Associations between social support, prevalent symptoms and health-related quality of life in Chinese women undergoing treatment for breast cancer: A cross-sectional study using structural equation modelling

Abstract

Background

There is little in the literature exploring the inter-relationship of social support, prevalent symptoms and health-related quality of life (HRQoL) among breast cancer patients. This study examines the inter-relationships among the three variables using the ‘Theory of Unpleasant Symptoms’ as a framework.

Methods

279 Chinese breast cancer patients undergoing treatment were recruited for face-to-face interviews. The instruments used were Chinese versions of the Brief Fatigue Inventory, Brief Pain Inventory, Hospital Anxiety and Depression Scales, Medical Outcomes Study Social Support Survey and Functional Assessment of Cancer Therapy for Breast Cancer.

Results

Goodness-of-fit and misfit indices were obtained for the final model (SRMR = 0.034, robust RMSEA = 0.051 and robust CFI = 0.981), and the results showed that social support had large total effects on social/family (total effect = 0.704, P < 0.05) and functional well-being (total effect = 0.450, P < 0.05), but a minimal effect on the breast cancer scale (total effect = 0.036, P > 0.05).

Conclusions

The inter-relationships among the three variables give us a better understanding of breast cancer patients' experience and provide guidance for developing effective strategies to improve their HRQoL and relieving unpleasant symptoms.

Introduction

Breast cancer is the most prevalent invasive cancer among women in Hong Kong. In 2009, there were 2945 new cases diagnosed and 555 deaths from the disease (Hong Kong Hospital Authority Cancer Registry, 2011). It was also the sixth major cause of death from cancer in China in 2006 (Chen and Kong, 2010). With recent advances in breast cancer treatment, the survival rate has greatly increased, with a prolonged lifespan, but the cancer- and treatment-related symptoms are still highly distressful for such patients.

According to the National Institute of Health (NIH), fatigue, pain and depression are the most common cancer- and treatment-related symptoms experienced by cancer patients (Patrick et al., 2003). They correlate significantly with each other and always present in a cluster (So et al., 2009). Additionally, anxiety is one of the major emotions in cancer patients to affect the patient's health-related quality of life (HRQoL) adversely (National Cancer Institute, 2011). According to the previous research we conducted among Chinese patients receiving breast cancer treatment, most had a mild to moderate level of fatigue and pain, while 21% and 36% respectively reported anxiety and depression disorder. Patients receiving chemotherapy experienced higher levels of these symptoms and lower HRQoL than those not receiving such treatment (So et al., 2010).

Several studies have found that social support is a major positive factor to affect patients' HRQoL and their experience of cancer- and treatment-related symptoms (Jones et al., 2012; Manning-Walsh, 2011). Sherbourne and Stewart (1991) concluded that the type of social support that patients perceived could be generalised into four categories (a) emotional/informational support, (b) tangible support, (c) affectionate support and (d) positive social interaction. There have been numerous studies investigating the associations between different aspects of social support, symptom distress and HRQoL. Higher social support is associated with all domains of HRQoL, except physical well-being (Kwan et al., 2010). Breast cancer patients who have received a psycho-educational support programme enjoy better emotional, functional and social/family well-being and have higher scores on the breast cancer-specific subscale than those who have not (Park et al., 2012). Adequate emotional and informational support predicts better global health and functionality and lower intensity of symptoms in Brazilian breast cancer patients (Ferreira et al., 2011). Furthermore, Caucasians breast cancer patients, who receive more personal support from friends and family, report less symptom distress and a better overall HRQoL (Manning-Walsh, 2005).

Chinese people may have different beliefs and coping strategies because of cultural differences which could affect their experience of cancer. Confucianism is one of the major fundamental philosophies that guide Chinese belief and behaviour, and emphasises ren, yi and li, li representing the proper way a person should behave in his social life (Kupperman, 1999). While Westerners emphasise religious belief in coping with cancer, Chinese patients emphasise family support and caring. Beliefs and values related to the family are very important to Chinese. Zeng et al. (2011) found that some cancer patients were afraid of ‘being a burden on the family’, and the change in household roles and in responsibility for daily chores had a negative effect on their social well-being (Zeng et al., 2011). Liu et al. (2011) found that ‘fear of family being harmed’ contributed significantly to the severity of depressive symptoms, while objective social support (behaviour that directly helps the person in need) significantly decreased it in breast cancer patients. Patients with adequate social support were found to have less anxiety and depressive symptoms. These features, concerning cultural beliefs and social support systems, may affect the Chinese patient's emotions, ability to cope with disease and HRQoL.

From the above findings, it is clear that social support, symptoms and HRQoL are the three major variables affecting the experience of breast cancer. However, previous studies usually took the situation as a simple associative relationship between two variables, or studied the variables as a single item instead of one with multiple dimensions (Manning-Walsh, 2005; Park et al., 2012). There is a lack of research investigating in detail inter-relationships among different domains of the three major variables. Additionally, studies conducted in Chinese communities are limited but, since Chinese culture differs from that of other ethnic groups, findings from such groups may not be directly applicable in the Chinese context.