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. Author manuscript; available in PMC: 2013 Sep 12.
Published in final edited form as: Acta Oncol. 2009;48(8):1128–1136. doi: 10.3109/02841860903188650

Prevalence of depression and its related factors among Chinese women with breast cancer

Xiaoli Chen 1, Ying Zheng 2, Wei Zheng 1, Kai Gu 2, Zhi Chen 1, Wei Lu 2, Xiao Ou Shu 1
PMCID: PMC3771388  NIHMSID: NIHMS510138  PMID: 19863220

Abstract

Background

Few data are available regarding depression among Asian breast cancer survivors.

Methods

We estimated the prevalence of depression and its correlates among 1400 participants of a population-based cohort study of women with stage 0–IV breast cancer in Shanghai, China. Through in-person interviews conducted at 6 months and 18 months post-diagnosis and review of medical charts, information on sociodemographic and clinical factors and quality of life (QOL) were collected. Depression was measured by the 20-item Center for Epidemiologic Studies Depression Scale 18 months after diagnosis.

Results

Approximately 26% of participants had mild to severe depression and 13% fulfilled the criteria of clinical depression at 18 months post-diagnosis. Women with lower income were more likely to have depression than those with higher income (prevalence: 16.6% vs. 6.9% for mild depression and 17.1% vs. 5.5% for clinical depression, respectively). Depression was more common among women who were widowed (18.9%) or divorced/separated/single (16.4%) than those who were married (11.8%). Women with comorbidity were more likely to have clinical depression (17.3% vs 11.2%). Multivariate analysis showed that low income, marital status, comorbidity, and low QOL scores were independent predictors for depression. We did not find that prevalence of depression differed by menopausal status, estrogen or progesterone receptor status, disease stage, or cancer-related treatments.

Conclusion

Depression is common among Asian women with breast cancer. Routine screening and prevention of depression are warranted among women with breast cancer.

Keywords: depression, breast cancer, prevalence, risk factor

INTRODUCTION

Breast cancer is the most common malignancy among women in the U.S. and many other countries in the world. Due to advances in early diagnosis and treatment, the population of breast cancer survivors is growing rapidly worldwide. Many breast cancer patients and survivors battle psychological distress caused by the consequences of cancer diagnosis and the sequelae of cancer-related treatment [1, 2]. It has been reported that depression occurs in 1.5% to 55% of women with breast cancer within 6 months of cancer diagnosis [1–16]. The variation in estimates of depression prevalence can be attributed to differences in study time frame, criteria for depression, disease stage, and study population [1, 2, 14].

Although there are numerous reports on depression and its correlates, the relation between sociodemographic and clinical factors and depression after diagnosis of breast cancer remain controversial [1, 2, 13–15, 17]. It has been suggested that sociodemographic factors, such as age, marital status, and socioeconomic status are associated with depression [1, 2, 14, 15, 17–19]. Some studies have linked cancer-related treatment or cancer stage with depression [17, 18, 20], whereas others have failed to find such connections [1, 2, 9, 14–16].

Most studies of depressive symptoms have been conducted among women with early stage breast cancer [1, 2, 8, 13–15], and most were based on cross-sectional surveys [1, 4, 8, 10, 13, 17]. Furthermore, existing data on clinical depression among breast cancer patients/survivors come mainly from Western populations; little information is available for Asian breast cancer patients and survivors. Given the considerable variability in the prevalence of depression and proposed risk factors found in Western populations and limited information on depression in Asian women, a better understanding of depression and its correlates in Asian populations would be informative for provision of appropriate services and targeted intervention for women at high risk for depression.

By using data from a population-based cohort study of women diagnosed with stage 0–IV breast cancer, we estimated the prevalence of depression approximately 18 months after cancer diagnosis. We also evaluated the association of sociodemographic and clinical factors, as well as QOL assessed approximately 6 months post-diagnosis, with depression assessed at 18 months post-diagnosis.

METHODS

Study participants

Study participants were women who were diagnosed with a primary breast cancer and enrolled in the Shanghai Breast Survival Study (SBCSS), a population-based cohort study of breast cancer survivors in Shanghai, China. Details of the SBCSS have been described elsewhere [21, 22]. Briefly, through the population-based Shanghai Cancer Registry, 6303 women were identified approximately 6 months after diagnosis of incident breast cancer and were invited to participate in the study between April 1, 2002 and December 31, 2006. A total of 5042 women provided written, informed consent and enrolled in the study. These participants were followed through in-person interviews administered at approximately 18 months after cancer diagnosis. Of these, 1400 cases were invited to participate in a depression survey administered as part of the 18-month follow-up interview. Women who participated in the depression survey were similar to the entire study population with regard to social demographics, age at cancer diagnosis, and clinical features. The SBCSS was approved by the institutional review boards of all institutions involved in the study.

