An observational cross-sectional study on breast cancer patients’ knowledge of their disease: A likely cause of depression and anxiety

Marta Peixoto; Sara Póvoa; Mónica Mariano; Sofia Broco; Pedro Madeira; António Pêgo; Teresa Carvalho; Isabel Pazos; Gabriela Sousa

doi:10.12688/f1000research.109417.1

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Research Article

An observational cross-sectional study on breast cancer patients’ knowledge of their disease: A likely cause of depression and anxiety

[version 1; peer review: 1 approved with reservations]

Marta Peixoto ¹, Sara Póvoa¹, Mónica Mariano¹, [...] Sofia Broco¹, Pedro Madeira¹, António Pêgo¹, Teresa Carvalho¹, Isabel Pazos¹, Gabriela Sousa¹

Marta Peixoto ¹, Sara Póvoa¹, [...] Mónica Mariano¹, Sofia Broco¹, Pedro Madeira¹, António Pêgo¹, Teresa Carvalho¹, Isabel Pazos¹, Gabriela Sousa¹

PUBLISHED 02 Sep 2022

Author details Author details

¹ Department of Medical Oncology, Instituto Português de Oncologia de Coimbra, Francisco Gentil, EPE, Coimbra, Coimbra, 3000-075, Portugal

Marta Peixoto
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation

Sara Póvoa
Roles: Conceptualization, Investigation, Methodology, Validation, Visualization, Writing – Review & Editing

Mónica Mariano
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing

Sofia Broco
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing

Pedro Madeira
Roles: Conceptualization, Writing – Review & Editing

António Pêgo
Roles: Conceptualization, Writing – Review & Editing

Teresa Carvalho
Roles: Conceptualization, Writing – Review & Editing

Isabel Pazos
Roles: Conceptualization, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Gabriela Sousa
Roles: Conceptualization, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Oncology gateway.

Abstract

Background: This study aimed to assess breast cancer awareness among patients undergoing active treatment for breast cancer at Day Hospital, assess their quality of life (QoL), and explore the association between minor knowledge of the disease and higher levels of anxiety.
Methods: This prospective observational study included patients with breast cancer undergoing active treatment at the Instituto Português de Oncologia Coimbra. The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30, QLQ-INFO25, and the Hospital Anxiety and Depression Scale (HADS) were completed, and demographic and clinical data were collected and processed using SPSSÒ.
Results: In total, 188 patients with breast cancer were included. A vast majority had a positive perception of their QoL, with a higher average value compared to “cognitive functioning” (c=77.22±22.53), “social functioning” (76.86±25.41), and “physical functioning” (75.67±17.24). Regarding the information received, an overall “score” below the “cut-off line” (47.96±14.40) was observed. When evaluating “satisfaction” in isolation, the average value for “satisfaction with the information received” was 53.55±23.99, and patients perceived that the information received was beneficial to them (67.38±23.87) and did not wish to have received less information (99.47±7.29). With decreased functionality, higher levels of depression and anxiety were observed (p<0.0001). Regarding “information related to illness and anxiety/depression”, it was noted that as satisfaction with information decreased, patients tended to have higher levels of anxiety/depression (p<0.013).
Conclusions: It is necessary to create dedicated spaces for information and clinical clarification, with regular assessments of patients’ perceptions. The information provided must be reinforced through written or digital support, or brochures.

Keywords

anxiety, depression, breast cancer, disease knowledge, disease information, quality of life

Corresponding author: Marta Peixoto

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Peixoto M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Peixoto M, Póvoa S, Mariano M et al. An observational cross-sectional study on breast cancer patients’ knowledge of their disease: A likely cause of depression and anxiety [version 1; peer review: 1 approved with reservations]. F1000Research 2022, 11:992 (https://doi.org/10.12688/f1000research.109417.1) First published: 02 Sep 2022, 11:992 (https://doi.org/10.12688/f1000research.109417.1) Latest published: 02 Sep 2022, 11:992 (https://doi.org/10.12688/f1000research.109417.1)

Introduction

Cancer, especially breast cancer, has been widely studied from different perspectives, including searching for information on the psychological impact of the disease.

