Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Review Article, J Womens Health Issues Care Vol: 3 Issue: 3

Female Breast Cancer Patients Need for Social Support: Implications for Patients without Partners and Health Care Professionals

Amanda C Ginter1* and Bonnie Braun2
1Family and Consumer Sciences, University of Maryland Extension, USA
2Family Science Department, University of Maryland, USA
Corresponding author : Dr. Amanda C. Ginter, Ph.D
Faculty Research Associate, Family and Consumer Sciences, University of Maryland Extension, 1202 Symons Hall | College Park, MD 20742, USA
Tel: (513) 687-7258
E-mail: [email protected]
Received: September 11, 2014 Accepted: May 28, 2014 Published: June 24, 2014
Citation: Ginter AC, Braun B (2014) Female Breast Cancer Patients’ Need for Social Support: Implications for Patients without Partners and Health Care Professionals. J Womens Health, Issues Care 3:3. doi:10.4172/2325-9795.1000147

Abstract

Female Breast Cancer Patients’ Need for Social Support: Implications for Patients without Partners and Health Care Professionals

This article describes findings from a review of literature initially targeting female breast cancer patients without partners. Women with breast cancer, the second most common cancer among women, often report that their main social support comes from intimate partners.

Keywords: Breast Cancer; Female; Health care; Partners; Patients

Keywords

Breast Cancer; Female; Health care; Partners; Patients

Introduction

Approximately one in eight women in the United States (between 12% and 13%) will develop invasive breast cancer sometime in her life [1]. In 2013, an estimated 296,980 new cases of breast cancer were diagnosed in women in the U.S. [2] (Table 1). For women in the U.S., breast cancer death rates are higher than those for any other cancer besides lung cancer. After skin cancer, breast cancer is the most commonly diagnosed cancer among U.S. women [1,2].
Table 1: Breast Cancer Statistics.
In the last few decades, many breast cancer cases have transitioned from guaranteed death sentences to manageable chronic diseases. More and more individuals are surviving longer, and thus there are more issues surrounding survivorship, including the family’s impact on the patient’s well-being [3]. There is extensive literature about grieving for family members who died from cancer, but not nearly as much about how patients’ social environments change during the course of treatment and how patients’ perspectives on the future change. Further, there is a serious gap in the literature on the breast cancer experiences of women without partners (single, divorced, separated, or widowed).
The following literature review examines forms of social support, interpersonal relationships that can alleviate or contribute to stress, health disparities, and challenges that breast cancer patients face post-diagnosis. This article builds the case that breast cancer patients in general require social support in order to cope with the fears and frustrations of diagnosis and treatment. The review discusses intimate partners as part of the social environment and, more specifically, lays the groundwork for potential implications for breast cancer patients without partners.
This review of literature provides insight into existing research that could be used to improve the practice of providing breast cancer care to women without partners. Future research could supplement existing literature and further improve treatment and support for this subset of women with breast cancer.

Method of Review

Social science, family science, and public health search engines (PsycINFO®, PubMed, Social Science Citation Index) were used to find articles examining the experiences of breast cancer patients without partners. Free-text and title text-word searches were conducted. After determining there were no existing articles on breast cancer patients without partners, the co-authors expanded the search to breast cancer patients in general, then narrowed terms by race/ethnicity, age, socioeconomic status, and geographic region. A total of 115 studies were reviewed. Although there are limitations in interpretation based on this methodology, when there is no existing information on the subject of interest, broadening the scope of the search can yield relevant information [4].

Review of the Literature

Breast cancer patients require ample social support to cope with their diagnoses, treatment, and all the surrounding challenges [5]. Among all racial, ethnic, and socioeconomic groups, patients that perceive having adequate social support experience less psychological distress post-diagnosis [6,7].
The following sections explore the literature on social support and stress for breast cancer patients. The review is divided into sections on the diversity of the population; forms of interpersonal and intrapersonal support needed by breast cancer patients; how breast cancer patients seek and use health information; and how women without partners make sense of their relationship status, particularly in poor health contexts.

