Comparison of couples' adjustment to lumpectomy and mastectomy

Offline Social Relationships and Online Cancer Communication: Effects of Social and Family Support on Online Social Network Building

This study investigates how social support and family relationship perceptions influence breast cancer patients' online communication networks in a computer-mediated social support (CMSS) group. To examine social interactions in the CMSS group, we identified two types of online social networks: open and targeted communication networks. The open communication network reflects group communication behaviors (i.e., one-to-many or "broadcast" communication) in which the intended audience is not specified; in contrast, the targeted communication network reflects interpersonal discourses (i.e., one-to-one or directed communication) in which the audience for the message is specified. The communication networks were constructed by tracking CMSS group usage data of 237 breast cancer patients who participated in one of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of a diagnosis of primary breast cancer or recurrence at the time of recruitment. Findings reveal that breast cancer patients who perceived less availability of offline social support had a larger social network size in the open communication network. In contrast, those who perceived less family cohesion had a larger targeted communication network in the CMSS group, meaning they were inclined to use the CMSS group for developing interpersonal relationships.

Predictors of Social Support and Psychological Distress in Women with Breast Cancer

This investigation sought to understand previous well-cited and worrisome findings that women treated for breast cancer with breast-conserving surgery compared to mastectomy experience less social support and more mood disturbance, and that social support from significant others erodes over time. Ninety-three women with breast cancer and a subset of their partners completed assessments at the time of surgical treatment and at 3 and 13 months post-treatment. Contrary to the previous findings, type of surgical treatment was not related to perceptions of social support or psychological functioning. Perceptions of social support and psychological distress decreased over time, and the discrepancy between recipients’ and providers’ judgments of available support increased over time. Low levels of physical functioning led to relative increases in social support, whereas high levels of psychological distress led to relative decreases in social support. Social support as rated by patients (but not their partners) was a significant predictor of changes in psychological distress.

The role of the family environment and computer-mediated social support on breast cancer patients' coping strategies

Despite the importance of family environment and computer-mediated social support (CMSS) for women with breast cancer, little is known about the interplay of these sources of care and assistance on patients' coping strategies. To understand this relation, the authors examined the effect of family environment as a predictor of the use of CMSS groups as well as a moderator of the relation between group participation and forms of coping. Data were collected from 111 patients in CMSS groups in the Comprehensive Health Enhancement Support System "Living with Breast Cancer" intervention. Results indicate that family environment plays a crucial role in (a) predicting breast cancer patient's participation in CMSS groups and (b) moderating the effects of use of CMSS groups on breast cancer patients' coping strategies such as problem-focused coping and emotion-focused coping.

Israeli and Chinese partners of women with breast cancer: a cross-cultural view of marital issues

OBJECTIVE

Cultural nuances may influence the interface between the cancer experience and marital issues, specifically for the partner. Most of the literature has focused on the woman's narrative or couple's adjustment to cancer in general. The purpose of this study was to describe and compare the marital relationship, sexuality, and marital adjustment of Israeli and Chinese husbands of women with breast cancer and the discussion of the health-care team concerning these issues.

METHODS

A convenience sample of 50 Chinese and 50 Israeli men, ages of 28-79 years, completed components of the Psychological Adjustment to Illness Scale, the Locke Wallace Adjustment Scale, and a background questionnaire.

RESULTS

The majority of husbands were in their first marriage. The average time since diagnosis was 16.7 months. No significant difference was found between the two groups on issues of marital relationship. Significant differences were found between Israeli and Chinese husbands on sexual interest, pleasure, and performance (p<0.05). Israeli husbands reported a significantly higher level of marital adjustment as opposed to the Chinese husbands (p = 0.006). Marital adjustment for both groups was significantly related only to perceived quality of the relationship (p<0.03).

CONCLUSIONS

Significant cultural differences were found in sexuality variables with no differences discerned on marital relationship variables. Couple-based interventions for marital issues are a critical component of support for both partners. Culturally sensitive assessment and care of the spouse as well as the woman with breast cancer should be part of a holistic, comprehensive family care plan.

Social, marital, and sexual adjustment of Israeli men whose wives were diagnosed with breast cancer

PURPOSE/OBJECTIVES

To explore the psychosocial adjustment of Israeli men whose wives were diagnosed with breast cancer.

DESIGN

Descriptive study.

SETTING

An urban tertiary medical center.

SAMPLE

A convenience sample of 50 Israeli men whose wives had been diagnosed with breast cancer. The average age was 53.8 years. All of the men spoke and wrote Hebrew.

METHODS

Husbands completed a demographic and wives' health-related questionnaire, the Social Support Questionnaire to measure social support from their wives, the Psychosocial Adjustment to Illness Scale to measure adjustment to a serious disease of the wives, and the Locke Wallace Marital Adjustment Scale to measure marital and sexual adjustment.

