Anxiety, depression and quality of life among Chinese breast cancer patients

during adjuvant therapy

Winnie K.W. So
a,
*
, Gene Marsh
b
, W.M. Ling
c
, F.Y. Leung
d
, Joe C.K. Lo
e
, Maggie Yeung
f
, George K.H. Li
g
a
Department of Nursing Studies, The University of Hong Kong, Hong Kong SAR, China
b
School of Nursing, University of Colorado Health Science Center, USA
c
Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
d
Infection Control Unit, Princess Margaret Hospital, Hong Kong SAR, China
e
Department of Oncology, Princess Margaret Hospital, Hong Kong SAR, China
f
Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong SAR, China
g
Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China
Keywords:
Anxiety
Depression
Quality of life
Adjuvant therapy
Chemotherapy
Radiotherapy
Breast cancer
a b s t r a c t
Purpose: The aim of the study was to examine anxiety and depression and their effects on the quality of
life (QOL) of patients with breast cancer undergoing chemotherapy or radiotherapy.
Methods: A cross-sectional descriptive design was used. Data were collected from a self-report survey
derived from the Hospital Anxiety and Depression Scale (HADS)-Cantonese/Chinese version, the Func-
tional Assessment of Cancer Therapy for Breast Cancer (FACT-B)-Chinese version, and from demographic
and clinical characteristics. Chi-square tests and the General Linear Model (GLM) were used for
secondary data analysis.
Sample: The study group consisted of 218 women (18 years old) who were midway through chemo-
therapy or radiotherapy for stage IIII breast cancer. All subjects were recruited from the outpatient
sections of the Departments of Clinical Oncology or Breast Centers of the four Hong Kong public
hospitals.
Results: The percentage of participants with anxiety (c
2
6.56, p 0.01) or depression (c
2
7.26,
p 0.007) was higher in the chemotherapy group. More participants in the chemotherapy group had
both anxiety and depression than those in the radiotherapy group, though no statistically signicant
difference was reported. Anxiety and depression had detrimental effects on the overall and other
domains of QOL of these women undergoing adjuvant therapy for breast cancer.
Conclusion: This study should increase nurses awareness of the importance of integrating psychological
symptom assessment into nursing assessment procedures, and enhance their clinical sensitivity in
identifying high-risk groups of patients undergoing specic cancer treatments.
2009 Elsevier Ltd. All rights reserved.
Introduction
Breast cancer is the most commonly diagnosed cancer among
women in Hong Kong, with the incidence rate increasing every year
(Hong Kong Cancer Registry, n.d.). In 2006, there were approxi-
mately 2600 newcases and the life-time risk for females was up to
1 in every 20 (Hong Kong Cancer Registry, n.d.).
The treatment modalities for primary breast cancer include
surgery, chemotherapy, radiotherapy and hormonal therapy, all
four of which can be used alone or in combination (Dow, 2004).
Surgery is a primary treatment for breast cancer, whereas adjuvant
therapies such as chemotherapy and radiotherapy are commonly
used after primary treatment in order to inhibit metastasis and
enhance long-term survival rates (National Cancer Institute, 2002).
Despite advances in cancer treatment which have increased breast-
cancer survival rates, the aggressiveness of the therapy increases
the exposure of patients to treatment side-effects. In fact, cancer
and treatment-related symptoms are major stressors in patients
with breast cancer undergoing treatment for the disease (Jim et al.,
2007).
Of all the symptoms, anxiety and depression are the most
prevalent psychological symptoms perceived by cancer patients
(Takahashi et al., 2008), the prevalence rate ranging from 13% to
54% (Burgess et al., 2005; Gaston-Johansson et al., 1999; Hopwood
* Corresponding author at: Dr Winnie K.W. So, Department of Nursing Studies,
The University of Hong Kong, 4/F., William M.W. Mong Block, 21 Sassoon Road,
Pokfulam, Hong Kong SAR, China. Tel.: 852 2819 2684; fax: 852 2872 6079.
E-mail address: wkw@hku.hk (W.K.W. So).
