Fear of Progression and its Associated Factors among Postoperative Patients with Breast Cancer: a cross-sectional study

Fear of Progression and its Associated Factors among Postoperative Patients with Breast Cancer: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fear of Progression and its Associated Factors among Postoperative Patients with Breast Cancer: a cross-sectional study Songyu Wu, Yaling Niu, Xiaohan Geng, Changgui Kou, Zheng Lv This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3855508/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Fear of progression (FoP) is commonly observed in breast cancer patients. It may exist for a period of time even after cancer survivorship. Our study aims at investigating the distribution and associated factors of FoP based on postoperative patients with breast cancer in Northeast China. Methods This is a cross-sectional study. 257 postoperative patients with breast cancer were recruited using convenience sampling method. Fear of Progression Questionnaire-Short Form was used to evaluated the FoP status of participants. Hierarchic multiple linear regression was applied to identify the independent relevant factors. Mediation effect analysis was conducted to explore the potential pathway between attitude towards cancer and FoP. All P values were two-tailed. P < 0.05 was considered to represent statical significance. Results The most frequent fear of the participants was “worrying that medications could damage the body”. After adjusting for other factors, the following independent variables were identified to be the associated factors for FoP: age, number of descendants, time after operation, postoperative pain, regular review, personality, anxiety and depression, self-esteem and self-acceptance and attitude towards cancer. Moreover, we have confirmed the mediation role of anxiety and depression in the relationship between FoP and attitude towards disease. Conclusion Clinicians should help and guide patients to correctly view the necessity and double-sided of operation and medication treatment. Additional attention should also be paid to patients with pessimistic personality or low psychosocial adaptability. breast cancer fear of cancer recurrence fear of progression oncology cross-sectional study Figures Figure 1 1. Background Cancer has emerged as the leading cause of premature death in 50 countries including China 1 . Among female population, breast cancer imposes a substantial disease burden 2 . By estimation, the morbidity of breast cancer in 16 countries including China is still on an upward trajectory 3 . The advancement of clinical treatment methods and the conduct of health education does have a positive impact on curing breast cancer patients and reducing the case fatality rate. In the United States, an estimated 4 million females were living with a history of breast cancer by estimation in 2022. And the general 5-year relative survival rate of breast cancer has raised from 75% in mid-1970s to 90% in the year during 2011 to 2017 4 . Similarly, although limited data is available, the general 5-year relative survival rate of breast cancer in China is also on the rise 5 . Despite these encouraging trends, for those patients diagnosed with breast cancer, they may very likely to fall into a status of fear of cancer recurrence (FCR) or fear of progression (FoP) 6 . Some patients even claimed that the fear of cancer recurrence is more distressing than the initial diagnosis or treatment of cancer 7 . This phenomenon not only imposes an increased personal financial and emotional burden but also contributes to the elevated cost of public healthcare resources 8 . FCR has been considered as one of the mostly reported unsatisfied needs of cancer patients 9,10 . It is to be believed to possess a unique, independent construct and reflects the fear and worry targeted at disease progression as well as cognitive dissonance. A comprehensive definition of FCR with consensus has been reached as “Fear, worry, or concern relating to the possibility that cancer will come back or progress” in a meeting held in Ottawa in 2015 11 . Investigators have tried several theoretical models or frameworks including common sense model (CSM), protection motivation theory and theory of uncertainty in illness to explain the mechanism of FCR 12 . However, no theoretical model can fully explain the complicated occurrence and development process of FCR. Age, marital status, occupation and employment status, education level, disease stage, radiation therapy, uncertainty in illness, self-efficiency, depression, anxiety and many other factors have been considered to be the relevant factors of the occurrence and degree of FCR(FoP) based on multiple previous studies 13–18 . However, there also exists study that argue for a contradictory result 19 . Specifically in breast cancer patients, dispute of related or risk factor of FCR still exist. These factors may also vary considering the social and cultural backgrounds of the population. In this study, we aim at: 1) Demonstrating the result of FoP-Q-SF and the most frequent fears; 2) Investigating the related factors of FoP; 3) Analyzing the possible mediating effect between attitude towards breast cancer and FoP. 2. Methods 2.1 Study design and participants This study is a cross-sectional study and convenience sampling method was performed. Hospitalized postoperative patients with breast cancer in the First Affiliated Hospital of Jilin University from October 2021 to January 2022 were enrolled. Inclusion criteria are as follows: ( 1 ) female; ( 2 ) aged ≥18; ( 3 ) postoperative patients with breast cancer diagnosed by pathological or immunohistochemical examinations; ( 4 ) patients who were aware of and understand their condition and the purpose of this study; ( 5 ) patients who provided informed consent to participate voluntarily; Exclusion criteria are as follows: ( 1 ) patients with breast cancer recurrence; ( 2 ) patients with critically illness or complicated with sever cardiovascular, respiratory, mental, hematology diseases or other tumors. ( 3 ) patients who can’t finish the questionaries by any reasons. According to estimation of incidence rate of FCR(FoP) among postoperative patients with breast cancer and sample size formula of cross-sectional studies 16,20,21 . We collected 267 cases for our study and 257 of them were finally taken into analysis based on inclusion and exclusion criteria and quality control measures with an effective response rate of 96.25%. 2.2 Instruments 2.2.1 Sociodemographic and clinical characteristics A self-designed questionnaire was used to collect characteristics of patients. Demographic characteristics include age, ethnic, education level, family income per month; personal and family characteristics include marital quality, relationship with family members, emotion regulation ability; clinical characteristics include surgical methods, stage of breast cancer, time after operation. 2.2.2 Fear of Progression Questionnaire-Short Form The Fear of Progression Questionnaire-Short Form (FoP-Q-SF) was used to measure FCR in this study. The Fear of Progression Questionnaire (FoP-Q) was designed and simplified into FoP-Q-SF by Peter Herschbach et al 22,23 . It contains 12 items while all the items were scored on a 5-point Likert Scale ranging from 1 (“never”) to 5 (“very often”). A higher score refers to a higher level of FCR. The Chinese version of FoP-Q-SF was translated by Chinese scholar WU et al in 2015 24 . And the Cronbach’s α equals to 0.856 in an investigation conducted in Chinese breast cancer patients using FoP-Q-SF 25 . FoP-Q-SF has performed with high reliability and validity among Chinese cancer patients. Based on a multicenter RCT study, the participants who score 34 or over 34 in FoP-Q-SF will be considered as have reached a level of in need of clinical psychological interventions 26 . 2.2.3 Psychosocial adaption A questionnaire designed by Chinese scholar Cheng was used to describe the psychosocial adaption status of breast cancer patients. This questionnaire contains 44 items and could be divided into 5 dimensions: anxiety and depression, self-esteem and self-acceptance, Attitude towards cancer, sense of belonging and self-control and self-efficiency. All the items were scored based on a 5-point Likert Scale ranging from 1 (“completely wrong”) to 5 (“completely correct”). The score ranges from 44 to 220. A higher score refers to a higher level of psychosocial adaption. The CVI of all 44 items are over 0.75. The Cronbach’α of general questionnaire is 0.945. The criterion-related validity between this questionary and Self-rating Anxiety Scale (SAS), General Self-Efficacy Scale (GSES) and Self-Acceptance Questionnaire (SAQ) were − 0.757, 0.505, 0.691 with P < 0.01. 2.3 Statistical Methods Medium, quartile and frequency with percentage were performed to describe the distribution of the social-demographic characteristics, personality and family situation and clinical features of the study sample. Mean value and standard deviation were used to illustrate the results of FoP-Q-SF items. The t/F test or nonparametric test was used to test the significance of differences between groups. Spearman correlation test was performed to analyze the correlation relationship between psychosocial adaption and FoP. Hierarchic multiple linear regression was applied to identify the independent relevant factors. P < 0.05 was considered to represent statical significance. All P values were two-tailed. Moreover, Bootstrap was used to conduct mediation effect analysis and Boot 95% confidence interval which did not include 0 was considered to represent statical significance. All statistical analyses were conducted with SPSS version 24.0 (IBM Corp, Armonk, NY, USA). 2.4 Ethical consideration Written informed consent was obtained from each subject participating in the study. Additionally, this research complied with the Declaration of Helsinki and has obtained the approval from the Ethics Committee of School of Public Health, Jilin University. 3. Results 3 .1 Descriptive analysis The mean value of total score of FoP-Q-SF was 30.26 (Standard Deviation = 9.867). 97 (37.7%) participants had reached the level of in need of clinical interventions (FoP-Q-SF total score ³ 34). The scores of single items and their rank could be seen in Table 1 . The most frequent fears include “worrying that medications could damage the body”, “being afraid of disease progression” and “being nervous prior to doctors’ appointment”. Table 1 FoP-Q-SF items responses Mean Standard Deviation Total 30.26 9.867 Worrying about medication could damage the body. 3.37 1.468 Being afraid of disease progression. 