Data collection

Structured questionnaires were administered by trained interviewers through in-person interviews to collect information on sociodemographic, clinical, and lifestyle characteristics, as well as QOL and depression. Age at diagnosis, education, monthly household income, marital status, menopausal status, and menopausal symptoms were assessed. Disease- and treatment-related information was collected, including stage of tumor-node metastasis (TNM) at the time of primary diagnosis, estrogen receptor (ER) and progesterone receptor (PR) status, type of surgery, chemotherapy, radiotherapy, immunotherapy, and tamoxifen use. Additionally, medical charts were reviewed to verify diagnosis, treatment, and disease stage information. ER and PR status were included in the analyses in the following joint categories: ER+/PR+ (receptor-positive), ER−/PR− (receptor-negative), and ER−/PR+ or ER+/PR− (mixed). The Charlson comorbidity index was created based on a validated comorbidity scoring system [23] and the diagnostic codes from the International Classification of Disease, 9th revision (ICD-9) [24].

The Medical Outcomes Short Form-36 Health Survey (SF-36) was administered at the baseline interview to evaluate participants’ QOL. The SF-36 is a generic health outcome measure with 36 items spread across 8 health scales: physical functioning, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health. The scale scores can be consolidated into two summary measures of health: the Physical Health Summary (PCS) and the Mental Health Summary (MCS). Total QOL and scale scores range from 0 to 100, with higher scores representing better QOL or health status. The SF-36 has been validated in the Chinese population [25] and has been used in epidemiological studies of breast cancer patients and survivors [26, 27].

The Center for Epidemiologic Studies Depression Scale (CES-D) was used as a measure of depression [28]. The 20-item CES-D scale measures depressive symptoms experienced in the week prior to its administration. Individual items are scored on a four-point scale, and the total score ranges from 0 to 60, with a higher score indicating more depressive symptoms. A total score of 0–9 suggests that the individual is not depressed, a score of 10–15 suggests mild depression, and a score ≥16 indicates clinical depression [28]. The Chinese version of the CES-D has been validated [29].

Statistical analysis

The prevalence of depression was computed as the percentage of women with mild and clinical depression at 18 months post-diagnosis. Median distributions were used to categorize QOL scores. The χ2 test was conducted to examine differences in the prevalence of depression across sociodemographic and clinical characteristics. Cases without depression (total depression score <10) served as the reference in multinomial logistic regression analyses that were conducted to evaluate sociodemographic and clinical factors in relation to mild and clinical depression. Only factors significantly related to depression in univariate analysis were included in our multivariate logistic regression analysis. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. The SF-36 QOL-related mental health index scale has been used to screen for mood disorders in the general population [30] and for depression among HIV outpatients [31], and was shown to be more predicative of prevalence of depression than any other QOL scale in our study population. For these reasons, it was included in the multivariate analysis along with sociodemographic and clinical factors as an indicator of depression at baseline. We also applied a modified 26-item CES-D, which includes an additional 6 questions specifically designed for the Chinese population [29]. We found high correlation between the 20-item CES-D and the 26-item CES-D scores (Spearman correlation coefficient: 0.98). Results of additional analyses conducted using data from the 26-item CES-D were similar to results generated by the 20-item CES-D. Given that the 20-item CES-D is widely used in clinical and epidemiological studies on depression, in this report we present only results based on the 20-item CES-D. All tests were performed by using Statistical Analysis Software (SAS, version 9.1; SAS Institute, Inc., Cary, North Carolina). The significance levels were set at P< 0.05 for two-sided analyses.

RESULTS

Of the 1400 study participants, the average age at cancer diagnosis was 53.7 years (standard deviation: 9.8), 44% had less than a high school education level, 88% were married, and 53% were post-menopausal. At 18 months post-diagnosis, 26% of women had symptoms of depression, and 12.6% fulfilled the criteria for clinical depression (Table 1). Women who were older at diagnosis were more likely to have depressive symptoms. The prevalence of clinical depression increased with age and was higher for women with lower income than for women with higher income. Depression was more common among women who were widowed (19%) or divorced/separated/single (16%) compared with women who were married (12%). There was no significant difference in the prevalence of depression by menopausal status.

Table 1.

