Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: https://www.tandfonline.com/loi/hhth20

Communication between Advanced Cancer

Patients and Their Family Caregivers: Relationship
with Caregiver Burden and Preparedness for
Caregiving

Amy K. Otto, Dana Ketcher, Richard E. Heyman, Susan T. Vadaparampil, Lee

Ellington & Maija Reblin

To cite this article: Amy K. Otto, Dana Ketcher, Richard E. Heyman, Susan T. Vadaparampil, Lee
Ellington & Maija Reblin (2020): Communication between Advanced Cancer Patients and Their
Family Caregivers: Relationship with Caregiver Burden and Preparedness for Caregiving, Health
Communication, DOI: 10.1080/10410236.2020.1712039

To link to this article: https://doi.org/10.1080/10410236.2020.1712039

Published online: 08 Jan 2020.

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HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2020.1712039

Communication between Advanced Cancer Patients and Their Family Caregivers:

Relationship with Caregiver Burden and Preparedness for Caregiving
Amy K. Otto a, Dana Ketcher a
, Richard E. Heyman b
, Susan T. Vadaparampil a
, Lee Ellington c
,
and Maija Reblin a
a
Department of Health Outcomes & Behavior, Moffitt Cancer Center; bFaculty of Health, New York University; cCollege of Nursing, University of Utah

ABSTRACT
Cancer impacts spouse caregivers, especially when couples engage in dyadic coping around the cancer.
Communication is a key factor in this process. Our goals were to describe cancer-related communication
between advanced cancer patients and their spouse caregivers, and to describe how dyadic communication
patterns are related to caregivers’ reported burden and preparedness for caregiving. Caregivers completed
measures of caregiver burden and preparedness for caregiving. Then, the patient and caregiver were asked
to interact with each other in two structured discussions: a neutral discussion and a problem discussion
focused on cancer. Discussions were coded using the Rapid Marital Interaction Coding System (RMICS2).
Caregivers reported moderate levels of preparation and burden. Greater caregiver hostility communication
predicted higher levels of caregiver burden, whereas greater caregiver dysphoric affect communication
predicted lower levels of caregiver burden. Whereas positivity was more common than hostility in couples’
communication, patient hostility was a significant predictor of caregiver preparedness. Patient neutral
constructive problem discussion was also associated with increased caregiver preparedness. Caregiver
outcomes are an understudied component to dyadic cancer research. Our paper describes observational
data on cancer-related communication between caregivers and advanced cancer patients and communica-
tion’s influence on caregiver outcomes. This work provides the foundation for future evidence-based
communication interventions that may influence both patient and caregiver outcomes.

Introduction 2014; Traa et al., 2015). Other work has found that commu-
nication is a specific unmet desire for caregivers, who recog-
Life-limiting cancer impacts both the patient and their spouse
nize that communication can be difficult but want more of it
caregiver. Not only will the cancer become a stressor for both
(Fried, Bradley, O’Leary, & Byers, 2005). A systematic review
(e.g., both spouses will be taking on new roles and may be
of psychosocial interventions for cancer caregivers suggested
worried about the patient’s health), but patients and their
that communication skills interventions might particularly
spouse caregivers often engage in dyadic coping. This involves
improve caregiver quality of life (Waldron, Janke, Bechtel,
making sense of and negotiating how to manage the illness
Ramirez, & Cohen, 2013). Additionally, worse dyadic com-
together. Various models and theories of dyadic coping exist
munication is associated with lower concordance between
(Traa, De Vries, Bodenmann, & Den Oudsten, 2015), but the
patient and caregiver preferences regarding end-of-life deci-
Cognitive-Transactional Model of couples’ adaptation to
sions (Shin et al., 2015), which may increase the risk of
chronic illness is a recent model that synthesizes and extends
patients receiving medical care that is inconsistent with their
previous work (Badr & Acitelli, 2017). In this model, indivi-
preferences. Perceived or actual incongruence between
dual appraisal and coping becomes dyadic when the owner-
a patient’s received care and preferences is also associated
ship of an illness is shared, or in response to the sharing of an
with greater patient physical distress and psychological dis-
individual coping process. Further, the effectiveness of coping
tress (Mack, Weeks, Wright, Block, & Prigerson, 2010), lower
on individual or relationship outcomes is dependent on self-
quality of life (Mack et al., 2010), and greater health care
and dyadic-efficacy.
utilization costs (Teno, Fisher, Hamel, Coppola, & Dawson,
Because individual coping processes often need to be
2002). Interventions that improve communication, and thus
shared to encourage dyadic coping, communication is a key
quality of life (Waldron et al., 2013), then have the potential
component to the Cognitive-Transactional Model (Falconier
to improve well-being for both patient and caregiver.
& Kuhn, 2019). Several reviews on couples coping with cancer
However, the evidence base is scant when it comes to deter-
have suggested that better communication between couples is
mining what is normal or ideal for communication about
associated with more congruent beliefs and goals and higher
cancer for patients and their spouse caregivers (Badr, 2017).
levels of intimacy and relationship satisfaction (Li & Loke,
Some research indicates that positive communication, such as