Contents lists available at ScienceDirect
European Journal of Oncology Nursing
j ournal homepage: www. el sevi er. com/ l ocat e/ ej on
1462-3889/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2009.07.005
European Journal of Oncology Nursing 14 (2010) 1722
et al., 2007; Takahashi et al., 2008; Zabora et al., 2001). A large
variation in the prevalence of anxiety and depression may be due to
the use of different measurement tools and heterogeneous
samples. Also, the fewstudies that have taken place have only used
small samples to examine the psychological symptoms of patients
undergoing either chemotherapy or radiotherapy (Byar et al., 2006;
Farrell et al., 2005). To the best of the authors knowledge, no study
has compared the prevalence of psychological symptoms in
different types of adjuvant therapy. Further research using larger
homogeneous samples to examine possible cases of anxiety and/or
depression during chemotherapy or radiotherapy is essential to
close the knowledge gap.
Quality of life (QOL) has been used as a primary outcome
measure in recent decades. It is a complex multi-dimensional
assessment of the physical, psychological and social well-being of
individuals (Akin et al., 2008). The adverse effects of different
cancer- or treatment-related symptoms and types of treatment
have been associated with QOL (Albert et al., 2004; Groenvold et al.,
2007; Safaee et al., 2008; Schreier and Williams, 2004; Takahashi
et al., 2008). Anxiety and depression have both been shown to be
negatively associated with the QOL of breast-cancer patients after
diagnosis, at the start of treatment and post-treatment (Weitzner
et al., 1997; Longman et al., 1999; Schreier and Williams, 2004;
Wong and Fielding, 2007). Nevertheless, the co-occurrence of
anxiety and depression and the combined effect of the two
psychological symptoms on the quality of life of breast-cancer
patients remain unclear.
Aim
The aimof the study was to examine anxiety and depression and
their effects on the QOL of patients with breast cancer undergoing
chemotherapy or radiotherapy. The research questions involved are
as follows:
1) What is the prevalence of anxiety and depression in patients
undergoing adjuvant therapy for breast cancer?
2) Are patients undergoing chemotherapy more likely to have
anxiety and/or depression than those receiving radiotherapy?
3) Do anxiety and/or depression in this population affect QOL?
Methods
Design
This study used a cross-sectional descriptive design.
Sample and settings
Potential subjects were recruited fromthe outpatient sections of
the Departments of Clinical Oncology or Breast Centers of the four
local public hospitals. Eligibility criteria included: Chinese women
who 1) were 18 years old or older, 2) had undergone surgery for
breast cancer, 3) were midway in their course of curative treatment
by chemotherapy or radiotherapy, and 4) were diagnosed with
stage IIII breast cancer. Those who 1) had difculty in under-
standing the questionnaire or communicating in Cantonese, 2) had
a history of psychiatric disorder, or 3) had metastatic brain disease
were all excluded from the study.
Instruments
The original self-report survey consisted of six parts. Details of
the instrument are reported elsewhere (So, 2007). In the present
paper, three parts of the survey were used for analysis and
discussion: 1) demographic and clinical characteristics, 2) anxiety
and depression, and 3) quality of life.
Demographic and clinical characteristics. The demographic data
consisted of age, income, marital status, educational level,
employment status, religious belief, family history of cancer, stage
of disease, comorbidity, duration of illness, type of current treat-
ment, time since initial treatment and type of surgery received.
Anxiety and depression. The Hospital Anxiety and Depression
Scale (HADS)-Cantonese/Chinese version is a screening tool for
measuring the severity of anxiety and depression (Zigmond and
Snaith, 1983). The Cantonese/Chinese version was developed by
Lam et al. (1995) and translated from the original version of the
HADS developed by Zigmond and Snaith (1983). The scale consists
of 14 items and two subscales (anxiety and depression) with seven
items in each subscale. Each item is scored on a 4-point Likert-type
scale (03). Total scores for each subscale are calculated by simple
summation of individual items, a higher score indicating more
distress. Consistent with the original version of HADS, the
Cantonese/Chinese version has been used for measuring the level
of psychological distress in various populations, including general
hospital in-patients (Leung et al., 1999) and the elderly (Lam et al.,
1995). The results showed that the scale had good internal
consistency and external validity with favorable sensitivity and
specicity in screening for patients with psychiatric disorders. In
this study, the Cronbachs alpha coefcients for the anxiety and
depression subscales were 0.806 and 0.724 respectively.