Demographic characteristics and related prevalence of depression 18 months post-diagnosis*

Characteristics N % Prevalence (%)
P value
Without depression (n=1036) Mild depression (n=188) Clinical depression (n=176)
Age at diagnosis (year) 0.234
 <40 64 4.6 82.8 14.1 3.1
 40–49 515 36.8 73.4 13.6 13.0
 50–59 469 33.5 75.5 13.0 11.5
 ≥60 352 25.1 71.3 13.6 15.1
Education level 0.028
 <High school 619 44.2 70.8 13.6 15.7
 High school 547 39.1 76.2 13.0 10.8
 >High school 234 16.7 77.4 14.1 8.6
Income (yuan/month/capita) <0.001
 <1000 645 46.1 66.4 16.6 17.1
 1000–1999 554 39.6 78.0 12.1 9.9
 ≥2000 201 14.4 87.6 6.9 5.5
Marital status 0.006
 Married 1234 88.1 75.6 12.6 11.8
 Widowed 111 7.9 60.4 20.7 18.9
 Divorced/separated/single 55 3.9 65.5 18.2 16.4
Menopausal status 0.907
 Pre-menopausal 660 47.1 74.6 13.2 12.3
 Post-menopausal 740 52.9 73.5 13.7 12.8
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*

χ2 test was conducted to test differences in the prevalence of depression among breast cancer survivors without depression, with mild depression, and with clinical depression.

Approximately 83% of women experienced menopausal symptoms after cancer diagnosis, 22% had a Charlson comorbidity index of 1 or higher, 41% had stage 0–I breast cancer, and 9% had stage III–IV breast cancer (Table 2). Half of women had ER/PR positive (51%) and 28% were ER/PR negative tumors. Women with menopausal symptoms or comorbidity were more likely to have depression than women who did not. The prevalence of depression varied little by ER/PR status or TNM stage.

Table 2.

Disease characteristics and related prevalence of depression among breast cancer survivors 18 months post-diagnosis

Characteristics N % Prevalence (%)
P value
Without depression (n=1036) Mild depression (n=188) Clinical depression (n=176)
Menopausal symptoms <0.001
 Yes 1156 82.6 71.1 14.6 14.3
 No 244 17.4 87.7 7.8 4.5
Charlson comorbidity index 0.002
 0 1087 77.6 76.2 12.6 11.2
 ≥1 313 22.4 66.5 16.3 17.3
ER/PR status 0.515*
 ER/PR positive 707 50.5 72.1 14.9 13.0
 ER/PR negative 386 27.6 76.4 11.4 12.2
 ER/PR mixed 288 20.6 75.0 12.5 12.5
 ER/PR unknown 19 1.4 79.0 15.8 5.3
TNM stage 0.266*
 0–I 570 40.7 75.6 13.2 11.2
 IIA 456 32.6 72.2 12.5 15.4
 IIB 185 13.2 76.2 15.1 8.7
 III–IV 123 8.8 71.5 13.8 14.6
 Unknown 66 4.7 71.5 13.8 14.6
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*

For the χ2 test, the ‘Unknown’ group was excluded.

Cancer-related treatments and corresponding prevalence of depression are presented in Table 3. Among women who received mastectomy, the prevalence of mild depression was 14% and the prevalence of clinical depression was 13%., whereas among women who received breast-conserving surgery the prevalence of mild depression was 3% and the prevalence of clinical depression was 6%. The prevalence of clinical depression among women who received radiotherapy was 9%, while among women who did not receive radiotherapy the prevalence was 14%. No significant differences were observed in the prevalence of depression by ER/PR status, disease stage, type of surgery, tamoxifen use, chemotherapy, or immunotherapy.

Table 3.

Breast cancer treatment and related prevalence of depression among breast cancer survivors 18 months post-diagnosis

Characteristics N % Prevalence (%)
P value
Without depression (n=1036) Mild depression (n=188) Clinical depression (n=176)
Type of surgery 0.195
 Mastectomy 1320 94.3 73.4 13.7 12.9
 Conservation 33 2.4 90.9 3.0 6.1
 Others 47 3.4 78.7 12.8 8.5
Tamoxifen use 0.677*
 Yes 663 47.4 73.8 14.2 12.1
 No 735 52.5 74.2 12.8 13.1
 Unknown 2 0.1 100.0 0.0 0.0
Chemotherapy 0.840
 Yes 1274 91.0 74.1 13.3 12.6
 No 126 9.0 73.0 15.1 11.9
Radiotherapy 0.004
 Yes 447 31.9 79.2 12.1 8.7
 No 953 68.1 71.6 14.1 14.4
Immunotherapy 0.267*
 Yes 222 15.9 72.1 12.2 15.8
 No 1172 83.7 74.3 13.7 12.0
 Unknown 6 0.4 83.3 0.0 16.7
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*

For the χ2 test, the ‘Unknown’ group was excluded.

