Effect of resilience on quality of life and anxiety in patients with breast cancer

Abstract

BACKGROUND

The incidence of breast cancer is high, with serious implications in terms of lives and health. Relevant data show that there are approximately 1 million new cases of breast cancer reported annually, with a rising trend. Some patients have poor treatment effects and are prone to anxiety and other negative emotions, which affect their quality of life (QoL).

AIM

To explore the correlation between mental resilience, QoL, and anxiety in patients with breast cancer.

METHODS

Using convenience sampling, 200 patients with breast cancer were selected from the First Affiliated Hospital of Hebei North University. These patients were investigated using the Conner-Davidson Resilience Scale, Self-Rating Anxiety Scale, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire to analyze the impact of resilience in patients with breast cancer on their QoL and anxiety.

RESULTS

The mean (SD) mental resilience score of the patients with breast cancer was 59.68 (± 9.84) points, the anxiety score was 49.87 (± 8.26) points, and the QoL score was 59.73 (± 8.29) points. Overall, they showed low mental resilience, mild anxiety, and medium QoL. Anxiety was negatively correlated with mental resilience and QoL (r = -0.275, r = -0.289, P < 0.05). QoL was positively correlated with mental resilience (r = 0.513, P < 0.05). Anxiety was a mediating variable between mental resilience and QoL, accounting for 8.58% of the mediating effect.

CONCLUSION

Regarding psychological elasticity, anxiety plays an intermediary role in QoL among patients with breast cancer. Medical staff can improve patients' mental resilience by reducing their anxiety and improving their QoL.

Key Words: Breast cancer; Mental resilience; Quality of life; Anxiety; Psycho-oncology; Mediation effect

Core Tip: Breast cancer is the most common form of malignant cancer among females. Given the long treatment cycle, patients are prone to negative emotions and serious psychological problems, leading to poor prognosis. This study investigated the correlation between anxiety, mental resilience, and quality of life with the aim of reducing negative emotions and poor prognosis.

INTRODUCTION

Breast cancer, as a global problem, will be the second cancer among women in the world in terms of incidence rate in 2022, with approximately 2.3 million new cases, accounting for 11.6% of new cancer cases[1]. Although the mortality rate of breast cancer is not the highest among women, it is still the fourth leading cause of cancer deaths among women worldwide with 666000 deaths, accounting for 6.9% of all cancer deaths[1]. Although the survival rate of patients with breast cancer has significantly improved in the past two decades, the incidence rate of this disease continues to rise globally[2]. At present, the treatment methods of breast cancer mainly include surgery, radiotherapy, chemotherapy, hormone therapy, targeted therapy, immunotherapy, and endocrine therapy[3-5]. These treatments can be used alone or in combination to adapt to the specific conditions of different patients with breast cancer. However, not all patients with breast cancer can achieve good results in these treatments. Some patients may have poor response to certain treatment methods due to their personal health status, biological characteristics of tumors, or treatment resistance[6,7]. Therefore, it is an important direction of medical research to actively seek methods that can improve the therapeutic effect of breast cancer treatments.

With the deepening of research on the treatment of breast cancer, in addition to traditional medical intervention, people gradually realize that mental health plays a vital role in the process of disease treatment and rehabilitation. Patients with breast cancer often experience various psychological pressures, such as anxiety, depression, and fear, when facing long-term treatment plans and uncertain prognosis. These psychological factors have been proved to have a significant impact on the treatment effect. Research[8] has shown that positive psychological states and effective psychological interventions can improve patients' treatment compliance, enhance the body's response to treatment, and potentially improve clinical outcomes. Mental resilience refers to the ability to rebound after experiencing difficulties. Therefore, patients with different levels of mental resilience may experience different therapeutic effects[9]. Current research has tended to analyze the correlations between mental resilience, anxiety, and quality of life (QoL) independently, and a comprehensive analysis of the combined three variables is lacking[10,11]. This study aimed to provide a preliminary exploration of the correlation between mental resilience, anxiety, and QoL and to establish a mediating model in relation to these factors.

