World Journal of Psycho-Social Oncology Volume No 5

Research Open Access

A Stage Wise Comparison of Psychological Distress and Quality of Life in Breast Cancer: A Cross-Sectional Study

* Sagarika Das,* Prasanta Kumar Roy

  • *Department of Clinical Psychology, Institute of Psychiatry- A Centre of Excellence, 7 D. L .Khan Road, Kolkata- 700025, India.
  • Submitted:Monday, February 4, 2019
  • Accepted: Friday, March 8, 2019;
  • Published: Monday, March 11, 2019

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



In India, breast cancer has been found to be the most frequently diagnosed cancer in women, accounting for almost 25% to 31% of all cancers. The impact of a cancer diagnosis may lead to several emotional consequences leading to changes in the functional, social and psychological aspects of the patient’s life. The aim of the current study was to compare Psychological distress (depression, anxiety and trauma) and Quality of life in the initial, middle and advanced stages of breast cancer.

Study design:

A cross-sectional observational comparative study.

Materials and methods:

Purposive sampling was used to study 30 women (28 to 59 years old) with breast cancer in the initial, middle and advanced stages (10 in each stage). The Clinical Outcomes in Routine Evaluation and WHOQOL-BREF was used.


Fifty three percent of the women were found to have symptoms of depression, anxiety and trauma; however the three stages did not differ with respect to the studied variables. Psychological distress was found to be associated with reduced quality of life.


Results show that psychological interventions are needed to aid the overall cancer experience irrespective of the stage at diagnosis in order to improve patient’s quality of life.


cancer staging, anxiety, depression, trauma


Breast cancer, previously thought to be a problem pertaining to developed nations, is now the leading cause of cancer death among females in economically developing countries [1]. Worldwide trends show that in developing countries going through rapid societal and economic changes, the shift towards an industrialized lifestyle leads to a rising burden of cancers related to reproductive and dietary risk factors [2]. A similar scenario is found in India where the treatment of breast cancer is still far from perfect with a vast discrepancy between treatment centers in the urban and rural areas. Moreover most women with breast cancer come for treatment in the locally advanced or metastatic stages, rather than in the initial stages [3]. Despite of this, the scenario is much better than what it was a decade ago. With improved technology and emphasis on early detection and diagnosis, chances of survival have vastly improved thereby increasing the need for psychological interventions and palliative care among Indian women with breast cancer.

Psychological interventions have also been found to improve the quality of life (QOL) of patients with breast cancer [4]. As a result studying the psychological variables such as negative emotionality and QOL have become highly important in understanding the patient’s needs and to be able to help breast cancer patients to better deal with their illness. Negative emotions such as depression, anxiety and trauma are not only a consequence of the diagnosis but may continue or even increase as treatment progresses. Feeling of psychological distress tends to be one of the primary stressors faced by cancer patients leading to coping difficulties [5]. Quality of life of cancer patients tends to be the same whether they receive surgery, radiotherapy or chemotherapy [6]. Thus the assessment of depression, anxiety and stress in breast cancer patients is crucial for complete recovery and well being.

Quality of life encompasses perceptions about one’s social relationships, physical and mental well being and how one perceives his or her environment. It has been shown that assessing QOL in cancer patients could contribute to improved treatment and could even be prognostic especially when the aims are palliative rather than curative. Above all, studies of QOL [7-9] have helped to indicate the directions needed for more efficient treatment. This is especially true for breast cancer as the number of women with breast cancer is increasing steadily resulting in more survivors.

Although several studies have been conducted on breast cancer, they have mostly focused on one particular stage of cancer at a time. Although the presence of depression and anxiety in breast cancer patients is common, studies on the psychosocial correlates of cancer is limited in a country like India, as cancer is widely believed to be a strictly medical condition by most clinical practitioners. Moreover, previous studies on breast cancer [10-12] have focused on the initial stages of cancer or those who have survived after surgery. Studies comparing women in the different stages of breast cancer are few. A stage wise comparison enables an understanding of more appropriate interventions by providing us more specific knowledge about the various needs of the patient’s depending on the stage of the illness. This study thus, attempted to study these variables across the various stages of the disease in the Indian context.

