Mental health status and associated factors among Chinese postoperative breast cancer survivors of working age: a cross-sectional study

Abstract

Purpose

Mental health is a critical component of overall wellness among breast cancer survivors of working age; however, research in this area remains limited in China. This study aims to evaluate the mental health status and identify associated factors among this particular population.

Methods

A cross-sectional study was conducted from July 5 to November 5, 2023, at a cancer hospital in Beijing, with patients from across China. A total of 443 postoperative breast cancer survivors of working age were recruited. Data on socio-demographics including occupation before diagnosis and current work status, diagnosis and treatments were self-reported by participants. Mental health status was assessed using GAD-7, PHQ-9, and FCRI-SF for anxiety, depression and fear of cancer recurrence (FCR) symptoms, respectively. Descriptive and logistic regression analyses were used to explore associations between socio-demographic, clinical factors and mental health outcomes.

Results

Among 443 participants (mean age: 49.4 years; age 18–60; all women), 27.1%, 29.3% and 31.8% were assessed to have anxiety, depression and fear of cancer recurrence symptoms, respectively. Residents of Beijing (44.0%) were significantly less likely to report FCR symptoms than non-residents (adjusted OR = 0.57, 95% CI: 0.37–0.90, p = 0.02). Those with non-professional occupations before cancer diagnosis (47.6%) showed a trend toward a lower likelihood of depression (adjusted OR = 0.58, 95% CI: 0.34–0.99, p = 0.05).

Conclusion

Residence and occupational disparities were associated with FCR and depressive symptoms. Digital health interventions may help address unmet psychological supportive care needs in non-central cities, while vocational rehabilitation support may benefit individuals with professional backgrounds.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1007/s00520-026-11334-1.

Introduction

Globally, breast cancer is the most commonly diagnosed cancer and a leading cause of cancer-related mortality among women [1, 2]. In China, its incidence is rising, especially with the gradual increase in breast cancer incidence in women under 35 years of age [3]. Concurrently, advances in screening and treatment have increased the number of long-term survivors of working age [4].

For breast cancer survivors of working age, mental health challenges such as anxiety, depression, and fear of cancer recurrence (FCR), significantly impair quality of life [5–7]. Previous international studies have reported that depression and anxiety symptoms not only occur within the first year after breast cancer diagnosis, but can be persistent during long-term survivorship [8–10]. FCR, a pervasive concern, can also persist for years post-treatment, contributing to psychological distress [11, 12]. Despite socio-demographic and clinical factors, occupation type and return to work status were found to be significantly associated with psychological outcomes in breast cancer survivors [13–15].

In China, marital status, household income, and comorbidity have been identified as significant predictors of depression, anxiety and FCR among breast cancer survivors [16–20]. Nevertheless, few studies have systematically examined how both socio-demographic and clinical factors jointly affect mental health outcomes among Chinese breast cancer survivors, especially considering return to work for working age survivors, highlighting the need for further research in this area.

This study aims to assess the prevalence of anxiety, depression, and FCR among Chinese breast cancer survivors of working age, and to investigate the associations of these outcomes with sociodemographic and clinical characteristics, occupation before diagnosis, and current work status.

Methods

Study design

This cross-sectional questionnaire survey study was designed to be conducted at a tertiary hospital specializing in oncology located in Beijing, with patients coming from across China. Patients were recruited at the hospital’s waiting area of the Breast Ultrasound Room of the Breast Cancer Surgical Center, a section for breast cancer patients waiting for their annual exam after surgery. Trained research assistants worked with patients face to face and recruited participants who met the recruiting criteria (details described below in “Participants” section). The study period was from July 5 to November 5, 2023. The questionnaire survey study was approved by the Ethics Committee of Peking University Cancer Hospital, with the ethical approval number 2023Y1237.

To the best of our knowledge, this is the first questionnaire-based study in China to examine mental health outcomes among breast cancer survivors while incorporating both current work status and occupation before diagnosis into the analysis.

Data collection: Questionnaires and mental health scales

Questionnaires were used to collect participants’ socio-demographic data (age, marital status, education, residence), cancer diagnosis-related data (clinical stage at first diagnosis, years since first diagnosis, recurrence), and treatment-related data (radiotherapy, chemotherapy). In addition, work-related questions were asked and data collected, including occupation before first cancer diagnosis, and current work status at research time (Supplementary Materials; Questionnaire). Category of occupation was defined by using International Standard Classification of Occupations (ISCO) [21].