Health Disparities and Diversity of Population

Documented health disparities include race, ethnicity, sex, socioeconomic status and health literacy [8-10]. Breast cancer incidence and mortality rates vary among racial and ethnic groups [11]. Racial and ethnic minorities and women from lower socioeconomic backgrounds are more likely to be diagnosed with breast cancer at later stages and they are more likely to die from breast cancer than white women or women from higher socioeconomic backgrounds [11,12]. One explanation for differences and disparities is that minority women may use screening services less frequently than white women. When they are diagnosed with breast cancer, it is at later stages. The disease has progressed further and is less likely to be treatable [13]. Breast cancer incidence rates are higher among white women than African American women, but African Americans are more likely to die from the disease [1]. Latinas have lower incidence and mortality rates of breast cancer than African American or white women [1].
Knowing that socioeconomic status (SES) and race/ethnicity are associated with different incidence and mortality rates for cancer, leads to the question whether breast cancer experiences vary as well. Ethnic minority cancer patients are more likely to experience depression, distress, and lower quality of life than cancer patients from majority groups [14]. Additionally, racial and ethnic minorities are more likely to stop being employed after a breast cancer diagnosis [15]. Not being employed significantly affects a patient’s ability to afford treatment and contributes to added stress and a more negative experience overall [16,17].
Socioeconomic status also contributes to health disparities. Uninsured women are more likely to have metastasized breast cancer and larger breast tumors than privately insured women [18]. Lowerincome women are also more likely to be diagnosed at later stages than higher-income women [19]. Finally, lower-income breast cancer patients are less likely to experience the immunological benefits of social support than higher-income breast cancer patients [20]. Socioeconomic status is a mediator of racial differences in breast cancer treatment outcomes [21]. In the United States, and much of the world, minority racial groups simply have less wealth [22,23].
Relationship status as a health disparity
Research suggests that relationship status should be added to the list of health disparities. Unmarried women are more likely to be diagnosed with breast cancer at later stages than married women [24]. Between 1970 and 2007, more never-married cancer patients compared with married patients had increased mortality rates [25]. Married individuals tend to have better overall health than nevermarried individuals. They are more likely to go to a physician when they experience suspicious symptoms [25-27]. Marital status and the presence of a partner are predictors of breast cancer patients’ quality of life and functioning [28]. One study found that among breast cancer patients, being single or unpartnered, as compared to being partnered or married, was associated with increases in depression and reexperiencing trauma symptoms as well as decreases in emotional well-being over time [29].
Support during diagnosis
Both interpersonal and intrapersonal resources are crucial for coping with disability and disease [30]. Interpersonal resources are those that come from other people (including family, friends, and colleagues). Types of interpersonal resources include: instrumental, informational, emotional, and appraisal [31]. Intrapersonal resources are intrinsic to individuals. For breast cancer patients, intrapersonal resources include having faith, finding something to live for, gaining insight about their lives and health, and actively working to get better, as well as activities such as meditation and yoga [32,33]. Another intrapersonal resource is health literacy. The following section outlines types of interpersonal and intrapersonal resources for breast cancer patients.