CONTACT Maija Reblin maija.reblin@moffitt.org Department of Health Outcomes & Behavior, Moffitt Cancer Center, 12902 Magnolia Dr, Tampa, FL 33602,
USA.
© 2020 Taylor & Francis Group, LLC
2 A. K. OTTO ET AL.
self-disclosure, partner responsiveness, and engagement will
facilitate positive psychological outcomes in couples coping
with cancer, whereas more hostile communication behaviors,
such as criticism, will compromise these outcomes (Manne &
Badr, 2008).
Thus far, little attention has been paid to caregiver out-
comes. A recent priority statement (Kent et al., 2016) identi-
fied informal cancer care burden as a key area for research.
Although some research exists to determine factors that influ-
ence caregiver burden, much of this work focuses on popula-
tions with early-stage cancer (Manne et al., 2004; Scott,
Halford, & Ward, 2004; Van Ryn et al., 2011). Notably,
caregivers for patients at later disease stages are at increased
risk for anxiety and depression (Kurtz, Kurtz, Given, & Given,
2005; Rhee et al., 2008; Rumpold et al., 2016). Some research
suggests that communication between caregivers and patients
is a determinant of caregiver burden, as would be expected
from the Cognitive-Transactional Model (Falconier & Kuhn,
2019). Without effective communication, dyadic coping is
impeded. Further, self-reported preparedness for caregiving
is important. Caregiver preparedness in previous work has
been shown to be a key factor for caregiver well-being and
can predict aspects of role strain (Archbold, Stewart,
Greenlick, & Harvath, 1990), quality of life (Rha, Park, Song,
Lee, & Lee, 2015), and multiple dimensions of mood
(Schumacher, Stewart, & Archbold, 2007).
More research is needed with a focus on communication in
couples coping with advanced cancer (Given, Given, &
Kozachik, 2001) and to determine how patient-caregiver com-
munication impacts caregiver burden. Additionally, little
research has been done to determine how communication
impacts caregiver preparedness for caregiving.
Objectives
First, we sought to describe cancer-related communication
between advanced cancer patients and their spouse
caregivers. Second, we aimed to describe how dyadic commu-
nication patterns are related to caregivers’ reported burden
and preparedness for caregiving. We hypothesized that more
positive communication during stressful cancer-related dis-
cussions would be related to higher self-reported caregiver
preparedness and lower self-reported caregiver burden,
whereas more hostile communication would have the inverse
effect.
Materials and methods
The present study is a secondary analysis of data gathered as
part of a prospective observational study of couples coping
with advanced cancer. A detailed description of study meth-
ods can be found elsewhere (Reblin et al., 2018). All proce-
dures were conducted with Institutional Review Board
approval.
Recruitment
Couples consisting of advanced cancer patients and their
spouse caregivers were recruited from thoracic and
gastrointestinal oncology clinics at a National Cancer
Institute Designated Comprehensive Cancer Center.
Inclusion criteria for patients were (a) a diagnosis of stage
III or IV non-small cell lung cancer or pancreatic, esophageal,
gastric, gallbladder, colorectal, hepatocellular, or bile duct
cancer; (b) a Karnofsky Performance Status (KPS) score of
70+ at time of enrollment; (c) a physician-estimated prognosis
of more than 6 months; and (d) undergoing active treatment
at the cancer center. Patients had to be cohabiting with
a spouse or partner who self-identified as providing some
care and who also agreed to participate in this study. All
participants were required to be over 18 years of age and
able to communicate in English.
Procedure
Participants provided informed consent and were asked to
complete a self-report questionnaire independently. Patients
and caregivers reported on demographics. Caregivers also
completed measures of caregiver burden and preparedness
for caregiving:
Montgomery Caregiver Burden Scale (MCBS)
The MCBS is a 14-item, 3-subscale measure assessing the
impact of caregiving on three dimensions of burden:
Objective Burden, Demand Burden, and Stress Burden
(Montgomery, Gonyea, & Hooyman, 1985; Montgomery,
Stull, & Borgatta, 1985). Objective Burden is the perceived
interruption of tangible aspects of a caregiver’s life. Demand
Burden is the perceived demands of caregiving responsibil-
ities. Stress Burden is the perceived emotional response to
caregiving responsibilities (Ferrell & Mazanec, 2009;
Montgomery et al., 1985). Responses are given on a five-
point Likert-type scale ranging from 1 (a lot less) to 5 (a lot
more).
Family Care Inventory (FCI) – Preparedness subscale
The 8-item Preparedness subscale of the FCI assesses the
perceived level of preparation for various facets of caregiving
such as dealing with physical needs and emotional problems,
as well as previous caregiving experience (Archbold et al.,
1990; Schumacher et al., 2007).
After completing the questionnaires, the couple was asked
to interact with each other in two structured discussions used
in previous research (Manne et al., 2004). First, couples
engaged in a 10-minute neutral discussion in which they
were instructed to talk as normally as possible about some-
thing they recently saw on television or read. Next, partici-
pants independently completed the Cancer Inventory of
Problem Situations (Heinrich, Schag, & Ganz, 1984), in
which a list of 20 common cancer concerns (e.g., lack of
energy, finances, overprotection) are rated as being not
a problem, somewhat of a problem, or a severe problem.
After completing this measure, concerns that (a) at least one
member of the couple rated as a severe problem, or (b) both
members of the couple rated as at least somewhat of a problem
were used as a prompt for a cancer-related problem discus-
sion. Couples were asked to have a 10-minute conversation
describing the concerns, how the concerns made them feel,
 HEALTH COMMUNICATION 3

