Introduction
Breast cancer is one of the most common cancer
types among women and is the leading cause of cancer
deaths in women.[] The World Health Organization
(WHO) reported that 685,000 women died
due to breast cancer, and 2.3 million women were
diagnosed with new breast cancer in 2020.[] Today,
however, with the development of conditions, mortality
rates are decreasing, and survival rates are increasing
due to diagnosis and treatment in the early
stages.[] Women who have completed cancer treatment
and recovered continue to be cancer survivors
with a diagnosis of breast cancer for the rest of their
lives.[] Breast cancer survivors (BCS) are uncertain
about their future and worry about the recurrence of
their disease.[] Therefore, the most common psychological
problems in survivors after treatment are
depression, anxiety, and posttraumatic stress disorder
(PTSD).[,] In addition, as today, BCS may be
exposed to an extra stressor such as the Coronavirus
disease 2019 (COVID-19) pandemic.
In December 2019, cases of pneumonia of unknown
origin were reported in Wuhan, China, and a new type
of coronavirus, 2019-nCoV (COVID-19), was identified
in these cases.[] Due to the rapid spread of the virus,
it was declared an epidemic by the WHO on January
5, 2020.[] Due to the spread of the epidemic to 114
countries, the detection of over 118 thousand cases and
the death of 4,291 people, a pandemic was declared on
March 11, 2020.[] The clinical symptoms of the COVID-
19 virus are a febrile respiratory disease and have
serious effects that can lead to death when symptoms
become severe.[-]
The COVID-19 virus is very stressful, as it threatens
human life due to its rapid spread and increasing
deaths.[] It suppresses the immune system due to
the treatment of cancer patients who continue their active
treatment during the pandemic. They are among
the vulnerable groups because they are at higher risk
of being infected and showing more severe symptoms
and even death when infected.[] The virus is also a
source of intense stress and anxiety for patients due to
both the increasing death rates in cancer patients and
the restrictive measures implemented to reduce transmission.[] However, the difference between healthy
and survivors" psychological distress from the physical
effects of the virus is unknown because research
is limited. In a study comparing 150 cancer patients
and 150 healthy individuals, no significant difference
was found between the groups regarding the fear of COVID-19, anxiety and stress levels. However, cancer
patients performed more COVID-19-related safety
behaviors, such as hand washing and avoiding public
environments, than the healthy group.[] In addition,
the decisions of some states to delay nonemergency
health services in health systems to reduce the
risk of infection make it difficult for cancer survivors
to continue their routine check-ups, or although there
is no disruption in the health system, it is known that
they postpone their appointments because they are
afraid of being infected.[-] Disruption of routine
controls causes the progression of a possible relapse,
increasing the anxiety levels of individuals even if
there is no recurrence.[] In another study conducted
with 1016 cancer survivors, half of the participants
who reported fear of recurrence could not access the
health care they needed.[]
In addition, individuals worry about their own
health and the health of their loved ones;[] the
restrictive decisions made lead to a more isolated
life, restriction of social support resources and sudden
life changes that would cause economic difficulties;[,] there is no definite treatment method
for COVID-19 yet,[] the virus continues to spread
with various variations[] and it contains uncertainties
about when the process will end,[] are the
stressors related to social support and intolerance to
the uncertainty that causes psychological distress.
Depression, anxiety and stress are among the most
common psychological problems in studies.[,-] Additionally, being diagnosed with COVID-19
and having an infected relative increase the level of
depression and anxiety.[,]
Although a high level of social support protects
against psychological distress,[] a high level of
intolerance of uncertainty, as one of the cognitive
evaluation processes, has a role in increasing psychological
distress.[] In addition, coping strategies are
also important in the face of stressful events. When
individuals perceive a stressful situation as manageable,
the strategies they use are problem-oriented; the
strategies they use when they perceive the stressful
situation as threatening and cannot be changed are
defined as emotion-focused coping strategies.[]
This study aims to examine the depression, anxiety
and stress levels of women who survived breast
cancer in the COVID-19 pandemic and the factors
intolerance to uncertainty, social support, and coping
strategies that may be associated with depression,
anxiety and stress levels and to examine the role of
BCS during the COVID-19 pandemic.
Methods
Study Population
The study group of this study consisted of 95 women
BCS aged between 26 and 74 (mean=49.86), diagnosed
between 1997 and 2018 (mean=2013.84), living with
the diagnosis of cancer for 2-23 (mean=6.16) years,
who completed active cancer treatments before the COVID-
19 pandemic period and whose routine controls
continued at Istanbul University Oncology Institute. The
control group consisted of 87 healthy control women
(HCs) aged 26-69 years (mean=47.60) who were selected
by a convenience sampling method to be equivalent
to the study group in terms of age and economic status.
