Evaluation of psychological status in early-stage breast cancer outpatients: a cross-sectional study utilizing the Kessler 10 Scale

Abstract

Objective

To evaluate the psychological status of early-stage breast cancer outpatients using the Kessler 10 Scale (K10) and to determine the feasibility of employing the K10 scale for psychological assessment in outpatient settings.

Methods

This cross-sectional study surveyed 250 patients at the Breast Surgery Outpatient Clinic of our hospital, from February to March 2023, using the Kessler 10 Scale (K10) questionnaire.

Results

A total of 120 breast cancer (BC) patients and 120 non-breast cancer (non-BC) patients completed the questionnaire. The K10 scores were significantly higher in BC patients compared to non-BC patients (15 [12.25, 20] vs. 13.5 [11.25, 17], P = 0.006). Among BC patients, those receiving postoperative endocrine therapy had significantly higher K10 scores than those not (19 [14, 22] vs. 15 [12, 20], P = 0.04). However, the type of surgery did not significantly impact the psychological status of BC patients (P = 0.57).

Conclusions

The Kessler 10 Scale (K10) is a practical tool for initial psychological screening in outpatient settings. BC patients demonstrate significantly higher levels of psychological distress compared to non-BC patients. Patients undergoing endocrine therapy as part of adjuvant treatment following surgery experience greater psychological distress compared to those not. These findings underscore the importance of early psychological monitoring and intervention for this population during outpatient visits.

Introduction

Breast cancer is the most prevalent malignant tumor among women globally [1]. The diagnosis of breast cancer often induces significant psychological stress, with female patients frequently experiencing emotions such as anger, anxiety, despair, helplessness, fear of death, and suicidal ideation. During treatment, clinical symptoms of anxiety and depression are highly prevalent, and treatment-related side effects can further disrupt daily life [2,3,4]. Research indicates that one in five women continue to experience depressive symptoms for at least two years post-diagnosis. Additionally, other adverse mental health outcomes, such as sleep disorders, have been reported both during and after treatment [5].

Adverse psychological states such as anxiety and depression significantly impact patients' physiological functions, comprehension and adherence to treatment, psychological well-being, and overall quality of life. Depression, in particular, has a profound effect on breast cancer treatment outcomes and survival rates. Studies have demonstrated that depressive symptoms present before and after diagnosis are significantly correlated with the likelihood of receiving guideline-recommended treatment and overall survival rates. Failure to manage depression can result in decreased treatment adherence and lower survival rates [6]. Meanwhile, a meta-analysis indicates that community and family support for women with breast cancer, along with lifestyle modifications and targeted training, can effectively mitigate the rise in depression prevalence [7]. Research underscores the importance of psychological assessment in early-stage breast cancer patients to evaluate their social support during treatment [8,9,10]. Early clinical assessment of social support, especially psychological fatigue surveillance, in breast cancer patients facilitates the provision of more comprehensive care and support [11, 12]. Therefore, understanding and addressing the psychological health issues of breast cancer patients, along with early outpatient detection and continuous management of their psychological state, is essential for enhancing their quality of life.

The Kessler 10 (K10) scale is a self-report instrument designed to assess psychological distress, extensively utilized in both clinical and research settings [13]. The K10 scale effectively screens for psychological distress, particularly symptoms of anxiety and depression, demonstrating robust predictive capabilities. It has shown good applicability across different age groups and cultural backgrounds. For instance, in elderly populations, the K10 scale effectively evaluates psychological distress and correlates with functional impairment and service utilization [14, 15]. Additionally, the K10 scale has exhibited strong internal consistency and construct validity in numerous studies [16, 17]. Confirmatory factor analysis (CFA) has demonstrated that the K10 questionnaire possesses robust construct validity. The K10 can be delineated into two primary factors: depression and anxiety, which collectively account for the principal components of psychological distress [18]. The BREAST-Q is a well-known questionnaire designed to assess the outcomes of breast reduction surgery. It meets international standards for questionnaire development and measures a variety of outcomes, including satisfaction with breasts and overall results, psychosocial well-being, sexual well-being, physical well-being, and satisfaction with care [19]. We concurrently utilize the psychosocial well-being section of the BREAST-Q and the K10 score to compare and evaluate the correlation between them, thereby assessing the efficacy of the K10 questionnaire in measuring the mental health of breast cancer patients.