Some authors describe information as a remarkable therapeutic tool that can be used in any physician-patient interaction.¹ Better communication skills in patient-doctor consultation have been linked to higher patient satisfaction, better health outcomes, greater adherence to treatment² and reductions in anxiety and mood disturbances.³^–⁵

Patients who were more involved in their consultation also reported a higher quality of life (QoL). These findings emphasise the importance of facilitating patient participation in decision-making to achieve their desired involvement.⁶

To better address their wishes and thus minimise the fault with changes in information-sharing patterns between breast cancer patients, it is important to understand the need for information of women with breast cancer. Beyond patients’ access to healthcare information, the level of satisfaction with the information received is equally crucial, because satisfaction with healthcare information has been associated with increased quality of life and decreased levels of psychological distress.⁷^,⁸ However, not all studies have demonstrated this association. Some studies have reported a negative relationship between access to and satisfaction with healthcare information and patient health outcomes.⁹^,¹⁰ Another study did not find a significant influence of healthcare information on patients´ levels of depression, anxiety, and QoL.¹¹

This study aimed to identify cancer patients’ perceptions of the quantity and quality of information provided in patient-physician consultations. It further intended to assess the QoL of patients and the possible relationship between a lack of information/QoL and higher levels of anxiety and depression.

This study can also contribute to a better understanding of patients’ needs and possibly allow the adjustment of medical consultations to address these needs. Breast cancer, due to its representativeness in terms of volume of day hospital treatments, encompasses patients at various stages of the disease; therefore, it is an effective and reproducible study population.

Methods

Study design and participants

Sampling strategy

During the four-week study period, breast cancer patients receiving any line of treatment (chemotherapy or biological agents) at Instituto Português Oncologia Coimbra Francisco Gentil (IPOCFG) Day Hospital were identified and invited to participate in the study. Participation occurred only after providing signed informed consent. The same person (Marta Peixoto) explained what the project entailed and supplied the questionnaire to all patients included in this study; questionnaires were handed out in a printed-paper format and self-reported on that same day, during the hospital stay.

Eligible patients were adults (≥ 18 years old), who had a history of invasive breast cancer, and received any line of treatment (chemotherapy or biological agents) at IPOCFG Day Hospital in Portugal. A total of 188 patients with breast cancer consented to participate in the study and the questionnaires were completed between January and February 2020.

Exclusion criteria

Illiterate patients or those with cognitive impairment or hearing loss were excluded.

Approval (41/2019) was obtained from the Instituto Português de Oncologia de Coimbra Francisco Gentil Ethics committee in accordance with the Declaration of Helsinki.

Questionnaires

Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3), EORTC QLQ-INFO25, and Hospital Anxiety and Depression Scale (HADS), validated for Portuguese.

The QLQ-C30 (v. 3.0) is a validated, widely used questionnaire that is suitable for observational, experimental, and randomised clinical trials; it contains five functional scales (physical, role, emotional, social, and cognitive function), nine symptom scales (fatigue, nausea and vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhoea, and financial difficulties), and one global health status/QoL scale. It also contains 30 questions, and the response format is a four-point Likert scale (1=not at all, 2=a little, 3=quite a bit, and 4=very much) for questions 1–28. The response format for questions 29 and 30 is a seven-point scale (ranging from 1 [very poor] to 7 [excellent]). The questions were answered by circling the option the patient considered applicable to him/her.

QLQ-INFO25 (hereafter referred to as INFO25) is a module of the EORTC QLQ-C30 that can be used in clinical practice and research to evaluate information-based interventions and programs.¹¹ It contains four multi-item scales (information about the disease, medical tests, treatments, and other services) and eight single items (places of care, self-help to get well, information channels, and information satisfaction and usefulness). INFO25 also includes two open questions related to the answers of questions 53 and 54, allowing patients to write about topics of their choice. Overall, INFO25 comprises 25 questions on a four-point Likert scale response format, except for dichotomous (yes/no) questions 50, 51, 53, and 54.