and why they felt the concerns were a problem. Discussions Table 1. Descriptions and examples of RMICS2 codes.
were audio-recorded . Code Definition Examples
Trained coders coded and timestamped communication Hostility, Intense negative affect. Includes ● Why are we still even
behaviors within discussion audio recordings using the High- contempt, belligerence, and in this relationship?
Intensity character assassination. ● Of course – you always
Rapid Marital Interaction Coding System, 2nd Generation (HH) think about yourself.
(RMICS2; Heyman, Wojda, Hopfield, & Salas, 2015). That’s just what you do.
Although the problem discussion was of primary interest for
the present study, both discussions were coded using Hostility, Low- Mild to medium intensity ● I’m bothered by you
Intensity negative affect. Includes blame/ not fixing anything
RMICS2. The unit of analysis used in the present study was (HL) criticism (focus on behavior around the house.
speaker turn, whereby each time an individual takes the floor instead of character) and ● Shut up.
demands.
to speak is a turn. For instance, an interaction where the
Constructive Includes descriptions of the ● When I take that
patient speaks, the caregiver speaks, and the patient speaks Problem problem, solutions, and medication I feel
again consists of three turns. Codes represent the emotional Discussion questions. groggy.
valence of the speaker’s behavior (verbal and paraverbal) (PD) ● We could be better at
scheduling.
during the turn and are organized into a continuum from
negative (i.e., hostile) to positive: high hostility, low hostility, Positivity, Measured positive affect and ● This is my favorite
constructive problem discussion, low positivity, and high posi- Low- low-level bonding within the time of day.
tivity. Constructive problem discussion represents a more emo- Intensity couple. Includes (low-intensity) ● I appreciate that you
(PL) self-disclosure, humor. cleaned the house the
tionally neutral discussion of the problem or conversational other day without me
topic. Two other communication codes exist outside of this asking you to do so.
hostility-positivity continuum: dysphoric affect and other.
Each speaker turn is given a single communication code. If Positivity, Intense positive affect, and ● I love you.
High- statements that focus on deep ● You’re the funniest per-
a speaker turn includes more than one type of communication Intensity connection and character. son I know.
behavior, it is coded based on the most salient behavior (PH) Includes (high-intensity) self-
during that speaker turn. If multiple behaviors are equally disclosure, humor.
Dysphoric Sad or depressed expressed ● I’m useless. I can’t
salient during a speaker turn, the code is assigned using on Affect (DY) emotional states. Includes even mow the lawn
a hierarchy based on intensity and valence: A high-intensity negative self-evaluations and anymore.
code supersedes a low-intensity code; a negative code super- helplessness. ● I just don’t know what
else I can do.
sedes a positive code, which supersedes the neutral code,
which supersedes the “other” code. Other (OT) Talk about the experimental ● Do you think the
Codes and examples are described in Table 1. Because situation. recorder stopped?
high-intensity behaviors were relatively infrequent in the pre-
sent study, high- and low-intensity hostility were collapsed
into a single hostility variable for analysis; similarly, high- and
low-intensity positivity were collapsed into a single positivity discussion. To address the second aim, these patient and
variable. The frequency of each code was calculated and caregiver difference scores (for hostility, positivity, construc-
divided by the total number of speaker turns in the discussion tive problem discussion, and dysphoric affect) were entered in
(including both patient and caregiver speaker turns); thus, a path analysis as predictors of caregiver burden and prepa-
participants were left with a total score for each of the five redness for caregiving.
codes (i.e., hostility, constructive problem discussion, positiv-
ity, dysphoric affect, and other) that represented a percentage
Results
of the total speaker turns in the discussion.
A random sample of 20% of problem discussions was Table 2 provides demographic information on the sample,
coded by a second coder to calculate interrater reliability; which comprised 84 patient-caregiver dyads.
interrater agreement was excellent, with kappa values on all Descriptive statistics for communication and caregiver self-
codes collapsed by interaction ranging from .76 to .98. report variables are displayed in Table 3. On average, care-
givers reported relatively high levels of Objective Burden
(M = 22.23), only slightly below the cutoff score of 23
Analysis
(Montgomery et al., 1985). Demand Burden was somewhat
To address the first aim, descriptive statistics were calculated lower (M = 11.80), but the average Stress Burden was over the
for the neutral and problem discussion communication vari- established cutoff of 13.5 for elevated levels (M = 14.02).
ables. Paired-samples t-tests were conducted to evaluate dif- Caregivers reported feeling moderately prepared for caregiv-
ferences in communication between caregivers and patients as ing on average (M = 21.33, possible range = 0–32).
well as between men and women. In both the neutral and problem discussions, patients and
For each participant, a difference score was calculated for caregivers averaged 50 speaker turns each. The most common
each RMICS2 variable to account for any baseline individual type of behavior in both discussions was constructive problem
differences in communication; for example, those who are discussion. The problem discussion had comparatively more
more hostile during a neutral discussion would be expected affective codes (i.e., hostility, positivity, and dysphoric affect),
to be more hostile during a cancer-related problem which is unsurprising given the discussion topic. In the
4 A. K. OTTO ET AL.