Mental health status was assessed using GAD-7, PHQ-9, and FCRI-SF for anxiety, depression and fear of cancer recurrence symptoms, respectively [22–24]. Clinical cut-offs were applied: a GAD-7 score of 5 or higher indicated anxiety symptoms with scores 5–9 as mild and scores 10–21 as severe; a PHQ-9 score of 5 or higher indicated depression symptoms with scores 5–9 as mild and scores 10–27 as severe; and an FCRI-SF score of 13 or higher indicated clinically possible FCR with scores 13–21 as subclinical level and scores 22–35 as clinically significant level.

Data completeness was ensured by trained research assistants during collection, and all missing responses were resolved on site.

Participants

Participants for this study were recruited from the waiting area of the Breast Ultrasound Room at the Breast Cancer Surgical Center of a tertiary hospital in Beijing, while they waited on their post-surgery annual exams. Inclusion criteria included having been diagnosed with breast cancer at least two years prior; post-surgery; being employed at the time of diagnosis; and being aged between 18 and 60 years at research time. Exclusion criteria included severe cognitive impairment and any hearing, vision, or language impairments that would prevent them from completing the questionnaire or cooperating with the interview. All participants were given written informed consent forms, which they read and signed before being included in the study.

A total of 2230 breast cancer patients were interviewed for the survey; 1777 were not qualified based on the survey’s inclusion and exclusion criteria; 10 didn’t give written consent. As a result, a total of 443 postoperative breast cancer patients were recruited to participate (Fig. 1).

Fig. 1.

Diagram of recruiting postoperative breast cancer survivors of working age for the survey (n = 443)

Outcomes

The primary outcome was participants’ mental health status, including the assessment results of anxiety, depression, and FCR (fear of cancer recurrence) symptoms. The secondary outcome regarded associated factors. Variables included socio-demographic factors (including work-related factors), and clinical (cancer diagnosis and treatment) factors.

Statistical analyses

Descriptive statistics were calculated to summarize the distribution of the participants’ mental health symptoms. Mental health assessment results were analyzed as binary outcomes. Categorical variables were summarized as frequencies (n) and percentages (%), and their distributions across groups were compared using contingency tables.

Associations between mental health outcomes and socio-demographic or clinical variables were examined using chi-square tests (χ²). Because return to work is one of the most examined indicators of work status among cancer survivors [13–15, 25, 26], it was measured and included in the univariable and multivariable analyses. In this study, return to work referred to resuming work in the same position and with the same working hours. For each test, chi-square values and p-values were reported. A significant threshold of p ≤ 0.05 was used for all tests. To further identify independent predictors of mental health symptoms, multivariate logistic regression analyses were performed for anxiety, depression, and FCR. Separate models were constructed for anxiety, depression, and fear of recurrence. Odds ratios (ORs), 95% confidence intervals (CIs), and p-values were reported.

To further characterize the relationship between occupation before diagnosis and current work status, we conducted an additional analysis examining this relationship. (Supplementary Table 2).

All statistical analyses were conducted using SPSS version 24 (IBM Corp., Armonk, NY, USA).

Results

Socio-demographic and clinical characteristics

Out of 443 participants, 80.3% were aged 55 or younger; 91.2% were married; 66.6% achieved higher education (Table 1). As the study was conducted at a major cancer hospital located in Beijing, we found that 44.0% of the participants were living in the city, while 56.0% were from other areas of China (Supplementary Table 1). 52.4% (232 out of 443) were professionals (ISCO Iⅈ skill level 4) before first diagnosis; 47.6% (211 out of 443) had non-professional occupations (ISCO III-IX; skill level 1–3). 44.5% (197 out of 443) returned to work (Table 1).

Table 1.

