Background
Breast cancer is one of the most common and fatal diseases in the female population, which has a great impact on the psychological, emotional, social and family life of breast cancer patients [
1]. In China, the incidence of breast cancer is growing at a rate twice as compared to that of global cancer rate of increase [
2]. Besides, female breast cancer showed an escalating trend in years of life lost from 1990 to 2017 [
3].The increase of morbidity in breast cancer afflicted patients, and aggravation for disease burden put a long-term impact on the psychological health of patients [
4]. Simultaneously, psychological distress or emotional changes also have a negative influence on quality of life (QOL), which of the impact is not only confined to the treatment phase but also in the post treatment period [
5].
QOL is generally considered to be a multidimensional concept that includes physical, psychological, and social well-being, feelings of health as well as symptoms associated with illness or treatment [
6]. It has already been an important indicator which monitors the process of cancer treatment and prognosis or rehabilitation effect in recent years [
7]. With the development of medical technology, the 5-year survival rate of breast cancer patients was as high as 68.1–93.2% [
8]. Even so, due to the pathological and physiological characteristics of cancer itself, the progression or recurrence of cancer has not been effectively solved and prevented [
9]. The recurrence rate of breast cancer patients in China was up to 5–30% [
10]. The high recurrence rate may bring psychological stress to patients and impair their QOL [
11]. Additionally, Chinese traditional culture stems from interdependent values that emphasize the importance of maintaining prestige and social status [
12]. Diagnosis of cancer might potentially affect patients’ expression and talk about their fear of cancer. Many patients did not receive adequate psychological support when confronted with the fear of illness progression or recurrence [
13]. Furthermore, negative psychological distress and unmet social demands were significantly associated with poor QOL [
14]. Consequently, the effect of internal psychological state and external social factors on QOL in breast cancer patients should be given enough attention.
Fear of progression (or recurrence, hereafter FOP) is defined as the fear of the illness progressing or recurring in the same place or in another part of the body [
9]. FOP has become an important psychological burden of breast cancer patients, which seriously affects their QOL [
15]. Foreign scholars showed that probably 50% of cancer survivors experience moderate to severe FOP [
9]. Moreover, a longitudinal study of QOL for early-stage breast cancer survivors presented that the poorer QOL in women was related to long-term worry about cancer progression [
16]. FOP can lead to decrement in physical, mental and social aspects of QOL as well as persist longer after the completion of an active treatment [
17]. However, to the best of our knowledge, few studies [
15] have examined the relationship between FOP and QOL among female breast cancer patients. Therefore, it is essential to implement relevant research.
Facilitating positive psychosocial outcomes is as crucial as the decreasing negative ones. One of the most effective ways to cope with a traumatic life event is social support [
18] which is commonly defined as informational, emotional, and useful assistance provided by one’s social network [
19]. It played a key role in promoting positive psychological outcomes among breast cancer survivors [
20]. The significance of social support has been justified by You et al. that it was successfully used in adjusting to cancer [
21]. Surveys of different cancer populations demonstrated that higher social support was linked to better QOL [
22,
23]. It was also found social support could alleviate psychosocial distress, thereby holds the potential to serve as a buffer against FOP as well [
24]. Additionally, influenced by Chinese Confucian family harmony, Chinese female breast cancer patients would rather prefer to bear the disease pressure alone because of being afraid of bringing a burden to others [
25]. Whereas, some scholars indicated that emotional support from family members, which is naturally expected from a closer family members such as spouse and children, have a positive effect on the mental and physical adaptation to the disease [
26,
27]. Internal and external positive coping strategies from society or family support are vital for patients to readjust with their surrounding changes [
28]. Leung et al. indicated that social support could help patients improve their mental health and enhance their confidence to better cooperate with treatment [
29]. Hence, it is necessary to study the role of social support on QOL of breast cancer patients to help alleviate the fear of disease recurrence and pressure of cancer.
Up to now, although the relationships among FOP, social support and QOL have been reported previously [
15], the mediating effect of social support between FOP and QOL for Chinese breast cancer patients have not been clearly examined. Social support might be regarded as an important mediating variable in interpersonal relationship, the role mainly relied on individuals’ ability to express their needs [
30]. Celik et al. found that social support might transform patients’ FOP and help them cope with uncertainty, in which way the patients had a better performance in adapting to society and in turn improved their QOL [
31]. Walsh assessed the mediating effect of social support by identifying the linkage between distress and QOL for breast cancer patients, the result indicated that social support partially mediated the relation between symptom distress and QOL [
32]. The above researches suggested that social support might help cancer patients ease the negative emotions and boost QOL.
Based on the above literature studies, we hypothesized that social support was an important factor in improving QOL. Given that FOP is common among breast cancer patients [
16,
17,
33] and may generate adverse consequences, hence, if social support is a mediator mechanism between FOP and QOL, it will provide significant intervention guidance for buffering the adverse effects of FOP on QOL. In view of the empirical studies above and different cultural context and conditions, the purpose of our study was to verify the following three hypotheses among Chinese female breast cancer patients: 1) FOP has a negative effect on QOL; 2) social support has a positive effect on QOL; 3) social support mediates the association between FOP and QOL.
