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Oncology
Original research
Contribution of coping style to the association between illness uncertainty and demoralisation in patients with breast cancer: a cross-sectional mediation analysis
  1. Ran Hao1,
  2. Meng Zhang1,2,
  3. Jinfan Zuo1,
  4. Yixin Qi3,
  5. Jie Hu4
  1. 1School of Nursing, Hebei Medical University, Shijiazhuang, Hebei, China
  2. 2Critical Medicine, Hospital of Qingdao University, Qingdao, Shandong, China
  3. 3Department of Breast Center, The Fourth Hospital of Hebei Medical University Cancer Institute, Shijiazhuang, Hebei, China
  4. 4Department of Science and Technology, Hebei Medical University, Shijiazhuang, Hebei, China
  1. Correspondence to Jie Hu; Hujie{at}hebmu.edu.cn; Yixin Qi; qiyixin{at}hebmu.edu.cn

Abstract

Objective Demoralisation is a common psychological issue in patients with cancer and aggravates depression, reduces the quality of life and even causes suicidal ideation. There is a lack of knowledge about illness uncertainty, coping style and demoralisation in patients with breast cancer. The current study explored the relationship between illness uncertainty and demoralisation among those patients, as well as the potential mediating role of coping style.

Design A cross-sectional study.

Setting Participants were recruited from the Breast Tumor Center in a tertiary hospital in Shijiazhuang, Hebei province.

Participants A total of 211 patients with breast cancer completed the survey.

Outcome measures A total of 211 patients with breast cancer completed the Mishel’s Uncertainty in Illness Scale, Trait Coping Style Questionnaire and the Mandarin version of Demoralization Scale (DS-MV).

Results Of the patients, 47.40% exhibited symptoms of demoralisation (DS-MV>30), and the mean of demoralisation score was (29.55±13.21). The results demonstrated that illness uncertainty and negative coping styles were positively related to demoralisation (p<0.001), while active coping styles were negatively related to demoralisation (p<0.001). Importantly, coping styles could partially mediate the relationship between illness uncertainty and demoralisation (p<0.01).

Conclusion Our study illustrated that illness uncertainty was associated with demoralisation in patients with breast cancer, and coping style acted as a mediator in this relationship. The findings highlighted the critical role of reducing negative coping styles to the early prevention and efficient treatment of demoralisation among those patients.

  • Breast tumours
  • Personality disorders
  • Depression & mood disorders
  • MENTAL HEALTH

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2022-065796

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    Strengths and limitations of this study

    • Using bootstrap method has higher statistical power than the Sobel test and causal steps.

    • Mediation analysis was used to quantify the contribution of coping style to the association between illness uncertainty and demoralisation.

    • Psychological measurement may be affected by patients’ recall and reporting bias.

    • Patients were all from the same hospital, thus the results’ extrapolation validity was poor.

    Introduction

    Breast cancer is the most common female malignancy and the leading cause of cancer death among women worldwide.1 According to the latest cancer statistics in China, the incidence of breast cancer is 100 cases per 100 000 women aged 55–69 years and ranks the first, reaching 2.5 million patients overall by 2021.2 With advances in early diagnosis and systemic adjuvant therapy, the survival of patients with breast cancer has been extended.3 Unfortunately, the side effects of long-term cancer treatment and the stress of physiological changes lead to a variety of psychological problems in patients with breast cancer. Among them, demoralisation was a common psychological problem in patients with cancer, and the incidence of medium demoralisation in patients with cancer was up to 28.8%–57.7%.4 It can aggravate depression, reduce the quality of life and even cause suicidal ideation.4–6 Thus, it is a significant psychological issue, which needs to be solved urgently and explored comprehensively.

