Association between postoperative anxiety and depression symptoms and willingness for breast reconstruction in breast cancer patients

Abstract

BACKGROUND

Breast cancer is the most frequently diagnosed malignancy in females globally, and total mastectomy commonly initiates substantial anxiety and depression symptomatology. Although previous studies have mainly evaluated breast reconstruction as a psychological intervention that achieves superior psychosocial outcomes, relatively limited research has investigated postoperative psychological distress as an influential factor in shaping patients’ cognition, attitudes and acceptance of reconstruction after mastectomy (especially from the perspective of Chinese patients, where a low rate of radical mastectomy being followed by immediate or delayed breast recon.

AIM

To investigate the prevalence of postoperative anxiety and depression symptoms in breast cancer patients and explore its associations with willingness, cognition, and attitudes toward breast reconstruction to provide evidence for improving mental health and quality of life.

METHODS

A total of 112 breast cancer patients receiving surgical management in Tianjin Medical University Cancer Institute and Hospital between October 2023 to October 2024 were enrolled in this retrospective study. The study utilized the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) to measure anxiety and depression symptoms. Concurrently, patients Search of demand knowledge and comprehension based on breast reconstruction operative was explored. To analyze the correlations between anxiety-depression symptoms and willingness for breast reconstruction and their influencing factors, Pearson correlation analysis, multiple linear regression and multivariate logistic regression were performed.

RESULTS

Among 112 patients, the prevalence of anxiety symptoms was 42.86% (48/112), depression symptoms 39.29% (44/112), and anxiety-depression comorbidity 28.57% (32/112). The SAS score was 46.25 ± 10.82, and the SDS score was 48.73 ± 11.35. The cognition score for breast reconstruction was 18.73 ± 4.72, the attitude score was 44.82 ± 8.83, and the reconstruction intention rate was 32.14%. Correlation analysis showed that the SAS score was negatively correlated with the cognition score (r = -0.412, P < 0.01) and attitude score (r = -0.386, P < 0.01); the SDS score was negatively correlated with cognition score (r = -0.435, P < 0.01) and attitude score (r = -0.402, P < 0.01). Multiple regression analysis showed that anxiety-depression scores were independent negative influencing factors for cognition and attitude (P < 0.05). Logistic regression showed that anxiety score [odds ratio (OR) = 0.876, 95% confidence interval (CI): 0.812-0.945], cognition score (OR = 1.193, 95%CI: 1.040-1.461), and attitude score (OR = 1.340, 95%CI: 1.098-1.792) were independent predictors for reconstruction intention.

CONCLUSION

The prevalence of anxiety and depression symptoms in breast cancer patients after total mastectomy is high. Anxiety and depression symptoms are significantly associated with lower cognition levels and more negative attitudes, and demand for breast reconstruction. The more severe the anxiety and depression, the lower the cognition, the more negative the attitude, and the lower the willingness for reconstruction. Clinical practice should emphasize the assessment and intervention of mental health in breast cancer patients. Improving anxiety and depression symptoms may help enhance patients’ cognition and acceptance of breast reconstruction, ultimately improving quality of life.

Key Words: Breast cancer; Anxiety; Depression; Breast reconstruction; Cognition; Attitude; Mental health

Core Tip: Postoperative anxiety and depression are highly prevalent among breast cancer patients after total mastectomy and are strongly associated with reduced willingness for breast reconstruction. This study demonstrates that anxiety and depression negatively affect patients’ cognition and attitudes toward breast reconstruction, which in turn diminishes reconstruction intention. Patients with anxiety-depression comorbidity show the most pronounced decline. These findings highlight mental health as a modifiable factor in reconstruction decision-making and underscore the importance of integrating psychological assessment and intervention into routine breast cancer care to improve reconstruction acceptance and overall quality of life.

