Analysis of alexithymia and resilience levels in young breast cancer patients following modified radical mastectomy

Abstract

Objective

This study aims to investigate the correlation between alexithymia and resilience levels in young breast cancer patients after undergoing modified radical mastectomy.

Methods

A prospective study was conducted on 70 young breast cancer patients, who were categorized based on the Toronto Alexithymia Scale-20 (TAS-20) scores into: non-alexithymia group (n = 24); moderate alexithymia group (n = 32); and severe alexithymia group (n = 14). The Toronto Alexithymia Scale-20 (TAS-20) and the Connor-Davidson Resilience Scale (CD-RISC) were utilized for evaluation to analyze the relationship between alexithymia and resilience levels post-modified radical mastectomy.

Results

In this study, the CD-RISC scores for the non-alexithymia group were 85.32 ± 7.65, for the moderate alexithymia group were 72.45 ± 8.32, and for the severe alexithymia group were 58.96 ± 9.13. The differences in CD-RISC scores among the three groups were statistically significant (P < 0.001), with the scores decreasing from the non-alexithymia group to the moderate and then to the severe group. Correlation analysis showed a negative correlation between the total and dimensional scores of TAS-20 and the total and dimensional scores of CD-RISC (-0.667 < r<-0.200, P < 0.05).

Conclusion

Young breast cancer patients exhibit a moderate level of alexithymia post-modified radical mastectomy, which negatively correlates with their level of psychological resilience. Clinically, appropriate intervention measures can be implemented based on the patients’ conditions to enhance their psychological resilience and alleviate alexithymia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-026-04422-8.

Introduction

Breast cancer remains the most prevalent malignant tumor among women. Cancer data from 2020 revealed that breast cancer fatalities represented 22% of all cancer deaths among women in 2017 [1]. Notably, the incidence of breast cancer among young women is on the rise, making it a primary cause of cancer death in this demographic [2].

Treatment for breast cancer typically involves surgical resection as the primary method, supplemented by chemotherapy, radiotherapy, targeted therapy, and endocrine therapy. Surgery is a key component of the comprehensive treatment for breast cancer [3], including mastectomy and lymph node surgery [4]. Currently, common breast surgery techniques include conventional breast-conserving surgery, oncoplastic breast-conserving surgery, total mastectomy, and breast reconstruction post-mastectomy [4, 5]. In China, the breast conservation rate is relatively low (14.6%-21.9%) [6], with approximately 70% of breast cancer surgery patients undergoing mastectomy, and breast reconstruction post-mastectomy occurring in approximately 10% of cases. Modified radical mastectomy (MRM) remains the most common surgical procedure for breast cancer in China [7, 8]. This phenomenon is thought to be attributable to several factors, including the smaller breast size observed in Chinese women, a scarcity of resources for the administration of radiation therapy, and the entrenched traditional beliefs regarding cancer prevalent among Chinese patients. These beliefs persist despite the increasing proportion of patients diagnosed at earlier stages, a trend facilitated by heightened public awareness and the advancement of screening programs [7]. The surgical scope of MRM includes the complete removal of the nipple-areola complex and all breast tissue, with lymph node dissection varying according to the stage of the disease [9]. The dissection range of the skin flap extends from the clavicle to the upper margin of the rib cage, medially to the sternum, and laterally to the anterior edge of the latissimus dorsi muscle [10], accompanied by the severance of numerous small blood vessels and lymphatics [11]. The surgery is associated with significant trauma, including a substantial potential cavity between the skin flap and chest wall, leading to a higher risk of postoperative complications, such as impaired wound healing [12]. Additionally, the absence or altered morphology of the breast can exert considerable psychological pressure and feelings of inferiority on young breast cancer patients [13], impacting their quality of life.

Psychological resilience, a concept in positive psychology, is defined as the ability of individuals to cope with and adapt to loss, hardship, or adversity effectively [14]. Studies have confirmed the importance of psychological resilience in fostering patients’ beliefs in overcoming cancer. Adequate psychological preparation and a positive mindset enable them to face the disease, cooperate with treatment willingly, and positively impact daily activities [15], thereby enhancing their quality of life.

