A Review on Communication Issues Related to The Process and Treatment for Breast Cancer Patients in Malaysia

Apart from the assistance from medical technology, the process and treatment for breast cancer patients are also closely related to the information perceived by the patients themselves. By stating this, consideration towards communication issues should then be taken into account. This article focuses on the most notable issue discussed in Malaysia in which the communication between breast cancer patients with family members, particularly the communication with the patient's partner effects the process and the treatment that they receive. The study in this article is needed to address the communication issues thus finding solutions which will help to reduce the stigma of breast cancer in Malaysia.


Introduction
Breast cancer patients in Malaysia require assistance to overcome depression, emotional stress and other challenges while suffering. The presence of people who are closest to them particularly their own partner is crucial to help overcome the problems they face. This is due to the fact that the patient's partner would understand their condition better resulting to having lived together. Yeoh, et al (2018) reported that breast cancer patients in Malaysia are among the patients with the lowest life expectancy in Asia Pacific that is only 49% of patients who have a chance to live for five years and 43% of patients at stage three and stage four are late for screening. In addition, the mortality rate is higher among patients receiving treatment in public hospitals than in private hospitals. This is in line with the study conducted by Ho, et al (2017) found that almost 2048 (88%) cases of death due to breast cancer in Malaysia could be avoided because 1167 (57%) cases were due to late patients in screening. While 881 (43%) cases of death due to not receiving complete treatment which indirectly indicates that there is a difference between the socioeconomic status of patients. The results of the "Malaysian Study on Cancer Survival" found Since communication plays an important role in marriage, communication skills can determine happiness between patients and their respective spouses. Good communication is able to improve the quality of relationships, can control conflicts that occur in the household and in turn contribute to the mental and physical health of patients (Haris & Kumar, 2018).
On the other hand, communication can build trust and intimacy between couples. This can increase the patient's level of trust in the partner. With this, the treatment process will be smoother because patients can be helped with a good communication system. On the other hand, the patient's condition will be worse if the partner practices negative communication to the patient such as embarrassing, criticizing, insulting or triggering an anxiety situation (Shaud & Asad, 2018).
This article discusses 13 communication issues related to the process and outcome of treatment of breast cancer patients in Malaysia obtained through findings from previous studies. The issues found which need to be given further attention are as follows:

Issue 1: Patients Vulnerable to Conflict in Marriage
Conflict in marriage can occur because communication in marital relationships is vulnerable to conflict. This is because sharing daily lives with each other causes each partner's vulnerability to be vulnerable (Bankole, 2019).
Such a situation can be detrimental to the patient's condition as the patient suffers from depression and stress due to self -stigma. If this issue is ignored, the risk to the patient will be more dangerous, and even the treatment process will be more difficult.

Issue 2: Patients Tend to Expect Their Spouse to Communicate in Parallel to Each Other's Expectations and Expectations
Based on theory, adults tend to expect their partner to communicate in parallel with each other's expectations and expectations (Shaud & Asad, 2018).
If the couple do not care or chooses the path of finding a third person for self -interest, then the solution path to help the patient is not successfully found. In addition, this can cause the treatment period to be prolonged. This is due to the patient's emotions being disturbed by things other than the patient's suffering due to breast cancer disease experienced by the patient.

Issue 3: Spouse Perceptions Affect Forms of Interpersonal Communication
If spouses' perceptions are not in line with communication patterns, marital relationships will experience conflict and in turn affect forms of communication with each other (Bravo & Martinez, 2017).
Conflicts of opinion between couples can have adverse effects during treatment. The couple should know the patient's attitude and exercise tolerance to help identify the causes and problems experienced by the patient. So, with this, the treatment process will be easier to implement and the treatment results will be more encouraging.