This present study has compared women in different stages of breast cancer (initial, middle and advanced) with respect to the presence of psychological distress (depression, anxiety and trauma) and Quality of life in the Indian context. The study also aimed to establish the relationship between psychological distress and QOL among breast cancer patients. This study is warranted as India is facing a rapid increase in the incidence of breast cancer and understanding the psychological impact of cancer is crucial in today’s context owing to the increased life expectancy and high survival rates. Furthermore, interventions aimed at alleviating psychological distress have been found to increase efficacy of treatments such as chemotherapy and radiotherapy. Finally assessing quality of life helps to identify problems related to social support, economic burden as well as acceptance of one’s own self.


Study design:

A cross-sectional observational comparative study

Sample size and procedure:

The current study consisted of 30 women diagnosed with breast cancer, 10 in each of the three stages of breast cancer, that is, initial, middle and advanced stages. The Mean age of the participants was 45.5 years (S.D. =7.49). Purposive sampling was done as per the National Cancer Institute’s (United States) breast cancer staging [13] which is based on the size of the tumour and whether it has spread to lymph nodes or other parts of the body. The Initial stage comprised of stages 0, IA and IB; Middle; stages IIA and IIB and Advanced, stages IIIA, IIIB, IIIC and IV. All the participants were seeking treatment and were chosen from the Oncology units of three hospitals (Two private and One Government) of the metropolitan city of Kolkata, West Bengal. Persons with other acute or chronic physical illness/disability including intellectual disability were excluded from the study. A brief psychiatric screening tool was used to exclude participants having a history of psychosis and substance abuse. The study was approved by the Institutional Ethics Committee of Institute of Post Graduate Medical Education & Research (IPGME&R), Kolkata. Informed consent was taken from the participants to be a part of the study and the following tests was administered.

Tools used:

1. Mini International Neuropsychiatric Interview-5th Edition (M.I.N.I) [14]

The M.I.N.I. was used as a screening tool to rule out individual’s having history of substance abuse and psychosis. It is a short, structured psychiatric interview which is widely used for psychiatric evaluation and outcome assessment in psychopharmacological trials and epidemiological studies [15]. It has been found to show good validity and reliability. The modules I (Alcohol Dependence/ Abuse, J (Substance Dependence/ Abuse Non-Alcohol) and K (Psychotic Disorders and Mood Disorders with psychotic features) was administered to the participants.

2 .Clinical Outcomes in Routine Evaluation (CORE Outcome Measure) [16]

This tool was used to assess the level of psychological distress and negative emotionality (depression, anxiety and trauma) in the breast cancer patients. It consists 34 items and gives a global index of distress score. It taps psychological distress and includes subjective well-being (4 items), commonly faced problems and symptoms (12 items), life/social functioning (12 items) and risk to self and to others (6 items). It addresses the patient’s global distress and like most subjective measures cannot be used to diagnose a specific disorder [16]. It is found to have good internal and test-retest reliability (0.75-0.95) and high convergent validity and sensitivity to change[17].

3. World Health Organization Quality of Life (WHOQOL-BREF) [18]

The WHOQOL-BREF, comprising of 26 items was used to assess the quality of life of the breast cancer patients in the domains of physical, psychological, social and environment. It reflects the view that QOL refers to a subjective evaluation which is embedded in a cultural, social and environmental context. Domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQOL-100 domain scores and demonstrate good discriminant, content and internal validity as well as good test-retest reliability [19].

Statistical analysis:

Statistical Package for Social Sciences for windows version 16 was used. Chi square test was done for categorical variables to determine whether there was a significant difference between the women in the three breast cancer stages on the basis of socio-demographic details (Family type, Area of stay, Family history of cancer and Family income).