Table 2. Demographic characteristics (N = 84 dyads). communication variables and Objective Burden. Patient com-
Patients Caregivers munication variables also were not associated with Demand
Variable M SD M SD Burden or Stress Burden. However, greater caregiver hostility
Age 66.6 9.3 64.4 9.1 was associated with greater Demand Burden (B = 0.27,
Years in relationship – – 34.2 15.6 z = 3.16, p = .002) and greater Stress Burden (B = 0.16,
n % n %
Female 24 28.6 60 71.4 z = 2.11, p = .035); that is, when caregivers exhibited more
Ethnicity hostility, they perceived caregiving to be more demanding and
Non-Hispanic/Latinx 81 96.4 77 91.7
Hispanic/Latinx 3 3.6 5 6.0 felt more stressed about caregiving responsibilities. Greater
Missing 0 0.0 2 2.4 caregiver dysphoric affect was associated with significantly
Race
White/Caucasian 79 94.0 77 91.7
lower Stress Burden (B = −0.18, z = −2.18, p = .029), meaning
Black/African American 4 4.8 3 3.6 that when caregivers exhibited more sadness, they felt less
American Indian/Alaska Native 1 1.2 1 1.2 stressed about their caregiving responsibilities.
Other 0 0.0 1 1.2
Missing 0 0.0 2 2.4 Patient hostility was significantly associated with caregiver
Education preparedness (B = 0.62, z = 2.00, p = .046), such that when
7–11 years 3 3.6 2 2.4
High school graduate or equivalent 13 15.5 13 15.5 patients exhibited more hostility, their caregivers felt more
Some college, or vocational school 28 33.3 30 35.7 prepared for caregiving. Patient constructive problem discus-
College graduate (4 years) 15 17.9 13 15.5 sion was also associated with increased caregiver preparedness
Some graduate or professional school 6 7.1 6 7.1
Graduate or professional degree 19 22.6 20 23.8 (B = 0.34, z = 1.97, p = .049). No caregiver communication
Employment variables were associated with caregiver preparedness.
Not currently employed 64 76.2 51 60.7
Employed part-time 5 6.0 10 11.9 As the Cognitive-Transactional Model suggests that prepa-
Employed full-time 14 16.7 20 23.8 redness for caregiving (conceptualized as a form of self-
Missing 1 1.2 3 3.6 efficacy) may be a mediating factor in the relationship
Annual household income
$10,000–$24,999 5 6.0 4 4.8 between dyadic communication and caregiver outcomes, pre-
$25,000–$39,999 12 14.3 13 15.5 paredness was also explored as a potential mediator of rela-
$40,000–$49,999 8 9.5 8 9.5
$50,000–$74,999 25 29.8 23 27.4 tionships between communication variables and caregiver
$75,000 or more 32 38.1 35 41.7 outcomes. Preparedness was removed from the model as an
Missing 2 2.4 1 1.2
outcome, and considered as a mediator of the remaining
significant effects between hostility and Stress Burden, hosti-
lity and Demand Burden, and dysphoric affect and Stress
problem discussion, patients and caregivers did not signifi- Burden. However, preparedness did not significantly mediate
cantly differ in hostility (t = −1.83, df = 83, p = .072) or any of these effects.
positivity (; t = 1.16, df = 83, p = .251), but patients expressed
significantly more dysphoric affect than caregivers (t = 3.15,
df = 83, p = .002). Analyses comparing males and females
Discussion
revealed no significant differences in any of these communi- This is one of the first studies to outline how advanced cancer
cation variables. patients and their spouse caregivers communicate about can-
Analyses to determine communication factors associated cer. Because communication is a critical process through
with caregiver preparedness and burden (see Figure 1) found which couples make sense of cancer and coordinate coping
no significant relationships between patient or caregiver (Badr, 2017; Traa et al., 2015), it is important to establish

