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Helping Women and Their Families Cope

With the Impact of Gynecologic Cancer

Deitra Lowdermilk, RNC, PhD, FAAN,
Barbara B. Germino, RN, PhD, FAAN

=The impact of gynecologic cancer on the There are ethnic differences and familial ten-
woman and her family depends on psychosocial fac- dencies for some gynecologic cancers. In the
tors and cancer-specific factors. Family assessments United States, both the incidence and mortality as-
determine how the family is adapting to the woman’s sociated with cancer are highest among African-
illness. Nursing interventions that families say are American women for most gynecologic cancers,
helpful include providing physical care, providing in- particularly cervical cancer. Caucasian women
formation, and giving support. Strategies used by have a higher incidence of endometrial and ovar-
families to cope with the stress and emotional strain ian cancers. Women who have had breast cancer
of caregiving include taking time for themselves, or have a family history of ovarian cancer are at
maintaining a sense of humor, and focusing on the increased risk for ovarian cancer; a family history
present. /OGNN, 29, 653-660; 2000. of breast or ovarian cancer increases the risk for
Keywords: Caregiver-Coping strategies- endometrial cancer (ACS, 2000).
Family assessment-Gynecologic cancer It is important to note these differences are
not fully understood. Some studies indicate ethnic
Accepted: February 2000
differences are really socioeconomic ones-poor
people have higher overall cancer rates. It has
The estimate of the number of women who been suggested that access to care is limited for the
will receive a diagnosis of cancer in 2000 in the poor and that they have disease diagnosed at a
United States is 600,400 (American Cancer Soci- later stage and may have fewer treatment options
ety [ACS], 2000). Carcinoma of the uterine corpus if they are uninsured or underinsured. Transporta-
(endometrial cancer) and ovarian cancer are the tion to care may be an issue, as may safety of the
fourth and fifth most common sites of cancer in environment. There also are cultural beliefs that
American women (ACS). The news about repro- may influence health-seeking behavior. Fatalism
ductive cancer trends in this country is mixed. The about cancer may be an issue for some older
incidence of invasive cervical cancer has decreased African-American women, whereas some Latino
70% during the last 30 years, whereas preinvasive women may not get needed cancer screening be-
cancers are increasing. Improved screening tech- cause they do not seek care when they feel well
niques and earlier detection have made the differ- (Lannin et al., 1998; Mishel, Germino, & Braden,
ence. However, endometrial carcinoma has de- 1999).
creased only very slightly since 1975, and its For years, women with gynecologic cancer
incidence remains consistently around 20 per and their families have dealt with the experiences
100,000 women. Ovarian cancer rates have of their illness and treatments on their own be-
changed little since 1973, and it kills more women tween any necessary hospitalizations and outpa-
each year in this country than all other gyneco- tient visits for diagnosis, treatments, and follow-
logic cancers combined (ACS, 2000). up monitoring. More recently, these women and

