The relationships among health-promoting lifestyle behaviors and perceived stress in women with early-stage breast cancer over 2 years

Abstract

Background:

Although the survival rate has increased among women with breast cancer, many women experience psychological sequelae, including stress, which affects their quality of life. Healthy lifestyle behaviors are essential for reducing stress in breast cancer survivors and minimizing long-term treatment complications.

Objective:

This study examined the temporal relationships among health-promoting lifestyle behaviors (HPLBs) and perceived stress in women with early-stage breast cancer.

Design:

This research was a secondary analysis of a longitudinal biobehavioral study of women with early-stage breast cancer funded by the National Institute of Nursing Research.

Methods:

This study included a sample of 73 participants. Measures of the study were evaluated at five-time points beginning just before the initiation of chemotherapy until 24 months from the first chemotherapy treatment. General linear mixed models and regression were used for analysis.

Results:

Study results showed an inverse association among the health-promoting lifestyle profile (HPLP) with perceived stress (p = <0.0001). The health-promoting lifestyle subscales with the highest means were interpersonal relationships and spiritual growth. In addition, the results demonstrated changes in perceived stress levels from baseline assessment until 24 months from the initial chemotherapy treatment.

Conclusions:

This study indicated that HPLBs, selected demographics, and clinical factors have a role in the perception of stress among women with early-stage breast cancer. Future studies, with larger samples, are needed to confirm these findings.

Keywords

breast cancer chemotherapy lifestyle behaviors perceived stress

Introduction

Breast cancer is the most common malignancy with an average risk of 13% among women in the united states¹ Chemotherapy is an essential part of breast cancer treatment that has been shown to significantly improve survival rate²; however, it has been associated with disease-related sequelae such as distress, depression, anxiety, fatigue, pain, and sleep disturbances.^3,4 Diagnosis, treatment, and distressing symptoms place women with early-stage breast cancer receiving chemotherapy under stress affecting immune and neuroendocrine systems, which contribute to cancer progression and metastasis.⁵ Previous research reported that 50% of women experienced psychological stress during the diagnosis and during the active treatment period into survivorship.^2,6 A study by Ranieri et al.⁷ reported that breast cancer survivors had moderate to strong anxiety and stress that were associated with negative thinking pattern at 12–18 months post-cancer treatment. Furthermore, Harris et al.⁸ conducted a longitudinal study showed that prolonged exposure to stress during the first year after breast cancer diagnosis correlated with symptoms of physical distress. Another study reported that 28% of women experienced clinical distress after treatment completion.^2,9 Developing and implementing strategies to assuage stress during and beyond active treatment may enhance outcomes for women with breast cancer.

Promoting healthy lifestyle among breast cancer survivors is an essential factor in decreasing stress, distressing symptoms, and improving quality of life.^3,10 It is well established that these practices reduce the risk of secondary tumors, comorbid diseases, and enhance the survivor’s quality of life.¹¹ The American Cancer Society recommends that breast cancer survivors engage routinely in moderate-intensity physical activity of 150 min/week, maintain a healthy weight, have a balanced diet that is high in vegetables, fruits, whole grains, and low in saturated fat with limited alcohol intake.¹² However, recent evidence reports a lack of adherence to healthy lifestyle behaviors among breast cancer survivors.⁹ Indeed, a meta-analysis on behavioral change interventions reported that behaviors such as poor diet and lack of regular exercise were common among cancer survivors.¹³ Also, recent review reported that breast cancer survivors tend to quit regular exercise after 1-year post-diagnosis.⁹ This lack of adherence to healthy lifestyle modifications during chemotherapy into survivorship remains a challenge among this population. Understanding the relationships between healthy lifestyle behaviors and stress may provide insight into strategies to improve survivorship. The aims of this study were (1) to examine the associations between health-promoting lifestyle behaviors (HPLBs) and perceived stress at baseline, midway through chemotherapy, 6 months, 1 year, and 2 years following initiation of chemotherapy; (2) to characterize temporal levels and changes in levels of health-promoting behaviors (physical activity, health responsibility, spiritual growth, nutrition, interpersonal relationships, stress management), and perceived stress over time; and (3) to examine the associations among interpersonal factors (education level, marital status, income, employment), and disease factors (tumor characteristics, surgery type, chemotherapy features, radiation) with perceived stress levels at baseline.

Conceptual framework

This study was guided by the theory of allostasis¹⁴ to explain the association among personal and lifestyle factors on perceived stress over time as illustrated in Figure 1. Breast cancer survivors experience multiple cumulative stress related to the disease trajectory.³ Known sources of stress in breast cancer are active treatments which accompanies symptoms such as depression, fatigue, and sleep disturbances.^3,15 Personal and socioeconomic factors such as young age, low education level, low income, unemployment, and marital status of widows or singles are essential sources of stress in women with breast cancer.^2,16,17 According to the allostatic model of stress, HPLBs have a bidirectional relationship with perceived stress and are indicators of positive allostasis.¹⁴ Nursing researchers have emphasized the importance of examining interactions between stressors and perceived stress, and their effects on health outcomes.^18,19 Unmanaged stress from the disease process may lead to allostatic overload, known as multisystem dysregulation, resulting in premature morbidity and mortality.^14,19 This is highly critical, specifically in the growing population of women living with breast cancer.

