Abstract
Purpose
The shared decision-making empowers breast cancer patients’ autonomy in joining treatment decision. However, unexpected side effects or unsatisfactory outcomes can lead to decision regret. This study examines decision regret levels and its relationship with quality of life, and the impact of mindfulness awareness and self-compassion on this relationship among early-stage breast cancer patients in post-treatment survivorship.
Methods
A cross-sectional study was conducted from March 2021 to March 2022. The early-stage breast cancer patients who completed treatments within the past 36 months were recruited from a medical center and a regional hospital. Participants completed the Decision Regret Scale, Mindful Awareness Attention Scale, Self-Compassion Scale, and the EORTC QLQ-C30 and QLQ-BR45.
Results
Among the 138 participants, 17.39 % reported no regret, 55.80 % expressed mild regret, and 26.81 % reported moderate to strong regret. Decision regret differed significantly based on the congruence between patients’ preferred and actual decision-making roles. Multiple regression analysis showed that, after controlling for covariates, lower decision regret levels were associated with higher EORTC QLQ-C30 and QLQ-BR45 function scores. Mindfulness awareness significantly mediated the relationship between decision regret and QOL, while self-compassion was not identified as a mediator.
Conclusion
Most breast cancer survivors experienced mild or moderate decision regret. Decision regret influences survivors’ general and breast specific functions. Mindfulness awareness could reduce the impact of decision regret on QOL. The mindfulness-based interventions could cultivate breast cancer patients living at the present moment experiences to reduce their negative rumination about the past treatment decision and enhance their QOL.
Keywords: Decision regret, Breast cancer, Mindfulness, Quality of life, Self-compassion
Highlights
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Most patients report mild or moderate decision regret.
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Decision regret influences the general and breast-specific quality of life.
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Mindfulness awareness reduces the impact of decision regret on QOL.
1. Introduction
Breast cancer treatments have contributed to high survival rates among patients in the early stages [1]. There is no significant difference in overall survival between mastectomy and breast-conserving surgery with radiation therapy [2]. Therefore, patients are encouraged to participate in the treatment decision-making process alongside clinicians, a practice known as shared decision-making (SDM). When breast cancer patients experience unexpected side effects or unsatisfactory outcomes, they are more likely to develop decision regret, which negatively affects their quality of life (QOL) [[3], [4], [5]]. Yamauchi et al. [6] found that early-stage patients (stage 0-II) were more likely to take active roles in decision-making than late-stage patients (stage III-IV) who faced the limited treatment options and intended to have their physicians make decision for them. The question remains not clear about to what extent the early-stage breast cancer patients experience decision regret at the post-treatment survivorship stage and how it influences their QOL. The recent review study found that the brief mindfulness intervention at perioperative period could enhance breast cancer patients' and surgeons’ well-being and surgical outcomes [7]. Nevertheless, few studies examine the role of mindfulness reducing the impact of decision regret on QOL among early-stage breast cancer survivors.
Decision regret is a psychological phenomenon integrating emotional and cognitive dimensions, occurring when individuals believe that an alternative decision might have yielded a better outcome [8,9]. Decision Justification Theory identifies two core components of decision-related regret: the comparative evaluation of outcomes and self-blame for poor choices [10]. Studies have indicated that 23.8 % and 51.4 % of breast cancer patients experienced decision regret [11,12]. The decision regret levels among breast cancer patients were primarily mild [3,13], while some expressed decision regret at moderate to strong level [5]. Regret can relate to the choice itself, the outcome of the choice, or the decision-making process, all of which affect future behaviors and decisions [[14], [15], [16]]. The preferences to participating in the treatment decision making were different among breast cancer patients [17]. Lam et al. [18] examined the congruence between preferred and actual levels in involving treatment decision-making process among breast cancer patients. The studies found that breast cancer women's participation preference and participation congruence were associated with their satisfaction with the treatment decision-making process [6,18]. The recent review study also revealed that the congruence between preference and actual participation was correlated with their decision regret [19]. Therefore, this congruence could continually play an important role in influencing decision regret.
A number of studies examined the correlations of decision regret with QOL (including the general QOL-physical, psychological and social holistic well-being, and the breast-specific QOL-the impact of breast cancer treatment on sexual well-being). Advani et al. [11] identified a correlation between decision regret and sexual well-being at six years post-diagnosis among older breast cancer patients. Zhuang et al. [5] found that patients who underwent mastectomy experienced higher levels of decision regret, which correlated with poorer holistic well-being. A recent study by Köksal et al. [3] revealed that patients with long-term side effects from adjuvant radiotherapy reported more regret at 14 months and 4 years of post-treatment and their regret correlated with lower QOL in aspect of psychological well-being. These findings consistently highlight the correlation between decision regret and QOL in overall holistic well-being, sexual well-being or psychological well-being among breast cancer patients at the post-treatment survivorship stage. About breast-specific QOL, the impacts of breast cancer and side effects of treatments on breast cancer patients’ functions and symptoms such as body image, breast satisfaction, arm symptoms, endocrine therapy symptoms, needs to be examined for their correlations with decision regret.