The HADS consists of two subscales: one measuring anxiety, with seven items, and the other measuring depression, with seven items scored separately. Each item was answered by the patient on a four-point (0–3) response scale. Thus, possible scores ranged from 0 to 21 for anxiety and depression. The HADS manual indicates that a score between 0 and 7 is “normal”; between 8 and 10, “borderline”; between 11 and 14, “moderate”; and between 15 and 21, “severe”.¹²

Sociodemographic and clinical data including sex, age, marital status, education level, profession, nationality, Eastern Cooperative Oncology Group (ECOG) performance status (PS), disease extent, line of treatment and if the patient was included in a clinical trial was collected by direct questioning of patients.

Outcomes

The primary outcome was an assessment of disease knowledge, QoL, and expectations among breast cancer patients under active treatment at a daily hospital of a comprehensive cancer centre.

The secondary outcome was an assessment of QoL and an exploration of the association between less knowledge of the disease and higher levels of anxiety and depression.

Statistical analysis

All statistical analyses were performed using IBM SPSS 23.0 program (Statistical Package for the Social Sciences) (IBM SPSS Statistics, RRID:SCR_016479) for Windows.

Descriptive and analytical statistics were used for data analysis. Absolute and percentage frequencies were determined according to the characteristics of the variables under study (measures of central tendency or location: mean, mode, and median; measures of variability or dispersion: coefficient of variation and standard deviation; and measures of asymmetry and flatness).

Regarding inferential statistics, non-parametric statistics were used because the requirements for the use of parametric statistics were not met. Thus, the Kolmogorov-Smirnov test was used to study the normality of the distribution of variables, and the Levene test was used to study the homogeneity of the variances. For non-parametric statistics, Spearman's correlation was used.

In the statistical analysis, the following significance values were used: p<0.05, statistically significant difference; p≥0.05, non-significant statistical difference.

Sample size was estimated using G*Power software version 3.1 (G*Power, RRID:SCR_013726).¹³ The minimum sample size required was 159 patients to have statistical power of 0.95 with a significance value of 0.05.

Results

Demographic data

The sex distribution was heterogeneous, 98.4% were women and 1.6% were men. The median age at diagnosis was 54 (range 25-84) years, and the majority of patients (28.7%) were aged between 51 and 60 years, followed by 27.1% aged between 41 and 50 years. Regarding marital status, the majority were married (66.5%). The level of education had a heterogeneous distribution: 49.5% had high school or 12 years of education; 27.1% had primary school education, and 23.4% had a university degree. Regarding occupation, using the Portuguese classification of occupations, the majority of patients (23.4%) were workers in personal and protective services, followed by 19.1% skilled industry workers, and 17.6% specialists in intellectual and scientific activities (Table 1¹⁴).

Table 1. Distribution of patients according to demographic variables.

Demographic data	n	%
Sex
Female	185	98.4
Male	3	1.6
Age group, years
21-30	3	1.6
31-40	18	9.6
41-50	51	27.1
51-60	54	28.7
61-70	46	24.5
71-80	12	6.4
81-90	3	1.6
Didn’t answer	1	0.5
Marital status
Married	125	66.5
Single	19	10.1
Civil union	7	3.7
Divorced	24	12.8
Widow	13	6.9
Education level
Primary school	51	27.1
High school	93	49.5
University education	42	22.3
Doctorate	2	1.1
Profession
Representatives of the legislative power and organs	2	1.1
Specialists in intellectual and scientific activities	33	17.6
Intermediate level technicians and professions	21	11.2
Administrative staff	11	5.9
Personal, protection services workers	44	23.4
Farmers and Skilled Workers	2	1.1
Skilled Industry Workers	36	19.1
Facility and Machine Operators	7	3.7
unskilled workers	32	17.0
Nationality
Portuguese	186	99.0
Brazilian	2	1.1
Total	188	100.0

Clinical data

ECOG PS was applied to all patients and 99.5% had no limitations, with an ECOG score of 0. Most patients had early breast cancer (72.3%); 38.3% received adjuvant treatment, and 34% received neoadjuvant treatment. Advanced disease was identified in 27.7% of the patients (14.9% received first-line palliative chemotherapy and 8% received third-line palliative chemotherapy).

Clinical data are summarised in Table 2.

Table 2. Distribution of patients according to clinical variables.

