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Korean J Adult Nurs : Korean Journal of Adult Nursing

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Original Article

Cognitive Decline and Quality of Life among Patients with Breast Cancer undergoing Chemotherapy: The Mediating Effect of Health Promotion Behavior

Jung Ran Lee1, Pok Ja Oh2
Korean Journal of Adult Nursing 2016;28(2):202-212.
Published online: April 30, 2016

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Corresponding author: Oh, Pok Ja Department of Nursing, Sahmyook University, 815 Kongnung-dong, Hwarang-ro, Nowon-gu, Seoul 01795, Korea. Tel: +82-2-3399-1589, Fax: +82-2-3399-1594, E-mail: ohpj@syu.ac.kr
• Received: February 17, 2016   • Accepted: April 19, 2016

Copyright © 2016 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The purpose of this study was to assess the relationship between cognitive function impairment and quality of life (QoL) among patients with breast cancer. Specifically, the intention was to verify the mediating effects for promoting behaviors leading to better health and QoL.
  • Methods
    A purposive sample of 152 patients undergoing chemotherapy was recruited. A cross-sectional survey design was used. Data were collected using four instruments: Everyday Cognition Scale, Korean Mini-Mental State Examination, Functional Assessment of Cancer Therapy-Breast Cancer Version 4, and Health Promoting Lifestyle Profile.
  • Results
    The mean score for subjective cognitive decline was 65.84; the health promotion behavior was 95.89, and 83.34 for QoL. Health promotion behavior was directly affected by cognitive decline (R2=6.0%) as was QoL (R2=43%). Subjective cognitive decline (β=-.57, p<.001) and health promotion behavior (β=.37, p<.001) were seen as predicting factors in QoL and explained 56% (R2=56%). Health promotion behavior had a partial mediating effect in the relationship between self-reported cognitive decline and QoL (Sobel test: Z=-3.37, p<.001).
  • Conclusion
    Based on the findings of this study, nursing intervention programs focusing on managing cognitive decline and promoting health promotion behavior are highly recommended to improve QoL in cancer patients.
  • Key Words: Quality of life; Cognitive function; Health promotion; Breast neoplasms
Figure 1.
Mediating effect of health promotion behavior between perceived cognitive decline and quality of life.
kjan-28-202f1.jpg
Table 1.
Cognitive Function, Health Promotion Behavior and Quality of Life according to General Characteristics of the Subject (N=152)
Variables Categories n (%) Perceived cognitive decline Objective cognitive function Health promotion behavior Quality of life
M±SD t t or F (p) Scheffé M±SD t or F (p) Scheffé M±SD t or F (p) Scheffé M±SD t or F (p) Scheffé
Age (year) ＜40a b 23 (15.1) 60.96±16.52 1.06 29.04±1.36 15.01 94.04±18.23 3.07 90.04±18.79 3.41
40~49b c 56 (36.8) 63.59±24.03 (.367) 28.84±1.06 (＜.001) 98.84±17.38 (.030) 87.98±23.05 (.019)
50~59c 59 (38.8) 68.39±23.77   28.37±1.34 a, b, c＞d 96.68±16.30 b＞d 79.10±21.76  
≥60d 14 (9.2) 71.14±30.05   26.29±2.23   83.79±16.00   71.64±29.01  