Women with lower QOL scores (<median) on each of the 8 scales were more likely to report depression than women with higher QOL scores (≥Median) (Table 4). Compared with women who had higher overall QOL scores, women with lower QOL scores were more likely to report mild depression (19% vs. 8%) or clinical depression (21% vs. 4%). Of women with lower QOL scores on the mental health index, approximately 19% were mildly depressed and 22% were clinically depressed, while of women with higher QOL scores, 8% were mildly depressed and 4% were clinically depressed.

Table 4.

Quality of life and prevalence of depression among breast cancer survivors 18 months post-diagnosis*

Quality of life N % Prevalence of depression (%)
P value
Without depression (n=1036) Mild depression (n=188) Clinical depression (n=176)
Total QOLa score <0.001
  <Median 699 49.9 60.2 18.5 21.3
  ≥Median 701 50.1 87.7 8.4 3.9
QOL summary scores
 Physical health <0.001
  <Median 701 50.1 63.5 15.8 20.7
  ≥Median 699 49.9 84.6 11.0 4.4
 Mental health <0.001
  <Median 701 50.1 58.4 19.7 22.0
  ≥Median 699 49.9 89.7 7.2 3.1
QOL subscale scores
 Physical functioning <0.001
  <Median 672 48.0 64.7 16.2 19.1
  ≥Median 728 52.0 82.6 10.9 6.6
 Social functioning <0.001
  <Median 679 48.5 64.2 16.8 19.0
  ≥Median 721 51.5 83.2 10.3 6.5
 Mental health index <0.001
  <Median 693 49.5 59.0 19.3 21.7
  ≥Median 707 50.5 88.7 7.6 3.7
 General health perceptions <0.001
  <Median 701 50.1 64.5 16.4 19.1
  ≥Median 699 49.9 83.6 10.4 6.0
 Role-physical <0.001
  <Median 1011 72.2 69.9 14.8 15.2
  ≥Median 389 27.8 84.6 9.8 5.7
 Bodily pain <0.001
  <Median 663 47.4 65.6 15.5 18.9
  ≥Median 737 52.6 81.6 11.5 6.9
 Vitality <0.001
  <Median 695 49.6 62.3 17.3 20.4
  ≥Median 705 50.4 85.5 9.7 4.8
 Role-emotional <0.001
  <Median 602 43.0 60.5 18.6 20.9
  ≥Median 798 57.0 84.2 9.5 6.3
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a

QOL: quality of life

Results of multinomial logistic regression analyses are shown in Table 5. Independent predictors for clinical depression were having lower household income (OR: 3.13; 95% CI: 1.51–6.48); being widowed (OR: 1.93; 95% CI: 1.03–3.61), being divorced, separated, or single (OR: 2.84; 95% CI: 1.20–6.74); having a higher comorbidity index score (OR: 1.59; 95% CI: 1.05–2.40); and having a lower QOL score (OR: 9.08; 95% CI: 5.65–14.6). Similar results were found for mild depression. Additionally, women with a higher educational level (>high school) were more likely to have mild depression (OR: 1.82; 95% CI: 1.06–3.10). Women who received radiotherapy were less likely to report clinical depression (OR: 0.53; 95% CI: 0.35–0.80). Other factors were not significantly related to depression.

Table 5.

Multivariate analysis for the association of sociodemographic and clinical characteristics with depression among breast cancer survivors 18 months post-diagnosis*

Characteristics Mild depression OR (95% CI) Clinical depression OR (95% CI)
Age at diagnosis (years)
 <40 1.00 1.00
 40–49 0.95 (0.42–2.16) 3.44 (0.78–15.3)
 50–59 0.91 (0.40–2.08) 2.84 (0.64–12.6)
 ≥60 0.90 (0.38–2.15) 3.91 (0.86–17.8)
Education level
 <High school 1.00 1.00
 High school 1.10 (0.75–1.61) 0.81 (0.54–1.21)
 >High school 1.82 (1.06–3.10) 1.06 (0.57–1.95)
Income (yuan/month/capita)
 ≥2000 1.00 1.00
 1000–1999 2.17 (1.14–4.12) 1.69 (0.82–3.47)
 <1000 3.72 (1.92–7.21) 3.13 (1.51–6.48)
Marital status
 Married 1.00 1.00
 Widowed 2.29 (1.29–4.09) 1.93 (1.03–3.61)
 Divorced/separated/single 2.15 (0.99–4.69) 2.84 (1.20–6.74)
Menopausal symptoms
 No 1.00 1.00
 Yes 1.36 (0.79–2.36) 1.63 (0.81–3.27)
Charlson comorbidity index
 0 1.00 1.00
 ≥1 1.45 (0.98–2.15) 1.59 (1.05–2.40)
Radiotherapy
 No 1.00 1.00
 Yes 0.73 (0.51–1.06) 0.53 (0.35–0.80)
QOL (Mental health index scale)
 <Median 3.82 (2.63–5.55) 9.08 (5.65–14.6)
 ≥Median 1.00 1.00
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*