Since the variables were found to have homogenous variances according to Levene’s test, One way analysis of variance (One-way ANOVA) was done to determine whether the three stages differed significantly on the basis of Age, Years of Education, Age of onset of disease, Age of detection of disease, CORE Outcome Measure and WHOQOL-BREF scores. The groups were then clubbed together and Pearson’s Correlation was computed to find out the association between quality of life and psychological distress.


All the women in the study have had breast surgery for treatment purpose and were seeking treatment for the disease. 13 of them (43.3%) were undergoing chemotherapy, 12 (40 %) had underwent both chemotherapy as well as radiotherapy, one of them (3.3 %) was taking only radiotherapy whereas four of the women (13.3 %) had not yet started any of the treatment procedures after surgery.

The P values for all the socio demographic variables were higher than the accepted P value of 0.05. Thus, there was no significant statistical difference between individuals in the initial, middle and advanced stages of breast cancer, making the three groups of women comparable and increasing the power of the study (Table 1,Table 2).

Table 1: Comparison of Socio-demographic (categorical) variables
Variables Sub-categories Initial stage Middle stage Advanced stage Chi-square p value
    (N=10) (N=10) (N=10) (df=2)  
Family type Nuclear 6 5 6 0.271 0.873
  Joint 4 5 4    
Area of stay Urban 10 7 6 4.845 0.089
0 3 4    
Family history of cancer Present 3 1 5 3.810 0.149
  None 7 9 5    
Family income <25,000 5 7 7 1.148 0.563
  25,000 and above 5 3 3    

Table 2: Comparison of Age, education and clinical details
  Stages Mean SD F P value
Age Initial 43.4 7.36659    
Middle 46.4 7.90499 .575 .569
Advanced 46.7 7.54321    
Yrs of Education Initial 11.5 2.01384    
Middle 11.4 3.65756 .011 .989
Advanced 11.3 3.09300    
Age of onset of disease Initial 42.3 7.27324    
Middle 45.5 7.80669 .641 .534
Advanced 45.7 7.51369    
Age of detection of disease Initial 42.9 7.30981    
Middle 46.0 7.70281 .566 .574
Advanced 46.0 7.54247    

Statistical analysis revealed no significant difference between the three stages with respect to the domains of psychological distress and quality of life. The P values for all the domains of the two tests were higher than the accepted P value of 0.05. (Table 3,Table 4).

Table 3: Comparison on the CORE Outcome Measure
  Stages Mean SD F P value
Wellbeing Initial 6.0 3.55903    
Middle 7.2 5.30827 .484 .622
Advanced 5.5 2.54951    
Problems/symptoms Initial 21.6 11.94618    
Middle 19.6 11.08753 .084 .920
Advanced 21.2 11.56431    
Functioning Initial 12.6 9.07010    
Middle 13.1 8.30596 .266 .768
Advanced 10.6 6.78561    
Risk score Initial 2.7 2.75076    
Middle 3.8 5.55378 .494 616
Advanced 2.1 2.60128    
Total score Initial 42.9 24.31940    
Middle 43.7 26.86199 .087 917
Advanced 39.4 21.98585    

Table 4: Comparison on Quality of life
  Stages Mean SD F P value
Overall QOL Initial 7.3 1.33749    
Middle 7.1 1.72884 .302 .742
Advanced 6.8 1.22927    
Physical Initial 20.6 7.36659    
Middle 22.9 4.81779 .364 .698
Advanced 22.3 6.30784    
Psychological Initial 19.1 5.76291    
Middle 19.0 6.11010 1.094 .349
Advanced 22.1 3.81372    
Social Initial 11.9 3.10734    
Middle 11.2 3.04777 .277 .760
Advanced 12.1 2.28279    
Environment Initial 30.9 5.32186 .337 .717
Middle 29.0 6.91215    
Advanced 29.0 5.57773    

Pearson’s correlation showed a significant negative correlation between the domains of Wellbeing, Problems/symptoms and Functioning, as well as the CORE total score with all the domains of the WHOQOL-BREF at 0.05 levels. Thus high level of psychological distress was associated with low QOL scores. Risk score was not found to be associated with QOL (Table 5).