November/Decernber 2000 JOGNN 653

their families face even more of a challenge because agement of family life, the nurturing of children, and the
health care systems in which cancer is diagnosed and care of extended family members. When a woman learns
treated have responded to a national mandate for cost she has gynecologic cancer, her ability to perform these
containment by limiting hospital admissions, shortening important roles can be limited, resulting in a negative im-
hospital stays, and discharging people with cancer ear- pact for the whole family system (Yates, 1999). However,
lier than ever before. Women who have been hospital- depending on the type of cancer, its stage, and the initial
ized for surgery or other treatment of their gynecologic treatment, many women can perform their usual family
cancer or for complications will be discharged so roles within 6 months of diagnosis.
quickly they still require a great deal of direct and indi- Several studies have identified situations that
rect care, including teaching, support of various kinds, evoke stress for family members who may be caregivers.
monitoring, and help managing the sequelae and side ef- Many of the situations listed are most acute after the
fects of treatment and symptoms of their cancer. Man- first hospitalization and particularly after surgery
aged care has profoundly affected cancer care. Home (Allen, Goldscheider, & Ciambrone, 1999; Northouse,
care agencies and other community agencies have not 1995; Steele & Fitch, 1996a, 199613; Yates, 1999):
been able to keep pace with the demands imposed by
the need to be available 24 hours a day, 7 days a
changes in the health care system, so families continue
to carry the largest part of the burden of care for
women with gynecologic cancer. In the United States, the fear of leaving the woman alone at home;
family members provide as much as 80% of home care disruption of household routines and changing
for patients with cancer. The spouse usually gives care plans at the last minute;
to the middle-aged woman. Although spouses are caring balancing work outside the home with care;
for some older women as they age, many are widowed,
maintaining or returning to the usual work pattern;
and their adult children, siblings, other family members
and friends may be involved in the care. strained relationships with other family members,
especially if they are not caregivers, and resent-
ment that this has happened;
having to manage the woman’s physical care and
treatment, including lack of knowledge in man-
H o m e care agencies and other agement of her physical symptoms or lack of con-
community agencies have not been able to fidence that they have done the care correctly
(such as changing dressings);
keep pace with the demands imposed by
having to provide emotional support to the
changes in the health care system, so families woman (one of the most difficult tasks identified
continue to carry the largest part of the burden is lack of knowledge about psychologic needs);
the lack of time to develop or maintain supportive
of care for women with gynecologic cancer.
social relationships for themselves and the feeling
of isolation; and
concerns about their own health and how they are
going to manage all of the demands on them.
A Framework for Examining the Impact of
Cancer on Women and Their Families Shifting roles from the ill woman to the well part-
The impact of gynecologic cancer on families is ner or other family member can be overwhelming. The
shaped by a number of factors, including the specific mental health of the family caregiver can be affected.
type of cancer and the implications of the diagnosis for Anger and depression have been reported in husbands as
the woman and her family; the meaning of the cancer ex- stress of the caregiver’s role increases, particularly when
perience to them; the social impact of physical changes; the role involves helping the woman with her activities of
the timing of the cancer in the woman’s and the family’s daily living (Allen et al., 1999). The impact of a mother’s
lives; and the costs of the cancer to her family. cancer on children may vary, depending on the age and
developmental stage of the child. For example, young
Impact of Diagnosis children may be concerned about the family’s safety and
There is limited nursing research on the impact of a the ability of their family to stay together. Older school-
diagnosis of gynecologic cancer on women and their fam- aged children may be worried about the added chores
ilies. The impact of the illness can be extremely stressful. they have to assume and the disruptions caused by the ill-
Women often play a central role in the day-to-day man- ness. Adolescents may want to be supportive and help

654 JOGNN Volume 29, Number 6

care for the woman, or they may not want to be involved social relationships that provide them with the energy,
at all and resent having to help. Older adolescent daugh- support, and encouragement that may be needed more
ters may be concerned about heredity and whether or not during their experiences with cancer than under everyday
this could happen to them. Children of all ages may have circumstances. Social support is a key factor in psycho-
adjustment problems (Gates & Lackey, 1998). Concerns logical adjustment to cancer for clients (Dunkel-Schetter,
about roles and relationship issues are common for adult Feinstein, Taylor, & Falke, 1992), and it is logical to as-
children whose parents are dealing with cancer (Germino sume that loss of or change in social relationships that are
& Funk, 1993). important to the family may have negative consequences.
Improvements in diagnostic techniques and treat- Often physical changes, particularly changes in
ments for gynecologic cancers have resulted in in- appearance and physical functioning, and fatigue may
creased survival rates. As more women survive the have a social impact. The woman whose appearance
acute phases of gynecologic cancer, they are faced with has, in her view, changed for the worse may not be will-
sometimes devastating chronic problems, such as ing to go out to social occasions, to church, or to her
changes in body image and function (Zacharias, Gilg, usual activities, and her family may curtail their activi-
& Foxall, 1994). Women who have recurrence or nu- ties both with her and as individuals. Fatigue may limit
merous symptoms related to cancer or the treatment re- the woman’s ability and willingness to see friends and
port significantly more problems in performing family neighbors and demand the immediate family’s time and
and domestic roles than do women with new diagnoses energy, having social impact on all of them.
(Northouse, 1995; Steele & Fitch, 1996a, 1996b; Steg-
inga & Dunn, 1997). Thus, as a woman’s disease pro- Finding Meaning in the Cancer Experience
gresses, she may be less capable of performing her roles The personal meaning of the cancer experience for
and will need a healthy partner (or other family mem- woman with cancer and her family is their perception of
ber) to assume additional family roles. the potential significance of the cancer for themselves
and for their plan of responding to it. Meaning may
change with time and may be negative or positive or