    Lazarus and Folkman’s model of stress and coping (MSC) contains two basic elements, appraisal and coping.7 Based on MSC theory, when coping mechanisms regulating problems and emotions are insufficient, and the person no longer figures out how to respond to, and helplessness and distress ensure.7 So, the illness uncertainty of patients with breast cancer would relate to the occurrence of demoralisation.8 Illness uncertainty could affect patients’ ability of psychological adjustment and the seeking of disease-related information and could be unfavourable for the rehabilitation.9 Illness uncertainty refers to the individual’s lack of the ability to determine things related to the disease.10 For patients with breast cancer, the treatment and rehabilitation is a long and complicated process. They have to not only bear the physical distress, but also face the complex treatment process, so there are generally different degrees of illness uncertainty.8 11 Several studies have demonstrated that there was a significant correlation between illness uncertainty and the mental health of patients with breast cancer.12 13 However, the effect of illness uncertainty on demoralisation and its mechanism is not clear. The core of demoralisation is the breakdown in coping. And a coping style is the typical manner of facing a stressful event and dealing with it.7 Thus, the coping style would be an important factor related to demoralisation. There are two types of coping styles: active and negative coping styles.14 The active coping style refers to take a direct and rational approach to solve problems, and negative coping style tends to deal with problems by neglecting, avoidance and denial.15 16 Ignatius and De La Garza17 pointed out that confronting the cancer with an active coping style was a protective factor to control demoralisation. Clarke and Kissane18 also found that demoralisation was positively related to negative coping style, and there was a significant positive correlation between demoralisation and the degree of depression in patients. So, the negative coping style is the characteristic of dealing with for subjects with demoralisation.18 It indicated that for patients with breast cancer, the choice of coping style facing the events will have an important impact on their physical and mental health. However, it is not clear whether the coping style is involved in the demoralisation progression of patients with breast cancer. In addition, Pahlevan et al19 found that illness uncertainty can affect the emotional state of patients through coping styles and then affect the quality of life. Ahadzadeh and Sharif reported that illness uncertainty in patients with breast cancer was negatively related to their active coping, which had an effect on the quality of life.13 Meanwhile, patients’ illness uncertainty was positively related to their negative coping styles in prostate cancer.20 Besides, illness uncertainty can regulate the psychosocial adjustment of patients with breast cancer by affecting coping styles.21 Importantly, in view of the overlap of the strong association between illness uncertainty and coping style, coping style and demoralisation, we hypothesised that coping style was probably one of the psychological pathways to illustrate the relationship between illness uncertainty and cognitive demoralisation. The potential mediating role of coping style needs to be explored in our study.

    Based on Lazarus and Folkman’s MSC, when coping mechanisms regulating problems and emotions are insufficient, and the person no longer figures out how to respond to, and helplessness and distress ensue.7 Thus, this study aimed to determine the association between illness uncertainty and demoralisation among patients with breast cancer. We also examined the mediation effect of coping style on the relationship between illness uncertainty and symptoms of demoralisation. Based on the review of previous literatures, we proposed the following hypotheses:

    Hypothesis 1: Illness uncertainty was related to the symptoms of demoralisation and also associated with coping style among patients with breast cancer.

    Hypothesis 2: Active coping style and negative coping style would mediate the relationship between illness uncertainty and demoralisation.

    Methods

    Participants

    A cross-sectional descriptive design was adopted in this study. Participants who met the inclusive criteria were recruited between 2019 and 2020 by convenience sampling from a tertiary hospital in Shijiazhuang, Hebei province. The inclusive criteria were the patients with breast cancer who (1) were 18 years or older, (2) had no communication and cognitive impairment and (3) were aware of their diagnosis and participated voluntarily. The exclusive criteria were patients who (1) had communication barrier, severe cognitive or physical impairment and (2) had severe cardiac, liver, renal dysfunction or other malignant tumours. Patients included in this study were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

    Patient and public involvement

    There was no patient or public involvement in the development and design of this study.

    Instruments

    In this study, we collected information on demographic and clinical characteristics, coping style, illness uncertainty and demoralisation from the participants. The demographic characteristics included age, employment status, religion, place of residence, marital status, income (¥/month) and education. The clinicopathological features included the clinical stages, tumour recurrence and metastasis. Data collection was conducted by questionnaires and checking medical records.

