Stress, Anxiety and Depression in Chemotherapy’s Patient with

Breast Cancer

Sri Eka Wahyuni

, Yenni Epri

anta Br Sitepu and Wardiyah Daulay

Faculty of Nursing Universitas Sumatera Utara, Jl. Prof.Maas No. 03 Kampus USU, Medan, Indonesia

Keywords: Stress, Anxiety, Depression, Breast Cancer, Chemotherapy

Abstract: Breast cancer is increases every year and very dangerous because it can cause death. Handling breast cancer

can be done with chemotherapy. But chemotherapy treatment takes a long time with various side effects of

chemotherapy accompanied by side effects from the cancer itself so that patients will experience

psychological problems that can make the patient want to stop the treatment. This study aims to describe the

stress levels, anxiety and depression of breast cancer patients breast cancer with chemotherapy. This

research is descriptive. The sample of this study were breast cancer patients with chemotherapy in RSUP

Haji Adam Malik Medan. Total of 41 patients taken by total sampling. The instrument used was DASS 42.

The results of this study showed that 73.2% did not experience stress, 58.5% did not experience anxiety,

80.5% do not experience depression. It is recommended to the health service team to involve families in

providing appropriate interventions to breast cancer patients who experience stress, anxiety and depression

so as to reduce treatment time, save costs and increase productivity.

1 INTRODUCTION

Breast cancer is the most common cancer in

women and is the second leading cause of death

(Rasjidi, 2009) with the most number of occurrences

of 26 per 100,000 in Indonesia (Gengatharan, 2013).

Dharmis Cancer Hospital in Jakarta also report that a

new case and mortality rate which a increasing

every years (Ministry of Health Republic of

Indonesia, 2015). Therefore, breast cancer is a

disease most feared by women (Yanti, 2015).

One of the management of breast cancer is

chemotherapy (Yanti, 2015) that using drugs or

hormones it can be used effectively in diseases that

have spread or are still localized (Rasjidi, 2007)

although chemotherapy is toxic and dangerous to

healthy cells (Sjamsuhidajat, 2005) but it is still a

powerful remedy for cancer.

Stress will emerge when someone who knows

for certain that he has breast cancer even in a very

early stage (Mardiana, 2009 in Aruan, 2011). Irfani

(2010 in Oetami, 2014) report that breast cancer

patients feel stressed because of death and thinking

of risks due to the effects of prolonged

chemotherapy treatment and financial demands that

must be met in the implementation of treatment.

Stress causes a decrease in the efficacy of

chemotherapy because stress affects the supply and

release of hormones (Su, et al., 2003 in Ling, et al.,

2009). Besides, stress causes a decrease in antibody

production and increases the risk of infection

(Suddarth, 2002). In addition, stress affects cell

development to become wild and effects that weaken

the immune system so T cells are not able to

eliminate cancer cells that are formed (Junaidi,

2007).

Patients with chemotherapy not only experience

stress but also has high levels of anxiety and

depression compared to patients who receive

radiation and / or surgical therapy (Mastro, 2002 in

Sonia, 2014). Anxiety occurs early in treatment

because of concerns about side effects and fear of

results after treatment (Zuraida, 2010 in Sonia,

2014). The other of effect of chemotherapy are

feeling sick, nausea, vomiting and afraid because the

disease suffered from cancer cells (Oetami, 2014).

Research by Susanti (2012) report, patients felt

very nauseous and 50% of them have a experienced

vomiting. Nausea and vomiting can occur more

frequently, if the number of chemotherapy cycles

Wahyuni, S., Sitepu, Y. and Daulay, W.

Stress, Anxiety and Depression in Chemotherapy’s Patient with Breast Cancer.

DOI: 10.5220/0008791402410248

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 241-248

ISBN: 978-989-758-438-1

241

undertaken also increases (Grunberg, 2005 in

Marisa, 2014). Patients with cancer also has many

experience such as depression caused by assessment

of situations that reduce self-esteem, situations that

hinder important goals, the presence of disease, and

the presence of negative ideas due to physical

decline (Pieter, 2011).