INTRODUCTION

Breast cancer is the most common malignant tumor among women globally, with approximately 2 million new cases annually and showing a trend toward younger age[1,2]. The management of the disorder is total mastectomy, which remains the most commonly adopted surgical approach as over 70% of patients undergo this surgery[3]. But breast loss not only impairs secondary sexual characteristics of women but also poses a huge psychological crisis to the patients. The accompanying symptoms of anxiety and depression are even more pronounced than those of the malignant tumor itself[4,5]. In breast cancer, a comparison of the baseline relationship and symptom or quality life between breast cancer patients as compared with that of the general population evidenced that there had been marked an extremely high incidence rate of develop anxiety and depression symptoms[6]. Breast loss has a considerable impact on patients’ body image, self-esteem and self-confidence, and hence causes a great psychological distress[7,8]. The existing literature has focused largely on the former-namely, breast reconstruction as an intervention that can improve psychological outcomes; however, a much smaller body of work has examined this question in reverse by addressing how patients’ postoperative psychological states (such as anxiety and depression), influence patient reflections on and interest in undergoing-breast reconstruction following mastectomy[9]. Anxiety and depression symptoms not only affect patients’ treatment compliance and recovery process but may also directly impact patients’ cognitive ability, attitude formation, and decision-making process regarding breast reconstruction. Patients with anxiety and depression often exhibit cognitive bias, negative thinking, and decision-making difficulties, which may lead to insufficient cognition and negative attitudes toward breast reconstruction, thereby missing opportunities to improve quality of life[10].

Breast reconstruction surgery is an effective measure to improve physical appearance and restore physical and mental health[11]. Research confirms that breast reconstruction does not increase the risk of recurrence or metastasis; rather, it is closely related to improvements in quality of life, body image, sexual behavior, and emotional health[12]. The post-reconstruction rate of breast cancer patients in the United States has exceeded 50%[13,14], but the reconstruction rate in China remains at a relatively low level[15]. Currently, research on the relationship between anxiety-depression symptoms and willingness for breast reconstruction is relatively limited. Previous studies have mostly focused on the improving effect of breast reconstruction on psychology, while less attention has been paid to how preoperative anxiety and depression status affect patients’ cognition and decision-making regarding breast reconstruction. If anxiety and depression symptoms indeed reduce patients’ cognition and acceptance of breast reconstruction, then preoperative psychological intervention may become a key strategy for improving reconstruction rates and improving patient outcomes. Therefore, this study aims to investigate the occurrence of postoperative anxiety and depression symptoms in breast cancer patients and their correlations with breast reconstruction cognition, attitudes, and demand, providing a scientific basis for formulating targeted psychological intervention measures.

MATERIALS AND METHODS

Study design and participants

This study employed a retrospective design and collected data from 112 breast cancer patients at the Breast Surgery Department of Tianjin Medical University Cancer Institute and Hospital from October 2023 to October 2024. Inclusion criteria: (1) Female patients with first-time diagnosed breast cancer; (2) Patients requiring total mastectomy; (3) Age ≥ 18 years; and (4) Ability to independently complete questionnaire surveys. Exclusion criteria: (1) Patients requesting breast-conserving surgery; (2) Patients unable to participate in surveys due to visual, auditory, or cognitive impairments; (3) Patients with other malignant tumors; (4) Patients with abnormal function of vital organs; and (5) Patients with a history of mental illness or currently taking psychiatric medications. This study was approved by the Ethics Committee, and all patients provided informed consent.

Mental health assessment

The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used to assess patients’ anxiety and depression symptoms[16]. The SAS contains 20 items using a 4-point Likert scale, with a standard score ≥ 50 indicating anxiety symptoms (50-59 mild, 60-69 moderate, ≥ 70 severe). The SDS also contains 20 items, with a standard score ≥ 53 indicating depression symptoms (53-62 mild, 63-72 moderate, ≥ 73 severe). Both scales have good reliability and validity in the Chinese population[17], with Cronbach’s α coefficients of 0.89 and 0.88 in this study, respectively.

Breast reconstruction cognition and attitude assessment

The “survey questionnaire on demand, cognition, and attitude toward breast reconstruction surgery” was used for assessment[18]. The cognition questionnaire includes 6 items (total score 6-30), assessing patients’ understanding of breast reconstruction. The attitude questionnaire includes 15 items (total score 15-75, including negative and positive attitude items), assessing patients’ attitude tendencies toward breast reconstruction. A 5-point Likert scale was used, with higher scores indicating better cognitive level and more positive attitudes. The Cronbach’s α coefficients of the questionnaires were 0.89 and 0.87, respectively.

