Social support and health-related quality of life in women with breast cancer: a longitudinal study

Social support and health-related quality of life in womenwith breast cancer: a longitudinal study

Janni Leung1*, Nancy A. Pachana2 and Deirdre McLaughlin11The University of Queensland, School of Population Health, Brisbane, Queensland, Australia2The University of Queensland, School of Psychology, Brisbane, Queensland, Australia

*Correspondence to: School ofPopulation Health, The Universityof Queensland, Herston Rd,Herston, Brisbane, Queensland4006, Australia. E-mail: [email protected]

Received: 26 July 2013Revised: 25 February 2014Accepted: 26 February 2014

AbstractObjectives: A breast cancer diagnosis is a distressing event that impacts on physical and psychologicalfunctioning. This study examined the longitudinal relationships among a diagnosis of breast cancer,social support, and health-related quality of life (HRQOL).

Methods: Participants were 412 women from the 1946–1951 birth cohort of the AustralianLongitudinal Study on Women’s Health who self-reported a new diagnosis of breast cancer between1998 and 2007. The three surveys of longitudinal data analyzed included data 3 years before diagnosis,at diagnosis (baseline), and 3 years after diagnosis (follow-up). Social support was measured using the19-item Medical Outcomes Study Social Support Survey; HRQOL was measured using the MedicalOutcomes Study 36-item Short-Form Health Survey.

Results: Compared with pre-diagnosis HRQOL, women newly diagnosed with breast cancerreported significantly poorer HRQOL in subscales related to pain, physical functioning, and healthand vitality. At 3-year follow-up, HRQOL had improved in most domains to levels consistent withpre-diagnosis. Levels of social support remained stable across time. The structural equation modelshowed that social support was positively predictive of better physical and mental HRQOL at3-year follow-up.

Conclusions: Longitudinal analyses indicate that social support appears to be an important predic-tor of HRQOL in women diagnosed with breast cancer. In particular, positive emotional and informa-tional support that may normally be provided by a partner is important in maintaining HRQOL.Identification of those lacking social support, especially patients without partners, will enable themto be guided to appropriate support networks and programs.Copyright © 2014 John Wiley & Sons, Ltd.

Introduction

Breast cancer is the second most prevalent cancer amongwomen and is one of the leading causes of death in womenworldwide [1]. Despite this, advances in screening and di-agnostic procedures mean that most breast cancers can bediagnosed at an early stage, leading to effective treatmentsand improved survival rates [2]. Nonetheless, a diagnosisof breast cancer is a distressing event that affects physicaland psychological functioning and impacts on lifestyleand relationships with family and friends [3–5]. Breastcancer treatments, including systemic adjuvant therapy,lead to long-term worsened quality of life in breast cancersurvivors [5]. Furthermore, treatment-related changes towomen’s physical appearance may affect self-image, andother effects of treatment, including fatigue, nausea, andpain, may decrease opportunities for social interactionsand limit the ability of women with breast cancer to con-tinue their normal lifestyle and social activities [6]. Thisin turn curtails their opportunities to maintain supportivesocial networks and to receive appropriate emotional andinstrumental support.

Social support has been identified as being protectivefor health and in particular for reducing cancer-related dis-tress [7–9]. Studies have found that social support is asso-ciated with better adjustment to disease and better qualityof life; however, the subjective appropriateness of the sup-port offered is important [10,11]. Not all social relation-ships are sources of support; although women possessextensive and robust social networks, these can come ata price (such as maintaining the networks and managingexpectations of providing support to others) [10,12]. Thestress-buffering model of social support focuses on theperceived availability, quality, and appropriateness of sup-port [13]. In particular, this model suggests that whenconfronted with a situation of high stress, the availabilityof appropriate levels of subjective support is more impor-tant than the number of contacts in the social network.Perceived social support in health-related contexts hasbeen categorized as (a) emotional/informational support,(b) tangible support, (c) affectionate support, and (d) pos-itive social interaction [14]. The provision of satisfactoryemotional and informational support has been associatedwith better health and lower symptom intensity in women

Copyright © 2014 John Wiley & Sons, Ltd.