Alexithymia, introduced in the 1960s and also known as “inability to express emotions” or “alexithymic syndrome,” is characterized by a lack of ability to verbally express emotions, limited imagination, a pragmatic approach to thinking, a focus on the minutiae of external events, difficulty distinguishing emotional states from physical sensations, and reluctance to discuss inner feelings [16]. Most research suggests that difficulty in identifying and describing emotions and a restricted imaginative life are primary features of alexithymia [17], with externally oriented thinking as a secondary feature [18]. Studies have linked alexithymia to psychological health, environmental factors, and a variety of somatic and mental illnesses. Alexithymia in breast cancer patients not only impacts their psychological health but also impacts the treatment and recovery of the disease [19].

All of the above studies have indicate that both psychological resilience and alexithymia are crucial factors affecting the daily lives of breast cancer patients. While studies on alexithymia among breast cancer patients are available both domestically and internationally, research specifically addressing the correlation between alexithymia and psychological resilience in young breast cancer patients following modified radical mastectomy is limited. Therefore, this study aims to figure out the current state of alexithymia and psychological resilience in young breast cancer patients post-MRM and to investigate the correlation between the two, providing a reference for promoting their physical and mental health through targeted psychological interventions.

Study subjects and methods

Study subjects

In this study, 70 young breast cancer patients admitted to the Affiliated Hospital of Hebei Engineering University in Hebei Province from December 2020 to December 2022 were prospectively enrolled as study subjects. Patients were categorized based on the Toronto Alexithymia Scale-20 (TAS-20) scores [20] into: non-alexithymia group (n = 24, score < 60), moderate alexithymia group (n = 32, score 61–74), and severe alexithymia group (n = 14, score > 75). The inclusion criteria were as follows: (1) aged 18 to 35 years; (2) pathologically diagnosed with breast cancer and had undergone modified radical mastectomy; (3) presenting unilateral primary lesions; (4) diagnosed with breast cancer for the first time, with patients and their families being aware of the diagnosis; (5) being conscious and capable of normal communication; and (6) having complete clinical data and follow-up records. The exclusion criteria were as follows: (1) patients with bilateral breast cancer; (2) those who were pregnant or breastfeeding; (3) those with functional impairments of major organs or tissues such as the brain, heart, or kidneys; (4) those with a history of psychiatric disorders or other aggressive malignant diseases such as tumors; and (5) those with severe communication disorders. This study was approved by the hospital’s ethics committee, with the ethical approval number 2021[K]087, and all participating patients signed informed consent forms.

Quality control

To ensure the rigor and reliability of the study, strict inclusion and exclusion criteria were applied to the selected patients. Initially, all patients were confirmed to have breast cancer via pathological examination and had undergone modified radical mastectomy. Secondly, patients with other severe diseases or mental disorders were excluded to ensure the singularity and accuracy of the study. Additionally, the follow-up records of selected patients were carefully reviewed to ensure the completeness and reliability of their data.

Data collection

Data collected included general patient data, Toronto Alexithymia Scale-20 (TAS-20) scores, and Connor Davidson-Resilience Scale (CD-RISC) scores one day post-surgery. General data comprised age, marital status, educational level, employment status, living conditions, breast cancer site, tumor staging, cancer pain level, medical payment, sleep-wakefulness, and neoadjuvant chemotherapy.

The Twenty-item Toronto Alexithymia Scale (TAS-20), developed by Taylor et al. [21] and translated by Yi Jin Yao et al. [22], consists of 20 items across three dimensions: difficulty identifying feelings (7 items), difficulty describing feelings (5 items), and externally-oriented thinking (8 items). It uses a Likert 5-point scale, where 1 point indicates “strongly disagree” and 5 points indicate “strongly agree,” with some items scored in reverse (items 4, 5, 10, 18, 19). The total score ranges from 20 to 100, with higher scores indicating greater levels of alexithymia. The scale’s Cronbach’s α reliability coefficient is 0.861.

The Connor Davidson-Resilience Scale (CD-RISC) was used in its Chinese version revised by Yu Xiaonan and Zhang Jianxin [23] in 2007. The scale measures psychological resilience across three dimensions: tenacity, strength, and optimism, with a total of 25 items. It employs a Likert 5-point scale, ranging from “not true at all” to “true nearly all the time,” scored from 0 to 4, with a total score ranging from 0 to 100. Higher scores indicate higher levels of psychological resilience. The overall Cronbach’s α coefficient of the scale is 0.882.

Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) [24], which covers seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, sleep medication usage, and daytime dysfunction. The total score is the sum of scores from these seven areas, ranging from 0 to 21. Higher scores indicate poorer sleep quality, categorized as follows: 0–5 indicates good sleep quality; 6–10 indicates fairly good sleep quality; 11–15 indicates average sleep quality; 16–21 indicates poor sleep quality.The overall Cronbach’s α coefficient of the scale is 0.769.

The Visual Analogue Scale (VAS) was used to assess pain levels in three treatment groups post-treatment, with scores directly correlating with the intensity of pain. A score of 0 indicates no pain, up to a maximum of 10. Scores of ≤ 3 indicate mild pain, 4–6 moderate pain, and ≥ 7 severe pain [25].

To guard against type-I error when correlating the three TAS-20 sub-scales with the three CD-RISC sub-scales (9 tests), we applied Bonferroni correction: the threshold was set at p < 0.05; all originally reported correlations remained significant after adjustment.

Statistical analysis

All data were statistically analyzed using the SPSS 26.0 software (SPSS Inc., Chicago, IL, USA). The normality of data was tested using the Kolmogorov-Smirnov (K-S) method. Measurement data conforming to normal distribution were expressed as mean ± standard deviation (x̄ ± s), and comparisons among multiple groups were performed using one-way ANOVA, with pairwise comparisons conducted using the SNK method. Enumeration data were presented as frequency (n) or percentage (%), with the χ² test applied if conditions were met, otherwise, Fisher’s exact test was used. Correlation analysis was conducted using Pearson’s correlation analysis. A two-tailed P value < 0.05 was deemed indicative of statistical significance.

To guard against type I error inflation due to multiple testing, we applied a Bonferroni correction for the nine correlations between the three TAS-20 subscales (difficulty identifying feelings, difficulty describing feelings, externally-oriented thinking) and the three CD-RISC subscales (optimism, strength, tenacity). The corrected significance level was set at P < 0.05/9 ≈ 0.0056. For all other correlations (e.g., involving total scores), an uncorrected P < 0.05 was considered indicative of statistical significance, but the exact p-values are reported to allow readers to interpret the findings.

Results

General information

The results revealed 24 cases in the non-alexithymia group with an average age of 31.22 ± 3.55 years; 32 cases in the moderate alexithymia group with an average age of 32.04 ± 3.12 years; and 14 cases in the severe alexithymia group with an average age of 31.34 ± 3.36 years. No statistically significant differences were observed among the groups in terms of age, marital status, income, etc. (P > 0.05), as shown in Table 1.

Table 1.

Comparison of general data

Item	Non-alexithymia group (n = 24)	Moderate alexithymia group (n = 32)	Severe alexithymia group (n = 14)	P value
Age	31.22 ± 3.55	32.04 ± 3.12	31.34 ± 3.36	0.212
Marital status				1.000*
Married	20	26	11
Unmarried	3	4	2
Other	1	2	1
Per capita monthly income				0.985*
< 2000	2	3	1
2000 ~ 4000	10	14	5
> 4000	12	15	8
Educational level				0.974*
Primary school or below	3	4	2
Junior high school	5	7	2
High school/Vocational school	7	11	6
College degree or above	10	10	4
Employment status				1.000*
Employed	23	30	13
Unemployed	1	2	1
Living conditions				0.462*
Urban	14	21	11
Rural	10	11	3
Breast cancer site				0.523
Left	13	17	5
Right	11	15	9
Tumor staging				0.368*
I	6	9	3
II	12	13	10
III	6	10	1
Pain level				0.269*
Mild	3	2	1
Moderate	20	26	9
Severe	1	4	4
Medical payment methods				1.000*
Health Insurance	20	27	12
Self-pay	4	5	2
Neoadjuvant chemotherapy				1.000*
Yes	21	27	12
No	3	5	2
Sleep quality				0.156*
Good	3	4	1
Fair	20	23	8
Poor	1	5	5

*: Fisher’s exact test was used

CD-RISC scores

In this study, the CD-RISC scores were 85.32 ± 7.65 for the non-alexithymia group, 72.45 ± 8.32 for the moderate alexithymia group, and 58.96 ± 9.13 for the severe alexithymia group. No statistically significant difference was observed in terms of CD-RISC scores among the three groups (P < 0.001); further pairwise comparisons showed that the CD-RISC scores decreased from the non-alexithymia group to the moderate alexithymia group, and then to the severe alexithymia group.