Interpersonal Resources

Family
A woman’s breast cancer diagnosis is likely to create the need for new family roles, because her focus shifts to treatment and recuperation [34]. Her family members may need to adjust their roles and handle more household responsibilities. It is important to understand how her family adjusts because that may determine how supportive they can be, which in turn has ramifications for the patient’s well-being [34,35]. Two common categories of family supporters are first degree female relatives and intimate partners [35,36]. (Intimate partners will be discussed in the following section).
At the time of diagnosis and treatment, families are challenged to reconcile the present and the future [34]. While they are assisting the ill family member and possibly living from one day to the next, they must also consider the future – their fears, their expectations, and their goals. Looking ahead is made especially difficult if the family member’s illness is severe, chronic, or unlikely to improve [34]. It may be further confusing if it is difficult to ascertain how soon, or if, the patient will recover, and whether the family needs to change their plans temporarily or permanently. Even if the changes are temporary, it may be hard for family members to restore their initial plans, before their relative was diagnosed. It is essential that health care professionals offer psychoeducation to their patients’ families, so that families are better prepared for the stress and chaos that may accompany a relative’s illness [34].
Regardless of the patient’s prognosis, his or her family members will rely on previous multigenerational experiences with similar situations, as well as their family’s values, to navigate such tribulations [34]. How the family has reacted to illness in the past suggests how family members will respond now. Other factors include the family’s personal style of functioning, as well as their resources, such as outside help, doctors, clergy, or counselors they may speak to [34]. Much also depends on where individual family members are in their life cycles when illness strikes the family – an adolescent preparing to leave for college will react to, and be affected by, a parent’s illness differently from a middle-aged adult child whose aging parents had expected news of illness [34].
Perceived social support from family and friends is an important contributor in the adjustment to breast cancer [37]. African American patients in post-diagnosis have reported higher emotional well-being than white patients [38]. This discrepancy is especially noteworthy because African Americans’ dissatisfaction with care providers is commonly reported, and negative patient-physician relationships are often tied to patients’ decreased quality of life [23,39]. Recognizing that African American families are often tightly connected and contain supportive networks may help us consider how the general support of extended family members might apply to African American breast cancer patients’ higher levels of well-being [40].
The emotional and social support from African American breast cancer patients’ families may buffer any negative impact from the perceived discrimination [41,42]. These synergistic female family relationships may even empower women to engage their relatives in healthy behaviors, including self-detection and preventive care; the family’s increased awareness of breast cancer improves informational support for the patient [43]. At the same time, because African American women are often called upon to be the caregivers in their family, they may not feel sufficiently supported when they need care [44]. Additional studies must examine how the typical caregivers receive support when it is their turn to receive care.
Latina breast cancer survivors are primarily supported by extended family and female friends [45,46]. Similar to the general population, Latina breast cancer patients require different types of social support at diagnosis, in treatment, and during post-treatment [7,47]. Women are usually the primary caregiver, often ignoring their own health to care for family members [45].
Intimate partners
Breast cancer can alter the female patient’s body and thus her selfperception and sexuality [36]. As a result, breast cancer can have effects on her intimate relationship unique from other cancers. Treatments such as chemotherapy may also negatively affect her sexual desire and functioning. These changes often stress intimate relationships [36]. Marital stress is also associated with slower recoveries and poor results [48]. Spousal stress is more likely caused by patient distress; spousal stress often leads to marital stress [49].
