Abstract
Objectives
To identify the subgroups of self-reported outcomes and associated factors among breast cancer patients undergoing surgery and chemotherapy.
Methods
A cross-sectional study was conducted between January and November 2021. We recruited patients from two tertiary hospitals in Shanghai, China, using convenience sampling during their hospitalization. Patients were assessed using a questionnaire that included sociodemographic and clinical characteristics, the Patient Reported Outcomes Measurement Information System profile-29 (PROMIS-29), and the PROMIS-cognitive function short form 4a. Latent class analysis was performed to examine possible classes regarding self-reported outcomes. Multiple logistic regression analysis was used to determine the associated factors. Analysis of variance (ANOVA) was conducted for symptoms across the different classes.
Results
A total of 640 patients participated in this study. The findings revealed three subgroups in terms of self-reported outcomes among breast cancer patients undergoing surgery and chemotherapy: low physical-social-cognitive function, high physical-low cognitive function, and high physical-social-cognitive function. Multivariable logistic regression analysis showed that age (≥ 60 years old), menopause, the third chemotherapy cycle, undergoing simple mastectomy and breast reconstruction, duration of disease 3–12 months, stage III/IV cancer, and severe pain were associated factors of the functional decline groups. Besides, significant differences in depression and sleep disorders were observed among the three groups.
Conclusions
Breast cancer patients receiving surgery and chemotherapy can be divided into three subgroups. Aging, menopause, chemotherapy cycle, surgery type, duration and stage of disease, and severe pain affected the functional decline groups. Consequently, healthcare professionals should make tailored interventions to address the specific functional rehabilitation and symptom relief needs.
Keywords: Breast neoplasms, Latent class analysis, Function, Surgery, Chemotherapy
What is known?
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Surgery and chemotherapy can result in varying degrees of functional impairment in patients with breast cancer.
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Nurses need to pay attention to functional clusters associated with breast cancer to guide timely care.
What is new?
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This study provides insights into the clusters of physical, social, and cognitive function in breast cancer patients who received both surgery and chemotherapy.
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The results indicate a need for tailored interventions targeting sociodemographic, clinical, and treatment-related factors in breast cancer patients to mitigate various functional impairments.
1. Introduction
Breast cancer is acknowledged as the most frequent disease among women worldwide [1]. Concurrently, with early detection and intervention, breast cancer survival rates have improved [2]. To better meet the preferences and needs of patients and to de-escalate treatment on the premise of ensuring safety, current breast cancer treatment leans more towards a multimodal approach that integrates surgery and systematic therapies [3,4]. The combination of chemotherapy and surgery is crucial in treating breast cancer [5,6]. Patients are more likely to choose surgical resection by either mastectomy or breast-conserving surgery before the onset of local symptoms [7]. Additionally, chemotherapy, especially neoadjuvant chemotherapy, has become a routine strategy for the treatment of operable breast cancer [8].
Some studies have demonstrated that surgery can result in varying degrees of functional impairment in patients with breast cancer [9,10]. Breast surgery has been perceived as negatively impacting social and physical function [10]. Furthermore, the situation differs for different types of surgery. For instance, patients treated with breast-conserving surgery have a higher level of social function than those treated with mastectomy alone in the long term [11]. Moreover, breast cancer patients typically experience chemotherapy-induced cognitive impairment manifesting as diminished attention, memory, and executive functioning [9].
Recently, advancements have been made in addressing symptom clusters associated with breast cancer. A research yielding 32 studies for inclusion, suggested that fatigue-sleep disturbance and psychological symptom clusters (anxiety, depression, nervousness, irritability, sadness, and worry) are the most commonly reported symptom clusters among breast cancer patients [12]. Nevertheless, these studies exhibit limitations in discerning high-risk individuals with diverse characteristics. In particular, they often concentrate on specific symptom clusters rather than comprehensively evaluate the patient’s functional status. This narrow focus constrains the depth of understanding regarding patient heterogeneity and consequently impedes the development of targeted interventions. The Patient-Reported Outcomes Measurement Information System (PROMIS) might guide healthcare providers to assess subjective functional status [13]. As opposed to examining heterogeneity in terms of only one property, latent class analysis (LCA) describes heterogeneity as differences between individuals for a set of criteria [14]. Furthermore, LCA is also useful for discovering hidden subgroups of individuals with distinct functional patterns that cannot be directly observed, and clinical decisions can be made more effectively by analyzing information about latent class membership risk characteristics [14].