Psycho-OncologyPsycho-Oncology 23: 1014–1020 (2014)Published online 3 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3523

with breast cancer [15]. Both tangible support, in the formof a psycho-educational program, and affectionate sup-port, from family and friends, have been associated withbetter well-being and improved health-related quality oflife (HRQOL) among breast cancer patients [16–18].Although previous studies have reported that positive

social support can enhance adjustment to breast cancerand improve HRQOL [18–20], these studies are largelycross-sectional. Little evidence has been presented thatexamines either the longitudinal impact of social supporton HRQOL in women with breast cancer or changes overtime in social support and HRQOL throughout the courseof the disease. A small number of previous studies thathave reported on patterns of social support associated withbreast cancer have found that levels of social supportfluctuated over time [21,22]. However, these studies didnot have information on pre-diagnosis levels of socialsupport, and analyses were based on short follow-up times(up to 6 months). Given the increasing incidence andhigher survival rate from breast cancer in recent years, afocus on factors associated with HRQOL, especially froma longitudinal perspective, can provide valuable insight toinform the development of strategies to support womenduring this distressing experience.The aim of this study is to examine the impact of a

breast cancer diagnosis on social support and quality oflife over time. Additionally, this paper will examine therole of social support as a predictor of better HRQOL inwomen newly diagnosed with breast cancer. Consistentwith previously reported cross-sectional research, it isexpected that women with high levels of social supportwill report higher HRQOL scores.

Method

Participants

The Australian Longitudinal Study on Women’s Health(ALSWH) is a prospective study of the health and well-being of three cohorts ofwomenwhowere aged 18–23 years(1973–1978 birth cohort), 45–50 years (1946–1951 birthcohort), and 70–75 years (1921–1926 birth cohort) whenrecruited in 1996. The study sample was selected randomlyfrom the Medicare Australia database (which covers allcitizens and permanent residents of Australia, includingrefugees and immigrants), with intentional oversamplingof women living in rural and remote areas in order to achievean adequate sample size in this population. The project usesmailed questionnaires to collect self-report data on healthand related variables every 3 years. Details of the ALSWHrecruitment and study design have been fully described else-where [23], and details of the study can be found at www.alswh.org.au. Participation is voluntary, and the ALSWHis approved by the University of Newcastle and Universityof Queensland Human Research ethics committees.

Data for these analyses are drawn from surveys 1 to 6(1996 to 2010) of the 1946–1951 birth cohort. Becauseof uncertainties about the accuracy of the MedicareAustralia database, response rates to the initial invitationcannot be exactly specified. However, it has beenestimated that 53–56% of women in this birth cohortresponded with 14,072 women responding to survey 1[24]. Of the total eligible women at each survey, responsesto subsequent surveys were 12,338 (90.7%) at survey 2(1998), 11,226 (84.3%) at survey 3 (2001), 10,905(84.0%) at survey 4 (2004), 10,638 (83.8%) at survey 5(2007), and 10,011 (83.3%) at survey 6 (2010).Participants were women who responded ‘yes’ to the

following question in survey 2 (1998), survey 4 (2004), orsurvey 5 (2007): ‘In the past three years, have you beendiagnosed or treated for breast cancer’. A baseline breastcancer diagnosis was a positive response at any of the threesurveys. This self-report item has been validated againstCancer Registry data with 93% sensitivity and 98%specificity [25]. Pre-diagnosis data were drawn from thesurvey immediately preceding the baseline (breast cancerdiagnosis) survey, and follow-up data were drawn fromthe survey immediately after the baseline survey. A totalof 519 women reported a new diagnosis of breast cancerbetween 1998 and 2007: 82 in 1998, 199 in 2004, and238 in 2007. There were 433 women (83%) who completedthe follow-up survey, in which 21 (5%) had missing data.The final sample included 412 women newly diagnosedwith breast cancer who had valid data. Missing data wereexcluded pair-wise for statistical analyses.

