初探乳癌病人於術後一個月之癌症態度、因應、及生活品質的關係

緒論：乳癌病人身心適應照護是近來備受重視的議題。然而，對癌症之態度可能是較少受到關注的重要議題之一。態度為個體對特定對象既有之一定程度的好惡與想法，此些傾向與其後續行為反應及應對結果有關。目前癌症態度研究多為針對特定面向（如罹癌原因、癌症治癒性），且大部分探討的是大眾癌症態度或癌症生存者態度。較少研究探究正處於疾病治療歷程中之癌症病人、或是較整體性的癌症態度。故本研究旨在以多面向態度作為主要研究概念，探討術後一個月之乳癌病人的癌症態度與因應、生活品質的關聯。研究方法：本研究邀請於台灣北部某醫學中心中接受手術的乳癌病人參與研究。於術後一個月時，請研究參與者填寫台灣癌症態度量表、短版因應量表及台灣簡明版世界衛生組織生活品質問卷，評估其癌症態度、因應策略及生活品質。以驗證性因素分析檢驗台灣癌症態度量表於本研究資料中是否適用原量表發展時之三因素結構，並進行信效度分析。以路徑分析檢驗癌症態度對因應、生活品質是否具顯著預測力，以及因應是否中介癌症態度與生活品質之間的關係。研究結果：共有104位研究參與者的資料納入分析，平均年齡為55.14歲（SD=11.75）。結果顯示原量表發展時之「外觀」、「復發恐懼」和「自我責怪」三因素模式適用於本研究中的台灣癌症態度量表資料，並整體具良好信度及效度。路徑分析之參數結果顯示(1)「自我責怪」可顯著負向預測個人因應、正向預測逃避因應；(2)「自我責怪」可邊緣顯著負向預測生理、社會生活品質；(3)個人因應可正向預測四個面向的生活品質，逃避因應負向預測心理、環境生活品質。中介模式結果顯示，「自我責怪」可(1)經由個人因應負向預測四個面向的生活品質，以及(2)經由逃避因應負向預測心理、環境生活品質。為更全面了解各個癌症態度因素與因應及生活品質的關係，故進一步將各癌症態度因素分別作為三次模式估計的唯一外生變項，進行模式估計（模式二A：外觀、模式二B：復發恐懼、模式二C：自我責怪）。路徑分析之參數結果顯示(1)「外觀」可負向預測個人因應、生理生活品質；(2)「復發恐懼」可負向預測個人因應、生理及社會生活品質；(3)「自我責怪」可負向預測個人因應、生理及社會生活品質，以及可正向預測逃避因應；(4)模式二A與模式二B中，個人因應可正向預測四個面向的生活品質，逃避因應負向預測心理、社會、環境生活品質；模式二C中，個人因應可正向預測四個面向的生活品質，逃避因應可負向預測心理、環境生活品質。中介模式結果顯示，模式二A、B、C中，「外觀」、「復發恐懼」、「自我責怪」分別可經由個人因應負向預測四個面向的生活品質，且「自我責怪」亦可經由逃避因應負向預測心理、環境生活品質。討論：研究結果支持「個人因應」與「逃避因應」是癌症態度與生活品質之關係中重要的中介因素。「自我責怪」為預測力最強的癌症態度面向，個人因應為主要的中介路徑、逃避因應為次要的中介路徑，社會支持因應路徑統計上皆未顯著，此或許和乳癌病人術後一個月這個時間點所面臨的挑戰多為個人層面有關。三個面向的癌症態度分別皆可經由因應負向預測生活品質，亦可直接預測生理及社會生活品質，反映出乳癌病人與癌症相關之價值觀對其因應及生活品質具龐大的影響力。於臨床上，雖然態度的改變較為困難，不過本研究結果顯示調整病人的因應應是有幫助的。