Discussion
Our findings showed that the mean score of QOL value was 90.6 ± 17.0 in the present study, which was lower compared with the level of QOL (96.4 ± 17.7) reported in Eastern China among female patients with breast cancer [
44]. Moreover, the mean score of QOL value was much lower than that of patients with breast cancer in other developed countries. Milbury et al. reported that the mean score of QOL was 104.12 ± 14.77 in USA during the year 2017 [
45], Matthies et al. reported a mean QOL score of 102.66 ± 22 in Germany during the year 2019 [
46]. However, the mean QOL score observed in our investigation was closer to the Asian situation-the mean score of QOL in Korea was 91.26 ± 20.08 as reported by Park et al. in 2019 [
47]. QOL in the current study was at a lower level in its individual capacity possibly because of three reasons. Firstly, although there is continuous improvement in diagnosis and treatment technology and it is more convenient to obtain quality care in China, the psychological fear brought by the cancer itself and unmet inner needs of patients have not been received adequate attention by nursing staff and family members [
48]. Secondly, Chinese cultural philosophies shape individual perceptions of disease, which are completely different from western cultural foundations. Influenced by traditional introvert culture, Chinese people are unwilling to share their feelings and thoughts with others, especially regarding disease-related issues [
49]. As a result, some emotional pressure cannot be released contributing to psychological disorders of Chinese female breast cancer patients. Particularly, surgery and relevant treatments (changes in sexual function and self-image) affect an individual’s physiology, psychology and social-relations [
50], thus promoting a lower QOL. Finally, subsistent medical institutions cannot offer targeted professional consultation to cancer patients in China, especially patients with recurrence, which is one of the most frustrating and difficult phase for cancer patients. Karam proposed that most recurrences are symptomatic (e.g. chest pain, cough, dyspnea, and so on) and occur during the interval between scheduled visits [
51]. Relapsed patients had a higher sense of fear of progression at reexamination time, together with disturbing thoughts, anxiety and poor QOL [
52]. By contrast, psychological counseling and supportive care are widely popularized in western countries [
53]. The above-mentioned conditions collectively intensified the negative impact on patients, which led to the poorer QOL of breast cancer patients.
Furthermore, the associations between FOP, social support and QOL of breast cancer patients were explored in our study. We found that FOP was negatively associated with QOL. Gotze et al. demonstrated that the FOP was associated with reduced emotional and social domains on QOL [
54]. Socio-demographic, psychosocial and clinical characteristics, such as age, living with a spouse, social support and poorer health conditions were important determinants of FOP [
55]. Gallenkamp et al. indicated that female survivors who were in five to seven years post-diagnosis, being socially isolated and those having less education or recurrence were at a greater risk to experience moderate or high levels of FOP [
24]. These factors had an impact on the QOL, reducing life expectancy as well. What is more, our results indicated that social support positively correlated with QOL among patients with breast cancer. Cancer patients revealed higher QOL and lower depression when they received more social support [
56]. Besides, in close relationships, women’s adaptation to breast cancer and family expression patterns significantly affect patients’ ability to cope with the disease [
57]. Lim et al. quoted that effective communication and support contributed to a higher QOL [
58]. As a consequence, medical staff and family caregivers must be aware of the importance of providing social support to breast cancer patients.
As expected, the result showed that social support acted as a mediator in the relation between FOP and QOL among Chinese breast cancer patients. A higher level of FOP might be alleviated by the higher level of social support and further led to the higher level of QOL. Social support (as a positive factor) weakened the negative impact of FOP (as a risk factor) on QOL. In brief, social support played a significant role in patients’ health outcomes including health-related quality of life [
29]. It meant we could improve the QOL of breast cancer patients via promoting the level of social support and reducing the sense of fear of disease. For this purpose, designing intervention programs via enhancing social support is an effective way to eventually achieve the goal of prolonging life expectancy and improving QOL. A supportive-expressive intervention program developed by the Stanford university laboratory proposed a kind of intervention model including social support which is mainly focused on encouraging emotional expression, arranging life priorities, dealing with a fear of death, cultivating relationships with families and friends, and increasing the adaptability to cope with a traumatic event and eventually improve the QOL [
59]. Kissane et al. using this intervention model on Australian patients with metastatic breast cancer, evidenced that the effectiveness of this model in improving QOL and suppress depressive emotions was significant [
60]. Therefore, future studies should be focused on the impact of interventions related to social support on Chinese breast cancer patients.
There were several limitations of our study. Firstly, a cross-sectional design was applied to the present study, so these findings could not be used to construct a formal causality or to identify the direction of causality between psycho-social resources and QOL. They are needed to be validated via longitudinal researches. Secondly, individuals with other types of diseases or variable comorbidities might not be surveyed. Additionally, we only recruited breast cancer patients from a single hospital in Liaoning Province, north of China, which might limit its applicable to other regions due to the cultural differences between North and South China. Thirdly, psychological variables were mainly evaluated using self-report instruments, which might be subject to recall and response bias. Our study tried to minimize the bias by using the QOL, FOP, and MSPSS that have been well validated for application among subjects in China. Finally, our study focused only on the association between FOP, social support and QOL. Further investigation needs to be taken into consideration to explore other social psychology and emotional predictors for the level of QOL in breast cancer patients, such as society, family environment factors and so on.
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