The individuals' psychological status influences the impact of regret distress on their psychological adjustment [9]. Mindfulness is defined as the awareness of the present moment experiences with non-judgement, non-reactivity and acceptance [20]. Garland et al. [21] proposed the mindfulness-to-meaning theory, which illustrates how cancer survivors' dispositional mindfulness influences the psychological state and QOL. According to this theory, patients with higher levels of mindfulness can be aware of the present moment experiences, decenter from stress, positively reappraise experiences, savor the present moment, find meaning in life, and ultimately reduce emotional distress while enhancing QOL. While the relationship between mindfulness and QOL has been widely studied for its emotional regulatory benefits [22], fewer studies have examined the role of mindfulness in reducing the impact of decision regret on cancer survivors’ QOL. The study on university students revealed that the guided mindfulness meditation significantly reduced the intensity of regretful emotions. The findings suggest that mindfulness could help individuals process regretful experiences by fostering self-acceptance and reducing negative rumination [23]. Accordingly, breast cancer patients with high mindfulness levels may less ruminate on past treatment decisions. To date, research on the relationship between decision regret, mindfulness, and QOL among breast cancer patients remains limited.
The correlations between decision regret, self-stigma, and QOL suggest that self-criticism may increase breast cancer patients' regret and reduce QOL [5]. In contrast to self-criticism, self-compassion may serve as a protective factor against emotional distress. Neff defined self-compassion as the ability to be kind to oneself during moments of suffering, adopting a nonjudgmental stance toward personal shortcomings, and recognizing that one's experiences are part of the shared human condition [24]. Gilbert similarly described self-compassion as a sensitivity to one's own suffering combined with a commitment to alleviate and prevent it [25]. Zhang and Chen found that self-compassion fosters acceptance of past regrets and promotes personal growth [26]. Herriot et al. [27] further examined how self-compassion influences emotional and physiological responses to age-related regret among older adults, finding a negative correlation between self-compassion and the intensity of regret. Although these studies highlight the importance of self-compassion in reducing regret, they primarily focus on general populations rather than cancer patients.
This study aims to examine (1) the levels of decision regret among breast cancer patients at the post-treatment survivorship stage, (2) the relationship between decision regret and QOL (general QOL-overall physical, emotional, and social function well-being, and breast-specific QOL-body image, sexual functioning, breast satisfaction, symptoms, and treatment-related side effects unique to breast cancer survivors), (3) the roles of mindfulness awareness and self-compassion in mediating the impact of decision regret on QOL among early-stage breast cancer patients.
2. Methods
2.1. Study design
A cross-sectional study was conducted from March 2021 to March 2022.
2.2. Study setting and sampling
Patients were recruited using purposive sampling from the breast surgery and oncology departments of a medical center and a regional hospital. Purposive sampling was used to allow us to intentionally select the adult participants who experienced treatment decision-making processes and might have the decision-regret experiences. The required minimum sample size of 127 for conducting multiple regression analysis was calculated by using G∗power software version 3.1.9.7. A total of 143 patients were recruited, and after excluding five who did not meet the inclusion criteria, the final sample size was 138 participants which achieved a sample power of 0.845.
2.3. Inclusion and exclusion criteria
The inclusion criteria were women who (1) aged 20 years and above diagnosed with primary stage 0-II breast cancer; (2) completed surgery, radiation, chemotherapy, or targeted therapy within the past 36 months and were undergoing regular follow-up. The exclusion criteria were (1) recurrent breast cancer, metastatic disease or a history of other malignancies; (2) severe cognitive impairment or psychiatric conditions that could affect questionnaire responses.
2.4. Instruments
2.4.1. Treatment decision-making role
The treatment decision-making role scale is developed and tested its validity among Chinese women with breast cancer by Lam et al. [18]. This scale consists of two items that assess the congruence between the breast cancer patients’ perceptions of their preferred role and their actual role in participating in treatment decision-making role.
2.4.2. Decision regret scale (DRS)
The 5-item DRS [28] assesses patients' experience of regret related to their breast cancer treatment decisions. This five-point Likert scale ranges from 1 (strongly agree) to 5 (strongly disagree) and is transformed into a 0 (no regret) to 100 (great regret) scale, with higher scores indicating greater levels of decisional regret. In this study, the Cronbach's alpha for the DRS was 0.76, indicating acceptable internal consistency. Decision regret levels [29] were classified as no regret (0), mild regret (1–25), and moderate to strong regret (26 and above).
2.4.3. Quality of life (QOL)
General QOL and Breast-specific QOL were measured using the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) [30] and its Breast Cancer Module (EORTC QLQ-BR45) [31]. The 30-items EORTC QLQ-C30 assesses physical, role, emotional, cognitive, and social functions and symptom distress, and a global health status. The 45-items EORTC QLQ-BR45 questionnaire assesses body image, sexual functioning, breast satisfaction, systemic therapy side effects, arm symptoms, breast symptoms, endocrine therapy symptoms, skin mucosa symptoms, and endocrine sexual symptoms. In addition, it includes single items assess sexual enjoyment, future perspective and being upset by hair loss. All scales and single-item measures are scored from 0 to 100, with higher scores indicating better functioning, higher QOL, or greater symptom burden. In this study, the Cronbach's alpha was 0.83 for the EORTC QLQ-C30 and 0.88 for the EORTC QLQ-BR45, indicating good internal consistency.
