乳癌與頭頸癌病人於「因應」上之差異 － 以「因應類別」與「因應方式」來探討

Abstract

緒論：臨床實務常見乳癌與頭頸癌病人因應壓力之行為表現不同。雖然過往研究可知壓力因應對於癌症病人後續的生理與心理適應有很大的影響，然少有研究細究以何種標準來比較因應較為適切。本研究目的為比較未進行分類之「因應方式（ways of coping）」以及基於「演繹法」與「歸納法」兩種方式建立的「因應分類（coping categories）」，以了解分類對於因應類別中的因應方式組成、乳癌與頭頸癌病人之因應特性差異、及因應對於後續心理適應之預測力影響為何。\n研究方法：本研究對象為台灣北部某醫學中心確診乳癌及頭頸部癌症入院接受腫瘤切除手術之病人，於病人術後一與三個月時進行收案。研究工具以「短版癌症因應量表（Brief-COPE）」測量病人的因應，並以情緒壓力評估、台灣簡明版世界衛生組織生活品質問卷測量病人後續之心理適應。透過演繹分類法與歸納分類法建立因應類別後，比較兩種分類方式之因應類別中因應方式組成的異同，並透過變異數分析與獨立樣本t檢定比較兩類癌別於不同因應類別與因應方式之差異，並以多元迴歸分析不同因應類別與因應方式對於病人後續心理適應的預測力。\n研究結果：本研究納入105位乳癌病人與76位頭頸癌病人。演繹分類法將短版因應量表之因應方式分成「問題取向因應」、「情緒取向因應」、及「失功能因應」等三個因應類別。歸納分類法利用探索性因素分析將短版癌症因應量表分成「個人內因應」、「社會支持因應」、及「逃避因應」等三個因應類別。兩種分類法建立之因應類別的因應方式組成差異多達八項。「因應類別」與「癌別」之混合設計變異數分析結果顯示，僅歸納分類法獲得之因應類別在因應與癌別的交互作用效果顯著，乳癌在「社會支持因應」上顯著高於頭頸癌，在其餘兩種因應上則無顯著差異。「因應類別」於後續心理適應預測比較上，「歸納分類法」之預測力較「演繹分類法」略佳。「個人內因應」可顯著負向預測兩類癌別病人的情緒壓力，顯著正向預測兩類癌別病人四個面向的生活品質；「逃避因應」可顯著正向預測兩類癌別病人的情緒壓力，顯著負向預測兩類癌別病人四個面向的生活品質。在「因應方式」之比較結果顯示，乳癌病人於「尋求情緒性社會支持」、「尋求工具性社會支持」、及「情緒宣洩」上顯著高於，於「自責」上顯著低於頭頸癌病人。在因應方式對於心理適應的預測分析中，「接受」、「幽默」、「情緒宣洩」、「正向再建構」、「分心」、「行為脫離」、及「自責」等因應方式皆能顯著預測情緒壓力或生活品質，其中「自責」與「正向再建構」為較具預測力的因應方式，「自責」可顯著負向預測頭頸癌病人的心理、社會、及環境生活品質，「正向再建構」可顯著正向預測乳癌病人四個面向的生活品質。討論與結論：本研究以單筆資料討論演繹法與歸納法之因應分類，發現分類方式會造成因應類別中所包含的因應方式組合不同，而有不同的比較結果。歸納分類法對於兩類癌別有較佳區辨力，且對後續心理適應有較佳的預測力。然而歸納分類法於不同研究間常得到不同的因應方式組合，造成跨研究之間比較的困難。本研究結果顯示，「因應方式」應最適合作為此類臨床因應研究之討論基準，其中以「正向再建構」與「自責」有最佳的區辨力及預測力。將罹癌原因歸因於不良的生活習慣（如：抽菸、嚼檳榔）可能使頭頸癌病人較易以「自責」來因應疾病壓力，若他人以限制與責備的方式來表達關心，病人可能加深自責、減少連結，而使生活品質變差。而乳癌病人較常使用「正向再建構」，可能與有較多的社會支持有關，進而促進較佳的生活品質。從「正向再建構」與「自責」等因應方式的層次來理解病人的因應歷程，亦應有助於臨床工作者針對乳癌與頭頸癌不同的因應特性，進行差異化的評估並協助調整，以利後續適應。