3.27 1.255 Being nervous prior to doctors’ appointments or periodic examinations 3.00 1.427 Being afraid of pain. 2.80 1.499 Worrying about what will become of the family. 2.70 1.431 Being afraid of severe medical treatment. Having physical sensations. Being afraid that the children could contract cancer. Being afraid of becoming less productive at work. Being afraid of not being able to work anymore. Being afraid of relying on strangers for ADL. Being afraid of no longer be able to pursue hobbies. 2.56 2.48 2.39 2.35 2.25 1.55 1.54 1.333 1.228 1.451 1.566 1.578 0.909 0.870 The distribution and univariate analysis of demographic, personality, family and clinical features is listed in Table 2 . Among 257 participants, 25 (9.728%) aged £ 40, 176 (68.483%) aged 41~59, 56 (21.790%) aged ³ 60. 25.292% ( n = 65) participants lived in rural area while 74.708% ( n = 192) lived in urban area. The proportion of participants who have more than 2 descendants were 24.903% ( n = 64). 147 (57.198%) participants had reported to have an optimistic personality and 23 (8.950%) participants reported a pessimistic personality. Meanwhile, 9.339% ( n = 24) of our participants had suffered from severe postoperative pain. After univariate analyses, the differences between groups of residential location, education level, family income per month, employment status, degree of financial hardship, marital quality, relationship with family members, personality, emotion regulation ability, number of descendants, family history of breast cancer, postoperative pain, distant metastasis, regular review, chemotherapy and time after operation were found to have statistical significance ( P < 0.05). Table 2 Distribution and univariate analysis of demographic, personality, family and clinical features Characteristics N (%) Median ( P 25 , P 75 ) t/F P P for trend Age £ 40 41~59 ³ 60 25 (9.728) 176 (68.483) 56 (21.790) 33 (25.50, 39.50) 30 (21.00, 38.00) 29 (24.25, 37.00) 0.796 0.452 0.210 Ethnic Han Others 239 (92.996) 18 (7.004) 29 (21.00, 37.00) 30.5 (21.75, 37.50) -0.131 0.896 Residential location Rural Urban 65 (25.292) 192 (74.708) 37 (29.00, 43.00) 27 (21.00, 35.00) 5.106 <0.001 Religion belief No Yes 225 (87.549) 32 (12.451) 30 (22.00, 37.00) 28 (19.50, 38.00) 0.485 0.628 Marital status 1.750 0.176 0.511 Married Divorced Others 217 (84.436) 18 (7.004) 22 (8.560) 29 (21.00, 37.00) 35 (27.75, 39.75) 28 (23.00, 36.25) Education level Middle school and below High school Bachelor and above Family income per month £1000 1001-3000 3001-5000 ³5000 Employment status Unemployed Employed Retired Way of medical payment Insurance Self-paying Degree of financial hardship Basically no General Some Extreme Caregiver Husband Descendants or parents Relatives or others Marital quality Bad General Good Relationship with family members General or aloof Close Personality Pessimistic General Optimistic Emotion regulation ability Poor General Good Number of descendants £1 ³2 Family history of breast cancer No Yes Stage of breast cancer Ⅰ Ⅱ Ⅲ Ⅳ Surgical methods Breast-conserving operation Modified radical surgery Mastectomy Breast Reconstruction Postoperative pain No or mild General Severe Distant metastasis Yes No Regular review Yes No Chemotherapy Yes No Radiation therapy Yes No Targeted therapy Yes No Endocrine therapy Yes No Time after operation £1 1~3 3~5 ³5 130 (50.584) 59 (22.957) 68 (26.459) 73 (28.405) 97 (37.743) 61 (23.735) 26 (10.117) 120 (46.693) 53 (20.623) 84 (32.685) 240 (93.385) 17 (6.615) 48 (18.677) 77 (29.961) 78 (30.350) 54 (21.011) 134 (52.140) 90 (35.019) 33 (12.840) 19 (7.393) 50 (19.455) 188 (73.152) 45 (17.510) 212 (82.490) 23 (8.950) 87 (33.852) 147 (57.198) 34 (13.230) 84 (32.685) 139 (54.086) 141 (54.864) 64 (24.903) 230 (89.494) 27 (10.506) 58 (22.568) 133 (51.750) 41 (15.953) 25 (9.728) 37 (14.397) 111 (43.191) 107 (41.634) 2 (0.778) 162 (63.035) 71 (27.626) 24 (9.339) 35 (13.619) 222 (86.381) 165 (64.202) 92 (39.798) 251 (97.665) 6 (2.335) 133 (51.751) 124 (48.249) 132(51.362) 125(48.638) 121 (47.082) 136 (52.918) 141(54.894) 64(24.903) 26(10.117) 26(10.117) 32 (22.00, 38.25) 31 (22.00, 38.00) 26 (21.00, 32.75) 37 (29.00, 43.50) 28 (20.00, 35.00) 26 (19.50, 32.00) 26.5 (22.50, 34.25) 35 (24.25, 41.75) 28 (21.00, 34.50) 26.50(19.25, 32.00) 29 (21.00, 37.00) 33 (23.00, 38.00) 27 (21.00, 36.00) 26 (20.00, 35.50) 31 (22.00, 39.00) 33.5 (27.00, 39.25) 29 (21.00, 37.00) 29.5 (21.75, 36.25) 33 (22.00, 40.35) 37 (30.00, 42.00) 33 (24.00, 39.25) 29 (21.00, 36.00) 38 (30.50, 43.00) 28 (21.00, 36.00) 37 (33.00, 43.00) 33 (25.00, 39.00) 26 (20.00, 34.00) 38 (31.00, 42.25) 33 (26.00, 38.75) 24 (19.00, 33.00) 29 (21.00, 36.00) 35 (27.00, 42.25) 29 (21.00, 37.00) 35 (26.00, 41.00) 28.5 (20.75, 38.00) 29 (21.00, 37.00) 30 (23.00, 36.00) 34 (26.50, 40.50) 28 (21.00, 36.00) 29 (22.00, 36.00) 30 (22.00, 40.00) 40 26.5 (20.00, 35.00) 34 (27.00, 39.00) 35.5 (31.00, 42.50) 36 (29.00, 41.00) 29 (21.00, 36.25) 27 (21.00, 36.00) 33 (26.25, 39.75) 29 (21.00, 37.00) 39 (30.75, 49.25) 29 (22.00, 36.00) 31 (21.00, 39.75) 29 (22.00, 37.00) 30 (21.00, 38.00) 29 (21.00, 37.50) 30 (22.00, 37.00) 32(23.00,39.00) 23.5(19.00,33.75) 28.5(21.75,36.25) 32.5(26.75,36.50) 13.400 13.940 -0.777 5.206 0.885 5.074 4.978 22.746 -3.321 -2.116 1.836 1.039 11.758 3.187 -3.391 -2.216 -1.518 -0.510 -0.614 4.968 0.017 * <0.001 <0.001 0.438 0.002 0.414 0.007 <0.001 <0.001 * <0.001 0.001 0.035 0.141 0.376 <0.001 0.002 0.001 0.034 0.130 0.610 0.540 0.002 0.005 <0.001 <0.001 0.001 0.297 0.002 <0.001 <0.001 0.050 0.210 <0.001 0.387 Psychosocial adaption and five of its dimensions had shown negative correlation relationship (correlation coefficient < 0) with FoP with statistical significance ( P < 0.001). 3.2 Hierarchical multiple linear regression We conducted a hierarchical multiple liner regression model using FoP-Q-SF scores as dependent variable. Those characteristics with statistical significance in previous univariate analyses and two more variable which may have clinical meanings (age and stage of breast cancer) were chosen as independent variables. And those independent variables were classified into four blocks as follows: Block 1: age, education level, employment status. Block 2: relationship with family members, marital status, number of descendants, family income per month, residential location. Block 3: time after operation, family history of breast cancer, postoperative pain, distant metastasis, regular review, chemotherapy, stage of breast cancer. Block 4: personality, emotion regulation ability, anxiety and depression, attitude towards cancer, self-control and self-efficacy, self-esteem and self-acceptance. As showed in Table 3 , after adjusting for other factors, the following independent variables were identified to be the associated factors for FoP: age ( β =-0.145, P =0.003), number of descendants ( β =0.108, P =0.024), time after operation ( β =0.157, P =0.005), postoperative pain ( β =0.141, P =0.002), regular review ( β =0.200, P <0.001), personality ( β =0.159, P =0.006), anxiety and depression ( β =-0.257, P <0.001), self-esteem and self-acceptance ( β =-0.207, P =0.005) and attitude towards cancer ( β = -0.229, P = 0.003). In addition, the fourth block had the greatest R 2 contribution ( R 2 change = 0.269). Which means the block of personality and psychological states had the strongest association relationship with FoP among all of the independent variables. Table 3 Hierarchic regression of associated factors of FoP Dependent variables Model 1 Beta(P) Model 2 Beta(P) Model 3 Beta(P) Model 4 Beta(P) Constant Age Education level <0.001 0.009(0.894) -0.045(0.519) <0.001 -0.066(0.311) 0.055(0.494) 0.001 -0.119(0.058) 0.089(0.262) <0.001 -0.145(0.003) ** 0.108(0.090) Employment status Relationship with family members Marital quality -0.292(<0.001) *** -0.118(0.139) -0.240(<0.001) *** -0.044(0.497) -0.097(0.200) -0.162(0.012) * -0.021(0.728) -0.079(0.187) 0.000(0.995) 0.008(0.871) Number of descendants 0.138(0.027) * 0.141(0.019) * 0.108(0.024) * Family average income per month -0.092(0.286) -0.080(0.332) 0.000(0.996) Residential location -0.159(0.026) * -0.174(0.013) * -1.577(0.116) Time after operation 0.143(0.042) * 0.157(0.005) ** Family history of breast cancer Postoperative pain Distant metastasis Regular review Chemotherapy Stage of breast cancer Personality Emotion regulation ability Anxiety and depression Attitude towards cancer Self-control and self-efficacy Self-esteem and self-acceptance Adjusted R 2 R 2 change 0.086 - 0.190 0.119 0.101(0.062) 0.214(<0.001) *** -0.058(0.358) 0.214(<0.001) *** 0.082(0.136) 0.055(0.406) 0.279 0.106 0.048(0.272) 0.141(0.002) ** 0.013(0.806) 0.200(<0.001) *** 0.064(0.144) 0.077(0.153) 0.159(0.006) ** 0.031(0.580) -0.257(<0.001) *** -0.229(0.003) ** -0.118(0.076) -0.207(0.005) ** 0.554 0.269 * P <0.05 ** P <0.01 *** P <0.001 3.3 mediation effect analysis Table 4 and Figure 1 demonstrated the result of mediation effect analysis. In this analysis, the score of FoP-Q-SF was taken as dependent variable, the dimension of attitude towards cancer was taken as independent variable, the dimension of anxiety and depression was considered as potential mediation variable. Anxiety and depression had shown a mediation effect with statistical significance ( β = -0.0783, Boost 95% CI (-0.1646, -0.0157)). Table 4. Direct, indirect, and total effects of associated variables on FoP Pathway Effect Boot SE Boot 95%CI Attitude towards cancer"Anxiety and depression"FoP Direct effect (c’) -0.2954 0.1087 (-0.5094, -0.0814) Indirect effect (a*b) -0.0783 0.0380 (-0.1646, -0.0157) Total effect (c) -0.3737 0.1070 (-0.5844, -0.1629) Prop. Mediated (%) 20.95 CI: Confidence intervals 4. Discussion Our study was conducted based on northeast Chinses population which have a different life pattern and economic situation than those people living in south China or other first-tier cites. Understanding their most frequent worry and the possible association factors for FoP is with quite practical meanings. The observed incidence rate of high level of FoP in our study was 37.7%. Based on a systemic review published in 2013 10 , the morbidity of high level of FCR or FoP in breast cancer patients ranges from 22–78%. This wide interval might be caused by non-uniform questionaries and cut-off value used by different investigators. By now, there exist quiet amount of diverse questionaries which differ in target disease, definition of FCR and cultural background 27 . As far as FoP, which representing the concept of fear of diseases progression, is concerned, it may have an obscurer demarcation between