This study utilized the Kessler 10 Scale (K10) to survey and score outpatients with Breast Cancer (BC) and non-Breast Cancer (non-BC) patients. The objective was to elucidate the psychological status of breast cancer patients and their psychological responses to various treatment regimens. The findings offer a reference and theoretical foundation for the early detection of adverse psychological states in breast cancer patients and for the implementation of proactive psychological interventions.

Methods

Participants enrollment and data collection

This cross-sectional study enrolled 120 BC patients and 130 non-BC patients who visited the Breast Surgery Outpatient Clinic at our hospital between February 2023 and March 2023. A total of 250 participants completed a 5-min questionnaire survey after providing informed consent. Ten non-BC patients withdrew from the study due to the retraction of informed consent. The survey collected data on age, education level, marital status, employment status, and income for both groups, as well as diagnosis time, endocrine therapy, and surgical treatment methods for the breast cancer group.

Questionnaire survey

We evaluated the psychological state of participants using the Kessler 10 (K10) scale, a brief questionnaire developed by Kessler and Mroczek at the University of Michigan in the early 1990s to measure psychological distress levels [20]. The K10 scale comprises 10 items that assess the frequency of non-specific psychological health symptoms, such as anxiety and stress, experienced by respondents over the past four weeks.

The Kessler 10 (K10) scale comprises 10 items: 1. How often did you feel tired for no good reason? 2. How often did you feel nervous? 3. How often did you feel so nervous that nothing could calm you down? 4. How often did you feel hopeless? 5. How often did you feel restless or fidgety? 6. How often did you feel so depressed that nothing could cheer you up? 7. How often did you feel that everything was an effort? 8. How often did you feel so restless that you could not sit still? 9. How often did you feel so sad that nothing could cheer you up? 10. How often did you feel worthless? Each item is rated on a scale from 1 (None of the time) to 5 (All of the time). Researchers calculate the total score for the 10 items and perform data analysis.

In the cohort of BC patients, the psychosocial well-being section of the BREAST-Q was utilized, which includes the following questions: "With your breasts in mind, how often have you felt confident in a social setting? Good about yourself? Self-assured? Confident about your body? Attractive?" The BREAST-Q score was calculated using the Q-Score program, which converts raw survey scores ranging from 1 to 5 into continuous scores from 0 to 100. Larger numbers indicated that patients were more satisfied, experienced symptoms more frequently, or more strongly agreed with a specific statement.

Data analysis

We utilized SPSS version 25 for data analysis. Demographic and clinical characteristics were described using the mean and standard deviation for continuous variables, and frequency and percentage for categorical variables. Independent sample t-tests and one-way ANOVA were employed to compare the means of continuous variables. Chi-square tests were used to compare the incidence rates between categorical variables. Pearson correlation analysis was conducted to examine the relationships between variables. For non-normally distributed data, the median and interquartile range (IQR) were used for description. The Mann–Whitney U test was applied to compare non-normally distributed data between two independent samples, while the Kruskal–Wallis H test was used for comparisons among multiple independent samples. The Pearson correlation coefficient is employed to evaluate the relationship between the two variables. A p-value of less than 0.05 was considered statistically significant.

