A Structural Model for Chemotherapy Related Cognitive Impairment and Quality of Life in Breast Cancer Patients

Jung Ran Lee; Pok Ja Oh

doi:10.4040/jkan.2019.49.4.375

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Lee and Oh: A Structural Model for Chemotherapy Related Cognitive Impairment and Quality of Life in Breast Cancer Patients

Original Article

J Korean Acad Nurs 2019;49(4):375-385.

Published online: 15 January 2019

DOI: https://doi.org/10.4040/jkan.2019.49.4.375

A Structural Model for Chemotherapy Related Cognitive Impairment and Quality of Life in Breast Cancer Patients

Jung Ran Lee¹, Pok Ja Oh²

¹Department of Nursing, Korea Cancer Center Hospital, Seoul

²Department of Nursing, Sahmyook University, Seoul, Korea

Received 31 August 2018 Revised 7 February 2019 Accepted 7 February 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.

Keywords: Breast Neoplasms, Chemotherapy Adjuvant, Menopause, Cognitive Dysfunction, Quality of Life

References

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Figure 1.

Conceptual framework of this study.

Figure 2.

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

Table 1.

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.

Table 2.

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

Variables	Range	Total	Mean of item	Skewness	Kurtosis	CCR	AVE
Variables	Range	M±SD	M±SD	Skewness	Kurtosis	CCR	AVE
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.

Table 3.

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.

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