Figure 1.

The Conceptual Model Illustrating Predisposing Factors and Their Hypothesized Influence on Perceived Stress. Adapted from, Beckie 17.

Methods

Study design and participants

This study was a secondary analysis of data from a longitudinal study [R01NR012667],¹⁶ the study employed a convenience sample of 77 and was conducted in a designated National Cancer Center in a major research university with 4 regional sites in Virginia. The study followed the STROBE guidelines for observational studies.²⁰ The inclusion criteria were women aged 21 years and older, with a diagnosis of early-stage breast cancer (stage I–IIIA) and a scheduled visit to receive chemotherapy. The exclusion criteria were a previous history of cancer or chemotherapy, a diagnosis of dementia, active psychosis, or a diagnosis of immune system disorders. The parent study’s data collection period was from January 2010 to December 2014.¹⁶ The study participants were asked to fill out the study’s questionnaires and were evaluated at five time points as follows: (T1) before the initiation of chemotherapy, (T2) midpoint at 4 and 6 weeks after the first chemotherapy, (T3) at 6 months of chemotherapy, (T4) at 12 months of chemotherapy, and (T5) 24 months after the initial chemotherapy treatment. All study participants provided written informed consent (VCU IRB #HM 13194).¹⁵ IRB approval to conduct this study was obtained from the Institutional Review Board of the University of Florida (IRB20140008).

Sample size determination

Detectable effect size given the available sample was estimated using the R package “pwrss.”²¹ For the overall regression model containing five predictors, an effect size of R² ⩾ 0.17 (corresponding to Cohen’s²² medium effect size) is detectable at a power of 0.82. An R² change of ⩾0.11 (corresponding to Cohen’s medium effect size) for one predictor while controlling for four is detectable at a power of 0.83. Finally, for the mixed model with five repeated measures, a within effect size of R² of ⩾0.03 (corresponding to Cohen’s small effect size) is detectable at a power of 0.83.

Measures

Health-promoting lifestyle behaviors

The health-promoting lifestyle profile (HPLP-II) by Walker and Hill-Polerecky²³ was used to measure healthy lifestyle behaviors. This scale measures the multidimensional pattern of an individual’s perceptions and actions to maintain or enhance their well-being. This scale includes 52 items, and individual responses are rated on a 4-point response scale. The items are scored as (1 = never, 2 = sometimes, 3 = often, and 4 = routinely). The scale includes the following six domains: health responsibility, nutrition, spiritual growth, physical activity, interpersonal relationships, and stress management. The total scores of the six subscales of health-promoting behaviors were calculated by adding the 4-point Likert scale scores for all items within each subscale. The total score was calculated as the sum of all the subscale scores. Higher scores on these scales indicate higher levels of HPLBs. The HPLP has been tested and validated in the literature, with a Cronbach’s alpha of 0.94.²³

Stress

Stress was measured using the perceived stress scale (PSS), a subjective measure of how individuals perceive stressful events as overwhelming and uncontrolled. This is a 10 items scale ranging from 0 (never) to 4 (very often). Scores range from 0 to 4, with higher scores indicating greater perceived stress. The PSS was tested and validated in previous studies, with a Cronbach’s alpha of 0.78.²⁴

Statistical analysis

Descriptive statistics were used to describe sample characteristics in the form of means and standard deviations for continuous variables and counts and percentages for categorical variables. Data distributions were screened graphically for normality and influential data points using diagnostic plots of the residuals of the models, such as Q–Q plots and scatter plots. General linear mixed-effects models (GLMMs) were used to explore the temporal associations between HPLBs, total scores, and their domains with perceived stress over time (Aims 1 and 2). The analysis of the study’s third aim utilized a general linear model (GLM). Covariates for inclusion in the models were selected using an all-subset regression technique with an elastic net procedure.²⁵ Bonferroni adjustments were used to test pairwise comparisons of means at p = <0.05.