    PASS V.15.0 was used to calculate sample size for hierarchical multiple regression.22 Thus, 14 predictors were considered for a medium effect size of 0.15 (Cohen’s f2), a power of 0.80 and an alpha level of 0.05. For this study, the minimum sample size was 138, and we estimated about 20% dropout rate. Finally, we excepted the minimum sample size was 173.

    The Mishel Uncertainty in Illness Scale for Adults (MUIS-A) was used to evaluate the uncertainty in the patients.23 MUIS-A consists of 25 items, including 2 dimensions of complexity and ambiguity. Each item is scored from 1 (strongly disagree) to 5 (strongly agree). And the total score of the scale ranges between 25 and 125, with higher scores indicating greater levels of uncertainty. According to Chinese norm, 25–57 indicate the low level of illness uncertainty, 58–91 indicate the moderate level and 92–125 indicate the high level.23 We used the mandarin version of the MUIS-A developed by Sheu.24 The validity and reliability of this questionnaire were 0.92 and 0.865, respectively. In this study, the Cronbach’s α of the ambiguity subscale and the complexity subscale were 0.866 and 0.746, respectively.

    We assessed the coping style using the Trait Coping Style Questionnaire (TCSQ).25 TCSQ was designed to assess two coping strategies that individuals may use when facing life-threatening illnesses: active coping and negative coping.26 It includes 20 items, and each item is measured on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). For individuals, a higher score of one dimension indicates more likely to adopt this type of coping style. Individual with active coping score≥35 tends to adopt the active coping style, and individual with negative coping score≥30 tends to adopt the negative coping style.26 We used the mandarin version of TCSQ developed by Jiang, and the validity and reliability have been validated.25 The structural validity was 0.488 (reported in cumulative variance percentage), and the reliability of negative coping and active coping was 0.69 and 0.70, respectively.25 In this study, the Cronbach’s α of the active coping dimension and the negative coping dimension were 0.866 and 0.746, respectively.

    The Mandarin version of Demoralization Scale (DS-MV) was used to measure the demoralisation for patients.18 It was developed by Kissane27 and constituted of 24 items in 5 dimensions: dysphoria, loss of meaning, helplessness, disheartenment and sense of failure. Each item is scored from 0 (strongly disagree) to 4 (strongly agree). The total score ranges from 0 to 96, with higher scores indicating higher levels of demoralisation. A score>30 is identified as a cut-off for the presence of demoralisation.27 In this research, the Cronbach’s α of the DS-MV was 0.937.

    Procedure

    The patients with breast cancer who satisfied the inclusive criteria were invited by clinicians or nurses to participate in this study. Then the researchers explained the purpose and procedure of the study and informed the patients that they could withdraw at any time. The researchers assisted in explaining and filling out the questionnaires if necessary. According to the Declaration of Helsinki, written informed consent was provided from all the patients, and data was anonymised. The questionnaires were handed out and reclaimed on the spot. The questionnaires that did not answer according to the regulations and had too many missing items, which were defined as invalid questionnaires, and the invalid questionnaires were excluded. We used the Strengthening the Reporting of Observational Studies in Epidemiology cross-sectional reporting guidelines.28

    Data analysis

    In this study, statistical analyses were conducted by SPSS V.22.0 and Mplus V.7.0 (Informer Technologies, Los Angeles, California, USA). Independent samples t-test and one-way analysis of variance were used to compare the differences of demoralisation between groups of discrete variables. We examined the relationships among illness uncertainty, demoralisation and coping style by performing the Pearson correlation analysis. Hierarchical multiple regressions were performed to determine the predictors of demoralisation. To be specific, in step 1, employment status and disease status as covariate variables were included in the hierarchical regression. In step 2, the illness uncertainty was added. In step 3, the coping style was added. The main effect of entered variables in each regression model was evaluated by comparing the changes in R2 and F values.

    The structural equation modelling (SEM) and the bootstrap method (5000 replicates) were employed to validate the hypotheses of the relationship among illness uncertainty, coping style and demoralisation. If the 95% CI of indirect effect did not include 0, it indicated that the mediation effect was significant. The bootstrap method has higher statistical power than the Sobel test and causal steps approach,29 and a two-tailed p value<0.05 was defined as statistically significant.