Correlation between alexithymia and various dimensions of psychological resilience

Pearson’s correlation analysis was used to examine the relationships between the dimensions of alexithymia and psychological resilience. The results, including exact p-values, are presented in Table 2. The total score of alexithymia and its three dimensions were negatively correlated with the total CD-RISC score and its three dimensions, with correlation coefficients ranging from r = − 0.667 to − 0.166. All correlations with the total scores remained significant at P < 0.001. However, after applying the Bonferroni correction for the nine subscale-to-subscale comparisons (adjusted threshold P < 0.0056), none of the individual subscale correlations reached statistical significance, although several were significant at the uncorrected P < 0.05 level (e.g., optimism with difficulty describing feelings, r = − 0.258, P = 0.031; strength with difficulty identifying feelings, r = − 0.297, P = 0.013). The strong negative correlation between the total alexithymia score and the total psychological resilience score (r = − 0.667, P < 0.001) remained highly significant even after correction for all 16 tests (adjusted α = 0.05/16 = 0.003125). These findings indicate that while the overall constructs are robustly associated, the relationships among specific facets are weaker and should be interpreted with caution.

Table 2.

Correlation between dimensions of alexithymia and psychological resilience

Dimension	Score	Difficulty Identifying Feelings	Difficulty Describing Feelings	Externally-Oriented Thinking	Total Alexithymia Score
Score	—	21.13 ± 4.35	13.87 ± 2.26	23.18 ± 3.27	58.17 ± 6.45
Optimism	8.53 ± 2.88	–0.200 (0.097)	–0.258 (0.031)	–0.292 (0.014)	–0.310 (0.009)
Strength	18.02 ± 6.37	–0.297 (0.013)	–0.239 (0.046)	–0.209 (0.083)	–0.400 (< 0.001)
Tenacity	29.96 ± 10.54	–0.229 (0.057)	–0.203 (0.092)	–0.166 (0.170)	–0.337 (0.004)
Total CD-RISC score	56.51 ± 18.33	–0.488 (< 0.001)	–0.366 (0.002)	–0.416 (< 0.001)	–0.667 (< 0.001) ‡

Data are presented as Pearson correlation coefficients r (two-tailed P value in parentheses)

The Bonferroni correction for the nine subscale‑to‑subscale comparisons (difficulty identifying feelings, difficulty describing feelings, externally‑oriented thinking vs. optimism, strength, tenacity) sets the significance threshold at P < 0.0056

None of the individual subscale correlations reached this corrected level

The correlation marked with ‡ (total alexithymia vs. total resilience) remained significant even after correcting for all 16 tests (adjusted α = 0.05/16 = 0.003125)

All other correlations with P < 0.05 (uncorrected) are shown in bold, but should be interpreted cautiously due to the risk of type I error

Discussion

Modified radical mastectomy (MRM) is a prevalent clinical approach for managing breast cancer, which can extend the survival period of patients. However, this procedure frequently results in complications such as upper limb edema and upper arm dysfunction, causing trauma and severe postoperative pain to the body. It results in the loss of secondary female characteristics, severely damaging body image and leading to negative emotions that affect recovery outcomes. Postoperative breast cancer patients not only suffer from the loss of physical image and functional integrity but also experience impacts on marital relationships, leading to feelings of inferiority and a series of psychological issues, forming a vicious cycle [26].