2.4.4. Mindful awareness attention scale (MAAS)
The 15-item MAAS [32] measures the frequency of mindful states in daily life using general and situation-specific statements. Responses are rated on a six-point Likert scale, ranging from 1 (almost always) to 6 (almost never), with higher scores indicating greater mindfulness. In this study, the Cronbach's alpha for the MAAS was 0.93, demonstrating excellent internal consistency.
2.4.5. Self-compassion scale (SCS)
The 13-item SCS [25] includes two subscales: the engagement subscale, which assesses an individual's sensitivity to and engagement with their own distress, and the action subscale, which evaluates their motivation to alleviate and prevent distress. Responses are rated on a 10-point Likert scale ranging from 1 (never) to 10 (always), with higher total scores indicating greater levels of self-compassion. In this study, the Cronbach's alpha for the SCS was 0.86, with 0.82 for the engagement subscale and 0.78 for the action subscale.
2.5. Data collection
Participants were identified through case managers who provided a list of eligible patients along with their scheduled clinical follow-up visits. The researcher or the trained research assistant then approached potential participants during their waiting times for clinical appointments. The researcher or research assistant introduced themselves, explained the study purpose and procedure. Moreover, participants were informed that the study adhered to the principles of voluntary participation, anonymity, and confidentiality.
The researcher or research assistant also explained to the participants that decision regret was a natural psychological response to the previous decision about the treatment, therefore, they were encouraged to express their thoughts and feelings about their decision-making experiences in the questionnaires. After participants provided their written consent form, they were invited to complete a paper-based questionnaire. For those who had difficulty reading or understanding the questions in the questionnaires, the research team provided assistance by reading the questions and explaining unclear items to ensure that all participants fully understood the questionnaire content before completing it.
2.6. Data analysis
Univariate analyses were conducted using t-tests and ANOVA to compare differences in decision regret and QOL based on demographic and clinical variables. Variables with significant differences in the univariate analysis were included as covariates in multiple linear regression analyses, along with main variables of decision regret, QOL, mindfulness and self-compassion. The significant levels for all statistical tests were set at p < 0.05 for two-tailed tests. A series of mediation analyses were conducted using PROCESS v4.0 for SPSS.
3. Results
3.1. Characteristics of participants
The demographic and clinical characteristics of the 138 participants are showed in Table 1. The mean age of participants was 56.5 years, ranging from 32 to 82 years. Over half of the participants held a bachelor's degree (52.17 %) and were employed (55.8 %). The majority were married (73.91 %) and identified with a religious affiliation (76.09 %). More than 70 % of the participants were diagnosed with stage I or II breast cancer. All participants received surgery, with over 50 % receiving breast conserving surgery. The average time since completing treatment was 1.55 years, ranging from 0.11 to 2.46 years.
Table 1.
Demographic and clinical characteristics of participants.
| Variables |
Number |
Percentage |
|---|---|---|
| Age (mean/SD) | 56.50 | 9.62 |
| Education | ||
| ≤ High school | 66 | 47.83 % |
| > Bachelor | 72 | 52.17 % |
| Employed status | ||
| Yes | 77 | 55.80 % |
| No | 61 | 44.20 % |
| Religion | ||
| Yes | 105 | 76.09 % |
| No | 33 | 23.91 % |
| Marital status | ||
| Single | 14 | 10.14 % |
| Married | 102 | 73.91 % |
| Divorced | 12 | 8.70 % |
| Widowed | 10 | 7.25 % |
| Family cancer history | ||
| Yes | 78 | 56.52 % |
| No | 60 | 43.48 % |
| Breast cancer stage | ||
| Stage 0 | 36 | 26.09 % |
| StageⅠ | 56 | 40.58 % |
| StageⅡ | 46 | 33.33 % |
| Surgery type | ||
| Breast Conserving Surgery (BCS) | 71 | 51.45 % |
| Modified Radical Mastectomy (MRM) | 67 | 48.55 % |
| Types of treatments | ||
| Surgery | 138 | 100.00 % |
| Chemotherapy | 67 | 48.55 % |
| Radiation treatment | 90 | 65.22 % |
| Target Therapy | 13 | 9.42 % |
| Hormone treatment | 118 | 85.51 % |
| Time since diagnosis (year) (mean/SD) | 2.00 | 0.35 |
| Time since surgery (year) (mean/SD) | 1.92 | 0.37 |
| Time since complete treatment (year) (mean/SD) | 1.55 | 0.47 |
3.2. The treatment decision-making role
Among the participants, 60.14 % preferred to play a collaborative role in treatment decision-making. The 77.54 % perceived that they participated in treatment decisions as much as they wanted, which referred to as “decision-making role congruence” while 20.29 % reported the decisions not as much as they want as “decision-making role incongruence.”
3.3. Decision regret
The mean DRS score was 20.94 (SD = 15.34, range 0–75). Based on the three levels of decision regret defined by Sheehan et al. [29], 17.39 % of participants reported no decision regret. The 55.80 % had mild regret, and 26.81 % experienced moderate to strong regret. There was a significant difference in decision regret between participants with decision-making role congruence or incongruence (t = −2.480, p = 0.018). Participants who experienced congruence between their preferred and actual decision-making roles were less likely to feel regret compared to those who reported incongruence.
