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Quality of Life and Hope Assessment in Women with Breast Cancer After Poetry Therapy as a Psychotherapy Method: A 6-Month Follow-Up Study

Background: Quality of life in patients with cancer is an important issue. It affects different aspects of the patients’ life. Supportive group therapy helps the majority of women with breast cancer to treat their disease and decrease the recurrence of the disease. Group poetry therapy, as a safe method, can be used to increase the quality of life of patients. Objectives: We designed this study to evaluate the effect of poetry therapy on the quality of life of patients with cancer. Methods: A total of 91 participants were divided into the poetry therapy group (n = 31) and the control group (n = 60). Six sessions of weekly poetry therapy were held. Miller Hope scale, Quality-of-Life Questionnaire Core 30 (QLQ-C30), and Quality of Life Questionnaires-Breast 23 (QLQ-BR23) were fulfilled by patients before, 1 week, and 2 and 6 months after the intervention. Results: Poetry therapy increased hope based on Miller Hope scale 1 week, 8 weeks, and 6 months after the intervention (P = 0.001). The improvement of the functional item of QLQ-BR23 and QLQ-C30 was significant in poetry therapy in comparison with the control group at the end of the study (P = 0.001). The change of side effect items does not differ over the course of the study (P > 0.05). Conclusions: Group poetry therapy can be a good psychotherapy way to increase the quality of life of patients with breast cancer.


Background
Breast cancer is the most frequent cancer among women and accounts for about 31% of all women cancers (1). An important issue in health care is the quality of life of patients with cancer due to the high economic burden of cancer in society. The life of many patients with cancer has been impaired due to physical and psychological problems. Moreover, a long period of the disease and following treatment for months and years impact the different aspects of their life such as their social and family life (2). At the initiation of the treatment, most women experience psychological problems, which interfere with their quality of life (3). Women with breast cancer have a high level of distress and depression; it often happens 6 months after the diagnosis and lasts for many years (4,5).
Quality of life includes physical actions, psychological condition (level of distress and depression), and social support. Chemotherapy has the most effect on the quality of life of patients with cancer. Survival and tumor size were traditionally two main measurements of assessing medical outcomes. Today, different questionnaires are used to evaluate responses to treatment and screening for psychological problems. The assessment of the quality of life can help to predict prognosis, decision-making about treatment, patient monitoring, designing an intervention, and effort with less cost (6).
Supportive group therapy helps the majority of women with breast cancer to treat their disease and decrease the recurrence of the disease. Over 20 years, group therapy has been examined for patients with breast cancer. The supportive-expressive method has many advantages for patients (7). In previous studies, it was shown that young and highly-distressed patients received the greatest benefits from this method at the start of the treatment. Creative modalities such as poems, drawings, and songs are helpful to express feelings and experiences. Poetry therapy is using pre-existing poems to evoke patients to present their psychological pain and rejecting.

Objectives
The aim of this study is evaluating the quality of life and hope of patients with breast cancer in a 6-month follow-up. We designed this study to evaluate the effect of poetry therapy on the quality of life of patients with cancer.

Methods
This study was carried out in the cancer research center, Shahid Beheshti University of Medical Sciences from 2017 to March 2019. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences and informed consent was achieved before starting the study. Female patients were enrolled to study based on the following inclusion criteria: having non-metastatic breast cancer in the age range of 18 to 65 years, being able to read and write, willing to fulfill the questionnaires, having no severe psychological disease, participating in the sessions, and being under treatment at least for 2 weeks. Weekly poetry therapy was held for 6 weeks. In each session, the selected Rumi poems were read and at the end of sessions, the patients were recommended a special book for patients to read between the sessions. The concept of each session included epistemology, hope, praying, believing in God, being tested by Allah, patience, and tolerance. The participants completed questionnaires before the study, 1 week, and 2 and 6 months after the last session. The instruments consisted of Miller Hope scale, Quality-of-Life Questionnaire Core 30 (QLQ-C30), and Quality of Life Questionnaires-Breast 23 (QLQ-BR23). QLQ-C30 is a 30-item specific cancer questionnaire that evaluates items, including physical, cognitive, emotional, and social status, as well as pain, fatigue, nausea, and vomiting that can be categorized into 3 key scales, consisting of physical and emotional functioning and side effects (8,9).
EORTC QLQ-BR23 is a 23-item self-administered questionnaire. The body image, sexuality, arm symptoms, breast symptoms, and systemic therapy side effects are evaluated in this questionnaire (10).

