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A QUANTITATIVE ANALYSIS OF SOCIAL EFFECTS OF CANCER PATIENTS AND ITS IMPACTS ON QUALITY OF LIFE
Corresponding Author(s) : Younas Khan
Humanities & Social Sciences Reviews,
Vol. 9 No. 3 (2021): May
Abstract
Purpose of the study: The present study explores the social effects of cancer patients and their impacts on their quality of life (QoL).
Methodology: A cross-sectional based study was conducted in district Dir lower from a cancer patient (n=155). A structured questionnaire technique was used for data collection. Descriptive statistics and inferential statistics were carried out for both variables, i.e. dependent variable (QoL) and independent variable (Social effects of cancer patients).
Principal Findings: Among all 155 sampled respondents, 75.5% were male, having 42.6% had age group of 26-40 years, 79.9% were married, 47.1% were literate, and 32.3% were dependent on family members on economic terms. However, the perceptions of cancer patients with regards to social effects of Cancer majority 76.8% were proclaimed that social support decline cancer illness, 71% stated that religious doctrine gives spiritual healings, 70.3% dismantled that after cancer family supports us, 45.2% were reported that Cancer is a fatalistic disease, and 51.6% proclaimed that preference is given to male over a female concerning cancer disease respectively.
Applications of this study: Cancer affects social life, especially domestic affairs; however, this study was not primarily identified cancer diagnoses parameters due to the cross-sectional and perception nature of the study. A longitudinal follow-up study is the order of the day to determine whether there is any link between sociological and Cancer contexts.
Novelty/Originality of this study: This study is an attempt to insight into the sociological exploration of cancer patients effects through perceptional based research methodology/ Likert Scale procedure along with quantitative research design to measure the association between the aforementioned variable above with an amalgamation of an addition in the field of medical sociology.
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- Arora, N. K., Hamilton, A. S., Potosky, A. L., Rowland, J. H., Aziz, N. M., Bellizzi, K. M., ... & Stevens, J. (2007). Population-based survivorship research using cancer registries: a study of non-Hodgkin’s lymphoma survivors. Journal of cancer survivorship: research and practice, 1(1), 49-63. https://doi.org/10.1007/s11764-007-0004-3 DOI: https://doi.org/10.1007/s11764-007-0004-3
- Badihian, S., Choi, E. K., Kim, I. R., Parnia, A., Manouchehri, N., Badihian, N., ... & Cho, J. (2017). Attitudes toward cancer and cancer patients in an urban Iranian population. The oncologist, 22(8), 944. https://doi.org/10.1634/theoncologist.2017-0073 DOI: https://doi.org/10.1634/theoncologist.2017-0073
- Balboni, T. A., Vanderwerker, L. C., Block, S. D., Paulk, M. E., Lathan, C. S., Peteet, J. R., & Prigerson, H. G. (2007). Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 25(5), 555. https://doi.org/10.1200/JCO.2006.07.9046 DOI: https://doi.org/10.1200/JCO.2006.07.9046
- Broom, A., & Doron, A. (2012). The rise of cancer in urban India: Cultural understandings, structural inequalities and the emergence of the clinic. Health: 16(3), 250-266. https://doi.org/10.1177/13 63459311403949 DOI: https://doi.org/10.1177/1363459311403949
- Bryant, H., Shin, H. R., Forman, D., Stevanovic, V., Park, S., Burton, R., ... & Sutcliffe, S. (2012). Managing population health to prevent and detect cancer and non-communicable diseases. Asian Pac J Cancer Prev, 13(4 Suppl), 13-22.