Statistical analysis

SPSS 26.0 statistical software was used. Measurement data were expressed as mean ± SD, and a t-test or analysis of variance was used to compare differences between groups. Count data were expressed as a n (%), and the χ² test was used. Pearson correlation analysis was used to explore the correlations between anxiety-depression scores and breast reconstruction cognition and attitudes. Multiple linear regression was used to analyze the influencing factors of anxiety-depression symptoms, cognition, and attitudes. Multivariate logistic regression was used to analyze influencing factors of breast reconstruction intention[19]. For multivariate models, variables with P < 0.1 in univariate analysis or of prior clinical relevance were entered into the initial models. Given that 36 patients reported reconstruction intention with five predictors in the logistic model, the events-per-variable ratio approximates 7, which falls at the lower boundary of conventional recommendations; findings should therefore be interpreted with appropriate caution and replicated in larger samples. Because multiple correlation and regression analyses were conducted, no formal correction for multiple comparisons (e.g., Bonferroni) was applied, and results at the P < 0.05 threshold should be treated as exploratory. P < 0.05 was considered statistically significant.

RESULTS

General characteristics of study participants

A total of 112 breast cancer patients were enrolled, with a mean age of 52.83 ± 5.92 years and BMI of 23.98 ± 6.02 kg/m². Married patients numbered 96 (85.71%), those with bachelor’s degree or above 28 (25.00%), employed patients 52 (46.43%), and urban residents 64 (57.14%). Patients with smoking history numbered 12 (10.71%), drinking history 18 (16.07%), comorbid chronic diseases 36 (32.14%), and family history of breast cancer 8 (7.14%) (Table 1).

Table 1 General characteristics of study participants, n (%).

Characteristics	Statistics
Age (years)	52.83 ± 5.92
BMI (kg/m2)	23.98 ± 6.02
Gender - female	112 (100.0)
Marital status - married	96 (85.71)
Education - Bachelor’s or above	28 (25.00)
Employed	52 (46.43)
Urban residents	64 (57.14)
Smoking history	12 (10.71)
Drinking history	18 (16.07)
Comorbid chronic diseases	36 (32.14)
Family history of breast cancer	8 (7.14)

BMI: Body mass index.

Prevalence of anxiety and depression symptoms in breast cancer patients

The SAS score of 112 patients was 46.25 ± 10.82, and the SDS score was 48.73 ± 11.35. According to diagnostic criteria, the prevalence of anxiety symptoms was 42.86% (48/112), including mild anxiety in 36 patients (32.14%), moderate in 10 patients (8.93%), and severe in 2 patients (1.79%). The prevalence of depression symptoms was 39.29% (44/112), including mild depression in 32 patients (28.57%), moderate in 10 patients (8.93%), and severe in 2 patients (1.79%). The prevalence of anxiety-depression comorbidity was 28.57% (32/112) (Table 2).

Table 2 Prevalence of anxiety and depression symptoms, n (%).

Psychological symptoms	Score	Prevalence
Anxiety symptoms (SAS)	46.25 ± 10.82	48 (42.86)
Mild anxiety		36 (32.14)
Moderate anxiety		10 (8.93)
Severe anxiety		2 (1.79)
Depression symptoms (SDS)	48.73 ± 11.35	44 (39.29)
Mild depression		32 (28.57)
Moderate depression		10 (8.93)
Severe depression		2 (1.79)
Anxiety-depression comorbidity		32 (28.57)