Considering this, this study hypothesized that the physical, social, and cognitive function of breast cancer patients who received surgery and chemotherapy could be clustered into several categories. There are substantial demographic and clinical differences between them, which may help healthcare providers quickly identify patients with different physical, social, and cognitive functions. Based on this hypothesis, this study aimed to identify subgroups of physical, social, and cognitive function among breast cancer patients undergoing surgery and chemotherapy and to identify associated factors.
2. Methods
2.1. Study design
A cross-sectional study was conducted. The study was prepared and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklists [14].
2.2. Study samples
Patients were recruited using a convenience sampling method during their hospitalizations from two tertiary hospitals in Shanghai, China, between January and November 2021. The inclusion criteria were as follows: a) diagnosed with breast cancer undergoing surgery and chemotherapy; b) aged 18 or older; and c) participated in the study voluntarily and provided informed consent. Those patients with mental diseases, cognitive impairments, or trouble communicating in Mandarin were excluded from this study. Empirical evidence has demonstrated that LCA tends to yield more accurate and reliable results when the sample size is substantial, and there is a consensus that a sample size exceeding 500 participants is preferable for ensuring the robustness of the model and the fit statistics [15]. Considering the 20% rate of ineffective responses, the calculated sample size necessary for this study was 625 participants.
2.3. Study instruments
2.3.1. Sociodemographic and clinical characteristics questionnaire
The sociodemographic and clinical variables encompass the age, marital status, number of children, menstrual status, employment status, health insurance, cycles of chemotherapy, complications (lymphedema, wound infection, etc), cancer stage, type of surgery, disease duration, pain interference.
2.3.2. Patient Reported Outcomes Measurement Information System profile-29
The PROMIS profile comprises three distinct forms: PROMIS-29, PROMIS-43, and PROMIS-57. Among these, the PROMIS-29 is the most concise, making it the preferred choice for application in chronic diseases [16]. This study used the Chinese PROMIS-29 version 2.1, translated by Professor Yuan’s team at Fudan University [17]. The PROMIS-29 version 2.1 is a 29-item assessment tool that assesses seven domains: anxiety, depression, physical function, fatigue, sleep disturbance, ability to engage in social roles and activities, and pain interference and intensity. Except for a single item measuring pain intensity, all domains comprise four questions, which are responded to using a five-point Likert scale. The pain intensity is assessed with a 0–10 numeric rating scale ranging from 0 (without pain) to 10 (worst pain imaginable). Scores for each domain were summed and converted to T-scores (http://www.healthmeasures.net). A higher score indicates a greater magnitude of the concept being measured. The Cronbach’s α coefficient was 0.965 [17].
2.3.3. Patient Reported Outcomes Measurement Information System cognitive function short form 4a
The PROMIS cognitive function short form 4a was applied to assess the patient’s perceived cognitive disorders [18]. It consists of four items measured over seven days, each scored on a five-point Likert scale from 1 (very often) to 5 (never), with a raw score ranging from 4 to 20, and the scores were converted into T-scores. A higher score indicates better perceived cognitive function. The Cronbach’s α coefficient was 0.963 [18].
2.4. Data collection
Four trained researchers performed data collection. The researchers explained the survey’s purposes and procedures to participants and obtained written informed consent. Then, they distributed paper questionnaires, collected them immediately after completion, and checked for missing items. For any questions encountered by the participants, the researchers provided timely clarification to ensure the completeness and integrity of the data. All data are anonymous and not be disclosed only for this study. Furthermore, the participants can decline or drop out of the study at any time without consequence. Among the 667 participants, 27 were excluded due to missing information, and the final sample size included in this study was 640.
2.5. Statistical analysis
The statistical analyses were conducted using SPSS 25.0 and Mplus 8.0. Descriptive statistics included frequencies (n), percentages (%), mean, and standard deviations (SD). To classify the latent profiles of breast cancer patients who received surgery and chemotherapy, LCA was performed in this study. In our research, entropy, the Akaike information criterion (AIC), Bayesian information criterion (BIC), sample size-adjusted BIC, Lo-Mendell-Rubin (LMR) test, and bootstrap likelihood ratio test (BLRT) were used to determine the number of classes. Generally, a model with smaller AIC, BIC, and sample size-adjusted BIC values and a higher entropy value indicates a better fit. A lower information index value indicates a better fit [15]. In terms of entropy, a higher entropy value ensures a more precise classification. An entropy value of 0.8 or higher indicates a good classification [19]. The relative goodness of fit of the model was verified by testing it against the k potential and k-1 models. In the case of a significant P, the k potential model was supported, whereas, in the absence of a significant P, the k-1 latent profiles were supported. Additionally, the ratio of each class and its clinical interpretability were used to determine the number of latent classes.