Being younger than 18 years old, not being literate, having
a mental or cognitive disorder and having a diagnosis
of psychosis were the exclusion criteria of this study.
Scales
Information Form Related to Sociodemographic,
Breast Cancer and COVID-19 Pandemic Process
This form was prepared by the researchers and included
three parts. In the first part, there were questions describing
the sociodemographic characteristics of the
participants, such as age, education level and monthly
income. In the second part, there was information that
determined the year the study group was diagnosed with
breast cancer. In the third part, there were questions that
included the descriptive information of the participants
about the COVID-19 process, and in addition, the study
group"s access to health services during the COVID-19
period and the questions in which they scored their disease
concerns compared to the past (Table 1).
Table 1 Information on the sociodemographic characteristics, the diagnosis of breast cancer and the COVID-19 pandemic
process of the participants
Depression Anxiety Stress Scale (DAS-21)
It was developed to measure the level of negative psychological
states of individuals in the last week, including
depression, anxiety and stress. It consists of 21
items in total and is in 4-point Likert type as "Never
(0)" and "Always (3)".[] The Turkish version of the
DAS-21 was adapted by Bilgel and Bayram.[] The
Cronbach"s alpha internal consistency coefficient was
found to be 0.92 for the depression dimension, 0.86
for the anxiety dimension and 0.88 for the stress dimension.
In this study, the Cronbach"s alpha reliability
values of the scale were calculated as.88 for depression,
0.76 for anxiety and 0.86 for stress.
Social Support Scale (SSS)
Torun used the SSS developed by Krespi (1993)[] to
measure the level of social support of individuals.[] It consists of 19 items in total and is scored on a 5-point
Likert scale ranging from "Never (0)" to "Always (4)." As
the scores obtained from the scale increase, the level of
social support also increases. The Cronbach"s alpha internal
consistency coefficient of the total score of the scale
was calculated as 0.92. The item loads of the 3 subdimensions
vary between 0.44 and 0.76 for the informational
and material support subdimension, between 0.52 and
0.76 for the emotional support subdimension, and between
0.56 and 0.68 for the togetherness support subdimension.
Dimensions explain 57.1% of the total variance.
In this study, the total score of the scale was used, and the
Cronbach alpha reliability value was calculated as 0.96.
Intolerance of Uncertainty Scale (IUS-12)
Based on the 27-item Uncertainty Intolerance Scale developed
by Freeston et al. (1994)[35] to measure individuals"
cognitive, emotional, and behavioral responses
to uncertain situations, a short 12-item form of the
IUS-12 was developed by Carleton et al. (2007).[]
The scale, which consists of 2 subdimensions, anxiety
for the future and inhibitory anxiety, is a 5-point Likert-
type scale of "Not suitable for me (1)" and "Completely
suitable for me (5)." The higher the scores, the
higher the level of intolerance to uncertainty. The Turkish
version of the IUS-12 was adapted by Sarıçam et
al.[] Cronbach's alpha reliability coefficient of the total
score of the scale was determined to be.88. It was determined
as.84 for the anxiety for the future subdimension
and.77 for the inhibitory anxiety subdimension. In
this study, the total score of the scale was used, and the
Cronbach alpha reliability value was calculated as 0.92.
Coping Strategies Scale Short Form
It was developed to measure the coping strategies individuals
use in the face of stressful events. It consists of
a total of 28 items and is answered on a 4-point Likert
scale ranging from "I never do this (1) to "I do this a lot
(4)."[] The scale has 14 subdimensions, but there are
also studies in the literature in which this scale is used
for problem-focused coping and emotion-focused coping.[] The Turkish adaptation of the scale was made
by Tuna, and Cronbach's alpha internal consistency coefficient
was calculated to be between.33 and.91 for all
dimensions.[] In this study, the scale was used in a
2-factor structure, and the Cronbach alpha reliability
coefficient was calculated as 0.84 for problem-focused
coping and 0.73 for emotion-focused coping.
