NEOcoping is a prospective, multicenter study of the Continuous Care Group of the Spanish Society of Medical Oncology (SEOM) that brings together 15 Medical Oncology departments in Spanish hospitals and 497 evaluable patients. To the best of our knowledge, this is among the largest series of variables covering different aspects of the process of coping and SDM on the suitability of adjuvant treatment. The study is ongoing, and results will be completed over time.
This study examines breast and colon cancer because they are common tumors, proven to benefit from adjuvant treatment, and with relatively high cure rates. Beaver et al. compared the same cancers and analyzed preferences in decision-making [25]. They found a more active and demanding attitude in breast cancer patients, which coincides with our findings in this regard. Our study, however, investigates a greater number of clinical, psychological, quality of life, and SDM variables over two very different periods of time: first, following curative surgery and prior to initiating adjuvant treatment and second, at the end of treatment.
Our results suggest that breast cancer patients respond worse to their cancer diagnosis, and are less satisfied with their doctors than colon cancer patients. The latter participants were older and had more physical symptoms and functional limitations at the beginning of adjuvant treatment. Previous studies evaluating patient preferences revealed that breast cancer patients are younger, healthier, and have more active or cooperative roles [5, 26] while individuals with colon cancer would like to be informed and involved in decision-making, but do not necessarily want to make autonomous treatment choices and many prefer a more passive role [27]. In addition, the greater psychological impact of breast cancer, with more symptoms of anxiety, depression, and somatization is not only explained by the fact that it affects younger patients, at a time of maximum professional and family activity, but also by significant changes in appearance (hair loss, mastectomy, weight gain due to hormonotherapy), physical symptoms, and uncertainty about prognosis [6, 7].
Another difference between the two groups is social support. Breast cancer patients look for support from friends and colleagues, while subjects with colon cancer are more family-dependent. This may be a simple generational issue related to the younger age of breast cancer patients.
At the end of adjuvant treatment, there are fewer differences between the groups that are most affected both psychologically (with more somatic symptoms and greater psychological distress) and physically (with lower functional and quality-of-life scores). Likewise, both groups score low on coping strategies except for anxious preoccupation in response to what they may perceive as a kind of a sword of Damocles.
Based on these results, it can be hypothesized that patients are better prepared to fight at the start of treatment and are at their worst psychologically once adjuvant treatment has ended. The subsequent scenario is no longer one of fighting, but of repairing damages and returning to their previous activities and roles, for which they do not yet feel ready. This last observation is especially relevant, given that from that point forward, most patients (at least according to the most usual follow-up protocols) will be left without medical supervision for months after a long series of frequent medical visits during adjuvant treatment. Perhaps, on the basis of these results, we should consider psychological intervention precisely at this point in time. A similar methodology was used by Boinon et al., who interviewed 102 women with breast cancer after surgery and at the end of adjuvant treatment, with special attention paid to the influence of social support on perceived well-being [27]. Patients responded to self-report questionnaires assessing psychological adjustment (depressive symptoms and anxiety related to cancer), social participation concerning their illness, and perceived social support (generic and cancer-specific).
Study limitations
This study is not without its limitations that must be taken into consideration. First of all, the use of self-report, subjective measures cannot accurately reflect patients’ experiences, expectations, and behaviors, as they are limited by response bias (social desirability, inaccurate memory, etc.), which we have attempted to minimize by reminding patients that answers were completely anonymous and that there were no right or wrong answers. Second, we have compared patients with breast and colon cancer, and 100% in stage I-III; therefore, the results may not generalize to patients with other tumors or in stage IV disease. Another limitation, despite sex was taken into consideration in subgroup analyses, is that breast cancer patients were mostly women, while colon cancer patients were men and women. Therefore, characteristics due to sex may have influenced the results. Finally, there are numerous factors that can influence treatment decision and that have not been considered, such as the presence of comorbidities, type of treatment, and side effects.
Given the size of our sample and the prospective nature of the evaluation, we consider the outcomes to be reliable, robust, and relevant, which allows us to suggest measures to improve coping and psychological well-being at the beginning and end of adjuvant chemotherapy. We believe this study to be a benchmark in this field. The limitation of exploring only two-time periods in a continuous process can be overcome with subsequent surveys, such as in the study by Ganz et al. [28] who collected data from 558 women with breast cancer after surgery and at 2.6 and 12 months, revealing significant physical and psychosocial recovery in the first year after treatment had been completed.