Statistical Analysis
The questionnaire was scored and the data were analyzed by SPSS version 17. The mean, median, standard deviation, and range were used to describe the data. After using the Kolmogorov-Smirnov test, parametric tests such as MANOVA and independent t test were used.
Non-parametric tests such as Friedman was, then, used to assess the changes in scores after the poetry therapy sessions. The Mann-Whitney test was used to compare scores between groups. To compare the groups, an independent ttest was run. The significance level was defined as P < 0.05.

Results
A total of 91 patients (31 patients in the intervention group and 60 patients in the control group) finished the trial and were, finally, included for the final analysis.
The mean age of the case and control groups was 45 years. In the case group, 4 (12.9%) patients had an education level of a high school diploma or less, while 18 (30%) of the controls were illiterate; 84% of the patients in the case group and 57% of patients in the control group were married. Overall, 20 (64.5%) patients of the case group and 53 (86.7%) patients of the control group were housewives. Total mastectomy in the case and control groups were 8 (22.2%) and 5 (8.3%), respectively. The income of 7% of the patients in the case group and 14% of the patients in the control group was lower than their expenses (Table 1). The poetry group did not significantly differ in Miller Hope scale, QLQ-C30, and QLQ-BR23 with the case group at baseline (P = 0.5, P = 0.9, P = 0.2, respectively).
The effects of poetry therapy on hope was evaluated by the Miller Hope scale at the beginning and at the end of the study. Hope scale was obviously increased in the case group (P = 0.001) and the improvement was significantly higher in the case group in comparison with the control one immediately, 8 weeks, and 6 months after the last session (P = 0.001).
The functional scale of the QLQ-BR23 score included improving in the case group immediately and 2 and 6 months after the last poetry therapy session (P = 0.001). However, the side effects of the QLQ-BR23 questionnaire did not improve in the case group in the follow-up period (P = 0.1) (Table 2).
The median scores of the QLQ-C30 scale of all patients at baseline and follow-up visit is presented in Table 3. Al-2 Int J Cancer Manag. 2020; 13(1):e96069. though the mean functional score of QLQ-30 is not significantly increased in the poetry group in the follow-up (P = 0.3), it was significantly higher in the case group in 8 weeks and 6 months after the last sessions (P = 0.01, P = 0.001, respectively).
Regarding the side effect of the QLQ-30 scale, there was no difference between groups (P > 0.05). The change of side effect does not differ over the course of study in the case group (P > 0.05) ( Table 3).

Discussion
Breast cancer is the most prevalent cancer that affects the physical and psychological health of patients. It is the third cause of death in women (11).
Hope is a mental power to believe in a better future and encourages humans to have better psychological and social performances. Psychological therapies for patients with breast cancer are a great debate in recent years and focus on hope and quality of life (12). Psychotherapy guides patients through the process of understanding their problems and developing solutions. Different methods include behavior therapy, cognitive therapy, humanistic therapy, and integrative therapy.
Poetry therapy is a form of psychotherapy that is known as expressive therapy.
It is a combination of literature and language (13). Today, the 13th-century poets are the center of attention for the poet therapist. Rumi's work, the Masnavi that is now accepted by modern psychology, was used in the current study.
The result of this study showed that group poetry therapy was effective regarding the hope and functional scale of quality of life of patients with breast cancer, but it did not affect the side effects items of the questionnaire such as nausea and pain.
In a study by Tegner et al. in 2009, they evaluated the emotional improvement of patients with cancer by the Hospital Anxiety and Depression scale (HADS), the Mini-Mental Adjustment to Cancer scale (Mini-Mac), and the Courtauld Emotional Control scale (CECS). They concluded that poetry therapy significantly improves anxiety levels (14).
In a study by Gozashti et al. (15), the quality of life in patients with breast cancer was evaluated by the QLQ-C30 questionnaire after 2 months and 8 weekly poetry therapy. There was a significant improvement in the functional score of the questionnaire.
Hope and mood improvement in patients with breast cancer was investigated in 2018 by Miller Hope scale and DASS-21 questionnaire. Group poetry therapy affects both mood and hopefulness in patients with breast cancer in a 2-month follow-up (16).
The current study showed a better quality of life in the point of function and emotion in a 6-month followup, which has not already been evaluated in this period of time; moreover, it is a unique work of Rumi therapy in patients with cancer. It seems that it can be a good way to increase the quality of life and hope of patients with breast cancer in a long period of time.

Conclusions
Poetry therapy can be a good group psychotherapy for patients with cancer.