3.4. The associations of decision regret, mindfulness awareness attention and self-compassion with general and breast cancer-specific QOL
Table 2 indicated that decision regret was correlated with global health status, QLQ-C30 functions and symptoms, and QLQ-BR45 functions but not correlated with QLQ-BR45 symptoms. Table 3 indicated the findings of multiple regression analysis for the main factors associated with general and breast-specific QOL. In the univariable analysis, EORTC QLQ-C30 functions were significantly different across types of surgery (t = 2.120, p = 0.036). In multiple regression analysis, the type of surgery, decision regret, mindful awareness attention and self‐compassion action accounted for 20.1 % of the variance in EORTC QLQ-C30 functions (F4,133 = 9.624, p < 0.001). Specifically, lower decision regret (β = −0.211, t = −2.605, p = 0.010) and higher mindful awareness attention (β = 0.300, t = 3.820, p < 0.001) were associated with better EORTC QLQ-C30 functions. The decision regret, mindful awareness attention and self‐compassion action accounted for 16.2 % and 13.8 % of the variance in global health status and EORTC QLQ-C30 symptoms (F3,134 = 9.830, p < 0.001; = 8.341, p < 0.001). Specifically, higher mindful awareness attention was associated with better global health status (β = 0.323, t = 4.023, p < 0.001) and lower EORTC QLQ-C30 symptoms (β = −0.339, t = −4.168, p < 0.001).
Table 2.
Descriptive statistics and correlations among the main study variables.
| Variable | Mean | SD | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1.Decision Regret | 20.94 | 15.34 | |||||||||
| 2. Mindful Awareness Attention | 4.69 | 0.86 | −0.207a | ||||||||
| 3.Self‐Compassion/Engagement | 50.28 | 12.77 | −0.101 | −0.054 | |||||||
| 4.Self‐Compassion/Action | 33.67 | 8.08 | −0.276b | 0.135 | 0.566b | ||||||
| 5.EORTC QLQ-C30 Global health status/QoL | 70.47 | 19.69 | −0.240b | 0.369c | 0.052 | 0.215a | |||||
| 6.EORTC QLQ-C30 Functions | 86.62 | 11.90 | −0.317c | 0.372c | −0.008 | 0.213a | 0.399c | ||||
| 7.EORTC QLQ-C30 Symptoms | 14.95 | 10.39 | 0.168a | −0.368c | −0.031 | −0.182a | −0.456c | −0.765c | |||
| 8.EORTC QLQ-BR45 Functions | 43.83 | 13.26 | −0.310c | 0.214a | −0.049 | 0.105 | 0.226b | 0.424c | −0.336c | ||
| 9.EORTC QLQ-BR45 Symptoms | 15.93 | 9.92 | 0.141 | −0.334c | 0.091 | 0.011 | −0.233b | −0.547c | 0.615c | −0.337c | |
| 10.AGE | 56.50 | 9.62 | 0.132 | 0.158 | −0.129 | −0.160 | −0.032 | −0.014 | 0.082 | −0.111 | −0.058 |
| 11.Time since diagnosis (year) | 2.00 | 0.35 | 0.035 | −0.001 | 0.025 | 0.091 | −0.082 | −0.110 | 0.046 | 0.056 | −0.013 |
| 12.Time since surgery (year) | 1.92 | 0.37 | 0.052 | 0.013 | 0.009 | 0.083 | −0.112 | −0.120 | 0.029 | 0.068 | −0.048 |
| 13.Time since complete treatment (year) | 1.55 | 0.47 | −0.018 | 0.073 | 0.063 | 0.100 | −0.067 | 0.033 | −0.039 | 0.186a | 0.011 |
p < 0.05.
p < 0.01.
p < 0.001.
Table 3.
Results of multiple regression of EORTC-QLQ-C30 and EORTC-QLQ-BR45.
| R2 | EORT C QL Q -C3 0 Global health status/QoL |
EORTC QLQ-C30 Functions |
EORTC QLQ-C30 Symptoms |
EORTC QLQ-BR45 Functions |
EORTC QLQ-BR45 Symptoms |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| 16.2 %c |
20.1 %c |
13.8 %c |
20.7 %c |
10.4 %b |
||||||
| B(SE) | β | B(SE) | β | B(SE) | β | B(SE) | β | B(SE) | β | |
| Covariates | ||||||||||
| Type of Surgery MRM (reference group) BCS |
– | – | 2.958 (1.834) | 0.124 | – | – | 7.006 (2.060) | 0.264c | – | – |
| Decision-making role Incongruence (reference group) Congruence |
– | – | – | – | – | – | 4.110 (2.551) | 0.129 | – | – |
| Time since complete treatment | – | – | – | – | – | – | 5.439 (2.179) | 0.192a | – | – |
| Main factors | ||||||||||
| Decision Regret | −0.175 (0.106) | −0.136 | −0.164 (0.063) | −0.211a | 0.044 (0.057) | 0.065 | −0.192 (0.072) | −0.222b | 0.062 (0.055) | 0.097 |
| Mindful Awareness Attention | 7.383 (1.835) | 0.323c | 4.152 (1.087) | 0.300c | −4.093 (0.982) | −0.339c | 1.749 (1.211) | 0.113 | −3.753 (0.957) | −0.325c |
| Self‐Compassion Action | 0.326 (0.199) | 0.134 | 0.165 (0.117) | 0.112 | −0.152 (0.106) | −0.118 | 0.008 (0.131) | 0.005 | 0.100 (0.104) | 0.082 |
Note: MRM = Modified Radical Mastectomy; BCS=Breast Conserving Surgery.
p < 0.05.
p < 0.01.
p < 0.001.