MATERIALS AND METHODS

General information

Using convenience sampling between February 2023 and December 2023 at The First Affiliated Hospital of Hebei North University, 230 patients with breast cancer were included in the study. The inclusion criteria were as follows: Breast cancer diagnosed by pathological examination, age > 18 years, female sex, complete clinical data, and voluntary participation. The exclusion criteria included severe mental illness or inability to communicate normally, serious underlying diseases, and malignant tumors in other parts of the body.

Specific methods of assessment

General information questionnaire: This self-designed questionnaire included questions on age, marital status, educational level, family per capita monthly income, tumor staging, and treatment methods.

Connor-Davidson resilience scale: This scale includes 25 items across three dimensions: Resilience, optimism, and strength. A Likert 5-point scale is used, with a total possible score of 100 points, and with scores being proportional to the level of mental resilience. Cronbach's α of this scale was 0.810[12].

Self-rating anxiety scale: This scale was developed by Zung to evaluate subjective feelings regarding individual anxiety symptoms, with a total of 20 items. A Likert 4-point scale is used for scoring, with the scores of each item summed to calculate the total score (< 50 indicates no anxiety, 50-59 indicates mild anxiety, ≥ 60 indicates severe anxiety). Cronbach's α of this scale was 0.830[13].

European Organization for Research and Treatment of Cancer QoL Questionnaire: This scale contains 30 items, including functional, symptom, and QoL domains, and six individual items. Items 29 and 30 are scored using a 7-point Likert scale, while the other items are scored using a 4-point Likert scale. Higher scores in the functional dimension indicate better QoL and functional status, while higher scores in each symptom or treatment side-effect dimension indicate more severe symptoms. Cronbach's α of this scale was 0.835[14].

Quality control: The purpose and safeguards of the survey were explained to the research participants, who were instructed to fill in the questionnaire anonymously. Two nurses were responsible for the distribution and collection of the questionnaires, and participant confidentiality was guaranteed. A total of 230 questionnaires were distributed, assuming a non-response rate of 20% or more, and 200 valid responses were obtained (86.96% response rate).

Statistical analysis

SPSS software (version 27.0, IBM, United States) was used to process the data of the 200 patients with breast cancer. Pearson’s correlation coefficient was used to analyze the correlations between the variables. P < 0.05 indicated statistical significance. Common method variance was tested using the Harman single factor test. Specifically, PROCESS Macro software was used for data processing, and Model 4 was used to analyze the variables in terms of an intermediary effect.

RESULTS

Common method variance evaluation

The Harman single factor test results indicated that in terms of three eigenvalues, the first factor variance explained 30.46% of the variance (the critical value being 40%) in this study; therefore, there was no serious common method variance.

Comparison of the scores of mental resilience, anxiety, and QoL in relation to different patient demographic factors

The general information of 200 patients with breast cancer and the scores of relevant scales are shown in Table 1. Among the 200 patients, the age ranged from 23 to 80 years, with an average of 59.17 ± 8.69 years, and 167 were married (83.50%) and 33 were unmarried (16.50%). In terms of educational level, 72 (36.00%) had junior high school level or below and 128 (64.00%) had above junior high school level. Taking 3000 yuan as the critical value, 47 patients (23.50%) had a low per-capita monthly family income and 153 patients (76.50%) had a high per-capita monthly family income. Stage I or II tumor staging had 139 cases (69.50%) and there were 61 cases (30.50%) in stage III or IV; 123 cases (61.50%) were treated with surgery, and 77 cases (38.50%) were treated with surgery along with radiotherapy and chemotherapy. Married patients had lower anxiety scores and higher QoL scores, while the QoL scores of patients with family income ≥ 3000 were also higher (P < 0.05). Patients aged ≥ 50 years and with a higher education level had higher mental resilience scores, lower anxiety scores, and higher QoL scores, but with no other clear differences (P > 0.05). There were significant differences in the scores of psychological resilience, anxiety, and QoL scales among patients with different tumor stages (P < 0.05), while there were no significant differences in the scores of various scales among patients with different treatment methods (P > 0.05).