Measures

Social support was measured by the 19-item MedicalOutcomes Study Social Support Survey [14], with a stemquestion that asks, ‘How often is each of the followingkinds of support available to you if you need it?’ Eachitem was answered on a five-point scale, ranging fromnone of the time to all of the time. Scores were from 1to 5 with higher scores indicating greater levels of socialsupport. The original four functional support subscales in-cluded (1) emotional/informational support (eight items),(2) tangible support (four items), (3) affectionate support(three items), and (4) positive social interaction (threeitems), and an additional item [14]. Emotional support isthe expression of positive affect, empathic understanding,and the encouragement of expressions of feelings (e.g.,share your most private worries and fears with); informa-tional support is the offering of advice, information, guid-ance, or feedback that can provide a solution to a problem(e.g., turn to for suggestions about how to deal with a per-sonal problem); positive social interaction is companion-ship or the availability of other persons to share leisureand recreational activities (e.g., have a good time with);affectionate support is the expression of love and affection

1015Social support, quality of life, and breast cancer

Copyright © 2014 John Wiley & Sons, Ltd. Psycho-Oncology 23: 1014–1020 (2014)DOI: 10.1002/pon

http://www.alswh.org.au

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(e.g., love and make you feel wanted); and tangiblesupport is the offering of material aid or behavioral assis-tance (e.g., take you to the doctor if you need it). Psycho-metric testing and scale validation in the current samplewas previously conducted [26]. Factor analysis and parallelanalysis in the current sample revealed three factors(Cronbach’s alphas 0.90–0.96), supporting the combinationof the affectionate support and positive social interactionsubscales, and the inclusion of the additional item in theemotional/informational support subscale [26]. Conse-quently, in our sample, the three subscales of social supportthat can be measured separately are mean emotional/infor-mational support (EMI), mean affectionate support/positivesocial interaction (AFF), and mean tangible support (TAN).Health-related quality of life was measured using the

Medical Outcomes Study 36-item Short-Form HealthSurvey (SF-36) [27]. The SF-36 assesses general physicaland psychological health and well-being over the preced-ing 4 weeks. The survey covers eight dimensions ofphysical and mental health: physical functioning, rolelimitations due to physical or emotional problems, bodilypain, general health perceptions, vitality, social function-ing, and emotional well-being or mental health. Theresponses to items within each dimension are summedand linearly transformed to produce scores ranging from0 to 100 with higher scores indicating better health.Sociodemographic characteristics examined included

marital status (single/divorced/widowed and married/cohabiting), education (no formal, high school, and trade/certificate/degree), country of birth (Australia, otherEnglish-speaking countries, and non-English-speakingcountries), and area of residence (major cities, innerregional, outer regional, remote, and very remote).

Statistical analysis

Statistical analyses were conducted using SPSS 19 (IBMCorp, Armonk, NY, USA). The women’s social supportwas compared over time, from the survey before diagnosisof breast cancer (pre-diagnosis) to the survey at whichbreast cancer was diagnosed (baseline) and at 3 years fol-low-up. Repeated-measures analyses of variance(ANOVAs) were conducted to compare levels of social sup-port over time. Within-subject contrasts were conducted tocompare pre-diagnosis social support with baseline socialsupport and baseline social support with social supportreported at follow-up. Similarly, repeated-measuresANOVAs were conducted to compare HRQOL over time.One-way between-subject ANOVAs were conducted to

compare social support and HRQOL by sociodemographics(marital status, education, country of birth, and area ofresidence) at baseline. The bivariate associations betweenbaseline social support and follow-up HRQOL were esti-mated using Pearson’s correlation. Partial correlation wasused to estimate the association between social support

andHRQOL adjusting for sociodemographic characteristicsfound to be significantly associated with both social supportand HRQOL.Structural equation modeling in Amos 17 was used to

model the effects of social support on both physical andmental HRQOL outcome in the same model. Socialsupport and HRQOL variables were standardized. Pathswere entered between latent variables from baseline socialsupport to physical and mental HRQOL. The observationson bodily pain, general health, physical functioning, androle physical were loaded onto the latent variable physicalHRQOL. The observations on mental health, roleemotional, social functioning, and vitality were loadedonto the latent variable mental HRQOL. The three socialsupport subscales, EMI, AFF, and TAN, were loaded ontothe latent variable social support. Covariance paths wereentered between the three social support subscales.Sociodemographic characteristics were controlled for byentering the observed characteristics with paths to latentsocial support, physical, and mental HRQOL. A goodmodel fit is indicated by a root mean square error ofapproximation ≤0.05, and normed-fit index and compara-tive fit index >0.90.