Process
After obtaining the necessary approval from the Ministry
of Health to be able to work on the COVID-19 pandemic due to the pandemic process, approval was
obtained from the FMV Işık University Ethics Committee
(December 17, 2020/9305). Study data were collected
between March 2021 and August 2021. The data
were collected from women diagnosed with breast cancer
who came to the IU Institute of Oncology Breast
Polyclinic for a control appointment after obtaining
the necessary permission for BCS, and the snowball
method was used to match the sample group in terms
of age and economic status for HC. After the necessary
explanation was given to the participants, they were
first asked to sign the "Informed Consent Form" stating
that they voluntarily accepted the study. Afterward, the scales were given, and it took the participants approximately
20-30 min to complete the scales.
Results
Descriptive Statistics
A total of 33.7% of women in BCS were primary school
graduates, and their average monthly income was
3805.91. Of the women in this group, 12.6% were diagnosed
with COVID-19, 66.3% had a COVID-19 diagnosis
in a loved one, 32.6% had a loved one who died due to
COVID-19, 65.3% were vaccinated against COVID-19,
and 77.9% provided access to health services during the pandemic process. In this process, the anxiety scores
that they get sick more easily were 4.42 on average.
On the other hand, 40.2% of women in the HC
group were university graduates, and their average
monthly income was 4324.71. Of the women in this
group, 23% were diagnosed with COVID-19, 87.4%
had a COVID-19 diagnosis in a loved one, 49.4% had a
loved one who died due to COVID-19, and 75.9% were
vaccinated against COVID-19 (Table 1).
Table 1 Information on the sociodemographic characteristics, the diagnosis of breast cancer and the COVID-19 pandemic
process of the participants
Differences of the Groups According to the
Variables
Independent groups t-test analyses were conducted to
determine the differences between dependent (depression,
anxiety, stress) and independent (social support,
intolerance to uncertainty, coping strategies) variables
of the study according to BCS and HC.
When the psychological distress (depression, anxiety,
stress) levels of women in BCS and HC were examined,
there was no significant difference between
the depression (t=-1.51, p>0.05) and anxiety (t=-0.90,
p>0.05) scores of the two groups. However, it was observed
that the stress scores of the women in the BCS
group were significantly lower than those of the women
in the HC group (t=-4.87, p<0.001).
When the differences in the independent variables
according to the groups were evaluated, the problemfocused
coping of the women in BCS was significantly
higher (t=2.18, p<0.05), and the emotion-focused coping
was significantly lower (t=-3.86, p<0.001) than the
women in the HC (Table 2).
Table 2 Information of participants on scale scores
Regression Analyses
First, the variables of breast cancer diagnosis, COVID-19
diagnosis, a loved one's COVID-19 diagnosis and a loved
one"s death due to COVID-19 were coded as dummy
variables (0=None, 1=Present). Then, breast cancer diagnosis
and sociodemographic variables in the first step,
social support in the second step, COVID-19-related factors
in the third step, and intolerance of uncertainty and
coping strategies in the final step were included in the
analysis. Thus, in line with the purpose of the study, a
4-stage hierarchical regression analysis was conducted to
determine the variables predicting psychological distress
(depression, anxiety, stress). In regression analyses including
all variables, the results showed that being diagnosed
with breast cancer was not a predictor for depression
and anxiety but was a predictor for stress (Table 3).
Table 3 Predictors of psychological distress (depression, anxiety and stress)
When the predictors of depression were analysed, a
total of 4 steps explained 36% of the variance (F=8.510,
p<0.001). In the final stage of the regression analysis,
social support negatively predicted and intolerance of
uncertainty and emotion-focused coping positively
predicted the level of depression.
When the predictors of anxiety were examined,
all variables explained 30% of the variance (F=6.609,
p<0.001). In the last stage of the regression analysis,
social support and problem-focused coping were
negatively predicted, and intolerance of uncertainty
and emotion-focused coping strategies positively predicted
the level of anxiety.
When the predictors of stress were examined, all variables
explained 49% of the variance (F=14.370, p<0.001).
In the last stage of the regression analysis, breast cancer
diagnosis, age, social support and problem-focused coping
negatively predicted, and COVID-19 diagnosis in a loved one, the death of a loved one due to COVID-19,
intolerance to uncertainty and emotion-focused coping
strategies predicted a positive level of stress (Table 3).
Discussion
Women who survive breast cancer continue to experience
various psychological problems even after their
active treatment has ended. In addition, they may be
exposed to extra stressors such as the COVID-19 pandemic.
Although the number of women surviving
breast cancer is quite high, the number of studies on the
psychological problems they experienced during the
pandemic is limited. The current study aimed to examine
psychological distress and related factors in the COVID-
19 process in BCS. The study is important in that
it is one of the limited studies conducted in this process,
includes various factors, and includes a control group.