Obtained from multinomial logistic regression model with mutual adjustment for other factors listed in the table. Cases without depression (total depression score<10) served as the reference. OR: odds ratio; 95% CI: 95% confidence interval

DISCUSSION

In this population-based cohort study, we found that approximately 26% of breast cancer survivors had mild to severe symptoms of depression and 13% met the criteria for clinical depression at 18 months post-diagnosis. Low household income, being single, presence of comorbidity, and low QOL shortly after cancer diagnosis were significantly related to mild and clinical depression. Most clinical features and cancer treatments were not significantly associated with depression. To our knowledge, this is the first study to systematically examine the prevalence of depression and its correlates among Chinese women diagnosed with breast cancer.

The prevalence of depression among breast cancer patients and survivors varies widely among studies, most of which have been conducted in Western populations [1, 2, 4, 10, 11, 13–15, 32–36]. Using the Hospital Anxiety and Depression scale (HADS) in a case-control study of 731 Australian women 23–60 years of age with stage I–IV breast cancer, Osborne et al. reported that 12% of women had depression and 3% had clinical depression at approximately 15 months post-diagnosis [4]. In a study of 115 Caucasian women diagnosed with stage I–IV breast cancer in Croatia, 36.5% of patients fulfilled the criteria for clinical depression as assessed by the CES-D at a median time of 7 months since diagnosis [10]. Another study of 210 US women (90% Caucasian, 9% African American, 1% Hispanic) with stage II–III breast cancer, which also used the CES-D, found that 18% were clinically depressed after surgery but before adjuvant therapy [13]. The prevalence of depression as assessed by the CES-D among 189 breast cancer patients was 22% one year after breast cancer treatment in Netherlands [37]. A South Korean study of 1933 breast cancer survivors with stage 0–III breast cancer reported that 24.9% had moderate to severe depression using the Beck Depression Inventory (BDI) at a mean time 4.6 years after surgery [1]. In our study, we found that the prevalence of clinical depression as assessed by the CES-D at approximately 18 months post-diagnosis was 13% among Chinese women with breast cancer, which is slightly lower than previous findings [1, 10, 11, 13]. It is worth noting that the above studies used different instruments to measure depression (e.g., the CES-D, the HADS, or the BDI). However, it has been shown that these instruments generally compare well and are considered suitable for assessing depression in cancer patients [15, 38, 39]. Differences in study population, timing of the depression assessment, and disease stage may have contributed to variations in the prevalence of depression observed in our and other studies.

Previous studies on the association of sociodemographic and clinical factors with depression have generated inconsistent results. Some research has reported that depression was related to age [2, 15, 18], education [17, 18], and income [1, 15, 17], while others have not [4]. A recent nationwide cohort study of 3343 women treated for early stage breast cancer in Denmark showed that socioeconomically deprived women were vulnerable to depression [15]. In our study, we found that low income was significantly associated with mild and clinical depression, consistent with previous findings [1, 11, 15, 17, 19]. Economic concerns are potential barriers to cancer treatment, and economic stress may lead to depression for breast cancer patients [13, 40]. Low-income, primary care patients have been found to have relatively high rates of depression, but are less likely to receive care for depression or to be prescribed antidepressants [41, 42]. Our findings, in line with previous studies, suggest that routine depression screening for low income women with breast cancer is important.

Only a few studies have suggested that cancer stage [18, 36] or cancer-related treatments [17, 20] are risk factors for depression, whereas the majority of existing research has failed to find such associations. For example, it has been reported that the prevalence of depression varies little by type of surgery [9, 14–16, 34]. Consistent with the majority of studies, we did not find that disease stage, receptor status, or type of surgery was related to depression in our study population.

We also found no association between depression and cancer treatments, including the use of tamoxifen or chemotherapy, which is in line with previous findings [2, 14, 15, 43]. Interestingly, we found that women who received radiotherapy were less likely to have depression. In a randomized, controlled trial of breast cancer patients aged ≥65 years in the UK, Prescott et al. found that women receiving radiotherapy reported less anxiety about recurrence than women who had not received radiotherapy. However, that study did not observe a significant association between receiving radiotherapy and depression [44]. This discrepancy may be the result of different study designs or study populations. Another possible explanation is that women may experience less psychological distress about receiving radiotherapy, since it is typically given to decrease the potential for recurrence or metastasis of breast cancer. Consistent with a recent finding [15], our study indicated that women with a high comorbidity index were more likely to have depression.