Table 3. Descriptive statistics for communication and caregiver self-report variables (N = 84 dyads).
Patients Caregivers
Variable M SD Mdn Min Obs Max Obs M SD Mdn Min Obs Max Obs
Questionnaire
MCBS Objective Burden – – – – – 22.23 3.71 22 14 30
MCBS Demand Burden – – – – – 11.80 3.03 12 4 19
MCBS Stress Burden – – – – – 14.02 2.48 14 8 20
FCI Preparedness – – – – – 21.21 6.28 21 5 32
Communication Variables: Neutral Discussion
Hostility (High & Low Intensity) 0.23 0.71 0 0 4 0.34 0.96 0 0 5
Constructive Problem Discussion 45.39 4.98 46.78 28 52 45.86 5.77 47 25 67
Positivity (High & Low Intensity) 2.99 3.43 2.26 0 16 2.78 3.38 2 0 16
Dysphoric Affect 0.24 0.82 0 0 5 0.05 0.26 0 0 2
Other 0.91 1.77 0 0 8 1.15 2.13 0 0 11
Grand Total (All Speaker Turns) 49.81 4.1 50 31 69 50.18 4.10 50 31 69
Communication Variables: Problem Discussion
Hostility (High & Low Intensity) 0.57 1.39 0 0 8 0.97 2.00 0 0 11
Constructive Problem Discussion 39.29 6.64 40.79 23 54 40.33 6.04 41 20 49
Positivity (High & Low Intensity) 7.19 5.38 5.88 0 29 6.45 4.79 6 0 24
Dysphoric Affect 2.03 3.22 0.81 0 13 0.96 2.17 0 0 13
Other 0.92 1.57 0 0 8 1.28 2.24 0 0 10
Grand Total (All Speaker Turns) 50.01 3.9 50 33 60 49.99 3.90 50 40 67