    Results

    Characteristics of the patients

    In this study, 230 questionnaires were distributed and 211 valid questionnaires recovered, with a recovery rate of 91.7%. A total of 211 patients with breast cancer were included in this study. All the patients were women and aged from 20 to 72 years. Overall, 92% of the patients were without religious affiliation, 67.77% were unemployed and 59.72% were cared for by spouses. The majority (87.68%) had located breast cancer, while 12.32% suffered metastasis or recurrence. The mean score of DS-MV was 29.55±13.21, with approximately 47.40% of the patients scored higher than the threshold (DS-MV=30) of demoralisation. We analysed the influence of demographic and clinical characteristics on the demoralisation status of patients with breast cancer (table 1). The results showed that patients suffered metastasis or recurrence (t=2.964, p=0.003) or without work (t=−2.225, p=0.027) tended to experience the demoralisation.

    View this table:
    Table 1

    The influence of the demographic and clinical characteristics of patients with breast cancer on their demoralisation level (N=211)

    Relationship between illness uncertainty and demoralisation

    The mean score of patients’ illness uncertainty was 66.14 (SD=12.6). As shown in table 2, illness uncertainty (r=0.559, p<0.001) was positively associated with demoralisation in patients with breast cancer. To further analyse the association between the demoralisation and illness uncertainty, we divided the total cohort into two subgroups, patients with a low level of illness uncertainty (MUIS-A<58, N=50) and patients with a moderate/high level of illness uncertainty (MUIS-A≥58, N=161). The moderate-level/high-level subgroup showed significantly higher demoralisation compared with the low-level subgroup (32.16±12.42 vs 21.16±12.24, p<0.001, figure 1A). For each dimension of demoralisation, higher scores were observed for moderate-level/high-level subgroup in patients with breast cancer (p<0.001, figure 1B–F).

    View this table:
    Table 2

    Correlation analysis of illness uncertainty, coping style and demoralisation in patients with breast cancer (N=211)

    Figure 1
    Figure 1

    Comparison of the levels of demoralisation in 211 patients with breast cancer with different illness uncertainty. The level of overall level of demoralisation (A), loss of meaning (B), dysphoria (C), disheartenment (D), helplessness (E) and sense of failure (F) was significantly different between the two subgroups. Statistical significance was tested by a non-parametric Mann-Whitney test. ***p<0.001.

    Relationship between coping style and demoralisation

    The correlation between coping style and demoralisation is displayed in table 2. The negative coping (r=0.445, p<0.001) was positively associated with demoralisation, respectively; while active coping was negatively related to demoralisation (r=−0.504, p<0.001). The mean score of patients’ active coping and negative coping was 35.16 (SD=6.73) and 29.37 (SD=7.76), respectively. According to the norm of active coping, 211 patients were divided into active subgroup (active coping≥35, N=126) and non-active subgroup (active coping<35, N=85). As presented in figure 2A, it showed that the level of demoralisation in the non-active subgroup was significantly higher than those in the active subgroup (35.85±11.3 vs 25.31±12.74, p<0.001). For each dimension of demoralisation, higher scores were observed for those in non-active subgroup (p<0.001, figure 2B–F). Meanwhile, we also categorised the total cohort into the negative subgroup (negative coping≥30, N=109) and non-negative subgroup (negative coping<30, N=102), based on the norm of negative coping. The patients in negative subgroup tended to experience higher level of demoralisation compared with those in non-negative subgroup (34.73±10.32 vs 24.02±13.75, p<0.001, figure 3A). Besides, all dimensions of demoralisation in negative subgroup were significantly higher than that of non-negative subgroup (p<0.001, figure 3B–F).

    Figure 2
    Figure 2

    Comparison of the levels of demoralisation in 211 patients with breast cancer with different active coping. The level of overall level of demoralisation (A), loss of meaning (B), dysphoria (C), disheartenment (D), helplessness (E) and sense of failure (F) was significantly different between the two subgroups. Statistical significance was tested by a non-parametric Mann-Whitney test. ***p<0.001.