FCR. Thus, confusions might occur when previous investigators were choosing questionaries and calculating incidence rate. However, a recent study which may benefit the later clinical doctors and researchers had indicated that the detailed theoretical constructs and influencing factors of these two concepts might not be exactly the same 28 . In a large sample ( n = 1083) research of breast cancer patients 29 , the most frequent worry was “Being nervous prior to doctors’ appointments or periodic examinations”. Followed by “Being afraid of relying on strangers for activities of daily living” and “Being afraid of pain”. Also, in another study focused on long-term cancer survivors with different types of cancer 30 , the most frequent worry was “Being nervous prior to doctors’ appointments or periodic examinations”. However, in our study, the score of the item “Worrying that medications could damage the body” ranked first among all 12 items of FoP-Q-SF. This finding may be explained by the fact that half (51.751%) the patients in our study received radiation therapy. Radiotherapy can significantly reduce the chance of breast cancer recurrence 31 , so it is widely adopted in clinical practice. Unfortunately, radiotherapy could bring a large number of side effects to patients, causing them to worry 32 . A previous meta-analysis also suggested that the weak correlation between radiotherapy and FoP shall be treated with great caution 33 . In addition, our study was conducted on the postoperative population of breast cancer, 87.825% of the study subjects underwent surgery requiring breasts removing. In Chinese cultural background, breasts are considered an important part of femininity and female confidence. When faced with having to remove breasts, feelings of worry and unease might appear. In terms of educational attainment, the majority (73.541%) of the studied population had only a high school education or less. Inadequate education can create barriers for patients to properly understand the benefits and side effects of surgical and medical treatments. Noteworthy, age, as a controversial factor in many previous studies 10 , did not show statistical significance in the hierarchical regression analysis until personality and psychological status were included. This might be explained by the potential association between age and personality and psychological status. Namely, the association between age and FoP was masked by personality and psychological status in univariate analyses. Another variable that had shown inconsistent results among the previous studies was the time after operation 10 . A recent study claimed that FoP levels were statistically slightly higher in cancer patients five years after diagnosis than in those ten years after diagnosis 30 . A qualitative study explored how the emotional needs of cancer patients change over time and treatment stages from the level of psychological mechanisms 34 . It indicated that compering with patients newly diagnosed with cancer those who had received a chemotherapy or radiotherapy expressed more need of emotional care. In our study, although time after operation showed a statistically significant between-group difference in ANOVA ( P = 0.002), the result of test of trend was negative ( P for trend = 0.387). Different from the Western social and cultural background, most Chinese parents still have to bear part of the responsibility for raising their children even after they are adults. In particular, women assume the role of raising and caring for their offspring. Thus, after suffering from breast cancer, patients will worry about their families and children. The more the number of children, the stronger the fear. According to Extended Parallel Process Model (EPPM), CSM and other theoretical models used to explain the fear of disease progression 35,36 . When faced with the potential threat of disease progression, patients evaluate the severity of the threat and the strength of their own ability to adapt it. This process is regulated by the individual's cognitive style and attitude towards the disease. Meanwhile, the Self-Regulatory Executive Function (S-REF) model suggested that FCR may have a similar pathway as anxiety 37 , and studies had shown that patients with anxiety have a more sensitive attention tendency to potential threats 38,39 . Based on the above theory, we analyzed the possible mediation effect in the association between attitude towards cancer and FoP. The results suggested that anxiety and depression might be the mediation factor. 4.1 Study limitations This research is not a longitudinal study nor a cohort study, a causal interpretation of the proposed relationship among variables cannot be made. Furthermore, the participants were recruited only from a single-study site which limits the generalizability of our findings. Also, some variables that could also potentially influence FoP were not available in our study. 4.2 Clinical implications Our findings underscore the importance for clinicians to assist and guide patients in developing a balanced perspective on the necessity and potential drawbacks of surgical and other medical treatments. Special consideration should also be given to patients exhibiting pessimistic personality traits or demonstrating lower psychosocial adaptability. Our results offer valuable insights into the varied patterns of Fear of Progression across diverse cultural and economic backgrounds which holds the potential to enhance the development of more effective clinical coping strategies. 5. Conclusion In summary, our study identified a different pattern of most frequent fear. Age, number of descendants, time after operation, postoperative pain, regular review, personality, anxiety and depression, self-esteem and self-acceptance and attitude had been found as the association factor of FoP among postoperative breast cancer patients. Among these factors, personality and psychological factors have the greatest contribution to FoP. And We also confirm the mediating effect of anxiety and depression in the pathway between attitude towards cancer and FoP. Therefore, based on our research, we suggest extra care for those breast cancer patients performed with low psychosocial adaptability or negative personality. Correct and positive guidance to enable the patient to face the development and treatment of the disease objectively will also be needed. Declarations Declaration of Competing Interest This study was not funded. The authors declare that there were no conflicts of interest with respect to the authorship or the publication of this article. Formatting of funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Conception & Design: YL.N., Z.L. AND CG.K.Analysis and interpretation of data: SY.W., XH,G AND YL.NDrafting the manuscript: SY.W. AND XH,GCritical revision of the manuscript: Z.L. AND CG.K.Final approval of the manuscript: Z.L. AND CG.K. References Bray, F., Laversanne, M., Weiderpass, E. & Soerjomataram, I. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer 127 , 3029-3030, doi:10.1002/cncr.33587 (2021). 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Journal of Cancer Survivorship 10 , 663-673, doi:10.1007/s11764-015-0512-5 (2016). Starreveld, D. E. J., Markovitz, S. E., van Breukelen, G. & Peters, M. L. The course of fear of cancer recurrence: Different patterns by age in breast cancer survivors. Psychooncology 27 , 295-301, doi:10.1002/pon.4505 (2018). Xie, J. et al. Predictors for Fear of Cancer Recurrence in Breast Cancer Patients Referred to Radiation Therapy During the COVID-19 Pandemic: A Multi-Center Cross-Section Survey. Front Oncol 11 , 650766, doi:10.3389/fonc.2021.650766 (2021). Yang, Y. et al. Network connectivity between fear of cancer recurrence, anxiety, and depression in breast cancer patients. J Affect Disord 309 , 358-367, doi:10.1016/j.jad.2022.04.119 (2022). Yu, Z., Sun, D. & Sun, J. Social Support and Fear of Cancer Recurrence Among Chinese Breast Cancer Survivors: The Mediation Role of Illness Uncertainty. Front Psychol 13 , 864129, doi:10.3389/fpsyg.2022.864129 (2022). Zhu, L. et al. Self-compassion and fear of cancer recurrence in Chinese breast cancer patients: The mediating role of maladaptive cognitive styles. Psychooncology 31 , 2185-2192, doi:10.1002/pon.6070 (2022). Hong, S. J. & Shin, N. M. Fear of cancer recurrence in Korean women after breast cancer treatment: A mixed methods study. Eur J Oncol Nurs 54 , 102010, doi:10.1016/j.ejon.2021.102010 (2021). Ashing-Giwa, K. T. & Lim, J. W. Examining emotional outcomes among a multiethnic cohort of breast cancer survivors. Oncol Nurs Forum 38 , 279-288, doi:10.1188/11.Onf.279-288 (2011). Luo, X. et al. High Fear of Cancer Recurrence in Chinese Newly Diagnosed Cancer Patients. Front Psychol 11 , 1287, doi:10.3389/fpsyg.2020.01287 (2020). HERRIN, D. BIOSTATISTICS - A FOUNDATION FOR ANALYSIS IN THE HEALTH-SCIENCES - DANIEL,WW. HOSPITAL & HEALTH SERVICES ADMINISTRATION 25 , 68-69 (1980). Herschbach, P. et al. Fear of progression in chronic diseases: psychometric properties of the Fear of Progression Questionnaire. J Psychosom Res 58 , 505-511, doi:10.1016/j.jpsychores.2005.02.007 (2005). Mehnert, A., Herschbach, P., Berg, P., Henrich, G. & Koch, U. [Fear of progression in breast cancer patients--validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF)]. Z Psychosom Med Psychother 52 , 274-288, doi:10.13109/zptm.2006.52.3.274 (2006). Wu Q Y, Y. Z. X., Li L, Liu P Y. Chinese translation and reliability and validity analysis of the FoP-Q-SF . Chinese Journal of Nursing 50 , 1515-1519 (2015). Cai J P, J. Z. F. The reliability and validity test of the simplified Chinese version of FoP-Q-SF appling to female breast cancer patients. Journal of Nursing(China) 25 , 5-8 (2018). Herschbach, P. et al. Group psychotherapy of dysfunctional fear of progression in patients with chronic arthritis or cancer. Psychother Psychosom 79 , 31-38, doi:10.1159/000254903 (2010). Thewes, B. et al. Fear of cancer recurrence: a systematic literature review of self-report measures. Psychooncology 21 , 571-587, doi:10.1002/pon.2070 (2012). Coutts-Bain, D. et al. Are fear of cancer recurrence and fear of progression equivalent constructs? Psychooncology 31 , 1381-1389, doi:10.1002/pon.5944 (2022). Mehnert, A., Berg, P., Henrich, G. & Herschbach, P. Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psychooncology 18 , 1273-1280, doi:10.1002/pon.1481 (2009). Götze, H., Taubenheim, S., Dietz, A., Lordick, F. & Mehnert-Theuerkauf, A. Fear of cancer recurrence across the survivorship trajectory: Results from a survey of adult long-term cancer survivors. Psychooncology 28 , 2033-2041, doi:10.1002/pon.5188 (2019). Fisher, B. et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347 , 1233-1241, doi:10.1056/NEJMoa022152 (2002). Sun, F. K., Hung, C. M., Yao, Y., Lu, C. Y. & Chiang, C. Y. The Effects of Muscle Relaxation and Therapeutic Walking on Depression, Suicidal Ideation, and Quality of Life in Breast Cancer Patients Receiving Chemotherapy. Cancer Nurs 40 , E39-e48, doi:10.1097/ncc.0000000000000458 (2017). Yang, Y., Cameron, J. & Humphris, G. The relationship between cancer patient's fear of recurrence and radiotherapy: a systematic review and meta-analysis. Psychooncology 26 , 738-746, doi:10.1002/pon.4224 (2017). Baker, P. et al. 'You're putting thoughts into my head': a qualitative study of the readiness of patients with breast, lung or prostate cancer to address emotional needs through the first 18 months after diagnosis. Psychooncology 22 , 1402-1410, doi:10.1002/pon.3156 (2013). Witte, K. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs 59 , 329-349, doi:10.1080/03637759209376276 (1992). Leventhal, H., Diefenbach, M. & Leventhal, E. A. Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions. Cognitive Therapy and Research 16 , 143-163, doi:10.1007/BF01173486 (1992). Wells, A. & Matthews, G. Modelling cognition in emotional disorder: the S-REF model. Behav Res Ther 34 , 881-888, doi:10.1016/s0005-7967(96)00050-2 (1996). MacLeod, C. & Hagan, R. Individual differences in the selective processing of threatening information, and emotional responses to a stressful life event. Behav Res Ther 30 , 151-161, doi:10.1016/0005-7967(92)90138-7 (1992). Taylor, L. M., Espie, C. A. & White, C. A. Attentional bias in people with acute versus persistent insomnia secondary to cancer. Behav Sleep Med 1 , 200-212, doi:10.1207/s15402010bsm0104_3 (2003). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3855508","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266703001,"identity":"6e5381ff-794c-4e59-9d0f-cf36f507022f","order_by":0,"name":"Songyu Wu","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Songyu","middleName":"","lastName":"Wu","suffix":""},{"id":266703002,"identity":"0047841c-981f-4af1-9abf-8d8e0b518510","order_by":1,"name":"Yaling Niu","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yaling","middleName":"","lastName":"Niu","suffix":""},{"id":266703003,"identity":"74478507-eddd-466e-bc1c-d59f97ae648e","order_by":2,"name":"Xiaohan Geng","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaohan","middleName":"","lastName":"Geng","suffix":""},{"id":266703004,"identity":"6cb19e1f-af04-41bb-a7de-04d2f6ac2636","order_by":3,"name":"Changgui Kou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBACCTBZwSaD4BCn5QwbD4laGNsYSNAi2d5j+PHrPD4egwPMB2/zMNjlEdQizXPGWFp2GxtQC1uyNQ9DcjFBLXISOWbMkmAtPGbSPAwHEhuI0zIHpIX/G3FapIFaGD82gG1hI06LZM+xYmmGY2w8kofZjC3nGCQT1iJxvHnjxx81x+T4jjc/vPGmwo6wFhBg5mE4BiRBTANi1AMB4w+GGiKVjoJRMApGwYgEAOcoMU7otQThAAAAAElFTkSuQmCC","orcid":"","institution":"Jilin University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Changgui","middleName":"","lastName":"Kou","suffix":""},{"id":266703005,"identity":"e1159b8e-1e78-4870-9984-95db1cb747ec","order_by":4,"name":"Zheng Lv","email":"","orcid":"","institution":"The First Affiliated Hospital of Jilin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zheng","middleName":"","lastName":"Lv","suffix":""}],"badges":[],"createdAt":"2024-01-12 03:29:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3855508/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3855508/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49646172,"identity":"441bce03-464a-483d-a399-e84dc081ba6a","added_by":"auto","created_at":"2024-01-15 21:02:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30995,"visible":true,"origin":"","legend":"\u003cp\u003eThe mediation model of attitude towards cancer to Fear of Progression.\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e**\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/p\u003e\n\u003cp\u003e***\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3855508/v1/ab31768f704f6a22fe40c361.png"},{"id":49842592,"identity":"197bfb76-1236-4da7-b55c-df0743779a9c","added_by":"auto","created_at":"2024-01-19 00:22:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":414771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3855508/v1/5467496f-ff38-4f91-b5e8-a033bf374f97.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fear of Progression and its Associated Factors among Postoperative Patients with Breast Cancer: a cross-sectional study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCancer has emerged as the leading cause of premature death in 50 countries including China\u003csup\u003e1\u003c/sup\u003e. Among female population, breast cancer imposes a substantial disease burden\u003csup\u003e2\u003c/sup\u003e. By estimation, the morbidity of breast cancer in 16 countries including China is still on an upward trajectory\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe advancement of clinical treatment methods and the conduct of health education does have a positive impact on curing breast cancer patients and reducing the case fatality rate. In the United States, an estimated 4\u0026nbsp;million females were living with a history of breast cancer by estimation in 2022. And the general 5-year relative survival rate of breast cancer has raised from 75% in mid-1970s to 90% in the year during 2011 to 2017\u003csup\u003e4\u003c/sup\u003e. Similarly, although limited data is available, the general 5-year relative survival rate of breast cancer in China is also on the rise\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite these encouraging trends, for those patients diagnosed with breast cancer, they may very likely to fall into a status of fear of cancer recurrence (FCR) or fear of progression (FoP)\u003csup\u003e6\u003c/sup\u003e. Some patients even claimed that the fear of cancer recurrence is more distressing than the initial diagnosis or treatment of cancer\u003csup\u003e7\u003c/sup\u003e. This phenomenon not only imposes an increased personal financial and emotional burden but also contributes to the elevated cost of public healthcare resources \u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFCR has been considered as one of the mostly reported unsatisfied needs of cancer patients\u003csup\u003e9,10\u003c/sup\u003e. It is to be believed to possess a unique, independent construct and reflects the fear and worry targeted at disease progression as well as cognitive dissonance. A comprehensive definition of FCR with consensus has been reached as \u0026ldquo;Fear, worry, or concern relating to the possibility that cancer will come back or progress\u0026rdquo; in a meeting held in Ottawa in 2015\u003csup\u003e11\u003c/sup\u003e. Investigators have tried several theoretical models or frameworks including common sense model (CSM), protection motivation theory and theory of uncertainty in illness to explain the mechanism of FCR\u003csup\u003e12\u003c/sup\u003e. However, no theoretical model can fully explain the complicated occurrence and development process of FCR.\u003c/p\u003e \u003cp\u003eAge, marital status, occupation and employment status, education level, disease stage, radiation therapy, uncertainty in illness, self-efficiency, depression, anxiety and many other factors have been considered to be the relevant factors of the occurrence and degree of FCR(FoP) based on multiple previous studies \u003csup\u003e13\u0026ndash;18\u003c/sup\u003e. However, there also exists study that argue for a contradictory result\u003csup\u003e19\u003c/sup\u003e. Specifically in breast cancer patients, dispute of related or risk factor of FCR still exist. These factors may also vary considering the social and cultural backgrounds of the population.\u003c/p\u003e \u003cp\u003eIn this study, we aim at: 1) Demonstrating the result of FoP-Q-SF and the most frequent fears; 2) Investigating the related factors of FoP; 3) Analyzing the possible mediating effect between attitude towards breast cancer and FoP.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and participants\u003c/h2\u003e \u003cp\u003eThis study is a cross-sectional study and convenience sampling method was performed. Hospitalized postoperative patients with breast cancer in the First Affiliated Hospital of Jilin University from October 2021 to January 2022 were enrolled.\u003c/p\u003e \u003cp\u003eInclusion criteria are as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) female; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) aged \u0026ge;18; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) postoperative patients with breast cancer diagnosed by pathological or immunohistochemical examinations; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) patients who were aware of and understand their condition and the purpose of this study; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) patients who provided informed consent to participate voluntarily;\u003c/p\u003e \u003cp\u003eExclusion criteria are as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) patients with breast cancer recurrence; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) patients with critically illness or complicated with sever cardiovascular, respiratory, mental, hematology diseases or other tumors. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) patients who can\u0026rsquo;t finish the questionaries by any reasons.