Quality of life. The Functional Assessment of Cancer Therapy for
Breast Cancer (FACT-B)-Chinese version was used to assess the
degree of the participants QOL (FACIT Functional Assessment of
Chronic Illness Therapy, n.d.) The scale consists of 36 items divided
into ve domains: the physical, emotional, social, functional well-
being and breast cancer subscales. Each item was rated on a ve-
point scale (0 not at all; 1 a little bit; 2 somewhat; 3 quite
a bit; 4 very much). In this way, the total score and the subscale
score for well-being are calculated. Higher scores indicate better
functional status. Internal consistency and content validity were
demonstrated in a sample of 60 Chinese patients with breast cancer
(Mak et al., 2007), where the Cronbachs alpha coefcient for the
subscales ranged between 0.524 and 0.872 and for the entire scale
was 0.725.
Procedure
The study was approved by the ethical committee of the study
institutions, and conducted in 20062007. Potential subjects were
approached by a research nurse midway through their regime of
chemotherapy and in the third to sixth week of radiotherapy. Data
were collected by face-to-face interview. Medical records were
reviewed by the research nurses for the purpose of recording
demographic and clinical variables.
Data analysis
Demographic and clinical variables were grouped by type of
current treatment, and chi-squared (dichotomous variables) or t-
tests (continuous variables) were used to determine if differences
occurred that were due to different types of current treatment. The
mean scores for anxiety, depression and QOL were grouped by type
of current treatment, and a t-test performed. Chi-squared analysis
was used to examine whether there was a signicant relationship
between psychological symptoms and the type of cancer treatment
being received by the subjects. A general linear model (GLM) was
used to investigate whether the degree of QOL showed signicant
difference among participants with different psychological
W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 18
symptoms after adjustment for confounding variables. Interaction
effects between the dichotomous variables were examined, but
insignicant results were found.
The six dependent variables were the overall QOL, physical well-
being (PWB), social/family well-being (SFWB), emotional well-
being (EWB), functional well-being (FWB) and breast cancer
subscale (BCS). The two independent variables were the anxiety
(HAD-A) and depression (HAD-D) subscales of HADS. Confounding
variables for adjustment included age (continuous), stage of disease
(stage I, II or III), type of treatment (chemotherapy or radiotherapy),
and type of surgery received (mastectomy (MRM) or breast
conservation treatment (BCT)/breast reconstruction). A p-value of
0.05 or less was considered as statistically signicant.
Results
Recruitment and response
Subjects were recruited from an original study examining the
symptom cluster and QOL of breast-cancer patients undergoing
adjuvant therapy (So, 2007). The response rate then was about 80%
(283 out of 354). For the present paper, 218 of these patients took
part in a secondary analysis.
Patient characteristics
Information on demographic and clinical characteristics grou-
ped by type of cancer treatment is presented in Table 1. Overall, the
mean age was 51.7 (SD10.32) and the mean duration of illness
was 7.35 (SD16.02). A large number of the subjects were married
(77.1%), had completed a secondary education (64.7%), were not
employed (73.9%), did not have a family history of cancer, and had
undergone mastectomy (74.3%). More than half of the subjects were
diagnosed with stage II cancer (52.8%). There was no signicant
difference in the demographic and clinical characteristics of the
two groups (Table 1).
Prevalence of anxiety and/or depression
The percentage of participants suffering from anxiety, depres-
sion or both was compared with the type of current treatment
(Table 2). Signicance differences were found between anxiety and
type of treatment (c
2
6.56, p 0.01), and between depression
and treatment (c
2
7.26, p 0.007). More participants in the
chemotherapy group [n (%) 25 (19.2)] suffered from both anxiety
and depression than in the radiotherapy group [n (%) 9 (10.2)],
though no statistically signicant difference was found.
