Gender Differences in the Use of Engagement and Disengagement Coping Strategies in Oncology Patients Receiving Chemotherapy

Review of the literature

Only four studies were identified that evaluated for gender differences in coping with cancer (Fife et al., 1994; Goldzweig et al., 2009; Jacobs-Lawson et al., 2010; McCaughan et al., 2012). In a United States study that evaluated 208 women and 125 men with a variety of cancer diagnoses (i.e., breast, testicular, lymphoma, lung) and assessed for differences in their coping styles using the Ways of Coping Checklist (Fife et al., 1994), the investigators found that compared to men, women used religion, social support, active coping, and positive focusing more frequently. In contrast, men used avoidance coping more frequently. In the second study of Israeli women (n=153) and men (n=186) with colorectal cancer (Goldzweig et al., 2009), the Mental Adjustment to Cancer (MAC) scale was used to asses gender differences in coping styles. Compared to men, women used a fighting spirit style of coping more often. In contrast, men were more likely to use a hopelessness/helplessness style or a fatalistic acceptance style of coping.

In the third qualitative study from the United Kingdom (McCaughan et al., 2012), gender differences in the experiences of 14 women and 24 men with colorectal cancer were evaluated. Women were less likely than men to downplay their long-term symptoms or side effects. Of note, some men reported embarrassment or negativity with showing emotions. In the fourth study done in the United States (Jacobs-Lawson et al., 2010), 47 women and 53 men with lung cancer completed the Coping Effectiveness Scale and the religious coping subscale of the Fetzert/National Institute on Aging Brief Multidimensional Measure of Religiousness/Spirituality. While no differences were found in coping effectiveness, women used religious forms of coping more frequently than men.

While these four studies provide some insights into gender differences in coping with cancer, several limitations warrant consideration. Sample sizes for two of the studies were very small (Jacobs-Lawson et al., 2010; McCaughan et al., 2012). The methods used to obtain information on biological sex and/or gender were not reported. Across the four studies (Fife et al., 1994; Goldzweig et al., 2009; Jacobs-Lawson et al., 2010; McCaughan et al., 2012), the measures used to assess coping were inconsistent and none of the studies used the most commonly used instrument to assess coping in oncology patients, namely the Brief COPE (Scrignaro et al., 2011; Yusoff et al., 2010). Given the limited amount of research on gender differences in coping with cancer, the purpose of this study, in a sample of women (n=277) and men (n=293) undergoing chemotherapy (CTX) for either GI or lung cancer, was to evaluate for gender differences in coping strategies using the Brief COPE (Carver, 1997).

Patients and Settings

This analysis is part of a larger, longitudinal study, that evaluated the symptom experience of oncology outpatients receiving CTX. Detailed methods for the parent study can be found elsewhere (Miaskowski et al., 2014). In brief, for the larger study, eligible patients were ≥18 years of age; had a diagnosis of a GI, breast, gynecological, or lung cancer; had received CTX within the preceding four weeks; were scheduled to receive at least two additional cycles of CTX; were able to read, write, and understand English; and gave written informed consent. Patients were recruited from two Comprehensive Cancer Centers, one Veteran’s Affairs hospital, and four community-based oncology programs. Of the 2234 patients approached, 1343 consented to participate (60.1% response rate). The major reason for refusal was being overwhelmed with their cancer treatment. Of the 1343 patients in the parent study, data from 570 patients with GI (n=412) and lung (n=158) cancer were used in this analysis. This sample was selected because GI and lung cancers occur equally among women and men (Siegel et al., 2019).

Instruments

A demographic questionnaire obtained information on: age, gender, ethnicity, marital status, living arrangements, education, employment status, income, and past medical history. The Karnofsky Performance Status (KPS) scale was used to evaluate functional status (Karnofsky, 1977; Karnofsky et al., 1948). The Self-Administered Comorbidity Questionnaire (SCQ) evaluated the occurrence, treatment, and functional impact of thirteen common comorbid conditions (Sangha et al., 2003). A total SCQ score can range from 0 to 39. The Alcohol Use Disorders Identification Test (AUDIT) evaluated alcohol consumption, alcohol dependence, and the consequences of alcohol abuse in the last 12 months (Babor et al., 2001). A smoking questionnaire assessed smoking history (Kozlowski et al., 1994).

