Feelings and Perceptions of Man facing his Lifemate submitted to Mastectomy: Integrative Review

Objective: The aim of this article is to investigate, from the scientific literature, feelings and perceptions presented by men facing the experience of having their women submitted to mastectomy. Methods: This is a literature integrative review collected in the databases LILACS, CINAHL, Scopus, PubMed, Web of Science and Science Direct, in November and December 2015. Results: The sample included 12 publications. In the selected articles, feelings and perceptions of the man before of women undergoing mastectomy were mostly linked to fear, anxiety, sadness, worry and anguish. Conclusion: Facing these findings is great relevance that not only women undergoing the procedure must be assisted during all stages of treatment. But also his companions need assistance as a way of these men take care of their women in full.


Introduction
Cancer results from uncontrolled division of abnormal cells, which may arise due to changes heritable or acquired upon exposure to environmental or physiological factors, which leads to tumor development [1].
According to the World Health Organization (WHO), it is expected over 1,050,000 new cases of breast cancer worldwide and is a leading cause of death among women. Brazil is one of the countries with a higher incidence of breast cancer worldwide, about 48,930 new cases of breast cancer are reported annually, and it is estimated that there are about 11,860 deaths from this cause. For Instituto Nacional de Câncer (INCA) the estimate for the year 2016 is 57,960 new cases in Brazil, of these, 11,190 will occur in the Northeast and 720 in Rio Grande do Norte. According to the Health Ministry, breast cancer is a leading cause of death in women in the country, constituting a serious problem for the national public health [2,3,4].
The cancer is a treatable disease with expectations of cure, especially when the diagnosis is early. However this disease remains loaded with stigmas, mysteries and uncertainties. Because of this comes a series of difficulties that can overcome the physical pain and reaching implications for the social and emotional life. After confirming the diagnosis, treatment and the fact of living with cancer causes changes in the way of seeing the world. In the case of women with breast cancer, they experience various concepts, prejudices, changes in self-esteem and in restructuring their body image [5,6].
Women affected by breast cancer may suffer emotional impact that affects not only them but also people who are nearby. Thus the family, as the main support, contributes to better deal with the changes caused by this disease. Among changes the partial or radical mastectomy is a treatment used in advanced cases of breast cancer considered prevention for the wrong disease. Besides, mastectomy may cause mutilation of self-image. This contributes to physical and emotional remoteness of these women to their companions. From this situation raise barriers in interpersonal relations of spouses, whereas women often feel physically maimed and unable to satisfy your partner [7].
According to the literature companions also are impacted with the disease of women, showing various feelings, similarly as women. Changes in routine these men after the procedure imply insecurity and discomfort. This is because the companions become caregivers of women and children. In addition, men have to provide support in the activities of home and let the activities developed in the background. Because men come to take over the activities that were of their women, which may cause a series of psychological conflicts [8].
Thus, the study aimed to: Identify, from the scientific literature, the feelings and perceptions of men before Experience of having their women submitted to mastectomy.
Interest in this study occurred by considering of great value to nursing, since when approaching these realities. Because knowing the feelings and perceptions of men, can subsidize nursing to use strategies to guide necessary actions and assist men in coping in this delicate moment.