Martial status Yes 135 (88.8) 65.98±24.01 -0.20 28.41±1.55 1.06 96.27±17.28 -0.77 83.06±23.53 0.42
No 17 (11.2) 64.76±20.56 (.842) 28.82±1.38 (.292) 92.82±17.93 (.441) 85.59±19.86 (.672)
Education ≤MSa 29 (19.1) 65.52±24.47 0.01 27.41±2.13 12.46 93.21±20.20 3.15 77.90±25.83 1.63
HSb c 70 (46.1) 65.71±25.73 (.991) 28.43±1.29 (＜.001) 93.40±17.48 (.046) 82.60±23.19 (.199)
≥Collegec 53 (34.9) 66.19±20.38   29.06±1.08 a＜b, c 1 100.64±14.54   87.30±21.07  
Monthly income (10,000 won) ＜200a b 46 (30.3) 74.11±26.44 3.05 28.44±1.60 0.55 90.48±16.43 3.35 74.13±22.20 4.93
200~399b c 71 (46.7) 63.56±23.22 (.031) 28.45±1.63 (.652) 97.90±17.65 (.021) 86.11±22.59 (.003)
400~599c d 20 (13.2) 60.25±16.21   28.20±1.32   94.45±14.96 a＜d 84.35±19.37 a＜b, d
≥600d 15 (9.9) 58.73±18.86   28.87±1.06 1 104.87±17.40   97.13±24.28  
Family support Satisfieda 97 (63.8) 62.03±21.10 3.66 28.53±1.45 0.65 98.99±17.92 4.74 87.46±23.29 5.14
Moderateb 47 (30.9) 72.91±26.94 (.028) 28.26±1.78 (.524) 91.06±15.07 (.010) 77.49±21.39 (.007)
Unsatisfied 8 (5.3) 70.50±23.90 a＜b 28.75±0.71   86.63±13.79 a＞b 67.75±18.01 a＞b
Age of menarche ＜13a b 38 (25.0) 63.39±20.10 0.27 28.84±1.35 3.73 1 101.03±16.38 2.30 89.11±25.70 2.16
14~15b c 68 (44.7) 66.68±22.96 (.764) 28.56±1.52 (.026) 94.51±14.03 (.104) 83.29±22.68 (.119)
＞15c 46 (30.3) 66.63±27.28   27.98±1.60 a＞c 93.67±21.52   78.65±20.77  
Menopause Noa b 39 (25.7) 61.44±20.35 1.84 29.00±1.24 10.25 98.69±16.65 2.03 90.41±23.60 5.21
Yesb c† 59 (38.8) 70.22±27.48 (.162) 27.80±1.85 (＜.001) 92.39±17.59 (.135) 76.27±24.96 (.006)
Yesc† 54 (35.5) 64.24±20.61   28.78±1.02 a, c＞b 97.69±17.18   85.96±18.44 a＞b
ECOG PS 0a b 25 (16.4) 51.16±12.97 5.20 28.48±1.29 0.09 1 105.20±21.64 4.07 100.28±19.32 9.47
1b c 85 (55.9) 64.88±21.12 (.001) 28.42±1.60 (.986) 96.41±16.52 (.004) 84.98±20.37 (＜.001)
2c d 25 (16.4) 75.44±26.82 a＜c, d 28.60±1.22   92.12±10.49 a＞d 74.72±23.69 a＞b, c, d
3d 15 (9.9) 78.13±32.57   28.33±2.09   84.93±16.90   64.13±21.71 b＞d
4 2 (1.3) 79.50±3.54   28.50±0.71   86.50±3.54   54.00±14.14  
Comorbidity Yes 44 (28.9) 64.82±27.96 0.34 28.50±1.65 0.58 96.58±17.46 0.77 84.51±22.42 0.98
No 108 (71.1) 66.26±21.70 (.734) 28.34±1.20 (.563) 94.18±17.07 (.440) 80.48±24.74 (.331)
Stage I 29 (19.1) 63.79±20.68 0.22 28.24±1.85 0.97 96.59±18.76 0.49 85.07±20.91 0.49
II 77 (50.7) 65.75±21.85 (.885) 28.65±1.14 (.408) 96.99±15.79 (.689) 84.48±22.84 (.687)
III 36 (23.7) 66.33±26.46   28.33±1.97   94.39±20.39   81.44±24.31  
IV 10 (6.6) 70.70±34.87   28.00±1.33   90.80±13.07   76.40±28.28  
Metastasis Yes 46 (36.5) 70.58±26.92 -2.35 28.50±1.68 -0.35 94.67±19.63 0.81 82.08±24.89 0.64
No 80 (63.5) 61.58±19.33 (.020) 28.41±1.39 (.726) 96.99±14.99 (.418) 84.48±21.47 (.526)
Total chemotherap cycles ≤6a b 82 (53.9) 61.85±20.56 3.34 28.55±1.39 0.53 97.88±16.61 1.21 85.88±22.65 1.16
py 7~12b 51 (33.6) 72.55±24.96 (.038) 28.41±1.71 (.590) 93.88±17.92 (.301) 79.67±21.19 (.315)
≥13 19 (12.5) 65.05±28.92 a＜b 28.16±1.64   92.68±18.56   82.26±29.20  
Hormone therapy Yes 107 (70.9) 64.28±22.96 -1.34 28.46±1.51 0.01 96.93±16.66 1.52 84.06±22.92 0.67
No 44 (29.1) 69.93±25.08 (.183) 28.46±1.62 (.990) 92.34±17.58 (.132) 81.30±23.85 (.507)

MS=Middle school; HS=High school;