Hartati (2008) report that number of the breast

cancer sufferers is a 33%, 66.3% of them

experienced low self-esteem cause of husbands

being indifferent, family acceptance with insincerity,

loss of confidence and enthusiasm, feelings of

shame if others know the illness, changes in daily

activities.

In addition, depression arises because the cancer

situation is perceived as frightening and has a

serious impact on its physical and social conditions

Moorey (2012 in Haryathi, 2014). Haryathi (2014)

said that patients experience depression due to

frequent thinking about the illness and the impact of

its treatment makes a person become helpless. The

impact of depression experienced will reduce a

person's quality of life, reduce compliance in

management and increase the risk of mortality

(Gross, 2007 in Amin, 2008). This study aims to

identify stress, anxiety and depression experienced

by breast cancer patients undergoing chemotherapy

at Hospital Medan.

2 METODHS

The research design is descriptive with total

sampling technique.. The number of samples was 41

breast cancer patients who undergoing

chemotherapy at Hospital Medan. The instrument

used is DASS 42 (Depression Anxiety Stress Scale).

Questionnaire modified from DASS 42 (Depressive

Depression Anxiety Scale) published by the

Psychology Foundation of Australia. The results of

the validity test is 100% valid with the value of the

validity validity index (CVI) is 0.67. The reliability

test results are 0.94.

3 RESULT

The results showed that all patients were female, had

been married and used insurance from government (

BPJS) for treatment as many as 41 people (100%);

the majority of patients were in the age range of 46-

55 years as many as 16 people (39%); the majority

of Islamic patients were 32 people (78%); the

majority of Javanese patients are 16 people (39%);

the majority of patients with a junior high school

education background were 15 people (36.6%); the

majority of patients had 27 housewives (65.9%); the

majority of patients earn Rp. <1,000,000 which is 34

people (82.9%); the majority of patients were in

stage II as many as 17 people (41.5%); the majority

of patients underwent chemotherapy treatment and

mastectomy as many as 28 people (68.3%); the

majority of patients underwent chemotherapy 4-6

times, namely 22 people (53.7%), the majority of

patients had breast cancer for> 1 year as many as 35

people (85.4%).

Table 1. Data of Demographic of cancer patients in

Hospital

( n= 41)

Characteristics of

Respondents

frequency

Percenta

e (%)

Sex

Female

Male

100,0

Marital

Married

ot Marrie

100,0

Health Insurance

ot Health Insurance

100,0

Age

26-35 years

36-45 years

46-55 years

56-65

ears

7,3

29,3

39,0

24,4

Religion

Moslem

Christian

Catholic

78,0

19,5

2,4

Ethnic

Padangnese

Melayunese

Jawanese

Bataknese

Niasnese

Acehnese

4,9

7,3

39,0

26,8

49,0

17,1

Education

Primary School

Junior School

High School

Universit

22,0

36,6

26,8

14,6

Chemotherapy status

1-3 years

4-6 years

ears

31,7

53,7

14,5

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

242

Treatment

Chemotherapy

Chemotherapy &

mastectom

31,7

68,3

Stadium

Level 1

Level 2

Level 3

Level 4

Occupational

House Wive

Government

Employees

Farmer

Enterprenuer

Retired

Income

<1 million

1.5 million – 2 million

> 2 million

Long Illness

<1 year

7,3

41,5

31,7

19,5

65,9

14,6

12,2

4,9

2,4

82,9

2,4

14,6

85,4

Table 2 .Distribution of frequency stress, anxiety and

depression ( n = 41)

Category Frequency

(f)

Percentage

(%)

Stress

o Stress 30 73,2

2. Low Stress 7 17,1

3. Moderate Stress 4 9,8

Anxiety

o Anxiet

24 58,5

2. Low Anxiet

6 14,6

3. Moderate

Anxiety

4. High Anxiety

5. Highest

Anxiet

14,6

4,9

7,3

Depression

o Depression 33 80,5

2. Low

Depression

4 9,8

3. Moderate

4. High

Depression

4,9

The results showed that the majority of breast cancer

patients who were undergoing chemotherapy at

Hospital Medan were not stressed as many as 30

people (73.2%), no anxiety as many as 24 people

(58.5%), not depressed as many as 33 people (80 ,

5%),

4 DISCUSSION

The results showed that breast cancer patients who

underwent chemotherapy did not experience stress

as much as 73.2% and experienced stress as much as

28.8%. Stress experienced according to Keliat

(1999) can from physiological changes that occur

due to signs and symptoms of the disease.