MAIN RESEARCH VARIABLES

Psychosocial adjustment, social support, relationships with their partners, and relationships with the healthcare system.

FINDINGS

A fifth of the men reported various levels of stress and concern. Half described financial difficulties. Three-quarters of the men noted changes in their relationships. More than a third of the husbands experienced a reduction in communication with their families. All of the men expressed satisfaction with the healthcare system, although some of them expressed a need to receive more information.

CONCLUSIONS

Husbands of women with breast cancer grapple with multiple issues on several fronts. They need support and information from the healthcare team even if they do not request it in a timely or direct manner.

IMPLICATIONS FOR NURSING

Response to the unspoken needs of men whose wives have breast cancer necessitates education and ongoing staff education to develop strategic support and communication.

A review of distress and its management in couples facing end-of-life cancer

The aim of this review paper is to (1) provide an overview of the impact of cancer on the couple, (2) to identify potential outcomes for couple's interventions targeted specifically when one spouse is facing end of life, (3) to review and critique the empirical literature on psychosocial interventions for couple's facing end of life to date, and (4) to provide direction for research in this area. Based on our review, we found that there is clear evidence of significant distress arising from the impact of terminal illness on the marital relationship, which can result in greater suffering in the last months and weeks of life. Currently, there is a very small body of evidence on the effectiveness of couple interventions for those where one is in palliative care. Future randomized controlled trials are needed to examine the impact of couple therapy adapted for couples facing the end of life, and to guide in providing information on the number of sessions and format required for this population. Outcomes, such as more effective communication, reduction in the experience of hopelessness, uncertainty, isolation, depression, anxiety, and more adaptive coping strategies should be considered.

Couples Who Get Closer After Breast Cancer: Frequency and Predictors in a Prospective Investigation

Purpose

Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this.

Patients and Methods

This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect.

Results

Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer.

Conclusion

Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.

Breast cancer: reactions of Israeli men to their wives' diagnosis

The purpose of this research was to describe Israeli husbands' reactions to their wives' diagnosis of breast cancer. This quantitative, descriptive, preliminary study employed a convenience sample of 20 men and investigated their perception of the information they received, their psychosocial responses, the effects on their marital relationship, and their perceived spousal social support. The study instruments included the Locke Wallace Marital Adjustment Scale, the Psychosocial Adjustment to Illness Scale, and a Social Support Questionnaire. This subject has not been researched in Israel previously. Husbands voiced total trust in the health-care delivery system, even though they reported a need for more information on the disease, treatment, and issues concerning their marital relationship. Husbands had difficulties with their day-to-day activities, and almost half of them cited problems both at work and at home. They described stress, including depression and sleep disturbances. They reported changes in their sexual interest and sexual functioning as well. In general, husbands felt the support of their wives. Husbands whose wives have breast cancer need a network of support to address their specific issues and concerns. The Breast Care Clinical Nurse Specialist is cited as being a pivotal component of such a support network.

Active consideration: conceptualizing patient-provided support for spouse caregivers in the context of prostate cancer

In this study, the authors examine the under-investigated topic of patient-provided support for spouse caregivers. Thirty-four men with prostate cancer and their female partners were interviewed separately three times: before the man's radical prostatectomy, 8 to 10 weeks postsurgery, and 1 year postsurgery. The core category of active consideration encompassed 4 dimensions: easing spousal burden, keeping us up, maintaining connection, and considering spouse. Patient-provided support entails two overlapping tasks: minimizing the practical and emotional impact of the illness and tending to the caregiver's social-emotional needs. A theory expounding on the double bind of being both a patient and an agent in light of masculine socialization practices is articulated and brought to bear on the phenomenon of patient-provided support.

Quality of life influenced by primary surgical treatment for stage I-III breast cancer-long-term follow-up of a matched-pair analysis

BACKGROUND

Breast-conserving therapy has been demonstrated to be just as safe and a less disruptive experience compared with mastectomy for surgically manageable breast cancer. There is, however, no agreement in the literature about the impact of these procedures on several important aspects of quality of life (QOL). The purpose of the present study is to compare the long-term impact of these two surgical approaches on QOL in patients with identical tumor stages and to suggest possible shortcomings of the standard QOL questionnaires.