In the first stage of the model-building process, a base model consisting of perceived stress as the dependent variable, with visit (baseline, mid-chemo, 6 months, 1 year, and 2-year post-chemotherapy), health-promoting behaviors, and health-promoting behaviors by visit interaction as independent variables as fixed effects. Linear mixed-effects models were used to model and test for potential differences in the temporal changes in health-promoting behaviors over time. Each health-promoting lifestyle domain was tested separately to determine changes over time. The effects of the models were statistically significant at an alpha level of p = <0.05. In the second stage, each potential covariate was examined individually for its association with perceived stress. A bivariate association approach was used to identify demographical and disease factors associated with perceived stress using a significance level of p = <0.10 as a selection criterion. The following variables marital status, income, triple-negative tumor, and neoadjuvant chemotherapy exhibited bivariate associations with perceived stress at p < 0.10 and were included as covariates in the final mixed models. Potential covariates included age, race, level of education, employment status, annual income, body mass index, marital status, tumor type (estrogen receptor positive, triple negative), surgery, chemotherapy timing (neoadjuvant and adjuvant), and radiation therapy. In addition, the models were gradually refined, and nonsignificant interactions were removed. In the final stage, the identified covariates were included in the final models after removing nonstatistically significant interaction effects. Data analysis was conducted using SAS software (version 9.4; SAS Institute, Cary, North Carolina, USA).

Results

A total of 77 women signed informed consent for enrolling in the study. Of these participants, three women, all Caucasian aged 66, 48, and 62, failed to finish all the required assessments. Two of these women reported that they felt overwhelmed after the first visit and withdrew from the study. The third woman developed osteomyelitis after the second visit (T2) and was excluded based on the study’s eligibility criteria. Seventy-three women were retained for this study because they finished all the study’s questionnaires for at least two visits. However, in the GLMMs, one participant’s observation was missing from the neoadjuvant chemotherapy variable which resulted in a final sample of 72 subjects for the mixed models. For the GLM, 66 participants were retained as there were few missing variables from adjuvant chemotherapy and surgery variables.

Participant characteristics

The average age of the participants was 51.5 years. Most of the women were White (69.86%) and (30.14%) were African Americans. The mean body mass index of women was 30.10. Most of the study participants had an education beyond high school (78.08%) and were working in full-time jobs (54.79%). Most of the women were married or in a relationship with significant others (63.01%). Owing to inclusion criteria, most of the recruited participants had early-stage breast cancer, mainly stage IIA disease (42.58%). Regarding tumor type, 52 women had triple-negative tumors, and 31 had estrogen-positive tumors. Also, nearly half (54.95%) of these tumors were categorized as grade III. About half of the study participants received an adjuvant chemotherapy (52.10%), and 78% of women received radiation therapy. The most frequently reported surgery was simple mastectomy (47.35%). The demographic and clinical characteristics of the participants are shown in Table 1.

Table 1.

Description of study participants (N = 73).

Variables	Category	Results, N (%) or M ± .SD
Age		51.5 (10.14)
Race	White	51 (69.86)
Race	African American	22 (30.14)
Body mass index		30.10 (7.43)
Marital status	Married/partner	46 (63.01)
Marital status	Divorced/separated/single	27 (36.99)
Employment	Full-time	40 (54.79)
	Part-time	5 (6.85)
	Unemployed	11 (15)
	Disabled	6 (8.22)
	Retired	10 (13.70)
	Student	1 (1.37)
Income	Less than 15,000	11 (15)
	Between 15,000 and 29,999	8 (10.96)
	Between 30,000 and 44,999	8 (10.96)
	Between 45,000 and 59,999	7 (9.59)
	Between 60,000 and 74,999	7 (9.59)
	Between 75,000 and 89,999	10 13.70
	Between 90,000 and 104,999	8 (10.96)
	⩾105,000	14 (19.18)
Education	Didn’t finish high school	7 (9.95)
	High school diploma	9 (12.3)
	Any education beyond high school	57 (78.08)
Tumor stage	Stage I	20 (27.20)
	Stage IIA	31 (42.58)
	Stage IIB	14 (19.23)
	Stage IIIA	8 (11)
Tumor grade	Grade 1	5 (6.87)
	Grade 2	28 (38.19)
	Grade 3	40 (54.95)
Estrogen positive tumor	Yes	31 (42.58)
Estrogen positive tumor	No	42 (57.42)
Triple negative	No	52 (71.1)
Triple negative	Yes	21 (28.85)
Neoadjuvant chemotherapy	Yes	7 (9.75)
Neoadjuvant chemotherapy	No	66 (90.25)
Adjuvant chemotherapy	Yes	38 (52.10)
Adjuvant chemotherapy	No	35 (47.90)
Radiation	No	16 (21.98)
Radiation	Yes	57 (78.02)
Surgery	Biopsy	2 (2.79)
	Simple surgery	35 (47.35)
	Lumpectomy	21 (28.97)
	Segmental	15 (20.89)

Values are mean ± SD or n (%) of participants. SD: standard deviation.