In the univariable analysis, EORTC QLQ-BR45 functions differed significantly by type of surgery (t = 3.871, p < 0.001) and decision-making role (t = 2.696, p = 0.008), and were correlated with time since treatment completion. In multiple regression analysis, type of surgery, decision-making role, time since treatment completion, decision regret, mindful awareness, and self-compassion accounted for 20.7 % of the variance in EORTC QLQ-BR45 functions (F6,131 = 6.963, p < 0.001). Specifically, breast conserving surgery (β = 0.264, t = 3.401, p < 0.001) and lower decision regret (β = −0.222, t = −2.671, p = 0.009) were associated with better EORTC QLQ-BR45 functions. The decision regret, mindful awareness attention and self‐compassion action accounted for 10.4 % of the variance in EORTC QLQ-BR45 symptoms (F3,134 = 6.286, p = 0.001). Specifically, higher mindful awareness attention (β = −0.325, t = −3.923, p < 0.001) was significant with less EORTC QLQ-BR45 symptoms.
In summary, decision regret was associated with both QLQ-C30 and QLQ-BR45 functions. Mindfulness awareness attention was associated with global health status, QLQ-C30 functions and symptoms, and QLQ-BR45 symptoms but not associated with QLQ-BR45 functions. Self-compassion was not significantly associated with any QOL. The mediation analysis was conducted to identify the impacts of mindfulness awareness attention on the relationships between decision regret and both general and breast-specific QOL.
3.5. Mediation analysis
Fig. 1, Fig. 2 shows that mindful awareness attention partially mediated the relationship between decision regret and global health status, between decision regret and EORTC QLQ-C30 functions. Fig. 3 shows that mindful awareness attention fully mediated the relationship between decision regret and EORTC QLQ-C30 symptoms.
Fig. 1.
The mediation effect of mindful awareness attention between decision regret and EORTC QLQ-C30 Global health status/QoL Indirect effect of decision regret to mindful awareness attention on Global health status/QoL wasβ = −0.089 (95%CI = −0.184 to −0.019).
Fig. 2.
The mediation effect of mindful awareness attention between decision regret and EORTC QLQ-C30 Functions Indirect effect of decision regret to mindful awareness on EORTC QLQ-C30 Functions wasβ = −0.051 (95%CI = −0.117 to −0.010).
Fig. 3.
The mediation effect of mindful awareness attention between decision regret and EORTC QLQ-C30 Symptoms Indirect effect of decision regret to mindful awareness on EORTC QLQ-C30 Symptoms was β = 0.049 (95%CI = 0.011 to 0.107).
4. Discussion
In our study, 17.39 % of breast cancer patients reported no regret while 55.80 % reported mild regret, and 26.81 % experienced moderate to strong regret. This study and the previous study found over fifty percent of breast cancer patients experienced mild regret. However, the median regret score (25.0 vs. 10.0) and percentage of moderate to strong regret (26.81 % vs. 13.9 %) differed from Köksal et al. [3], likely due to 81.4 % of their participants undergoing breast-conserving surgery. Different from our findings, Zhuang et al. [5] reported the majority of patients (61.2 %) experienced moderate to strong regret among breast cancer women. The discrepancy may be related to differences in cancer stages and the types of surgery. In our study, participants were stage 0 to II breast cancer, whereas Zhuang's study included stage III patients. Moreover, over 50 % of patients in our study received breast-conserving surgery, compared to only 21 % in Zhuang's study. Advanced cancer stages have been linked to higher levels of decision regret, particularly with more invasive surgeries like mastectomies. Women may experience decision regret when they feel uncertain after making a choice, questioning whether the selected surgery was the best option [5,12,15,16,33,34]. In addition to disease and treatment factors, our study supports findings from previous research that suggest patients whose decision-making roles match their preferences are less likely to experience regret [12,34]. These findings highlight the importance of matching patients' participation in treatment decisions with their preferences to reduce decision regret.
In our study, decision regret was significantly correlated with EORTC QLQ-C30 global health status and functions, as well as EORTC QLQ-BR45 functions. Consistent with previous studies, the findings demonstrate the direct impact of decision regret on general and breast specific QOL among breast cancer patients [3,5,11]. In the multiple regression model, in addition to lower levels of decision regret, higher mindful awareness attention was significantly associated with better EORTC QLQ-C30 functions. Further mediation analysis revealed that mindful awareness attention could reduce the impact of decision regret on global health status and general functions. According to the mindfulness-to-meaning theory proposed by Garland [21], cancer patients with higher levels of mindfulness can remain aware of the present moment experiences, decenter from stress, assess positive information to foster reappraisal, savor the present moment, find meaning in life, and ultimately reduce emotional distress while enhancing QOL. Accordingly, mindfulness awareness and attention to the present moment living experiences might shift breast cancer patients’ focus away from ruminating on past treatment choices and amplify positive life experiences.