Rochmawati (2015) who stated that despite

experiencing loss of part of the body when

previously operated on, changes in body shape, hair

loss, but did not cause poor self-image perception.

One perception of a good self-image is due to age.

cause old age factors self-image to be ignored. This

study showed that all patients who were aged 56-65

years had no stress.

According to Rochmawati (2015) another factor

that causes the perception of good self-image is the

absence of changes in body shape because the illness

suffered recently. This is consistent with the results

of the study which showed that patients who were

sick for more than 1 year had mild stress and

moderate level of stress, in contrast to patients

whose <1 year old illness showed that none of them

experienced moderate stress only experienced mild

stress levels.

Besides, stress can be solved by solving

problems, responding to changes or threatening

situations that called coping (Keliat, 1999). One

coping strategy is emotion focused coping, which is

an effort to overcome stress by regulating emotional

responses in order to adjust to the impact that will be

caused by a condition or situation that is considered

stressful (Lazarus, 1984). According to Saragih

(2010) the coping of patients on chemotherapy

treatment in the good category was 12 people (48%).

This is supported by Aini's research (2015) which

states that patients perceive unpleasant experiences

as a challenge to life by being grateful and giving up

their life problems to God. In addition, the

perspective on life becomes more positive so that it

increasingly struggles with cancer (Junaidi,2007) .

Research by Yanti (2015) which states that patients

also continue to strive to be able to do a good and

healthy lifestyle, including taking care of the

environment to avoid cigarette smoke and optimism

for recovery is increasing (Wardiyah, 2012)

Researchers observed that the majority of

patients were placed in a chemotherapy room

Stress, Anxiety and Depression in Chemotherapy’s Patient with Breast Cancer

243

because in one room there were several patients,

patients in general patients revealed that they felt

they had more hope after hearing the experiences of

other patients who had the same cancer and

managed to survive and live their daily lives well.

So all of them was eager to be optimistic about

undergoing treatment because the group gave a real

picture of the success of cancer treatment( Suryani ,

2014).

All patients in this study were married and the

observations of the researchers, the majority of

patients were accompanied by their families at the

time of treatment. Breast cancer patients needed

support while chemotherapy it can decreasing stress

Keliat (1999) and can be improve the ability of

patients to resolve stress (Saragih, 2010). Family

support is taking patients to treatment, reminding

them that chemotherapy is not too late, reminding

them to take drugs, and keeping other family

members if they seek treatment (Rochmawati's

2015).

Therefore, patients have a strong desire to

recover because of their love and affection for their

children so they can always be together and

accompany their children and make children as

motivation to recover. ( Aini, 2015)

In addition to being married, the majority of

patients also have more than 50 years of age as

much as 41.4%, optimism of healing is also

influenced by the age of marriage (Wardiyah ,

2012)

The length of marriage affects breast cancer

patients in interpreting the meaning of marriage, for

newly married patients, sexual needs are still a

priority in relationships with partners. Different

things happen to patients who have been married for

a long time, they interpret marriage as a bond of

love, mutual ownership, respect, and mutual care for

each other. The patient has entered the stage of

emotional maturity, closeness to God and is ready to

face death. This is consistent with the results of a

study showing that no patients experience stress

above the age of 55 years.Someone who is able to

recognize and manage stress appropriately is the

character of someone who has good resilience.

Resilience is the ability of individuals to face,

overcome, strengthen themselves, and continue to

make changes in connection with the exam

experienced (Grotberg 1999, in Listianty, 2012).