Our study also indicated that QOL measured at the baseline survey was significantly and independently associated with depression at 18 months post-diagnosis. Previous studies based on cross-sectional data have shown that depression is inversely related to QOL among breast cancer patients and survivors [1, 8, 45]. Two recent studies observed that the physical functioning aspect of QOL as assessed by the SF-36 was strongly associated with the prevalence of depressive symptoms among women with early stage breast cancer [14, 15]. Similarly, we found a strong association between physical functioning and risk for depression.

Our study has several potential limitations. Although we adjusted for the QOL-related mental health index measured at the baseline interview in the multivariate analyses, confounding from pre-existing depression cannot be ruled out. In our study, women with lower income had a higher prevalence of depression than women with higher income. However, the nature of the relationship between socioeconomic status and depression remains unclear. Finally, due to differences in the aggressiveness of cancer treatments, disease stage distribution, and lifestyle factors (e.g., obesity, physical activity, and dietary intake) between Chinese women and other populations (e.g., U.S. women), the results of the current study may not be directly generalizable to other populations.

In summary, our population-based cohort study indicates that depression is a major concern for breast cancer survivors. Clinicians and other health care providers should be aware of depression and communicate effectively with breast cancer patients and survivors about depression. Low socioeconomic status, being single, presence of comorbidity, and low QOL scores shortly after cancer diagnosis may identify groups or populations of women with breast cancer that are particularly vulnerable to depression. Our cohort study contributes to the existing literature on depression and provides important information for the development of effective strategies to manage depression among women with breast cancer.

Acknowledgments

Funding Sources: This study was supported by grant number DAMD17-02-1-0607 from the Department of Defense Breast Cancer Research Program and grant number R01 CA118229 from the National Institutes of Health (NIH), USA. The content of the information does not necessarily reflect the position or the policy of the government, and no official endorsement should be inferred.

The authors thank Dr. Fan Jin for her support in study implementation and the participants and staff members of the SBCSS for making this study possible. The authors also thank Ms Bethanie Hull for her assistance in manuscript preparation.