Issue 4: Patients Experiencing Depressive Symptoms
Patients can be prone to depression if there is a husband's behavior that can trigger conflict in the marriage. This will cause the patient to experience symptoms of depression. Husband's warmth and sincerity can help control the conflict and depression experienced by breast cancer patients (Ozguc & Tanrıverdi, 2018).
The role of the partner is very important in helping the patient to be free from the symptoms of depression. Thus, effective communication skills between the partner and the patient can help the patient overcome the problem of depression. If the patient is successfully free of depression, the chances for the patient to recover will be faster. Even patients will feel calmer and happier during the treatment process.

Issue 5: Relationship Satisfaction and Low Relationship Levels During Conflict
Forms of communication between couples shape each other's behaviors where good relationship levels shape relationship satisfaction. While low levels of contact during conflict occur due to communication of mutual blame, hope or rejection, avoidance as well as harboring feelings (Tan et al., 2017).
Ideally, in assisting the patient during the treatment process, the couple should be more understanding of the patient's condition and more tolerant of the patient. Good communication can give the patient peace of mind even if the patient is in emotional stress or depression. Therefore, good communication can prevent patients from harboring feelings to facilitate and streamline the treatment process.

Issue 6: Self -Stigma Only Occurs in Individuals Forming Negative Attitudes in Patients
Individuals who receive societal stigma will not necessarily also accept the problem of selfstigma where self -stigma only occurs in individuals forming negative attitudes which in turn worsens their health as well as themselves (Kato, et al., 2017).
Yet if a patient has communication problems with a partner, self -stigma can occur to the patient. This is because conflicts between the partner and the patient can form negative attitudes and can adversely affect the health of the patient.
Issue 7: Lowering the Level of Self -Care of Chronic Patients Stigma resulting from the experience or acceptance of societal stigma is likely to lower the level of self-care of chronic patients where patient self -care consists of the knowledge, skills, confidence, and behaviors of patients to manage their disease (Kato, et al., 2020).
Societal stigma can affect a patient's thinking style. The patient's tendency to believe or disbelieve any information obtained through his or her environment will affect the patient's thinking. However, if the patient has a high level of motivation and good support from a partner, the patient can be controlled even at a chronic level.

Issue 8: Negative Assessments and Biased Views of Patients
Acceptance of societal stigma becomes a barrier factor for individuals to get help or support and subsequently perform negative assessments to undergo treatment. This also influences health professionals who generally give biased views of patients such as not adhering to treatment, manipulating, and having low levels of motivation to change (Hammarlund et al., 2018). Patients typically place a high level of trust in professionals. If professionals are biased, this can affect patients to avoid continuing to receive treatment. Even societal stigma can also influence the thoughts, attitudes, and even decisions that a patient and his or her partner will make.

Issue 9: Patients Keeping the Illness a Secret
This condition in turn causes patients who are in a chronic stage to keep their illness a secret and state that they have no invisible symptoms. This suggests that self-stigma has a relationship with self -perception is more important than societal stigma (Seo & Song, 2020).
In addition, self-stigma is a concept in the field of mental health, yet it is becoming popular because the effects of self-stigma can increase mortality and also cause patients to neglect the health care system. The care and evaluation of patients with self-stigma requires good communication skills because there are patients who tend to be "secretive" and avoid communicating openly (Harding, 2017). The situation is becoming increasingly worrying. Based on a study conducted by Zulkipli, et al (2018), he found that the Malays are the largest use of Complimentary and Alternative Medicine-CAM, and kept it a secret from the knowledge of doctors who care for them in which breast cancer patients in stage three or more likely to use CAM based on a recommendation by family members and friends.

Issue 10: Patients Feel Afraid of Attitudes from Others
This situation occurs because the stigma formed by individuals will cause them to feel afraid of attitudes from others such as ridicule, bias, or discrimination which in turn influences negative behaviors to overcome the resulting fear of others (Lillis et al., 2020).
Depression, low self-esteem, or loneliness will be detrimental to the patient. Therefore, couples need to play an important role and need to improve communication skills with patients in order to care for and control the patient's emotions. With this, patients can increase self-confidence and can avoid being influenced by the attitudes of others.