Socio-demographic and clinical characteristics (n = 443)

Variable	n	%
Socio-demographic factors
Age (at questionnaire time)
≤ 40	48	10.8
41–50	180	40.6
51–55	128	28.9
> 56	87	19.6
Marital status
Married	404	91.2
Unmarried	19	4.3
Divorced	20	4.5
Education
Low	51	11.5
Middle	97	21.9
High	295	66.6
City of residence
Non-Beijing	195	56.0
Beijing	248	44.0
Type of residence
Urban	388	87.6
Rural	55	12.4
Returned to worka
No	246	55.5
Yes	197	44.5
Type of occupation before first diagnosis
Professionalsb	232	52.4
Managers (ISCO I)	53	12.0
Professionals (ISCO II)	179	40.4
Non-professionalsc	211	47.6
Skilled technicians, clerical workers and sales, etc. (ISCO III-V)	118	26.6
Others (ISCO VI-IX)	39	8.8
Not responded	54	12.2
Clinical factors
Clinical stage (at first diagnosis)
0–2 or unknown	378	85.3
3–4	65	14.7
Years since first diagnosis (at research time)
< 5	233	52.6
6–10	141	31.8
> 10	69	15.6
Radiotherapy
No	135	30.5
Yes	308	69.5
Chemotherapy
No	147	33.2
Yes	296	66.8
Recurrence
No	423	95.5
Yes	20	4.5

^a Return to work referred to returning to the same position and working hours in this study

^b Professionals include: Managers (ISCO I) and Professionals (ISCO II)

^c Other occupations include: Technicians and Associated Professionals (ISCO III), Clerical Support Workers (ISCO IV), Service and Sales Workers (ISCO V), Skilled Agricultural, Factory, and Fishery Workers (ISCO VI), Craft and Related Trade Workers (ISCO VII), Plant and Machinery Operators, and Assemblers (ISCO VIII), Elementary Occupations (ISCO IX)

Clinically, 85.3% of the participants were at stages 0–2 or unknown at first breast cancer diagnosis, with 14.7% at stages 3–4. By research time, 52.6% were five years or less since first diagnosis, 31.8% between six to ten years, and 15.6% more than ten years. Other treatment modalities included radiotherapy in 69.5% of the participants and chemotherapy in 66.8%. Recurrence was reported in only 4.5% of the participants (Table 1).

Mental health status and associated factors

Mental health assessments revealed that 27.1% of participants experienced anxiety symptoms as measured by the GAD-7 scale including 18.5% with mild and 8.6% with severe anxiety symptoms; 29.3% exhibited symptoms of depression as assessed by the PHQ-9 scale including 19.4% with mild and 9.9% with severe depression symptoms; 31.8% reported FCR symptoms according to the FCRI-SF scale including 28.0% with subclinical and 3.8% with clinically significant FCR (Table 2).

Table 2.

Mental health status distribution (n = 443)

	n	%
Total	443	100
Anxiety symptoms (measured by GAD-7a)
No (scored 0–4)	323	72.9
Yes (scored 5–21)	120	27.1
- Mild anxiety (scored 5–9)	82	18.5
- Severe anxiety(scored 10–21)	38	8.6
Depression symptoms (measured by PHQ-9b)
No (scored 0–4)	313	70.7
Yes (scored 5–27)	130	29.3
- Mild depression (scored 5–9)	86	19.4
- Severe depression (scored 10–27)	44	9.9
Fear of cancer recurrence symptoms (measured by FCRI-SFc)
No (scored 0–12)	302	68.2
Yes (scored 13–35)	141	31.8
- Subclinical FCR (score 13–21)	124	28.0
- Clinical significant FCR (score 22–35)	17	3.8

^a GAD-7 stands for Generalized Anxiety Disorder-7 item

^b PHQ-9 stands for Patient Health Questionnaire-9 item

^c FCRI-SF stands for Fear of Cancer Recurrence Inventory-Short Form

Univariate analysis showed statistically significant differences in FCR in terms of residence, with higher levels of FCR observed among non-Beijing residents (χ² = 5.05, p = 0.03). Furthermore, a significant difference in FCR was found between professionals and non-professionals (χ² = 4.04, p = 0.04). No statistically significant differences were observed in anxiety, depression, or FCR across age groups, marital status, education level, current work status, clinical stage, years since diagnosis (at research time), chemotherapy, or recurrence status (all p > 0.05) (Table 3).

Table 3.