Figure 1. Simplified diagram of path model with results.
Note. Predictors represent difference scores (neutral discussion score subtracted from problem discussion score). Bolded lines indicate significant relationships
(p < .05); thin, dotted lines represent non-significant relationships (p > .05).
a sense of what typical and beneficial communication patterns
look like before developing interventions.
The majority of communication about cancer in our
study was emotionally-neutral constructive problem discus-
sion. However, about 20% of talk in the problem discussions
was more affective; of this affective talk, positivity vastly
outweighed both hostility and dysphoric affect. This sug-
gests that most of couples’ discussion about cancer-related
concerns may involve information exchange, deliberation,
and logistics, rather than emotional expression. This is
similar to patterns seen in other cancer-relevant interperso-
nal interactions between patients and caregivers and their
providers (Ellington, Clayton, Reblin, Donaldson, &
Latimer, 2018; Laidsaar-Powell et al., 2016). However,
when couples do express emotion, it most often is positive
and rarely hostile. These patterns are similar to findings in
previous research on non-clinically distressed couples
(Braun, Mura, Peter-Wight, Hornung, & Scholz, 2010;
Heyman, Eddy, Weiss, & Vivian, 1995; Manne et al.,
2004). Further, these are, on average, long-term relation-
ships among older adults. Previous research has shown that
this population tends to optimize positive experiences, often
by avoiding conflict (Luong, Charles, & Fingerman, 2011);
more hostile relationships may have ended prior to this
point.
Patient-caregiver communication patterns were not related
to Objective Burden, although they were significantly asso-
ciated with more subjective types of burden (i.e., Demand
Burden and Stress Burden). This is similar to other work
that suggests that although the actual tasks caregivers take
on are important, the appraisal of tasks as either demands
or opportunities can shape the caregiving experience
(Fletcher, Miaskowski, Given, & Schumacher, 2012; Kang
et al., 2013). Communication specifically may be
a fundamental mechanism by which couples mutually
appraise caregiving and process stress associated with cancer
(Li & Loke, 2014). For example, more effective interpersonal
communication may ensure patients and caregivers have con-
gruent and mutually-agreed-upon expectations for care.
HEALTH COMMUNICATION 5
When both individuals have agreed to the same expectations,
it is less likely for conflict to arise.
Although positivity was more common than hostility in
our study, patient hostility was more strongly associated with
greater caregiver burden and, interestingly, preparedness. This
may be due to the greater weight that negative emotional
communication may carry in impacting psychosocial out-
comes (Gottman, 1994; Manne, Badr, Zaider, Nelson, &
Kissane, 2010; Manne et al., 2004). In contrast, previous
work on dementia patient-caregiver communication and care-
giver depression indicates that patient positive communica-
tion is linked to lower levels of caregiver depression (Braun
et al., 2010). Our finding that caregiver hostility is associated
with more subjective types of burden may indicate that hosti-
lity disrupts this congruence of expectations, leading to higher
perceived caregiver burden. Evidence from research on dyads
coping with cancer indicates that communication that inhibits
open communication, like hostility, can have an adverse effect
on outcomes (Regan et al., 2015). Alternatively, when expec-
tations differ such that caregivers take on more than they can
cope with, they may deplete their emotion-regulation capacity
and respond with hostility (Arndt et al., 2014; Trougakos,
Beal, Cheng, Hideg, & Zweig, 2015).
Only caregiver communication was associated with per-
ceived caregiver burden, whereas only patient communication
was associated with preparedness for caregiving. Although
subjective burden and caregiver preparedness have often
been highly correlated in previous research (Fujinami et al.,
2015; Grant et al., 2013), our findings may indicate how these
two related measures are distinguished conceptually. Burden
may be a more intrapersonal assessment of one’s own current
capacity, whereas preparedness for caregiving may be a more
interpersonal assessment of one’s future capacity, based on
the status of another individual. For example, a caregiver at
any given time may feel overwhelmed and thus indicate high
levels of burden, but because the patient seems to be improv-
ing, the caregiver may also indicate a high level of prepared-
ness for future care. Similarly, our finding that increased
patient hostility and constructive problem discussion was
6 A. K. OTTO ET AL.
associated with greater caregiver preparedness may indicate
that when patients are able to better communicate about their
issues and even express anger, the caregiver may have a better
sense of what is needed and the caregiving task may seem less
daunting. Previous research indicates that although avoidance
and protective buffering – hiding negative information or
emotions from one another – are common in couples coping