Issue 11: Delay in Process Duration and Treatment Outcome
Based on a study conducted by Bahri et al (2021), breast cancer patients in Malaysia use CAM due to delay in process and treatment outcome where patients post-menopausal breasts using CAM consisting of ruqyah recitations (prayers according to Islam), Chinese herbs, and supplements. This situation is explained based on a study by Kirubakaran et al (2017) who found that the majority of breast cancer patients in Malaysia consider that treatment for breast cancer requires a long period and is a painful process. Among the reasons patients choose alternative treatment methods is due to the stigma of society. This is because the patient is easily influenced by environmental factors. Therefore, couples need to play an important role in helping patients to select and undergo the appropriate treatment process. Nies, et al (2017) found that physicians failed to understand the perspectives and choices of breast cancer patients in the context of treatment-related decision making where the relationship between physician and patient perceptions was low. This is because patients feel they have sought a doctor's opinion to make a decision regarding their treatment.

Issue 12: The Relationship between Physician and Patient Perceptions is Low
Therefore, the involvement of the partner is necessary in helping to convey the message to the doctor, in case the doctor fails to understand the patient. If the patient and his partner have good communication with each other, then the relationship between the patient and the doctor can be improved and the treatment process will be smoother and more effective. Yeoh, et al (2018) reported that breast cancer patients in Malaysia are among the patients with the lowest life expectancy in Asia Pacific where only 49% of patients have a chance to live for five years and 43% of patients in Stage three and Stage four are late for screening as well as higher mortality rates among patients receiving treatment in public hospitals compared to private hospitals.

Issue 13: Chronic Patients Through Screening
The societal stigma that affects patients can be a factor in why patients avoid receiving treatment. In addition, self-stigma can also be a cause of chronic patients late to undergo screening due to patients neglecting the health care system (Harding, 2017). Therefore, the role of the partner is very important in helping and reminding the patient to immediately undergo treatment.

Proposed Solutions to the Issues of Breast Cancer Patients in Malaysia
Although there are various other issues, but researchers highlight these issues to find solutions together to help patients and partners practice appropriate communication throughout the treatment period.
Thus, the Model of Seeking Mental Health Assistance (MMBK) has combined three interrelated domains namely (1) problem identification; (2) the decision to seek assistance; and (3) selection of services agreed upon by the individual. This model was developed based on the assumption that culture includes race, ethnicity and gender in influencing all three domains (Cheng, Wang, McDermott, Kridel, & Rislin, 2018).
In addition, awareness among women to undergo breast cancer screening has increased in October through the campaign "Pink October" launched by major international charities to raise awareness on the dangers and prevention measures of cancer (Mohamad & Kok, 2019). The World Health Organization (WHO) has explained that the well -being of individuals is to be aware of the ability and skills to cope with the stresses of life, work optimally and contribute to the surrounding community in line with the ideas set by the Ministry of Health Malaysia (MOH). This idea will be a factor of improvement in the mental health management system in Malaysia as a key key in the National Mental Health Strategic Action Plan 2016-2020 (Eui & Tan, 2019).

Conclusion
Malaysia is a country that has limited resources to control cancer with a campaign to raise awareness of cancer that can lead to death. Therefore, Malaysians need more awareness campaigns through time media that are sensitive to the culture of society in Malaysia (Schliemann, et al., 2018). The current campaign is putting more focus at identifying the communication methods needed by cancer patients in Malaysia.
This can be evidenced through a study conducted by Dominic, et al (2018) that he found that programs conducted based on groups of breast cancer patients in Malaysia can reduce the level of depression, anxiety, and stress because they can interact, exchange ideas, and share information and support each other.
This indirectly indicates that the communication role of the partner of breast cancer patients is very important. Therefore, various parties should also help in terms of awareness, information, effective communication methods and others. With the help and cooperation from various parties, the issues listed can be avoided and reduced in accordance with the knowledge channeled through the media of the time. This can also help improve the health of patients and reduce cases of death due to negligence or negligence either from the patient, spouse or from a medical representative in Malaysia.