As a woman’s disease progresses, she may

somewhere in between (Germino & O’Rourke, 1996).
The meaning of cancer to the family and to individual
members is an important factor in adjustment. For the
be less capable of performing her roles and woman, the meaning she makes of her situation may
will need a healthy partner (or other family provide some indication of her ability to adjust to the
stresses with which she is living (Lewis, 1992; Lewis &
member) to assume additional family roles. Hammond, 1992; Lewis, Hammond, & Woods, 1993).
The many changes imposed by gynecologic cancer must
somehow be integrated by the woman and her family
members, and this may involve major shifts in the way
Women with gynecologic cancer have described a they view their family, their life, their values and rela-
number of specific psychosocial and physical difficul- tionships, and how they address fears and concerns
ties associated with diagnosis and treatment. They have (Germino, Fife, & Funk, 1995).
reported anxiety, depression, and fear of dying. They Women with gynecologic cancer and their families,
have described physical side effects that have changed in the process of making some meaning out of potentially
their physical abilities and functioning and altered their frightening and difficult experiences, must sort through
social relationships. Some of the physical side effects of the events and relate them to their past experiences with
treatment include fatigue, pain, bladder dysfunction, illness and loss and their encounters with the health care
and vaginal stenosis. system. They also must deal with changes from the can-
Women voice fears and concerns about the spe- cer and the fears and concerns generated. Finding some
cific treatments. For example, concerns about feminin- understanding of the significance of the cancer for their
ity and changes in sexual functioning have caused lives, thinking about the consequences of the cancer,
women to experience a wide range of difficulties after looking at their attitudes toward themselves and others
surgery, specifically hysterectomy, and after radiation and toward life, learning to live with the cancer, and find-
treatment (Wilmoth & Spinelli, 2000). ing sources of hope are issues involved in finding mean-
ing (O’Connor, Wicker, & Germino, 1990).
Social Impact The importance of understanding this process and
Gynecologic cancer may have a significant impact of some ongoing assessment of where women and their
on the social aspects of life for the woman and her fam- family members are in the process is related to their ad-
ily. It may alter the nature of or isolate women from the justment. When individuals and their families view their

NovemberlDecember 2000 JOGNN 655

illness experiences very negatively and see the future with times as people marry and have children later, divorce,
great anxiety and little hope, they may need some help in remarry, and reconstitute families containing children of
reframing meaning to integrate the cancer experiences in a broad range of ages. Family changes, losses, and tran-
a way that allows them optimal quality of life. Family sitions are ongoing. Some of these are normative; others
members may have their own struggles and needs for as- are highly disruptive and stressful. Family stress theory
sistance in this process. In addition, if adjustment is to be suggests that an accumulation of stressors eventually
achieved by the family as a unit, some communication can affect even the most resilient of families and make
about the struggle to find meaning is important for each it difficult for them to continue to function effectively
person in the family to respect and understand their dif- (McCubbin, Sussman, & Patterson, 1983).
ferences and support each other (Germino et al., 1995).
Timing Cancer’s economic impact on the family can be sub-
When the gynecologic cancer occurs is an impor- stantial, especially for families who are uninsured or un-
tant factor to be considered. The stresses associated with derinsured. But many families with seemingly adequate
gynecologic cancer are added to and complicate the nor- insurance coverage may experience the cost of cancer
mal demands of family life; those demands vary with the through gaps in coverage for medical expenses; loss of or
family life cycle. For example, when gynecologic cancer gaps in employment and accompanying earnings; addi-
occurs in a young woman, family members may be cop- tional out-of-pocket expenses, such as transportation,
ing with starting careers, less-than-optimal finances, and overnight stays, and child care; and quality-of-life factors
caring for young children. These demands are difficult (Berkman & Sampson, 1993; Given, Given, & Stommel,
enough on a day-to-day basis, but when a woman in the 1994). Unfortunately, there have been, until recently, few
family has gynecologic cancer, the diagnosis superim- studies that define costs beyond those associated with
poses added worries of a life-threatening illness, possibly medical expenses and loss of employment (Given et al.).
body-changing surgery, threats to sexuality and the sex- The costs of caring at home for a family member with
ual relationship, and the side effects of treatment. Young, cancer have been described only recently. When family
newly married couples trying to create their own families labor is included in cost calculation, home care by family
and separate from their families of origin may experience members during a 3-month period was only slightly less
conflicts if the cancer diagnosis pushes them back to inti- than the costs of nursing home care (Stommel, Given, &
macy with their parents and siblings, rather than with Given, 1993). A number of factors influence the costs of
each other (Rait & Lederberg, 1990). caring for a family member at home, including the extent
Disruption appears to occur in families with all of impairment of the family member’s functioning espe-
ages of children, and at the time of diagnosis, there are cially in activities of daily living, family living arrange-
no reported differences by children’s age in the level of ments, and survival status (Given et al.). Quality-of-life
disruption. However, by 6 months after diagnosis, fam- costs, including reduced work effort, decreased produc-
ilies with older (adolescent) children report less role tivity in the home, loss of promotion opportunities at
strain and role conflict than do families with preschool work, and others, have not been well studied.
and school-aged children (Gates & Lackey, 1998). Role
and relationship concerns may be a major issue for
adult children when a mother has cancer (Germino &
Management of Care
Funk, 1993). For instance, adult children may have un- Assessment of Needs of Caregivers
resolved relationship issues with their parents. Taking In clinical practice settings, family-based assess-
on the new role of support person to a mother with gy- ments are needed to determine how families are adapt-
necologic cancer is a challenge to young adults. Balanc- ing to the woman’s illness. Identifying what families see
ing the demands of a mother’s illness with the pressures as their greatest need provides important information
of their own work and family lives exemplifies the im- for designing interventions that best use the family’s re-
pact of cancer for middle-aged children, sometimes sources and external resources. It also is important to
known as “the sandwich generation” because they are reassess needs at various intervals, especially during
in the middle of two demanding situations. transition times, such as after hospitalization, at the be-
During periods of life transitions such as child- ginning of a new treatment, at recurrence, and when
birth, career changes, and retirement, where demands palliative or terminal care needs to be considered.
for adjustment are extraordinary, there can be a more In acute care settings and in office or clinic settings,
intense response to a gynecologic cancer diagnosis. In nurses do not always have time to do a comprehensive
today’s families, where traditional developmental assessment during one encounter. A few directed ques-
phases are no longer necessarily the norm, changes and tions can determine how the family is adjusting. Table 1
their resulting demands may occur at many different lists questions that can be asked to collect essential infor-