Association among health-promoting lifestyle behaviors and perceived stress

Temporal associations between health-promoting behaviors and perceived stress were explored using GLMMs. The HPLBs total score was inversely associated with perceived stress (p = <0.0001) while adjusting for covariates including marital status, income, triple-negative tumor, and neoadjuvant chemotherapy. The results did not support an interaction between HPLBs and time on perceived stress (p = 0.5497). In the separate linear mixed models testing each of the subscales of HPLBs, there was support for an inverse associations between perceived stress, spiritual growth (p = <0.0001), and marginally significant for nutrition subscale (p = 0.0475). The remaining domains, including health responsibility, physical activity, stress management, and interpersonal relations, showed no significant association with perceived stress over time (p = 0.2266; p = 0.5378; p = 0.5241; p = 0.9407). Regarding the moderation of the time effect on perceived stress by the HPLP subscales (the time by subscale interaction), the presence of an interaction was not supported for any of the subscales of the HPLP. The associations between HPLBs and perceived stress over time are presented in Table 2.

Table 2.

General linear mixed models of associations among health-promoting behaviors with perceived stress (N = 72).

Predictors	Estimates	SE	F value	p value
Health-promoting lifestyle profile	−0.1488	0.02070	51.71	<0.0001
Health responsibility	0.1197	0.09879	1.47	0.2266
Physical activity	−0.04740	0.07684	0.38	0.5378
Nutrition	−0.1836	0.09233	3.95	0.0475
Spiritual growth	−0.6392	0.1120	32.59	<0.0001
Interpersonal relations	−0.00848	0.1139	0.01	0.9407
Stress management	−0.07281	0.1142	0.41	0.5241
HPLP total score × visit (baseline. Reference)	NA	NA	0.76	0.5497

General linear mixed models were adjusted for marital status, income, triple negative tumor, and neoadjuvant chemotherapy. NA: not applicable; SE: standard error of the estimate; HPLP: health-promoting lifestyle profile.

Health-promoting behavior levels and changes overtime

The total score of women’s HPLP averaged 142.90 (2.59 SE), and the 95% CI for HPLP total score was [137.80, 148.01] at the baseline visit. The HPLP total score increased to 146.27 (2.61 SE) at the 2-year follow-up visit, [141.12, 151.42] at 95% CI. This finding indicates that women engaged in health-promoting behaviors “sometimes” to “often” and none “routinely.” The participants’ HPLP total scores showed no statistically significant changes in the means over time (p = 0.3168). The highest engagement in healthy behaviors was noted at T5, 2 years after the initiation of chemotherapy.

In the HPLP domain, the average physical activity was 16.94 (0.64 SE) at baseline. The highest physical activity score was 18.43 (0.65 SE), reported at the last visit T5 (95% CI [17.15, 19.71]). This indicates that women engaged in physical activity “sometimes.” Notably, the level of physical activity decreased to 15.82 (0.64 SE) during T2 (95% CI [14.55, 17.09]), which is the time when women were actively receiving chemotherapy treatment. The mean score of the nutrition domain ranged from 24.13 (0.59 SE) at baseline (95% CI [22.96, 25.30]) to 24.86 (0.59 SE) at 2 years (95% CI [23.68, 26.04]). The health responsibility mean was almost similar across visits and was at the lowest level of 23.63 (0.57 SE) during the baseline visit (95% CI [22.49, 24.76]), indicating women engaged “sometimes” in the health responsibility and nutrition subscales. The women engaged “often” in activities that promote interpersonal relations, and spiritual growth with the highest mean level of interpersonal relations during the second visit, 28.94 (0.52 SE), 95% CI [27.90, 29.98]), and highest level 28.73 (0.57 SE) during the baseline 95% CI [27.59, 29.88] for spiritual growth. The participants engaged “sometimes” to “often” in activities that control stress, and highest score of 21.95 (0.48 SE) were noted at 2 years (95% CI [21.00, 22.91]). Overall, participants’ engagement in healthy behaviors was highest for interpersonal relationships and spiritual growth. In comparison, they were the lowest in the domains of physical activity, stress management, nutrition, and health responsibility. The means and standard deviations of HPLBs at each visit are shown in Table 3 and Figure 2, and adjusted means in Supplemental Table 4. The mean change overtime for total HPLBs and PSS are in Supplemental Table 5.

Table 3.

Means and standard deviations of health promoting lifestyle profile and perceived stress at each visit.