Our study showed that decision regret was not associated with EORTC QLQ-C30 symptoms. However, the mediation analysis revealed that the impact of decision regret on general symptoms was mainly through mindfulness awareness attention. Individuals practicing mindfulness can perceive and accept the present moment without becoming overly absorbed in negative self-evaluations or worries [24]. Our findings suggest that mindfulness may reduce breast cancer patients' over-identification with regret-related experiences, thereby diminishing the impact of regret feelings and thoughts on the general symptoms. In our study, not the decision regret but mindfulness awareness attention was associated with QLQ-BR45 symptoms. The findings also demonstrate the significant role of mindfulness awareness attention in reducing self-absorbing breast-related symptoms.
In our study, self-compassion did not serve as a mediator in the relationship between decision regret and QOL while breast cancer patients' mindfulness awareness at present-moment experiences plays a key role in mitigating the negative impact of decision regret on QOL. Self-compassion refers to an individual's sensitivity to and engagement with their distress and their motivation to alleviate or prevent it. The findings suggest that actively guiding patients' engagement with their decision regret distress unlikely reduce decision regret. Instead, cultivating breast cancer patients' mindfulness awareness at the present-moment living experiences is important to reduce the impact of decision regret on QOL.
This study has several limitations. The findings of our study focusing on early-stage breast cancer (stage 0-II) in Chinese society could not be generalized to the patients with advanced cancer stages or diverse demographic and cultural backgrounds. The future study may include diverse cancer stages and backgrounds to provide a broader understanding of decision regret and QOL among patients with different social and cultural contexts. In our study, the youngest participant was 32 years old and the mean ages of our study were 56.5 years old ranging from 32 to 82 years. This reflects epidemiological trends in globally: Breast cancer also mainly occurs in middle-aged and older women [35]. This study found that there was no any relationship between ages with the levels of decision regret. The future studies might explore the differences in experiencing decision regret with a qualitative approach. This study is not a prospective design therefore, the recall bias might occur. Moreover, the cross-sectional design limits our ability to confirm causal relationships between decision regret, mindfulness, self-compassion, and QOL. The self-reported questionnaires did not provide survivors’ in-depth explanations of their decision regret experiences such as their coping mechanisms they employed. To address the limitations, future studies could adopt the prospective longitudinal design with the mixed-methods approach by incorporating qualitative interviews to provide deeper insights into patients' lived experiences. This approach would provide a more comprehensive understanding of how decision regret occurs over time, patients cope with decision regret, and decision regret influences their general and breast-specific QOL, and mindfulness awareness at the present-moment experiences reduce decision regret. Despite these limitations, decision regret is a persistent emotional response, therefore, the findings of this study could present to what extent the early-stage breast cancer patients remain these feelings and thoughts during the post-treatment survivorship stage. Moreover, to the best of our knowledge, this is the first study to explore the mediating roles of mindfulness awareness and self-compassion on the impacts of decision regret on QOL among women with early-stage breast cancer.
About the clinical implications, firstly, about the decision making process, clinical caregivers could do the assessments (1) breast cancer patients’ preferences to participating in the treatment decision making and enhancing the congruence between preferred and actual levels in involving treatment decision-making process; (2) decision regret levels after treatments and their impacts on general and breast-specific QOL. Secondly, clinical caregivers could also provide a mindfulness awareness training at time of guiding breast cancer patients join the decision-making process and at the post-treatment survivorship stage in order to help patients understand inner voice of their needs for making the appropriate treatment decision and reduce their regret after decision.
5. Conclusion
Most patients experienced mild or moderate decision regret, which was negatively associated with QOL. Mindfulness awareness reduces the impact of decision regret on QOL. These findings suggest the potential benefits of mindfulness-based interventions in cultivating breast cancer patients to live at the present moment experiences to reduce their negative rumination about the past treatment decision and enhance their QOL.
CRediT authorship contribution statement
Yu-Ling Kao: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Ming-Shen Dai: Investigation. Wan-Chen Tsai: Investigation. Fei-Hsiu Hsiao: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Formal analysis, Conceptualization.
Data availability statement
The data that support the findings of this study are available on request from the corresponding author.
Ethical approval
This study was approved by the Institutional Review Board of Tri-Service General Hospital, National Defense Medical Center (TSGHIRB No.:C202105040).
Declaration of generative ai and ai-assisted technologies in the writing process
During the preparation of this work, the authors used ChatGPT in order to improve language clarity and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Funding
This study was supported by a grant from Taoyuan Armed Forces General Hospital (TYAFGH-D-110037).
Declaration of competing interest
All authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgements
We are grateful to the participants for participating in this study.
Contributor Information
Yu-Ling Kao, Email: ling4086@yahoo.com.tw.
Ming-Shen Dai, Email: dms1201@gmail.com.
Wan-Chen Tsai, Email: greenmai2013@gmail.com.
Fei-Hsiu Hsiao, Email: hsiaofei@ntu.edu.tw.