The 28-item Brief COPE scale was designed to assess a broad range of coping responses among adults with a variety of medical conditions (Carver, 1997). This measure was developed based on Lazarus’ Cognitive Appraisal Theory (Lazarus & Folkman, 1984). Each item was rated on a four-point Likert scale that ranged from 1 (I haven’t been doing this at all) to 4 (I have been doing this a lot). Higher scores indicate greater use of the various coping strategies. In total, 14 strategies are evaluated using this instrument (with their respective Cronbach alphas for this study), namely: self-distraction (0.46), active coping (0.75), denial (0.72), substance use (0.87), use of emotional support (0.77), use of instrumental support (0.77), behavioral disengagement (0.57), venting (0.65), positive reframing (0.79), planning (0.74), humor (0.83), acceptance (0.68), religion (0.92), and self-blame (0.73). Each coping strategy is evaluated using two items. The eight engagement coping strategies on the Brief Cope include: active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, and using instrumental support. The six disengagement coping strategies on the Brief Cope include: self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. The Brief COPE has well established validity and reliability in oncology patients (Scrignaro et al., 2011; Yusoff et al., 2010).

Study Procedures

The study was approved by the Committee on Human Research at the University of California, San Francisco and by the Institutional Review Board at each of the study sites. Eligible patients were approached by a research staff member in the infusion unit during their first or second cycle of CTX to discuss participation in the study. Patients completed the self-report questionnaires in their homes and returned them to the research office using a postage paid envelope. Written informed consent was obtained from all patients. Medical records were reviewed for disease and treatment information.

Data Analysis

Data from the enrollment assessment (i.e., the week prior to the initiation of the patients’ second or third cycle of CTX) were analyzed using SPSS version 22 (IBM, Armonk, NY). Descriptive statistics and frequency distributions were calculated for the demographic and clinical characteristics. Gender differences in demographic and clinical characteristics of the study participants, as well as gender differences in the use of various coping strategies were evaluated using Independent sample t-tests, Chi Square analyses, and Mann Whitney U-tests. A p-value of <0.05 was considered statistically significant. Effect size calculations were done (i.e., Cohen’s d) to evaluate for clinically meaningful differences in the use of various coping strategies by women and men. Effect sizes of 0.2 to 0.5 are considered small, >0.5 to 0.8 are moderate, and >0.8 are large (Cohen, 1988).

Demographic characteristics

Of the 570 patients, 48.6% were female and 51.4% were male (Table 1). Gender was identified by patient self-report from the options male, female, or transgender. Biological sex was identified through genomic analysis and aligned with self-reports of gender for all of the patients. While this study evaluated both biological sex and gender, we will use the term gender to contextualize differences between women and men. Compared to the males, females were significantly younger, were less likely to be employed, and reported a lower annual household income. In addition, females had a lower body mass index (BMI), a higher number of comorbid conditions, a higher SCQ score, a lower functional status score, a lower AUDIT score, were less likely to exercise on a regular basis, and were more likely to have lung cancer. While hemoglobin and hematocrit were lower in women, these findings are not unexpected.

Gender differences in the use of coping strategies

As shown in Table 2, compared to males, females reported significantly greater use of six of the 14 coping strategies assessed by the Brief COPE, namely, positive reframing (p = 0.020), religion (p < 0.001), instrumental support (p = 0.007), self-distraction (p = 0.006), denial (p = 0.001), and venting (p < 0.001). In contrast, males reported higher use of humor (p = 0.032), and substance use (p < 0.001). No significant gender differences were found in self-reported use of active coping, planning, acceptance, emotional support, behavioral disengagement, and self-blame. For the subscale scores of the Brief COPE that demonstrated significant differences, effect sizes ranged from 0.18 (i.e., humor) to 0.35 (i.e., venting).

Use of engagement coping strategies

Consistent with a previous report (Fife et al., 1994), women in our study were more likely than men to use positive reframing (d= 0.20). Positive reframing has been shown to decrease feelings of depression and allow for stressful situations to be redefined as less stressful (Lambert et al., 2012). Of note, in one study of men with prostate cancer (Pascoe & Edvardsson, 2016), positive reframing was a coping characteristic associated with the development of positive feelings. In another study of patients with breast cancer (Robbins et al., 2019), women reported that positive reframing served as a beneficial coping strategy.

Again, consistent with previous studies (Fife et al., 1994; Jacobs-Lawson et al., 2010), women in our study reported more frequent use of religious coping (d= 0.31). Previous research has identified religion as a positive coping mechanism for females with breast cancer (Gonzalez et al., 2016) and males with prostate cancer (Mollica et al., 2017; Pascoe & Edvardsson, 2016; Rand et al., 2012). Religious coping during cancer is dynamic and is used by individuals differently (e.g., to facilitate closeness with a god, for spiritual connection with others, for comfort, to make meaning of the cancer experience) (Pargament et al., 2000).

Consistent with previous research (Fife et al., 1994), the women in our study reported higher use of instrumental support (d= 0.23). The Brief Cope assesses instrumental support by asking patients to rate how often they are “getting help or advice from other people” (Carver, 1997). Most patients with cancer, regardless of gender, will need some amount of instrumental support, as treatment plans are often lengthy and complex (Pinquart et al., 2007). With that in mind, traditional views of masculinity as it relates to help-seeking could account for the gender differences in the scores for the use of this strategy (Addis & Mahalik, 2003).