Effect of anxiety and/or depression on QOL
GLM was performed to examine whether the psychological
symptoms had signicant adverse effects on the overall QOL and
the ve domains of QOL (Table 3). Statistically signicant effects of
HAD-D were reported in all dependent variables after being
adjusted for age, stage of disease, type of treatment and type of
surgery. Participants with depression were signicantly associated
with poorer overall QOL (b 18.47, p <0.001) and all ve domains
of QOL (p 0.001). Statistically signicant effects of HAD-A were
reported in overall QOL (b 13.22, p <0.001), PWB (p 0.017),
EWB (p <0.001), FWB (p 0.044) and BCS (p <0.001). Participants
with anxiety were more likely to have poorer overall QOL and other
domains of QOL except SFWB. It was also found that participants
with both anxiety and depressionwould see a decrease of 31.6 units
in their overall QOL when compared with those in the non-case
anxiety or depression groups. See Table 3.
Table 1
Demographic and clinical characteristics of the participants grouped by types of cancer treatment (N218).
Characteristics All subjects Chemotherapy Radiotherapy c
2
p-value
N (%) N (%) N (%)
N (%) 218 (100) 130 (59.6) 88 (40.4)
Marital status Single/divorced/widowed 50 (22.9) 27 (20.8) 23 (26.1) 0.855 0.355
Cohabitation/married 168 (77.1) 103 (79.2) 65 (73.9)
Education levels No formal / primary 77 (35.3) 44 (33.8) 33 (37.5) 0.307 0.580
Secondary or above 141 (64.7) 86 (66.2) 55 (62.5)
Employment status Employed 49 (23.3) 28 (22.0) 21 (25.3) 0.297 0.586
Not employed 161 (73.9) 99 (78.0) 62 (74.7)
Monthly household income 10,000 87 (40.8) 51 (39.5) 36 (42.9) 1.444 0.486
10,00130,000 96 (44.0) 62 (48.1) 34 (40.5)
>30,000 30 (13.8) 16 (12.4) 14 (16.7)
Religious belief Yes 104 (47.7) 60 (46.2) 44 (50.0) 0.311 0.577
No 114 (52.3) 70 (53.8) 44 (50.0)
Stage of disease Stage I 33 (15.1) 17 (13.1) 16 (18.2) 1.359 0.507
Stage II 115 (52.8) 72 (55.4) 43 (48.9)
Stage III 70 (32.1) 41 (31.5) 29 (33.0)
Type of surgery received Mastectomy (MRM) 162 (74.3) 102 (78.5) 60 (68.2) 2.905 0.088
Breast conservation treatment
(BCT)/MRMbreast reconstruction
56 (25.7) 28 (21.5) 28 (31.8)
Family history of cancer Yes 24 (11.0) 10 (7.7) 14 (15.9) 3.616 0.057
No 194 (89.0) 120 (92.3) 74 (84.1)
Characteristics M (SD) M (SD) M (SD) t p-value
Age 51.70 (10.32) 50.99 (9.22) 52.75 (11.73) 1.179 0.240
Charlson index 2.12 (0.38) 2.08 (0.31) 2.17 (0.46) 1.535 0.127
Time since diagnosis (months) 7.35 (16.02) 6.70 (16.70) 8.31 (14.99) 0.727 0.468
Time since initial treatment started (weeks) 8.43 (50.52) 20.61 (62.91) 21.97 (22.27) 0.194 0.847
W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 19
Discussion
Prevalence of anxiety and/or depression
The results of the study showed that more than half of the
participants had anxiety or depression and 15.6% had both of these
psychological symptoms. The ndings reect those reported in
other studies (Hopwood et al., 2007; Takahashi et al., 2008), and
indicate the importance of assessing the mental health of such
patients throughout the process of cancer treatment. Since this
study excluded patients with a history of psychological disorder,
the symptoms of anxiety and depression are likely to be caused by
cancer or by its treatment. However, this study measured the
symptoms at one point in time. More research is needed to examine
the onset time of the symptoms, their causes and their patterns in
the whole process of cancer treatment.
