Fertility concerns in reproductive-aged breast cancer patients: Correlation with negative psychology and social relationship quality, and influencing factors

Abstract

BACKGROUND

Patients of reproductive age with breast cancer (BC) experience different degrees of fertility concerns, which may aggravate negative psychological states, compromise social relationships, and hinder condition amelioration.

AIM

To examine fertility concerns in relation to negative psychology and social relationship quality in reproductive-age patients with BC, and analyzed the associated influencing factors.

METHODS

A total of 153 reproductive-aged BC patients (March 2022 to March 2025) were enrolled. All patients completed the Reproductive Concerns After Cancer (RCAC) Scale, Self-Rating Anxiety Scale/Self-Rating Depression Scale (SDS), and Social Relational Quality Scale (SRQS) to assess fertility concerns, negative psychology, and social relationship quality, respectively. Pearson correlation coefficients were used to examine associations between RCAC scores and Self-Rating Anxiety Scale, SDS, and SRQS scores. Uni- and multivariate analyses were performed to identify contributors related to fertility concerns.

RESULTS

The mean total RCAC score was (49.56 ± 6.59), with concerns regarding personal and child’s health being the most prominent. Anxiety was found in 37.91% and depression in 35.95% of the patients, mostly with mild symptoms. The total SRQS score was (45.04 ± 7.04). Fertility concerns were positively correlated with negative psychology and negatively correlated with social relationship quality. Uni- and multivariate analyses indicated that marital status (B = -2.219, P = 0.024), educational level (B = -2.248, P = 0.014), annual income (B = -3.886, P < 0.001), and number of children (B = -2.369, P = 0.011) were independent protective factors for fertility concerns among reproductive-aged BC women, whereas occupational status (B = 2.170, P = 0.018) and SDS (B = 2.958, P = 0.002) were independent risk factors.

CONCLUSION

Fertility concerns patients of reproductive age with BC are significantly correlated with negative psychological states and social relationship quality. Being married, employed, having a high school education or above, having an annual income of < 40000 yuan, having 0-1 children, or experiencing depression increases the risk of fertility concerns in this population.

Key Words: Breast cancer of reproductive age; Fertility concerns; negative psychology; Quality of social relationships; Correlation analysis; Influencing factors

Core Tip: This study enrolled 153 reproductive-aged breast cancer (BC) patients to clarify the relationship between fertility concerns, negative psychology, and social relationship quality, and to explore the influencing factors. The findings indicate that patients of reproductive age with BC generally experience fertility concerns to varying degrees. In clinical practice, attention should be directed toward high-risk groups, including those who are married, employed, highly educated, low-income earners, have few children, or experience depression. Comprehensive intervention strategies - such as fertility preservation consultation, psychological support with partners’ participation, and vocational rehabilitation guidance - are recommended to systematically alleviate fertility-related concerns and improve overall quality of life.

INTRODUCTION

Breast cancer (BC), one of the most common malignancies of the female reproductive system worldwide, accounted for 560000 cases in 2021, with age-standardized incidence rates showing a steady increase[1]. Approximately 15% of patients are diagnosed before menopause and 7% are under 40 years of age, indicating an increasing risk of BC among women of reproductive age[2,3]. Due to treatment-induced reductions in ovarian reserve, amenorrhea, premature ovarian dysfunction, patients with BC often experience impaired fertility and varying degrees of fertility concerns[4,5]. Fertility concerns refer to patients’ worries regarding their reproductive potential and parenting ability, including concerns about personal and child health, uncertainty about pregnancy, and pressure to disclose illness to partners[6]. These concerns may compromise patients’ quality of life and aggravate negative psychological states, potentially affecting subsequent treatment compliance and recovery[7]. Patients with BC generally experience mental health disorders. Emotional disturbances occur in approximately 37% of patients in the early stage, with severe depression observed in approximately 10%, largely due to the life-threatening nature of the disease and treatment-induced declines in quality of life[8]. Social relationships refer to the connections between patients and their family members and friends. High-quality social relationships can help alleviate the concerns about childbirth and reducing associated psychological stress[9,10]. Therefore, complex interactions may exist among fertility concerns, negative psychological states, and social relationship quality in reproductive-aged BC patients. Although social support may sometimes worsen fertility concerns, it may also indirectly ameliorate fertility-related concerns by alleviating negative emotions.