Results

Social support and quality of life over time

Women newly diagnosed with breast cancer had moder-ately high levels of EMI, AFF, and TAN social supportoverall, indicated by a mean of 3.97–4.16 out of a five-point scale at baseline (Table 1). Repeated-measuresANOVA results showed that there was no change in socialsupport pre-diagnosis, at baseline, and after breast cancerdiagnosis.Compared with pre-diagnosis HRQOL, women newly

diagnosedwith breast cancer had significantly worse qualityof life on the subscales of bodily pain, general health,physical functioning, role physical, and vitality. However,compared with when they were newly diagnosed, at fol-low-up, the women had increased scores in some domainsof HRQOL. Specifically, significant improvements wereobserved in their general health, role physical, role emo-tional, social functioning, and vitality (Table 1).

Social support by sociodemographic characteristics

Analysis of variance results by sociodemographic charac-teristics showed that at baseline, women who weremarried/cohabiting reported higher EMI, AFF, and TANsupport scores and had better HRQOL scores (Table 2).Therefore, marital status was included as a control variablein the analysis between social support and HRQOL. Therewere no significant differences in social support scores byeducation, country of birth, and area of residence.

1016 J. Leung et al.


Correlation between social support and quality of life

Pearson’s correlation results showed that the social supportsubscales were highly correlated (Table 3). Therefore, thecombined effects of the three social support subscales wereexamined in the multivariate analysis. Higher baselinesocial support scores were associated with higher physicaland mental HRQOL scores at follow-up. This indicated thatbetter social support was associated with better quality oflife. The effects of EMI and AFF support appeared to beslightly stronger than the effect of TAN support atpredicting HRQOL at follow-up. Partial correlation resultswere consistent after controlling for marital status.

Structural equation model

The structural equation model results showed a goodmodel fit (root mean square error of approximation = 0.02,

normed-fit index= 0.92, and comparative fit index = 0.93).In women with newly diagnosed breast cancer at baseline,more social support overall was predictive of betterHRQOL, both physical and mental, at follow-up (Figure 1).The effect was slightly stronger for mental HRQOL.

Discussion

Findings from this study indicate that, over time, a diagno-sis of breast cancer impacted negatively on HRQOL, butnot on perceived social support, which remained stable.Those aspects of HRQOL, which were susceptible totreatment effects (bodily pain, general health, physicalfunctioning, and vitality), were most likely to be impairedat time of diagnosis. The correlational results suggestedthat emotional/informational support and affectionatesupport/positive social interaction, rather than tangible

Table 1. Social support and health-related quality of life at pre-diagnosis, at baseline diagnosis, and at 3-year follow-up after breast cancerdiagnosis

Before diagnosis Baseline Follow-up Repeated-measures ANOVA

M [95% CI] (1) M [95% CI] M [95% CI] (2) F Partial eta squared

Social support (N=124)EMI 3.98 [3.80, 4.16] 3.97 [3.79, 4.16] 4.00 [3.82, 4.18] 0.06 <0.01AFF 4.20 [4.03, 4.37] 4.16 [3.98, 4.34] 4.16 [3.99, 4.32] 0.30 <0.01TAN 4.01 [3.80, 4.22] 4.10 [3.90, 4.29] 4.01 [3.81, 4.22] 0.66 0.01

Health-related quality of life (N=345)Bodily pain 68.08 [65.40, 70.76] * 65.12 [62.38, 67.85] 67.24 [64.61, 69.88] 2.73 0.01General health 69.74 [67.42, 72.06] *** 63.70 [61.21, 66.18] 67.22 [64.70, 69.74] ** 15.84 *** 0.05Physical functioning 80.84 [78.70, 82.98] ** 77.80 [75.49, 80.11] 78.48 [76.15, 80.82] 5.86 ** 0.02Role physical 73.90 [69.97, 77.83] ** 65.18 [60.61, 69.74] 72.73 [68.61, 76.84] ** 7.59 ** 0.02Mental health 73.42 [71.46, 75.37] 72.60 [70.49, 74.70] 74.05 [72.07, 76.03] 1.37 <0.01Role emotional 77.38 [73.49, 81.28] 73.80 [69.63, 77.96] 79.99 [76.20, 83.78] ** 4.07 * 0.01Social functioning 79.45 [76.81, 82.08] 77.04 [74.15, 79.93] 82.14 [79.60, 84.68] ** 6.07 ** 0.02Vitality 57.89 [55.56, 60.22] * 55.86 [53.30, 58.41] 58.55 [56.14, 60.96] * 3.44 * 0.01

Repeated within-subject contrasts were (1) before diagnosis versus baseline and (2) baseline versus follow-up.CI, confidence interval; ANOVA, analysis of variance; EMI, emotional/informational support; AFF, affectionate/positive social interaction support; TAN, tangible support.*p< 0.05, **p< 0.01, ***p< 0.001.