\u003c/p\u003e \u003cp\u003eAccording to estimation of incidence rate of FCR(FoP) among postoperative patients with breast cancer and sample size formula of cross-sectional studies\u003csup\u003e16,20,21\u003c/sup\u003e. We collected 267 cases for our study and 257 of them were finally taken into analysis based on inclusion and exclusion criteria and quality control measures with an effective response rate of 96.25%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Instruments\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Sociodemographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eA self-designed questionnaire was used to collect characteristics of patients. Demographic characteristics include age, ethnic, education level, family income per month; personal and family characteristics include marital quality, relationship with family members, emotion regulation ability; clinical characteristics include surgical methods, stage of breast cancer, time after operation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Fear of Progression Questionnaire-Short Form\u003c/h2\u003e \u003cp\u003eThe Fear of Progression Questionnaire-Short Form (FoP-Q-SF) was used to measure FCR in this study. The Fear of Progression Questionnaire (FoP-Q) was designed and simplified into FoP-Q-SF by Peter Herschbach et al\u003csup\u003e22,23\u003c/sup\u003e. It contains 12 items while all the items were scored on a 5-point Likert Scale ranging from 1 (\u0026ldquo;never\u0026rdquo;) to 5 (\u0026ldquo;very often\u0026rdquo;). A higher score refers to a higher level of FCR. The Chinese version of FoP-Q-SF was translated by Chinese scholar WU et al in 2015\u003csup\u003e24\u003c/sup\u003e. And the Cronbach\u0026rsquo;s α equals to 0.856 in an investigation conducted in Chinese breast cancer patients using FoP-Q-SF\u003csup\u003e25\u003c/sup\u003e. FoP-Q-SF has performed with high reliability and validity among Chinese cancer patients. Based on a multicenter RCT study, the participants who score 34 or over 34 in FoP-Q-SF will be considered as have reached a level of in need of clinical psychological interventions\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Psychosocial adaption\u003c/h2\u003e \u003cp\u003eA questionnaire designed by Chinese scholar Cheng was used to describe the psychosocial adaption status of breast cancer patients. This questionnaire contains 44 items and could be divided into 5 dimensions: anxiety and depression, self-esteem and self-acceptance, Attitude towards cancer, sense of belonging and self-control and self-efficiency. All the items were scored based on a 5-point Likert Scale ranging from 1 (\u0026ldquo;completely wrong\u0026rdquo;) to 5 (\u0026ldquo;completely correct\u0026rdquo;). The score ranges from 44 to 220. A higher score refers to a higher level of psychosocial adaption. The CVI of all 44 items are over 0.75. The Cronbach\u0026rsquo;α of general questionnaire is 0.945. The criterion-related validity between this questionary and Self-rating Anxiety Scale (SAS), General Self-Efficacy Scale (GSES) and Self-Acceptance Questionnaire (SAQ) were \u0026minus;\u0026thinsp;0.757, 0.505, 0.691 with P\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Methods\u003c/h2\u003e \u003cp\u003eMedium, quartile and frequency with percentage were performed to describe the distribution of the social-demographic characteristics, personality and family situation and clinical features of the study sample. Mean value and standard deviation were used to illustrate the results of FoP-Q-SF items. The \u003cem\u003et/F\u003c/em\u003e test or nonparametric test was used to test the significance of differences between groups. Spearman correlation test was performed to analyze the correlation relationship between psychosocial adaption and FoP. Hierarchic multiple linear regression was applied to identify the independent relevant factors. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to represent statical significance. All \u003cem\u003eP\u003c/em\u003e values were two-tailed. Moreover, \u003cem\u003eBootstrap\u003c/em\u003e was used to conduct mediation effect analysis and \u003cem\u003eBoot\u003c/em\u003e 95% confidence interval which did not include 0 was considered to represent statical significance.\u003c/p\u003e \u003cp\u003eAll statistical analyses were conducted with SPSS version 24.0 (IBM Corp, Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Ethical consideration\u003c/h2\u003e \u003cp\u003e Written informed consent was obtained from each subject participating in the study. Additionally, this research complied with the Declaration of Helsinki and has obtained the approval from the Ethics Committee of School of Public Health, Jilin University.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.1 Descriptive analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean value of total score of FoP-Q-SF was 30.26 (Standard Deviation = 9.867). 97 (37.7%) participants had reached the level of in need of clinical interventions (FoP-Q-SF total score\u0026nbsp;\u0026sup3;\u0026nbsp;34).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe scores of single items and their rank could be seen in \u003cstrong\u003eTable 1\u003c/strong\u003e. The most frequent fears include \u0026ldquo;worrying that medications could damage the body\u0026rdquo;, \u0026ldquo;being afraid of disease progression\u0026rdquo; and \u0026ldquo;being nervous prior to doctors\u0026rsquo; appointment\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1\u0026nbsp;FoP-Q-SF items responses\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"556\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e30.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e9.867\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eWorrying about medication could damage the body.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e3.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eBeing afraid of disease progression.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eBeing nervous prior to doctors\u0026rsquo; appointments or periodic examinations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eBeing afraid of pain.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.499\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eWorrying about what will become of the family.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.14388489208633%\" valign=\"top\"\u003e\n \u003cp\u003eBeing afraid of severe medical treatment.\u003c/p\u003e\n \u003cp\u003eHaving physical sensations.\u003c/p\u003e\n \u003cp\u003eBeing afraid that the children could contract cancer.\u003c/p\u003e\n \u003cp\u003eBeing afraid of becoming less productive at work.\u003c/p\u003e\n \u003cp\u003eBeing afraid of not being able to work anymore.\u003c/p\u003e\n \u003cp\u003eBeing afraid of relying on strangers for ADL.\u003c/p\u003e\n \u003cp\u003eBeing afraid of no longer be able to pursue hobbies.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.352517985611511%\" valign=\"top\"\u003e\n \u003cp\u003e2.56\u003c/p\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.503597122302157%\" valign=\"top\"\u003e\n \u003cp\u003e1.333\u003c/p\u003e\n \u003cp\u003e1.228\u003c/p\u003e\n \u003cp\u003e1.451\u003c/p\u003e\n \u003cp\u003e1.566\u003c/p\u003e\n \u003cp\u003e1.578\u003c/p\u003e\n \u003cp\u003e0.909\u003c/p\u003e\n \u003cp\u003e0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe distribution and univariate analysis of demographic, personality, family and clinical features is listed in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong 257 participants, 25 (9.728%) aged\u0026nbsp;\u0026pound;\u0026nbsp;40, 176 (68.483%) aged 41~59, 56 (21.790%) aged\u0026nbsp;\u0026sup3;\u0026nbsp;60. 25.292% (\u003cem\u003en\u003c/em\u003e = 65) participants lived in rural area while 74.708% (\u003cem\u003en\u003c/em\u003e = 192) lived in urban area. The proportion of participants who have more than 2 descendants were 24.903% (\u003cem\u003en\u003c/em\u003e = 64). 147 (57.198%) participants had reported to have an optimistic personality and 23 (8.950%) participants reported a pessimistic personality. Meanwhile, 9.339% (\u003cem\u003en\u003c/em\u003e = 24) of our participants had suffered from severe postoperative pain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter univariate analyses, the differences between groups of residential location, education level, family income per month, employment status, degree of financial hardship, marital quality, relationship with family members, personality, emotion regulation ability, number of descendants, family history of breast cancer, postoperative pain, distant metastasis, regular review, chemotherapy and time after operation were found to have statistical significance (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2\u0026nbsp;Distribution and univariate analysis of demographic, personality, family and clinical features\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003eMedian (\u003cem\u003eP\u003csub\u003e25\u003c/sub\u003e, P\u003csub\u003e75\u003c/sub\u003e\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et/F\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP \u003csub\u003efor trend\u003c/sub\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e\u0026pound;\u0026nbsp;40\u003c/p\u003e\n \u003cp\u003e41~59\u003c/p\u003e\n \u003cp\u003e\u0026sup3;\u0026nbsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (9.728)\u003c/p\u003e\n \u003cp\u003e176 (68.483)\u003c/p\u003e\n \u003cp\u003e56 (21.790)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (25.50, 39.50)\u003c/p\u003e\n \u003cp\u003e30 (21.00, 38.00)\u003c/p\u003e\n \u003cp\u003e29 (24.25, 37.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e0.452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eEthnic\u003c/p\u003e\n \u003cp\u003eHan\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e239 (92.996)\u003c/p\u003e\n \u003cp\u003e18 (7.004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e30.5 (21.75, 37.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e-0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eResidential location\u003c/p\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65 (25.292)\u003c/p\u003e\n \u003cp\u003e192 (74.708)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (29.00, 43.00)\u003c/p\u003e\n \u003cp\u003e27 (21.00, 35.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e5.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eReligion belief\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e225 (87.549)\u003c/p\u003e\n \u003cp\u003e32 (12.451)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (22.00, 37.00)\u003c/p\u003e\n \u003cp\u003e28 (19.50, 38.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e0.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e1.750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e217 (84.436)\u003c/p\u003e\n \u003cp\u003e18 (7.004)\u003c/p\u003e\n \u003cp\u003e22 (8.560)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e35 (27.75, 39.75)\u003c/p\u003e\n \u003cp\u003e28 (23.00, 36.