References
- 1.American Cancer Society Survival rates for breast cancer. 2024, January 17. https://www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-survival-rates.html
- 2.Rajan K.K., Fairhurst K., Birkbeck B., Novintan S., Wilson R., Savović J., Holcombe C., Potter S. Overall survival after mastectomy versus breast-conserving surgery with adjuvant radiotherapy for early-stage breast cancer: meta-analysis. BJS Open. 2024;8(3):zrae040. doi: 10.1093/bjsopen/zrae040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Köksal M., Hoppe C., Schröder A.-K., Scafa D., Koch D., Sarria G.R., Leitzen C., Abramian A., Kaiser C., Faridi A., Henkenberens C., Schmeel L.C., Giordano F.A. Decision regret in breast cancer patients after adjuvant radiotherapy. Breast. 2023;68:133–141. doi: 10.1016/j.breast.2023.01.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Liu J., Chan S.W., Guo D., Lin Q., Hunter S., Zhu J., Lee R.L.T. Decision-making experiences related to mastectomy: a descriptive qualitative study. J Adv Nurs. 2024;80(5):1967–1983. doi: 10.1111/jan.15948. [DOI] [PubMed] [Google Scholar]
- 5.Zhuang H., Wang L., Yu X., Chan S.W., Gao Y., Li X., Gao S., Zhu J. Effects of decisional conflict, decision regret and self‐stigma on quality of life for breast cancer survivors: a cross‐sectional, multisite study in China. J Adv Nurs. 2022;78(10):3261–3272. doi: 10.1111/jan.15250. [DOI] [PubMed] [Google Scholar]
- 6.Yamauchi K., Nakao M., Nakashima M., Ishihara Y. Congruence between preferred and actual participation roles increases satisfaction with treatment decision making among Japanese women with breast cancer. Asian Pac J Cancer Prev APJCP. 2017;18(4):987–994. doi: 10.22034/APJCP.2017.18.4.987. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Palmer Kelly E., McGee J., Klatt M., Beckers G., Pawlik T.M. The use of brief mindfulness interventions in the context of perioperative care. Am Surg. 2024;90(6):1657–1665. doi: 10.1177/00031348241230092. [DOI] [PubMed] [Google Scholar]
- 8.Landman J. Regret: a theoretical and conceptual analysis. Journal for the Theory of Social Behavior. 1987;17(2):135–160. doi: 10.1111/j.1468-5914.1987.tb00092.x. [DOI] [Google Scholar]
- 9.Zeelenberg M., Pieters R. A theory of regret regulation 1.0. J Consum Psychol. 2007;17(1):3–18. doi: 10.1207/s15327663jcp1701_3. [DOI] [Google Scholar]
- 10.Connolly T., Zeelenberg M. Regret in decision making. Curr Dir Psychol Sci. 2002;11(6):212–216. doi: 10.1111/1467-8721.00203. [DOI] [Google Scholar]
- 11.Advani P.G., Lei X., Swanick C.W., Xu Y., Shen Y., Goodwin N.A., Smith G.L., Giordano S.H., Hunt K.K., Jagsi R., Smith B.D. Local therapy decisional regret in older women with breast cancer: a population-based study. Int J Radiat Oncol Biol Phys. 2019;104(2):383–391. doi: 10.1016/j.ijrobp.2019.01.089. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Yamauchi K., Nakao M., Nakashima M. Correlates of regret with treatment decision-making among Japanese women with breast cancer: results of an internet-based cross-sectional survey. BMC Womens Health. 2019;19(1):86. doi: 10.1186/s12905-019-0783-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Karuturi M.S., Lei X., Shen Y., Giordano S.H., Swanick C.W., Smith B.D. Long-term decision regret surrounding systemic therapy in older breast cancer survivors: a population-based survey study. Journal of geriatric oncology. 2019;10(6):973–979. doi: 10.1016/j.jgo.2019.04.011. [DOI] [PubMed] [Google Scholar]
- 14.Connolly T., Reb J. Regret in cancer-related decisions. Health Psychol. 2005;24(4):29–34. doi: 10.1037/0278-6133.24.4.S29. https://psycnet.apa.org/doi/10.1037/0278-6133.24.4.S29 [DOI] [PubMed] [Google Scholar]
- 15.Tyner T.E., Freysteinson W.M. A concept analysis of decision regret in women with breast cancer. Nurse Forum. 2022;57(1):112–120. doi: 10.1111/nuf.12642. [DOI] [PubMed] [Google Scholar]
- 16.Szproch A.K., Maguire R. A systematic review of the factors associated with regret post-cancer treatment. J Psychosoc Oncol. 2022;40(1):1–25. doi: 10.1080/07347332.2020.1844846. [DOI] [PubMed] [Google Scholar]
- 17.Degner L.F., Kristjanson L.J., Bowman D., Sloan J.A., Carriere K.C., O'Neil J., Bilodeau B., Watson P., Mueller B. Information needs and decisional preferences in women with breast cancer. JAMA. 1997;277(18):1485–1492. doi: 10.1001/jama.277.18.1485. [DOI] [PubMed] [Google Scholar]
- 18.Lam W., Fielding R., Chan M., Chow L., Ho E. Participation and satisfaction with surgical treatment decision-making in breast cancer among Chinese women. Breast Cancer Res Treat. 2003;80(2):171–180. doi: 10.1023/A:1024568732213. [DOI] [PubMed] [Google Scholar]