Results

A total of 240 participants were enrolled in the study, consisting of 120 patients diagnosed with BC and 120 individuals Non-BC. The age distribution in the BC group spanned from 32 to 81 years, with a mean age of 54.57 ± 11.72 (mean ± standard deviation) years. Correspondingly, the Non-BC group's age range was from 31 to 80 years, with a mean age of 54.03 ± 12.56 years. In terms of educational attainment, 42 participants (35%) in the BC group had completed higher education, in contrast to 78 participants (65%) who had not. Conversely, within the Non-BC group, 48 participants (40%) had attained higher education, and 72 participants (60%) had not. A comparative analysis of baseline demographic characteristics revealed no statistically significant disparities between the two cohorts (P > 0.05). Further details regarding demographic and baseline characteristics are delineated in Table 1.

Table 1 The demographic and clinical characteristics of respondents

Upon the administration of the Kessler 10 Psychological Distress Scale, which ranges from 10 to 50 points, to the two study cohorts, it was observed that the BC group exhibited a mean score of 15, with an interquartile range extending from 12.25 to 20. In contrast, the Non-BC group demonstrated a mean score of 13.5, with an interquartile range from 11.25 to 17. A statistically significant divergence was ascertained between the psychological distress levels of the two groups (P = 0.006). These findings indicate that individuals diagnosed with breast cancer are more likely to manifest elevated psychological distress in comparison to their non-affected peers. Furthermore, within both the BC group (P = 0.25) and the Non-BC group (P = 0.28), no discernible variations in scale scores were noted when stratified by age, suggesting that age does not significantly influence psychological well-being in this study's context.

In this study's cohort of 120 BC patients, 19 individuals were administered endocrine therapy. The Kessler 10 scale scores for this subgroup were significantly elevated compared to those not receiving endocrine therapy (median [IQR]: 19 [14, 22] vs. 15 [12, 20], P = 0.04). This finding implies that endocrine therapy may exert a substantial influence on the psychological well-being of breast cancer patients (Fig. 1). As for the surgical interventions, the distribution of procedures was as follows: total mastectomy was performed in 74 cases with a median score of 15 (IQR: 13, 19.25), breast-conserving surgery in 18 cases with a median score of 18 (IQR: 12, 20), breast reconstruction in 7 cases with a median score of 12 (IQR: 11, 19), and 21 patients were on neoadjuvant therapy prior to breast surgery with a median score of 15 (IQR: 12.5, 25). Statistical analysis of the scores across these surgical categories revealed no significant differences (P = 0.57), suggesting that the type of surgery may not be a determinant factor in the psychological status of breast cancer patients (Fig. 2).

Fig. 1

The scatter plot delineates the relationship between endocrine therapy status and K10 scores across various treatment durations. The dashed line represents the mean score for the overall breast cancer patient population, with yellow dots signifying individuals on endocrine therapy and blue dots representing those not undergoing such treatment. It can be observed from the plot that the majority of patients receiving endocrine therapy exhibit scores above the mean (as evidenced by the majority of yellow dots positioned above the dashed line). BC pts: breast cancer patients

Fig. 2

The scatter plot illustrates the correlation between different surgical treatment modalities and K10 score outcomes. The dashed line indicates the average K10 score across the entire breast cancer patient cohort. Specifically, orange dots represent patients who underwent mastectomy, yellow dots denote those who had breast-conserving surgery, green dots correspond to individuals who underwent breast reconstruction, and brown dots signify patients on neoadjuvant therapy who have not yet undergone breast surgery. This visual representation facilitates the comparison of psychological distress levels, as measured by the K10 scale, in relation to the type of surgical intervention received

The psychosocial well-being scores of the BREAST-Q were evaluated in this cohort of 120 BC patients, yielding a mean score of 67.53 ± 13.43. The analysis revealed a strong negative correlation between the variables, as indicated by a Pearson correlation coefficient of −0.945 (P < 0.001) (Fig. 3).