Univariate analysis: socio-demographic and clinical characteristics in respect to mental health status (n = 443)

	Anxietya				Depressionb				Fear of cancer recurrencec
	no	yes	χ2	p	no	yes	χ2	p	no	yes	χ2	p
Socio-demographic factors
Age (at research time)			3.33	0.34			0.49	0.92			0.87	0.83
≤ 40	34	14			34	14			33	15
41–50	124	56			124	56			119	61
51–55	97	31			92	36			91	37
> 56	68	19			63	24			59	28
Marital status			0.44	0.80			2.78	0.25			1.11	0.57
Married	294	110			285	119			273	131
Unmarried	15	4			16	3			15	4
Divorced	14	6			12	8			14	6
Education			0.41	0.82			0.01	0.99			2.35	0.31
Low	39	12			36	15			30	21
Middle	71	26			69	28			68	29
High	213	82			208	87			204	91
City of Residence			0.47	0.49			0.34	0.56			5.05	0.03
Non-Beijing	139	56			135	60			122	73
Beijing	184	64			178	70			180	68
Type of Residence			0.46	0.50			0.35	0.56			0.02	0.88
Urban	285	103			276	112			265	123
Rural	38	17			37	18			37	18
Returned to work			1.47	0.23			0.06	0.80			0.07	0.79
No	185	61			175	71			169	77
Yes	138	59			138	59			133	64
Type of occupation before first diagnosis			2.15	0.14			2.85	0.09			4.04	0.04
Professionals	176	56			172	60			168	64
Non-professionals	147	64			141	70			134	77
Clinical factors
Clinical stage (at first diagnosis)			0.62	0.43			2.24	0.14			0.44	0.51
0–2 or unknown	273	105			262	116			260	118
3–4	50	15			51	14			42	23
Years since first diagnosis (at research time)			1.00	0.61			0.25	0.88			2.22	0.33
≤ 5	171	62			167	66			164	69
6–10	105	36			98	43			96	45
> 10	47	22			48	21			42	27
Radiotherapy			1.06	0.30			0.29	0.59			0.77	0.38
No	94	41			93	42			96	39
Yes	229	79			220	88			206	102
Chemotherapy			0.04	0.85			0.001	0.98			0.67	0.41
No	108	39			104	43			104	43
Yes	215	81			209	87			198	98
Recurrence			0.66	0.42			0.004	0.95			1.68	0.20
No	310	113			299	124			291	132
Yes	13	7			14	6			11	9

^a Anxiety was measured by using GAD-7 (Generalized Anxiety Disorder-7 item) and categorized into two groups—“no (scored 0–4)” and “yes (scored 5–21)”

^b Depression was measured by using PHQ-9 (Patient Health Questionnaire-9 item) and categorized into two groups—“no (scored 0–4)” and “yes (scored 5–27)”

^c Fear of cancer recurrence was measured by using FCRI-SF (Fear of Cancer Recurrence Inventory-Short Form) and categorized into two groups—“no (scored 0–12)” and “yes (scored 13–35)”

Furthermore, multivariate analysis of socio-demographic and clinical characteristics in respect to mental health status was performed (Table 4). The multivariate analysis confirmed that residing in Beijing was significantly associated with lower odds of fear of cancer recurrence symptoms (adjusted OR = 0.57, 95% CI: 0.37–0.90, p = 0.02) compared to those who traveled to Beijing for cancer treatments and follow-ups, while non-professional occupations showed a trend toward a lower likelihood with reduced odds of depression symptoms (OR = 0.58, 95% CI: 0.34–0.99, p = 0.05). No other socio-demographic or clinical variables demonstrated consistent significant associations across all mental health outcomes (Table 4).

Table 4.

Multivariate analysis: socio-demographic and clinical characteristics in respect to mental health status (n = 443)