Variables	T1, mean ± SD	T2, mean ± SD	T3, mean ± SD	T4, mean ± SD	T5, mean ± SD
Health responsibility	23.63 (5.35)	24.20 (4.77)	24.24 (4.94)	23.98 (4.84)	24.50 (4.83)
Physical activity	16.94 (5.68)	15.82 (5.30)	16.71 (5.74)	17.35 (5.55)	18.57 (5.47)
Nutrition	24.13 (5.23)	25.06 (5.28)	25.02 (4.95)	24.67 (5.18)	25.05 (4.69)
Spiritual growth	28.73 (4.72)	28.23 (4.92)	27.91 (5.06)	28.33 (5.20)	28.56 (4.90)
Interpersonal relations	28.71 (4.19)	28.94 (4.57)	28.15 (4.81)	28.05 (4.51)	28.42 (4.49)
Stress management	20.73 (4.30)	21.86 (3.95)	21.31 (4.20)	20.91 (4.00)	22.13 (4.08)
Health-promoting lifestyle profile	142.90 (22.62)	144.13 (21.71)	143.36 (22.81)	143.32 (22.48)	147.26 (21.14)
Perceived stress	16.73 (8.05)	14.59 (7.51)	14.04 (7.78)	13.54 (7.33)	12.78 (7.55)

T1, before the initiation of chemotherapy; T2, midpoint at 4 and 6 weeks from first chemotherapy; T3, at 6 months of chemotherapy; T4, at 12 months of chemotherapy; T5, at 24 months from the initial chemotherapy treatment. SD: standard deviation.

Figure 2.

Health-Promoting Lifestyle Profile, Physical Activity, Nutrition, Spiritual Growth, Health Responsibility, Interpersonal Relationships, and Stress Management, Means at Each Visit.

Perceived stress levels and changes over time

The mean perceived stress was the highest at the baseline visit (M 16.73, 8.05 SD). The lowest score for perceived stress was 13.08 (0.91 SE) at 2 years post-inception of chemotherapy (95% CI [11.28, 14.88]). These findings indicate that women experienced a “moderate stress” ranging from 14 to 26 and a “low stress,” which is between 0 and 13 on the PSS. The means and standard deviations of the perceived stress are provided in Table 3, and level at each visit in Figure 3.

Figure 3.

Mean Perceived Stress Levels over Time.

In the general linear mixed model of perceived stress, an overall change in the mean PSS scores over time was supported (p = <0.0001). There was an observed change in adjusted mean levels of perceived stress scores (p = 0.0034) between baseline visit (T1) and midway (T3) at 6 months post-initial chemotherapy 95% CI [0.6065, 3.545]. Changes in PSS from baseline visit until 1 year after the first chemotherapy session were supported (p = 0.0002; 95% CI [1.792, 4.756]). The PSS levels remained moderately elevated at the second visit and changed from baseline to 2 years post-chemotherapy (p = <0.0001; 95% CI [2.1485, 5.1685]). The remaining pairwise comparisons did not support differences in perceived stress levels. The temporal changes in perceived stress levels and pairwise comparisons between visits are presented in Supplemental Table 6.

The association between demographics and disease factors with perceived stress at baseline visit

A GLM was used to test the baseline associations between the selected demographic and clinical variables and perceived stress. Certain variable subcategories, including surgery and employment, were reduced to address multicollinearity. The overall regression model was supported, F(13,52) = 2.65, p = 0.006, with predictors explaining 40% of perceived stress variance (Supplemental Table 7). The model’s average perceived stress was 16.63, indicating a moderate baseline stress level in women with breast cancer. Specifically, the model supported independent associations of education (p = 0.0470), surgery (p = 0.0234), and tumor grade (p = 0.0435) with stress level at baseline. The GLM of the selected patients’ demographic and clinical variables with perceived stress is reported in Supplemental Table 7.

The analyses of education subcategories showed differences in means (p = 0.0463) between women who did not finish high school (M = 22.55) and those with any education beyond high school (M = 13.21). Pairwise comparisons among the surgery groups indicated a difference in the means (p = 0.0199) between women who underwent simple surgery (M = 20.23) and women who underwent segmental surgery (M = 12.11). The other categories, such as simple surgery and lumpectomy, showed no differences in the means. Finally, multiple comparisons for tumor grade supported a difference in means (p = 0.0435) between women with tumor grade 1 (M = 10.96) and tumor grade 2 (M = 20.07). Associations for the other demographic variables, including marital status and income, and perceived stress were not supported (p = 0.1660) (p = 0.2813, respectively). In addition, tumor stage (p = 0.1690), adjuvant chemotherapy (p = 0.4710), and radiation treatment (p = 0.3797) were not supported by perceived stress at baseline visit T1. The pairwise comparisons between education, surgery type, and tumor grade are displayed in Supplemental Table 8.