Abbreviations Used

BDI

Beck Depression Inventory

CES-D

Center for Epidemiologic Studies Depression Scale

CI

confidence interval

ER

estrogen receptor

HADS

Hospital Anxiety and Depression Scale

ICD-9

International Classification of Disease, 9th revision

MCS

Mental Health Summary

OR

odds ratio

PCS

Physical Health Summary

PR

progesterone receptor

QOL

quality of life

SBCSS

Shanghai Breast Cancer Survival Study

SF-36

Medical Outcomes Short Form-36 Health Survey

TNM

tumor-node metastasis

References

  • 1.Kim SH, Son BH, Hwang SY, et al. Fatigue and depression in disease-free breast cancer survivors: prevalence, correlates, and association with quality of life. J Pain Symptom Manage. 2008;35:644–55. doi: 10.1016/j.jpainsymman.2007.08.012. [DOI] [PubMed] [Google Scholar]
  • 2.Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ. 2005;330:702. doi: 10.1136/bmj.38343.670868.D3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.McDaniel JS, Musselman DL, Porter MR, Reed DA, Nemeroff CB. Depression in patients with cancer. Diagnosis, biology, and treatment. Arch Gen Psychiatry. 1995;52:89–99. doi: 10.1001/archpsyc.1995.03950140007002. [DOI] [PubMed] [Google Scholar]
  • 4.Osborne RH, Elsworth GR, Hopper JL. Age-specific norms and determinants of anxiety and depression in 731 women with breast cancer recruited through a population-based cancer registry. Eur J Cancer. 2003;39:755–62. doi: 10.1016/s0959-8049(02)00814-6. [DOI] [PubMed] [Google Scholar]
  • 5.Groenvold M, Fayers PM, Sprangers MA, et al. Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison? J Clin Epidemiol. 1999;52:523–30. doi: 10.1016/s0895-4356(99)00022-0. [DOI] [PubMed] [Google Scholar]
  • 6.Maraste R, Brandt L, Olsson H, Ryde-Brandt B. Anxiety and depression in breast cancer patients at start of adjuvant radiotherapy. Relations to age and type of surgery. Acta Oncol. 1992;31:641–3. doi: 10.3109/02841869209083846. [DOI] [PubMed] [Google Scholar]
  • 7.Grabsch B, Clarke DM, Love A, et al. Psychological morbidity and quality of life in women with advanced breast cancer: a cross-sectional survey. Palliat Support Care. 2006;4:47–56. doi: 10.1017/s1478951506060068. [DOI] [PubMed] [Google Scholar]
  • 8.Kissane DW, Clarke DM, Ikin J, et al. Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey. Med J Aust. 1998;169:192–6. doi: 10.5694/j.1326-5377.1998.tb140220.x. [DOI] [PubMed] [Google Scholar]
  • 9.Rijken M, de Kruif AT, Komproe IH, Roussel JG. Depressive symptomatology of post-menopausal breast cancer patients: a comparison of women recently treated by mastectomy or by breast-conserving therapy. Eur J Surg Oncol. 1995;21:498–503. doi: 10.1016/s0748-7983(95)96898-9. [DOI] [PubMed] [Google Scholar]
  • 10.Aukst-Margetic B, Jakovljevic M, Margetic B, Biscan M, Samija M. Religiosity, depression and pain in patients with breast cancer. Gen Hosp Psychiatry. 2005;27:250–5. doi: 10.1016/j.genhosppsych.2005.04.004. [DOI] [PubMed] [Google Scholar]
  • 11.Ell K, Sanchez K, Vourlekis B, et al. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol. 2005;23:3052–60. doi: 10.1200/JCO.2005.08.041. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Somerset W, Stout SC, Miller AH, Musselman D. Breast cancer and depression. Oncology (Williston Park) 2004;18:1021–34. [PubMed] [Google Scholar]
  • 13.Golden-Kreutz DM, Andersen BL. Depressive symptoms after breast cancer surgery: relationships with global, cancer-related, and life event stress. Psychooncology. 2004;13:211–20. doi: 10.1002/pon.736. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Bardwell WA, Natarajan L, Dimsdale JE, et al. Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. J Clin Oncol. 2006;24:2420–7. doi: 10.1200/JCO.2005.02.0081. [DOI] [PubMed] [Google Scholar]
  • 15.Christensen S, Zachariae R, Jensen AB, et al. Prevalence and risk of depressive symptoms 3–4 months post-surgery in a nationwide cohort study of Danish women treated for early stage breast-cancer. Breast Cancer Res Treat. 2009;113:339–55. doi: 10.1007/s10549-008-9920-9. [DOI] [PubMed] [Google Scholar]
  • 16.Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ. 1990;301:575–80. doi: 10.1136/bmj.301.6752.575. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Casso D, Buist DS, Taplin S. Quality of life of 5–10 year breast cancer survivors diagnosed between age 40 and 49. Health Qual Life Outcomes. 2004;2:25. doi: 10.1186/1477-7525-2-25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Mehnert A, Koch U. Psychological comorbidity and health-related quality of life and its association with awareness, utilization, and need for psychosocial support in a cancer register-based sample of long-term breast cancer survivors. J Psychosom Res. 2008;64:383–91. doi: 10.1016/j.jpsychores.2007.12.005. [DOI] [PubMed] [Google Scholar]
  • 19.Pinder KL, Ramirez AJ, Black ME, Richards MA, Gregory WM, Rubens RD. Psychiatric disorder in patients with advanced breast cancer: prevalence and associated factors. Eur J Cancer. 1993;29A:524–7. doi: 10.1016/s0959-8049(05)80144-3. [DOI] [PubMed] [Google Scholar]
  • 20.Leedham B, Ganz PA. Psychosocial concerns and quality of life in breast cancer survivors. Cancer Invest. 1999;17:342–8. doi: 10.3109/07357909909032876. [DOI] [PubMed] [Google Scholar]
  • 21.Lu W, Cui Y, Chen X, et al. Changes in quality of life among breast cancer patients three years post-diagnosis. Breast Cancer Res Treat. 2009;114:357–69. doi: 10.1007/s10549-008-0008-3. [DOI] [PubMed] [Google Scholar]