Table 5: Association between psychological distress and QOL
Variables Overall QOL Physical Psychological Social Environment
Wellbeing -.616** -.491** -.681** -.425* -.455*
Problems/Symptoms .624** .761** -.711** -.397* -.487**
Functioning -.646** -.574** -.815** -.658** -.613**
Risk score -.242 -.348 -.348 -.295 -.315
CORE total score -.650** -.687** .775* -.524** -.560**
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).


The present study attempted to compare the psychological distress and quality of life in the three stages of breast cancer to see how the cancer stage affected the patient’s psychological response and quality of life. The study also assessed the relationship between psychological distress and QOL. Results show that the three breast cancer stages did not differ, although more than half of the participants showed symptoms of depression, anxiety and trauma as a result of the cancer diagnosis. Psychological distress and QOL was found to be related with more psychological symptoms leading to poorer quality of life.

There was no difference between the three stages of breast cancer with respect to socio-demographic and clinical variables, making the study free from confounding variables and facilitating the effective comparison of the cancer stages (Table 1,Table 2).

Breast cancer patients in the initial, middle and advanced stages of breast cancer did not differ with respect to psychological distress and symptoms (Table 3). The Problems/symptoms domain of the CORE Outcome Measure assessed the presence of symptoms of depression, anxiety and trauma in the women with breast cancer. In the present study it was found that 16 out of 30 women (53 %) had scores higher than the cut off values indicating clinically significant levels of psychological distress and presence of depressive and anxiety symptoms. Recent studies also yielded similar findings [20, 21]. Depressive and anxiety symptoms did not vary stage wise. This finding is especially important in the Indian context as patients in India, especially in the rural areas are often kept unaware of the diagnosis and illness by family members and clinicians. Lack of knowledge and awareness about the stage of cancer and its implications coupled with the stigma and fear attached to a cancer diagnosis may be an important reason for there being no difference between the three stages of breast cancer in this study. Elevated levels of psychological distress in more than half the women reveals the importance of psychological interventions such as counselling and psychotherapy in the treatment of breast cancer in India at every stage of the illness.

In this study the three breast cancer stages also did not differ on any of the domains of the WHOQOL-BREF (Table 4). Psychosocial factors are found to be the strongest predictors of QOL, not the stage of cancer or treatment [22]. Quality of life is found to be disrupted in individuals in all three stages. This is because breast cancer affects a woman’s identity, regardless of the stage and tumour size. The loss of one’s breasts, which is a vital part of a woman’s being, interferes with the patient’s role as a mother, wife and partner [23]. The diagnosis of the disease, fears and concerns regarding death, disturbed body image, and alteration of femininity, sexuality and attractiveness are factors that cause psychological distress at all stages of breast cancer [24, 25]. Moreover the diagnosis of cancer not only changes the patient’s perception of herself but also changes others perception of her. Thus not only psychological and physical but social functioning is also affected having an impact on the patient’s overall wellbeing.

There was no difference between the three stages on the Risk score(Table 3). One study however found that the risk of suicide increased with increasing stage of breast cancer [26]. The study was longitudinal and the same individuals were assessed as their disease progressed. Moreover it was conducted on women in the United States and Scandinavia. The difference in the study methods and participants may have resulted in the difference in findings with the current study. Although our study did not find difference between the three stages it does not undermine the need for interventions to prevent risk to self and others in breast cancer patients. In fact, it indicates that interventions and preventive measures should be provided to all patients irrespective of the stage.

Results found that high CORE outcome measure score were associated with low score of the WHOQOL-BREF (Table 5). Among the breast cancer patients, greater difficulties in wellbeing/ functioning and increasing symptoms of anxiety, depression and trauma was found to be related to lowered quality of life. Other studies [27, 28] also found that anxiety and depression was associated with a lowered quality of life in cancer patients. This is because depression and anxiety tends to reduce biological functioning and tends to interfere with treatment procedures thereby reducing one’s quality of life. Not only do the patients feel helpless and less optimistic, it brings about social isolation and feelings of worthlessness. Quality of life measures including social support, nutrition and home environment in turn are important to alleviate psychological symptoms in breast cancer patients.