Variable	Anxietya		Depressionb		Fear of recurrencec
	OR (95% CI)	P-value	OR (95% CI)	P-value	OR (95% CI)	p-value
Socio-demographic Factors
Age (at research time)
≤ 40	1 (ref)		1 (ref)		1 (ref)
41–50	1.29 (0.58–2.83)	0.53	1.45 (0.65–3.21)	0.37	1.07 (0.50–2.29)	0.87
51–55	0.88 (0.37–2.07)	0.76	1.31 (0.55–3.08)	0.54	0.80 (0.35–1.82)	0.59
> 56	0.56 (0.21–1.50)	0.25	1.06 (0.41–2.74)	0.91	0.74 (0.30–1.85)	0.52
Marital status
Married	1 (ref)		1 (ref)		1 (ref)
Unmarried	0.79 (0.25–2.54)	0.69	0.46 (0.13–1.66)	0.24	0.52 (0.16–1.63)	0.26
Divorced	0.99 (0.33–2.96)	0.98	1.84 (0.65–5.22)	0.25	0.91 (0.30–2.71)	0.86
Education
Low	1 (ref)		1 (ref)		1 (ref)
Middle	1.47 (0.61–3.53)	0.40	1.05 (0.46–2.40)	0.92	0.52 (0.23–1.16)	0.11
High	1.91 (0.76–4.78)	0.17	1.35 (0.56–3.22)	0.50	0.61 (0.26–1.40)	0.24
City of Residence
Non-Beijing	1 (ref)		1 (ref)		1 (ref)
Beijing	0.80 (0.50–1.28)	0.36	0.82 (0.52–1.29)	0.39	0.57 (0.37–0.90)	0.02
Type of Residence
Urban	1 (ref)		1 (ref)		1 (ref)
Rural	1.52 (0.70–3.33)	0.29	1.20 (0.56–2.55)	0.65	0.86 (0.40–1.85)	0.70
Returned to work
No	1 (ref)		1 (ref)		1 (ref)
Yes	1.39 (0.88–2.18)	0.16	1.11 (0.72–1.74)	0.63	1.12 (0.72–1.72)	0.62
Type of occupation before first diagnosis
Professionals	1 (ref)		1 (ref)		1 (ref)
Non-professionals	0.59 (0.34–1.02)	0.06	0.58 (0.34–0.99)	0.05	0.64 (0.38–1.09)	0.10
Clinical Factors
Clinical stage (at first diagnosis)
0–2 or unknown	1 (ref)		1 (ref)		1 (ref)
3–4	0.71 (0.37–1.37)	0.30	0.56 (0.29–1.09)	0.09	1.04 (0.57–1.90)	0.89
Years since first diagnosis (at research time)
< 5	1 (ref)		1 (ref)		1 (ref)
6–10	1.01 (0.61–1.67)	0.96	1.12 (0.70–1.82)	0.63	1.13 (0.70–1.83)	0.61
> 10	1.56 (0.78–3.13)	0.21	1.10 (0.55–2.17)	0.79	1.46 (0.75–2.83)	0.26
Radiotherapy
No	1 (ref)		1 (ref)		1 (ref)
Yes	0.72 (0.44–1.17)	0.19	0.87 (0.54–1.39)	0.55	1.25 (0.77–2.01)	0.37
Chemotherapy
No	1 (ref)		1 (ref)		1 (ref)
Yes	1.10 (0.67–1.81)	0.70	1.13 (0.70–1.82)	0.61	1.08 (0.67–1.74)	0.75
Recurrence
No	1 (ref)		1 (ref)		1 (ref)
Yes	1.66 (0.62–4.47)	0.32	1.07 (0.39–2.93)	0.90	1.70 (0.66–4.38)	0.27

^a Anxiety was measured by using GAD 7 (Generalized Anxiety Disorder 7-item) and categorized into two groups—“no (scored 0–4)” and “yes (scored 5–21)”

^b Depression was measured by using PHQ9 (Patient Health Questionnaire-9) and categorized into two groups—“no (scored 0–4)” and “yes (scored 5–27)”

^c Fear of cancer recurrence was measured by using FCRI-SF (Fear of Cancer Recurrence Inventory-Short Form) and categorized into two groups—“no (scored 0–12)” and “yes (scored 13–35)”

Return to work (in the same position and same hours) was not significantly associated with mental health outcomes (p > 0.05) (Tables 3 and 4). However, analysis of the association between current work status and occupation before diagnosis (Supplementary Table 2) showed 53.0% (123 out of 232) of professionals returned to work; while 35.1% for non-professionals. In addition, 8.2% (19 out of 232) and 5.6% (13 out of 232) chose resignation or retirement for professionals, while the rates were 17.1% (36 out of 211) and 13.7% (29 out of 211) for non-professionals, respectively (p < 0.001).

Discussion

This study found 27.1% with anxiety symptoms and 29.3% with depression symptoms among postoperative breast cancer survivors of working age, suggesting psychological support is needed for this population. However, the prevalence of anxiety and depression symptoms in our findings were higher than previous Chinese studies: a 2014 Hong Kong study revealed 18.4% with anxiety one year after treatments [27], while a 2012 Shanghai study found that 20.6% had MDD (major depressive disorder) [18]. Our study narrowed the focus to participants being employed at diagnosis time and working age at research time, while the previous Chinese studies were not limited in these ways. In addition, the differences could also be explained by the assessment scales, as the Hong Kong study used the Supportive Care Needs Survey (SCNS-SF34) for self-reporting anxiety [27]; the Shanghai study used the Mini Neuropsychiatric Interview for assessing depression, according to the Diagnostic and Statistical Manual Fourth Edition (DSM-IV) [18]. Another possible explanation could be that our study was conducted in 2023, shortly after the COVID-19 pandemic, when its profound impacts on daily life and the economy might have added psychological distress to the participating breast cancer survivors.