Clinical variables	n	%
Performance status (ECOG)
0	187	99.5
1	1	0.5
Disease extent
Limited	136	72.3
Metastatic	52	27.7
Line of treatment
Neo-adjuvant	64	34.0
Adjuvant	72	38.3
Metastatic	52	27.7
- 1^st	28	14.9
- 2^nd	9	4.8
- ≥3^rd	15	8.0
Clinical trial
yes	6	3.2
No	182	96.8
Total	188	100.0

Characterisation of QoL/Health status perceived by patients

The EORTC QLQ-30 assessed QoL with an average global value obtained at 58.95±18.13 (for a maximum of 100).

The analysis by functional scales showed that the “cognitive” subscale had the highest mean value (χ=77.22±22.53), followed by “social” (χ=76.86±25.41) and “physical” (χ=75.67±17.24) subscales. With the exception of the “emotional” (χ=68.53±23.78) subscale, the mean values obtained were higher than 70.

Regarding symptom scales (0% corresponds to the absence of symptoms and 100% to the presence of elevated symptoms), all mean values verified were much lower than the midpoint of the questionnaire (50). “Fatigue” was the most reported symptom by patients (χ=35.70±22.39), followed by “insomnia” (χ=34.22±30.14), “financial difficulties” (χ=33.33±35.15), and “pain” (χ=26.51±23.80). For other symptoms, such as “nausea and vomiting”, “dyspnoea”, and diarrhoea”, the mean values were less than 10 (Table 3).

Table 3. Descriptive statistics regarding the results verified with the EORTC QLQ-30 questionnaire.

	EORTC QLQ-C30	χ	SD	Minimum observed	Maximum observed
	Sub-scales	χ	SD	Minimum observed	Maximum observed
Functional scale	Physical	75.67	17.24	26.67	100
	Role	71.54	26.50	0	100
	Emotional	68.53	23.78	0	100
	Cognitive	77.22	22.53	0	100
	Social	76.86	25.41	0	100
Symptoms scale	Fatigue	35.70	22.39	0	100
	Nausea/vomiting	7.62	13.50	0	83.33
	Pain	26.51	23.80	0	100
	Dyspnoea	8.86	18.68	0	100
	Insomnia	34.22	30.14	0	100
	Loss of appetite	14.54	22.37	0	100
	Constipation	17.38	27.89	0	100
	Diarrhoea	9.57	20.46	0	100
	Financial impact	33.33	35.15	0	100
Global health status/quality of life		58.95	18.13	0	100

Characterisation of information received by patients and their satisfaction

In order to evaluate the information received by patients and their satisfaction, the EORTC QLQ-INFO25 questionnaire was used.

The global score was lower than the cut-line (χ=47.96±14.40) with the average values oscillating between a minimum of 16.67 and a maximum of 80.79. Patients under study considered the information received about their disease insufficient, and they were negatively satisfied with it.

Regarding “information related to the disease”, the average values were greater than 50 only in the following subscales: “medical examination” (χ=58.98±24.02), “information about treatments” (χ=56.09±22.02), and “written information” (χ=55.85±49.79). It should be noted that in relation to “other services” (home services, physiotherapy, occupational therapy, psychology, etc.), the average value found was 10.55±12.99 and information in digital support was 4.25±20.24. As for the dimension of “satisfaction,” the average value of “satisfaction with the information received” was 53.55±23.99, and patients were aware that the information received was useful to them (67.38±23.87). Patients did not wish to receive less information about their disease (99.47±7.29) (Table 4).

Table 4. Descriptive statistics regarding the results verified with the EORTC QLQ-INFO25 questionnaire.

	EORTC QLQ-INFO 25	χ	SD	Minimum observed	Maximum observed
	Subscales	χ	SD	Minimum observed	Maximum observed
Information related to the disease	Information about the disease	49.60	20.76	8.33	100
	Medical tests	58.98	24.02	0	100
	Treatments	56.09	22.02	0	100
	Other services	10.55	12.99	0	66.67
	Places of care	31.56	30.58	0	100
	Self-help to get well	42.02	28.24	0	100
	Written information	55.85	49.79	0	100
	CD/Video information	4.25	20.24	0	100
Satisfaction	Satisfaction with the information received	53.55	23.99	0	100
	Desire to receive more information	46.27	49.99	0	83.33
	Desire to receive less information	99.47	7.29	0	100
	Overall, the information was useful	67.38	23.87	0	100
Global score		47.96	14.40	16.67	80.79

The INFO25 questionnaire contained two open questions that the patients were asked to answer. Patients could freely list topics they wanted to receive more information about (question number 53b in the case of an affirmative response to 53a) or less information about (question number 54b following an affirmative response to 54a). In our study, majority of the patients (53.7%) wanted to receive more information about their disease.