†Related to cancer treatment

Table 2.
Descriptive Statistics of Perceived Cognitive Decline, Objective Cognitive Function, Health Promotion Behavior and Quality of Life (N=152)
Variable n (%) Possible range Actual range M±SD Mean of item±SD
Objective cognitive function 0~30 22~30 28.45±1.53
≤23 score 24~26 score 2 (1.3) 13 (8.6)
24~26 score 13 (8.6)
≥27 score 137 (90.1)
Perceived cognitive decline 0~156 35~146 65.84±23.56 1.69±0.60
Daily memory 0~32 5~32 15.22±6.06 1.90±0.76
Language 0~36 6~36 14.38±5.86 1.60±0.65
Executive function: Planning 0~20 1~20 7.70±3.36 1.54±0.67
Executive function: Organization 0~24 5~24 9.87±4.22 1.64±0.70
Executive function: Divided attention 0~16 3~16 7.41±3.53 1.85±0.88
Visuospatial abilities 0~28 4~28 11.27±5.01 1.61±0.72
Health promotion behavior 0~152 51~144 95.89±17.33 2.52±0.46
Self-actualization 0~40 10~40 24.70±6.70 2.47±0.67
Health responsibility 0~32 10~32 20.91±4.31 2.61±0.54
Exercise 0~12 3~12 6.71±2.12 2.24±0.71
Nutrition 0~24 8~24 16.56±3.38 2.76±0.56
Interpersonal support 0~16 5~16 10.51±2.50 2.63±0.62
Stress management 0~28 7~28 16.49±4.03 2.36±0.58
Quality of life 0~148 21~133 83.34±23.10 2.25±0.63
Physical well being 0~28 0~28 17.91±7.27 2.56±1.04
Social/family well being 0~28 0~28 15.09±6.74 2.16±0.96
Emotional well being 0~24 0~24 15.28±5.13 2.55±0.85
Functional well being 0~28 0~28 14.24±6.74 2.03±0.96
Additional concerns 0~40 2~37 20.82±7.14 2.08±0.71
Table 3.
Mediating Effect of Health Promotion Behavior between Perceived Cognitive Decline and Quality of Life (N=152)
Variables B β t p Adj. R2 F p
Step 1. Perceived cognitive decline → HPB -.19 -.25 -3.22 .002 .06 10.35 .002
Step 2. Perceived cognitive decline → QoL -.65 -.66 -10.75 ＜.001 .43 115.60 ＜.001
Step 3. Perceived cognitive decline, HPB → QoL         .56 95.40 ＜.001
1) Perceived cognitive decline → QoL -.56 -.57 -10.10 ＜.001      
2) HPB → QoL .49 .37 6.55 ＜.001      
Sobel test: Z=-3.37, p＜.001

HPB=health promotion behavior; QoL=quality of life.

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    Cognitive Decline and Quality of Life among Patients with Breast Cancer undergoing Chemotherapy: The Mediating Effect of Health Promotion Behavior
    Korean J Adult Nurs. 2016;28(2):202-212.   Published online April 30, 2016
    DOI: https://doi.org/10.7475/kjan.2016.28.2.202
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    Cognitive Decline and Quality of Life among Patients with Breast Cancer undergoing Chemotherapy: The Mediating Effect of Health Promotion Behavior
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    DOI: https://doi.org/10.7475/kjan.2016.28.2.202
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    Cognitive Decline and Quality of Life among Patients with Breast Cancer undergoing Chemotherapy: The Mediating Effect of Health Promotion Behavior
    Image
    Figure 1. Mediating effect of health promotion behavior between perceived cognitive decline and quality of life.

    Figure 1.

    Cognitive Decline and Quality of Life among Patients with Breast Cancer undergoing Chemotherapy: The Mediating Effect of Health Promotion Behavior

    Cognitive Function, Health Promotion Behavior and Quality of Life according to General Characteristics of the Subject (N=152)