Table 1 Comparison of mental resilience, anxiety, and quality of life scores of the patients with different demographic factors, mean ± SD.

Items	Mental resilience	Anxiety	Quality of life
Age (years)
≥ 50	59.86 ± 9.78	49.74 ± 8.25	60.00 ± 8.11
< 50	58.46 ± 10.32	50.73 ± 8.43	57.88 ± 9.36
t value	0.676	-0.572	1.215
P value	0.500	0.568	0.226
Marital status
Unmarried	57.76 ± 10.39	52.70 ± 7.13	56.88 ± 9.07
Married	60.06 ± 9.71	49.31 ± 8.37	60.28 ± 8.04
t value	1.230	-2.176	2.178
P value	0.220	0.031	0.031
Level of education
Junior high school and below	59.00 ± 10.02	50.34 ± 9.14	58.76 ± 8.60
Above Junior high school	60.02 ± 9.76	49.62 ± 7.80	60.21 ± 8.12
t value	-0.693	0.693	-1.168
P value	0.489	0.489	0.244
Per-capita monthly household income
< 3000	58.81 ± 10.81	51.02 ± 7.82	57.55 ± 8.53
≥ 3000	59.95 ± 9.54	49.51 ± 8.38	60.39 ± 8.13
t value	-0.694	1.098	-2.070
P value	0.489	0.273	0.040
Tumor staging
I or II	60.95 ± 9.40	48.58 ± 7.52	60.93 ± 7.55
III or IV	56.79 ± 10.26	52.54 ± 8.70	56.98 ± 9.27
t value	-2.803	3.264	-3.167
P value	0.006	0.001	0.002
Treatment methods
Surgical treatment	58.30 ± 9.96	49.69 ± 8.40	58.71 ± 8.71
Surgery along with radiotherapy and chemotherapy	60.54 ± 9.70	49.85 ± 7.92	60.36 ± 7.99
t value	-1.577	-0.140	-1.367
P value	0.116	0.889	0.173

Mental resilience, anxiety, and QoL scores

The mental resilience scores ranged from 33 to 85 points (59.68 ± 9.84), the anxiety scores ranged from 26 to 82 points (49.87 ± 8.26), and the QoL scores ranged from 34 to 80 points (59.73 ± 8.29), as shown in Table 2.

Table 2 Mental resilience, anxiety, and quality of life scores of the patients with breast cancer.

Project	Score	Score range
Mental resilience	59.68 ± 9.84	33-85
Anxiety	49.87 ± 8.26	26-82
Quality of life	59.73 ± 8.29	34-80

In addition, to facilitate better targeted measures for patients with different degrees of resilience, anxiety, and QoL, the scores on the three scales were classified as follows. In terms of mental resilience, < 60, 60-69, and ≥ 70 indicated low, medium, and high mental resilience, respectively. Regarding anxiety, < 50 was considered as indicating no anxiety, 50-59 as mild anxiety, and ≥ 60 as severe anxiety. In terms of QoL, < 60 points was considered as indicating low QoL, 60-69 points as medium QoL, and ≥ 70 points as high QoL. The results showed that there was low mental resilience, mild anxiety, and medium QoL in terms of psychological elasticity among the 200 patients with breast cancer. The specific distribution is shown in Figure 1.

Figure 1 Distribution of mental resilience, anxiety, and quality of life in the patients with breast cancer.

Correlation analysis results of mental resilience, anxiety, and QoL

Mental resilience was positively correlated with QoL (r = 0.513) and negatively correlated with anxiety (r = -0.275). Anxiety was negatively correlated with QoL (r = -0.289). The results are shown in Figure 2.

Figure 2 Correlation analysis among mental resilience, anxiety, and quality of life in the patients with breast cancer. ^aP < 0.01.