- 19.Liu J., Hunter S., Lee R.L.T., Zhu J., Chan S.W.-C. Decision regret about treatment amongst women with early breast cancer: an integrative review. J Adv Nurs. 2025;0:1–25. doi: 10.1111/jan.16767. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kabat-Zinn J. Piatkus Books; London, England: 1994. Mindfulness meditation for everyday live. [Google Scholar]
- 21.Garland E.L., Thielking P., Thomas E.A., Coombs M., White S., Lombardi J., Beck A. Linking dispositional mindfulness and positive psychological processes in cancer survivorship: a multivariate path analytic test of the mindfulness‐to‐meaning theory. Psychooncology. 2017;26(5):686–692. doi: 10.1002/pon.4065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Lin L.-Y., Lin L.-H., Tzeng G.-L., Huang Y.-H., Tai J.-F., Chen Y.-L., Wu C.-J., Chen P.-H., Hung P.-L. Effects of mindfulness-based therapy for cancer patients: a systematic review and meta-analysis. J Clin Psychol Med Settings. 2022;29(2):432–445. doi: 10.1007/s10880-022-09862-z. [DOI] [PubMed] [Google Scholar]
- 23.Oviedo E.M., Snapp S.B., Kazanecki G., Pedigo T., Karadgon F. The effects of mindfulness on regret: an explorative analysis. GSU Research Day. 2023;12 https://opus.govst.edu/research_day/2023/poster/12 [Google Scholar]
- 24.Neff K.D. The development and validation of a scale to measure self-compassion. Self Identity. 2003;2(3):223–250. doi: 10.1080/15298860309027. [DOI] [Google Scholar]
- 25.Gilbert P., Catarino F., Duarte C., Matos M., Kolts R., Stubbs J., Ceresatto L., Duarte J., Pinto-Gouveia J., Basran J. The development of compassionate engagement and action scales for self and others. Journal of Compassionate Health Care. 2017;4(1):1–24. doi: 10.1186/s40639-017-0033-3. [DOI] [Google Scholar]
- 26.Zhang J.W., Chen S. Self-compassion promotes personal improvement from regret experiences via acceptance. Pers Soc Psychol Bull. 2016;42(2):244–258. doi: 10.1177/0146167215623271. [DOI] [PubMed] [Google Scholar]
- 27.Herriot H., Wrosch C., Gouin J.P. Self-compassion, chronic age-related stressors, and diurnal cortisol secretion in older adulthood. J Behav Med. 2018;41(6):850–862. doi: 10.1007/s10865-018-9943-6. [DOI] [PubMed] [Google Scholar]
- 28.Brehaut J.C., O'Connor A.M., Wood T.J., Hack T.F., Siminoff L., Gordon E., Feldman-Stewart D. Validation of a decision regret scale. Med Decis Mak. 2003;23(4):281–292. doi: 10.1177/0272989x03256005. [DOI] [PubMed] [Google Scholar]
- 29.Sheehan J., Sherman K.A., Lam T., Boyages J. Association of information satisfaction, psychological distress, and monitoring coping style with post-decision regret following breast reconstruction. Psychooncology. 2007;16(4):342–351. doi: 10.1002/pon.1067. [DOI] [PubMed] [Google Scholar]
- 30.Aaronson N.K., Ahmedzai S., Bergman B., Bullinger M., Cull A., Duez N.J., Filiberti A., Flechtner H., Fleishman S.B., de Haes J.C.J.M., Kaasa S., Klee M., Osoba D., Razavi D., Rofe P.B., Schraub S., Sneeuw K., Sullivan M., Takeda F. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. JNCI: Journal of the National Cancer Institute. 1993;85(5):365–376. doi: 10.1093/jnci/85.5.365. [DOI] [PubMed] [Google Scholar]
- 31.Bjelic-Radisic V., Cardoso F., Cameron D., Brain E., Kuljanic K., da Costa R.A., Conroy T., Inwald E.C., Serpentini S., Pinto M., Weis J., Morag O., Lindviksmoen Astrup G., Tomaszweksi K.A., Pogoda K., Sinai P., Sprangers M., Aaronson N., Velikova G.…Bottomley A. An international update of the EORTC questionnaire for assessing quality of life in breast cancer patients: EORTC QLQ-BR45. Ann Oncol. 2020;31(2):283–288. doi: 10.1016/j.annonc.2020.02.001. [DOI] [PubMed] [Google Scholar]
- 32.Brown K.W., Ryan R.M. The benefits of being present: mindfulness and its role in psychological well-being. Journal of personality and social psychology. 2003;84(4):822–848. doi: 10.1037/0022-3514.84.4.822. [DOI] [PubMed] [Google Scholar]
- 33.Lee W.Q., Tan V.K.M., Choo H.M.C., Ong J., Krishnapriya R., Khong S., Tan M., Sim Y.R., Tan B.K., Madhukumar P., Yong W.S., Ong K.W. Factors influencing patient decision-making between simple mastectomy and surgical alternatives. BJS Open. 2019;3(1):31–37. doi: 10.1002/bjs5.50105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Wang A.W.-T., Chang S.-M., Chang C.-S., Chen S.-T., Chen D.-R., Fan F., Antoni M.H., Hsu W.-Y. Regret about surgical decisions among early‐stage breast cancer patients. Psychooncology. 2018;27(2):508–514. doi: 10.1002/pon.4522. [DOI] [PubMed] [Google Scholar]
- 35.American Cancer Society Key statistics for breast cancer. 2025. https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-cancer.html
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.