656 JOGNN Volume 29, Number 6

facilitate identification of alternative acceptable goals
for their lives.
Identifying what families see as their greatest Values. How do cultural values relate to family
roles and function and the family's beliefs about health
need provides important information for
promotion? What family activities are most important?
designing interventions that best use the Optimal functioning of the woman can be promoted by
incorporating cultural and family values. For example,
family's resources and external resources.
if having dinner together is a priority, nursing interven-
tions can be directed at helping the woman and her fam-
ily meet that goal, perhaps by helping the woman use
assistive devices to get to the dinner table.
mation for planning care. If a more in-depth assessment, Behavior. Which family members work together?
such as the one described in the following section, is Does the family do things together? Look for cohesive-
needed, the information can be gathered during several ness among family members.
encounters with the woman and her family. Coping Ability. What does the family see as the
A comprehensive family assessment begins with strengths of the family and its individual members?
history taking to determine family functioning. Family What is the meaning of the cancer event to the family?
member ages, geographic location, socioeconomic status, How vulnerable is the family to crisis? Can family mem-
ethnic background, roles, relationship to client, develop- bers modify their roles and change their personal ex-
mental level, major stressors, alliances, and frictions arc pectations and goals. For example, a mother's cancer
identified. Questions address the following areas. may interfere with an adolescent daughter's autonomy
Structure. What is the family composition-house- and peer relations, especially if she has to be a caregiver.
hold members, divisioddistribution of household activ- She may become resentful or unwilling. The nurse can
ities, members not living at home, young children in the assist members to identify measures to change the expe-
home, caregiver's role in family? This information can rience and cope more effectively.
be used to assist the family to redefine roles and redis- Health and Functional Status. What is the health
tribute household tasks. These issues may be more com- and functional status of the primary caregiver? He or
plex for nuclear families with no extended family living she needs to be in good health for 24-hour care. Is the
close, lesbian couples, and single/divorced/widowed caregiver physically able to perform the necessary tasks
women. or procedures, such as lifting or moving the patient?
Pattern of authority. Who is the decision maker? Stressors. Are there other stressors affecting the
Identifying the persons of authority can facilitate care. family, such as illness or work issues of other family
Level of Family Development. What is the members? Families experiencing a high number of other
level-older adult, mid-adult, young adult? Young cou- stressors in their lives may be at higher risk for prob-
ples may be establishing a household and family. Un- lems (Northouse, 1995).
derstanding the developmental level of the family can Support Systems. Does the family have an outside
support system? Families may be reluctant to ask for
help or may not be aware of community resources. The
nurse can help the family identify and gather support

