Introduction

The diagnosis of breast cancer is a stressful event that causes psychological distress (^{Hamama-Raz, 2012}; ^{Pereira, Figueiredo & Fincham, 2012}; ^{Kangas, 2013}). Women undergoing cancer treatment have to face a variety of potentially stressful situations, and it has been shown that mastectomised women have a lower level of self-esteem and a more negative body image than women undergoing conservative surgeries, with significant differences between self-esteem scores according to the type of surgical intervention (^{Segura, García & Saúl, 2014}). Alopecia induced by chemotherapy represents the most distressing side effect of chemotherapeutic agents and is of great concern for most patients, negatively affecting their mood and self-esteem (^{Dunnill, Al-Tameemi, Collett, Haslam & Georgopoulos, 2018}). Other symptoms such as frequent and intense fatigue, and sleep disturbances that increase progressively throughout the chemotherapy treatment (^{Henneghan, Carter, Stuifbergan, Parmelee & Kesler, 2018}) usually affect patients with breast cancer, in addition to frequent and intense emotional disturbances such as anxiety (^{Yang et al., 2016}) and depression (^{García-Torres & Alós, 2013}).

Coping strategies are a determining factor for adapting to these situations (^{Hopman & Rijken, 2014}). According to their consequences, the strategies can be categorised as being either more or less adaptive (^{Figueroa, Contini, Lacunza, Levín & Suedan, 2005}).

Coping strategies such as avoidance (^{Lan, L. Zhang, Y, Zhang & Yan, 2018}), repression (^{Cardona, Jaramillo & Díaz, 2013}), passive coping (^{Vargas, Herrera, Rodríguez & Sepúlveda, 2011}), self-blaming (^{Teo, Fingeret, Liu & Chang, 2016}), acceptance (^{Browall, Kenne, Persson, Wengström & Gaston-Johansson, 2016}) and ruminative thoughts (^{González, Ibáñez & Barrera, 2017}), are all generally considered to be less adaptive. When faced with a cancer diagnosis, it has been found that these strategies predicted a greater number of depressive symptoms and lower self-esteem (^{Cieslak & Golusinski, 2018}). When a person develops coping strategies that are mainly of the avoidant type, such as denial, the absence of positive reframing, or self-blaming -all of which are associated with a low quality of life- they usually present emotional states that make it difficult to directly address the stressful event (^{Brunault et al., 2016}).

In contrast, strategies such as positive reframing (^{Ortiz et al., 2014}), problem solving, and coping based on religion (^{Park, Waddington & Abraham, 2018}), which are generally considered more adaptive, are associated with a higher quality of life (^{Finck, Barradas, Zenger & Hinz, 2018}), a minor alteration of mood (^{Ringwald et al., 2016}), fewer depressive symptoms (^{Avis, Levine, Naughton, Case & Naftalis, 2013}) and a higher level of self-esteem (Ortiz et al., 2014). These more adaptive coping strategies are related to greater psychological wellbeing (^{Danhauer et al., 2013}).

The most frequently observed adaptive strategies are characterized by being active and focused on the problem (^{Cao, Qi, Cai & Han, 2018}), the most notable of these being positive reframing and personal growth, active coping and planning, followed by the use of religious beliefs (^{Granero-Molina et al., 2014}), acceptance, and social support (^{Cardenal & Cruzado, 2014}). It has been observed that the majority of women present an active coping style, helping them to carry out activities that are enjoyable such as reading, walking, or physical exercise (^{Falo, Villar, Rodríguez, Mena & Font, 2014}).

These adaptive strategies tend to be associated with variables such as self-esteem, optimism (^{Dumalaon-Canaria, Prichard, Hutchinson & Wilson, 2018}) and family support, all of which are variables that intervene and influence the quality of life of cancer patients, particularly those with breast cancer (^{Eun & Young, 2014}). This quality of life can be affected by various risk factors in patients with breast cancer, these factors being mainly individual variables such as younger age, and less use of active coping, acceptance, or coping based on religion (^{Brunault et al., 2016}; ^{Elumelu, Asuzu & Akin-Odanye, 2015}). High scores in self-esteem have shown to be mediators in coping and adaptability in mastectomised women (^{Gómez, Bragado & Hernández, 2014}). Thus, a radical mastectomy is associated with an increase in depressive symptomatology (^{Sun, Ang, Darryl & López, 2018}), alterations in body image (^{Phillips & McAuley, 2015}) and low self-esteem (^{Pintado, 2017}).