The findings suggest that the cancer experience does not differ in entirety based on the stage at diagnosis, and more individual factors such as age, coping style and personality factors may instead be more important when understanding the patient’s psychological and social functioning in breast cancer, thereby warranting further research in the Indian context. It also suggests the need for psychological assessment and intervention at every stage in order to improve patient’s quality of life and treatment outcome.


The study had a small sample size and a larger sample would have increased the power of the study. There was no control group thereby limiting our understanding of how much the breast cancer patients differed from the healthy cancer free individuals with respect to psychological distress and QOL. Predictive statistics could not be used due to the small sample size. Therefore, no conclusion could be drawn regarding which variable predicts the other. The CORE Outcome Measure did not have standardized norms for the Indian population thus acting as a limitation of the study.


This study found that psychological distress associated with breast cancer diagnosis can interfere with functioning and lower quality of life irrespective of the stage at diagnosis. Psychological interventions should therefore be provided at every stage. The current study is an attempt to understand the psychological aspects of the breast cancer experience thereby helping in the better management of breast cancer patients. Psychological response and QOL influence each other and are related. Therefore efforts at improving quality of life by reducing psychological distress can be brought about by strengthening the breast cancer patient’s coping repertoire and support system. The findings re-establish the importance of psycho-oncology and role of mental health professionals in the area. Future studies on the Indian population with respect to the psychological correlates of breast cancer are warranted.

List of Abbreviations

WHOQOL-World Health Organization quality of life; QOL; quality of life; M.I.N.I- Mini International Neuropsychiatric Interview, ANOVA-analysis of variance.

Conflict of interest

There was no conflict of interests.

Ethical Considerations

The study was approved by the institute ethics committee.

Author’s Contribution

Both Authors contributed equally for the paper.


[1].Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011 Mar-Apr; 61(2):69-90.[PubMed] [Free Full Text]

[2].Bray F, Ren JS, Masuyer E, Ferlay J. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer. 2013 Mar 1;132(5):1133-45.[PubMed] [Free Full Text]

[3]Hussein AA, Khoury KE, Dbouk H, Khalil LE, Mouhieddine TH, El Saghir NS. Epidemiology and prognosis of breast cancer in young women. J Thorac Dis. 2013 Jun; 5(1): S2–S8.[PubMed][PMC Full Text]

[4]Falagas ME, Zarkadoulia EA, Ioannidou EN, Peppas G, Christodoulou C, Rafailidis PI. The effect of psychosocial factors on breast cancer outcome: a systematic review. Breast Cancer Res. 2007; 9(4): R44.[PubMed] [PMC Full Text]

[5]Kyei KA, Oppong SD, Opoku SY, Antwi WK, Tagoe S. Assessment on the Quality Of Life of Breast Cancer Patients Undergoing Radiation Treatment in Ghana. World Journal of Psycho-Social Oncology .2014, 3:2

[6]Snöbohm C, Heiwe S. Stressors, Coping and Coping Strategies Among Young Adults with Cancer. World Journal of Psycho-Social Oncology.2013,2:3.

[7].Avis N E, Crawford S, Manuel J. Quality of life among younger women with breast cancer. J Clin Oncol. 2005 May 20; 23(15):3322-30.[PubMed]

[8]Reich M, Lesur A, Perdrizet-Chevallier C. Depression, quality of life and breast cancer: a review of the literature. Breast Cancer Res Treat. 2008 Jul; 110(1):9-17. [PubMed]

[9]Anderson JH, Ganz PA, Bower JE, Stanton AL. Quality of Life, Fertility Concerns, and Behavioral Health Outcomes in Younger Breast Cancer Survivors: A Systematic Review. J Natl Cancer Inst. 2012; 104(5): 386-405.[PubMed]

[10]Watson M, Greer S, Rowden L, Gorman C, Robertson B, Bliss JM, Tunmore R. Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients. Psychol Med.1991 Feb; 21(1):51-7.[PubMed]