After determining the optimal model, the chi-square test or Fisher’s exact probability method was used to examine latent class differences. A logistic regression model was constructed only with statistically significant variables. Finally, analysis of variance (ANOVA) was conducted for symptoms across the different classes. Statistical significance was determined by P < 0.05 (two-tailed test).
2.6. Ethical considerations
Research approval was obtained from the Ethics Committee of Fudan University Cancer Hospital (No. 1810192-22) and Fudan University Zhongshan Hospital (No. 2020-076).
3. Results
3.1. The participants’ characteristics
A total of 640 participants were included. The mean age of the participants was 48.84 ± 9.74, with a range of 24–83 years. Among them, 93.3% were married, and 21.4% were employed. Most (96.2%) had children and health insurance (93.9%). Regarding clinical characteristics, 76.4% of patients were diagnosed within one year, and only a tiny percentage of patients experienced complications (13.3%) or severe pain (1.7%).
3.2. Latent class analysis
Five-class models were examined to perform LCA. The development of the initial model is outlined in Table 1. The AIC, BIC, and aBIC values decreased as the included classes increased. The three-class model also showed the highest entropy value, which had more rigorous theoretical and clinical distinctions than the four-class model. Therefore, it was determined to be the best model. Fig. 1 shows the probability of a three-class model. The scores of each subgroup are shown in Table 2. Among them, patients in class 1 (20.7%) showed seriously lower physical, social, and cognitive functions, so it was named low physical-social-cognitive function. Class 2 (27.7%) was named high physical-low cognitive function because the score was high in physical function and lower in cognitive function. The scores of the three types of function in class 3 (51.6%) were relatively high, it was named. Among the various functions assessed, approximately 48.4% of women were likely to be classified within the impaired function subgroup.
Table 1.
Latent class model fit comparison.
| Fit indices | Class 1 | Class 2 | Class 3 | Class 4 | Class 5 |
|---|---|---|---|---|---|
| AIC | 10,093.7 | 6,068.3 | 5,275.3 | 4,882.4 | 4,700.4 |
| BIC | 10,147.2 | 6,179.8 | 5,444.9 | 5,109.9 | 4,985.9 |
| aBIC | 10,109.1 | 6,100.5 | 5,324.2 | 4,948.0 | 4,782.7 |
| LMR P | – | <0.001 | <0.001 | <0.001 | 0.023 |
| BLRT P | – | <0.001 | <0.001 | <0.001 | <0.001 |
| Entropy | – | 0.976 | 0.984 | 0.983 | 0.986 |
Note: AIC = Akaike information criterion. BIC = Bayesian information criterion. aBIC = Adjusted BIC. LMR = Lo-Mendell-Rubin. BLRT = Bootstrap Likelihood Ratio Test.
Fig. 1.
Distribution of the three latent classes.
Class 1 = low physical-social-cognitive function. Class 2 = high physical-low cognitive function. Class 3 = high physical-social-cognitive function. PF = physical function. SF = social function. CF = cognitive function.
Table 2.
Overall scores of the three classes in the physical, social, and cognitive functions.
| Items | Class 1 | Class 2 | Class 3 |
|---|---|---|---|
| Physical function | 31.03 ± 4.87 | 46.36 ± 5.49 | 45.50 ± 5.09 |
| Social function | 35.92 ± 6.85 | 50.47 ± 7.62 | 52.35 ± 7.09 |
| Cognitive function | 32.60 ± 6.91 | 37.71 ± 4.54 | 52.79 ± 6.15 |
Note: Data are Mean ± SD. Class 1 = low physical-social-cognitive function. Class 2 = high physical-low cognitive function. Class 3 = high physical-social-cognitive function.
