JKAN Journal of Korean Academy of Nursing J Korean Acad Nurs 2005-3673 2093-758X Korean Society of Nursing Science 10.4040/jkan.2019.49.4.375 jkan-49-375 Original Article A Structural Model for Chemotherapy Related Cognitive Impairment and Quality of Life in Breast Cancer Patients LeeJung Ran1 OhPok Ja2 Department of Nursing, Korea Cancer Center Hospital, Seoul Department of Nursing, Sahmyook University, Seoul, Korea 012019 15012019 494 375385 310820180702201907022019 Copyright © 2019 Korean Society of Nursing Science 2019 This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium. Abstract Purpose

This study aimed to develop and test a structural model for chemotherapy-related cognitive impairment of breast cancer patients based on a literature review and Hess and Insel's chemotherapy-related cognitive change model.

 Methods

The Participants consisted of 250 patients who were ≥19 years of age. The assessment tools included the Menopause Rating Scale, Symptom Experience Scale, Hospital Anxiety and Depression Scale, Everyday Cognition, and Functional Assessment of Cancer Therapy-Breast Cancer. Data were analyzed using the SPSS 21.0 and AMOS 21.0 programs.

 Results

The modified model was a good fit for the data. The model fit indices were χ 2=423.18 (p<.001), χ 2/df=3.38, CFI=.91, NFI=.91, TLI=.89, SRMR=.05, RMSEA=.09, and AIC=515.18. Chemotherapy-related cognitive impairment was directly influenced by menopausal symptoms (β=.38, p=.002), depression and anxiety (β=.25, p=.002), and symptom experiences (β=.19, p=.012). These predictors explained 47.7% of the variance in chemotherapy-related cognitive impairment. Depression and anxiety mediated the relations among menopausal symptoms, symptom experiences, and with chemotherapy related cognitive impairment. Depression and anxiety (β=-.51, p=.001), symptom experiences (β=-.27, p=.001), menopausal symptoms (β=-.22, p=.008), and chemotherapy-related cognitive impairment (β=-.15, p=.024) had direct effects on the quality of life and these variables explained 91.3%.

 Conclusion

These results suggest that chemotherapy-related toxicity is highly associated with cognitive decline and quality of life in women with breast cancer. Depression and anxiety increased vulnerability to cognitive impairment after chemotherapy. Nursing intervention is needed to relieve chemotherapy-related toxicity and psychological factor as well as cognitive decline for quality of life in patients undergoing chemotherapy.

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Conceptual framework of this study.

Hypothetical model and path diagram for the modified model. (A) Hypothetical model. (B) Path diagram for the modified model.

Demographic and Disease Related Characteristics of the Participants (N=250)

Variable Category n % M±SD
Age (yr) ≤40 41 16.4 49.2±9.5
41~50 85 34.0
51~60 93 37.2
≥61 31 12.4
Martial status No 27 10.8
Yes 205 82.0
Others 18 7.2
Education ≤Middle school 49 19.6
High school 118 47.2
≥College 83 33.2
Occupation Employed 81 32.4
Unemployed 169 67.6
Monthly income <200 88 35.2
(10,000 won) 200~399 112 44.8
400~599 32 12.8
≥600 18 7.2
Menopause No 67 26.8
Menopause 103 41.2
Chemotherapy- 80 32.0
induced menopause
ECOG PS 0 50 20.0
1 145 58.0
2 33 13.2
3 20 8.0
4 2 0.8
Comorbidity No 179 71.6
Yes 71 28.4
Cancer stage I 58 23.2
II 127 50.8
III 55 22.0
IV 10 4.0
Metastasis No 149 59.6
Yes 101 40.4
Type of surgery Total mastectomy 88 35.2
Partial mastectomy 133 53.2
No response 29 11.6
Hormone No 187 74.8
treatment Yes 63 25.2
Number of 1~2 37 14.8 6.9±5.3
chemotherapy 3~6 121 48.4
cycle ≥7 92 36.8

ECOG PS=Eastern Cooperative Oncology Group Performance Status; M=Mean; SD=Standard deviation.