with advanced cancer, these strategies are associated with
worse mental health outcomes and quality of life (Langer,
Rudd, & Syrjala, 2007; Manne et al., 2007).
Less caregiver dysphoric affect predicted more Stress
Burden (the emotional response to burden). Although, on
its face, the finding that more caregiver-expressed sadness is
related to lower emotional burden may be counterintuitive, in
the general population it has been shown that non-hostile
negative emotional expression may benefit relationship func-
tion (Campbell, Renshaw, & Klein, 2017). This type of emo-
tional expression can indicate a need for social support and
may serve to elicit comfort and help from others (Clark,
Fitness, & Brissette, 2001; Clark, Pataki, & Carver, 1996); if
met with a positive response, this expression can also increase
intimacy, which has been shown to improve relationship out-
comes and specifically adjustment to cancer (Manne & Badr,
2008; Reis & Franks, 1994).
Limitations
Because of the cross-sectional nature of our data, we are
unable to determine the directionality of our results. For
example, it is possible that caregivers who naturally commu-
nicate with more hostility during stressful situations are more
prone to perceived burden; alternatively, caregivers who are
experiencing higher levels of burden may lack emotional
regulation and thus express more hostility in their commu-
nication. Our sample was also relatively homogeneous.
Further, our findings represent a single audiotaped conver-
sation in a structured environment. As noted earlier, the con-
versations contained a large proportion of more emotionally-
neutral constructive problem discussion behavior. The lack of
video may have limited identification of non-verbal cues.
Couples may also tend to have more emotionally-charged con-
versations during more transitional times, such as cancer diag-
nosis, progression, or response to treatment. Unfortunately, we
did not have data on the length of time since the patient’s
diagnosis or the details of their treatment and we were not
able to explore this possibility. Whereas analogue discussions
are widely-used in research and communication patterns are
often are representative (Foster, Caplan, & Howe, 1997;
Heyman, 2001), using a single audiotaped discussion does
ignore the larger context of couples’ communication. It is pos-
sible that the preponderance of constructive problem discussion
was related to the prompted, somewhat artificial nature of the
conversation; for instance, being prompted to discuss a specific
problem may have discouraged couples from sharing their
emotions as much as they might during a typical conversation.
However, it is also possible that the preponderance of construc-
tive problem discussion behaviors seen in the present study
reflected a preexisting tendency to engage in avoidance of
more emotionally-charged discussion (Floyd & Rogers, 2004).
To address all of these issues, a larger, more naturalistic, long-
itudinal study would better inform the ongoing process of
communication’s impact on caregiver preparedness and
burden.
Implications
Researchers have agreed that communication between advanced
cancer patients and their spouse caregivers is an important
mechanism for coping and, as such, it has been included as
a component to many interventions to improve quality of life
for patients and caregivers. However, there is little consensus
about what communication should look like (Badr, 2017). This
research suggests patient and caregiver communication patterns
that are predictive of lower burden and higher preparedness for
caregivers are marked by lower levels of caregiver and patient
hostility, respectively, but also include caregiver expression of
dysphoric affect and patient constructive problem discussion.
This study represents an important first step toward under-
standing the types of communication that are most beneficial
for patients and spouse caregivers when discussing cancer-
related concerns. Future interventions may benefit from speci-
fically targeting expression of negativity (including dysphoria
and hostility) in both patients and caregivers. However, addi-
tional research is needed to determine when these communica-
tion behaviors are most beneficial, as well as specific levels of
communication that are most effective.
Acknowledgments
The authors would like to thank the patient and caregiver participants
who contributed to this work.
Disclosure of potential conflicts of interest
No potential conflict of interest was reported by the authors.
Data availability statement
The data that support the findings of this study are available from the
corresponding author, MR, upon reasonable request.
Funding
This work was supported by the American Cancer Society under ACS
MRSG 13-234-01-PCSM (PI: Reblin).
ORCID
Amy K. Otto http://orcid.org/0000-0003-3712-6435
Dana Ketcher http://orcid.org/0000-0003-3569-9344
Richard E. Heyman http://orcid.org/0000-0002-5365-0037
Susan T. Vadaparampil http://orcid.org/0000-0002-1052-6917
Lee Ellington http://orcid.org/0000-0002-7035-490X
Maija Reblin http://orcid.org/0000-0003-3108-465X
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