The impact due to the diagnosis of cancer undoubtedly poses a challenge not only for the patients, but also for their environment. The most essential component of this environment is the partner relationship which is normally one of the most relevant issues for the patient. Some studies show that most patients refer to their partner when asked to designate the family member most significant for them (Estapé et al., 1995). On the other hand, according to Baider and Kaplan De-Nour (2000), it is now beyond doubt that the partner of the patient with cancer suffers at least the same level of psychological distress and adjustment problems when faced with the disease as the patient him/herself. As for the partner relationship, the diagnosis of cancer in one of the members can lead to separation.. Nevertheless, some more exhaustive studies clarify this shocking statement by explaining that cancer uncovers latent conflicts in disharmonic couples, while has a cushioning effect and even may strengthen the existing relationship in harmonic couples. Thus Van Wiel (1992) highlights that closely related couples who offer support and solidarity to each other share the load derived from the disease, while those patients who do not feel supported by their partner also have to cope with additional stress due to the lack of interest or the less than expected help from their partner.
Peteet and Greenberg (1995) described four types of partner relationships which have a specific risk of entering into crisis due to the demands of the disease.
- Immature relationships: The partners are not used to trusting each other, and do not feel committed. In these cases, cancer may lead to the separation of the relationship if relevant discrepancies between the partners are revealed.
- Hostile and dependant relationships: Highly conflictive relationships or relationships with distorted communication between partners. They will certainly require therapy when facing cancer in order to have a space where they can reach consensus, but they have a high probability of separation.
- Abusive relationships: Although uncommon, there are some cases of abusive relationships in oncology. Health care staff should be aware and perform regular follow-up of these couples.
- Emotionally distant couples: Despite living together, some couples have an emotionally distant relationship. Cancer may make them realise how distant they are and the lack of intimacy and involvement between them.
Nevertheless, we intuitively believe that the onset of cancer in one of the partners rarely results in divorce in our context, although this does not mean that the impact of cancer does not lead to readjustment in the closest relationships of the patient. Generally speaking, the most common problems in couples facing the challenge posed by cancer together are the following:
- ANXIETY AND DEPRESSION. These are the most common reactions in patients with cancer. The available studies generally show some grade of positive, although moderate, correlation between the anxiety and depression levels observed in patients and their partners (Baider and Kaplan De-Nour, 2000). This conclusion is quite generalised, although with some reservations with respect to the localisation of the tumor and also other characteristics of the patient such as gender. Given that the family is increasingly more involved in the psychological treatment of the patient, both the specific impact of cancer on each component of the patient’s environment and the relationships established as a result of the disease should be assessed. Thus, the partner of the patient may also receive therapy or be involved in the patient’s treatment as a supportive agent. Moorey and Greer (2002) highlight the potential and essential role of the partner as co-therapist. These authors suggest a structured therapy in which the patient’s partner is included in specific aspects.
- BARRIERS TO COMMUNICATION. The people we treat in oncology are immersed in a socio-cultural reality. Health- and disease-related attitudes are part of this reality. Cancer is a disease that unquestionably raises connotations of death, pain, and suffering even in the 21st century (Estapé, 2004). The stress present in the different phases of the disease progress is closely linked to a change experienced not only by the patient but also his/her partner. In many cases, the questions which come up in this situation result in fears which can hardly be spoken out loud. This leads to avoiding certain issues and to a decreased level of communication and trust even in harmonic couples. Both the patient and his/her partner may begin to suppose or “work out” feelings of the other, even to analyse gestures and attitudes. Patients with cancer become especially sensitive to the reactions of other people towards them; therefore they can be over-attentive to their partner and assume that certain comments and behaviour are related to them. In extreme cases, this may result in a feeling of extreme solitude for the patient and, of course, also for his/her partner (Estapé, 2002). Feelings should be expressed or even provoked, with the help of a professional if required, no matter how harmful they may seem.