關鍵字

癌症態度；乳癌病人；因應；生活品質；中介

並列摘要

Objective: Psychological care for breast cancer patients has been an issue that has received much attention nowadays. However, attitude toward cancer might be one of the essential topics that received little attention. Attitude is a predisposing tendency expressed by evaluating a particular entity with some degree of favor or disfavor related to individual's subsequent behavioral reactions and results. However, most cancer attitude researches are focused on specific aspects, such as the cause, the curability, and cancer attitudes of cancer survivors or the public. However, little research endeavors cancer patients during treatment or a more general view of "attitude toward cancer." Therefore, this study aimed to use multi-aspected attitudes to explore the relationship among cancer attitudes, coping, and quality of life among breast cancer patients one month after surgery. Method: Breast cancer patients who underwent surgery in a medical center in northern Taiwan were invited to join the study. At the time of 1-month post-surgery, participants were asked to fill the Taiwan Attitude towards Cancer Scale (TACS), the Brief-COPE, and the WHOQOL-Taiwan Brief version, to measure the cancer attitude, coping, and quality of life (QOL). Confitmatory factor analysis (CFA) was used to validate if the original three-factor structure appliable, and the reliability and vadility were also tested. Path analysis was used to explore whether cancer attitudes can predict coping and QOL, and if coping could serve as mediators. Results: A total of 104 breast cancer patients were included in the study. The mean age was 55.14 (SD=11.75) years old. Results showed that the three-factor model of "appearance," "fear of recurrence," and "self-blame" of the TACS is suitable for the current study and has good reliability and validity overall. The estimation results of the parameters showed (1) "self-blame" could negatively predict self-suffificient coping, and positively predict avoidant coping significantly. (2) "Self-blame" could negatively predict physical and social aspects of QOL marginally. (3) Self-suffificient coping could positively predict all four aspects of QOL; avoidant coping could negatively predict psychological and environmental aspects of QOL. The mediation model results showed that "self-blame" could negatively (1) predict all four aspects of QOL via self-suffificient coping and (2) predict psychological and environmental aspects of QOL via avoidant coping. In order to fully understand the relationship of each cancer attitude with coping, and QOL, each factor of cancer attitude was used as the only exogenous variable in the three futher models of estimations (Model 2A: appearance; Model 2B: fear of recurrence; Model 2C: self-blame). The estimation results of the parameters showed (1) "appearance" could negatively predict self-suffificient coping and the physical aspect of QOL; (2) "fear of recurrence" could negatively predict self-suffificient coping and the physical and socail aspects of QOL; (3) "self-blame" could negatively predict self-suffificient coping and the physical and socail aspects of QOL and could positively predict avoidant coping. (4) In Model 2A and Model 2B, self-suffificient coping could positively predict all four aspects of the QOL, and avoidant coping could negatively predict psychological, social, and environmental aspects of QOL. In Model 2C, self-suffificient coping could positively predict all four aspects of QOL, and avoidant coping could negatively predict psychological and environmental aspects of QOL. The results of the mediation models showed that, respectively, "appearance," "fear of recurrence," and "self-blame" could negatively predict all four aspects of QOL via self-suffificient coping. Futher, "self-blame" could also negatively predict the psychological and environmental aspects of QOL via avoidant coping. Discussion: The results supported that the "self-sufficient" and "avoidant" coping were crucial mediators of the relationship between attitudes toward cancer and the quality of life. "Self-blame" is the most influential aspect of cancer attitude, and the primary mediation path is via self-sufficient coping, and the secondary mediation path is via avoidance coping. The socially-supported coping path was not significant statistically, which may be related to the challenges faced by breast cancer patients one month after surgery are primarily personal. All three aspects of cancer attitudes could negatively predict the QOL via coping and could directly predict physical and social aspects of QOL, respectively. These results might reflect the cancer-related values one had could have a colossal impact on breast cancer patient's coping and quality of life. Clinically speaking, although the attitude might be harder to change, the current results showed that modifying patient's coping should be helpful.