- Chen, X., & Fan, R. (2010). The family and harmonious medical decision making: cherishing an appropriate Confucian moral balance. Journal of Medicine and Philosophy, 35(5), 573-586. https://doi.org/10.1093 /jmp/jhq046 DOI: https://doi.org/10.1093/jmp/jhq046
- Cho J, Choi E-K, Kim SY, et al. 2013a. Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea. Psycho-oncology, 22, (237)2–8. https://doi.org/10.1002/pon.3302 DOI: https://doi.org/10.1002/pon.3302
- Cho, J., Choi, E. K., Kim, S. Y., Shin, D. W., Cho, B. L., Kim, C. H., ... & Park, J. H. (2013). Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea. Psychoâ€Oncology, 22(10), 2372-2378. https://doi.org/10.1002/pon.3302 DOI: https://doi.org/10.1002/pon.3302
- Dey, S., Sharma, S., Mishra, A., Krishnan, S., Govil, J., & Dhillon, P. K. (2016). Breast cancer awareness and prevention behavior among women of Delhi, India: identifying barriers to early detection. Breast cancer: basic and clinical research, 10, BCBCR-S40358. https://doi.org/10.4137/BCBCR.S40358 DOI: https://doi.org/10.4137/BCBCR.S40358
- DiMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes a meta-analysis. Medical care, 794-811. https://doi.org/10.1097/00005650-200209000-00009 DOI: https://doi.org/10.1097/00005650-200209000-00009
- Feher, S., & Maly, R. C. (1999). Coping with breast cancer in later life: the role of religious faith 1. Psychoâ€Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 8(5), 408-416. https://doi.org/10.1002/(SICI)1099-1611(199909/10)8:5<408::AID-PON409>3.0.CO;2-5 DOI: https://doi.org/10.1002/(SICI)1099-1611(199909/10)8:5<408::AID-PON409>3.0.CO;2-5
- Gupta, A., Dhillon, P. K., Govil, J., Bumb, D., Dey, S., & Krishnan, S. (2015). Multiple stakeholder perspectives on cancer stigma in North India. Asian Pacific journal of cancer prevention: APJCP, 16(14), 6141. https://doi.org/10.7314/APJCP.2015.16.14.6141 DOI: https://doi.org/10.7314/APJCP.2015.16.14.6141
- Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American journal of public health, 103(5), 813-821. https://doi.org/10.2105/AJPH.2012.301069 DOI: https://doi.org/10.2105/AJPH.2012.301069
- Heckman, J. E., Chamie, K., Maliski, S. L., Fink, A., Kwan, L., Connor, S. E., & Litwin, M. S. (2011). The role of self-efficacy in quality of life for disadvantaged men with prostate cancer. The Journal of urology, 186(5), 1855-1861. https://doi.org/10.1016/j.juro.2011.06.059 DOI: https://doi.org/10.1016/j.juro.2011.06.059
- Karbani, G., Lim, J. N., Hewison, J., Atkin, K., Horgan, K., Lansdown, M., & Chu, C. E. (2011). Culture, attitude and knowledge about breast cancer and preventive measures: a qualitative study of South Asian breast cancer patients in the UK. Asian Pac J Cancer Prev, 12(6), 1619-26.
- Magai, C., Consedine, N., Neugut, A. I., & Hershman, D. L. (2007). Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis. Journal of Women's Health, 16(1), 11-23. https://doi.org/10.1089/jwh.2006.0024 DOI: https://doi.org/10.1089/jwh.2006.0024
- Maly, R. C., Umezawa, Y., Leake, B., & Silliman, R. A. (2004). Determinants of participation in treatment decision-making by older breast cancer patients. Breast cancer research and treatment, 85(3), 201-209. https://doi.org/10.1023/B:BREA.0000025408.46234.66 DOI: https://doi.org/10.1023/B:BREA.0000025408.46234.66
- Marlow, L. A., & Wardle, J. (2014). Development of a scale to assess cancer stigma in the non-patient population. BMC cancer, 14(1), 1-12. https://doi.org/10.1186/1471-2407-14-285 DOI: https://doi.org/10.1186/1471-2407-14-285
- Mazhari azad F, Abedi HA, Nagi SA 2010. Psychological and emotional outcomes in patients with systemic lupus erythematous. J Quall Res Health Sci, 10:14-23. (Persian).