    Figure 3
    Figure 3

    Comparison of the levels of demoralisation in 211 patients with breast cancer with different negative coping. The level of overall level of demoralisation (A), loss of meaning (B), dysphoria (C), disheartenment (D), helplessness (E) and sense of failure (F) was significantly different between the two subgroups. Statistical significance was tested by a non-parametric Mann-Whitney test. ***p<0.001.

    Hierarchical multiple regression analysis

    We performed the hierarchical multiple regression to explore the effect of multiple variables on the patients’ demoralisation, which included the illness uncertainty, coping style, employment status and disease status (table 3). The analysis strategy was divided into three steps. First, the linear combination of employment status and disease status as covariate variables significantly explained their relationship with demoralisation (F=6.559, R2=0.059, p=0.002). Second, illness uncertainty was positively related to demoralisation (β=0.539, p<0.001) and explained 33.2% of the variability in demoralisation (F=35.744, R2=0.341, adjusted R2=0.332, p<0.001). In step 3, once again, it was demonstrated that illness uncertainty (β=0.411, p<0.001) and negative coping (β=0.184, p=0.001) were positively associated with demoralisation, while active coping was found to be negatively correlated to demoralisation (β=−0.311, p<0.001). Importantly, the changes in both the R2 and F value from one to the next model suggested illness uncertainty and coping styles exhibited significantly the predictive effects on demoralisation (F=40.348, R2=0.496, adjusted R2=0.484, p<0.001).

    View this table:
    Table 3

    Hierarchical multiple regression analysis of influencing factors of demoralisation in patients with breast cancer (N=211)

    Mediating effect of coping style

    The results of hierarchical multiple regression suggested that coping style may function the mediation effect on the association between illness uncertainty and demoralisation. First, we used the SEM to verify the significance of the mediation model. Path analysis of the model is shown in figure 4. It confirmed that illness uncertainty was negatively correlated with active coping (path coefficient=−0.321) and positively correlated with demoralisation (path coefficient=0.496). Meanwhile, active coping was negatively correlated with demoralisation (path coefficient=−0.335). Besides, illness uncertainty was positively correlated with negative coping (path coefficient=0.410), and negative coping was positively correlated with demoralisation (path coefficient=0.164). The fit of model was measured by Tucker-Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA). The fit of model to the data was acceptable: χ2=536.557, χ2/df=1.682, TFI=0.901, CFI=0.91, RMSEA=0.057, p<0.01). Next, the bootstrap method was used to estimate the indirect effect of active coping and negative coping. Results are presented in table 4 and figure 4. From illness uncertainty to demoralisation, two significant indirect paths were identified through active or negative coping. The mediation effect of active coping was significant (β=0.108, 95% CI: 0.016 to 0.058, p<0.001), represented by the path of illness uncertainty→active coping→demoralisation (table 4 and figure 4). Meanwhile, the path of illness uncertainty→negative coping→demoralisation depicted the significant mediation effect of negative coping (β=0.067, 95% CI: 0.005 to 0.046, p=0.032; table 4 and figure 4). Altogether, the coping style was a partially mediator between illness uncertainty and demoralisation.

    View this table:
    Table 4

    Mediation effect analysis of illness uncertainty on demoralisation of patients with breast cancer (N=211)

    Figure 4
    Figure 4

    The estimated coefficients of mediation effects of coping styles and on illness uncertainty and demoralisation.*p<0.05,***p<0.001.

    Discussion

    Demoralisation is regarded as a psychological issue associated with a variety of cancers, and characterised by hopelessness, a sense of failure, helplessness and the inability to cope.4 30 This study intended to examine the relationships among illness uncertainty, coping style and demoralisation in patients with breast cancer and investigate the mediating effect of coping style. We identified that demoralisation afflicted 47.40% of 211 patients with breast cancer. The findings of our study have validated prior results that the positive influences of illness uncertainty on the negative coping style of patients. We also found that the negative coping style was directly positively with demoralisation, while the active coping style could increase the severity of demoralisation. Importantly, we found illness uncertainty positively influenced the demoralisation through coping style in patients with breast cancer.