The mediating role of anxiety between mental resilience and QoL

Mental resilience had a positive predictive effect on QoL (β = 0.469), and anxiety had a negative predictive effect on QoL (β = -0.161) and mental resilience (β = -0.275). With anxiety, the mental resilience of patients with breast cancer still had a significant positive predictive effect on their QoL, as shown in Table 3. The relationship between the relevant variables and path coefficients is shown in Figure 3.

Figure 3 Model of the mediating effect of anxiety between mental resilience and quality of life. ^aP < 0.05, ^bP < 0.01.

Table 3 Mediating effect of anxiety on the relationship between mental resilience and quality of life.

Dependent variable	Independent variable	R	R2	SE	F	β	t value	P value
Quality of life	Mental resilience	0.513	0.263	0.740	70.756	0.513	8.412	< 0.05
Anxiety	Mental resilience	0.275	0.076	0.929	16.196	-0.275	-4.024	< 0.05
Quality of life	Mental resilience	0.536	0.287	0.720	39.666	0.469	7.495	< 0.05
	Anxiety					-0.161	-2.565	0.011

Furthermore, the mediating effect of anxiety was tested and analyzed using the bootstrap method. The mediation effect (-0.044) accounted for 8.58% (95% confidence interval: 0.012, 0.082) and was significant, as shown in Table 4.

Table 4 Bootstrap estimates of the mediating effect of anxiety.

	Effect value	Boot SE	Boot LLCI	Boot ULCI	Effect ratio
Gross effect	0.513	0.061	0.393	0.633	-
Direct effect	0.469	0.063	0.346	0.592	91.42%
Indirect effect	0.044	0.018	0.012	0.082	8.58%

LLCI: Low limit confidence interval; ULCI: Upper limit confidence interval.

DISCUSSION

Mental resilience, anxiety, and QoL scores of the patients with breast cancer with different demographic characteristics

Patients with breast cancer may experience different levels of anxiety when facing the pressure of disease, uncertainty of treatment, and changes in body image. Self-Rating Anxiety Scale (SAS) is a tool used to assess an individual's anxiety state, and its score can reflect the level of psychological anxiety of the subject. Currently, SAS has been used to assess the anxiety level of patients with breast cancer[15]. European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire is a standardized tool developed by the EORTC to assess the QoL of patients with cancer; this has been proved to reflect the QoL of patients with breast cancer[16,17]. The design of the scale is concise and clear, easy for patients to complete, and convenient for medical professionals to interpret and apply, making it highly practical in clinical practice. The results showed that married patients had lower anxiety levels and higher QoL scores, while the QoL scores of patients with family income ≥ 3000 were also higher. Related studies have shown that the health levels and life expectancy of married people are higher than those of unmarried people. Marriage provides stability and support, which can reduce stress and moderately improve psychological well-being, and a good marital life can reduce negative emotions. In addition, the presence of a partner can provide intellectual and emotional support, increase one’s courage and determination to face difficulties, and improve QoL[18,19]. Higher levels of income are likely to have facilitated maintaining better health for such patients in terms of housing and diet, and for obtaining more medical resources, which could have effectively reduced their life pressures and mental burdens. Relevant healthcare departments should strengthen mechanisms to help low-income patients in a variety of ways[20,21]. In addition, there were significant differences in the scores of psychological resilience, anxiety, and QoL scales among patients in different tumor stages. Among them, patients in stage I or II had significantly higher scores in both psychological resilience and QoL scales than those in stage III or IV, while SAS scores were significantly lower than those in stage III or IV.