Methods
This is a bibliographic research, in the modality of integrative review. This type of review gathers and synthesizes results of previous researches about a defined topic or issue in a systematic way. This contributes to the deepening of knowledge about a particular area [9]. Integrative review was conducted in five steps: identification of guiding research question, search the literature in databases, evaluation of the documents concerning methodological accuracy, data analysis and presentation of results. Integrative review also allows synthesis of multiple published studies, makes it feasible to understand the state of art of theme of interest and enhances pre-existing knowledge [10].
In order to perform search and analysis of results of investigated literature, following question was launched: what feelings and perceptions presented by men facing experience of having their women submitted to mastectomy?
Then the selection of studies was conducted by two researchers in November and December 2015. For this it was used six databases accessed at the Universidade Federal do Rio Grande do Norte (UFRN): Latin American and Caribbean Center on Health Sciences (LILACS); Cumulative Index to Nursing and Allied Health (CINAHL); Scopus; PubMed; Web of Science and Science Direct.
After this initial step it was proceeded reading titles and abstracts, applying the following inclusion criteria: full papers available by accessing electronic portal CAPES available UFRN; articles that answer the main question of the study. It will be pertinent to point out that to develop integrative review did not choose to use time frame. It is justified this choice because there are few publications concerning the theme of this study. Thus, the article could have been published in any year and in any language Note also that there were articles excluded by the following exclusion criteria: studies in editorial format, letter to the editor, abstracts, review and expert opinion.
The studies were selected based on three procedures: Title analysis, summary analysis and detailed analysis of full article. Articles containing no titles related to the subject were excluded from second part of the analysis. Articles containing no adequate summaries on aim of this study were excluded from third part of analysis. So, this last phase dismissed or has selected article for developing this publication.
After use of eligibility criteria and selection by title and abstract it was resulted in 85 studies. Of these 85 studies, 32 were duplicate articles and for this reason have been used only once. The selection criteria, which duplicated article would be considered, was based on the first database searched in which this one article has been read. This reduced the number of articles found for amount of 53 studies. After reading these 53 scientific publications in full, 41 researches were excluded. Thus in total 12 articles were included in this integrative review. Table  2 presents the results of selected studies described from intersections second database.   Table 2. Results from selections in each database after using inclusion and exclusion criteria. The selected articles were organized in the form of composite frame by the following variables: identification of the article; authors; title of the article; year of publication; methodological design; level of evidence; and study site.

Results
Using the analysis of selected articles, Table 3 presents the final composition of the integrative review. It is observed prevalence in evidence level IV which is considered low [11], corresponding to the methods of observational and descriptive studies. Furthermore, only three studies were conducted in Based on the analysis and categorization of studies listed some experienced feelings and perceptions they stood out. Furthermore, it was noted that there were variations of feelings into these men were involved, resulting from mastectomy their women.

Discussion
When discussing the feelings and perceptions of man before his lifemate submitted a mastectomy, it is important to conceptualize the term "companion" as that one who or that which: " follows; makes the company; lives in the same home; is member of a couple relative to the other; walks together; is always connected to other" [23].
Moreover, although it is considered that historically care has been represented in figure woman. However, this woman hopes an unconditional support from the person she chose to share life, especially in times of illness considered serious. Thus, from the results found in integrative review conducted this study, it will be discussed feelings and perceptions experienced by men who share these moments together their women.

Companion keeping unshaken facing his lifemate submitted to mastectomy
Regarding to the category "keeping unshaken," it is worth noting that man denies things he is feeling in order to spare his mate. This fact was named inhibition of shares [12]. The companions avoid interacting with your partner with disagreements, conversations about cancer, about death because they consider harmful to it.
Moreover, they feel the need to show their lifemate that they are always cheerful, confident. In fact they hide reality, which is often of fatigue and discouragement. Thus, it is seen that it eventually affects the mental health of companions who do not have a moment to blow off steam or express real emotions and allow themselves to feel what is really going on [24].
Is worth emphasizing that men do not always have a proper structure to experience all the situations that illness of his wife and the care she requires. Thus they develop various psychological and behavioral reactions. Thereby, there is the need for nursing staff working with these men as companion subjects such as: process of death, the caregiver, living with their own emotions, good communication. This is based on the quest of supplying the needs presented by them [25].
In the same category is found, through consulted studies, fellow option for misinformation. Husband avoid going to inquiries of his wife and part of the hospital routine of woman and he prefer to await her at home for fear of "knowing too much" [8].
Another point highlighted in several studies is the acceptance and coping with the disease by fellow that addresses the situation primarily through faith and patience. The attachment to religion in times of trouble is common in society. This practice brings sense of hope, strength and serves as protection to feelings of sadness and depression [8,12,13].
According to studies, men cling to faith as a way to gain strength to overcome obstacles. This strategy helps to calm and patience of men in perspective they expect the future, causing the partner believe that everything is already outlined according the will of God [8,12,13].