Finally, age is an aspect to be assessed when analysing the diagnosis of breast cancer, with a younger age being consistently associated with a greater negative impact of the diagnosis. Conversely, at an older age, an association with a more adaptive and positive coping style is usually observed (^{Boyle, Stanton, Ganz & Bower, 2017}). Younger women are more concerned about their family, economic, or work responsibilities (^{Rosen, Rodriguez-Wallberg & Rosenzweig, 2009}), which, among other issues leads to more problematic coping.

The present work aims to: 1. Explore the possible influence of age on coping psychologically with breast cancer, 2. Describe the coping strategies developed by women based on their self-esteem scores, and 3. Analyse the relationship between age, self-esteem, and coping strategy.

The proposed hypotheses of this study were as follows:

Method

Results

Among the main characteristics related to the oncological disease, it was found that the mean time elapsed since the women were diagnosed with breast cancer was 50.75 months (SD = 60.91), and the mean time since the mastectomy was 45.07 months (SD = 57.66).

When observing the strategies used for coping with the cancer diagnosis, the one that showed the highest score among the patients was active coping (M = 6.17, SD = 1509); conversely, the coping strategy with the lowest score was the use of substances (M = 2.66, SD = 1.179).

When analysing coping strategies between the three age groups established in the study (a: 30-45 years, b: 46-52 years and c: > 53 years), it was found that age determines the use of active coping strategies such as acceptance (F (2,120) = 4.708, p = .011) and humour (F (2,120) = 4.062, p = .020). In the corresponding post hoc analyses, Tukey’s test revealed that these differences according to the age groups are significant between b and c, with b ˃ c (p = .007) for acceptance, and also, b ˃ c (p = .019) for humour. No differences were established in the development of coping strategies according to marital status (Active coping (F (5,120) = 1.165, p = .331); Planning (F (5,120) = .574, p = .720); Use of emotional support (F (5,120) = .580, p = .715); Social support (F (5,120) = .204, p = .960); Religion (F (5,120) = 1.660, p = .150); Positive reframing (F (5,120) = 1.313, p = .264); Acceptance (F (5,120) = .915, p = .474); Denial (F (5,120) = 1.166, p = .330); Humour (F (5,120) = 2.156, p = .064); Self-management (F (5,120) = .218, p = .954); Self-blaming (F (5,120) = .661, p = .653); Behavioural disengagement (F (5,120) = .456, p = .808); Venting (F (5,120) = 1.334, p = .255) and Substance use (F (5,120) = .911, p = .477).

Table 1 Coping strategies for dealing with the diagnosis (COPE-28) according to age groups. 

As the results in Table 2 show, there is a relationship between the different scores obtained in self-esteem and the use of each of the coping strategies. The self-esteem scores were grouped into low self-esteem (a = < 25 points), average self-esteem (b = 26-29 points) and high self-esteem (c = 30-40 points). Women with high self-esteem scores reported the use of more active coping strategies (F (2,120) = 6.955, p = .001), with differences between c and a (p = .016), and c ˃ b (p = .020). This same relationship is observed in the strategies based on the acceptance of the oncological diagnosis (F (2,120) = 11.433, p <.001) where c ˃ a (p = .024), c ˃ b (p = .017) and positive reframing of the situation (F (2,120) = 6.711, p = .002) where c ˃ a (p = .001) and c ˃ b (p = .002). When faced with a cancer diagnosis, receiving emotional support and the understanding and comfort of others appears to be significantly related to self-esteem, with these strategies being more likely to appear in those patients with high scores on self-esteem (F (2,120) = 6.252, p = .003). In the post hoc analyses these differences were shown to occur between the following self-esteem groups: c ˃ a (p = .010) and c ˃ b (p = .071). On the other hand, the women with low self-esteem score use, to a lesser extent, strategies based on social support (F (2,120) = 4.099, p = .019), the score on this strategy differing between self-esteem groups as follows: c ˃ b (p = .063).

Table 2 Strategies for coping with the diagnosis (COPE-28) based on self-esteem scores (Rosenberg-EAR Self-Esteem Scale). 

When analysing the correlations between the self-esteem scores and the coping strategies used, it is possible to observe (Table 3) that the strategies most strongly correlated with self-esteem are those that are more active and adaptive, particularly positive reframing (r = .502, p ˂ .001), use of emotional support (r = .423, p <.001), active coping (r = .421, p ˂ .001), social support (r = .371, p ˂ .001), acceptance (r = .342, p ˂ .001) and planning (r = .280, p = .001).

In contrast, passive and less adaptive coping strategies, such as denial (r = -.229, p = .006), behavioural disengagement (r = -.212, p = .010) and self-blaming (r = -. 194, p = .017), correlate inversely and significantly with self-esteem. Thus, women with a lower self-esteem score deal with their cancer by denial of the disease and by blaming themselves for its development.