    The present study showed that illness uncertainty had a positive relationship with demoralisation. Further analysis indicated that the level of demoralisation in patients with a moderate-level/high-level illness uncertainty (MUIS-A≥58) was significantly higher than those with low-level (MUIS-A<58). As far as we know, the relationship between illness uncertainty and demoralisation remains unclear and still lacks empirical researches. This study extended our understanding of the causes of demoralisation, that was, patients with breast cancer with higher illness uncertainty had higher demoralisation. The reasons possibly were as follows. First, individuals with more illness uncertainty tend to be deficient for seeking the information about the disease, resulting in patients in a state of no longer ‘knows what to do’ and demoralisation.9 30 31 Second, illness uncertainty has emerged as a prevalent problem for patients with cancer, and it would lead to patients’ psychological distress.27 The existential distress can manifest through demoralisation.32 Third, prior studies demonstrated that illness uncertainty was positively related to depression in patients with cancer.33 34 Subsequently, their depression could bring about further aggravation of demoralisation.35 These findings offered further supportive evidence for the association between illness uncertainty and demoralisation as proposed in Lazarus and Folkman’s MSC.7

    Our study also emphasised the importance of evaluating coping style for its significant effect on the demoralisation. After controlling for sociodemographic, clinical features and illness uncertainty, the results indicated a positive correlation between negative coping style and demoralisation severity levels, while a negative correlation between active coping style and demoralisation severity levels in patients with breast cancer. This finding was consistent with the previous studies.36–38 Bovero et al36 found that negative coping style was a significant predictor for demoralisation, such as self-blaming among patients with cancer. Another study of demoralised women with breast cancer reported that lower life quality and higher preoccupation was related to cancer, and compared with non-demoralised women, they tended to adopt a hopeless–helpless and pessimistic attitude toward cancer, along with less active coping styles.37 38 Meanwhile, we found that patients in non-active (active coping<35) and negative (negative coping≥30) subgroups exhibited higher level of demoralisation. That is to say, patients who adopted the non-active or negative coping style to manage cancer-related stress, tended to develop into the demoralisation. The results suggest that coping style is a strategy adopted by individuals to maintain psychological balance in stressful situations,39 on one hand, the negative coping style would aggravate the demoralisation38 40; on the other hand, the demoralisation affects the progression of the disease, which in turn determines how the patient copes with it.41 42 According to the above results, this study provides supportive evidence for reorganising the patients’ coping strategies by including more active coping and reducing the use of negative coping styles.

    The structural equation model further confirmed that coping style exerted a partial mediating effect on illness uncertainty and demoralisation among the patients with breast cancer. This means that illness uncertainty could predict directly the level of demoralisation of the patients. Besides, illness uncertainty also indirectly affected the demoralisation through the mediating effect of coping style among patients with breast cancer. Particularly, our study for the first time elucidated the mediating roles of coping style between illness uncertainty and demoralisation in patients with breast cancer. In addition, a similar study found that among Chinese patients with breast cancer, there was a positive association between resignation and demoralisation, and it was identified that resignation was the only medical coping style predicting the demoralisation significantly.43 Additionally, prior evidence showed that illness uncertainty could affect patients’ psychological adjustment and mental well-being by regulating their coping styles, which was similar to our findings.10 20 44 Based on Lazarus and Folkman’s MSC, we speculate that patients are usually under considerable stress of cancer, full of illness uncertainty which produces distress and helplessness through more negative coping style and less active coping style and then develop into demoralisation. Importantly, the mediating effect of negative coping style on demoralisation was demonstrated in this study (β=0.164, p<0.05; table 4 and figure 4). This means that negative coping style implying ‘give up’ to some degree, leading to the disability to establish relief and the hope lost, thus aggravated the extent and severity of demoralisation.45 Moreover, demoralisation exacerbates the symptoms of the distress, may develop depression if attributions of negative outcomes become global and promotes the adoption of the negative coping style.4 5 46 This finding supports the fact that patients with breast cancer who adopt the negative coping style, tend to increase the severity of demoralisation; in turn, the demoralisation affects the course of negative coping style. Meanwhile, we found that active coping had an impact on reducing breast cancer patients’ demoralisation (β=−0.335, p<0.001; table 4 and figure 4). Prior study proved that patients with breast cancer mostly adopted active coping, then positive reappraisal, self-controlling, confronting behaviour and escape–avoidance.47 It suggested that patients with breast cancer would experience diverse changes of coping style in the long-term rehabilitation. We should encourage their active coping style, and pay more attention to the negative coping, such as escape–avoidance.

