Health-related quality of life and social constraints among Chinese breast cancer patients: a cross-sectional study

Breast cancer (BC) is the most frequently diagnosed cancer and the leading cause of cancer death in the vast majority of countries. According to the most recent GLOBOCAN publication, the five most frequent cancers in Chinese women are breast, lung, colorectum, thyroid and stomach [1]. It was estimated in 2020 that the age-standardized (world) incidence of BC was 39.10/100,000 in China [2]. Furthermore, there are approximately 416,371 new BC cases and 117,174 deaths per year among Chinese women [2]. Due to early screening, early diagnosis and better treatment, patients with BC have a long survival time after diagnosis. Studies have reported that breast-conserving surgery and adjuvant radiotherapy in early BC patients result in 5-year overall survival rates of > 80% in China [3, 4]. As BC patients live longer, concerns about quality of life have increased. Hence, it is urgent and significant to evaluate and improve the health-related quality of life (HRQOL) of BC patients after treatment.

At present, BC treatment involves state-of-art biomedical therapy but can fail to address HRQOL issues, particularly emotional well-being and social/family well-being after diagnosis and treatment. Doege et al. conducted a study to compare disease-free BC patients’ HRQOL to that of non-cancer female controls and found that long-term BC survivors suffer significantly lower social, emotional, functional, physical well-being, fatigue, insomnia, and dyspnoea than female population controls [5]. However, a study conducted by Bower et al. indicated that many BC patients have relatively healthier lifestyles and found a new meaning to their lives in the long term [6]. In addition, long-term survivors reported similar or improved HRQOL levels based on exercise interventions compared to controls without BC [7]. Some sociodemographic and clinical characteristics among BC patients affect their HRQOL, including age [8], socioeconomic status (SES) [9], cancer stage [10] and treatment methods [11]. Moreover, an increasing number of investigators have focused on studying sociopsychological factors related to HRQOL among BC patients [5‐8, 12, 13].

Most evidence has shown that low social support and high social stigma are importantly and significantly associated with impairments in HRQOL among BC patients [9, 13‐15]. Social support refers to a combination of perceiving assistance available from family, friends and other significant relationships in times of need [16]. Based on the theory of the “stress buffering hypothesis” [17], social support can enhance individuals’ well-being and health by acting as a “direct agent”. In addition, it can act as an “antecedent factor” to increase individuals’ positive coping styles and psychological empowerment, which thus has a positive effect on mental health and HRQOL. For example, Strayhorn SM thought that positive social support has a positive association with HRQOL in BC patients [15]. In other words, social support is a positive psychological resource to evaluate BC patients’ HRQOL. Stigma is defined as feelings of isolation, degradation, criticism and rejection during personal experience and a social process that affects psychological, physical and social adjustment [18]. Indeed, previous studies have found that people with stigma have worse health outcomes than their non-stigmatized counterparts [19, 20]. A growing number of studies have examined stigma associated with cancer as cancer is perceived more negatively in society than some other diseases [21]. Cancer treatment leaves psychological and physical scars, such as stigma, surgical scars and hair loss [22]. BC patients with perceived stigma may avoid social relationships, which may result in an interpersonal stressor [23]. More importantly, perceived stressors may influence HRQOL among BC patients.

There is some evidence that social constraints have a strong association with decreased HRQOL and increased emotional distress among women with BC [9, 24, 25]. Social constraints are defined as the objective existence and subjective perceptions of social conditions, which hinder individuals from disclosing or modifying the ways of their disclosure of illness-related feelings or concerns [26]. Based on social cognitive processing theory [26, 27], individuals’ cognitive assimilation or accommodation of cancer experience can be facilitated by emotional disclosure (talking with empathic and supportive others, providing reappraisal, validation and meaning-making); cognitive processing thereby contributes to improving mental adjustment to cancer within a receptive social environment. When cancer patients experience unsatisfying interpersonal factors (others’ withdrawal, criticism and denial), an opposing effect occurs. Additionally, social constraints negatively affect healthy behaviours, including self-examination among BC patients [27], adherence to self-care activities among diabetes patients [28], and exercise [29]. However, most research studying social constraints has been performed among Caucasian or Asian American BC cancer patients, and few studies have evaluated social constraint levels and explored the effect of social constraints on integrative HRQOL among Chinese BC patients living in mainland China. There is only a study conducted by Yeung et al. [30] to explore the adverse effect of social constraints on functional well-being among BC patients living in Shandong Province, China. Owing to cultural differences, Chinese emotional disclosure is difficult to practice. Namely, Chinese people are more likely to value emotional suppression to avoid disturbing the interpersonal harmony that Chinese society emphasizes, whereas people from Western cultures tend to express their emotions due to the independent culture [31, 32]. Therefore, our study aimed to examine the association of social constraints with HRQOL among Chinese women with BC.