Table 2. Social support at baseline and health-related quality of life at follow-up by marital status at baseline

Single/divorced/widowed Married/cohabiting One-way ANOVA

M [95% CI] M [95% CI] F Eta squared

Social support (N=412)EMI 3.51 [3.28, 3.73] 4.06 [3.96, 4.16] 22.43 *** 0.05AFF 3.43 [3.20, 3.65] 4.28 [4.18, 4.38] 61.20 *** 0.13TAN 3.25 [3.01, 3.49] 4.16 [4.05, 4.26] 58.56 *** 0.13

Health-related quality of life (N=358)Bodily pain 62.27 [56.10, 68.44] 68.06 [65.22, 70.91] 3.24 0.01General health 61.11 [55.55, 66.66] 69.01 [66.36, 71.66] 7.13 ** 0.02Physical functioning 70.38 [65.94, 74.82] 74.76 [72.62, 76.90] 3.37 0.01Role physical 72.57 [67.19, 77.96] 79.91 [77.41, 82.40] 6.75 * 0.02Mental health 69.33 [60.00, 78.66] 82.73 [78.80, 86.66] 8.70 ** 0.02Role emotional 62.33 [52.49, 72.18] 74.73 [70.32, 79.14] 6.10 * 0.02Social functioning 75.17 [68.87, 81.47] 83.42 [80.72, 86.13] 7.01 ** 0.02Vitality 52.13 [46.57, 57.70] 60.00 [57.44, 62.56] 7.37 ** 0.02

CI, confidence interval; ANOVA, analysis of variance; EMI, emotional/informational support; AFF, affectionate/positive social interaction support; TAN, tangible support.*p< 0.05, **p< 0.01, ***p< 0.001.



support, were more important in improving quality of lifeafter diagnosis. Better social support at time of diagnosispredicted better physical and mental HRQOL at subse-quent follow-up.A diagnosis of breast cancer, while no doubt a stressful

and distressing event, did not impact on existing levels ofsocial support in the women in this study over time. Thewomen had moderately high levels on all three aspectsof social support prior to diagnosis, and there was littlevariation at the two subsequent measurement points. Thestability of social support in the current analyses is incon-sistent with the results from previous studies that showedlevels of social support, which either decreased within6 months [21] or increased in the first 12 weeks of a socialsupport intervention and then decreased [22]. Neither ofthese studies had pre-diagnosis measures, however, andtheir measurement time frame was relatively short. Thecurrent study is the first to examine the long-term effectsof a breast cancer diagnosis on women’s social support

and HRQOL employing a 6-year longitudinal design.Consistent with these results was the stability over timeof the women’s mental health. Prior research has shownthat poor mental health is associated with lower levels ofsocial support, possibly either through withdrawal fromexisting networks or resistance to approaches from withinthe network [9,28]. However, the impact of diagnosis wasclearly evident on HRQOL, particularly in those areas ofquality of life functioning that would be most affected bytreatment side effects (pain, general health, and vitality).Despite this, by 3-year post-diagnosis, the women hadreturned to pre-diagnosis functioning on most aspects ofHRQOL.The positive effect of social support on HRQOL is con-

sistent with previous cross-sectional studies [17–19] andwith the stress-buffering model of social support [12].Our findings indicate that certain aspects of social supportsuch as the provision of emotional, affectionate, and infor-mational support were more influential on HRQOL thanthe provision of instrumental support. When confrontedwith a high stress situation, such as a diagnosis of breastcancer, the stress-buffering model suggests that the receiptof subjectively appropriate support optimizes outcomes.For women who are managing a distressing diagnosisand concomitant treatment, the most appropriate subjec-tive support may be emotionally focused and most likelyprovided by husbands or other intimate partners [20].The importance of spousal support for women with

breast cancer was highlighted in our findings. Married orpartnered women had higher levels of social support onthe three measured dimensions and better HRQOL. Thisis consistent with previous research among women withbreast cancer, which has shown that spousal support is as-sociated with improved emotional and physical well-beingand better quality of life [20].Our findings raise a number of issues relating to the

treatment and support provided to women diagnosed withbreast cancer. Those women who face diagnosis andsubsequent treatment without a partner, or other adequate