Out of the 115 articles reviewed, one study found that being single may be a protective factor against depression among breast cancer patients [50]. Explanations for this association between relationship status and depression include that married/partnered women may experience relationship dysfunction or dissolution following diagnosis [36,49,50]. In fact, a partnership or marriage need not end in dissolution or divorce before the breast cancer patient is negatively affected by her partner: simply being unaccompanied by one’s spouse for hospital follow-ups is associated with higher levels of depression and anxiety [51]. As this is only one study, and contrasts with other research, further research is needed to better understand this phenomenon.S
Do breast cancer diagnoses directly cause intimate relationship dysfunction and even partner abandonment? [52] Research suggests that relationships and marriages that do not survive the breast cancer experience had preexisting problems that ultimately caused the dissolution, and relationships in which someone is diagnosed with breast cancer are no more likely to end than other relationships [53,54]. Not all of these studies were racially/ethnically diverse, which is a significant limitation.
Among a sample of African American breast cancer patients, those with intimate partners felt emotionally supported by them, although the partners did not assist them in making health decisions [44]. While Latina breast cancer survivors report feeling emotionally, socially, and functionally supported by their social network of friends and family, their male relatives (including intimate partners) are less likely to acknowledge their change in health status, which was unsettling for them [45]. This lack of acknowledgement is problematic because strained relationships post-diagnosis can have negative impacts on patients’ mental health and physical health that can lead to earlier mortality [55-58]. Among an all-Latina sample, 25% of the participants’ partners left them post-diagnosis, and several other women stated that although their husbands did not leave them, their husbands did reject them post-mastectomy and no longer acknowledged them as wives [45].
Female partners play a critical role in sexual minority women’s breast cancer treatment experiences, taking on additional household roles and offering verbal support and encouragement [59,60]. Their role stands in contrast to previous literature on different-sex partners’ reactions to women’s breast cancer diagnoses and treatment – namely, avoidance and withdrawal strategies that caused distress to the patient [61,62]. At the same time, female partners who are caregivers of cancer patients generally report more anxiety and care burden than male partners [63]. Among a sample diverse in relationship status, breast cancer patients who got a new partner post-diagnosis were more sexually satisfied than patients who retained the same partner [64].
Articles using both qualitative and quantitative research methods examine how intimate partners provide support. There is also research to suggest that single women are protected from the simultaneous stress of illness and dysfunctional relationships [50]. It is possible that single women will reflect on past relationships or their peers’ relationships in an effort to explain how their lives might be different if they had had partners during their diagnoses and treatment [65].
Friends
Increased contact with friends post-diagnosis is associated with lower risk of death for breast cancer patients [66]. Simply having someone to share one’s problems with improves breast cancer patients’ quality of life [51]. Benefits of contact with friends postdiagnosis include improving coping skills, receiving emotional and instrumental support, and increased opportunities for sharing health information [66].
Formal support groups
Breast cancer support groups offer a very specific form of social support: being surrounded by individuals who understand the breast cancer experience because they are also living through it [67]. In a longitudinal study of newly diagnosed breast cancer patients, those who took part in a seven-day support group were more likely to have lower levels of anxiety at the two-month follow-up as compared with the control group [68]. Support groups traditionally last longer than a week; additional studies might look at breast cancer patients’ mental health after several weeks or months of support group participation. Another study examined breast cancer survivors’ mental health following a year of psychoeducational support group participation (consisting of individual face-to-face education, healthcoaching sessions via telephone, and small-group meetings). Those who took part in the program reported both a higher quality of life overall and higher emotional well-being [67]. Additional studies that focus on such programs for patients receiving treatment would also be informative. Among a sample of Latina breast cancer patients, participants reported more satisfaction and social support talking with a formal support group of patients than their other friends [45].

