Marital Satisfaction in Women with Breast Cancer : A Comparison between Mastectomy and Breast Conserved patients

Marital satisfaction is a multidimensional concept and depends on many factors. Breast cancer is the most common cancer specific to one part of the body in women and the leading cause of death due to malignancy in women of 40 to 44. Breasts are a symbol of femininity, when they are lost due to cancer treatment or there is transformation in them, in addition to physical pain, psychological burden on the patients will be significant. This study was performed on 50 patients with breast cancer referring to the radiotherapy clinic of Golestan Hospital in Ahvaz. Patients were divided into two groups (n=25) patients with mastectomy and breast conserved patients. Data were collected through interviews and 47-item Enrich marital satisfaction questionnaire. The data were analyzed using SPSS15. The statistical level of p <0.05 was considered as statistically significant level. A comparison of the relationship between marital satisfaction and the elapsed time between mastectomy and breast-conserved groups showed that with increase of time in the mastectomy group, the level of marital satisfaction reduced.


INTRODUCTION
Marital satisfaction is influenced by different factors, the collection of which results in marital satisfaction [1][2][3][4][5] .Marital life quality may be the first thing that women are concerned about when they are diagnosed with breast cancer.Mastectomy results in the loss of an important part of a woman's body and this causes a loss of confidence and a sense of charm in the patients [6][7][8][9]3 . Th main advantage for women with breast cancer is breast conservation and preservation of the body form 10,11 .
There are common signs of anxiety and depression in patients with cancer.This mental turmoil has impacts on healthy sexual performance and can be a significant problem for patients.Patients with higher levels of psychological distress experience extra sexual dysfunction [12][13][14][15][16] .Decreased physical performance, lack of sleep, fatigue, loss of appetite, pain associated with psychological distress, each of which can affect sexual desire [17][18][19][20] .
The results of a study that examined the relationship between social interaction and marital satisfaction showed that people who are dissatisfied with their lives are unable to maintain satisfactory relationships outside the family and tends to isolation and loneliness and depression 21 .The results showed significant differences in body image, self-esteem and feelings of attractiveness in mastectomy patients in comparison of before and after surgery 22 .Today, the conservative surgery for breast cancer in which the breast tissue is only partly taken out is an acceptable method, but is used limitedly.The statistical survey showed that only 20% of general surgeons used a conservative approach, and the rest preferred mastectomy 11 .
Given the high rate of incidence of breast cancer and mastectomy and treatment effect on marital satisfaction, and also the fact that so far not many reviews are conducted about it, especially in Iran, the present research studied and compared marital satisfaction in patients with breast cancer in two groups the ones who underwent breastconserving surgery and the mastectomy group.Understanding this relationship helps the family and doctors to increase the satisfaction of patients in normal life, especially given the impact of treatment on their marital relationship.

MATERIALS AND METHODS
The study conducted was an epidemiologic analytical study that assessed the life satisfaction in 50 married women with breast cancer compared in two groups with mastectomy and breast conservation.Patients aged from 20 to 55. Enrich questionnaire developed in 1989 in America to identify areas of strength to evaluate potential prolific and productive problems relationship, modified in Iran by Soleimanian (1994) as a shorter form with 47 questions, including 12 sub-scale was used.In this questionnaire, nine subscales (personal issues, marital communication, conflict resolution, financial management, leisure events, sex, marriage and children, relatives and friends, and religious orientation) were evaluated.
To examine the findings of the investigation descriptive statistics and to examine the differences between the groups inferential statistics (t test) were used.Data analysis was performed using SPSS17.

RESULTS
The relationship of marital satisfaction and breast cancer was evaluated in patients with breast cancer in two groups with breast conservation and mastectomy.Moreover, marital satisfaction subscales were calculated and compared between two groups.All statistical calculations were done with the help of SPSS17, and statistical level P <0.05 was considered as statistically significant level.
Tables 1 and 2 indicate descriptive research findings in breast conservation and mastectomy groups, is these two groups, common life satisfaction score (based on Enrich questionnaire), the scores of marital satisfaction subscales (based on Enrich questionnaire) and age of sickness were calculated.
In this group, the elapsed time from start of treatment was about 28.2 months.The average marital satisfaction scores in mastectomy group was 157.08, which represents the average satisfaction of marital relationship of spouses.
Research variables were compared.The results of this comparison in Table 3, where subscales of marital satisfaction in both groups has been shown, demonstrated that there was no significant difference between the two groups in any of subscales and there is no difference between the subscales of marriage and children between the two groups.
Marital satisfaction sub-scales were compared in the two groups and there was no significant difference between the two groups.Table 4 shows the correlation between the variables used in the study and the results of the relationship between marital satisfaction and the elapsed time from the start of treatment in the breast conservation group.In this study, there was no significant correlation between these two variables.
By increase the elapsed time from start of treatment (sickness age) marital satisfaction did not change, i.e., there was no difference between age and marital satisfaction in the breast conservation group.The relationship between marital satisfaction and the elapsed time from start of treatment in the mastectomy group is shown in Table 5.The results of this study showed that by increase in the elapsed time from disease, marital satisfaction decreased.
Based on these results, in the mastectomy group marital satisfaction decreased with increasing age of sickness (P <0.05).