Objective: Breast cancer (BCa) and head and neck cancer (HNC) patients appear to cope with their illness differently during treatments. While previous studies have suggested that coping could remarkably impact on illness adaptation, there is no consensus on how to compare coping. Therefore, by investigating (1) ways of coping, (2) inductive coping categories, and (3) deductive coping categories, this current study aims to identify an appropriate method to compare coping differences between BCa and HNC patients, and to reveal the predictability differences of coping on the well-being of these patients based on these categories.\nMethod: A total of one 105 breast cancer patients and 76 head and neck patients were included in this study. All patients were recruited from the same medical center in northern Taiwan. Participants were asked to fill questionnaires on coping (the Brief COPE) at 1-month post-surgery, emotional distress (The Distress Thermometer), and quality of life (WHOQOL-Taiwan Brief) at 3-month post-surgery. Deductive coping categories (problem-focused, emotion-focused, and maladaptive coping) were defined by the original design of the brief COPE. Exploratory factor analysis (EFA) was used to identify inductive coping categories. Analysis of Variance (ANOVA) and independent sample t-tests was used to examine the coping differences in BCa and HNC patients. Finally, multiple regression analysis was applied to examine if ways of coping, inductive, and deductive coping categories could predict BCa and HNC patients` well-being.\nResults: The results of the EFA showed that the Brief COPE inventory could be merged into three inductive coping categories: self-sufficient, socially-supported, and avoidant coping. Eight out of 14 "ways of coping" were clustered into different categories between inductive and deductive coping categories. The ANOVA results showed a significant interaction on inductive coping categories, such that while BCa and HNC patients were not different in "self-sufficient coping" and "avoidant coping", BCa patients showed a higher level of "socially-supported coping" than HNC patients. Furthermore, the inductive coping categories had better predictabilities on well-being than the deductive coping categories. In both BCa and HNC patients, (1) the self-sufficient coping could negatively predict emotional distress and positively predict all four aspects of QoL at 3-month post-surgery; (2) the avoidant coping could positively predict emotional distress and negatively predict all four aspects of QoL of both types of cancer patients at 3-month post-surgery. Regarding the differences of the "ways of coping," results revealed that patients with BCa were higher on "using emotion social support," "using instrumental social support," and "venting," and lower on" self-blame" than HNC patients. Furthermore, results of multiple regressions also showed that "accept," "humor," "venting," "positive reframing," "self-distraction," "behavioral disengagement," and "self-blame" could significantly predict emotional distress and QoL. In which "self-blame" and "positive reframing" had the best predictability: "self-blame" could negatively predict mental, social, and environmental aspects of QoL in HNC patients, and "positive reframing" could positively predict all four aspects of QoL in BCa patients.\nDiscussion: By comparing the compositions of the deductive and the inductive coping categories, the present study has demonstrated different categorizing approaches could result in different combinations of coping behaviors, thereby leading to unexplainable mixed results. This study suggests the inductive coping categories should be outstanding in differentiating coping used by BCa from HNC patients as well as predicting subsequent well-being. However, the inductive approach often results in different combinations of "ways of coping" in different studies, making it difficult to compare results among studies. Thus, the current study recommends the "ways of coping" as an appropriate benchmark for coping comparison in clinical settings. Among all 14 "ways of coping," the most important ones concerning BCa and HNC patients might be "self-blame" and "positive reframing." HNC patients might tend to use "self-blame" to coping to illness if they attribute their unhealthy habits (such as smoking and chewing betel nut) as the cause of cancer. If the others also blamed the HNC patients on these habits, these patients` social resources could be reduced, and leading to worsened quality of life. On the other hand, BCa patients often show higher social support levels, thus having more resources for "positive reframing," facilitating a better quality of life. In conclusion, "ways of coping" (such as "positive reframing" and "self-blame") might be a better approach while discussing the concept of coping in clinical settings. According to their characteristics on the "ways of coping," it might enable us to help patients with different cancer with better communication, evaluation, and intervention.