3.3. Multivariate analysis of the three classes among breast cancer patients undergoing surgery and chemotherapy
The three classes differed in age, menstrual status, employment status, cancer stage, surgery type, disease duration, chemotherapy cycles, health insurance, and pain interference (P < 0.05) (Table 3). The multivariable logistic regression models were conducted using class 3 as the reference. As shown in Table 4, each variable was compared with odds ratios (ORs) and confidence intervals (CIs). The patients with breast cancer in class 1 were predominantly aged 60 or older (OR = 3.37, 95%CI = 1.39–8.12, P = 0.007) compared to class 3. They were more likely to be postmenopausal (OR = 1.81, 95%CI = 1.01–3.28, P = 0.048) and in the third cycle of chemotherapy (OR = 0.13, 95%CI = 1.09–6.73, P = 0.002). Additionally, they were significantly more likely to undergo simple mastectomy (OR = 5.68, 95%CI = 1.87–17.25, P = 0.002) and breast reconstruction (OR = 0.05, 95%CI = 0.01–0.22, P < 0.001) compared to modified radical mastectomy. Furthermore, there is a higher likelihood of having a disease duration of 3–6 months (OR = 3.19, 95%CI = 1.64–6.20, P < 0.001) and 6 months to 1 year (OR = 2.23, 95%CI = 1.08–4.61, P = 0.031) in class 1.
Table 3.
Comparision of the three classes by demographic and clinical characteristics.
| Characteristics | Total (n = 640) | Classification of latent classes |
χ2/F | P | ||
|---|---|---|---|---|---|---|
| Class 1 (n = 133) | Class 2 (n = 177) | Class 3 (n = 330) | ||||
| Age (years) | ||||||
| 18–44 | 206 (32.2) | 27 (20.3) | 65 (36.7) | 114 (34.5) | 20.3 | ＜0.001 |
| 45–59 | 353 (55.1) | 81 (60.9) | 84 (47.5) | 188 (57.0) | ||
| ≥ 60 | 81 (12.7) | 25 (18.8) | 28 (15.8) | 28 (8.5) | ||
| Marital status | ||||||
| Married | 597 (93.3) | 124 (93.2) | 162 (91.5) | 311 (94.2) | 1.4 | 0.507 |
| Unmarried/divorced/widowed | 43 (6.7) | 9 (6.8) | 15 (8.5) | 19 (5.8) | ||
| Number of children | ||||||
| 0 | 24 (3.8) | 7 (5.3) | 8 (4.5) | 9 (2.7) | 3.8 | 0.434 |
| 1 | 403 (63.0) | 83 (62.4) | 116 (65.5) | 204 (61.8) | ||
| ≥ 2 | 170 (33.2) | 43 (32.3) | 53 (30.0) | 117 (35.5) | ||
| Menstrual status | ||||||
| Premenopausal | 260 (40.6) | 40 (30.1) | 67 (37.8) | 153 (46.4) | 16.1 | 0.003 |
| Menopausal | 88 (13.8) | 21 (15.8) | 18 (10.2) | 49 (14.8) | ||
| Postmenopausal | 292 (45.6) | 72 (54.1) | 92 (52.0) | 128 (38.8) | ||
| Employment status | ||||||
| Employed | 137 (21.4) | 24 (18.1) | 37 (20.9) | 76 (23.0) | 77.7 | ＜0.001 |
| Medical leave | 121 (18.9) | 22 (16.5) | 23 (13.0) | 76 (23.0) | ||
| Unemployed/retired | 382 (59.7) | 87 (65.4) | 117 (66.1) | 178 (54.0) | ||
| Health insurance | ||||||
| Citizen program | 484 (75.6) | 99 (74.4) | 138 (78.0) | 247 (74.8) | 20.6 | ＜0.001 |
| Rural program | 117 (18.3) | 16 (12.0) | 35 (19.8) | 66 (20.0) | ||
| No health insurance | 39 (6.1) | 18 (13.6) | 4 (2.2) | 17 (5.2) | ||
| Chemotherapy cycle | ||||||
| The first cycle | 172 (26.9) | 39 (29.3) | 44 (24.9) | 89 (27.0) | 20.9 | 0.002 |
| The second cycle | 80 (12.5) | 18 (13.5) | 19 (10.7) | 43 (13.0) | ||
| The third cycle | 74 (10.0) | 3 (2.3) | 13 (7.3) | 48 (14.5) | ||
| The fourth cycle or above | 324 (50.6) | 73 (54.9) | 101 (57.1) | 150 (45.5) | ||
| Complications | ||||||
| Yes | 85 (13.3) | 17 (12.8) | 20 (11.3) | 48 (14.5) | 1.1 | 0.580 |
| No | 555 (86.7) | 116 (87.2) | 157 (88.7) | 282 (85.5) | ||
| Cancer stage | ||||||
| Ⅰ/Ⅱ | 241 (37.7) | 52(39.1) | 53(29.9) | 136(41.2) | 19.3 | 0.001 |
| Ⅲ/Ⅳ | 215 (33.6) | 46(34.6) | 81 (45.8) | 88(26.7) | ||
| Not clear | 184 (28.7) | 35(26.3) | 43(24.3) | 106(32.1) | ||