Correlated variables
The correlation coefficient Significance level Number of samples Sickness age and marital satisfaction 0.34 0.09 25

Correlated variables The correlation coefficient Significance level Number of samples
Sickness age and marital satisfaction -0.149 0.01 25

DISCUSSION
Breast conservation group had moderate status in marital satisfaction.Reduction of this measure can be due to fatigue caused by chronic therapy and chemotherapy effects (fatigue, nausea, etc.).
In interviews, many people said that, the majority of family income is devoted to their treatment.Due to the high costs of treatment, the patient's expectation level reduced and was satisfied about how the family spends.
In previous studies, including the study of Norder Center, breast cancer was considered as a risk factor for sexual relations, as well as the study conducted at Georgia University breast cancer had reduced sexual understanding and sexual attraction (6, 11).In the Norder study, reduction of sexual activity in patients with breast cancer was with increased supportive role of their spouses, in this study, patients did not have more problems than the control group (6).Group mastectomy in marital satisfaction sub-scale was moderate.
Feeling bad body shape, costs and consequences of the disease treatment can be effective in reducing the satisfaction with level and type of relation.Both groups had high satisfaction in the area of financial management, due to the heavy costs of chemotherapy and surgery, most patients felt gratitude towards their spouses, and expectations about the rest of their household income had decreased.In religious orientation the mastectomy group had high satisfaction.
It is justified according to the culture of our society and that many people have religious beliefs.Marital satisfaction in the mastectomy group was 157.08, which indicates the relative and average satisfaction with marital relations by the spouses.In the study conducted in Norder Center, despite the decline in sexual relations, the role of spousal support had increased and on the whole, breast cancer was considered as a risk factor for relations between the spouses.Mastectomy and breast conservation groups had no differences in subscales of marriage and children.This can be the result of the culture of our society, and that the children have a key role in the lives of Iranian families and are often of couple's priorities of thought, so that even the disease, such as pain due to disease and other problems caused by breast cancer treatment costs do not affect the thinking and practice of parents towards their children.Moreover, often the couples agree in the care of their children and the importance of children in the family.
The main objective of this study was to investigate the relationship between mastectomy and breast-conserving surgery in the marital satisfaction in patients with breast cancer.The results of the survey data showed that there is no significant difference between the two groups in of breast conservation and mastectomy in the rate of marital satisfaction.
These results were similar to the results of study by Bokovic (19).In this study, the type of surgery had no effect on marital satisfaction and sexual compatibility.In examining relationships between couples in the study by Bokovic, the sense of satisfaction from sexual life in breast cancer patients fell after surgery in both groups, but there was no significant difference between the two groups.The results for the difference between the two groups are consistent with this study.
The results of this study showed that, there was no relationship between marital satisfaction and the time elapsed since the disease.This means that by increasing the elapsed time from illness, marital satisfaction did not change.Also checking out the results of the comparison between marital satisfaction and the elapsed time of the mastectomy surgery showed that, with increasing elapsed time of surgery, marital satisfaction decreased in mastectomy group.This can be due to the reduced spousal support after the passage of time.At the start of the sickness, factors such as pity increase the attention and support of the spouses, but gradually over time, given that breast is an important organ in sexual relations, the created sexual dysfunction decreases marital satisfaction.In the mentioned study, sexual performance, satisfaction with marital life, a sense of sexuality, body image, quality of life and marital satisfaction have been surveyed where most problems during had been during the first months after the operation and reduced over time.These results are justified because immediately after surgery, there are the problems such as pain from surgery, the stress of dealing with the disease, and, over time, the increase of understanding of the patients from the disease can help reduce the problems.
In a study at the University of Georgia that was done during one year (21) with the passage of time, sexual problems had decreased, but increased in total before the operation.In the present study, the most time passed of the sickness was about 6 years that was longer than in the study at Georgia University, which could be the reason of difference in the results.The main objective of the project was comparing marital satisfaction in breast cancer patients with breast conservation and mastectomy and there is no significant relationship between the two groups (Table 3).Of the implications of the findings is delivering results to health care officials as a strategy to select the best type of procedure in relation to the treatment of patients with breast cancer.