    Several factors can also affect demoralisation of patients with breast cancer. The demoralisation of patients with breast cancer was significantly associated with recurrences/metastases and employment status. First, there was more social support available for patients who have been employed, as a result, they were less likely to be demoralised.48 49 Second, demoralisation was an existential distress syndrome that consists of an incapacity of coping, helplessness, hopelessness, loss of meaning and purpose and impaired self-esteem.36 Yildirim et al, found that recurrence and metastasis would make patients feel less confident about their future.50 Meanwhile, previous studies also proved that demoralisation was most relevant to depression in patients with advanced cancer.4 36 51 According to Pan et al, patients with metastases tended to experience depression.52 Thus, patients with recurrences/metastases had higher level of demoralisation, which was consistent with our results.

    Our findings provide a valuable direction for developing interventions by investigating the mediating role of coping style on illness uncertainty and demoralisation of patients with breast cancer. Coping is generally viewed as an individual’s effort to adapt to the change of the real environment.38 And an individual’s coping style is often stable and consistent.53 This study suggested that psychological interventions aimed at reducing negative coping style, such as avoiding the neglecting, avoidance or denial when confronted with problems, should be applied to relieve the level of demoralisation. Even though the underlying mechanism of demoralisation remains obscure, it may originate from the interplay of many factors, such as illness uncertainty and coping style.

    There are several limitations in our study. First, cross-sectional study design cannot accurately demonstrate the characteristics of coping style, illness uncertainty and demoralisation at different stages of the disease. As far as we know, illness uncertainty and demoralisation can change over time. Therefore, longitudinal studies should be considered to explore the dynamic relationship among illness uncertainty, coping styles and demoralisation in patients with breast cancer. Second, psychological measurement is conducted by questionnaire, which may be affected by patients’ recall and reporting bias. The repeat measurements could be performed in a proportion of patients to test the reliability of the results. Third, the patients surveyed in this study were all from the same hospital in Hebei province and the extrapolation validity was poor. A multicenter study with larger sample size is suggested in the future.

    In summary, we found that positive correlations between illness uncertainty, negative coping styles and demoralisation, while the mediation effect of coping styles on the correlation between illness uncertainty and demoralisation was detected in patients with breast cancer. Our findings suggest that the significance of mitigating negative coping styles, because the negative coping styles could intensify the negative effect of illness uncertainty on demoralisation. Thus, we may be able to moderate the demoralisation by targeting at reducing negative coping styles of patients with breast cancer.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study was reviewed and approved by the Ethics Committee of the Fourth Hospital of Hebei Medical University (ID: 2019MEC067). Informed consent forms were signed by all patients in this study.

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    Footnotes

    • Contributors JH conceptualised and designed the research and approved the final manuscript as submitted. YQ critically reviewed the manuscript and approved the final manuscript as submitted. RH collected the data, conducted the statistical analysis, drafted the initial manuscript and approved the final manuscript as submitted. MZ conducted the statistical analysis and prepared the manuscript, figures and tables. JZ collected and analysed the data, prepared the manuscript and approved the final manuscript as submitted. All the authors read and approved the final manuscript. JH was responsible for the overall content as guarantor.

    • Funding This work was supported by the National Natural Science Foundation of China (grant number 72074067), Key project of Humanities and Social Sciences Research, Hebei Province (grant number ZD201908), Hebei Key Research and Development Project (grant number 19277799D, 21377729D), Natural Science Foundation of Hebei Province (grant number H2020206483, H2021206289) and Technical Innovative Youth Talents of Hebei Medical University (grant number TJSK202103).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.