Discussion

Findings from this study demonstrated an inverse linear association between the total score of HPLBs and perceived stress. This indicates that if a person’s engagement in healthy lifestyle behaviors increases, their stress perception might decrease. Specifically, this concerns the spiritual growth and nutrition subscales while controlling for covariates such as marital status, income, triple-negative tumor type, and neoadjuvant chemotherapy. However, the results did not show any moderating effect on healthy lifestyle behaviors and perceived stress over time. This finding of inverse associations aligns with recent research on healthy lifestyle behaviors and psychological disorders, such as depression and anxiety.^3,26

Physical activity and stress

Interestingly, the findings did not support any relationship between physical activity and perceived stress. This result contradicts the current literature on the benefits of regular exercise in reducing stress and other psychosocial symptoms.^9,26,27 Most research firmly favors promoting regular physical activity among breast cancer patients.²⁷ In a recent review by Hwang and Nho,²⁶ the authors indicated that breast cancer patients who participated in regular exercise have better psychological and social outcomes. Specifically, there was a decrease in psychological symptoms, including depression, fatigue, and stress. In this study, the lack of association between perceived stress and physical activity might be attributed to many factors, such as the timing of active treatment, including chemotherapy and radiation. In this study, it was evident that women’s physical activity score was lowest when they started receiving chemotherapy, and this aligns with recent literature.^28,29 Also, it is essential to consider the limitations of the self-reported measurements and the small sample size, which might skew the study’s results. Future research should consider a larger sample and use an independent measure of physical activity to provide better insight into assessing the benefits of physical activity among breast cancer survivors.

Nutrition and stress

This study supports a marginal negative association between nutrition and perceived stress. It is possible that women’s dietary choices may help manage their perception of stress by following practice recommendations for cancer patients such as consuming healthy diet. Several studies have reported the benefits of healthy dietary behavior in enhancing survival and preventing cancer recurrence among breast cancer patients.²⁸ The findings of this study are consistent with current research on the importance of adopting healthy dietary intake in improving the overall quality of life.^30,31 For example, Pisegna et al.³² indicated that a healthy diet was associated with better mental health-related quality of life in breast cancer patients. Future research should develop nutritional counseling and dietary intervention programs that may help decrease stress and improve the psychological health of breast cancer survivors.

Health responsibility and stress

The role of health responsibility in decreasing the stress levels of patients with breast cancer was not supported. These findings are inconsistent with recent evidence emphasizing the importance of informed decisions-making among Breast Cancer survivors (BCS) to alleviate their stress and enhancing quality of life.^32,33 As reported in the literature, breast cancer patients prefer lifestyle interventions that integrate the individual’s choice in initiating a positive lifestyle modification. For example, a qualitative study found that patients who had positive perspectives and were informed about their disease could regulate their psychological needs and emotions.³² However, studies examining the individual’s choice concerning psychological factors, including stress, are underreported within breast cancer patients and warrants further reserach.³³

Interpersonal relations and stress

There was no association between women’s interpersonal relationships and their perceived stress. In contrast, recent research primarily supports the importance of social support in managing stress.^34–36 This lack of association is complex in nature, especially regarding the study’s measurement of interpersonal relations as subscale of HPLP. There could be other pathways to understanding how breast cancer patients’ social relationships influence their perception of stress. Zhao et al.³⁷ examined the role of both physical activity and perceived stress as mediators in the relationship between social support and improved quality of life. This study examined 520 women with breast cancer and found that social networks were positively associated with quality of life through increased physical activity and low levels of perceived stress. Research is needed to investigate the relationship between social factors and perceived stress in this population.

Spiritual growth and stress

The spiritual growth domain of the HPLP is inversely associated with perceived stress levels. This result is consistent with previous research on the positive effect of spirituality in reducing stress among patients with cancer.^6,33,37 A systematic review conducted by Hulett and Armer³⁸ found that spiritual interventions such as body–mind–spirit and yoga were beneficial in improving psychological outcomes such as depression, stress, and anxiety in patients with breast cancer. Developing interventions targeting spiritual growth is essential to reduce stress in women living with breast cancer.

Stress management and stress

Unexpectedly, the study showed no significant association between stress management and breast cancer patients perception of stress, which contrast recent research that highlights the importance of stress management modalities.^26,38,39 In a recent systematic review, Borgi et al.³⁹ comprehensively examined the benefits of multiple stress management interventions, such as mindfulness-based stress reduction, complementary therapies, yoga, tai chi, and therapeutic massage, which were utilized widely by breast cancer patients. However, a recent meta-analysis examining the role of cognitive-behavioral stress management on stress found no significant differences in perceived stress levels between the intervention and control groups.⁴⁰ The limited sample size and heterogeneity of study designs and measures may lead to these varying outcomes in the relationship between stress and stress management. Future research should integrate longitudinal interventional studies that examine stress management and its effect on stress levels among women with breast cancer during active treatment period and into survivorship. An independent measure of stress management with perceived stress may clarify this association and provide a better conclusion among this population.