Companion demonstrating feelings facing his lifemate submitted to mastectomy
In the second category established called "variation feelings", it is observed that the companions react to the mastectomy of their women in various ways, and may have alternate feelings in the process.
Because of the mastectomy be an impactful treatment to physical and mental health of those involved, the reactions facing this process are variants.

6
Findings indicate how most apparent in studies the following reactions: worry, fear, anguish/anxiety. It is noted that all of these are related to the future be in doubt: of woman know if the situation will be well accepted by her companion; of man concerning the proper recovery and how to care for your partner; of both about disease recurrence; of both on the performance of activities of the home. Sadness mentioned in the studies occurs as a way companion stand in solidarity to his woman.
Besides the explained above, in the same category appeared the encouragement of the husband to the wife, in several studies. In these studies it was realized the prevalence of stigma of the disease, lack of information and adaptation in learning how to deal with the mastectomy. Nevertheless, husbands are strong motivators for women to follow firm in treatment. In this encouraging companions encourage women and also follow medical guidelines, seeking to strengthen in hopes of improvement and possible cure. [8]

Companion in relationship with his lifemate after her mastectomy
The last category nominated "conjugal relationship" is influenced by feelings and perceptions that are the basis for the adaptation of the couple throughout treatment. It is noticed that most studies brings the perception of companion that the intimacy of the couple was not modified after mastectomy. These studies also show that the change in couple's relationship, when it happened, it was for the better. Somehow, strengthening the bond and establishing communication between the couple [13,14,15,16]. Despite this finding it was possible to perceive the idea that after mastectomy woman stops being attractive. Thus, this fact becomes one of the causes for the loss of the marital relationship [17,21,22].
There is a dichotomy in the findings. Despite the mastectomy to make the woman feel uncomfortable, embarrassed, the companion shows loving, affectionate, worried about making a woman feel good. Moreover the man shows that fact that she is experiencing that treatment does not prevent a couple from having a good relationship. On the other hand, a few companions do not deal with the situation that way. This kind of man turns away from his woman and left her helpless and may cause separation or even extramarital relationships [26].
Literature presents the need of those who live with a sick person with cancer to be understood, supported and helped, either by family and friends or by professionals involved in the care. The explanations provided help guide on how to proceed facing the experienced situation, treatment, and decreases in adversity inherent in this condition [27,28,29].
It is believed that men are dispensers of greater support to women, resulting in a better adaptation to the disease. Because the companion constantly experiences the suffering and difficulties of women, he presents mixed feelings and doubts. For this situation it is necessary to include him as care object in process [25].
In another study it is found that receive prior guidance on what may occur during treatment alleviates the psychological impact. Moreover, if the companion shares with others the experience of fighting the disease it may contribute to make him feel supported and find new meanings to the situation experience [30].
Therefore, the dimensions worked in the three categories of this study previously presented demonstrate that man presents different feelings and perceptions have experienced the moment for his lifemate. Moreover, the man really shows his willingness to assume the caregiver companion paper. However is necessary to the support from the professionals involved to contribute to the safety of companion to take your caring role.

Conclusions
According to the findings, it is clear that breast cancer is a very dreaded disease and there are still many stigmas related to it. When it comes these stigmas mastectomy tend to increase. So, given this reality is observed need of support for companions women submitted to mastectomy.
As previously mentioned the companions are the support and support their women. Even though feelings and perceptions of fear, pessimism, misinformation, anguish, shock, insecurity are experienced by men. Thus, it is necessary to include companions in the care from the perspective that men receive information about: disease, treatment and sexual relationship. Regarding the latter item, this is based on findings that reveal often mastectomy becomes an obstacle to sexuality.
Faced with this situation, it is necessary for health staff to establish a peaceful and opening relationship with women and his companions. From this approachit will be possible to promote guidelines in the perspective of to minimize doubts, strengthen linkages and provide psychosocial support. It intends to minimize unnecessary suffering and strengthen the people involved in coping with the disease. Therefore, it is essential to approach this theme in the context of research. Upon further investigation will increase in the publication of studies that could support the care to be offered from the experience of these men.