- McCorkle, R., Ercolano, E., Lazenby, M., Schulmanâ€Green, D., Schilling, L. S., Lorig, K., & Wagner, E. H. (2011). Selfâ€management: Enabling and empowering patients living with cancer as a chronic illness. CA: a cancer journal for clinicians, 61(1), 50-62. https://doi.org/10.3322/caac.20093 DOI: https://doi.org/10.3322/caac.20093
- National Program of Cancer Registries, CDC 2015 WWW page. www.cdc.gov/cancer/npcr/about.htm
- Parker, P. A., Baile, W. F., Moor, C. D., & Cohen, L. (2003). Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psychoâ€Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 12(2), 183-193. https://doi.org/10.1002/pon.635 DOI: https://doi.org/10.1002/pon.635
- Qian, H., & Yuan, C. (2012). Factors associated with self-care self-efficacy among gastric and colorectal cancer patients. Cancer nursing, 35(3), E22-E31. https://doi.org/10.1097/NCC.0b013e31822d7537 DOI: https://doi.org/10.1097/NCC.0b013e31822d7537
- Risch, H. A., Yu, H., Lu, L., & Kidd, M. S. (2015). Detectable symptomatology preceding the diagnosis of pancreatic cancer and absolute risk of pancreatic cancer diagnosis. American journal of epidemiology, 182(1), 26-34. https://doi.org/10.1093/aje/kwv026 DOI: https://doi.org/10.1093/aje/kwv026
- Robb, K., Stubbings, S., Ramirez, A., Macleod, U., Austoker, J., Waller, J., ... & Wardle, J. (2009). Public awareness of cancer in Britain: a population-based survey of adults. Nature Precedings, 1-1. https://doi.org/10.1 038/npre.2009.3817.1
- Schreiber, J. A., & Brockopp, D. Y. (2012). Twenty-five years later—what do we know about religion/spirituality and psychological well-being among breast cancer survivors? A systematic review. Journal of Cancer Survivorship, 6(1), 82-94. https://doi.org/10.1007/s11764-011-0193-7 DOI: https://doi.org/10.1007/s11764-011-0193-7
- Sherman, AC.; Simonton, S. (2007). Spirituality and Cancer. In: Plante, TG; Thoresen, AC., editors. Spirit, Science, and Health: How the Spiritual Mind Fuels Physical Wellness. Westport, CT: Praeger; 2007.157-175. https://doi.org/10.5860/CHOICE.45-2070 DOI: https://doi.org/10.5860/CHOICE.45-2070
- Silvestri, G. A., Knittig, S., Zoller, J. S., & Nietert, P. J. (2003). Importance of faith on medical decisions regarding cancer care. Journal of Clinical Oncology, 21(7), 1379-1382. https://doi.org/10.1200/JCO .2003.08.036 DOI: https://doi.org/10.1200/JCO.2003.08.036
- Sudhakar, C., Nagabhushana, A., Jain, N., & Swarup, G. (2009). NF-κB mediates tumor necrosis factor α-induced expression of optineurin, a negative regulator of NF-κB. PloS one, 4(4), e5114. https://doi.org/10.1 371/journal.pone.0005114 DOI: https://doi.org/10.1371/journal.pone.0005114
- Suwankhong, D., & Liamputtong, P. (2016). Breast cancer treatment: experiences of changes and social stigma among Thai women in southern Thailand. Cancer nursing, 39(3), 213-220. https://doi.org/10.1097/NCC.0000 000000000255 DOI: https://doi.org/10.1097/NCC.0000000000000255
- Tang, P. L., Mayer, D. K., Chou, F. H., & Hsiao, K. Y. (2016). The experience of cancer stigma in Taiwan: a qualitative study of female cancer patients. Archives of psychiatric nursing, 30(2), 204-209. https://doi.org/10.1016/j.apnu.2015.08.015 DOI: https://doi.org/10.1016/j.apnu.2015.08.015
- Uchino, B. N. (2009). Understanding the links between social support and physical health: A life-span perspective with emphasis on the separability of perceived and received support. Perspectives on psychological science, 4(3), 236-255. https://doi.org/10.1111/j.1745-6924.2009.01122.x DOI: https://doi.org/10.1111/j.1745-6924.2009.01122.x
- Umberson, D., Crosnoe, R., & Reczek, C. (2010). Social relationships and health behavior across the life course. Annual review of sociology, 36, 139-157. https://doi.org/10.1146/annurev-soc-070308-120011 DOI: https://doi.org/10.1146/annurev-soc-070308-120011
- Yılmaz, M., Dişsiz, G., Demir, F., Irız, S., & Alacacioglu, A. (2017). Reliability and validity study of a tool to measure cancer stigma: Patient version. Asia-Pacific journal of oncology nursing, 4(2), 155. https://doi.org/10.4103/apjon.apjon_10_17 DOI: https://doi.org/10.4103/apjon.apjon_10_17
- Zamani, L., Parvizy, S., & Farahani, M. (2012). The cancer stigma: more terrible than disease. In Mashhad University of Medical Science Congress.