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003cp\u003eMiddle school and below\u003c/p\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003cp\u003eBachelor and above\u003c/p\u003e\n \u003cp\u003eFamily income per month\u003c/p\u003e\n \u003cp\u003e\u0026pound;1000\u003c/p\u003e\n \u003cp\u003e1001-3000\u003c/p\u003e\n \u003cp\u003e3001-5000\u003c/p\u003e\n \u003cp\u003e\u0026sup3;5000\u003c/p\u003e\n \u003cp\u003eEmployment status\u003c/p\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003cp\u003eWay of medical payment\u003c/p\u003e\n \u003cp\u003eInsurance\u003c/p\u003e\n \u003cp\u003eSelf-paying\u003c/p\u003e\n \u003cp\u003eDegree of financial hardship\u003c/p\u003e\n \u003cp\u003eBasically no\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003eSome\u003c/p\u003e\n \u003cp\u003eExtreme\u003c/p\u003e\n \u003cp\u003eCaregiver\u003c/p\u003e\n \u003cp\u003eHusband\u003c/p\u003e\n \u003cp\u003eDescendants or parents\u003c/p\u003e\n \u003cp\u003eRelatives or others\u003c/p\u003e\n \u003cp\u003eMarital quality\u003c/p\u003e\n \u003cp\u003eBad\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003cp\u003eRelationship with family members\u003c/p\u003e\n \u003cp\u003eGeneral or aloof\u003c/p\u003e\n \u003cp\u003eClose\u003c/p\u003e\n \u003cp\u003ePersonality\u003c/p\u003e\n \u003cp\u003ePessimistic\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003eOptimistic\u003c/p\u003e\n \u003cp\u003eEmotion regulation ability\u003c/p\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003cp\u003eNumber of descendants\u003c/p\u003e\n \u003cp\u003e\u0026pound;1\u003c/p\u003e\n \u003cp\u003e\u0026sup3;2\u003c/p\u003e\n \u003cp\u003eFamily history of breast cancer\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eStage of breast cancer\u003c/p\u003e\n \u003cp\u003eⅠ\u003c/p\u003e\n \u003cp\u003eⅡ\u003c/p\u003e\n \u003cp\u003eⅢ\u003c/p\u003e\n \u003cp\u003eⅣ\u003c/p\u003e\n \u003cp\u003eSurgical methods\u003c/p\u003e\n \u003cp\u003eBreast-conserving operation\u003c/p\u003e\n \u003cp\u003eModified radical surgery\u003c/p\u003e\n \u003cp\u003eMastectomy\u003c/p\u003e\n \u003cp\u003eBreast Reconstruction\u003c/p\u003e\n \u003cp\u003ePostoperative pain\u003c/p\u003e\n \u003cp\u003eNo or mild\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003eDistant metastasis\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eRegular review\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eRadiation therapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eTargeted therapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eEndocrine therapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eTime after operation\u003c/p\u003e\n \u003cp\u003e\u0026pound;1\u003c/p\u003e\n \u003cp\u003e1~3\u003c/p\u003e\n \u003cp\u003e3~5\u003c/p\u003e\n \u003cp\u003e\u0026sup3;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.398550724637682%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e130 (50.584)\u003c/p\u003e\n \u003cp\u003e59 (22.957)\u003c/p\u003e\n \u003cp\u003e68 (26.459)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e73 (28.405)\u003c/p\u003e\n \u003cp\u003e97 (37.743)\u003c/p\u003e\n \u003cp\u003e61 (23.735)\u003c/p\u003e\n \u003cp\u003e26 (10.117)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e120 (46.693)\u003c/p\u003e\n \u003cp\u003e53 (20.623)\u003c/p\u003e\n \u003cp\u003e84 (32.685)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e240 (93.385)\u003c/p\u003e\n \u003cp\u003e17 (6.615)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48 (18.677)\u003c/p\u003e\n \u003cp\u003e77 (29.961)\u003c/p\u003e\n \u003cp\u003e78 (30.350)\u003c/p\u003e\n \u003cp\u003e54 (21.011)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e134 (52.140)\u003c/p\u003e\n \u003cp\u003e90 (35.019)\u003c/p\u003e\n \u003cp\u003e33 (12.840)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (7.393)\u003c/p\u003e\n \u003cp\u003e50 (19.455)\u003c/p\u003e\n \u003cp\u003e188 (73.152)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45 (17.510)\u003c/p\u003e\n \u003cp\u003e212 (82.490)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (8.950)\u003c/p\u003e\n \u003cp\u003e87 (33.852)\u003c/p\u003e\n \u003cp\u003e147 (57.198)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (13.230)\u003c/p\u003e\n \u003cp\u003e84 (32.685)\u003c/p\u003e\n \u003cp\u003e139 (54.086)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e141 (54.864)\u003c/p\u003e\n \u003cp\u003e64 (24.903)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e230 (89.494)\u003c/p\u003e\n \u003cp\u003e27 (10.506)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58 (22.568)\u003c/p\u003e\n \u003cp\u003e133 (51.750)\u003c/p\u003e\n \u003cp\u003e41 (15.953)\u003c/p\u003e\n \u003cp\u003e25 (9.728)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (14.397)\u003c/p\u003e\n \u003cp\u003e111 (43.191)\u003c/p\u003e\n \u003cp\u003e107 (41.634)\u003c/p\u003e\n \u003cp\u003e2 (0.778)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e162 (63.035)\u003c/p\u003e\n \u003cp\u003e71 (27.626)\u003c/p\u003e\n \u003cp\u003e24 (9.339)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (13.619)\u003c/p\u003e\n \u003cp\u003e222 (86.381)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e165 (64.202)\u003c/p\u003e\n \u003cp\u003e92 (39.798)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e251 (97.665)\u003c/p\u003e\n \u003cp\u003e6 (2.335)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e133 (51.751)\u003c/p\u003e\n \u003cp\u003e124 (48.249)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e132(51.362)\u003c/p\u003e\n \u003cp\u003e125(48.638)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e121 (47.082)\u003c/p\u003e\n \u003cp\u003e136 (52.918)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e141(54.894)\u003c/p\u003e\n \u003cp\u003e64(24.903)\u003c/p\u003e\n \u003cp\u003e26(10.117)\u003c/p\u003e\n \u003cp\u003e26(10.117)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.108695652173914%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (22.00, 38.25)\u003c/p\u003e\n \u003cp\u003e31 (22.00, 38.00)\u003c/p\u003e\n \u003cp\u003e26 (21.00, 32.75)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (29.00, 43.50)\u003c/p\u003e\n \u003cp\u003e28 (20.00, 35.00)\u003c/p\u003e\n \u003cp\u003e26 (19.50, 32.00)\u003c/p\u003e\n \u003cp\u003e26.5 (22.50, 34.25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (24.25, 41.75)\u003c/p\u003e\n \u003cp\u003e28 (21.00, 34.50)\u003c/p\u003e\n \u003cp\u003e26.50(19.25, 32.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e33 (23.00, 38.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e26 (20.00, 35.50)\u003c/p\u003e\n \u003cp\u003e31 (22.00, 39.00)\u003c/p\u003e\n \u003cp\u003e33.5 (27.00, 39.25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e29.5 (21.75, 36.25)\u003c/p\u003e\n \u003cp\u003e33 (22.00, 40.35)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (30.00, 42.00)\u003c/p\u003e\n \u003cp\u003e33 (24.00, 39.25)\u003c/p\u003e\n \u003cp\u003e29 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (30.50, 43.00)\u003c/p\u003e\n \u003cp\u003e28 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (33.00, 43.00)\u003c/p\u003e\n \u003cp\u003e33 (25.00, 39.00)\u003c/p\u003e\n \u003cp\u003e26 (20.00, 34.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (31.00, 42.25)\u003c/p\u003e\n \u003cp\u003e33 (26.00, 38.75)\u003c/p\u003e\n \u003cp\u003e24 (19.00, 33.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e35 (27.00, 42.25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e35 (26.00, 41.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28.5 (20.75, 38.00)\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e30 (23.00, 36.00)\u003c/p\u003e\n \u003cp\u003e34 (26.50, 40.50)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e29 (22.00, 36.00)\u003c/p\u003e\n \u003cp\u003e30 (22.00, 40.00)\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26.5 (20.00, 35.00)\u003c/p\u003e\n \u003cp\u003e34 (27.00, 39.00)\u003c/p\u003e\n \u003cp\u003e35.5 (31.00, 42.50)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36 (29.00, 41.00)\u003c/p\u003e\n \u003cp\u003e29 (21.00, 36.25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (21.00, 36.00)\u003c/p\u003e\n \u003cp\u003e33 (26.25, 39.75)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.00)\u003c/p\u003e\n \u003cp\u003e39 (30.75, 49.25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (22.00, 36.00)\u003c/p\u003e\n \u003cp\u003e31 (21.00, 39.75)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (22.00, 37.00)\u003c/p\u003e\n \u003cp\u003e30 (21.00, 38.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (21.00, 37.50)\u003c/p\u003e\n \u003cp\u003e30 (22.00, 37.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32(23.00,39.00)\u003c/p\u003e\n \u003cp\u003e23.5(19.00,33.75)\u003c/p\u003e\n \u003cp\u003e28.5(21.75,36.25)\u003c/p\u003e\n \u003cp\u003e32.5(26.75,36.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.514492753623188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13.400\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13.940\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.777\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.206\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.885\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.074\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.978\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22.746\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-3.321\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-2.116\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.836\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.039\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.758\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.187\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-3.391\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-2.216\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-1.518\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.510\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.614\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.507246376811594%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.610\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.601449275362318%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePsychosocial adaption and five of its dimensions had shown negative correlation relationship (correlation coefficient \u0026lt; 0) with FoP with statistical significance (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Hierarchical multiple linear regression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a hierarchical multiple liner regression model using FoP-Q-SF scores as dependent variable. Those characteristics with statistical significance in previous univariate analyses and two more variable which may have clinical meanings (age and stage of breast cancer) were chosen as independent variables. And those independent variables were classified into four blocks as follows:\u003c/p\u003e\n\u003cp\u003eBlock 1: age, education level, employment status.\u003c/p\u003e\n\u003cp\u003eBlock 2: relationship with family members, marital status, number of descendants, family income per month, residential location.\u003c/p\u003e\n\u003cp\u003eBlock 3: time after operation, family history of breast cancer, postoperative pain, distant metastasis, regular review, chemotherapy, stage of breast cancer.