The study found that the prevalence of psychological symp-
tom(s) was higher in those subjects undergoing chemotherapy
than in those receiving radiotherapy. Possible reasons include
severe treatment side-effects from chemotherapy (Rao et al., 2009)
and poorer self-esteem through side-effects involving changes in
physical appearance. Also, the main purpose of chemotherapy is to
reduce the risk of recurrence of cancer, whereas that of radio-
therapy is to eliminate localized cancer cells (National Cancer
Institute, 2002). Uncertainty about the recurrence of cancer in
patients undergoing chemotherapy may cause higher levels of
anxiety and depression (van den Beuken-van Everdingen et al.,
2008). Further studies are needed to investigate whether these
factors lead to anxiety and depression in the same patient
population.
Effect of anxiety and/or depression on QOL
A signicant relation was observed between the groups in their
overall and ve domain results on the FACT-B, except social/family
well-being. Participants with depression experienced overall
a poorer level of QOL and other domains of QOL than those in the
non-case group. Those in the anxiety case group had signicantly
poorer overall QOL, PWB, EWB, FWB and BCS than those in the non-
case group. The ndings provide evidence that psychological
symptoms could have profound effects on the physio-psycho-social
well-being of patients during cancer treatment.
The results of this study show that anxiety did not have
a signicant adverse effect on the SFWB of the participants. This
may be due to the provision of social and family support not being
affected by anxiety exclusively. In other words, when cancer
patients have adequate support from their family and friends,
healthcare professionals and the society around them, their SFWB
can be maintained.
Limitations
The cross-sectional design of this study provided information
about the prevalence of psychological symptoms at one point in
time. The pattern and intensity of the symptoms over time were not
evaluated. In future research, baseline data before treatment should
be collected so that whether or not the risk of anxiety or depression
is directly associated with cancer treatment can be investigated.
Also, longitudinal studies are recommended to capture more in-
depth information about the psychological symptoms experienced
Table 2
A comparison of anxiety and depression grouped by types of cancer treatment
(N218).
All subjects Chemotherapy Radiotherapy c
2
p-Value
N (%) N (%) N (%)
Anxiety Yes
a
46 (21.1) 35 (26.9) 11 (12.5) 6.56 0.010
No
b
172 (78.9) 95 (73.1) 77 (87.5)
Depression Yes
c
75 (34.4) 54 (41.5) 21 (23.9) 7.26 0.007
No
d
143 (65.6) 76 (58.5) 67 (76.1)
Anxiety and
depression
Yes
e
34 (15.6) 25 (19.2) 9 (10.2) 3.23 0.072
No
f
184 (84.4) 105 (80.8) 79 (89.8)
a
Anxiety subscale score >7.
b
Anxiety subscale score 7.
c
Depression subscale score >7.
d
Depression subscale score 7.
e
Anxiety subscale score >7 and depressive subscale score >7.
f
Anxiety subscale score 7 and/or depressive subscale score 7.
Table 3
Parameter estimates of the overall and ve domains of QOL
1
using GLM test.
QOL HADS
2
Beta SE t p-Value 95%CI
Overall QOL
a
HAD-A
3
cases 13.219 2.999 4.407 <0.001 19.131, 7.306
HAD-D
4
cases 18.465 2.634 7.010 <0.001 23.658, 13.272
Physical well-being
b
HAD-A cases 2.863 1.188 2.410 0.017 5.206, 0.521
HAD-D cases 4.725 1.044 4.528 <0.001 6.783, 2.668
Social/family well-being
c
HAD-A cases 0.923 0.995 0.928 0.354 1.038, 2.885
HAD-D cases 2.935 0.874 3.358 0.001 4.685, 1.212
Emotional well-being
d
HAD-A cases 5.523 0.788 7.008 <0.001 7.076, 3.969
HAD-D cases 3.992 0.692 5.768 <0.001 5.357, 2.628
Functional well-being
e
HAD-A cases 2.058 1.014 2.030 0.044 4.057, 0.059
HAD-D cases 3.945 0.891 4.430 <0.001 5.701, 2.190
Breast cancer subscale
f
HAD-A cases 3.698 0.873 4.237 <0.001 5.418, 1.977
HAD-D cases 2.867 0.767 3.741 <0.001 4.378, 1.356
Note.
