Background
Breast cancer is the most commonly diagnosed cancer in women worldwide [
1]. With improvements in detection and treatment, the survival rate of breast cancer has increased dramatically since the 1990s [
2], but patients’ quality of life (QOL) continues to be affected by stressors induced, for example, by exposure to treatment side effects [
3,
4]. Survival is not sufficient; patients also want to live well. QOL has also been shown to be a significant prognostic factor for mortality and cancer recurrence [
5]. Thus, researchers have faced the important problem of how to improve the QOL of women with breast cancer in recent decades.
QOL is a multidimensional concept involving aspects of individuals’ physical, psychological, and social well-being [
6]. The determinants of QOL in women with breast cancer include psychosocial factors, such as coping style, as well as sociodemographic and medical factors [
7]. Interventions are presumed to be capable of changing psychosocial factors and thereby QOL outcomes [
8,
9], whereas achieving change in the other two factor categories is generally difficult.
According to psychological stress theories [
10], coping is the main mediator between stressful events and outcomes. Coping is defined as “an individual’s efforts (both behavioral and cognitive) to manage demands (condition of harm, threat or challenge) that are appraised (or perceived) as exceeding or taxing his or her resources” [
10]. Garnefski et al. [
11] argued that all coping efforts can be classified broadly as emotion regulation, which refers to a wide range of biological, social, behavioral, and conscious and unconscious cognitive processes. Previous studies, focused primarily on behavioral coping, have shown that different coping strategies had distinct effects on QOL in women with breast cancer [
12,
13], but they did not recognize the importance of the cognitive component of the coping process. Garnefski et al. [
11] reported that this cognitive component may help patients manage or regulate emotions or feelings to avoid becoming overwhelmed, and they defined cognitive emotion regulation strategies as the conscious mental strategies that individuals use to cope with the intake of emotionally arousing information. In some situations, cognitive coping is more important than other coping strategies; for example, Kraaij et al. [
14] found that cognitive coping strategies had stronger effects than behavioral coping strategies on emotional problems in patients with definitive infertility, and they suggested that intervention programs should place more emphasis on cognitive techniques.
Certain cognitive emotion regulation strategies that an individual uses to deal with a life stressor may be associated with psychological distress and QOL [
15,
16]. For example, Garnefski et al. [
16] found that rumination was associated not only with the reporting of internalizing problems, but also with lower health-related QOL. Some studies have found that cognitive emotion regulation strategies accounted for considerable variance in psychological adjustment and somatic symptoms in women with breast cancer; the strategies of acceptance, positive refocusing, and positive reappraisal may be beneficial, whereas the strategy of catastrophizing may not be useful [
13,
17-
20].
A previous study found that the behavioral coping style most often observed among women with breast cancer was extreme suppression of feelings, which negatively affected prognosis [
21]. As individuals’ behaviors are closely associated with cognition, women with breast cancer may also have a particular cognitive coping style, which may have important effects on QOL. However, the characteristics of cognitive coping styles in these women remain unclear. To our knowledge, no study has investigated how cognitive emotion regulation styles among women with breast cancer relate to QOL. Thus, the aims of this study were to characterize cognitive emotion regulation styles among women with breast cancer and to explore the effects of cognitive emotion regulation strategies on QOL. As previous studies have found that people with physical and mental diseases report more rumination and catastrophizing and less positive reappraisal than do healthy control subjects [
22,
23], we hypothesized that women with breast cancer would exhibit this pattern of cognitive coping. As the core of behavioral coping among women with breast cancer is the acceptance and control of emotions [
21], we hypothesized that these patients would use cognitive coping strategies such as acceptance more than they use the strategy of blaming others. According to previous findings regarding psychological adjustment and somatic symptoms in women with breast cancer [
17-
20], we hypothesized that rumination and catastrophizing would negatively affect QOL, whereas positive reappraisal, positive refocusing, and acceptance would be beneficial to QOL.
Discussion
To our knowledge, the present study is the first to report on the use of cognitive emotion regulation strategies and the effects of these strategies on QOL among Chinese women undergoing breast cancer treatment.
Consistent with our first hypothesis, the results showed that cognitive emotion regulation strategies differed significantly between women with breast cancer and physically healthy women. Compared with healthy women, women newly diagnosed with breast cancer reported more frequent use of catastrophizing, a maladaptive cognitive emotion regulation strategy, and less frequent use of adaptive strategies (positive refocusing, refocusing on planning, and positive reappraisal). These findings are similar to those of previous research in patient and general-population samples [
15,
22]. However, it is still unknown to us that whether those differences existed before the diagnosis or just were patients’ reflection of the stress induced by the disease. In either case, emotion regulation strategies do play a crucial role when an individual encounters negative events and stress. Catastrophizing involves exaggerated threat appraisal and thoughts that explicitly emphasize the terror of an experience. In general, a catastrophizing coping style is positively related to depression and anxiety [
11]. Refocusing on planning refers to thinking about what steps to take and how to handle a negative event. Carver et al. [
30] showed that the use of planning as a coping strategy was negatively related to anxiety. Min et al. [
31] reported that refocusing on planning was the common strategy contributing to resilience and depression. Positive refocusing, characterized by thinking about joyful and pleasant matters instead of a negative event, is negatively related to depression [
11]. Positive reappraisal refers to the attachment of a positive meaning to a negative event in the context of personal growth. Garnefski et al. [
11] and Carver and Scheier [
30] showed that this strategy is negatively related to anxiety. Taken together, these findings imply that women who were recently informed the diagnosis of breast cancer have many fears related to the disease, they may not yet have had a chance to process all the information and events surrounding their diagnosis and let alone to find positive aspects of their condition.