Descriptive Statistics and Convergent Validity of Measured Variables (N=250)

Variables Range Total
 Mean of item
 Skewness Kurtosis CCR AVE
M±SD M±SD
Hemoglobin (g/dl) 11.84±1.07 -0.23 -0.34
Symptom experience 0~96 39.80±17.45 1.66±.73 0.09 -0.63 .96 .90
  Frequency 0~4 13.81±6.22 1.73±.78 0.13 -0.70
  Severity 0~4 12.16±5.75 1.52±.72 0.34 -0.44
  Distress 0~4 13.83±6.12 1.73±.76 -0.13 -0.69
Menopausal symptom 0~44 14.08±9.17 1.28 ±.83 0.50 -0.49 .84 .64
  Somatic 0~4 5.30±3.73 1.33 ±.93 0.44 -0.77
  Psychological 0~4 5.59±3.92 1.40±.98 0.46 -0.77
  Urogenital 0~4 3.19±2.80 1.06±.93 0.84 -0.12
Depression and anxiety 0~42 14.78±6.92 1.06±.49 0.36 0.01 .84 .72
  Depression 0~3 7.18±3.70 1.03±.53 0.44 0.24
  Anxiety 0~3 7.60±3.77 1.09±.54 0.27 -0.21
Perceived cognitive decline 0~156 67.34±23.29 1.73±.60 0.96 0.52 .94 .72
  Everyday memory 0~4 16.52±6.81 2.06±.85 0.73 -0.40
  Language 0~4 15.19±6.34 1.69±.70 0.90 -0.03
  Executive function: Planning 0~4 7.88±3.47 1.58±.69 1.08 0.79
  Executive function: Organization 0~4 9.50±4.03 1.58±.67 1.15 0.54
  Executive function: Divided attention 0~4 7.50±3.44 1.88±.86 0.87 -0.09
  Visuospatial Abilities 0~4 10.76±4.63 1.54±.66 1.38 1.63
Quality of life 0~148 83.98±22.03 2.29±.60 -0.06 -0.44 .81 .52
  Physical well-being 0~4 17.99±6.92 2.57±.99 -0.60 -0.46
  Social/Family well-being 0~4 14.61±6.63 2.09±.95 -0.23 -0.58
  Emotional well-being 0~4 15.99±4.93 2.67±.82 -0.46 -0.59
  Functional well-being 0~4 14.12±6.60 2.02±.94 0.07 -0.73
  Breast cancer 0~4 21.27±6.92 2.13±.69 -0.04 -0.56

AVE=Average variance extracted; CCR=Composite construct reliability; M=Mean; SD=Standard deviation.

Direct, Indirect, and Total Effect Analysis of Modified Model (N=250)

Endogenous variables Exogenous variables Mediator Direct effect β (p) Indirect effect β (p) Total effect β (p) SMC
Perceived cognitive decline .477
  Symptom experience .19 (.012) .09 (.001) .285.002
  Menopausal symptom .38 (.002) .08 (.001) .463.002
  Depression and anxiety .25 (.002) .25 (.002)
Depression and anxiety .406
  Symptom experience .39 (.001) .39 (.001)
  Menopausal symptom .34 (.002) .34 (.002)
Quality of life .913
  Symptom experience -.27 (.001) -.24 (.001) -.51 (.001)
  Menopausal symptom -.22 (.008) -.24 (.001) -.46 (.002)
  Depression and anxiety -.51 (.001) -.04 (.011) -.55 (.001)
  Cognitive decline -.15 (.024) -.15 (.024)
  Symptom experience Depression and anxiety -.19 (.001) -.19 (.001)
Cognitive decline -.03 (.010) -.03 (.010)
Cognitive decline← -.02 (.023) -.02 (.023)
depression and anxiety
  Menopausal symptom Depression and anxiety -.17 (.001) -.17 (.001)
Cognitive decline -.06 (.013) -.06 (.013)
Cognitive decline← -.01 (.010) -.01 (.010)
depression and anxiety
  Depression and anxiety Cognitive decline -.04 (.001) -.04 (.001)

SMC=Squared Multiple Correlations.