Fig. 3

The scatter plot demonstrates a pronounced negative correlation between the K-10 scores and the BREAST-Q scores

Discussion

An increasing body of research confirms the presence of psychological health issues among breast cancer patients, yet previous studies have predominantly focused on younger patients with breast cancer [21,22,23]. A cohort study evaluated the quality of life and reproductive health outcomes in young breast cancer survivors. The study involved 577 women who were surveyed approximately six years post-diagnosis. The findings indicated that treatment-induced amenorrhea is common among women diagnosed at 40 years of age or older and is associated with poorer health perceptions. Despite generally good physical functioning, younger women reported poorer mental health and vitality [24]. A cross-sectional survey of 204 breast cancer women aged 50 and under investigated specific psychosocial issues. Early menopause and fertility-related concerns were significant problems, and sexual function and body image were also areas of concern. This study concluded mastectomy was correlated with body image issues and sexual interest problems, while chemotherapy was associated with sexual dysfunction. The study also emphasizes the need to develop interventions to help women cope with early menopause and sexual function issues following chemotherapy [25]. Our research indicates that age is no longer the primary factor affecting psychological health in both BC and non-BC groups; psychological health has become a reality that must be faced across all age groups. Postmenopausal patients, like their younger counterparts, also experience varying degrees of psychological health issues, which warrant particular attention and management in clinical settings.

In this study, the K10 scale was successfully employed to screen for differences in psychological health between breast cancer patients and the general patient population in an outpatient setting. This confirms the K10 scale's utility as a convenient screening tool for psychological distress, enabling rapid identification of patients with abnormal psychological health in the busy outpatient workflow for targeted intervention and treatment. Furthermore, a strong negative correlation was observed between the K-10 and the psychosocial well-being scores of the BREAST-Q. This indicates that the K-10 is equally valuable as the BREAST-Q in evaluating the psychological state of BC patients.

The treatment modalities for breast cancer, beyond the inherent fear associated with the disease itself, play a significant role in the psychological state of patients. Anxiety and depression are common psychological issues among breast cancer patients. Studies have indicated that certain procedures during treatment, such as decisions regarding antitumor therapies and surgery, can significantly increase patients' levels of anxiety [26]. Different surgical management approaches may also have varying impacts on patients' physical and mental states. Day surgery management (DS) has demonstrated significant psychological benefits in the treatment of early-stage breast cancer. Research has found that DS not only excels in reducing the rate of surgical re-intervention but also significantly decreases patients' symptoms of anxiety and depression [27]. Additionally, different surgical strategies can have varying effects on patients' psychological states and body image. Breast-conserving surgery and breast reconstruction surgery have been shown to improve patients' body image more effectively than mastectomy alone. Although there is little difference in quality-of-life assessments among the three surgical methods, patients who undergo breast conservation and reconstruction surgery have significantly higher body image scores than those who have mastectomy alone. Furthermore, patients who have breast reconstruction surgery also exhibit higher satisfaction and aesthetic outcome scores [28]. Within the parameters of this investigation, no statistically significant disparities were detected in the psychological outcomes associated with varied surgical approaches for breast cancer. Specifically, no discernible reduction in psychological distress scores was identified among patients who received breast-conserving surgery and reconstructive procedures. This lack of significant difference may be attributed to the heightened psychological preparedness of patients in the digital era, where they are better informed and thus potentially more resilient to the psychological repercussions of their surgical choices. Furthermore, the demographic imbalance of patients across different surgical groups within this study could also contribute to the observed findings, suggesting that sample distribution may be a confounding variable in the analysis of psychological impacts. However, as can be seen from Fig. 2, in the short term (< 12 months), there is a noticeable increase in yellow dots (breast-conserving surgery) above the baseline (blue dashed line), while in the long term (> 12 months), the orange dots (mastectomy) are predominant above the baseline, indicating that patients who undergo breast-conserving surgery experience a significant increase in anxiety and depression in the short term, while the adverse psychological state of patients who have mastectomy is mainly reflected in long-term follow-up after one year.