Mental resilience, anxiety, and QoL among the patients

The results showed that the patients with breast cancer had low mental resilience, moderate anxiety, and moderate QoL. Mental resilience refers to the dynamic process of psychological adaptation to and acceptance of major pressures or dangers. Improving patients’ mental resilience can effectively improve their ability to cope with challenging situations. Cancer is inherently fear-inducing, while the substantial financial pressure often associated with the treatment process can aggravate patients' psychological stress responses, leading to a decrease in the level of mental resilience[9,22]. Patients with breast cancer are prone to nausea and vomiting, liver function damage, bone marrow suppression, local tissue necrosis, and other side-effects following chemotherapy and radiotherapy, which can become a major mental burden on patients and produce negative emotions such as tension and anxiety[23,24]. Informational support should be provided to help such patients gain relevant disease-related knowledge, strengthen their cognitive abilities, and relieve anxiety. The QoL of these patients was at a moderate level, which may be related to the malignancy of the disease itself, poor prognosis, and strong side-effects. These patients have been reported to be physically and mentally traumatized and to have difficulty returning to normal life in society, which can exhibit as limited social activities, reduced communication and contact with others, and reduced comprehensive social adaptability[25,26].

Correlation between mental resilience, anxiety, and QoL

Pearson’s correlation analysis results revealed that mental resilience was negatively correlated with anxiety. Mental resilience is often used to evaluate body maintenance ability after experiencing stress and trauma; that is, a higher mental resilience level in patients is indicative of a lower risk of anxiety. Anxiety was negatively correlated with QoL, indicating that negative emotions reduced the mental health of patients to a certain extent and affected their QoL. Furthermore, a reduction in QoL has been shown to intensify the negative emotions of patients, creating a vicious cycle[27,28]. Mental resilience was positively correlated with QoL, which is consistent with the findings of another study in China[29].

The partial mediating effect of anxiety between mental resilience and QoL

In the process by which mental resilience affects patients' QoL, anxiety was found to play a mediating role; that is, the effect of mental resilience on patients' QoL could be produced directly or indirectly. More than 30% of the patients with breast cancer were anxious, with some having a poor QoL and prognosis. Effective mental resilience can encourage such patients to maintain an optimistic attitude and address issues better, actively use various resources to seek help, effectively relieve psychological pressure, reduce their psychological burden and anxiety, and improve their QoL[30-32]. The impact of resilience on the QoL and anxiety level of patients with breast cancer involves multiple mechanisms. Firstly, psychological resilience enables patients to face illness with a positive attitude, reducing anxiety and stress. Secondly, effective emotional regulation ability helps patients maintain emotional stability, adapt to treatment and life changes. In addition, a strong social support network provides emotional comfort and practical assistance to patients, further alleviating anxiety. High self-efficacy enhances patients' confidence in disease management, promotes treatment compliance and self-care. Effective coping strategies, such as actively seeking information and participating in decision-making, can facilitate better management of their illness. Psychological resilience may also be related to the function of emotional regulation areas in the brain, which helps maintain emotional balance. Finally, as a protective factor, psychological resilience helps patients maintain their mental health and improve their QoL under the pressure of illness.

Limitations and prospects of research

This study still has some objective limitations in exploring the relationship among resilience, anxiety, and QoL in patients with breast cancer. Firstly, there is a lack of qualitative data: This study mainly relies on quantitative data analysis and fails to combine qualitative data or in-depth interviews to explore patients' experiences concerning resilience, anxiety, and QoL. This limits our understanding of individual differences and deep psychological experiences among patients. Future research can capture patients' psychological states and comprehensively combine qualitative methods such as semi-structured interviews. Furthermore, there may be potential biases in statistical assumptions and analysis: During statistical analysis, there may be issues where some assumptions do not fully align with reality, which could lead to biases in the analysis results. For example, the score of a scale may be influenced by the patient's emotional state, rather than simply a reflection of their psychological resilience. Future research should focus on the randomness and representativeness of samples, as well as the suitability of statistical methods.

CONCLUSION

This study established a mediating effect model to explore the relationship between mental resilience, anxiety, and QoL in patients with breast cancer and to clarify the relationships between these variables. The results showed that anxiety in patients with breast cancer played a partial intermediary role between mental resilience and QoL, suggesting that improving patients’ anxiety can improve their mental resilience and QoL. Based on these findings, it is recommended that greater efforts be made to understand the psychological state of patients over time, implement appropriate and targeted intervention measures, provide psychological support, and improve the QoL of patients with breast cancer.