Our findings reveal that the psychological resilience score of 70 young breast cancer patients post-surgery was 56.51 ± 18.33, which is lower than that of gynecological cancer patients (60.1) [27]. The reason might be that breast cancer patients, compared to gynecological cancer patients, directly suffer from impaired limb function and external image due to surgery, which more readily elicits negative emotional reactions. Among the three dimensions of psychological resilience in this study, tenacity scored the highest, while optimism scored the lowest. This is consistent with the findings of Siegel RL et al. [28], suggesting that young breast cancer patients possess significant endurance and strength to confront hardships, and they can quickly recover and become stronger after experiencing hardships. The lowest average score for optimism might be due to young breast cancer patients having a worse prognosis compared to older patients, higher expectations for disease prognosis, and returning to family and work, lacking confidence in overcoming the disease, worrying about prognosis and recurrence, and generating negative emotions, unable to control the adverse effects brought by the disease effectively. Research [29] shows that psychological resilience is not innate but can be improved through interventions and training. Psychological resilience can reduce patients’ anxiety and depression, showing more confidence and hope in facing life’s challenges and difficulties. Therefore, it is necessary to pay timely attention to the psychological resilience level of young breast cancer patients and develop intervention measures to enhance their disease coping ability.

The study shows that the total alexithymia score in patients after radical mastectomy was (58.17 ± 6.45), which was at a moderate level, indicating that patients experience a certain degree of alexithymia following radical mastectomy. This score is slightly higher than the results of Wang Xumei’s study [30], possibly because the subjects in this study were all female, who are more emotional and sensitive, unable to regulate their psychology well when facing setbacks, and easily produce negative emotional responses. The highest average score among the items of difficulty identifying feelings is similar to the results of Jiang Yunqin et al. [31], possibly because radical mastectomy causes changes in the body image of breast cancer patients, making them more sensitive to their physical defects and easily interpreting others’ casual remarks as insults.

Further correlation analysis revealed a negative relationship between the dimensions of alexithymia and psychological resilience in young breast cancer patients post-modified radical mastectomy (P < 0.05). It is evident that improving the psychological resilience level of young breast cancer patients after modified radical mastectomy is beneficial in alleviating their alexithymia. Integrating resilience-targeted care into the standard MRM pathway is therefore warranted. A practical package would start with a single 20-minute pre-operative session in which the nurse screens alexithymia (TAS-20) and introduces a brief expressive-writing leaflet; continue with two facilitator-led couples sessions during the first post-operative month to rehearse emotion-talk and body-image coping; and finish by auto-inviting patients ≤ 35 y to a moderated WeChat peer-group that meets weekly for 6 weeks. Concurrently, family members are advised to offer emotional support to help patients adjust their mental outlook, proactively express their inner emotions, and alleviate alexithymia. This approach is expected to improve negative emotional states, actively engage in postoperative treatment, and facilitate the healing process.

Nonetheless, this study is not without its limitations. The included patients all come from a single hospital, which has regional and personnel restrictions. There are issues with a small sample size, short study duration, and limited participant diversity, which necessitates expanding the number and scope of samples and extending the study period for deeper observations.

Conclusion

To conclude, young breast cancer patients exhibit a moderate level of alexithymia post-modified radical mastectomy, which negatively correlates with their level of psychological resilience. Clinically, appropriate intervention measures can be implemented based on the patients’ conditions to enhance their psychological resilience and alleviate alexithymia.

Abbreviations

CD-RISC

Connor-Davidson Resilience Scale

MRM

Modified radical mastectomy

PSQI

Pittsburgh Sleep Quality Index

TAS-20

Toronto Alexithymia Scale-20

VAS

Visual Analogue Scalea

Authors' contributions

Study design: He RJ, Su YC, Hu XX, Gao LM, Wu AL, Xing Y, Zhang J, Du BData acquisition: He RJ, Su YC, Hu XX, Gao LM, Wu AL, Xing Y, Zhang J, Du BData analysis and interpretation: He RJ, Su YC, Hu XX, Gao LM, Wu AL, Xing YManuscript preparation: He RJ, Su YC, Hu XX, Gao LM, Wu AL, Xing YCritical revision of the manuscript for intellectual content: Zhang J, Du BManuscript review: He RJ, Su YC, Hu XX, Gao LM, Wu AL, Xing Y, Zhang J, Du BObtaining financing: Zhang J.

Funding

Not applicable.

Data availability

Data will be made available on request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Affiliated Hospital of Hebei University of Engineering (ethical batch number: 2021[K]087), and written informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.