Intrapersonal Resources

Spirituality
Spirituality is key in helping breast cancer patients cope with their diagnosis and treatment [69]. The benefits of spirituality are numerous, including less mood disturbance and higher quality of life [70]. Spiritual activities include prayer and attending church [45,71]. Spirituality is a protective factor against anxiety among breast cancer patients [72] and against depression in general [73].
African American breast cancer patients and survivors especially report spirituality as a coping mechanism [23,74,75]. Specifically, spirituality helps patients overcome their fear of death immediately following diagnosis [44].
Latina breast cancer survivors also find solace in their spirituality [45,46]. For patients lacking a familial network in the United States, support groups and spiritual practices offer an alternative emotional support [6]. However, newer research suggests that spirituality is a protective factor only if the patient has a long-established belief system; struggling with one’s faith post-diagnosis is associated with decreased well-being [76]. Moreover, spirituality can be a deterrent in seeking adequate and timely medical treatment if Latinas only rely on faith-based cures [45]. Even controlling for length of time in the United States, many lower-SES Latina breast cancer patients rely on traditional faiths instead of scientific procedures such as chemotherapy and radiation [45].
Complementary and alternative medicine
Breast cancer patients require care for the mental and emotional turbulence that they may experience during and following treatment [77]. A growing movement toward integrative oncology incorporates mind-body therapy into traditional medical treatment [78]. Complementary and alternative medicine (CAM) offers patients the opportunity to “go within” and bolster their intrapersonal resources, which leads to improved mental health [79]. Previous research has analyzed CAM therapies for advanced cancer patients, including massage, acupuncture, meditation, yoga, spiritual healing, and prayer [33]. CAM may even help individuals in their identity construction as cancer patients, as they make decisions about their biomedical treatment [80].
Among a review of papers that discussed art therapy interventions for cancer patients, self-expression, decreased anxiety, increased coping skills, and social intervention were listed as outcomes for the patients [81]. Among cancer patients on chemotherapy who attended watercolor painting classes, those who attended four or more classes had significantly lower levels of depression post-intervention [82]. Conversely, among a sample of newly diagnosed Stage I and Stage II breast cancer patients, taking part in creative arts therapy (pencils, pastels, acrylic paints and drawing/painting tablets) was not effective in increasing participants’ emotional expression. However, it was effective in enhancing psychological well-being [83].
In a meta-analysis of 10 articles that examined health of yoga groups for cancer patients compared with waitlist control groups of cancer patients, the yoga groups showed significant improvement in psychological health [84]. Similarly, among a pilot study of female breast cancer patients and survivors, those in yoga groups were more likely to report improved mental health, positive affect, spirituality, and diminished depression, as compared with the waitlist control group [85]. Both articles’ results reflect that of a multiethnic sample of breast cancer patients who engaged in yoga classes: patients who did yoga reported a higher quality of life than patients who were in the waitlist control group [86].
Health literacy
Health literacy is an intrapersonal resource because it is a measure of the individual’s capacity to access, understand, and act upon health information. The Institution of Medicine defined health literacy as “[t] he degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (p. 1) [87]. Common threats to the patient’s access to, and comprehension of, health information include inability to understand medical forms, perceptions about treatment, and not using the same language as the medical team or forms [88]. While these threats are embedded in multiple social systems, they also lie in the patient’s individual experience.
Health literacy is affected by the culture in which an individual is embedded [43]. Culture includes the values, norms and behaviors of social systems including families, communities, and societies [89]. A woman’s culture impacts her search and receipt of health information, in that the culture shapes her “knowledge, attitudes, and personal practices, which affects [her] responses to health information” (p. 166) [90].
Health literacy is a key tool in reducing cancer disparities [91]. Health literacy may also explain some breast cancer disparities [92]. For example, breast cancer outcomes are influenced by choice of treatment, types of treatment, level of understanding of treatment options, and emotions surrounding decision-making; health literacy is a determinant of these factors [92].