However, fertility concerns in reproductive-aged BC patients, their correlations with negative psychology and social relationship quality, and associated influencing factors remain insufficiently investigated. Further analyses are required to deepen our understanding of these relationships, thereby providing more effective intervention strategies for this patient population.

MATERIALS AND METHODS

Patient information

Inclusion criteria: Pathology-based BC diagnosis[11]; estrogen-dependent BC with positive estrogen receptor expression in carcinomas; age 18-40 years; intact clinical data and good compliance; normal cognitive and communication abilities.

Exclusion criteria: Pre-existing mental disorders (e.g., anxiety, depression, and bipolar disorder); estimated survival < 1 year; infertility or additional malignancies; audiovisual-verbal dysfunction. A total of 153 patients of reproductive age with BC treated in our hospital (March 2022 to March 2025) were strictly screened according to the above inclusion and exclusion criteria. Figure 1 presents the detailed patient screening process.

Figure 1  Patient screening flowchart.

Investigation methods

Clinical data were collected, including age, marital status, occupation status, education level, residence, annual income, number of children, fertility desire, fertility preservation, Self-Rating Anxiety Scale/Self-Rating Depression Scale (SAS/SDS), Social Relational Quality Scale (SRQS), and Reproductive Concerns After Cancer (RCAC) scale. Before the investigation, all team members received unified training to introduce the questionnaire content, research significance, and precautions using standardized guiding language, ensuring that the patients could make independent judgments. During the formal investigation, trained professionals conducted one-on-one, face-to-face interviews to explain the purpose, significance, and composition, and completion requirements of the questionnaire to obtain patient understanding and cooperation. Questionnaires were distributed and completed on site within 30 minutes. For patients unable to complete the forms independently, the researchers read the questions and recorded responses based on the patients’ own choices. After completion, the investigators reviewed each questionnaire item to ensure accuracy and logical consistency before collecting the forms. All data were subsequently entered into the database.

Evaluation indexes

Fertility concern status. The 18-item RCAC (score range: 18-90; Cronbach’s α = 0.849)[12] was used to assess patients’ fertility concerns across six dimensions (Cronbach’s α range: 0.720-0.864): Personal health (influence of fertility on overall health), child’s health (risk of fetal birth defects caused by conception), becoming pregnant (preparatory conditions for optimal pregnancy), fertility potential (ovarian reserve capacity), acceptance (cognition regarding optimal pregnancy and childbearing), and partner disclosure (spousal knowledge and acceptance of reproductive risks). All items were scored using the 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with reverse scoring applied to items 5, 10, and 15. Higher scores indicate greater reproductive concern.

Negative psychology. SAS and SDS[13] were used to evaluate patients’ anxiety and depression, respectively. For SAS (20 items), < 50 points indicate no anxiety, 50-59 indicate mild anxiety, 60-69 indicate moderate anxiety, and ≥ 70 indicate severe anxiety. For SDS, < 53 points indicate no depression, 53-62 indicate mild depression, 63-72 indicate moderate depression, and ≥ 72 indicate severe depression. Raw scores are converted to standard scores, with a total score of 100. Higher scores indicate more severe negative emotions.

Social relationship quality. The 17-item SRQS[14] was used to assess social relationship quality across three dimensions: Family intimacy (7 items, 7-28 points; Cronbach’s α = 0.831), family commitment (5 items, 5-20 points; Cronbach’s α = 0.820), and friendship (5 items, 5-20 points; Cronbach’s α = 0.749). All items used the 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Total scores range from 17 to 68, with higher scores indicating better social relationship quality.