Table 3. Correlation between social support at baseline breastcancer diagnosis and health-related quality of life at 3-year follow-up

Baseline social support

EMI AFF TAN

Baseline social supportEMI —

AFF 0.85** —

TAN 0.72** 0.71** —

Follow-up health-related quality of lifeBodily pain 0.27** 0.25** 0.18**General health 0.24** 0.23** 0.18**Physical functioning 0.20** 0.19** 0.13*Role physical 0.22** 0.23** 0.18**Mental health 0.27** 0.29** 0.21**Role emotional 0.18** 0.24** 0.19**Social functioning 0.22** 0.28** 0.18**Vitality 0.25** 0.25** 0.19**

EMI, emotional/informational support; AFF, affectionate/positive social interactionsupport; TAN, tangible support.*p< 0.05 **p< 0.01.

Figure 1. Structural equation model of social support at baseline predicting health-related quality of life at 3-year follow-up. Standardizedestimates for significant paths at p< 0.001 are presented. EMI, emotional/informational support; AFF, affectionate/positive social interactionsupport; TAN, tangible support



support provider, are at clear risk of impaired HRQOL.Treatments that focus wholly on the physical aspects ofbreast cancer and that exclude psychological and socialaspects leave patients vulnerable to continuing distress.This is an important ethical issue that needs to beaddressed when health professionals and their patientsare discussing treatment options and available supportand counseling programs. Further, access to breast cancersupport groups and other assistance-providing agenciesmay be affected by a range of factors including area ofresidence, mobility, and financial constraints. Womenexperiencing these additional barriers may be doublydisadvantaged if their available social support isinadequate.There are a number of limitations in our study. Other

possible variables that may be associated with both socialsupport and HRQOL, such as stage of breast cancer atdiagnosis and timing and efficacy of treatment, were notavailable in the dataset. We did not have a cancer-specificmeasure of HRQOL (e.g., Functional Assessment ofCancer Therapy) in our dataset, and rather have used ageneric instrument (SF-36) to examine HRQOL, whichshould be taken into consideration in the interpretationof our findings. Our results reflect the overall effects of so-cial support, rather than specific effects of social supportfor women with different stages of cancer and with vary-ing responses to their treatments. We did not have infor-mation on the women’s subjective feelings about thesocial support they were receiving. Previous research inbreast cancer patients has shown that unwanted supportcan have adverse psychological effects [29]. The womenwho provided data for this paper generally reported goodmental health at the three time points, and women withpoor psychological health may be underrepresented. Asnegative affect can result in poorer self-assessment andlower social support, the results may reflect this possiblebias. The majority of participants in the current study were

Australian born; as the need for social support after breastcancer treatment differs by cultural background [30], ourresults may not be generalizable to women of othercultural background. However, our oversampling ofwomen residing in rural areas has provided an adequatesample size in this group; so our results can be generalizedto women with breast cancer living in both urban and ruralareas of Australia.Health care support staff should inquire about the levels

of social support available to women diagnosed withbreast cancer. Although tangible support in the form ofassistance with activities such as transportation to medicalappointments is a useful and perhaps obvious form ofsocial support for women diagnosed with breast cancer,our data suggest that emotional/informational supportand affectionate/positive social interaction were asimportant, if not more important, to quality of life. Thus,encouragement of activities and behaviors to promotecompanionship and quality time with those who can pro-vide these types of support should be stressed, particularlyfor those patients who do not have partners. In this way,the negative effects of a diagnosis of breast cancer onquality of life post-diagnosis can be ameliorated.

AcknowledgementsThe research on which this paper is based was conducted as part ofthe ALSWH by investigators at the University of Newcastle and theUniversity of Queensland. The study was approved by the Univer-sity of Newcastle and University of Queensland Human Researchethics committees. We are grateful to the Australian GovernmentDepartment of Health and Ageing for funding and to the womenwho provided the survey data. The funding source had no role inthe design, conduct, and reporting of the study.

Conflict of interest

The authors have declared no conflicts of interest.

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Social support and health-related quality of life in women with breast cancer: a longitudinal study