METHOD

Between August 1999 and May 2000, QOL questionnaires were answered by 152 pair-matched patients at the I. Frauenklinik, Ludwig-Maximilians University Munich, as part of routine follow-up examinations. The pairs of patients, each consisting of one patient after mastectomy and one after breast conservation, were selected according to the highest degree of equivalence in tumor stage. All patients had been initially treated for stage I-III breast cancer without evidence of distant metastases. The QOL was evaluated by using the QLQ-C30 questionnaire version 2.0 of the EORTC Study Group on Quality of Life. We formulated seven additional questions about the patients' satisfaction with the primary surgical treatment modality as viewed from their current perspective. The QOL questionnaires were answered after a median interval of 46 months following primary treatment.

RESULTS

Tumor stage, prognostic factors, and adjuvant systemic treatment were well balanced between the two groups. No differences between the two groups were observed in terms of all QOL items measured by the QLQ-C30. Our additional questions, however, revealed that patients in the mastectomy group were less satisfied with the cosmetic result of their primary operation (P < .0001), were more likely to feel basic changes in their appearance (P < .0001), and were more likely to be emotionally stressed by these facts (P < .0001). From their perspective at the time of completing the questionnaires, 11 patients in the mastectomy group (15%) would decide differently about the surgical treatment modality, compared with only 3 patients (4%) in the breast conservation group (P = .025).

CONCLUSION

While the primary surgical treatment modality seems to have no long-term impact on general QOL, certain body-image-related problems may be caused by mastectomy. Standard measuring instruments for QOL may fail to detect differences in satisfaction and adaptation with the primary surgical treatment modality.

Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life

Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a woman's life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.

Mastectomy or lumpectomy? Helping women make informed choices

PURPOSE

To develop an instrument to help clinicians inform their patients about surgical treatment options for the treatment of breast cancer and to evaluate the impact of the instrument on the clinical encounter.

METHODS

We developed an instrument, called the Decision Board, to present information regarding the benefits and risks of breast-conserving therapy (lumpectomy plus radiation therapy) and mastectomy to women with early-stage breast cancer to enable them to express a preference for the type of surgery. Seven surgeons from different communities in Ontario administered the instrument to women with newly diagnosed clinical stage I or II breast cancer over an 18-month period. Patients and surgeons were interviewed regarding acceptability of the instrument. The rates of breast-conserving surgery performed by surgeons before and after the introduction of the instrument were compared.

RESULTS

The Decision Board was administered to 175 patients; 98% reported that the Decision Board was easy to understand, and 81% indicated that it helped them make a decision. The average score on a true/false test of comprehension was 11.8 of 14 (84%) (range, 6 to 14). Surgeons found the Decision Board to be helpful in presenting information to patients in 91% of consultations. The rate of breast-conserving surgery decreased when the Decision Board was introduced (88% v 73%, P =.001)

CONCLUSION

The Decision Board is a simple method to improve communication and facilitate shared decision making. It was well accepted by patients and surgeons and easily applied in the community.

Type of mastectomy and quality of life for long term breast carcinoma survivors

BACKGROUND

Despite numerous studies of partial mastectomy and psychologic morbidity in the first 24 months following surgery, little is known about the long term psychosocial repercussions of partial and total mastectomy.

METHODS

The effect of the type of mastectomy on psychologic adjustment was assessed among 124 breast carcinoma survivors, 47 of whom underwent partial mastectomy and 77 of whom underwent total mastectomy, 8 years after initial treatment. Interviews were also conducted 3 and 18 months after surgery. Psychologic distress was assessed using the Psychiatric Symptom Index. Other outcomes included physical symptoms, patients' perceptions of their own health, satisfaction with the type of surgery performed and with the appearance of the scar, and marital and sexual adjustments.

RESULTS

No statistically significant differences between partial and total mastectomy were observed with respect to long term quality of life. Age at diagnosis modified the relation between the type of mastectomy and psychologic distress in both the short term and the long term (P = 0.04). Among women younger than 50 years, partial mastectomy appeared to be protective against distress when compared with total mastectomy. In contrast, among women age 50 years or older, partial mastectomy was associated with higher psychologic distress levels at all interviews.

CONCLUSIONS

Assessed globally, partial and total mastectomy appear to be equivalent treatments in terms of patients' long term quality of life. However, both short term and long term distress levels after partial and total mastectomy may depend on patients' age at diagnosis. The findings of this study suggest that the increased use of partial mastectomy may lessen the negative effects of breast carcinoma on younger survivors' quality of life. Nevertheless, total mastectomy may be an appropriate initial treatment for some women who truly choose it.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

A comparative study of post-operative psychosocial function in women with primary operable breast cancer randomized to breast conservation therapy or mastectomy

In a randomized patient series of 184 women suffering from primary operable breast carcinoma, psychosocial adjustment to breast-conserving therapy (BCT) vs mastectomy (M) was analysed retrospectively, including: (i) a comparison of intergroup characteristics; (ii) patient experience of the quality of professional pre-operative information; and (iii) the extent to which influence on choice of treatment was required. Using LASA (Linear Analogue Self-Assessment Scale), STAI (State-Trait Anxiety Inventory), and a semi-structured interview, no psychosocial benefits were found in BCT compared with M. Mean observation time was 31 months (range: 15-65). Body image was less impaired in BCT than in M. Both groups scored highly on professional information, but reported reduced ability to take in such information in the peri-operative period. Both groups tended to depend on the surgeon when choosing between surgical options. Irrespective of primary therapy, women must still confront the fact that they have had cancer, a life-threatening disease which may recur. A need for further research into peri-operative information procedures was demonstrated, and some suggestions were derived concerning the surgeon's role in deciding on surgical options.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.