Quick Family Assessmerit (such as from neighbors or church members) to prevent
or diminish caregiver fatigue.
Key starting questions Knowledge of Illness and Health Practices. What
1. Who does this woman consider to be her family, does the family know about the cancer and its treat-
and are these the people most involved with her ill- ment? The nurse may need to provide information
ness right now? about increased risk for female family members and
2. What is the most pressinglupsettingldistressing issue what diagnostic tests are appropriate (e.g., genetic test-
for the family right now? Is it the same for all im- ing for ovarian cancer). The nurse also may have to
mediate family members, or does it differ from per- teach caregivers the skills necessary for care, such as
son to person? What are they doing right now to wound care.
deal with the issue? With their distress? Are their
strategies working?
Nursing Interventions
3. Does this family have or know about the resources Most of the research on the impact of cancer on the
it needs to deal with this issue and others? Do they
know how to access the resources, and are there family has been done with families of women with breast
any barriers to doing this? cancer. Other major research has been focused on family
caregivers of patients with cancer at home, without indi-

NovemberlDecember 2 000 JOG" 657

cating the type of cancer. The most common phases of Allow the woman to be as independent in self-care
cancer studied are during the initial diagnosis and in the as possible.
terminal stages. Not much is known about the treatment, Infomation. Teach family members how to keep
post-treatment, and rehabilitation phases. Although find- the woman comfortable (e.g., pain management, posi-
ings of these research studies may or may not be general- tioning). Repeating information as necessary and pro-
izable to the gynecologic cancer population, current prac- viding demonstrations and written information are use-
tice in gynecologic oncology nursing reflects ful strategies in helping families recall information and
implementation of many of the following interventions techniques.
that have been found to be beneficial in relation to pro- Answer questions honestly and willingly; convey a
viding care, information, and support (Harrington, nonjudgmental attitude.
Lackey, & Gates, 1996; Hull, 1992; Given & Given, Teach not only what to do but also what to ex-
1996; Steginga & Dunn, 1997; Zacharias et al., 1994): pect. For example, teach about the possible side effects
Care. Give excellent, knowledgeable, skilled, and of chemotherapy and suggestions for dealing with them.
personalized care to the woman in a calm, unhurried Fact sheets given to the family are useful reminders.
approach. It is especially important in home care that a Table 2 displays the various phases of gynecologic can-
nurse competent in gynecologic cancer nursing should cer and general information needed by women and their
be assigned to provide care. family caregivers in each phase. Families also can be di-
Provide the woman with emergency care if rected to formal caregiver cancer education programs
needed. that offer topics such as symptom management, finding
Be available 24 hours a day (e.g., 24-hour hot community resources, and improving communication
line), 7 days a week to reduce anxiety about caregiving. skills (Robinson et al., 1998).

Tinting of b t fovritntiort Needed by Womert with
Gyitecologic Caiicer and their Fantilies

Phase of illness Itttimnalion needed

Diagnostic phase Explanation of procedures to be done, including
preparation if needed
When to expect test results
What emotions can be expected while awaiting diagnosis
Discuss familial risks if appropriate and available testing
if recommended
Hospital phase Explanation of type of surgery planned
When to expect pathology report
Postoperative expectationsflimitations
Treatment phase Explanation of type and length of treatment planned (e.g.,
radiation, chemotherapy)
Potential side effects and how to minimize these effects
Effects on normal activities
Infomation on support groups
Adaptation phase Timing of follow-up tests and examinations if needed
Common concerns about follow-up
Availability of support groups
Recurrent phase Explanation of type of treatment planned
Potential effects
Common feelings regarding recurrence
Ways to keep up hopes
Support group availability
Community resources