Considering the prevalence of fear of cancer recurrence (FCR) symptoms, a previous Hong Kong-based study used the FCRI-SF for assessing FCR symptoms, the same tool used in our study [28]. We found a 31.8% prevalence including 28.0% with subclinical level and 3.8% with clinically significant level, which is lower than that of the Hong Kong-based study which showed 45.7% of breast cancer patients showing FCR symptoms, including 31.2% reported at subclinical level and 14.5% at clinically significant level [28]. The difference may be explained by the study design. The Hong Kong–based study assessed participants at 8 weeks post-surgery. Although our study did not collect data on the exact number of weeks post-surgery, all of our participants were at least two years from their initial breast cancer diagnosis. Therefore, our patients were likely to be much further along in their postoperative recovery and, as a result, may have had greater confidence in their physical condition.

Importantly, our study found a statistically significant association between residence and FCR symptoms, with participants residing locally in Beijing showing lower odds of FCR symptoms compared to those who resided in other cities but traveled to Beijing for cancer treatments and examinations (p = 0.02). We also found that occupation type had marginally significant association with depression, with non-professional workers exhibiting lower odds of depressive symptoms compared to professionals (p = 0.05).

Our finding suggests that place of residence plays an important role in shaping mental health outcomes among Chinese breast cancer survivors. Participants with Beijing household registration were significantly less likely to report fear of cancer recurrence (FCR) (p = 0.002). Beijing, where the research hospital is located, hosts a concentration of specialized oncology hospitals and medical resources [29]. Patients residing in Beijing may have greater access to advanced cancer care, social networks, and psychosocial support, which may contribute to lower levels of FCR. Previous studies have documented substantial urban–rural disparities in quality of life (QoL) and health-related QoL in China, which have been attributed to differences in socioeconomic status, healthcare accessibility, social welfare resources, and educational attainment [30, 31]. However, in the present study, urban versus rural residence was not significantly associated with any of the mental health outcomes examined. This finding may be partly explained by the limited statistical power resulting from the relatively small proportion of rural participants (12.4%). Nevertheless, the observed association between Beijing residence and lower FCR highlights the potential influence of geographic disparities in healthcare resources and underscores the need for region-specific interventions to improve psychosocial support for breast cancer survivors across diverse settings.

Considering the factor of occupation, our study result found that non-professional workers (ISCO III to IX; skill level 1–3) showed lower odds of depressive symptoms compared to professionals (ISCO I&II; skill level 4). Our finding is in contrast with a previous Danish study regarding the association between pre-treatment occupational skill level and depressive symptoms among postmenopausal breast cancer survivors; in that study, those employed at lower skill levels reported significantly higher depressive symptoms [32]. The Danish study included only 49 participants and all postmenopausal and during the first year of anastrozole therapy; the scope, cohort and timing of research may help explain the difference. On the other hand, previous studies reported that cancer-related cognitive difficulties—such as problems with attention, memory, and executive function—affect work outcomes [33]. In the present study, individuals with non-professional occupations before diagnosis were more likely to choose resignation or retirement, whereas those with professional occupations were more likely to return to work (Supplementary Table 2). Leaving the workforce may reduce work-related stress and thereby contribute to the lower prevalence of depressive symptoms observed among individuals with non-professional occupations. However, this explanation remains speculative and requires confirmation in larger studies.

Return to work was not significantly associated with mental health outcomes in the present study, which differs from findings reported in previous international studies. Prior research has shown that cancer survivors who returned to work generally experienced lower levels of depression, anxiety, and FCR [25, 26]. In addition to the relatively small and distinct sample characteristics (discussed in the “Limitations” section), one possible explanation for this discrepancy may be differences in how return to work was operationalized. In the present study, return to work referred to returning to the same position and working hours at the time of the survey. During questionnaire administration, some participants reported that working in a different position or with reduced hours often involved remaining employed in government agencies or state-owned enterprises while assuming substantially reduced responsibilities. Consequently, the work-related demands and stress associated with these arrangements may differ from those associated with returning to the same position and working hours. This difference in the operationalization of return to work may have contributed to the lack of association observed in our study. Another possible explanation is that return to work may confer both psychological benefits and work-related stress, resulting in varying effects on mental health outcomes across individuals. Further research is needed to investigate these possibilities.