| Surgery type | ||||||
| Modified radical mastectomy | 283 (44.2) | 68 (51.2) | 95 (53.7) | 120 (36.4) | 76.4 | ＜0.001 |
| Breast-conserving surgery | 239 (37.3) | 49 (36.8) | 56 (31.6) | 134 (40.6) | ||
| Simple mastectomy | 37 (5.8) | 14 (10.5) | 18 (10.2) | 5 (1.5) | ||
| Breast reconstruction | 81 (12.7) | 2 (1.5) | 8 (4.5) | 71 (21.5) | ||
| Disease duration | ||||||
| ≤ 3 months | 191 (29.8) | 31 (23.3) | 40 (22.6) | 120 (36.4) | 44.9 | ＜0.001 |
| 3–6 months | 154 (24.1) | 47 (35.3) | 46 (26.0) | 61 (18.5) | ||
| 6 months–1 year | 144 (22.5) | 30 (22.6) | 60 (33.9) | 54 (16.3) | ||
| > 1 year | 151 (23.6) | 25 (18.8) | 31 (17.5) | 95 (28.8) | ||
| Pain interference | ||||||
| Mild limits (or normal) | 505 (78.9) | 104 (78.2) | 147 (83.0) | 254 (77.0) | 15.4 | 0.004 |
| Moderate | 124 (19.4) | 26 (19.5) | 23 (13.0) | 75 (22.7) | ||
| Severe | 11 (1.7) | 3 (2.3) | 7 (4.0) | 1 (0.3) | ||
Note: Data are n (%). Class 1 = low physical-social-cognitive function. Class 2 = high physical-low cognitive function. Class 3 = high physical-social-cognitive function.
Table 4.
Multivariate analysis of the three classes among breast cancer patients undergoing surgery and chemotherapy.
| Characteristics | β | SE | Wald χ2 | OR | 95%CI | P |
|---|---|---|---|---|---|---|
| Class 1 (ref.: Class 3) | ||||||
| Age (years) (ref.:18–44) | ||||||
| 45–59 | 0.473 | 0.302 | 2.457 | 1.61 | 0.89–2.90 | 0.117 |
| ≥ 60 | 1.215 | 0.451 | 7.272 | 3.37 | 1.39–8.12 | 0.007 |
| Menstrual status (ref.: premenopausal) | ||||||
| Menopausal | 0.23 | 0.37 | 0.382 | 1.26 | 0.60–2.64 | 0.537 |
| Postmenopausal | 0.60 | 0.30 | 3.915 | 1.81 | 1.01–3.28 | 0.048 |
| Chemotherapy cycle (ref.: first cycle) | ||||||
| The second cycle | 0.114 | 0.390 | 0.086 | 1.23 | 0.52–2.41 | 0.770 |
| The third cycle | −2.055 | 0.664 | 9.575 | 0.13 | 0.04–0.47 | 0.002 |
| The fourth cycle or above | −0.140 | 0.307 | 0.207 | 0.87 | 0.48–1.59 | 0.649 |
| Surgery type (ref.: modified radical mastectomy) | ||||||
| Breast-conserving surgery | −0.239 | 0.248 | 0.929 | 0.79 | 0.48–1.28 | 0.335 |
| Simple mastectomy | 1.738 | 0.566 | 9.411 | 5.68 | 1.87–17.25 | 0.002 |
| Breast reconstruction | −2.986 | 0.745 | 16.052 | 0.05 | 0.01–0.22 | ＜0.001 |
| Disease duration (ref.: ≤3 months) | ||||||
| 3–6 months | 1.159 | 0.339 | 11.677 | 3.19 | 1.64–6.20 | ＜0.001 |
| 6 months–1 year | 0.800 | 0.371 | 4.646 | 2.23 | 1.08–4.61 | 0.031 |
| > 1 year | 0.126 | 0.369 | 0.117 | 1.14 | 0.55–2.34 | 0.732 |
| Class 2 (ref.: Class 3) | ||||||
| Cancer stage (ref.: Ⅰ/Ⅱ) | ||||||
| Ⅲ/Ⅳ | 0.798 | 0.255 | 9.754 | 2.22 | 1.35–3.66 | 0.002 |
| Not clear | −0.045 | 0.274 | 0.027 | 0.96 | 0.56–1.64 | 0.870 |
| Surgery type (ref.: modified radical mastectomy) | ||||||
| Breast-conserving surgery | −0.437 | 0.232 | 3.564 | 0.65 | 0.41–1.02 | 0.059 |
| Simple mastectomy | 1.534 | 0.554 | 7.670 | 4.64 | 1.57–13.72 | 0.006 |
| Breast reconstruction | −1.844 | 0.416 | 19.689 | 0.16 | 0.07–0.36 | ＜0.001 |
| Disease duration (ref.: ≤3 months) | ||||||
| 3–6 months | 0.727 | 0.318 | 5.234 | 2.07 | 1.11–3.86 | 0.022 |
| 6 months–1 year | 0.929 | 0.319 | 8.472 | 2.53 | 1.36–4.74 | 0.004 |
| > 1 year | −0.261 | 0.335 | 0.604 | 0.77 | 0.40–1.49 | 0.437 |
| Pain interference (ref.: mild limits (or normal) | ||||||
| Moderate | −0.402 | 0.293 | 1.884 | 0.67 | 0.38–1.12 | 0.170 |
| Severe | 2.410 | 1.115 | 4.669 | 11.13 | 1.25–19.03 | 0.031 |
Note: Class 1 = low physical-social-cognitive function. Class 2 = high physical-low cognitive function. Class 3 = high physical-social-cognitive function.