Statistical analysis

SPSS 23.0 software was used for data analysis. Counting data are expressed as n (%). Measurement data passed normality testing and are presented as mean ± SD or median (interquartile range). The two groups were compared using independent samples t-tests. RCAC correlations to SAS, SDS, and SRQS were analyzed using Pearson correlation coefficients. Univariate and multiple linear regression analyses were conducted to explore fertility-associated determinants in patients of reproductive age with BC. Statistical significance was set at P < 0.05.

RESULTS

Fertility concern status in patients of reproductive age with BC

A total of 153 patients of reproductive age with BC were enrolled in this study. The RCAC total score was (49.56 ± 6.59). Dimension scores, ranked from highest to lowest, were personal health 9.00 (7.00, 12.00), child’s health 9.00 (6.00, 11.00), acceptance 8.00 (6.00, 10.00), becoming pregnant 8.00 (6.00, 10.00), fertility potential 8.00 (6.00, 10.00), and partner disclosure 7.00 (5.00, 10.00) (Table 1).

Table 1 Reproductive Concerns After Cancer Scale-based fertility concern assessment in reproductive-aged breast cancer patients.

Indicators	Score
Personal health (points)	9.00 (7.00, 12.00)
Child’s health (points)	9.00 (6.00, 11.00)
Acceptance (points)	8.00 (6.00, 10.00)
Becoming pregnant (points)	8.00 (6.00, 10.00)
Fertility potential (points)	8.00 (6.00, 10.00)
Partner disclosure (points)	7.00 (5.00, 10.00)
RCAC (points)	49.56 ± 6.59

RCAC: Reproductive Concerns After Cancer.

Negative psychology in patients of reproductive age with BC

SAS and SDS scores were (47.99 ± 6.59) and (50.32 ± 5.85), respectively. Anxiety and depression prevalence were 37.91% and 35.95%, respectively. Most of the affected patients exhibited mild symptoms (Table 2).

Table 2 Negative psychology evaluation of reproductive-aged breast cancer patients by Self-Rating Anxiety Scale and Self-Rating Depression Scale, n (%).

Indicators	Score
SAS (points), mean ± SD	47.99 ± 6.59
No anxiety	95 (62.09)
Mild anxiety	50 (32.68)
Moderate anxiety	8 (5.23)
Anxiety rate	58 (37.91)
SDS (points)	50.32 ± 5.85
No depression	98 (64.05)
Mild depression	53 (34.64)
Moderate depression	2 (1.31)
Depression rate	55 (35.95)

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Social relationship quality in patients of reproductive age with BC

The total SRQS score was 45.04 ± 7.04, with subscale scores of 12.28 ± 3.25 for friendship, 19.00 (17.00, 23.00) for family intimacy, and 13.33 ± 3.31 for family commitment (Table 3).

Table 3 Evaluation of social relationship quality of reproductive-aged breast cancer patients by Social Relational Quality Scale, mean ± SD.

Indicators	Score
Friendship (points)	12.28 ± 3.25
Family intimacy (points), median (interquartile range)	19.00 (17.00, 23.00)
Family commitment (points)	13.33 ± 3.31
SRQS (points)	45.04 ± 7.04

SRQS: Social Relational Quality Scale.

Pearson correlation analysis

Pearson’s r analysis showed that RCAC was positively correlated with SAS (r = 0.415) and SDS (r = 0.437) and negatively correlated with SRQS (r = -0.427; all P < 0.05; Figure 2).

Figure 2 The correlation of fertility concerns with negative psychological and social relationship quality. A: Reproductive Concerns After Cancer-Self-Rating Anxiety Scale correlation; B: Reproductive Concerns After Cancer-Self-Rating Depression Scale correlation; C: Reproductive Concerns After Cancer-Self- Social Relational Quality Scale correlation. RCAC: Reproductive Concerns After Cancer; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SRQS: Social Relational Quality Scale.