References
Arora, N. K., Hamilton, A. S., Potosky, A. L., Rowland, J. H., Aziz, N. M., Bellizzi, K. M., ... & Stevens, J. (2007). Population-based survivorship research using cancer registries: a study of non-Hodgkin’s lymphoma survivors. Journal of cancer survivorship: research and practice, 1(1), 49-63. https://doi.org/10.1007/s11764-007-0004-3 DOI: https://doi.org/10.1007/s11764-007-0004-3
Badihian, S., Choi, E. K., Kim, I. R., Parnia, A., Manouchehri, N., Badihian, N., ... & Cho, J. (2017). Attitudes toward cancer and cancer patients in an urban Iranian population. The oncologist, 22(8), 944. https://doi.org/10.1634/theoncologist.2017-0073 DOI: https://doi.org/10.1634/theoncologist.2017-0073
Balboni, T. A., Vanderwerker, L. C., Block, S. D., Paulk, M. E., Lathan, C. S., Peteet, J. R., & Prigerson, H. G. (2007). Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 25(5), 555. https://doi.org/10.1200/JCO.2006.07.9046 DOI: https://doi.org/10.1200/JCO.2006.07.9046
Broom, A., & Doron, A. (2012). The rise of cancer in urban India: Cultural understandings, structural inequalities and the emergence of the clinic. Health: 16(3), 250-266. https://doi.org/10.1177/13 63459311403949 DOI: https://doi.org/10.1177/1363459311403949
Bryant, H., Shin, H. R., Forman, D., Stevanovic, V., Park, S., Burton, R., ... & Sutcliffe, S. (2012). Managing population health to prevent and detect cancer and non-communicable diseases. Asian Pac J Cancer Prev, 13(4 Suppl), 13-22.
Chen, X., & Fan, R. (2010). The family and harmonious medical decision making: cherishing an appropriate Confucian moral balance. Journal of Medicine and Philosophy, 35(5), 573-586. https://doi.org/10.1093 /jmp/jhq046 DOI: https://doi.org/10.1093/jmp/jhq046
Cho J, Choi E-K, Kim SY, et al. 2013a. Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea. Psycho-oncology, 22, (237)2–8. https://doi.org/10.1002/pon.3302 DOI: https://doi.org/10.1002/pon.3302
Cho, J., Choi, E. K., Kim, S. Y., Shin, D. W., Cho, B. L., Kim, C. H., ... & Park, J. H. (2013). Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea. Psychoâ€Oncology, 22(10), 2372-2378. https://doi.org/10.1002/pon.3302 DOI: https://doi.org/10.1002/pon.3302
Dey, S., Sharma, S., Mishra, A., Krishnan, S., Govil, J., & Dhillon, P. K. (2016). Breast cancer awareness and prevention behavior among women of Delhi, India: identifying barriers to early detection. Breast cancer: basic and clinical research, 10, BCBCR-S40358. https://doi.org/10.4137/BCBCR.S40358 DOI: https://doi.org/10.4137/BCBCR.S40358
DiMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes a meta-analysis. Medical care, 794-811. https://doi.org/10.1097/00005650-200209000-00009 DOI: https://doi.org/10.1097/00005650-200209000-00009
Feher, S., & Maly, R. C. (1999). Coping with breast cancer in later life: the role of religious faith 1. Psychoâ€Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 8(5), 408-416. https://doi.org/10.1002/(SICI)1099-1611(199909/10)8:5<408::AID-PON409>3.0.CO;2-5 DOI: https://doi.org/10.1002/(SICI)1099-1611(199909/10)8:5<408::AID-PON409>3.0.CO;2-5
Gupta, A., Dhillon, P. K., Govil, J., Bumb, D., Dey, S., & Krishnan, S. (2015). Multiple stakeholder perspectives on cancer stigma in North India. Asian Pacific journal of cancer prevention: APJCP, 16(14), 6141. https://doi.org/10.7314/APJCP.2015.16.14.6141 DOI: https://doi.org/10.7314/APJCP.2015.16.14.6141
Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American journal of public health, 103(5), 813-821. https://doi.org/10.2105/AJPH.2012.301069 DOI: https://doi.org/10.2105/AJPH.2012.301069
Heckman, J. E., Chamie, K., Maliski, S. L., Fink, A., Kwan, L., Connor, S. E., & Litwin, M. S. (2011). The role of self-efficacy in quality of life for disadvantaged men with prostate cancer. The Journal of urology, 186(5), 1855-1861. https://doi.org/10.1016/j.juro.2011.06.059 DOI: https://doi.org/10.1016/j.juro.2011.06.059
Karbani, G., Lim, J. N., Hewison, J., Atkin, K., Horgan, K., Lansdown, M., & Chu, C. E. (2011). Culture, attitude and knowledge about breast cancer and preventive measures: a qualitative study of South Asian breast cancer patients in the UK. Asian Pac J Cancer Prev, 12(6), 1619-26.
Magai, C., Consedine, N., Neugut, A. I., & Hershman, D. L. (2007). Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis. Journal of Women's Health, 16(1), 11-23. https://doi.org/10.1089/jwh.2006.0024 DOI: https://doi.org/10.1089/jwh.2006.0024
Maly, R. C., Umezawa, Y., Leake, B., & Silliman, R. A. (2004). Determinants of participation in treatment decision-making by older breast cancer patients. Breast cancer research and treatment, 85(3), 201-209. https://doi.org/10.1023/B:BREA.0000025408.46234.66 DOI: https://doi.org/10.1023/B:BREA.0000025408.46234.66
Marlow, L. A., & Wardle, J. (2014). Development of a scale to assess cancer stigma in the non-patient population. BMC cancer, 14(1), 1-12. https://doi.org/10.1186/1471-2407-14-285 DOI: https://doi.org/10.1186/1471-2407-14-285
Mazhari azad F, Abedi HA, Nagi SA 2010. Psychological and emotional outcomes in patients with systemic lupus erythematous. J Quall Res Health Sci, 10:14-23. (Persian).