658 JOGNN Volume 29, Number 6

Support. Accept the family’s feelings and con- coping strategies may find the following suggestions
cerns; respect different religious (spiritual) beliefs. Ac- helpful.
knowledge the caregivers’ efforts and contributions to Changing the Environment. Try to keep life as
care at every contact. normal as possible by taking time away from the house.
Assist the family to problem solve on a daily basis, Caregivers should ask a friend, neighbor, or other vol-
such as using support systems and identifying commu- unteer to stay with the woman and go to the health
nity resources. Table 3 lists information about some club, a sports event, or a movie. Encourage visits from
support groups and community resources for women friends and other family members if leaving the house is
with gynecologic cancer and their families. In addition, not an option. Use distraction by doing something en-
nurses need to know their local resources and how to joyable, such as working in the garden, listening to
refer women and families. It is useful to know how ac- music, watching a favorite television show, or working
cessible these may be for the family, including distance a puzzle.
from home, eligibility, and cost. Changing the Meaning Attributed to a Situation.
Promote communication among the family mem- Think positively. Maintain a sense of humor. Talk the
bers. The nurse can talk with the woman and her fam- problem over with family and friends. Ask for help.
ily separately and together to help them initiate dialogue Talk the problem over with a professional person, such
about their concerns. Setting up family conferences also as the health care provider or clergy.
can help families deal with conflicts. Selecting What Needs Attention. Focus on the
Use humor-laughing, joking, teasing-to help present, not the potential future problems. Be active in
recharge family members both physically and psycho- caregiving activities. Handle things one step at a time.
Evaluation of Care
Coping Strategies Reports on the woman’s status from family care-
Caring for the woman with gynecologic cancer givers need to be given careful consideration. Nurses
can cause the family to experience chronic stress and can use this evaluative data to work with the woman
emotional strain. Research on how families cope in and family to identify alternative methods for meeting
these situations is limited mainly to family caregivers of goals or changing goals when needed.
patients with terminal cancer. Coping efforts of these
family caregivers have been reported as being directed
toward trying to change the environment, changing the Implications for Nursing Research
meaning attributed to a situation, and selecting what Nurses who work with patients with gynecologic
merits attention (Steele & Fitch, 1996b). Family care- cancer need to use the research base that exists but also
givers of women with gynecologic cancer who use these need to seek research answers for clinical practice ques-
tions when a research base is not available. Based on the
review of the literature for the current article, both
qualitative and quantitative studies are needed on the
TABLE 3 impact of specific gynecologic cancers; the impact of gy-


American Cancer Society: or

necologic cancer on women of different cultural and
ethnic groups; the impact of gynecologic cancer on les-
bian women; survivors of gynecologic cancer, especially
young women who may be faced with making decisions
Local chapters for the support groups, I Can Cope, about becoming pregnant and starting a family; and dif-
and We Can Weekend ferences in the needs of caregivers of women in different
Gynecologic Cancer Foundation: phases of cancer and in different settings.
or 1-800-444-4441
National Cancer Institute Cancer Information Service: Conclusion
http:llwww.nci.nih.govor 1-800-4-CANCER
National Cervical Cancer Coalition: Nursing interventions for the family of the woman
http:llwww.nccc-online.orgor 1-800-685-5531 with gynecologic cancer that are based on the needs
National Ovarian Cancer Coalition: identified by the family can foster the family’s cohesion or 1-888-682-7426 and strengthen interaction, communication, coopera-
Hospices: tion, and emotional involvement. Meeting the needs of
Local agencies: check newspapers and yellow pages of the woman and family caregivers may minimize stress.
telephone books The quality of life for the woman with cancer and her
family can be enhanced.

NovemberlDecember 2000 JOG” 659

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1801-1807. School of Nursing at the University of North Carolina at
Lewis, F. M. (1992). Psychosocial transitions and the family’s Chapel Hill.
work in adjusting to cancer. Seminars in Oncology
Nursing, 9, 127-129. Barbara B. Gennino is an Associate Professor in the School of
Lewis, E M., & Hammond, M. A. (1992). Psychosocial reha- Nursing at the University of North Carolina at Chapel Hill.
bilitation of the family to breast cancer: A longitudinal
analysis. ]ournal of the American Medical Women’s As- Address for correspondence: Deitra Leonard Lowdermilk,
sociation, 47, 194-200. RNC, PhD, FAAN, School of Nursing, University of North
Lewis, F. M., Hammond M. A., & Woods, N. F. (1993). The Carolina at Chapel Hill, CB 7460 Cam‘ngton Hall, Chapel
family’s functioning with newly diagnosed breast cancer Hill, NC 27599.

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