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

Jung Ran Lee; Pok Ja Oh

doi:10.7469/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

Jung Ran Lee¹, Pok Ja Oh²

Korean Journal of Adult Nursing 2016;28(2):202-212.
Published online: April 30, 2016

DOI: https://doi.org/10.7469/kjan.2016.28.2.202

¹Department of Nursing, Graduate School, Sahmyook University, Seoul

²Department of Nursing, Sahmyook University, Seoul, Korea

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

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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Abstract
REFERENCES

Abstract

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.

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
Variables	Categories	n (%)	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)	＜40^a ^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
	40~49^b ^c	56 (36.8)	63.59±24.03	(.367)	28.84±1.06	(＜.001)	98.84±17.38	(.030)	87.98±23.05	(.019)
	50~59^c	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
	≥60^d	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
Martial status	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	≤MS^a	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
	HS^b ^c	70 (46.1)	65.71±25.73	(.991)	28.43±1.29	(＜.001)	93.40±17.48	(.046)	82.60±23.19	(.199)
	≥College^c	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)	＜200^a ^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
	200~399^b ^c	71 (46.7)	63.56±23.22	(.031)	28.45±1.63	(.652)	97.90±17.65	(.021)	86.11±22.59	(.003)
	400~599^c ^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
	≥600^d	15 (9.9)	58.73±18.86		28.87±1.06	1	104.87±17.40		97.13±24.28
Family support	Satisfied^a	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
	Moderate^b	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	＜13^a ^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
	14~15^b ^c	68 (44.7)	66.68±22.96	(.764)	28.56±1.52	(.026)	94.51±14.03	(.104)	83.29±22.68	(.119)
	＞15^c	46 (30.3)	66.63±27.28		27.98±1.60	a＞c	93.67±21.52		78.65±20.77
Menopause	No^a ^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
	Yes^b ^c†	59 (38.8)	70.22±27.48	(.162)	27.80±1.85	(＜.001)	92.39±17.59	(.135)	76.27±24.96	(.006)
	Yes^c†	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	0^a ^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
	1^b ^c	85 (55.9)	64.88±21.12	(.001)	28.42±1.60	(.986)	96.41±16.52	(.004)	84.98±20.37	(＜.001)
	2^c ^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
	3^d	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
Comorbidity	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
Metastasis	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	≤6^a ^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 7~12^b	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
Hormone therapy	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

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

Figure

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

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

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
Variables	Categories	n (%)	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)	＜40^a ^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
	40~49^b ^c	56 (36.8)	63.59±24.03	(.367)	28.84±1.06	(＜.001)	98.84±17.38	(.030)	87.98±23.05	(.019)
	50~59^c	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
	≥60^d	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
Martial status	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	≤MS^a	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
	HS^b ^c	70 (46.1)	65.71±25.73	(.991)	28.43±1.29	(＜.001)	93.40±17.48	(.046)	82.60±23.19	(.199)
	≥College^c	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)	＜200^a ^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
	200~399^b ^c	71 (46.7)	63.56±23.22	(.031)	28.45±1.63	(.652)	97.90±17.65	(.021)	86.11±22.59	(.003)
	400~599^c ^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
	≥600^d	15 (9.9)	58.73±18.86		28.87±1.06	1	104.87±17.40		97.13±24.28
Family support	Satisfied^a	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
	Moderate^b	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	＜13^a ^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
	14~15^b ^c	68 (44.7)	66.68±22.96	(.764)	28.56±1.52	(.026)	94.51±14.03	(.104)	83.29±22.68	(.119)
	＞15^c	46 (30.3)	66.63±27.28		27.98±1.60	a＞c	93.67±21.52		78.65±20.77
Menopause	No^a ^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
	Yes^b ^c†	59 (38.8)	70.22±27.48	(.162)	27.80±1.85	(＜.001)	92.39±17.59	(.135)	76.27±24.96	(.006)
	Yes^c†	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	0^a ^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
	1^b ^c	85 (55.9)	64.88±21.12	(.001)	28.42±1.60	(.986)	96.41±16.52	(.004)	84.98±20.37	(＜.001)
	2^c ^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
	3^d	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
Comorbidity	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
Metastasis	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	≤6^a ^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 7~12^b	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
Hormone therapy	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.

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.

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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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