Resilience refers to the positive side of a person who

distinguishes them from others when experiencing

stress (Campbell, 2009 in Min, 2012). Good

resilience means not only having a high tolerance for

stress but also understanding ways to overcome the

causes and symptoms of stress. This can be seen

from someone whose resilience is well aware when

experiencing failure but can see it as an opportunity

to move forward and accept that failure as part of

life (Nisa, 2013). Therefore, resilience is negatively

related to stress levels (Norman, 2001) and good

resilience is associated with good quality of life and

low stress levels so that resilience can help a person

reduce psychological burden (Cohen, 2014 in Li,

2016). Besides that good resilience is also associated

with good coping (Davidson, 2005 in Min, 2012).

The form of resilience that is used in cancer

patients is to motivate themselves, to convince

themselves that all this can certainly be passed, start

looking for friends as much as possible, often

refreshing with friends (Nisa, 2013). Optimism,

responsibility, ability to cope with stress and

anxiety, focusing on problem solving are elements

that contribute to improving one's resilience (Herth,

1992; Snyder et al., 1991 in Molina, 2016). In

addition, spirituality is also expected to improve

one's resilience (Min, 2012).

The results showed 58.5% of patients did not

experience anxiety and 41.5% experienced anxiety.

The perceived anxiety can cause anger which is

manifested by insult, or blame the nurse for the

situation and health services he receives (Keliat

1996). However, Tiolena's (2009) study stated that

all breast cancer patients stated that the treatment

facilities at Adam Malik General Hospital Medan

were more complete than the previous treatment

facilities and all patients believed that health

workers could treat the disease and cure the disease

because the attitudes of health workers were

considered good by patient. This is consistent with

the results of the study showing that the majority of

patients are not anxious.

In addition to obtaining family support according

to Suddarth (2002) anxiety can be lost when the

patient knows the side effects of treatment and a way

out of the problem at hand. This is consistent with

the results of research showing that patients with no

tertiary education have experienced severe anxiety.

It's different with those who have elementary,

middle and high school education having very

severe anxiety. This is supported by Tiolena (2009)

stating that breast cancer patients do not have

knowledge about the disease and even find out BSE

(breast self examination) when told by health

workers.

Besides having knowledge, patients also have

experience in chemotherapy. The majority of

patients in this study were undergoing chemotherapy

4-6 times. According to Utami (2013) there is an

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

244

influence of the patient's experience on the level of

anxiety in undergoing chemotherapy. This is in

agreement with Silalahi (2014) who stated that the

initial experience that had been about chemotherapy

would reduce the level of patient anxiety later on.

This is consistent with the results of the study that

patients who had more than 6 times chemotherapy

only experienced mild and moderate anxiety and

none experienced severe and very severe anxiety.

Unlike those who underwent a cycle of 1-3 times,

there were those who experienced very severe

anxiety. According to Sari (2012) anxiety occurs

because patients have not adapted to perceived side

effects.

The other factor related to anxiety is resilience,

Bitsika (2010) states that resilience is negatively

related to anxiety, resilience is the ability to survive

and not despair of bad events or calamities and is

able to take lessons from what happened to be able

to rise again (Listianty, 2012). Resilience can reduce

anxiety that is being experienced by developing

optimism, a sense of responsibility, tolerance, ability

to adapt, and a view of reality (Bitsika, 2010). In

addition, spirituality and ways of interpreting life

also contribute to increasing the level of one's

resilience (Min, 2012) a high level of resilience that

will improve a person's quality of life (Li, 2016).

Setiyaningsih (2011) who said that there was no

significant relationship between resilience and

anxiety in undergoing chemotherapy. This is

possible because the patient's knowledge and

experience contribute significantly to reducing

anxiety rather than resilience. This is shown by as

many as 48 patients having high resilience and 27

patients experiencing anxiety facing low

chemotherapy. Two patients had moderate levels of

resilience and 15 patients had anxiety levels

undergoing chemotherapy. There are no patients

who have low resilience, whereas as many as 8

patients have high anxiety in undergoing

chemotherapy.

All patients in this study were married.

According to Ningsih (2015) the better the family

support, the lower the level of patient anxiety. This

result is supported by Sari's (2012) study which

states that family support can motivate patients to

undergo chemotherapy more. The patient feels that

there are still those who give attention, love or

someone who cares for him even though he is sick.