1
Functional Assessment of Cancer Therapy for Breast Cancer (FACTdB)-Chinese version.
2
Hospital Anxiety and Depression Scales (HADS),
3
Anxiety subscale of HADS,
4
Depression subscale of HADS.
Inuence of signicance variables on the overall QOL and QOL domains after adjusted for age, stage of disease, types of current treatment and type of surgery received.
a
Adjusted R squared 0.403; corrected model: F 21.818, p <0.001.
b
Adjusted R squared 0.275; corrected model: F 12.690, p <0.001.
c
Adjusted R squared 0.391; corrected model: F 28.708, p <0.001.
d
Adjusted R squared 0.407; corrected model: F 22.210, p <0.001.
e
Adjusted R squared 0.193; corrected model: F 8.381, p <0.001.
f
Adjusted R squared 0.245; corrected model: F 11.020, p <0.001.
W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 20
by groups of cancer patients. This study only focused on examining
anxiety, depression and QOL. Other factors that may be associated
with the overall and other domains of QOL were not investigated.
This might in future be another research area helping to close the
knowledge gap.
Implications
The ndings of the study have several implications. In Chinese
culture, the virtues of tolerance and harmony are emphasized
(Bond, 1991). One of the characteristics of Chinese people is to avoid
extremes and maintain harmony through the balance of feelings
aroused (Wu, n.d.). Conicts should not therefore be openly
expressed, to maintain harmony between different people. Chal-
lenging an expert is inappropriate as this may induce conicts with
the expert (Chen, 2001). These cultural beliefs may inhibit Chinese
patients from openly expressing their queries and emotions to
healthcare professionals. Thus, it is vital to incorporate the
measurement of anxiety and depression in nursing assessment
procedures. Once psychological symptoms are detected, patients
can be referred to the clinical psychologist or psychiatrist promptly
for further examination.
Additionally, psychological symptoms may reduce the efcacy of
chemotherapy incases of breast cancer (Su et al., 2005). Although the
mechanism of how psychological distress alters the efcacy of the
treatment is poorly understood, evidence suggests that psychological
distress may cause stress which alters hormonal and neuronal
secretions and affects the biological activity of breast cancer cells
(Drell et al., 2003). Therefore, the early detection of psychological
symptoms and provision of effective symptom management may
well maintain the effectiveness of the cancer treatment.
Results can also help nurses to offer better support to breast-
cancer patients who are at risk of psychological symptoms during
the course of cancer treatment. For example, nurses may use the
ndings to tailor the information they provide to prepare patients
more adequately for treatment. Nurses can also perform symptom-
distress assessments periodically and implement effective
symptom-relieving strategies for those in need.
Conclusion
Anxiety, depression and QOL in patients undergoing chemo-
therapy or radiotherapy for breast cancer were examined in this
study. The prevalence of anxiety and/or depression was higher in
patients undergoing chemotherapy. The ndings provide evidence
that psychological symptoms have a detrimental effect on various
aspects of a patients QOL. Nurses awareness of the importance of
integrating psychological symptom assessment into their proce-
dures should therefore be increased, and their clinical sensitivity in
identifying high-risk groups of patients undergoing specic cancer
treatments should be enhanced.
Conict of interest statement
None of the authors have any conicts of interests.
Acknowledgements
The University of Hong Kong and the University of Colorado
funded this study. The authors would like to thank Prof Joan K.
Magilvy, Dr Paula Nelson-Martin, Dr Ellyn E. Mathews and Prof
Sarah H. Kagan for their valuable comments throughout the study;
Mr David Wong for assisting in data analysis; and the research
nurses and staff of the participating hospitals for supporting the
study.
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