McCorkle, R., Ercolano, E., Lazenby, M., Schulmanâ€Green, D., Schilling, L. S., Lorig, K., & Wagner, E. H. (2011). Selfâ€management: Enabling and empowering patients living with cancer as a chronic illness. CA: a cancer journal for clinicians, 61(1), 50-62. https://doi.org/10.3322/caac.20093 DOI: https://doi.org/10.3322/caac.20093
National Program of Cancer Registries, CDC 2015 WWW page. www.cdc.gov/cancer/npcr/about.htm
Parker, P. A., Baile, W. F., Moor, C. D., & Cohen, L. (2003). Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psychoâ€Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 12(2), 183-193. https://doi.org/10.1002/pon.635 DOI: https://doi.org/10.1002/pon.635
Qian, H., & Yuan, C. (2012). Factors associated with self-care self-efficacy among gastric and colorectal cancer patients. Cancer nursing, 35(3), E22-E31. https://doi.org/10.1097/NCC.0b013e31822d7537 DOI: https://doi.org/10.1097/NCC.0b013e31822d7537
Risch, H. A., Yu, H., Lu, L., & Kidd, M. S. (2015). Detectable symptomatology preceding the diagnosis of pancreatic cancer and absolute risk of pancreatic cancer diagnosis. American journal of epidemiology, 182(1), 26-34. https://doi.org/10.1093/aje/kwv026 DOI: https://doi.org/10.1093/aje/kwv026
Robb, K., Stubbings, S., Ramirez, A., Macleod, U., Austoker, J., Waller, J., ... & Wardle, J. (2009). Public awareness of cancer in Britain: a population-based survey of adults. Nature Precedings, 1-1. https://doi.org/10.1 038/npre.2009.3817.1
Schreiber, J. A., & Brockopp, D. Y. (2012). Twenty-five years later—what do we know about religion/spirituality and psychological well-being among breast cancer survivors? A systematic review. Journal of Cancer Survivorship, 6(1), 82-94. https://doi.org/10.1007/s11764-011-0193-7 DOI: https://doi.org/10.1007/s11764-011-0193-7
Sherman, AC.; Simonton, S. (2007). Spirituality and Cancer. In: Plante, TG; Thoresen, AC., editors. Spirit, Science, and Health: How the Spiritual Mind Fuels Physical Wellness. Westport, CT: Praeger; 2007.157-175. https://doi.org/10.5860/CHOICE.45-2070 DOI: https://doi.org/10.5860/CHOICE.45-2070
Silvestri, G. A., Knittig, S., Zoller, J. S., & Nietert, P. J. (2003). Importance of faith on medical decisions regarding cancer care. Journal of Clinical Oncology, 21(7), 1379-1382. https://doi.org/10.1200/JCO .2003.08.036 DOI: https://doi.org/10.1200/JCO.2003.08.036
Sudhakar, C., Nagabhushana, A., Jain, N., & Swarup, G. (2009). NF-κB mediates tumor necrosis factor α-induced expression of optineurin, a negative regulator of NF-κB. PloS one, 4(4), e5114. https://doi.org/10.1 371/journal.pone.0005114 DOI: https://doi.org/10.1371/journal.pone.0005114
Suwankhong, D., & Liamputtong, P. (2016). Breast cancer treatment: experiences of changes and social stigma among Thai women in southern Thailand. Cancer nursing, 39(3), 213-220. https://doi.org/10.1097/NCC.0000 000000000255 DOI: https://doi.org/10.1097/NCC.0000000000000255
Tang, P. L., Mayer, D. K., Chou, F. H., & Hsiao, K. Y. (2016). The experience of cancer stigma in Taiwan: a qualitative study of female cancer patients. Archives of psychiatric nursing, 30(2), 204-209. https://doi.org/10.1016/j.apnu.2015.08.015 DOI: https://doi.org/10.1016/j.apnu.2015.08.015
Uchino, B. N. (2009). Understanding the links between social support and physical health: A life-span perspective with emphasis on the separability of perceived and received support. Perspectives on psychological science, 4(3), 236-255. https://doi.org/10.1111/j.1745-6924.2009.01122.x DOI: https://doi.org/10.1111/j.1745-6924.2009.01122.x
Umberson, D., Crosnoe, R., & Reczek, C. (2010). Social relationships and health behavior across the life course. Annual review of sociology, 36, 139-157. https://doi.org/10.1146/annurev-soc-070308-120011 DOI: https://doi.org/10.1146/annurev-soc-070308-120011
Yılmaz, M., Dişsiz, G., Demir, F., Irız, S., & Alacacioglu, A. (2017). Reliability and validity study of a tool to measure cancer stigma: Patient version. Asia-Pacific journal of oncology nursing, 4(2), 155. https://doi.org/10.4103/apjon.apjon_10_17 DOI: https://doi.org/10.4103/apjon.apjon_10_17
Zamani, L., Parvizy, S., & Farahani, M. (2012). The cancer stigma: more terrible than disease. In Mashhad University of Medical Science Congress.