Agree with Aruan (2011) which states that all

patients receive support from the family, in the form

of prayer support, encouragement, and financial

support. In addition, the support given by Oetami

(2014) makes patients eager to seek treatment, do

not care and relax, because many families are

entertaining.

The majority of patients work as housewives as

much as 65.9%. Ningsih (2015) states that by acting

as a housewife the patient does not feel embarrassed

despite suffering from breast cancer because a

housewife does not have a lot of work outside the

home, she often interacts with neighbours in the

surrounding environment so she does not have

intensity high that requires interacting with people

outside the home. This is consistent with the results

of research that 56.1% of patients do not feel

embarrassed.

The majority of patients have had breast cancer

for more than 35 years (85.4%). The longer the

patient is sick, the patient will be more accustomed

to treatment and its side effects (Sari, 2012). In

addition, someone will form new behaviours to

adapt and anticipate grieving (Potter & Perry, 2005

in Siburian 2012). This is in accordance with the

study that patients who had more than one year of

illness were the majority who did not experience

anxiety as much as 51.2%. In accordance with Aini's

research (2015) which states that patients also do not

question if they have to lose their breasts because the

most important thing for him is his health.

The results showed that 80.5% of breast cancer

patients who underwent chemotherapy were not

depressed and 19.5% had depression. According to

Suryani (2016) a person who is first diagnosed with

cancer will experience depression so that it

stimulates the patient to develop coping strategies.

The majority of patients have had breast cancer for

more than one year as many as 35 people (85.4%).

So according to Suryani (2016) patients have been

able to develop coping strategies, among others,

refusing, getting closer to Allah SWT, seeking

opinions from other health professionals (second

opinion), discussing the situation experienced by a

partner / family, searching for various alternative

treatments, discussion with other cancer patients

who have already been diagnosed, ask for a doctor's

direction to diagnose related actions. This is in

accordance with the results of the study of patients

who had experienced pain> 1 year, the majority did

not experience depression as much as 82.9%.

Another case with those who experienced pain <1

year who did not experience depression as much as

66.7%. This is supported by Guan (2015) stating that

a better quality of life after 12 weeks was diagnosed

with breast cancer.

Another factor that contributes to reducing the

level of depression of patients according to Dewi

(2004) and (Burton, 2009 in Min, 2012) is resilience,

Stress, Anxiety and Depression in Chemotherapy’s Patient with Breast Cancer

245

they state that resilience can also reduce the level of

depression. Individuals who are in a good state of

resilience can experience decreased levels of

depression. This can improve the stability of

individual emotional health. So, if an individual has

a high resilience score, it will have a low depression

score, and vice versa (Hiew, 2000 in Fransisca,

2004).

Resilience is the ability of individuals to adapt

and place themselves well towards unpleasant

experiences or in situations of severe problems

(Nisa, 2012). Therefore, Dewi (2004) states that the

higher the resilience dimension consisting of "I

Have", "I am", and "I can" factors, the lower the

depression experienced by women undergoing breast

cancer treatment. Dimensions "I have "Sourced from

the power of support that exists from the outside of

the individual," I am "comes from the strength

contained in the individual and" I can "comes from

social support and interpersonal skills. In addition,

high patient resilience, influenced by social support

and spiritual (Listianty, 2012) Likewise, the low

level of spirituality causes low resilience as well

(Min, 2012).

5 CONCLUSIONS

The results of this study are expected to be

additional information and input for nursing

education, as well as be able to educate future nurses

so that they better understand human psychological

needs and are able to help the surrounding people

who are dealing with sources of stress, anxiety and

depression in their lives. For nursing practice is

expected to be able to use this research as a

reference for nurses in providing health education

about patients who experience stress, anxiety and

depression even though the results of the study

found that overall patients did not experience stress,

anxiety and depression but when viewed from each

item the questionnaire was still some are not

satisfying. For further researchers, it is expected to

further develop this research by looking at factors

that influence stress, anxiety and depression.

ACKNOWLEDGEMENTS

The author would like thank to Prof. Dr. Runtung,

SH, M.Hum as the President of University of

Sumatera Utara.

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