Table 3 Regression model taking age and self-esteem score as predictor variables (Rosenberg Self-Esteem Scale) for coping strategies (COPE-28). 

Next, the predictive capacity of self-esteem with respect to each of the coping strategies was analysed, having controlled for the effect of age (Table 3). The results show that self-esteem increases the explanatory capacity of the model by 24.7% with respect to the age variable, when positive reframing is used as a coping strategy (p ˂ .001) (β = .500, p ˂ .001). And when emotional support is used as a strategy, 17.5% of the model is accounted for by self-esteem (p ˂ .001), with a predictive capacity of β = .420 (p ˂ .001). For coping based on social support, self-esteem increases the proportion of variance explained with respect to age by 13.2% (p ˂ .001). A similar relationship can be observed when coping is based on the acceptance of cancer, thus increasing the proportion of variance explained by self-esteem by 12.8% (p ˂ .001) (β = .360, p ˂ .001) once age has been controlled. Self-esteem also increases the explanatory power of the use of planning strategies by 8.8% (p = .001) with respect to age, with a predictive value of (β = .298, p ˂ .001).

The less adaptive and passive coping strategies have a lower explanatory value, particularly denial, a strategy that explains only 5.6% of the variance (p = .009) (β = -.237, p ˂ .001).

Discussion

The aim of the study was to analyse the influence of age and self-esteem on the use of coping strategies used by female oncological patients with breast cancer. Active coping appears to be the strategy most used by these women, which is in accord with other observations in the literature (^{Dumalaon-Canaria, Prichard, Hutchinson & Wilson, 2018}; ^{Finck, Barradas, Zenger & Hinz, 2018}; ^{Ortiz, et al., 2014}; ^{Park, Waddington & Abraham, 2018}).

In terms of our first objective, which sought to determine the influence of the age of the patients on the strategies used to address the diagnosis and development of cancer, it was found that this variable has an impact on the development of such strategies. Thus, women between the ages of 46 and 52 were those with the highest scores on acceptance and humour strategies. In spite of data that appears to indicate a relationship between age and coping strategies (^{You, Wang, Rodríguez, Wang & Lu, 2018}, ^{Brunault et al., 2016}) in which younger people tend to use more emotionally-focused ways of coping (^{Compas et al., 1999}), our findings reveal that it is the 46-52 year age group that is more strongly linked to the use of active coping strategies (acceptance, humour).

Moreover, it was found that women who have high self-esteem scores are those who show a greater use of coping strategies of the following types: active coping, use of emotional support, social support, positive reframing, acceptance, humour and venting. In particular, it was observed that those patients diagnosed with breast cancer who had high self-esteem tend to face the oncological disease in a more active and positive way, showing a greater tendency to use active coping and positive reframing. These results support the findings of other related studies such as that of ^{Ortiz et al. (2014}) who reported a link between the use of adaptive strategies such as positive reframing and self-esteem (^{Dumalaon-Canaria, Prichard, Hutchinson & Wilson, 2018}).

When analysing the relationship between the variables of age, self-esteem, and coping strategies, it was observed how the inclusion of the self-esteem variable, when controlling for the age of the patients, increased the predictive capacity for the type of coping strategy used to face the disease. In a previous study, ^{De Haro-Rodríguez et al. (2014}) analysed the relationship between age and coping strategies, concluding that there was a negative relationship between age and strategies linked to problem-solving, social support, and positive reframing. However, they had not considered self-esteem scores to be a moderating factor in these patients, as shown in the results obtained in this work. However, ^{Robert et al. (2010}) showed that coping strategies such as religion are related to adjusting to the disease and maintaining adequate self-esteem, findings that are not confirmed in our work. Therefore, the present findings make a novel contribution by revealing the impact of self-esteem - as an individual variable - on strategies for coping with breast cancer, along with finding that this is interrelated with the age variable.

As limitations of the study, it is important to emphasize that the design employed here does not allow for establishing the directionality or the causality of the relationships between self-esteem and coping strategies. Similarly, it is worth mentioning the transversal nature of this work, which does not allow us to identify how the use of coping strategies and self-esteem scores in these patients evolves throughout the development of the disease or with the advancement of age.

Future studies should approach this issue using larger sample sizes and in different conditions and stages of the disease. Moreover, it would be of interest to use designs that explore the role of other variables such as quality of life, use of pharmacological therapy and / or surgery, physical impact, alterations in body image, along with other consequences derived from the disease and its treatment, all of which can affect the way in which patients cope during the course of the disease.