Characterisation of anxiety and depression manifested by patients

The HADS was applied to all patients to detect the presence/absence and severity of anxiety/depression.

Table 5 shows that the mean value observed was higher for depression (χ=8.07±3.92) compared to anxiety (χ=6.01±3.76), with a maximum of 21.

Table 5. Descriptive statistics regarding the results verified with the HADS.

HADS	χ	SD	Minimum observed	Maximum observed
Depression	8.07	3.92	0	21
Anxiety	6.01	3.76	0	18

Table 6 represents the distribution of patients according to the reference values of the HADS score (score between 0 and 7 is “normal”, between 8 and 10 is “borderline”, between 11 and 14 is “moderate”, and between 15 and 21 is “severe”). It shows that majority (64.7%) of patients had “normal” levels of anxiety, 44.9% were not depressed, and 32.1% had a clinical picture of borderline depression (Table 5 and Table 6).

Table 6. Distribution of patients according to the presence/intensity of anxiety and depression.

HADS	n	%
Depression (scores)
Normal (0-7)	85	45.2
Borderline (8-10)	60	31.9
Moderate (11-14)	34	18.1
Severe (15-21)	9	4.8
Anxiety (scores)
Normal (0-7)	122	64.9
Borderline (8-10)	45	23.9
Moderate (11-14)	18	9.6
Severe (15-21)	3	1.6
Total	188	100.0

Relationship between levels of anxiety/depression, patients’ perception of QoL, and information received

The relationship between levels of anxiety and depression manifested by patients and their perception of life (QoL) and health status (Spearman’s correlation) showed that the correlation was negative and significant (p<0.000). As patients’ functionality (QoL) decreases, they tend to show higher levels of depression and anxiety.

In the “symptoms scale”, the correlation was positive in most subscales and significant in relation to depression and anxiety (except for the “nausea and vomiting”/“anxiety” subscale). As the intensity of symptoms increases, patients tend to show higher levels of anxiety and depression (Table 7).

Table 7. Statistical results related to the application of the Spearman’s correlation coefficient, the quality of life perceived by patients and the levels of depression and anxiety experienced.

	EORTC QLQ-C30	Depression		Anxiety
	Sub-scales	ró Spearman	p	D	p
Functional scale	Physical	-0.318	0.000	-0.445	0.000
	Role	-0.336	0.000	-0.423	0.000
	Emotional	-0.600	0.000	-0.417	0.000
	Cognitive	-0.362	0.000	-0.363	0.000
	Social	-0.341	0.000	-0.395	0.000
Symptoms scale	Fatigue	0.418	0.000	0.489	0.000
	Nausea/vomiting	0.211	0.004	0.131	0.073
	Pain	0.414	0.000	0.413	0.000
	Dyspnoea	0.321	0.000	0.292	0.000
	Insomnia	0.393	0.000	0.267	0.000
	Loss of appetite	0.264	0.000	0.190	0.009
	Constipation	0.220	0.002	0.218	0.003
	Diarrhoea	0.227	0.002	0.261	0.000
	Financial impact	0.172	0.018	0.227	0.002
Global health status/quality of life		-0.327	0.000	-0.460	-0.000

According to the information received by patients and its possible relation to higher levels of anxiety and depression, in “Information related to the disease”, the correlation was negative and statistically significant in relation to depression and anxiety in the following subscales: “medical tests”, “treatments”, “other services”, “self-help to get well”, and “places of care” (only anxiety).

Taking “satisfaction” into account, the correlation was negative and significant in relation to anxiety and depression, in the following subscales: “satisfaction with the information received” and “overall, the information was useful.” Globally, as satisfaction with information about their disease decreased, patients tended to show higher levels of anxiety (p<0.001) and depression (p<0.003) (Table 8).