[11]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 Mar 4; 330(7493):702.[PubMed][PMC Full Text]

[12]oodwin PJ, Leszcz M, Ennis M, Koopmans J, Vincent L, Guther H, Drysdale E, Hundleby M, Chochinov HM, Navarro M, Speca M, Masterson J, Dohan L, Sela R, Warren B, Paterson A, Pritchard KI, Arnold A, Doll R, O'Reilly SE, Quirt , Hood N, Hunter J. The Effect of Group Psychosocial Support on Survival in Metastatic Breast Cancer. N Engl J Med. 2001; 345:1719-1726.[PubMed] Free Full Text]

[13]National Cancer Institute. Retrieved from:

[14] Sheehan DV, Lecrubier Y. Mini International Neuropsychiatric Interview. 2010, 5th Edition.

[15Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (M.I.N.I): The Development and Validation of a Structured Diagnostic Psychiatric Interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998; 59(20):22-33.[PubMed] [Free Ful;l text]

[16]Core System Group. CORE System (Information Management) Handbook. 1998. Leeds, Core System Group.

[17 Evans C, Connell J, Barkham M, Margison F, McGrath G, Mellor-Clark J, Audin K. Towards a standardised brief outcome measure: psychometric properties and utility of the CORE—OM. The British Journal of Psychiatry. 2002 Jan; 180 (1) 51-60.[Pubmed]

[18] The WHOQOL group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998 May; 28(3):551-8. [PubMed]

[19Trompenaars FJ, Masthoff ED, Van Heck G L, Hodiamont P, De Vries J. Content validity, construct validity, and reliability of the WHOQOL-Bref in a population of Dutch adult psychiatric outpatients. Qual Life Res. 2005; 14: 151.[PubMed]

[20]Baqutayan SM. The Effect of Anxiety on Breast Cancer Patients. Indian J Psychol Med 2012; 34:119-23.[PubMed] [PMC Full Text]

[21]Mosher CE, Duhamel KN. An examination of distress, sleep, and fatigue in metastatic breast cancer patients. Psychooncology. 2012 Jan;21(1):100-7.[PubMed[PMC Full Text]

[22]Lehto US, Ojanen M, Kellokumpu-Lehtinen P. Predictors of quality of life in newly diagnosed melanoma and breast cancer patients. Ann Oncol. 2005 May; 16 (5):805-816.[PubMed]

[23]Mandelblatt J, Armetta C, Yabroff KR, Liang W, Lawrence W. Descriptive review of the literature on breast cancer outcomes: 1990 through 2000. J Natl Cancer Inst Monogr. 2004 (33): 8-44.[PubMed]

[24]peigel D. Psychosocial aspects of breast cancer treatment. Semin Oncol. 1997 Feb; 24(1 Suppl 1):S1-36-S1-47.[PubMed]

[25] Baucom DH, Porter LS, Kirby JS, Gremore TM, Keefe F.J. Psychosocial issues confronting young women with breast cancer. Breast Dis. 2005-2006; 23:103-13.[PubMed]

[26]Schairer C, Brown LM, Chen BE, Howard R, Lynch CF, Hall P, Storm H, Pukkala E, Anderson A, Kaijser M, Andersson M, Joensuu H, Fosså SD, Ganz PA, Travis LB. Suicide after Breast Cancer: an International Population-Based Study of 723810 Women. JNCI J Natl Cancer Inst. 2006 Oct; 98 (19): 1416-1419.[PubMed]

[27]Stark D, Kiely M, Smith A, Velikova G, House A, Selby P. Anxiety Disorders in Cancer Patients: Their Nature, Associations, and Relation to Quality of Life. J Clin Oncol. 2002 Jul 15; 20(14):3137-48.[PubMed]

[28]Damodar G, Smitha T, Gopinath S, Vijaykumar S, Rao YA. Assessment of Quality of Life in breast cancer patients at a tertiary care hospital. J Can Res Ther. 2011 July-Sept; 7( 3): 275-279.[PubMed] [Free Full Text]