    Variables Categories n (%) Perceived cognitive decline Objective cognitive function Health promotion behavior Quality of life
    M±SD t t or F (p) Scheffé M±SD t or F (p) Scheffé M±SD t or F (p) Scheffé M±SD t or F (p) Scheffé
    Age (year) ＜40a b 23 (15.1) 60.96±16.52 1.06 29.04±1.36 15.01 94.04±18.23 3.07 90.04±18.79 3.41
    40~49b c 56 (36.8) 63.59±24.03 (.367) 28.84±1.06 (＜.001) 98.84±17.38 (.030) 87.98±23.05 (.019)
    50~59c 59 (38.8) 68.39±23.77   28.37±1.34 a, b, c＞d 96.68±16.30 b＞d 79.10±21.76  
    ≥60d 14 (9.2) 71.14±30.05   26.29±2.23   83.79±16.00   71.64±29.01  
    Martial status Yes 135 (88.8) 65.98±24.01 -0.20 28.41±1.55 1.06 96.27±17.28 -0.77 83.06±23.53 0.42
    No 17 (11.2) 64.76±20.56 (.842) 28.82±1.38 (.292) 92.82±17.93 (.441) 85.59±19.86 (.672)
    Education ≤MSa 29 (19.1) 65.52±24.47 0.01 27.41±2.13 12.46 93.21±20.20 3.15 77.90±25.83 1.63
    HSb c 70 (46.1) 65.71±25.73 (.991) 28.43±1.29 (＜.001) 93.40±17.48 (.046) 82.60±23.19 (.199)
    ≥Collegec 53 (34.9) 66.19±20.38   29.06±1.08 a＜b, c 1 100.64±14.54   87.30±21.07  
    Monthly income (10,000 won) ＜200a b 46 (30.3) 74.11±26.44 3.05 28.44±1.60 0.55 90.48±16.43 3.35 74.13±22.20 4.93
    200~399b c 71 (46.7) 63.56±23.22 (.031) 28.45±1.63 (.652) 97.90±17.65 (.021) 86.11±22.59 (.003)
    400~599c d 20 (13.2) 60.25±16.21   28.20±1.32   94.45±14.96 a＜d 84.35±19.37 a＜b, d
    ≥600d 15 (9.9) 58.73±18.86   28.87±1.06 1 104.87±17.40   97.13±24.28  
    Family support Satisfieda 97 (63.8) 62.03±21.10 3.66 28.53±1.45 0.65 98.99±17.92 4.74 87.46±23.29 5.14
    Moderateb 47 (30.9) 72.91±26.94 (.028) 28.26±1.78 (.524) 91.06±15.07 (.010) 77.49±21.39 (.007)
    Unsatisfied 8 (5.3) 70.50±23.90 a＜b 28.75±0.71   86.63±13.79 a＞b 67.75±18.01 a＞b
    Age of menarche ＜13a b 38 (25.0) 63.39±20.10 0.27 28.84±1.35 3.73 1 101.03±16.38 2.30 89.11±25.70 2.16
    14~15b c 68 (44.7) 66.68±22.96 (.764) 28.56±1.52 (.026) 94.51±14.03 (.104) 83.29±22.68 (.119)
    ＞15c 46 (30.3) 66.63±27.28   27.98±1.60 a＞c 93.67±21.52   78.65±20.77  
    Menopause Noa b 39 (25.7) 61.44±20.35 1.84 29.00±1.24 10.25 98.69±16.65 2.03 90.41±23.60 5.21
    Yesb c† 59 (38.8) 70.22±27.48 (.162) 27.80±1.85 (＜.001) 92.39±17.59 (.135) 76.27±24.96 (.006)
    Yesc† 54 (35.5) 64.24±20.61   28.78±1.02 a, c＞b 97.69±17.18   85.96±18.44 a＞b
    ECOG PS 0a b 25 (16.4) 51.16±12.97 5.20 28.48±1.29 0.09 1 105.20±21.64 4.07 100.28±19.32 9.47
    1b c 85 (55.9) 64.88±21.12 (.001) 28.42±1.60 (.986) 96.41±16.52 (.004) 84.98±20.37 (＜.001)
    2c d 25 (16.4) 75.44±26.82 a＜c, d 28.60±1.22   92.12±10.49 a＞d 74.72±23.69 a＞b, c, d
    3d 15 (9.9) 78.13±32.57   28.33±2.09   84.93±16.90   64.13±21.71 b＞d
    4 2 (1.3) 79.50±3.54   28.50±0.71   86.50±3.54   54.00±14.14  
    Comorbidity Yes 44 (28.9) 64.82±27.96 0.34 28.50±1.65 0.58 96.58±17.46 0.77 84.51±22.42 0.98
    No 108 (71.1) 66.26±21.70 (.734) 28.34±1.20 (.563) 94.18±17.07 (.440) 80.48±24.74 (.331)
    Stage I 29 (19.1) 63.79±20.68 0.22 28.24±1.85 0.97 96.59±18.76 0.49 85.07±20.91 0.49
    II 77 (50.7) 65.75±21.85 (.885) 28.65±1.14 (.408) 96.99±15.79 (.689) 84.48±22.84 (.687)
    III 36 (23.7) 66.33±26.46   28.33±1.97   94.39±20.39   81.44±24.31  
    IV 10 (6.6) 70.70±34.87   28.00±1.33   90.80±13.07   76.40±28.28  
    Metastasis Yes 46 (36.5) 70.58±26.92 -2.35 28.50±1.68 -0.35 94.67±19.63 0.81 82.08±24.89 0.64
    No 80 (63.5) 61.58±19.33 (.020) 28.41±1.39 (.726) 96.99±14.99 (.418) 84.48±21.47 (.526)
    Total chemotherap cycles ≤6a b 82 (53.9) 61.85±20.56 3.34 28.55±1.39 0.53 97.88±16.61 1.21 85.88±22.65 1.16
    py 7~12b 51 (33.6) 72.55±24.96 (.038) 28.41±1.71 (.590) 93.88±17.92 (.301) 79.67±21.19 (.315)
    ≥13 19 (12.5) 65.05±28.92 a＜b 28.16±1.64   92.68±18.56   82.26±29.20  
    Hormone therapy Yes 107 (70.9) 64.28±22.96 -1.34 28.46±1.51 0.01 96.93±16.66 1.52 84.06±22.92 0.67
    No 44 (29.1) 69.93±25.08 (.183) 28.46±1.62 (.990) 92.34±17.58 (.132) 81.30±23.85 (.507)