Investigations into the psychological ramifications of endocrine therapy for breast cancer are relatively limited; however, there is consensus that the side effects of such treatment are intricately linked to the incidence of depression and anxiety among affected patients. A cross-sectional Chinese study reported a prevalence of 33.4% for depression and 13.3% for anxiety among individuals undergoing endocrine therapy. Depression was found to be associated with lower educational attainment, night sweats, vaginal dryness, and fatigue, whereas anxiety was linked to similar educational disparities, shorter diagnostic intervals, osteoporosis, alopecia, and fatigue [29]. Subsequently, a prospective observational study assessed the evolution of disease perception and depressive symptoms in breast cancer patients undergoing adjuvant endocrine therapy (AET) at three distinct junctures: prior to treatment initiation, three months post-therapy, and twelve months post-therapy. The findings indicated a general enhancement in disease cognition over the 12-month period; nevertheless, an increased proportion of patients characterized their illness as chronic, endured a greater number of symptoms, and harbored pessimistic views regarding the efficacy of treatment in managing their condition. A noteworthy decrease in depressive symptoms was observed; however, initial depressive states, cancer staging, and perceptions of personal control were significantly correlated with depressive symptoms after 12 months. These insights underscore the necessity for healthcare providers to implement timely psychological interventions at the commencement of treatment. Such interventions should aim to alleviate symptomatology, foster optimistic beliefs regarding treatment efficacy, and preempt the onset of chronic depressive symptoms [30].

Our study corroborates these research outcomes, as depicted in Fig. 1, where a substantial preponderance of endocrine therapy patients (indicated by yellow dots) is situated above the median value (demarcated by the blue dashed line). This pattern is consistent across both short-term (< 6 months) and long-term (> 60 months) endocrine therapy recipients, who exhibit elevated scores. This suggests that patients on endocrine therapy are at a significantly higher risk of experiencing anxiety and depression compared to their non-endocrine therapy counterparts, and these adverse psychological states may persist over an extended period. The data advocates for the implementation of targeted, intensified psychological interventions for this particular patient cohort, emphasizing the importance of initiating such interventions at the outset of treatment and continuing them throughout the course of care.

This study also has several limitations. The K10 scale, while instrumental in screening for generalized psychological distress, does not offer a nuanced evaluation of the gradations of anxiety and depressive states. Furthermore, the K10 scale's scoring may be susceptible to biases introduced by varying recall periods and the sequencing of response choices, potentially leading to subtle discrepancies in the assessment of psychological morbidity. Subsequent research endeavors should consider the inclusion of complementary psychometric instruments to more precisely delineate the severity of negative psychological conditions. Given the cross-sectional design of this study, it is constrained in its ability to thoroughly interpret the effects of chronicity of illness and the duration of therapeutic interventions on psychological well-being. Future inquiries may necessitate the employment of longitudinal study designs, complete with extended follow-up periods, to more accurately chart the trajectory of depressive and anxious symptomatology throughout the treatment continuum. Additionally, the cross-sectional approach precludes optimal standardization of disparate treatment strategies, such as surgical interventions and endocrine therapies, which may exert confounding influences on the study's outcomes.

Conclusions

The present cross-sectional investigation, employing the K10 scale as a metric for psychological distress among outpatients, demonstrated that individuals with breast cancer experience notably elevated levels of depression and anxiety in comparison to their non-breast cancer counterparts. Specifically, within the breast cancer group, patients who were recipients of endocrine therapy exhibited significantly higher scores on measures of psychological morbidity, irrespective of the treatment duration. In contrast, the modality of surgery did not exert a substantial influence on the psychological outcomes. These findings underscore the imperative for proactive intervention to address the psychological well-being of breast cancer patients, with special consideration for those undergoing endocrine therapy. The K10 scale emerges as a facile and effective instrument for the preliminary assessment of psychological states in the outpatient setting, thereby offering clinical utility in the identification of patients who may require further psychological support.