Univariate and multivariate analyses

Univariate analysis showed no significant correlations between fertility concerns and age, residential area, fertility preservation, SAS, or SRQS (P > 0.05). Significant correlations were observed with marital status, occupational status, educational level, annual income, number of children, fertility desire, and SDS (P < 0.05; Table 4).

Table 4 Univariate analysis, mean ± SD/median (interquartile range).

Indicators	n	RCAC (points)	t/Z	P value
Age (years)			0.027	0.979
< 30	105	49.57 ± 6.12
≥ 30	48	49.54 ± 7.59
Marital status			1.991	0.048
Married	107	50.25 ± 6.84
Single	46	47.96 ± 5.71
Employment status			-5.700	< 0.001
Unemployed	87	47.00 (43.00, 52.00)
Employed	66	53.00 (50.00, 56.00)
Educational level			5.431	< 0.001
Senior high school or above	83	52.00 ± 5.60
Below senior high school	70	46.67 ± 6.54
Residence			0.636	0.526
Rural	51	49.08 ± 6.75
Urban	102	49.80 ± 6.53
Annual income (in ten thousand yuan)			2.905	0.004
< 4	76	51.08 ± 6.50
≥ 4	77	48.06 ± 6.36
Number of children			2.631	0.009
0-1	62	51.23 ± 7.00
≥ 2	91	48.43 ± 6.07
Fertility desire			-3.488	0.002
Yes	46	53.00 (49.50, 55.50)
No	107	48.00 (44.00, 53.00)
Fertility preservation			0.383	0.702
Yes	15	48.07 ± 8.56
No	138	49.72 ± 6.36
SAS (points)			0.191	0.849
< 50	95	49.64 ± 6.21
≥ 50	58	49.43 ± 7.22
SDS (points)			-4.689	< 0.001
< 53	98	48.00 (43.00, 53.00)
≥ 53	55	53.00 (50.00, 57.00)
SRQS (points)			0.938	0.350
< 45	75	49.05 ± 5.91
≥ 45	78	50.05 ± 7.19

RCAC: Reproductive Concerns After Cancer; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SRQS: Social Relational Quality Scale.

Multiple linear regression analysis confirmed model significance (F = 11.298, P < 0.001), explaining 32.2% of the total variance (adjusted R² = 0.322). Variance inflation factor of all independent variables was < 2, indicating no multicollinearity problem in the model. The analysis results indicated that marital status (B = -2.219, P = 0.024), educational level (B = -2.248, P = 0.014), annual income (B = -3.886, P < 0.001), and number of children (B = -2.369, P = 0.011) were independent protective factors of fertility concerns. Occupational status (B = 2.170, P = 0.018) and SDS (B = 2.958, P = 0.002) were independent risk factors. Notably, annual income showed the largest standardized coefficient in absolute terms (Beta = -0.296), indicating the strongest negative correlation with fertility concerns. Fertility desire was not independently correlated with fertility concerns (P = 0.504; Table 5).

Table 5 Multivariate analysis.

Indicators	Unstandardized coefficient		Standardized beta coefficient	t	P value	95%CI for B
	B	SE				Lower bound	Upper bound
Marital status	-2.219	0.972	-0.155	-2.283	0.024	-4.139	-0.298
Employment status	2.170	0.907	0.164	2.392	0.018	0.378	3.962
Educational level	-2.248	0.900	-0.171	-2.498	0.014	-4.027	-0.470
Annual income	-3.886	0.919	-0.296	-4.226	< 0.001	-5.703	-2.068
Number of children	-2.369	0.924	-0.177	-2.565	0.011	-4.195	-0.544
Fertility desire	0.650	0.970	0.045	0.670	0.504	-1.267	2.567
SDS	2.958	0.951	0.216	3.110	0.002	1.078	4.839

CI: Confidence interval; SDS, Self-Rating Depression Scale.