\u003c/p\u003e\n\u003cp\u003eBlock 4: personality, emotion regulation ability, anxiety and depression, attitude towards cancer, self-control and self-efficacy, self-esteem and self-acceptance.\u003c/p\u003e\n\u003cp\u003eAs showed in \u003cstrong\u003eTable 3\u003c/strong\u003e, after adjusting for other factors, the following independent variables were identified to be the associated factors for FoP: age (\u003cem\u003e\u0026beta;\u003c/em\u003e=-0.145, \u003cem\u003eP\u003c/em\u003e=0.003), number of descendants (\u003cem\u003e\u0026beta;\u003c/em\u003e=0.108, \u003cem\u003eP\u003c/em\u003e=0.024), time after operation (\u003cem\u003e\u0026beta;\u003c/em\u003e=0.157, \u003cem\u003eP\u003c/em\u003e=0.005), postoperative pain (\u003cem\u003e\u0026beta;\u003c/em\u003e=0.141, \u003cem\u003eP\u003c/em\u003e=0.002), regular review (\u003cem\u003e\u0026beta;\u003c/em\u003e=0.200, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), personality (\u003cem\u003e\u0026beta;\u003c/em\u003e=0.159, \u003cem\u003eP\u003c/em\u003e=0.006), anxiety and depression \u0026nbsp;(\u003cem\u003e\u0026beta;\u003c/em\u003e=-0.257, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), self-esteem and self-acceptance (\u003cem\u003e\u0026beta;\u003c/em\u003e=-0.207,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e=0.005) and attitude towards cancer (\u003cem\u003e\u0026beta;\u0026nbsp;\u003c/em\u003e= -0.229, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.003).\u003c/p\u003e\n\u003cp\u003eIn addition, the fourth block had the greatest \u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e contribution (\u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e change = 0.269). Which means the block of personality and psychological states had the strongest association relationship with FoP among all of the independent variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 Hierarchic regression of associated factors of FoP\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eDependent variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003cp\u003eBeta(P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003eModel 2\u003c/p\u003e\n \u003cp\u003eBeta(P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003eModel 3\u003c/p\u003e\n \u003cp\u003eBeta(P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003eModel 4\u003c/p\u003e\n \u003cp\u003eBeta(P)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e0.009(0.894)\u003c/p\u003e\n \u003cp\u003e-0.045(0.519)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e-0.066(0.311)\u003c/p\u003e\n \u003cp\u003e0.055(0.494)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e-0.119(0.058)\u003c/p\u003e\n \u003cp\u003e0.089(0.262)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e-0.145(0.003) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.108(0.090)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eEmployment status\u003c/p\u003e\n \u003cp\u003eRelationship with family members\u003c/p\u003e\n \u003cp\u003eMarital quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.292(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.118(0.139)\u003c/p\u003e\n \u003cp\u003e-0.240(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.044(0.497)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.097(0.200)\u003c/p\u003e\n \u003cp\u003e-0.162(0.012) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.021(0.728)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.079(0.187)\u003c/p\u003e\n \u003cp\u003e0.000(0.995)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.008(0.871)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of descendants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.138(0.027) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.141(0.019) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.108(0.024) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eFamily average income per month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.092(0.286)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.080(0.332)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.000(0.996)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eResidential location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.159(0.026) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-0.174(0.013) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e-1.577(0.116)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eTime after operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.143(0.042) \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.157(0.005) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.201342281879196%\" valign=\"top\"\u003e\n \u003cp\u003eFamily history of breast cancer\u003c/p\u003e\n \u003cp\u003ePostoperative pain\u003c/p\u003e\n \u003cp\u003eDistant metastasis\u003c/p\u003e\n \u003cp\u003eRegular review\u003c/p\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003cp\u003eStage of breast cancer\u003c/p\u003e\n \u003cp\u003ePersonality\u003c/p\u003e\n \u003cp\u003eEmotion regulation ability\u003c/p\u003e\n \u003cp\u003eAnxiety and depression\u003c/p\u003e\n \u003cp\u003eAttitude towards cancer\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSelf-control and self-efficacy\u003c/p\u003e\n \u003cp\u003eSelf-esteem and self-acceptance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAdjusted R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.101(0.062)\u003c/p\u003e\n \u003cp\u003e0.214(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-0.058(0.358)\u003c/p\u003e\n \u003cp\u003e0.214(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.082(0.136)\u003c/p\u003e\n \u003cp\u003e0.055(0.406)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.449664429530202%\" valign=\"top\"\u003e\n \u003cp\u003e0.048(0.272)\u003c/p\u003e\n \u003cp\u003e0.141(0.002) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.013(0.806)\u003c/p\u003e\n \u003cp\u003e0.200(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.064(0.144)\u003c/p\u003e\n \u003cp\u003e0.077(0.153)\u003c/p\u003e\n \u003cp\u003e0.159(0.006) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.031(0.580)\u003c/p\u003e\n \u003cp\u003e-0.257(\u0026lt;0.001) \u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-0.229(0.003) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-0.118(0.076)\u003c/p\u003e\n \u003cp\u003e-0.207(0.005) \u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003cp\u003e0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e**\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/p\u003e\n\u003cp\u003e***\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 mediation effect analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;Figure 1\u0026nbsp;\u003c/strong\u003edemonstrated the result of mediation effect analysis. In this analysis, the score of FoP-Q-SF was taken as dependent variable, the dimension of attitude towards cancer was taken as independent variable, the dimension of anxiety and depression was considered as potential mediation variable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnxiety and depression had shown a mediation effect with statistical significance (\u003cem\u003e\u0026beta;\u003c/em\u003e = -0.0783, \u003cem\u003eBoost\u003c/em\u003e 95% \u003cem\u003eCI\u003c/em\u003e (-0.1646, -0.0157)). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Direct, indirect, and total effects of associated variables on FoP\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003ePathway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e\u003cem\u003eBoot SE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e\u003cem\u003eBoot\u003c/em\u003e 95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003eAttitude towards cancer\u0026quot;Anxiety and depression\u0026quot;FoP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003eDirect effect (c\u0026rsquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003e-0.2954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e0.1087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e(-0.5094, -0.0814)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003eIndirect effect (a*b)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003e-0.0783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e0.0380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e(-0.1646, -0.0157)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003eTotal effect (c)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003e-0.3737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e0.1070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e(-0.5844, -0.1629)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.83388704318937%\"\u003e\n \u003cp\u003eProp. Mediated (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.96345514950166%\"\u003e\n \u003cp\u003e20.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.119601328903654%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.083056478405314%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: Confidence intervals\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur study was conducted based on northeast Chinses population which have a different life pattern and economic situation than those people living in south China or other first-tier cites. Understanding their most frequent worry and the possible association factors for FoP is with quite practical meanings.