The only engagement coping strategy that had higher scores in males was the use of humor (d= −0.18). A concept analysis of the use of humor in the context of adults with cancer found that humor helped patients positively cope with their situations, as well as facilitated closeness between the patient and nurse (Tanay et al., 2013).

Use of disengagement coping strategies

While not reported previously, females in our study had higher scores for the use of self-distraction. Self-distraction is a form of disengagement coping that has been associated with decreased self-esteem, fewer functional relationships, and decreased meaning in life in both women and men with cancer (Schroevers et al., 2011). However, similar to other forms of disengagement coping, self-distraction may have some adaptive utility (Collie et al., 2005).

While in our study, females reported higher scores for denial (d= 0.29), previous research that evaluated for associations between gender and the use of denial as a coping strategy in oncology patients yielded inconclusive findings (Vos & de Haes, 2007). Denial can be viewed as either a maladaptive or adaptive response depending on how it is used and its utility in dealing with illness is debated in the literature (Vos & de Haes, 2007). However, evidence suggests that denial can lead to worse outcomes (e.g., delay in seeking care and in getting treatment) and decreases in oncology patients’ survival (Richards et al., 1999).

Given that previous reports found that men are less likely to express emotions through venting (McCaughan et al., 2012; Zakowski et al., 2003), it is not surprising that females in our study reported higher scores for this coping strategy (d= 0.35). While in one study (Brown et al., 2005), the use of venting was shown to perpetuate negative emotions, in other studies it provided an avenue to enlist needed social support (Asuzu & Elumelu, 2013; Nils & Rime, 2012).

While no studies were found on gender differences in substance use as a coping strategy in patients with cancer, in our study, males reported higher scores for this subscale (d= −0.27). This finding is consistent with the higher AUDIT scores reported by men in this study. In a recent systematic review (Yusufov et al., 2019), substance use was present in 2% to 35% of oncology patients and these rates have remained relatively stable from 1995 to 2018. Substance use can lead to less desirable outcomes because of its negative effects on physical and emotional health; its potential to create barriers to treatment adherence; and its potential to impact pain tolerance (Compton & Chang, 2017). Furthermore, in a meta-analysis of coping strategies used by men with prostate cancer, men who coped in ways that did not allow them to face their cancer “head on” experienced more physical and emotional pain (Roesch et al., 2005).

While coping with cancer has been studied extensively (Kvillemo & Branstrom, 2014; Roesch et al., 2005), much of the literature provides information on sex-specific cancers (Hoyt & Rubin, 2012). In our large sample of patients with GI and lung cancers, the use of a number of coping strategies did, in fact, differ between women and men. It is worth noting that compared to males, females had higher scores for three types of disengagement coping (i.e., denial, venting, self-distraction), all of which have been correlated with higher levels of distress in patients with cancer (Culver et al., 2002). Males reported a higher score for the disengagement coping strategy of substance use, which suggests not only that men are more likely to utilize substances to cope, but that they may be more vulnerable to their negative consequences.

Implications for nursing

Clinicians can use these findings to assess patients’ use of various coping strategies, as well as reinforce more positive ones and intervene on more negative ones through appropriate referrals. In addition, clinicians need to be mindful that gender is constructed by a variety of cultural, political, and social norms (Kiss & Meryn, 2001) and has an influence on the way that people cope with various stressors, as well as on their health outcomes (Verdonk et al., 2009). Gender-based stereotypes of emotional expression may impact how women and men express themselves and the ways in which support is offered to them by others (Zakowski et al., 2003). These nuances could account for some of the differences in our patients’ scores. With these findings in mind, clinicians should be more aware of their own preconceived notions about sex and gender and reflect on how these stereotypes may influence the psychosocial care they provide to oncology patients.

Limitations and directions for future research

Several limitations should be noted. First, the major reason for refusal to participate in this study was being overwhelmed with cancer treatment, which suggests a missed opportunity to measure coping strategies in patients who may be experiencing higher levels of stress. In addition, coping was assessed at only one point in the treatment trajectory. Future research needs to evaluate whether gender differences in the use of various coping strategies change throughout the course of cancer treatment and into survivorship.

Conclusions

This large descriptive study is the first to provide detailed information on gender differences in the use of engagement and disengagement coping strategies in oncology patients undergoing chemotherapy. This information can assist clinicians when they assess for challenges that patients have with coping with cancer and its treatments. This information can guide clinicians in how to intervene with men and women to enhance their use of a variety of engagement coping strategies.