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

Comparison of patient characteristics between anxiety and non-anxiety groups

Patients were divided into the anxiety group (n = 48) and the non-anxiety group (n = 64) based on the SAS score. In terms of mental health, the SDS score in the anxiety group (56.42 ± 9.87) was significantly higher than that in the non-anxiety group (42.94 ± 8.26) (P < 0.001), indicating that anxiety and depression symptoms often coexist. The prevalence of depression symptoms in the anxiety group was 75.00% (36/48), significantly higher than 12.50% (8/64) in the non-anxiety group (P < 0.001). Regarding breast reconstruction indicators, the cognition score in the anxiety group (15.83 ± 4.26) was significantly lower than that in the non-anxiety group (20.88 ± 3.95) (P < 0.001). The attitude score in the anxiety group (39.67 ± 7.84) was significantly lower than that in the non-anxiety group (48.75 ± 7.62) (P < 0.001). The proportion of patients with reconstruction intention in the anxiety group was 16.67% (8/48), significantly lower than 43.75% (28/64) in the non-anxiety group (P = 0.027). These results indicate that anxiety symptoms significantly reduced patients’ cognitive level, positive attitudes, and willingness for breast reconstruction (Table 3).

Table 3 Comparison of patient characteristics between anxiety and non-anxiety groups, n (%).

Indicators	Anxiety group (n = 48)	Non-anxiety group (n = 64)	P value
SDS score	56.42 ± 9.87	42.94 ± 8.26	< 0.001
Depression prevalence	36 (75.00)	8 (12.50)	< 0.001
Cognition score	15.83 ± 4.26	20.88 ± 3.95	< 0.001
Attitude score	39.67 ± 7.84	48.75 ± 7.62	< 0.001
Reconstruction intention	8 (16.67)	28 (43.75)	0.027
Mean age (years)	54.67 ± 5.38	51.50 ± 5.94	0.036

SDS: Self-Rating Depression Scale.

Comparison of breast reconstruction cognition and attitudes among patients with different psychological states

Patients were divided into a normal group (n = 40), an anxiety-only group (n = 16), a depression-only group (n = 12), and an anxiety-depression comorbidity group (n = 32). Cognition scores showed a significant gradient change: Normal group (22.35 ± 3.42) > anxiety-only group (18.25 ± 3.86) > depression-only group (17.83 ± 4.12) > anxiety-depression comorbidity group (14.19 ± 3.75) (F = 18.74, P < 0.001). Attitude scores also showed a gradient change: Normal group (50.85 ± 6.92) > anxiety-only group (42.75 ± 7.34) > depression-only group (41.67 ± 7.89) > anxiety-depression comorbidity group (36.25 ± 6.58) (F = 16.92, P < 0.001). Reconstruction intention rate: Normal group 55.00% > anxiety-only group 25.00% > depression-only group 16.67% > anxiety-depression comorbidity group 6.25% (P = 0.005). This clearly demonstrates the negative impact of anxiety and depression symptoms on patients’ breast reconstruction cognition, attitudes, and demand, with the most severe impact on comorbid patients (Table 4).

Table 4 Comparison of breast reconstruction cognition and attitudes among patients with different psychological states.

Indicators	Normal (n = 40)	Anxiety-only (n = 16)	Depression-only (n = 12)	Comorbidity (n = 32)	P value
Cognition score	22.35 ± 3.42	18.25 ± 3.86	17.83 ± 4.12	14.19 ± 3.75	< 0.001
Attitude score	50.85 ± 6.92	42.75 ± 7.34	41.67 ± 7.89	36.25 ± 6.58	< 0.001
Reconstruction intention (%)	55.00	25.00	16.67	6.25	0.005
SAS score	42.15 ± 6.23	54.38 ± 4.12	43.67 ± 5.89	59.88 ± 8.45	< 0.001
SDS score	44.23 ± 5.67	46.85 ± 6.12	56.92 ± 7.34	61.45 ± 9.12	< 0.001

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

Correlation analysis between anxiety-depression scores and breast reconstruction cognition and attitudes

Pearson correlation analysis showed that the SAS score was significantly negatively correlated with cognition score (r = -0.412,P = 0.002) and attitude score (r = -0.386, P = 0.003). SDS score was significantly negatively correlated with cognition score (r = -0.435, P = 0.001) and attitude score (r = -0.402, P = 0.002). This indicates that the more severe the patients’ anxiety and depression, the lower their cognitive level regarding breast reconstruction and the more negative their attitudes (Table 5). In the anxiety-depression comorbidity group, the correlation was more significant: SAS score with cognition score r = -0.528 (P = 0.034), with attitude score r = -0.491 (P = 0.051, approaching statistical significance); SDS score with cognition score r = -0.562 (P = 0.022), with attitude score r = -0.517 (P = 0.041). This suggests that in comorbid patients, the negative impact of psychological symptoms on breast reconstruction cognition and attitudes is more pronounced, possibly requiring more aggressive psychological intervention.