  • 22.Chen Z, Gu K, Zheng Y, Zheng W, Lu W, Shu XO. The use of complementary and alternative medicine among Chinese women with breast cancer. J Altern Complement Med. 2008;14:1049–55. doi: 10.1089/acm.2008.0039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Grunau GL, Sheps S, Goldner EM, Ratner PA. Specific comorbidity risk adjustment was a better predictor of 5-year acute myocardial infarction mortality than general methods. J Clin Epidemiol. 2006;59:274–80. doi: 10.1016/j.jclinepi.2005.08.007. [DOI] [PubMed] [Google Scholar]
  • 24.Department of Health and Human Services. Clinical modification, ICD-9-CM. 9. Washington, DC: U.S Government Printing Office; 1998. The international classification of diseases. [Google Scholar]
  • 25.Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalisation. J Epidemiol Community Health. 2003;57:259–63. doi: 10.1136/jech.57.4.259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Trentham-Dietz A, Sprague BL, Klein R, et al. Health-related quality of life before and after a breast cancer diagnosis. Breast Cancer Res Treat. 2008;109:379–87. doi: 10.1007/s10549-007-9653-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Buijs C, Rodenhuis S, Seynaeve CM, et al. Prospective study of long-term impact of adjuvant high-dose and conventional-dose chemotherapy on health-related quality of life. J Clin Oncol. 2007;25:5403–9. doi: 10.1200/JCO.2007.11.2813. [DOI] [PubMed] [Google Scholar]
  • 28.Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Appllied Psychological Measurement. 1977;1:385–401. [Google Scholar]
  • 29.Lin N. Measuring depressive symptomatology in China. J Nerv Ment Dis. 1989;177:121–31. doi: 10.1097/00005053-198903000-00001. [DOI] [PubMed] [Google Scholar]
  • 30.Rumpf HJ, Meyer C, Hapke U, John U. Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard. Psychiatry Res. 2001;105:243–53. doi: 10.1016/s0165-1781(01)00329-8. [DOI] [PubMed] [Google Scholar]
  • 31.Holmes WC. A short, psychiatric, case-finding measure for HIV seropositive outpatients: performance characteristics of the 5-item mental health subscale of the SF-20 in a male, seropositive sample. Med Care. 1998;36:237–43. doi: 10.1097/00005650-199802000-00012. [DOI] [PubMed] [Google Scholar]
  • 32.Yeter K, Rock CL, Pakiz B, Bardwell WA, Nichols JF, Wilfley DE. Depressive symptoms, eating psychopathology, and physical activity in obese breast cancer survivors. Psychooncology. 2006;15:453–62. doi: 10.1002/pon.974. [DOI] [PubMed] [Google Scholar]
  • 33.Goodwin JS, Zhang DD, Ostir GV. Effect of depression on diagnosis, treatment, and survival of older women with breast cancer. J Am Geriatr Soc. 2004;52:106–11. doi: 10.1111/j.1532-5415.2004.52018.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Schou I, Ekeberg O, Ruland CM, Sandvik L, Karesen R. Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology. 2004;13:309–20. doi: 10.1002/pon.747. [DOI] [PubMed] [Google Scholar]
  • 35.Ramirez AJ, Richards MA, Jarrett SR, Fentiman IS. Can mood disorder in women with breast cancer be identified preoperatively? Br J Cancer. 1995;72:1509–12. doi: 10.1038/bjc.1995.538. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Aapro M, Cull A. Depression in breast cancer patients: the need for treatment. Ann Oncol. 1999;10:627–36. doi: 10.1023/a:1008328005050. [DOI] [PubMed] [Google Scholar]
  • 37.van Wilgen CP, Dijkstra PU, Stewart RE, Ranchor AV, Roodenburg JL. Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer. Psychosomatics. 2006;47:465–70. doi: 10.1176/appi.psy.47.6.465. [DOI] [PubMed] [Google Scholar]
  • 38.Hann D, Winter K, Jacobsen P. Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D) J Psychosom Res. 1999;46:437–43. doi: 10.1016/s0022-3999(99)00004-5. [DOI] [PubMed] [Google Scholar]
  • 39.Berard RM, Boermeester F, Viljoen G. Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management. Psychooncology. 1998;7:112–20. doi: 10.1002/(SICI)1099-1611(199803/04)7:2<112::AID-PON300>3.0.CO;2-W. [DOI] [PubMed] [Google Scholar]
  • 40.Kasper AS. Experience of low-income women with breast cancer: Final report to the Agency for Health Care Policy and Research. Center for Research on Women and Gender, University of Illinois; Chicago, IL: 1999. [Google Scholar]
  • 41.Miranda J, Cooper LA. Disparities in care for depression among primary care patients. J Gen Intern Med. 2004;19:120–6. doi: 10.1111/j.1525-1497.2004.30272.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA. 2002;287:203–9. doi: 10.1001/jama.287.2.203. [DOI] [PubMed] [Google Scholar]
  • 43.Patten SB, Barbui C. Drug-induced depression: a systematic review to inform clinical practice. Psychother Psychosom. 2004;73:207–15. doi: 10.1159/000077739. [DOI] [PubMed] [Google Scholar]
  • 44.Prescott RJ, Kunkler IH, Williams LJ, et al. A randomised controlled trial of postoperative radiotherapy following breast-conserving surgery in a minimum-risk older population. The PRIME trial. Health Technol Assess. 2007;11:1–149. iii–iv. doi: 10.3310/hta11310. [DOI] [PubMed] [Google Scholar]
  • 45.Weitzner MA, Meyers CA, Stuebing KK, Saleeba AK. Relationship between quality of life and mood in long-term survivors of breast cancer treated with mastectomy. Support Care Cancer. 1997;5:241–8. doi: 10.1007/s005200050067. [DOI] [PubMed] [Google Scholar]

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