Stages of acculturation as reflected by depression reduction in immigrant nursing students

Depression amongst immigrant students from the former Soviet Union was assessed as an index of the stage of their acculturation into the new host society, Israel. At the beginning of the first year of nursing school, three groups completed the Beck Depression Inventory. The two groups of immigrants: immigrant nurses preparing for licensing (N = 26) and immigrant students (N = 16), reported mild levels of depression, while Israeli students (N = 33) were significantly less depressed, within the normal range. Six months later, both immigrant groups were within the normal range, the immigrant nurses group showing the greatest decrease in depression. This change may be explained by adaptation to the educational setting, mastering the host society's language and social anchorage. The importance of background variables for predicting depression reduction is examined. The findings are discussed within the framework of multistage models of acculturation and the implications for counseling immigrant students are presented.

Issues, problems, and challenges for families coping with breast cancer

There is a scarcity of research that examines the adaptation of the family to breast cancer from the family's perspective. This study analyzed 12 families from the time of diagnosis to 12 months later. Issues, problems, and challenges that partnered families faced during the initial year were identified through five interview points. Frequency of the problems identified and the challenges encountered shifted over time.

Psychosocial adjustment among husbands of women treated for breast cancer; mastectomy vs. breast-conserving surgery

Psychosocial adjustment was measured among 56 spouses of women operated for breast cancer. Of 69 eligible husbands, 56 participated. Twenty women underwent breast-conserving surgery (BCT) and 36 had a mastectomy (MT). An interview was conducted with each woman and her husband separately, 4 and 13 months after surgery. Two instruments were used; SBAS (Social Behaviour Assessment Schedule) and a scale (TB) constructed specifically for the study. The husbands of the women in the MT group were significantly more depressed after 4 months and reported complaints related to their wive's disease more often than did those in the BCT group. After 4 months, the marital relation was assessed as more positive in the MT group. A total of 48% of the husbands in the sample expressed some emotional distress during the investigation period, which is similar to levels seen among breast cancer-operated women themselves. Overall, only marginally better scores were seen for husbands married to women who had undergone breast-conserving surgery. Few researchers have studied psychosocial reactions in the breast cancer patient's family. Since patterns of social support empirically influence the rehabilitation of the cancer patient, this field of investigation is important.

Gender and adjustment to chronic disease. A study of couples with colon cancer

The adjustment of 39 couples in which one partner has cancer of the colon was assessed. The main findings were that the adjustment of male patients was superior to that of female patients. In the spouses' group the opposite was found, namely the adjustment of husbands was far worse than that of wives of cancer patients.

The psychosocial adjustment of patients and spouses to dialysis treatment

Sixty-eight patients on hospital dialysis and their spouses were studied to compare their levels of adjustment and to examine gender differences. Two measures were used: BSI for psychological distress and PAIS for psychosocial adjustment to dialysis. High scores of psychological distress and adjustment problems were found both for patients and their spouses, with high correlations between the partners. Female patients and their husbands had higher scores than male patients and their wives respectively, and in some areas the husbands of female patients reported even more problems than the male patients. Clinical and theoretical conclusions are discussed.

Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy

This study of the relation between type of mastectomy and psychological distress was based on all newly diagnosed breast cancer patients with localized or regional disease who were surgically treated in seven Quebec City hospitals in 1984. Among 235 eligible patients, 227 (96%) participated in a home interview 3 months after diagnosis and 205 of these women gave a second interview approximately 15 months later. The Psychiatric Symptom Index (PSI) was used to measure the severity of symptoms of psychological distress. At 3 months, 38.8% of partial mastectomy patients had high PSI scores compared to 25.8% of women treated by total mastectomy (OR = 1.8, p = 0.044). Fifteen months later, percentages with high scores were identical, 35.1%, in the two treatment groups. Age appeared to modify the surgery-distress relation. These results suggest that partial mastectomy does not protect against psychological distress after breast cancer. Moreover, they highlight the importance of adequate preparation and support for all breast cancer patients, regardless of type of initial surgery.