The mean FACT-B score was 96.05 (SD = 18.70) in Chinese women with BC. The level of overall HRQOL in the current study was lower than that in Americans in BC studies that adopted the same measurement tool [41‐43]. In addition, Lu et al. found that Chinese BC patients reported lower HRQOL than their American counterparts [35]. Lu et al. suggested that Chinese BC patients undergoing more aggressive treatment or taking drugs may be likely to experience more adverse side effects [35]. Additionally, strategies of symptom control may be different. Despite the fact that there are affordable and advanced treatments to obtain better cancer care for Chinese BC patients, our results showed that patients with BC still suffer poorer HRQOL than patients in Western countries. Thus, identifying psychological factors is a top priority among Chinese BC patients.

The results of our study reported no association of sociodemographic and clinical variables with HRQOL among Chinese BC patients. However, other studies have suggested that SES indicators are uniquely associated with overall HRQOL and its dimensions in BC patients [9]. SES is defined as a multidimensional construct containing social position (education), economic status (income) and work conditions (occupation) [44]. For example, Xia et al. reported that financial difficulties were a stronger predictor of impaired global HRQOL for BC patients. You et al. also found a significant association of education and income with different aspects of HRQOL among BC patients [9].

The findings in our study presented a strong adverse effect of social constraints on HRQOL among Chinese BC patients, which was in accordance with the results in Caucasian [45] and Chinese American [24] patients with BC. Namely, patients with more social constraints tend to have worse HRQOL. Their abilities to perceive and ask for the social support they need and to express emotion are limited in a negative environment [25]. Finally, the way patients perceive their social environment seems to influence perceived stress [37]. For example, patients with a negative perception of their environment are more likely to consider a cancer diagnosis a more threatening, less manageable and stressful event, which results in adverse outcomes [37]. Additionally, our results revealed that social constraints among Chinese BC patients (Mean = 1.82) were higher than Caucasian BC patients (Mean = 1.77) in previous study [45], but were lower than those reported by Chinese American BC patients (Mean = 2.02) [24]. In Chinese culture, cancer is considered “bad luck”, and emotional expression is rare among Chinese families, which implies a high level of social constraints in Chinese BC patients. Hence, future research should adopt a cross-cultural design to directly compare the differences in social constraints in different countries.

Our study found that social support was positively associated with HRQOL, and the association of social support with HRQOL has been widely examined among BC patients [9, 15]. In addition, social support is beneficial for patients with different cancer types [46]. Patients with sufficient social support have a platform to share and communicate, which helps them adapt psychological changes and reconstruct cognitive processes. With regard to social stigma, the current study found that it was negatively related to HRQOL in BC patients. Previous research has also reported similar findings [14]. Some studies suggest that stigma may cause cognitive changes, including increases in negative thoughts and decreases in positive thoughts. These changes have an adverse influence on Chinese BC patients’ HRQOL. Therefore, psychological interventions to enhance the HRQOL of Chinese BC patients may attempt to foster social support and reduce social stigma and constraints.

Our study is the first attempt to examine the relationship between social constraints and overall HRQOL among Chinese BC patients. The findings from the current study suggest that Chinese BC patients’ HRQOL needs to be enhanced after treatment. Social constraints have a strong association with HRQOL, while social support and stigma are also important factors. Given the above results, intervention strategies focusing on less personal disclosure should be considered to avoid social constraints and improve HRQOL among Chinese BC patients.