The patients with breast cancer in class 2 were more likely to have stage III/IV cancer (OR = 2.22, 95%CI = 1.35–3.66, P = 0.002) relative to class 3. They also had a higher likelihood of undergoing simple mastectomy (OR = 4.64, 95%CI = 1.57–13.72, P = 0.006) and breast reconstruction (OR = 0.16, 95%CI = 0.07–0.36, P < 0.001). Additionally, patients diagnosed between 3 months and 6 months (OR = 2.07, 95%CI = 1.11–3.86, P = 0.022) and between 6 months and 1 year (OR = 2.53, 95%CI = 1.36–4.74, P = 0.0044) had significantly higher odds of being classified in class 2. Lastly, class 2 patients reported a higher rate of severe pain (OR = 11.13, 95%CI = 1.25–19.03, P = 0.031) compared to class 3.
3.4. Differences in symptom scores for different latent classes
As shown in Table 5, the average symptom outcome scores in different domains were all in the normal range according to the PROMIS score manual. Statistically significant differences were found for depression and sleep disturbance (P < 0.001).
Table 5.
Differences in symptom scores across different latent classes.
| Items | Class 1 | Class 2 | Class 3 | F | P |
|---|---|---|---|---|---|
| Anxiety | 53.61 ± 9.56 | 52.65 ± 9.83 | 51.82 ± 10.46 | 1.45 | 0.235 |
| Depression | 52.42 ± 9.51 | 50.83 ± 9.05 | 52.58 ± 8.45 | 2.41 | ＜0.001 |
| Fatigue | 50.21 ± 7.13 | 47.75 ± 7.56 | 50.58 ± 5.03 | 12.56 | 0.091 |
| Sleep disturbance | 52.96 ± 7.85 | 52.11 ± 8.92 | 47.06 ± 7.85 | 42.40 | ＜0.001 |
| Pain intensity | 1.87 ± 1.01 | 1.84 ± 1.86 | 1.76 ± 1.51 | 0.31 | 0.733 |
Note: Data are Mean ± SD. Class 1 = low physical-social-cognitive function. Class 2 = high physical-low cognitive function. Class 3 = high physical-social-cognitive function.
4. Discussion
4.1. The subgroups of functions among breast cancer patients receiving surgery and chemotherapy
The study identified three distinct subgroups categorized by levels of functional capacity: low physical-social-cognitive function, high physical-low cognitive, and high physical-social-cognitive function. Notably, 48.5% of the patients fell into the impaired function category, aligning with existing literature that emphasizes the profound and potentially disabling impact of surgery-related impairments across various aspects of breast cancer survivors’ lives [20]. Specifically, the class 1 subgroup presented with significantly diminished physical, social, and cognitive functions. In contrast, the class 2 subgroup exhibited relatively preserved physical function yet was marked by a notable decline in cognitive function. Conversely, the class 3 subgroup displayed relatively robust physical, social, and cognitive function, representing most of the study’s population. These findings underscore the heterogeneity in functional outcomes among breast cancer patients.