Access to Health Care and Health Information

Common methods for accessing breast health information include talking with members of the medical team, conducting online research, and reading books [93]. However, many barriers potentially obstruct access to, and use of, detection and treatment services. Having prior negative experiences with professional care providers, lacking leave time from work or the ability to afford treatment, and not being able to travel to health care facilities all impact the likelihood of receiving medical treatment [94]. This is true of health care in general and breast cancer specifically [94-96]. Physician-patient communication, perceptions of discrimination, patients’ employment status, and geography all relate to patients’ ability to access adequate health care and health information [97-99]. People who are less health literate have less access to adequate health care and health information [100]. Many of the determinants of health literacy also determine the quality of medical team-patient encounters [101].
Physician-patient communication
Communication with physicians is critical to patients’ well-being [97,102]. Ability to communicate is especially necessary when making decisions about chemotherapy and surgery [93]. Breast cancer patients report desiring more holistic conversations with their oncologists about the impact of the disease on other areas of their lives [103].
African American breast cancer patients report receiving insufficient information about cancer terminology, their diagnoses, and subsequent treatment; they attributed this dearth to their medical teams failing to provide them with relevant information [44]. African American breast cancer patients have attributed their unhappiness with physicians to their own race or ethnicity, lack of health insurance, and the physicians’ insensitivity [44]. African American breast cancer patients reported severe displeasure with their surgeons, regardless of the surgeons’ race/ethnicity [44].
The literature varies on the relationships between Latina breast cancer patients and their physicians. In some studies Latina breast cancer survivors report positive feelings toward their care providers [46]. In other cases, they report distrust of their own physicians, but they hold respect for the authority of physicians in general and therefore follow their doctors’ orders without researching their options independently [45]. Miscommunication between Latina breast cancer patients and their physicians also leads patients to believe their diagnosis is correlated with a bad prognosis [45]. It is possible that combined with a fatalistic mentality, this lessens the likelihood that patients will be proactive in getting continuous treatment [45].
Perceptions of discrimination
Breast cancer patients have reported feeling discrimination because of their race, ethnicity, and sexual orientation [44,102]. Many African American breast cancer patients are concerned about racism within the health care system [44,104]. Types of discrimation experienced include internalized discrimination and group discrimination [105]. At the same time, African American breast cancer patients often feel it is safer to follow the oncologist’s medical advice rather than researching their options independently [44]. Their predilection for compliance is similar to Latina patients’ attitudes toward physicians and oncologists [45].
There is an association between discrimination experiences and sexual minority women patients’ poor physical health [102]. These sexual orientation-based forms of discrimination include lack of medicolegal rights, the oncologist’s uncertainty or discomfort acknowledging the patient’s sexual orientation, and the intentional or unintentional exclusion of the patient’s partner [96,106].
One systemic barrier to health care is the fear of disclosure about sexual orientation to physicians and oncologists [107,108]. Having a good oncologist-patient relationship is key to feeling secure about disclosure and including one’s partner in conversations with the oncologist [109,110].
Health information: seeking, processing, using
African American breast cancer patients report receiving insufficient health information, and young African American patients report a particular deficit in the receipt of information about infertility post-diagnosis [111]. A diagnosis of cancer may feel like a death sentence, especially among individuals with lower incomes and less education who know people that had late or end-stage cancer and died soon after being diagnosed [43]. This fatalism is associated with less likelihood of early detection and pursuit of medical opinions for suspicious symptoms, which perpetuates the cycle of lower-SES women being diagnosed with breast cancer at later stages [112]. Other contributing factors to later-stage diagnoses among lower-SES women include affordability and accessibility, even among samples with full mammogram coverage [113]. Based on this literature, it is possible that some lower SES women may be less likely to envision their lives as survivors because they believe they will probably die from breast cancer.
Socioeconomic status also plays a role in information-seeking behaviors. Cancer patients with low SES are less likely to seek health information or independently research their options [114]. If they are unhappy with their oncologists and do not feel capable of seeking health information independently, such a lack of self-efficacy may lead to decreased well-being [115-117].
The principles of plain language dictate that patients must fully understand their medical team’s directions [118]. This means that oral and written instructions should beclear to the targeted user, exclude any unnecessary details, and use comprehensible words [119]. The extent of understanding can vary by health literacy levels of patients and their caregivers’ abilities to communicate. Among a sample of breast cancer patients, the majority were able to read written medical instructions provided to them, but fewer were able to understand and act upon the information [119].
Employment during treatment
A thorough review of the literature yielded no articles on the social support that co-workers might offer breast cancer patients; existing literature regarding breast cancer patients’ employers suggests that support from employers is a protective factor against concerns about continuing to work post-diagnosis and during treatment [98]. Most breast cancer patients, if employed, continue working during treatment or anticipate going back to work post-treatment, but they may face obstacles relating to their physical health (fatigue, nausea, and “chemo brain”) or their work-related expectations post-diagnosis [99,120]. Support from supervisors and co-workers greatly impacts breast cancer patients’ return-to-work process [98]. Employment status is linked to poorer quality of life among breast cancer patients [121].
Latina breast cancer patients are more likely to report high levels of worry during treatment than white or African American patients [16]. This may be attributed to having less access to health information or to the difficulty in maintaining their job [16]. Latina breast cancer patients are more likely to lose their jobs than white breast cancer patients; job loss leads to increased stress within families [16,45]. Latinas are overrepresented in jobs that do not offer health insurance or sick leave (“caretakers, housekeepers, factory workers,” p. 27) [45], and often must choose between keeping their job and continuing treatment [45]. Among an all-Latina sample of breast cancer patients, 50% of the participants applied for financial help; none of them were qualified due to strict requirements [45]. Lack of health insurance is associated with later-stage breast cancer diagnosis [122].
Some patients choose not to disclose their diagnosis to supervisors or colleagues for fear of discrimination [120]. In one study of African American breast cancer patients, participants had enough sick leave and vacation days that they perceived no need in telling their employers about their diagnoses and thus risk discrimination [44].
Geography
Geographic proximity to health care facilities indicates the likelihood of using preventive and detection services, such as mammography. Women in urban areas are more likely to get mammograms than women in rural areas [98]. Thus it follows that women in rural areas are more likely to be diagnosed at later stages than women in urban areas [123]. Census tracts with predominantly African American populations have longer travel time to mammography facilities than tracts with other racial/ethnic populations [124]. This association confirms that African American women are more likely to be diagnosed at later stages than white women [11,12]. Census tracts with low and middle SES families are more likely to illustrate African American and Latina health disparities in terms of later-stage breast cancer diagnoses and mortality rates [125]. Later stage at diagnosis for Medicaid breast cancer patients is associated with travel burden [95].
Travel time to health facilities is associated with type of treatment; women who live farther away from facilities are more likely to select mastectomy over a breast-conserving surgery [126]. This suggests that if travel time is a concern, women might opt for services requiring fewer visits [126].