DISCUSSION

This study assumed a close correlation between fertility concerns, negative psychology, and social relationship quality in patients of reproductive age with BC and conducted a verification analysis. The total RCAC score of our cohort (n = 153) was 49.56 ± 6.59, with fertility concerns primarily focused on personal health, child’s health, and acceptance. Therefore, psychological interventions for such patients should be prioritize these domains, with efforts aimed at enhancing their awareness and acceptance of related risks. In addition to the negative effects of disease diagnosis and associated treatment, the elevated fertility concerns observed in this study is also closely related to the strengthened family fertility intentions following the implementation of the two-child policy in China and pressure from traditional social customs[15]. Chen et al[16] reported a 36.00%-64.00% prevalence of fertility concerns among young women with BC. They identified education, full-time employment, and depression severity as contributing factors. Another study reported a mean total RCAC score of 55.84 in young adult women with BC, slightly lower than that observed in our study[17]. This difference may be explained by the inclusion of a broader reproductive-age range in our, including older women who may have a relatively lower desire to have children. Liu et al[18] suggested a possible and certain association between fertility concerns and fear of cancer recurrence among patients of reproductive age with BC.

Negative psychological evaluation showed anxiety and depression prevalence rates of 37.91% and 35.95%, respectively, indicating that anxiety and depression are common psychological burdens in this population. The mean SAS and SDS scores were 47.99 ± 6.59 and 50.32 ± 5.85, respectively, suggesting generally mild anxiety and depression; however, the scores approached clinical thresholds, requiring clinical attention. These findings may reflect the dual pressures of cancer treatment and fertility demands faced by patients. Treatment uncertainty and reproductive concerns may further aggravate psychological distress. Tsaras et al[19] reported depression and anxiety risks of 38.20% and 32.20%, respectively, in patients with BC, which are close to our results. The total SRQS score was 45.04 ± 7.04, indicating a moderate level of social relationship quality that requires improvement. Correlation analysis demonstrated that fertility concerns were positively correlated with anxiety and depression and negatively correlated with the quality of social relationships.

Regression analysis indicated that patients of reproductive age with BC who are married, employed, have a high school education or above, annual income < 40000 yuan, 0-1 children, or depression are at a high risk of fertility concerns. Specifically, married patients may experience stronger family demands regarding childbearing, increasing are psychological pressure and coercion. Employed patients considering their own development needs, income, and social status, may face multiple pressures, elevating fertility concerns. Patients with a high school education or above are more likely to independently access medical information and better understand treatment risks and prognostic implications, potentially leading to pessimism and aggravated fertility concerns. Those with an annual income < 40000 yuan may experience difficulties in making reproductive decisions due to significant economic pressure, a heavier family burden, and a lower ability to withstand risks, heightening their fertility concerns. Influenced by traditional culture and family expectations, patients with 0-1 child may experience stronger reproductive pressure and thus experience higher levels of concern. Depressed patients may exhibit helplessness and cognitive bias, further intensifying reproductive concerns. Rodriguez-Wallberg et al[20] found that desire for future children, anxiety, and low self-efficacy were independently associated with childbirth-related pain in patients of reproductive age with cancer, complementing this study’s results.

Several limitations in this study should be acknowledged. First, this was a single-center study; future multi-center studies are needed to improve generalizability. Second, only BC patients of childbearing age were enrolled, without healthy controls or patients with non-fertility-related for comparison. Future studies should expand sample size and incorporate comparative groups to more comprehensively characterize the specificity of fertility concerns in patients of reproductive age with BC.

CONCLUSION

In summary, patients od reproductive age with BC experience different levels of fertility concerns influenced by multiple factors. Clinically, comprehensive intervention programs should be targeted toward high-risk groups (married, employed, high school education or above, annual income < 40000 yuan, 0-1 child, and depressed), including fertility preservation counseling, partner-inclusive psychological support, and vocational rehabilitation guidance.