Table 5 Correlation analysis between anxiety-depression scores and breast reconstruction cognition and attitudes.

Variables	Cognition score	Attitude score
SAS score	r = -0.412, P = 0.002b	r = -0.386, P = 0.003b
SDS score	r = -0.435, P = 0.001b	r = -0.402, P = 0.002b
Age	r = -0.325, P = 0.014a	r = -0.298, P = 0.025a
Education level	r = 0.418, P = 0.001b	r = 0.385, P = 0.003b
Employment status	r = 0.312, P = 0.018a	r = 0.341, P = 0.012a

^aP < 0.05.

^bP < 0.01.

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

Multiple linear regression analysis of the influencing factors of anxiety and depression symptoms

Multiple linear regression analysis with SAS score as the dependent variable showed (F = 32.86, P < 0.001, adjusted R² = 0.742): Age (β = 0.412, P = 0.003) and lymph node metastasis (β = 3.758, P = 0.024) were risk factors for anxiety; employment status (β = -4.327, P = 0.012), bachelor’s degree or above (β = -5.186, P = 0.007), and urban residence (β = -3.942, P = 0.018) were protective factors. Multiple linear regression analysis with SDS score as the dependent variable showed (F = 28.94, P < 0.001, adjusted R² = 0.716): Age (β = 0.387, P = 0.006) and comorbid chronic diseases (β = 4.023, P = 0.028) were risk factors for depression; employment status (β = -4.681, P = 0.009), bachelor’s degree or above (β = -5.524, P = 0.005), and urban residence (β = -4.215, P = 0.014) were protective factors (Figure 1).

Figure 1 Multiple linear regression analysis of factors influencing postoperative anxiety and depression in breast cancer patients following total mastectomy. A: Influencing factors of anxiety; B: Influencing factors of depression. Orange circles indicate risk factors (β > 0) and purple circles indicate protective factors (β < 0). Standardized beta coefficients (β) with corresponding P-values are shown for each variable. Both models demonstrated good fit (A: F = 32.86, P < 0.001, adjusted R² = 0.742; B: F = 28.94, P < 0.001, adjusted R² = 0.716). SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Analysis of influencing factors of breast reconstruction cognition and attitudes

Regression analysis of cognition score showed (F = 42.78, P < 0.001, adjusted R² = 0.826): Age had a negative impact on cognition (β = -0.128, P = 0.042); monthly family income ≥ 20000 yuan (β = 0.204, P = 0.018), bachelor’s degree or above (β = 0.372, P = 0.001), and urban residence (β = 0.402, P < 0.001) were promoting factors; SAS score had a significant negative impact on cognition (β = -0.186, P = 0.006), and SDS score also had a negative impact on cognition (β = -0.195, P = 0.004). Regression analysis of attitude score showed (F = 38.64, P < 0.001, adjusted R² = 0.802): Employment status (β = 0.234, P = 0.008), bachelor’s degree or above (β = 0.209, P = 0.014), and urban residence (β = 0.283, P = 0.002) were promoting factors; SAS score had a significant negative impact on attitude (β = -0.172, P = 0.012), and SDS score also had a negative impact on attitude (β = -0.188, P = 0.008). This confirms that after controlling for other factors, anxiety and depression symptoms remain independent predictors for patients' breast reconstruction cognition and attitudes (Figure 2).