- PERCEIVED SOCIAL SUPPORT. The influence of social support provided for the patient as preventive or reducing factor for psychological distress is one of the aspects whose study revealed the most consistent findings. The partner is obviously included in the social network of the patient (Parker, 2003). In Psycho-oncology, however, this aspect is known as “perceived social support” due to the often high discordance between the quantitative and the qualitative support, as well as between the support effectively provided to the patient and his/her satisfaction with it. A proportion of the patients, even in closely related couples, have been found to qualify the support they receive inadequate or insufficient. This finding should be studied in depth, as it should be necessary to analyse to which extent the satisfaction with the perceived support has also to do with other factors. For example, several studies have shown that those patients with higher levels of psychological distress give lower scores to the support provided by their partner (Baider and Kaplan De-Nour, 2000).
- SEXUAL PROBLEMS. It is difficult to consider the partner relationship separately from sexual functioning. However, reducing the sexual alteration of the patient with cancer to a supposed alteration of his/her relationship may result in bias. The impact of the diagnosis and the treatment on the life of the patient has to be taken into account. Some of the affected aspects can simply be psychosocial, but paying attention solely to these aspects would also result in reducing the problem, as increasingly more treatment-related physiological effects are being detected. Both the hormonal and non hormonal effects may directly or indirectly impair sexual life (e.g.: in the case of the prostatectomy which effectively prevents sexual performance, or mastectomy which, in itself, should not impair sexual functioning but does affect it due to its connotations). Sexual relations constitute a complex issue which has often deserved to be considered separately in literature. During the first year after diagnosis, complementary treatments are usually performed and both the patient and his/her partner accept the decreased frequency or even the complete lack of sexual relations, but once the treatment has been overcome and the cure appears to be tangible, sexual relations become a crucial aspect (Estapé, 2004). Certain emotional factors (anxiety, depression, self-esteem, etc.) and physical factors (related to the after-effects of cancer, the localisation of the tumor, etc.) also play a role in this aspect (Andersen and Golden-Kreutz, 2000). We can consider this as a typical problem of the survival phase, which is sometimes difficult to manage and remains taboo between the partners, and is left to one side (Alterowitz and Alterowitz, 2004). In many cases, the use of a therapeutic approach is required in order to restore communication and encourage the emotions of both partners to be expressed.
We have solely mentioned those problems which should be faced by the partners in their relationship, but there are many other aspects and challenges derived from cancer that they have to cope with together. In general, we refer to problems such as the employment situation of both partners (the patient may have difficulties in resuming work, while his/her partner may often need to be absent from work to provide specific care for the patient), difficulties related to their children (care-giving and information disclosure may be problematic in small children), social isolation (those couples with a social network may feel lonely and poorly understood by their friends) (Langeveld et al., 2003). Couples who haven’t had children before the disease face another increasingly more relevant aspect, as many treatments complicate or even prevent having children. The fact that maternity is currently being delayed by many women aggravates this problem which results in depression and decreased self-esteem (Schover, 2000). Some couples decide to adopt a child, but their medical history can be an obstacle in some cases. All this makes the patients’ adjustment difficult after cancer, as many of them comment that they “want to feel normal” but often do not succeed in achieving it.
Last but not least, we also have to mention those often young patients who overcome cancer without any partner. Their doubts about how to establish relations (whether or not to explain what happened, when to explain it, etc.) and their fear of beginning sexual life may prevent them from getting involved in social contacts (Hill and Stuber, 1998).
In conclusion, cancer is a disease that has an impact on the life of both the patient and his/her environment. We can not consider the significant others of the patient separately, as they are undoubtedly as, or more affected as the patient him/herself. One of the most affected persons is unquestionably the partner who is required to provide practical and emotional care for the patient, even if he/she is also having difficulties to cope with the situation. This issue needs to be further studied in order to improve the psychological care of the patient and his/her partner.