Within the scope of this study, first, the effects of
breast cancer diagnosis and sociodemographic variables
on psychological distress were examined. It was
concluded that there was no significant difference between
the depression and anxiety levels of both groups
according to the diagnosis of breast cancer. Although
studies comparing the psychological distress of individuals
who survived cancer in the COVID-19 pandemic
and the normal population are limited, the results of
the studies differ from each other. Cordova et al.[]
compared the depression levels of women with breast
cancer diagnosed at least 2 months after cancer treatment
and women without cancer diagnosis and found
that there was no significant difference in depression
levels between the two groups. Ng et al.[] stated that
during the COVID-19 process, women who survived
breast cancer had lower levels of depression and anxiety
than healthy women. An explanation for the lack of difference
in depression and anxiety levels of BCS and HC
in this study may be that cancer patients were not in the
active treatment period and therefore had similar isolation
conditions with the healthy group during the COVID-
19 process. Studies have reported that cancer survivors
and cancer patients who are in active treatment
are affected psychologically at different levels during
the COVID-19 pandemic. Islam et al.[] concluded
that cancer patients receiving active treatment experienced
higher levels of anxiety, hopelessness, loneliness,
and depressive symptoms than those without a cancer
diagnosis. However, in another study comparing the
depression, anxiety and stress levels of 658 women who
were treated for active breast cancer and those who survived
breast cancer, it was found that women who were
in active treatment had higher levels of depression, anxiety
and stress.[] At this point, cancer patients in the
active treatment process need to go to the hospital more
frequently,[] and the physiological results of treatments
such as chemotherapy and radiotherapy may
have negative effects on their psychology.[] For this
reason, it is thought that the psychological distress levels
of those who were treated for active cancer and those
who survived cancer during the COVID-19 period differed.
Another explanation is the evaluations and comments
of cancer survivors about COVID-19. One of the
important problems affecting cancer survivors during
the COVID-19 period is the restriction of health needs.
Because fear of relapse occurs in those who cannot go
to their regular check-ups, their psychological distress
levels increase.[,] In this study, women who survived
breast cancer were asked, "Did you have access to
the health services you needed during the COVID-19
pandemic?" Most of the women answered "Yes" to the
question. Studies have concluded that perceived poor
health status during the COVID-19 period is associated
with increased anxiety levels.[] In the current
study, the BCS asked, "Are you worried about getting
sick more easily during COVID-19?" According to the
answer they gave to the question asked, it was seen that
their anxiety about getting sick more easily during this
period was not high on average. In conclusion, most of
the BCSs participating in this study reported that they
had easy access to health services during this period
and were less worried about getting sick easily. Therefore,
it is thought that the depression and anxiety levels
of BCSs do not differ from those of HCs. However,
BCSs had significantly lower stress levels than HCs, and
in the regression analysis, it was found that being diagnosed
with breast cancer negatively predicted the stress
level. Findings obtained from studies in the literature
contradict this finding in the current study. In a metaanalysis
study, it was seen that those who had a traumatic
event in the past had higher PTS symptoms when
they encountered another traumatic event in the future
than those who did not have a traumatic experience in
the past.[] According to another study conducted in
Italy during the pandemic, it was observed that those
who experienced stressful life events had higher levels
of depression, anxiety and stress than those who did not
experience stressful life events.[] Stress is the mental
tension that occurs when it is thought that the difficulties
encountered cannot be addressed.[] BCS had
previously been diagnosed with life-threatening cancer
and completed its treatment. Khan et al.[] stated
that cancer survivors see themselves as "warriors" and
think that they have won this war. This suggests that
they believe that they can cope with a process such as
a pandemic more easily than HCs by being effective in
their coping mechanisms. Supportingly, in the current study, it was observed that BCS women used problemfocused
coping strategies, which are adaptive coping
strategies,[] more than women in the HC group. In
addition to the diagnosis of breast cancer, it was concluded
that age, one of the sociodemographic variables,
is a final step predictor. The COVID-19 pandemic also
causes uncertainty in people's work and economic
situations and causes an increase in psychological distress
levels, especially among younger people.[] It is
known that exposure to news about the process on social
media also increases the levels of psychological distress
and that the use of social media is higher in young
people.[] Considering that the COVID-19 virus has
entered our lives quickly, it is thought that the information
pollution in the media about cancer patients may
have affected BCS women without any scientific study
yet. In this study, it is seen that stress levels increase as
the age of women decreases.