In this study, both subgroups (class 1 and class 2) demonstrated a significant prevalence of cognitive impairment, affecting 48.5% of the participants. This result is supported by a web-based survey, which found that the majority of patients (over 50%) experience cognitive decline post-chemotherapy [21]. Moreover, a substantial proportion of cancer patients (up to 75%) report enduring cognitive issues of varying severity long after treatment concludes [22]. In the context of breast cancer, cognitive complaints are notably the most commonly reported post-treatment challenge [23], underscoring the need for heightened awareness among healthcare providers. Cognitive impairments among cancer patients are typically manifested through deficits in memory, processing speed, attention, concentration, and executive functions [24]. While this study does not delve into the specifics of cognitive function impairment, the high prevalence observed underscores the necessity for further research. It is noteworthy that a subset of survivors has been identified to experience a confluence of physical, emotional, and cognitive symptoms [25]. Additionally, research has shown that breast cancer patients undergoing systemic treatments often face increased physical challenges, such as fatigue, alongside more significant cognitive difficulties and a decline in executive functioning [26]. This contrasts with the class 2 subgroup in our study, where despite better physical function, cognitive function was compromised. Our analysis defined physical function as the ability to engage in a spectrum of activities, from essential self-care to more demanding tasks requiring mobility, strength, and stamina [27]. It is crucial to recognize that a patient’s self-assessed physical capacity may not always align with their actual physical condition. For instance, patients might be physically capable of getting out of bed but may choose not to due to fatigue, which could account for the observed characteristics of the class 2 subgroup. This discrepancy highlights the complexity of physical and cognitive function interplay in breast cancer survivors and the importance of a nuanced approach to assessment and intervention.
4.2. Association between sociodemographic and clinical characteristics and different subgroups
Older patients were more likely to be categorized into the low-function classes, a finding consistent with previous research, which indicated that older individuals are at a higher risk of functional impairment following surgical interventions [28]. This susceptibility in older women may be attributed to a higher prevalence of comorbidities and a lower baseline functional status, suggesting that any type of surgery can significantly affect their postoperative functional capabilities [29]. A comprehensive review of the literature supports the notion that the physical function of older women tends to decline more rapidly and substantially after surgery when compared to younger patients [30]. Furthermore, the increased disease burden and frailty in older adults can reduce their likelihood of resuming preoperative physical activity levels [31]. Menstrual status also emerged as a significant predictor in our study, with postmenopausal patients exhibiting a higher likelihood of impaired physical, social, and cognitive functions. This aligns with existing evidence that menopausal status is a strong predictor of physical function, with premenopausal and perimenopausal women generally demonstrating better physical function [32]. Menstrual status also emerged as a significant predictor in our study, with postmenopausal patients exhibiting a higher likelihood of impaired physical, social, and cognitive functions. This aligns with existing evidence that menopausal status is a strong predictor of physical function, with premenopausal and perimenopausal women generally demonstrating better physical function [33]. Additionally, a study has shown that premenopausal breast cancer patients who underwent chemotherapy following mastectomy experienced significant impacts on their emotional well-being, which may subsequently affect their social function [34]. These findings underscore the importance for healthcare providers, particularly nurses, to monitor older women for signs of functional impairment closely and to provide targeted support.
Our study observed that a subset of patients experienced pain following breast cancer surgery, a finding that corroborates existing literature suggesting that pain can lead to temporary physical function impairments [35]. The intensity of postoperative pain also appears to be a significant factor explaining variability in functional outcomes among breast cancer survivors [36]. It is imperative for nursing professionals to enhance the management of postoperative pain by employing a variety of pain assessment tools and implementing tailored interventions based on the nature and severity of the pain experienced.
Additionally, evidence suggests that advanced cancer stages are predictive of reduced cognitive performance [37]. Patients with more severe cancer stages have been observed to exhibit diminished executive functions [38]. However, it is essential to note that impaired physical functioning in breast cancer survivors is not solely attributed to cancer-related factors; instead, it is often linked to the difficulty in performing routine daily activities [39]. The duration of the disease post-surgery also plays a significant role in postoperative functional outcomes, with patients who have been living with the disease for a period ranging from 3 months to a year being at an increased risk of experiencing physical, social, and cognitive function impairments. The interplay between cancer stage and postoperative functional status is complex and warrants further investigation, particularly in the context of the comprehensive impact on the various dimensions of patients’ function.