Levels and changes of levels in health-promoting lifestyle behaviors

This study found that women engaged in HPLBs sometimes. These results are in line with research focused on lifestyle behaviors of patients with breast cancer.^3,28,30 Notably, this study showed variations in women’s participation in physical activity with lowest level of at visit two, where women were actively receiving chemotherapy. This result is consistent with previous literature on physical activity assessment.^28,29 Despite the current recommendation of promoting moderate-intensity exercise for 150 min/week, breast cancer patients still did not meet this requirement. Recent evidence suggests that this lack of exercise could be related to chemotherapy and lack of motivation to maintain physical activity.⁴¹ Moreover, participants were engaged “sometimes” in the HPLP nutrition scores and not “routinely” as recommended for cancer survivors. In addition, no changes were observed over time in maintaining a healthy diet, which is comparable to recent studies targeting dietary guidelines.¹² Many studies have explained that low levels of healthy diet modification are related to a lack of nutritional assessment and counseling of healthcare providers.^42,43 Diet plays a critical role in reaching an optimal body weight. As noted in this study, women’s body mass index was in the “overweight” to “obese” category. Therefore, developing dietary interventions for patients with breast cancer is essential to prevent cancer recurrence and improve survival. The health responsibility levels were at the same range “sometimes” compared to nutrition and physical activity. This finding is inconsistent with previous research on interventions that examine self-care during cancer.⁴⁴ However, qualitative data reported that breast cancer patients had difficulty managing their social and family roles along with their survivor care checkups.³² More studies are needed to empower patients to gain responsibility in caring for themselves and their families. In this study, women often participated in activities that promote interpersonal relationships, which aligns with recent evidence.^34,35,41 Particularly, the interpersonal relations scale had the highest reported score on the HPLP scale compared to other scales. Moreover, the participants’ often participated in spiritual practices, and this is consistent with research focused on role of spirituality among BCS.^45,46 It seems that women’s spirituality behaviors are superior to that of other health-promoting behaviors in coping with breast cancer. It is important to frequently assess spirituality among this population to improve coping with breast cancer.⁵¹ Lastly, women engage in activities that control stress “sometimes” but not “regularly.” Recent studies have supported the need for interventions targeting stress in breast cancer patients.^40,44 For example, the CaringGuidance is a randomized control trial designed to manage stress after a breast cancer diagnosis, the study showed reduction in distress and anxiety levels.⁴⁷ Future research should implement stress management interventions in timely manner to effectively help breast cancer patients to cope during and beyond the treatment period.

Levels and changes of levels in perceived stress

This study indicated that stress levels were highest at baseline assessment, likely due to beginning of active therapy including chemotherapy and surgery aligning with recent research.^6,48,49 This finding implies the importance of stress assessment and management, specifically before starting chemotherapy, to improve coping in patients with breast cancer. The study’s findings showed that perceived stress was moderately elevated and almost stable during the second and third visits, and gradually decreased at 2 years, which is consistent with prior literature.^48,50 For example, Park et al.⁶ found that 20% of women were distressed at 6 months after the active treatment period. The allostasis theory proposes that stress is primarily related to individuals’ perceptions of stress and their ability to adapt to stressors.¹³ Further studies are needed to explore the patterns of stress after the primary therapy by including multiple time assessments to help clinicians identify the optimal time to assess stress and manage it effectively.

The relationship between demographical and clinical variables with perceived stress

This study hypothesized that specific breast cancer factors, such as tumor characteristics and treatment types, would influence the perception of stress among the participants. As supported by the allostasis framework and prior research on stress, the findings showed that some personal and clinical variables were associated with perceived stress. Notably, and in line with previous research, education was associated with perceived stress, as less-educated women showed moderate stress levels compared to those with higher education.^2,6 Furthermore, the other factors tested in the model, including marital status, income, tumor stage, adjuvant chemotherapy, and radiation treatment, showed no differences in perceived stress levels at baseline. In contrast, recent evidence demonstrates a negative influence of chemotherapy on stress and other psychological symptoms, such as worry, cognitive changes, and sleep disturbances.¹⁵ A recent study by Joseph et al.⁵² revealed that 1329 cancer patients undergoing chemotherapy experienced gastrointestinal symptoms associated with higher perceived stress and other psychoneurological symptoms that affected their quality of life. Regarding social factors, this study’s results did not support any difference in stress levels of patients with or without a partner which could be related to the measurement of partner support, as the study reported only marital status. Numerous studies have evaluated the importance of social and partner support in managing the stress of patients living with breast cancer.^34,35 Further research is needed to examine the partner’s role in the perception of stress among women with breast cancer. Moreover, income is a known source of stress in patients living with cancer.² Although this research did not show any difference in stress concerning income, a growing body of evidence highlights the importance of assessing financial sources of stress within cancer survivors.⁵² A recent prospective study by Chan et al.⁵³ explored demographical and clinical variables that influenced financial distress among 387 breast cancer survivors. Their findings showed that having a lower income was associated with worsening financial distress and other cancer-related symptoms such as pain and depression over 12 months. The assessment of financial factors, such as income, is essential for improving the quality of care for breast cancer patients. Moreover, of the clinical variables tested in the model, tumor grade and surgery type were associated with perceived stress, as women with grade 2 had higher stress levels than those with grade 1. In addition, women who underwent simple surgery showed increased perceived stress compared to those who underwent other surgeries, such as segmental or lumpectomy. Recent preliminary research has shown that women with specific breast cancer tumors, such as triple-negative tumors, experience a higher stress level.¹⁷ Another study by Keir et al.,⁵⁴ examined the perceived stress levels according to the tumor grade in a sample of 60 patients with brain cancer and found that patients with grade 1 tumors had slightly lower stress levels than those with other grades. However, there is limited research on the association between perceived stress and tumor characteristics in this population. More studies are needed to validate this finding using a larger representative sample of patients with breast cancer.