Furthermore, clinical factors—including cancer stage, time since diagnosis, treatment modalities, and recurrence status—were not found to be significantly associated with mental health outcomes in the present study. In contrast, previous studies conducted in other countries have reported that clinical factors, such as exposure to chemotherapy and longer duration of primary treatment, were significant predictors of depression, anxiety, and FCR among breast cancer survivors [32, 34–38]. Although not assessed in the present study, endocrine therapies, including tamoxifen and aromatase inhibitors, may influence psychosocial well-being and quality of life among breast cancer survivors [30], and therefore could have affected the observed associations. In addition, the low recurrence rate in this sample (4.5%) may have reduced the statistical power to detect an association with FCR. Differences in measurement instruments, population characteristics, and timing of psychological assessment may account for these discrepancies across studies.

Limitations

This study has several limitations. First, because work-related factors were key variables of interest, eligibility criteria required participants to have been employed at the time of diagnosis and to be of working age at the time of the survey. In addition, participants were required to have been diagnosed at least two years before enrollment to allow assessment of current work status, including return to work, resignation, and retirement. Consequently, 1777 of the 2230 screened postoperative patients were excluded, resulting in a relatively small sample size. These selection criteria may have limited the representativeness of the study population with respect to Chinese breast cancer survivors.

Second, although the tertiary hospital in Beijing attracts patients across China for cancer treatments, approximately half of the studied participants were residents of Beijing, where cancer survivors have better access to advanced medical resources, including psychological supportive therapies. Such advanced medical care and therapies may have positive impacts on mental health status and underestimate the overall mental health issues among widely dispersed Chinese breast cancer survivors.

Third, this study targeted postoperative breast cancer survivors who generally have a better survival rate than those in later stages who cannot undergo surgical treatments. Therefore, our findings may reflect less severe mental health issues and could potentially underestimate the mental health burden among the broader population of Chinese breast cancer survivors.

Additionally, this study collected work-related information only on participants’ current work status and occupations before diagnosis. As a result, longitudinal changes in work status and work quality could not be captured, and the dynamic trajectories and potential causal relationships between work-related factors and mental health outcomes could not be evaluated. Furthermore, occupations before diagnosis were broadly classified as professionals (ISCO I&II) or non-professionals (ISCO III–IX), which may have resulted in some loss of occupational information.

Future multicenter studies involving participants from non-central cities, rural areas, and diverse occupational backgrounds are warranted. Longitudinal studies would improve the representativeness of the study population and enable both quantitative and qualitative examination of changes in work status over time, including changes in employer, job quality, working hours, salary, and work-related stressors, as well as their associations with mental health outcomes. Such studies would also help elucidate potential mediators of residence-related disparities, including access to care, social support networks, illness perceptions, and unemployment risk among breast cancer survivors in China.

Conclusion

Our study found that mental health concerns, including anxiety, depression, and fear of cancer recurrence (FCR), remain prevalent among Chinese breast cancer survivors of working age. Residing outside Beijing and having a professional occupation before cancer diagnosis were associated with a higher likelihood of psychological distress. Digital health tools that provide standardized FCR screening and psychoeducation may help address unmet supportive care needs among survivors in non-central cities. In addition, clinicians should be attentive to the mental health needs of survivors from professional backgrounds and consider integrating vocational rehabilitation with psychological support.

Supplementary information

Below is the link to the electronic supplementary material.

Author contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Zhongge Su, Yongshi Wang, Lili Tang, Yi He, Hirohide Yokokawa, Toshio Naito and Yan Yan. The first draft of the manuscript was written by Zhongge Su, Yongshi Wang, Yan Yan, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by JSPS KAKENHI Grant Number 22K21183. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Data availability

All the details have been provided in the manuscript.

Declarations

Ethics approval

This study was performed in line with the principle of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Peking University Cancer Hospital, with ethical approval number 2023Y1237.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare no competing interests.