Table 8. Statistical results regarding the application of the Spearman’s correlation coefficient, the information received by patients, and their levels of depression and anxiety experienced.

	EORTC QLQ-INFO 25	Depression		Anxiety
	Subscales	ró Spearman	p	D	p
Information related to the disease	Information about the disease	-0.118	0.108	-0.131	0.073
	Medical tests	-0.169	0.021	-0.189	0.009
	Treatments	-0.169	0.021	-0.216	0.003
	Other services	0.324	0.000	-0.289	0.000
	Places of care	-0.045	0.538	-0.171	0.019
	Self-help to get well	-0.226	0.002	-0.291	0.000
	Written information	-0.141	0.054	-0.080	0.277
	CD/Video information	-0.089	0.222	-0.101	0.169
Satisfaction	Satisfaction with the information received	-0.165	0.024	-0.181	0.013
	Desire to receive more information	-0.091	0.215	-0.053	0.471
	Desire to receive less information	0.027	0.713	0.045	0.543
	Overall, the information was useful	-0.189	0.010	-0.250	0.001
Global score		-0.214	0.003	-0.245	0.001

Discussion

Breast cancer patients represent a large proportion of the patients at our institution’s day hospital. Its representativeness allowed us to draw conclusions about this patient population.

The patients in the study had a positive perception of their overall health status and QoL. When evaluating several dimensions of QoL, patients reported higher levels of cognitive, physical, and social functionality.

Most patients had normal levels of anxiety, and almost one-half were not depressed. However, almost one-third of patients had a clinical picture of borderline depression. Early intervention in this particular area may be crucial.

Regarding the INFO25 questionnaire, patients under study considered the information received about their disease insufficient, and they were negatively satisfied. Patients reported higher levels of satisfaction with respect to information regarding medical examinations, treatments, and written information. However, it should be noted that in relation to “other services” (home services, physiotherapy, occupational therapy, psychology, etc.) and information in digital support, patients reported receiving insufficient information. The patients were aware that the information was useful to them; however, they did not wish to have received less information about their disease. By contrast, they would like to receive more information. Most would like to know more about the evolution of their disease and the treatment options.

Regarding the perception of the information received, QoL, and levels of anxiety and depression, when patients’ functionality decreases, they tend to show higher levels of depression and anxiety. The same could be said regarding satisfaction with information about their disease (patients tend to show higher levels of anxiety and depression when satisfaction decreases). Thus, patients want to know more about their illness, which can affect the emotional quality felt by them.

Clinical implications

It is therefore important to improve doctor-patient communication, since by intervening in this area, we can allay patients’ anxiety and consequently improve their QoL. It is also necessary to create dedicated spaces for information and clinical clarification, with regular assessment of patients’ perceptions. The information provided must be reinforced through written support, brochures, or digital support.

Study limitations

This study involved only one institution; therefore, the findings may not be generalisable to other institutions. Only patients with breast cancer were included in the study. We are yet to determine if these findings apply to other patient groups as well. Also, other factors associated with anxiety and depression, rather than disease knowledge, were not analysed. Their influence on the overall anxiety and depression scores was not determined. Some of these questions can be answered in future.

Conclusions

Patients under study considered the information received about their disease insufficient, and they were not satisfied with that. There is a relationship between the level of satisfaction with the information received and the level of anxiety and depression experienced by patients. Thus, as satisfaction decreases, patients tend to show higher levels of anxiety and depression. The same can be said about the perception of QoL/symptom control. As symptom control decreases, patients tend to show higher levels of anxiety and depression.

Therefore, patient-physician communication is an area that requires urgent attention. Early intervention by a psychologist/psychiatrist is key for this group of patients.

Data availability

Underlying data

Dryad: ‘Breast cancer patients’ knowledge. Results of EORTC QLQ30, QLQ-INFO25 and HADS’. https://doi.org/10.5061/dryad.05qfttf4t.¹⁴

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgments

We would like to thank João Reis (JR), trained in the area of statistics, for helping with the statistical procedures involved in the manuscript.

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