\u003c/p\u003e \u003cp\u003eThe observed incidence rate of high level of FoP in our study was 37.7%. Based on a systemic review published in 2013\u003csup\u003e10\u003c/sup\u003e, the morbidity of high level of FCR or FoP in breast cancer patients ranges from 22\u0026ndash;78%. This wide interval might be caused by non-uniform questionaries and cut-off value used by different investigators. By now, there exist quiet amount of diverse questionaries which differ in target disease, definition of FCR and cultural background\u003csup\u003e27\u003c/sup\u003e. As far as FoP, which representing the concept of fear of diseases progression, is concerned, it may have an obscurer demarcation between FCR. Thus, confusions might occur when previous investigators were choosing questionaries and calculating incidence rate. However, a recent study which may benefit the later clinical doctors and researchers had indicated that the detailed theoretical constructs and influencing factors of these two concepts might not be exactly the same\u003csup\u003e28\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn a large sample (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1083) research of breast cancer patients\u003csup\u003e29\u003c/sup\u003e, the most frequent worry was \u0026ldquo;Being nervous prior to doctors\u0026rsquo; appointments or periodic examinations\u0026rdquo;. Followed by \u0026ldquo;Being afraid of relying on strangers for activities of daily living\u0026rdquo; and \u0026ldquo;Being afraid of pain\u0026rdquo;. Also, in another study focused on long-term cancer survivors with different types of cancer\u003csup\u003e30\u003c/sup\u003e, the most frequent worry was \u0026ldquo;Being nervous prior to doctors\u0026rsquo; appointments or periodic examinations\u0026rdquo;. However, in our study, the score of the item \u0026ldquo;Worrying that medications could damage the body\u0026rdquo; ranked first among all 12 items of FoP-Q-SF. This finding may be explained by the fact that half (51.751%) the patients in our study received radiation therapy. Radiotherapy can significantly reduce the chance of breast cancer recurrence\u003csup\u003e31\u003c/sup\u003e, so it is widely adopted in clinical practice. Unfortunately, radiotherapy could bring a large number of side effects to patients, causing them to worry\u003csup\u003e32\u003c/sup\u003e. A previous meta-analysis also suggested that the weak correlation between radiotherapy and FoP shall be treated with great caution\u003csup\u003e33\u003c/sup\u003e. In addition, our study was conducted on the postoperative population of breast cancer, 87.825% of the study subjects underwent surgery requiring breasts removing. In Chinese cultural background, breasts are considered an important part of femininity and female confidence. When faced with having to remove breasts, feelings of worry and unease might appear. In terms of educational attainment, the majority (73.541%) of the studied population had only a high school education or less. Inadequate education can create barriers for patients to properly understand the benefits and side effects of surgical and medical treatments.\u003c/p\u003e \u003cp\u003eNoteworthy, age, as a controversial factor in many previous studies\u003csup\u003e10\u003c/sup\u003e, did not show statistical significance in the hierarchical regression analysis until personality and psychological status were included. This might be explained by the potential association between age and personality and psychological status. Namely, the association between age and FoP was masked by personality and psychological status in univariate analyses. Another variable that had shown inconsistent results among the previous studies was the time after operation\u003csup\u003e10\u003c/sup\u003e. A recent study claimed that FoP levels were statistically slightly higher in cancer patients five years after diagnosis than in those ten years after diagnosis\u003csup\u003e30\u003c/sup\u003e. A qualitative study explored how the emotional needs of cancer patients change over time and treatment stages from the level of psychological mechanisms\u003csup\u003e34\u003c/sup\u003e. It indicated that compering with patients newly diagnosed with cancer those who had received a chemotherapy or radiotherapy expressed more need of emotional care. In our study, although time after operation showed a statistically significant between-group difference in ANOVA (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), the result of test of trend was negative (\u003cem\u003eP\u003c/em\u003e \u003csub\u003e\u003cem\u003efor trend\u003c/em\u003e\u003c/sub\u003e = 0.387).\u003c/p\u003e \u003cp\u003eDifferent from the Western social and cultural background, most Chinese parents still have to bear part of the responsibility for raising their children even after they are adults. In particular, women assume the role of raising and caring for their offspring. Thus, after suffering from breast cancer, patients will worry about their families and children. The more the number of children, the stronger the fear.\u003c/p\u003e \u003cp\u003eAccording to Extended Parallel Process Model (EPPM), CSM and other theoretical models used to explain the fear of disease progression\u003csup\u003e35,36\u003c/sup\u003e. When faced with the potential threat of disease progression, patients evaluate the severity of the threat and the strength of their own ability to adapt it. This process is regulated by the individual's cognitive style and attitude towards the disease. Meanwhile, the Self-Regulatory Executive Function (S-REF) model suggested that FCR may have a similar pathway as anxiety\u003csup\u003e37\u003c/sup\u003e, and studies had shown that patients with anxiety have a more sensitive attention tendency to potential threats\u003csup\u003e38,39\u003c/sup\u003e. Based on the above theory, we analyzed the possible mediation effect in the association between attitude towards cancer and FoP. The results suggested that anxiety and depression might be the mediation factor.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Study limitations\u003c/h2\u003e \u003cp\u003eThis research is not a longitudinal study nor a cohort study, a causal interpretation of the proposed relationship among variables cannot be made. Furthermore, the participants were recruited only from a single-study site which limits the generalizability of our findings. Also, some variables that could also potentially influence FoP were not available in our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Clinical implications\u003c/h2\u003e \u003cp\u003eOur findings underscore the importance for clinicians to assist and guide patients in developing a balanced perspective on the necessity and potential drawbacks of surgical and other medical treatments. Special consideration should also be given to patients exhibiting pessimistic personality traits or demonstrating lower psychosocial adaptability.\u003c/p\u003e \u003cp\u003eOur results offer valuable insights into the varied patterns of Fear of Progression across diverse cultural and economic backgrounds which holds the potential to enhance the development of more effective clinical coping strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn summary, our study identified a different pattern of most frequent fear. Age, number of descendants, time after operation, postoperative pain, regular review, personality, anxiety and depression, self-esteem and self-acceptance and attitude had been found as the association factor of FoP among postoperative breast cancer patients. Among these factors, personality and psychological factors have the greatest contribution to FoP. And We also confirm the mediating effect of anxiety and depression in the pathway between attitude towards cancer and FoP.\u003c/p\u003e \u003cp\u003eTherefore, based on our research, we suggest extra care for those breast cancer patients performed with low psychosocial adaptability or negative personality. Correct and positive guidance to enable the patient to face the development and treatment of the disease objectively will also be needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclaration of Competing Interest\u003c/h2\u003e\n\u003cp\u003eThis study was not funded. The authors declare that there were no conflicts of interest with respect to the authorship or the publication of this article.\u003c/p\u003e\n\u003ch2\u003eFormatting of funding sources\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConception \u0026amp; Design: YL.N., Z.L. AND CG.K.Analysis and interpretation of data: SY.W., XH,G AND YL.NDrafting the manuscript: SY.W. AND XH,GCritical revision of the manuscript: Z.L. AND CG.K.Final approval of the manuscript: Z.L. AND CG.K.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray, F., Laversanne, M., Weiderpass, E. \u0026amp; Soerjomataram, I. 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Attentional bias in people with acute versus persistent insomnia secondary to cancer. \u003cem\u003eBehav Sleep Med\u003c/em\u003e \u003cstrong\u003e1\u003c/strong\u003e, 200-212, doi:10.1207/s15402010bsm0104_3 (2003).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"breast cancer, fear of cancer recurrence, fear of progression, oncology, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-3855508/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3855508/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eFear of progression (FoP) is commonly observed in breast cancer patients. It may exist for a period of time even after cancer survivorship. Our study aims at investigating the distribution and associated factors of FoP based on postoperative patients with breast cancer in Northeast China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional study. 257 postoperative patients with breast cancer were recruited using convenience sampling method. Fear of Progression Questionnaire-Short Form was used to evaluated the FoP status of participants. Hierarchic multiple linear regression was applied to identify the independent relevant factors. Mediation effect analysis was conducted to explore the potential pathway between attitude towards cancer and FoP. All \u003cem\u003eP\u003c/em\u003e values were two-tailed. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to represent statical significance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe most frequent fear of the participants was \u0026ldquo;worrying that medications could damage the body\u0026rdquo;. After adjusting for other factors, the following independent variables were identified to be the associated factors for FoP: age, number of descendants, time after operation, postoperative pain, regular review, personality, anxiety and depression, self-esteem and self-acceptance and attitude towards cancer. Moreover, we have confirmed the mediation role of anxiety and depression in the relationship between FoP and attitude towards disease.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eClinicians should help and guide patients to correctly view the necessity and double-sided of operation and medication treatment. Additional attention should also be paid to patients with pessimistic personality or low psychosocial adaptability.\u003c/p\u003e","manuscriptTitle":"Fear of Progression and its Associated Factors among Postoperative Patients with Breast Cancer: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-15 21:02:00","doi":"10.21203/rs.3.rs-3855508/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d08ab9d2-dd8e-4be7-ac5b-922c9d106516","owner":[],"postedDate":"January 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-19T00:14:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-15 21:02:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3855508","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3855508","identity":"rs-3855508","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}