Limitations

This study has several limitations. First, it was a secondary analysis, there were limitations to the self-reported measures used in the study, which are subject to recall bias and can either underestimate or overestimate participants’ responses. Second, the conceptual framework was based on the allostatic theory of stress, emphasizing the integration of biological data in explaining perceived stress. Future research should consider subjective and biological markers of perceived stress, such as cortisol.⁵⁴ Third, the sample size was relatively small, and there were few missing data. This may limit the generalizability of the study findings to women diagnosed with early-stage breast cancer. Lastly, the absence of a pre-cancer assessment of lifestyle behaviors is essential in understanding the association and changes overtime among the examined variables.³ Researchers should incorporate a control group of age-matched women to compare the differences in their lifestyle behaviors to those with early-stage breast cancer. Future studies should consider collecting healthy lifestyle information from patients or medical records to assess lifestyle changes throughout cancer treatment.

Implications

Implications for clinical practice

Nurses should frequently monitor and evaluate patients’ engagement in healthy lifestyle behaviors as recommended for all cancer patients. These modifiable factors are essential for preventing the reoccurrence of secondary tumors and other chronic diseases. In addition, nurses play a direct role in the early screening and management of stress to enhance coping and reduce the adverse outcomes of breast cancer. Nurses should also collaborate with healthcare providers and social workers to advocate and support women facing breast cancer with available resources to facilitate their engagement in healthy lifestyle behaviors.

Implications for future research

This study highlights an important link between healthy lifestyle behaviors and the perception of stress. Future research should examine and replicate these findings with a larger sample of women diagnosed with early-stage breast cancer. Specifically, researchers should develop interventions targeting modifiable factors detected in this study, including spiritual growth and nutrition, for stress reduction in women with breast cancer. This study did not support reducing stress levels through other health-promoting behaviors, such as physical activity. However, future research should use independent measurements of each health-promoting lifestyle factor in designing interventions that help reduce stress and improve health outcomes for women living with breast cancer.

Conclusion

This study addressed a critical knowledge gap regarding the temporal relationships between HPLBs and perceived stress throughout chemotherapy treatment and beyond in women with early-stage breast cancer. Although the study indicated a potential for lifestyle interventions in reducing stress, many variables showed lack of association and no change overtime. Additionally, the study revealed the highest level of perceived stress at the baseline assessment which highlights the need for of stress management interventions and psychological counseling during this period. Lastly, the relationships between women’s clinical and demographic variables and perceived stress may provide insight into how certain factors such as education and tumor type relate to an individual’s perception of stress. Future research may benefit from these findings in designing personalized healthy lifestyle interventions with a larger sample size among women with early-stage breast cancer.

Supplemental Material

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Supplemental material, sj-docx-1-whe-10.1177_17455057251351411 for The relationships among health-promoting lifestyle behaviors and perceived stress in women with early-stage breast cancer over 2 years by Amal Khualif Alanazi, Michael Weaver, Debra Lynch-Kelly, Catherine Striley and Debra Lyon in Women's Health

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Footnotes

Acknowledgements

Amal K. Alanazi would like to thank the Saudi Cultural Mission and King Saud bin Abdul Aziz University for Health Sciences for their sponsorship and assistance throughout her doctoral studies.

ORCID iD

Amal Khualif Alanazi

Ethical considerations

IRB approval was obtained from the University of Florida’s Institution Review Board to conduct this study (IRB20140008).

Consent to participate

All study participants completed written informed consent in the parent study (VCU IRB #HM 13194).

Consent for publication

Not applicable.

Author contributions

Amal Khualif Alanazi: Conceptualization; Formal analysis; Methodology; Writing – original draft; Writing – review & editing.

Michael Weaver: Conceptualization; Formal analysis; Methodology; Writing – review & editing.

Debra Lynch-Kelly: Conceptualization; Supervision; Writing – review & editing.

Catherine Striley: Conceptualization; Writing – review & editing.

Debra Lyon: Conceptualization; Supervision; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this article was supported by the National Institute of Nursing Research of the National Institutes of Health Grant: [R01NR012667], PIs D Lyon and C Jackson-Cook. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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