Figure 2 Comparison of standardized beta coefficients for factors influencing anxiety (Self-Rating Anxiety Scale, blue) and depression (Self-Rating Depression Scale, orange) symptoms. Positive β values indicate risk factors, and negative β values indicate protective factors. Lymph node metastasis and comorbid chronic diseases were identified as risk factors, while employment status, bachelor’s degree or above, and urban residence were protective factors for both anxiety and depression (Self-Rating Anxiety Scale: F = 32.86, R² = 0.742; Self-Rating Depression Scale: F = 28.94, R² = 0.716). SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Logistic regression analysis of influencing factors of breast reconstruction intention

Logistic regression analysis with whether there was breast reconstruction intention as the dependent variable was performed (χ² = 38.72, P < 0.001, Nagelkerke R² = 0.658). Results showed: Age was negatively associated with willingness for breast reconstruction [odds ratio (OR) = 0.893, 95% confidence interval (CI): 0.834-0.972, P = 0.007]; SAS score was a protective factor (OR = 0.876, 95%CI: 0.812-0.945, P < 0.001), with each 1-point increase in anxiety score, the likelihood of having reconstruction intention decreased by 12.4%; cognition score was a risk factor (OR = 1.193, 95%CI: 1.040-1.461, P = 0.015); attitude score was a risk factor (OR = 1.340, 95%CI: 1.098-1.792, P = 0.006) (Table 6). It is noteworthy that the SDS score did not enter the final model (P = 0.124), which may be due to strong collinearity between the SAS and SDS scores (r = 0.782, P < 0.001). This suggests anxiety and depression symptoms often coexist and have a synergistic negative impact on breast reconstruction intention.

Table 6 Logistic regression analysis of influencing factors of breast reconstruction intention¹.

Variables	β	OR	95%CI	P value
Age	-0.114	0.893	0.834-0.972	0.007
SAS score	-0.132	0.876	0.812-0.945	< 0.001
Cognition score	0.176	1.193	1.040-1.461	0.015
Attitude score	0.293	1.340	1.098-1.792	0.006
Education level	0.198	1.219	1.056-1.407	0.007

¹Model statistics: χ² = 38.72, P < 0.001; Hosmer-Lemeshow test: χ² = 5.84, P = 0.665; Nagelkerke R² = 0.658.

SAS: Self-Rating Anxiety Scale; OR: Odds ratio; CI: Confidence interval.

DISCUSSION

This simply retrospective study discovered a relatively higher prices of anxiousness and despair signs in breast cancer sufferers after complete mastectomy (anxiety 42.86%; depression 39.29%; comorbidity 28.57%) than the final inhabitants. More notably, this study provided a systematic demonstration of a powerful negative correlation between anxiety-depression symptoms and breast reconstruction cognition, attitudes and demands in patients for the first time. Severe anxiety and depression results in relative lower cognitive level of the patients concerning breast reconstruction, negative attitude and poor willingness for reconstruction. The clinical relevance of this finding was also clear, as preoperative mental health assessment and intervention may represent a key opportunity to improve reconstruction rates and ultimately patient outcomes.

Several perspectives can largely explain the high levels of anxiety and depression identified in this study. In psychosocial terms, loss of a breast attacks patients’ body integrity, damage their sex appeal as well as feminine identity and may contribute to body image disturbance and low self-esteem[20,21]. Neurobiologically, in the cancer situation, activation of hypothalamic-pituitary-adrenal axis brings about elevated cognate corticoid secretion. Hippocampal atrophy and reduced neuroplasticity are crucial mechanisms in the pathophysiology of depression, which is associated with chronic elevation of cortisol[22]. In-terms of inflammation, cancer and its treatment leads to self-perpetuating inflammatory responses, and high levels of pro-inflammatory cytokines can evoke depressive symptoms by altering neurotransmitter metabolism[23,24].