In the context of the impact of surgical approaches on patient outcomes, our study indicated that patients who underwent simple mastectomy were more prone to report diminished physical, social, and cognitive functioning. This finding aligns with existing literature, which generally reports more favorable psychosocial outcomes for individuals who receive breast-conserving surgery compared to those who undergo mastectomy [11]. Research has shown that at the one-year mark postoperatively, individuals who have breast-conserving surgery tend to exhibit superior physical and psychological well-being, along with better social functioning [40]. Given that breasts are often perceived as emblematic of femininity and sexuality, mastectomy can have a profound psychological and social impact, particularly on younger women. However, it is essential to note that some studies have not found significant disparities in physical, cognitive, or social functioning between those who have breast-conserving surgery and those who undergo mastectomy [32]. Regardless of the surgical method, our study, along with others, has identified chemotherapy as a significant factor influencing long-term functional outcomes for breast cancer survivors [41]. We found that patients had worse physical, social, and cognitive function during the third cycle of chemotherapy. According to an observational multicentre study, social function among elderly breast cancer patients undergoing chemotherapy deteriorates after 3 months due to chemotherapy-related side effects. However, the scores returned to baseline at 1 year [42]. In other studies, breast cancer patients’ memory, attention, executive function, and processing speed declined after conventional chemotherapy (one month after chemotherapy), with no significant change in overall cognitive function [43]. It is clear that surgery and chemotherapy are standard treatment methods for breast cancer patients, but their adverse effects are a cause for concern, and further research on them should be conducted.
Lastly, in our study, there were statistical differences in depression and sleep disorders by group. Study results suggest that patients with different cognitive functions suffer from different symptoms, such as depression, fatigue, and sleep disturbances [44]. Besides, social interaction predicted sleep disturbances in breast cancer chemotherapy patients [45]. However, these associations between personal psychology and physical function are not yet adequately investigated in breast cancer populations [46]. Given the complex context of cancer diagnosis and treatment, exploring the associations between related functions and symptoms is even more critical in this population.
4.3. Clinical implementations
This study highlights the critical role of early identification of risk factors in improving patient function. Nurses are the leading force in finding the risk factors in time as the person who has the most extended contact with patients. Exploring the subgroups of physical, social, and cognitive function among breast cancer patients receiving surgery and chemotherapy and the associated factors of patients in the subgroups could provide helpful information for the nurses to identify patients who are most likely to have low functions. Moreover, the results of this study also reminded us that patients’ functions may perform differently than analogously. So, targeted support needs to be provided to patients based on their specific deterioration in function. Finally, patients’ functions may gradually change across the disease treatment period. Hence, nurses are strongly recommended to follow patients as their function develops to ascertain their trajectory.
4.4. Limitations
There are some limitations in the study. First, the sociodemographic and clinical characteristics collected were inadequate, especially with few details on treatment. Second, patients’ functions change throughout the disease treatment period after cancer diagnosis. The present study is cross-sectional and cannot speculate the trajectory of patients’ function development. A longitudinal study is needed to explore the future developmental trend of patients’ functions. Lastly, his study concentrated on breast cancer patients who had received both chemotherapy and surgical interventions. We have overlooked the distinction between preoperative and postoperative chemotherapy. We will investigate this aspect through longitudinal research, which is crucial to understanding the relationship between functional impairment and various treatment modalities in breast cancer patients.
5. Conclusions
According to the study, breast cancer patients can be categorized into three distinct subgroups based on their physical, social, and cognitive functioning following surgery and chemotherapy: low physical-social-cognitive function, high physical-low cognitive function, and high physical-social-cognitive function. Furthermore, factors such as aging, menopause, and pain, among others, were found to influence the postoperative functional status of these patients. The identified subgroups have direct implications for clinical nursing practice. The low-function subgroup requires comprehensive support, including physical therapy and cognitive rehabilitation. The high physical-low cognitive subgroup benefits from targeted cognitive interventions, while the high-function subgroup can serve as a benchmark for recovery goals. Customizing care to address the distinct functional requirements of each subgroup while simultaneously prioritizing individuals at elevated risk can enhance patient outcomes and improve quality of life.
CRediT authorship contribution statement
Feixia Ni: Conceptualization, Methodology, Writing - original draft. Tingting Cai: Methodology, Data curation, Writing - review & editing. Tingting Zhou: Writing - review & editing. Changrong Yuan: Conceptualization, Methodology, Writing - original draft, Supervision, Writing - review & editing.
Data available statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Funding
This study was supported by the Hospital-level Nursing Research Project of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (xhhlcx2023-017); the third period of the 14th Five-Year nursing talent project of Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine (Xhlxm014); the Ministry of Education of Humanities and Social Science Project (23YJC630002) and High-level local university construction project founded by Shanghai Municipal Education Commission.
Declaration of competing interest
The authors declare that there are no conflicts of interest.
Footnotes
Peer review under responsibility of Chinese Nursing Association.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2024.12.007.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
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