Making Meaning of Relationship Status

Although “single” is frequently used as an umbrella term to describe people without partners, there are several types of single: eversingle, divorced, and widowed [127]. These variations of relationship status invite different contextual explanations for women’s current life experiences [127]. The experience of singlehood also differs by race, ethnicity, age, and gender [127].
Among a sample of single women, white women were more likely to explain their relationship status by personal fault rather than structural issues as compared with African American women [128]. As single women age, they report an increased awareness of their changing social world (including the diminished pool of eligible partners) and acknowledge feeling displaced in their families, particularly if other relatives their age are married [129]. While they may still hope for a long-term partner, ever-single women simultaneously grieve for the absence of a partner and children and the fact that their families have decreased interest in their romantic lives [129]. Older and divorced women are more likely to adjust to their single status as compared with younger or ever-single women [74,130].
These feelings may be indicative of singlism, a form of discrimination against single people [131]. Singlism is a reflection of our society’s ideology that promotes couples and marriage over singles “in everyday thoughts, interactions, laws, and social policies” (p. 957) [129]. Upon reviewing recent U.S. Census data as well as literature on single women, Sharp and Ganong posit:
The demographic shifts in women’s marital and childbearing patterns suggest that individual life pathways are acceptable but, at the same time, women remain restricted (and face stigma and discrimination) in a society that promotes marriage and motherhood as central to women’s identities. (p. 958) [129].
Thus, despite growing numbers of women without partners in the United States [132], these women may still face covert discrimination owing to their single status.

Discussion

The review of 115 articles did not produce any studies on breast cancer patients without partners. With no existing studies, there is no evidence from which to determine the effect of presence or absence of an intimate partner. Research is needed to expand the body of knowledge on women experiencing breast cancer without a partner.
The review did provide findings on the experience of breast cancer patients with partners. Breast cancer patients are not a monolithic group: their interactions with medical professionals, perceived support from family and friends, and ability to access health information vary widely. These experiences fluctuate by race and ethnicity, socioeconomic status, geographic region, and level of health literacy. Below we discuss implications from the existing literature for patients and for providers.
Implications for patients without partners
The review of literature documents the dearth of information on patients without partners. Academic literature concerning breast cancer and the family has focused on patients with partners. This review indicates that if intimate relationships are solid prior to diagnosis, partners may provide emotional and instrumental support to female breast cancer patients. Very little is known about who provides emotional and instrumental support to breast cancer patients without partners. Although some studies indicate differences in use of detection services between breast cancer patients with and without partners, there is a gap in the literature concerning the lived experience of patients without partners. Additional research is needed into this phenomenon to yield information that would help patients without partners cope with unique challenges and experiences.
Implications for health care providers
Without research findings on patients without partners, the health care team for women with breast cancer can draw on literature focused on women with partners. Findings about the association between partners, social support and a woman’s health are particularly relevant. Common clinical assumptions about breast cancer patients’ support systems are often mistaken [133]. It is important that members of the medical team inquire into patients’ social support systems, and offer suggestions for gaining additional support from professional organizations. As evidenced by the literature reviewed, doctors and other members of the medical team should consider the racial or ethnic differences among breast cancer patients. For participants to feel comfortable with their medical teams, these medical providers must be up-to-date on racial health disparities [44,60].
Breast cancer patients have conveyed interest in using complementary and alternative medicine (CAM) but lamented that their doctors did not know much about CAM. Because integrative oncology is becoming increasingly popular, physicians and other members of the medical team should learn more about these supplemental treatment options and share the information with patients. A next step would be to consider including integrative oncology programs in hospitals and clinics [134].
Additionally, breast cancer patients regularly interact with multiple members of their medical team (oncologists, radiologists, surgeons, nurses, oncology therapists, and Nurse Navigators) separately and sometimes as a whole. All members of oncology medical teams should be trained in how to communicate and work with patients, as they all could have impacts on patients’ well-being.

Conclusion

Until research is conducted on female breast cancer patients without partners, family and health professionals will need to rely on existing research. This review could help professionals develop an understanding of interpersonal relationships on which women with breast cancer rely. Professionals will then have a better concept of the coping mechanisms which might be employed by patients without partners. By better understanding the meaning women make of their relationship status within the context of their cancer experience, family scientists and health care specalists will be better able to serve women facing breast cancer with and without partners.

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