well as those who declinedparticipation.

CONCLUSIONS

Interestingly almost 30% of all diary entries recorded nostressful events during the CT treatment period. Nauseaand vomiting was the most frequently reported andmost expected stressful event. Curiously, although thissymptom is one of the most commonly known and widelystudied CT-induced symptoms and despite the availabil-ity of special anti-emetic medication programmes, it isstill a frequent problem.

The women used several coping strategies to managetheir stressful events during adjuvant CT. The most com-monly used strategies were acceptance, relaxation anddistraction, whereas religion was rarely used. Furtherresearch is needed to better understand the relationshipbetween stressful events and the different copingstrategies used by these women.

ACKNOWLEDGEMENTS

We are most grateful to all the women who took part inthe study. This study was funded and supported by theKing Gustav V Jubilee Clinic Cancer Research Founda-tion, Göteborg, and the Sahlgrenska Academy at GöteborgUniversity, Institute of Health and Care Sciences,Göteborg, Sweden.

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