Data support a sequential, mutually reinforcing mechanistic pathway over parallel independent effects. Anxiety preferentially channels attentional resources towards surgical risk and adverse outcomes, a closely studied threat-related attentional bias[25], while at the same time exhausting cognitive bandwidth for processing reconstructive information dispassionately. Clinically, this finding is represented in our sample with the high levels of fear about cancer prognosis (91.67%) and uncertainty about surgery success rates (87.50%). At multiple levels depression is superimposed: Impaired concentration and memory (66.67% reported difficulty concentrating while 77.27% complained of fatigue[26]) limits the patient ability to integrate new information, while an Hedonia and reduced motivation suppressed the need to seek out reconstructive options[27]. At the schema level, core beliefs of hopelessness - particularly pessimism about the future (68.18%) and reduced self-evaluation (72.73%) - weaken expectations regarding benefits of reconstruction before attitudinal deliberation[28,29]. More importantly, the mechanisms do not act in isolation: Anxiety-driven attentional bias corrupts the information environment, depression-driven cognitive impairment restricts processing capacity, and negative schemata inhibit motivational engagement - each step escalating to the next stage of disillusion with attitudes; and yielding the large attitude deficits we observe in the anxiety, depression comorbidity group (attitude score 36.25 ± 6.58 vs normal group 50.85 ± 6.92)[30].

Logistic regression revealed a mediating mechanism: Anxiety score itself is a protective factor (negative impact) for reconstruction intention, while cognition and attitude scores are risk factors (positive impact). This suggests anxiety-depression symptoms may affect reconstruction intention through direct and indirect pathways[31]. In the direct pathway, anxiety-depression symptoms cause patients to lack motivation to pursue an improved quality of life. In the indirect pathway, anxiety and depression first reduce cognition and attitudes, and low cognition and negative attitudes further reduce reconstruction intention. This finding has important implications for clinical practice: Merely providing reconstruction information may not be sufficient to improve reconstruction rates; anxiety and depression symptoms must be improved simultaneously.

The mechanistic account above has direct implications for clinical practice that extend beyond general recommendations for psychological support. Because anxiety and depression appear to distort information processing prior to attitude formation and because our logistic model demonstrates that attitudes, in turn, mediate reconstruction intention - the sequencing of clinical intervention is critical: Psychological assessment and treatment must logically precede, rather than merely accompany, the delivery of reconstructive information[32]. This means that routine preoperative SAS and SDS screening must be not an add-on, but a gate-keeping stage linking patients identified as high risk with evidence-based psychological intervention (e.g., cognitive bias modification to alleviate negative schemata[33] or mindfulness-based stress reduction to restore capacity for regulatory functions[34]) before reconstructive therapeutic counseling commences. The approach therefore is individualized, staged health education (stages of change)-a direct consequence of the cognitive resource depletion mechanism: Patients whose processing capacity is compromised by depression are unable to absorb comprehensive reconstruction information delivered all at once, requiring graduated, capacity-matched delivery[35]. Finally, as our data identify age[36], low education[37], rural residence and limited income[38,39] as independent correlates of greater psychological distress and poorer reconstruction cognition, a multidisciplinary team including breast surgeons, plastic surgeons, psychological counselors and special nurses - should provide additional targeted support to these subgroups whose attitudinal and cognitive deficits are compounded by structural disadvantage[40]. So all the recommendations that follow are not separate recommendations, but rather be evidence-based consequences to an actionable pathway from a specific identified pathway corresponding part in the anxiety-depression-cognition-attitude-demand chain. These results build on earlier findings, as they illustrate an inverse pathway from psychological distress to reconstruction decision making.

Limitations

There are some limitations to this study that deserve attention. While this is an important study, there are limitations: First, the cross-sectional design, a retrospective survey, inherently precludes any ascertainment of causal or temporal associations between psychological measure and reconstruction perception, and the entire discussion has been adjusted throughout to reflect that these findings should be viewed associatively rather than predictively. Second, the single-center design of a tertiary oncology hospital may have enrolled a more medically complex patient population that would be seen in lower-resource or community settings and limit generalizability. Next steps should utilize large-sample, multicenter prospective designs with formal reconstruction candidacy assessment, oncological staging variables and long-term follow-up on actual receipt of rebuilding.

CONCLUSION

It can effectively improve patients’ anxiety and depression symptoms, cognitive level and attitude to breast reconstruction, promote the acceptance of breast reconstruction in the short term, and ultimately change the body image of breast cancer patients from “survival” to “living”, improve self-esteem or self-confidence quality of life.