Second, the role of social support in psychological
distress was examined. Many women receive support
from their relatives when they are diagnosed with cancer
and during their treatment. Although they continue
to experience the ongoing physical and psychological
problems of the treatment after their treatment
is completed and these problems are not understood
by their relatives, they feel that they have lost support.
[] Therefore, the role of social support is important
both after active treatment and during the COVID-19
process. However, no difference was found between the
two groups in terms of social support. It is known that
social support creates a buffering effect and is a protective
factor against psychological distress.[] Similarly,
in this study, increased social support was associated
with decreased depression, anxiety and stress levels.
Third, factors associated with COVID-19 are also
important in assessing psychological distress. It was
determined that the stress levels of women with a loved
one who were diagnosed with COVID-19 were significantly
higher. It can be thought that this difference is
due to the concerns of those whose loved ones are infected
that they may also become infected. This situation
can be a trigger, especially for the health anxiety of
BCSs. Since deaths due to COVID-19 occur suddenly,
PTSD can be seen in loved ones who died in this process.[] For this reason, it may be an expected result
that the stress levels of the women whose loved ones
died due to COVID-19 were high in the study.
Finally, the cognitive processes of individuals to
evaluate the life crisis and their ability to cope with this
event are determinative of the psychological outcome.
People with a high intolerance of uncertainty see uncertain situations as stressful and sad.[] Uncertainty
is related to the future and causes anxiety, but there is
also a positive relationship with depression.[] Satıcı
et al.[] emphasize that intolerance to uncertainty has
a direct impact on mental health during the pandemic.
Similarly, in the current study, it was found that women
with a high intolerance to uncertainty had high levels of
depression, anxiety and stress. In other words, it can be
said that those who feel more inadequate in the face of
uncertainty in the COVID-19 process have increased
levels of psychological distress. Yu et al.[] reported
that dysfunctional coping strategies increase the psychological
distress associated with the pandemic. It
is known that problem-focused strategies, similar to
adaptive coping strategies, have negative effects on individuals"
depression and anxiety levels, and emotionfocused
strategies, similar to maladaptive coping strategies,
have positive effects.[] In the current study, it
was concluded that while decreasing problem-focused
coping was effective in increasing anxiety and stress
levels, increasing emotion-focused coping was effective
in increasing depression, anxiety and stress levels.
When all the findings of the study are evaluated, it
is seen that the variables of education level, monthly
income and being diagnosed with COVID-19 are not
significant, although they are significant in other studies.
It is thought that there are differences between the
groups, especially according to the level of education,
which may have an effect on the results of this study. In
addition, all participants except two participants had a
regular income. Therefore, economic difficulties do not
create an extra source of stress in this process. In addition,
when the data of the study were collected, it was
time since women were diagnosed with COVID-19,
and the low number of people diagnosed with COVID-
19 may affect the results.
The fact that the sample of the study consisted of
only women and those with a diagnosis of breast cancer
and that women with a diagnosis of breast cancer
were not in the active treatment process limits the generalizability
of the results. In addition, the fact that the
study was conducted with a cross-sectional method
also limits the cause-effect relationship.
Conclusion
Overall, the results suggest that first, being diagnosed
with cancer during the COVID-19 pandemic period is
not a vulnerability factor, especially for the BCS group,
and perhaps even has an empowering effect in terms
of coping with stress. Second, increased intolerance to uncertainty, emotion-focused (nonfunctional) coping
strategies, and lack of social support were found to be
cognitive factors that increased psychological distress
levels for BCS patients and the HC group during the
COVID-19 pandemic. Implementation of emotion
regulation interventions to reduce the stress applied to
patients and survivors of a stressful life event such as
cancer will be effective in reducing psychological distress.
In addition, interventions for cognitive restructuring
to be applied to these patients will be effective
in terms of both tolerating uncertainty and developing
problem-focused coping strategies.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by
the FMV Işık University Institute of Social Sciences Clinical
Psychology Master's Program Ethics Committee (no: 9305,
date: 17/12/2020).
Financial Support: None declared.
Authorship contributions: Concept - B.T., D.A., B.A.Y.;
Design - B.T., D.A., B.A.Y.; Supervision - D.A., B.A.Y.; Materials
- B.T., D.A., B.A.Y.; Data collection and/or processing -
B.T.; Data analysis and/or interpretation - B.T., D.A., B.A.Y.;
Literature search - B.T., D.A., B.A.Y.; Writing - B.T., D.A.,
B.A.Y.; Critical review - D.A., B.A.Y.
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