    MS=Middle school; HS=High school;

    †Related to cancer treatment

    Descriptive Statistics of Perceived Cognitive Decline, Objective Cognitive Function, Health Promotion Behavior and Quality of Life (N=152)

    Variable n (%) Possible range Actual range M±SD Mean of item±SD
    Objective cognitive function 0~30 22~30 28.45±1.53
    ≤23 score 24~26 score 2 (1.3) 13 (8.6)
    24~26 score 13 (8.6)
    ≥27 score 137 (90.1)
    Perceived cognitive decline 0~156 35~146 65.84±23.56 1.69±0.60
    Daily memory 0~32 5~32 15.22±6.06 1.90±0.76
    Language 0~36 6~36 14.38±5.86 1.60±0.65
    Executive function: Planning 0~20 1~20 7.70±3.36 1.54±0.67
    Executive function: Organization 0~24 5~24 9.87±4.22 1.64±0.70
    Executive function: Divided attention 0~16 3~16 7.41±3.53 1.85±0.88
    Visuospatial abilities 0~28 4~28 11.27±5.01 1.61±0.72
    Health promotion behavior 0~152 51~144 95.89±17.33 2.52±0.46
    Self-actualization 0~40 10~40 24.70±6.70 2.47±0.67
    Health responsibility 0~32 10~32 20.91±4.31 2.61±0.54
    Exercise 0~12 3~12 6.71±2.12 2.24±0.71
    Nutrition 0~24 8~24 16.56±3.38 2.76±0.56
    Interpersonal support 0~16 5~16 10.51±2.50 2.63±0.62
    Stress management 0~28 7~28 16.49±4.03 2.36±0.58
    Quality of life 0~148 21~133 83.34±23.10 2.25±0.63
    Physical well being 0~28 0~28 17.91±7.27 2.56±1.04
    Social/family well being 0~28 0~28 15.09±6.74 2.16±0.96
    Emotional well being 0~24 0~24 15.28±5.13 2.55±0.85
    Functional well being 0~28 0~28 14.24±6.74 2.03±0.96
    Additional concerns 0~40 2~37 20.82±7.14 2.08±0.71

    Mediating Effect of Health Promotion Behavior between Perceived Cognitive Decline and Quality of Life (N=152)

    Variables B β t p Adj. R2 F p
    Step 1. Perceived cognitive decline → HPB -.19 -.25 -3.22 .002 .06 10.35 .002
    Step 2. Perceived cognitive decline → QoL -.65 -.66 -10.75 ＜.001 .43 115.60 ＜.001
    Step 3. Perceived cognitive decline, HPB → QoL         .56 95.40 ＜.001
    1) Perceived cognitive decline → QoL -.56 -.57 -10.10 ＜.001      
    2) HPB → QoL .49 .37 6.55 ＜.001      
    Sobel test: Z=-3.37, p＜.001

    HPB=health promotion behavior; QoL=quality of life.
    Table 1. Cognitive Function, Health Promotion Behavior and Quality of Life according to General Characteristics of the Subject (N=152)

    MS=Middle school; HS=High school;

    Related to cancer treatment

    Table 2. Descriptive Statistics of Perceived Cognitive Decline, Objective Cognitive Function, Health Promotion Behavior and Quality of Life (N=152)

    Table 3. Mediating Effect of Health Promotion Behavior between Perceived Cognitive Decline and Quality of Life (N=152)

    HPB=health promotion behavior; QoL=quality of life.

    Table 1.

    Table 2.

    Table 3.

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