In contrast to previous findings [
22,
23], women newly diagnosed with breast cancer more often reported acceptance and less often reported self-blame, rumination, and blaming others than did physically healthy women. Self-blame refers to thoughts of blaming oneself for what one has experienced. Rumination refers to thinking about the feelings and thoughts associated with a negative event. Among maladaptive strategies, these strategies have shown the strongest correlations with depression [
11,
32,
33]. The infrequency of rumination suggests that women newly diagnosed with breast cancer avoid cognition related to the disease. Acceptance refers to thoughts of accepting what one has experienced and resigning oneself to what has happened. Blaming others refers to thoughts of putting the blame for what one has experienced on others. Blaming someone else, an external attribution style, has been associated with poorer emotional well-being [
34]. Patients’ greater use of acceptance and less-frequent blaming of others are partly consistent with the characteristics of a type C coping style [
35], which describes individuals as being “cooperative and appeasing, unassertive, patient, inexpressive of negative emotions and compliant with external authorities.” Thus, cognitive coping is to some extent consistent with behavioral coping in women with breast cancer.
The findings that greater use of catastrophizing and acceptance, and less-frequent use of positive reappraisal, strongly and independently predicted patient group membership agree in part with previously reported findings [
36] that clinical individuals with symptoms of depression and anxiety commonly practiced more catastrophizing and less positive reappraisal than controls, leading to poor adjustment to stress. The less-frequent use of rumination and blaming others may reflect cognitive coping strategies consistent with the type C coping style. As previous studies have established a possible link between Type C personality and cancer [
35,
37], women with other cancer may have similar cognitive coping pattern; however, individuals with other illnesses, such as cardiovascular disease, may present different patterns of cognitive emotion regulation (e.g., Type A behavior pattern [
37]).
Previous studies have confirmed that the effects of stress on health outcomes depend on how a person copes with stress [
38]. In this study, cognitive coping was correlated with overall QOL and all QOL domains. Patients reporting more frequent use of maladaptive strategies (self-blame, rumination, catastrophizing, and blaming others) had worse perceived QOL, whereas those reporting more frequent use of adaptive strategies (acceptance, positive refocusing, refocusing on planning, and positive reappraisal) had better perceived QOL. The strategies of catastrophizing, acceptance, and positive reappraisal were strongly related to QOL, consistent with the findings of previous studies. For example, Jacobsen et al. [
18] and Khan et al. [
19] found that catastrophizing was related to fatigue and pain in women with breast cancer. Acceptance has been found to be beneficial for both psychological adjustment and QOL in patients with breast cancer [
13,
19]. Positive reappraisal has been shown to be a good predictor of positive mood, perceived health, and posttraumatic growth in women with breast cancer [
39]. Surprisingly, however, patients in this study reporting more frequent use of the putting into perspective adaptive strategy had worse perceived QOL. This strategy is arguably similar to the concept of social comparison [
11], and more frequent use of it may involve more attention to information on breast cancer treatment and similar or worse related events, which may reduce QOL.
Multiple regression analyses revealed that sociodemographic and medical factors had significant effects on QOL. Patients in relationships and those from urban areas had better perceived QOL than did patients who were divorced or widowed and those from rural areas, respectively; patients undergoing chemotherapy had worse perceived QOL than did those undergoing surgery alone. These findings are consistent with the results of previous studies [
40,
41]. Disease stage and time since diagnosis had no significant effect on QOL, however it is important to take into consideration that all patients were at early stage of the disease and enrolled in this study shortly after diagnosis (within a month). After controlling for sociodemographic and medical variables, cognitive coping had a significant effect on QOL. Maladaptive strategies (self-blame, rumination, and catastrophizing) had negative effects and adaptive strategies (acceptance and positive reappraisal) had positive effects on QOL. These findings are consistent with previous research demonstrating that cognitive coping mediates and moderates associations between various stressors and psychosomatic adjustment [
14,
42]. Clinical staff should pay particular attention to catastrophizing, which showed the largest difference among maladaptive strategies between the patient and control samples, to reduce patients’ fear of the disease. Clinical education about breast cancer should be implemented as early as possible. Acceptance had a positive effect on QOL. Some authors have argued that this strategy has distinct effects as an active process of self-affirmation and as a passive form of resignation to negative experiences [
16]. In the current study, acceptance results reflected self-affirmation, typically considered to be a functional coping response, as accepting the reality of a situation implies a certain attempt to deal with that situation. The results thus imply that cognitive acceptance was more important than behavioral acceptance among our patients. Folkman et al. [
38] argued that the value of positive reappraisal was not limited to the alleviation of distress, as positive interpretation of a stressful event should lead individuals to continue active and effective coping actions. In this study, positive reappraisal showed the largest difference among adaptive strategies between the patient and control samples. Thus, future research should focus on identifying and developing professional interventions that improve patients’ ability to accept stressors as real during primary appraisal and to attach positive meanings to stressful events through positive reappraisal.
The limitations of the present study include its cross-sectional nature, which prevented us from drawing conclusions about the development, course, and changes in QOL and patterns of cognitive emotion regulation over time. Thus, longitudinal studies should be conducted to address the potential bidirectional relationship between reported use of coping strategies and the experience of illness. Also, the assessment of cognitive emotion regulation strategies was based on a self-reported measure, which may have introduced bias (e.g., social desirability) and in future studies, the inclusion of other assessments may be useful to validate these findings. Thirdly, as the data of patients uninformed with the disease were not available, findings in this study could not be generalized to all women with breast cancer.
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Competing interests
The authors declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper.
Authors’ contributions
LL, YY and XZ conceived and designed the study. LL, JH and YW organized and supervised data collection and inputting. LL drafted the paper; organized and supervised the data analysis. JY provided critical comments on various drafts of the paper. JZ helped to organize data collection, commented on drafts of the paper. All authors read and approved the final manuscript.