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Sleep quality, mental health, and quality of life in women with breast cancer

1 Department of Family Medicine, Pamukkale University School of Medicine, Pamukkale/Denizli, Turkey
2 Department of General Surgery, Pamukkale University School of Medicine, Pamukkale/Denizli, Turkey

Date of Submission30-Jul-2020
Date of Decision03-Feb-2021
Date of Acceptance30-Mar-2021
Date of Web Publication29-Jun-2022

Correspondence Address:
Nilufer Emre,
Department of Family Medicine, Pamukkale University School of Medicine, Pamukkale/Denizli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_859_20


Background: Breast cancer is the most frequent malignancy among women and its prevalence keeps growing. Today, it is important to optimize the quality of life of breast cancer patients because the survival rates increase with early diagnosis and treatments. Our aim was to examine the sleep quality of patients with breast cancer, compare them with the healthy control group, and evaluate the relationship between quality of life and mental health.
Materials and Methods: This cross-sectional study included 125 patients diagnosed with breast cancer and 125 healthy control patients who were admitted to the general surgery department of a university.
Results: In 60.8% of breast cancer patients, sleep quality was poor and sleep subscale scores were high. In addition, these patients had a poorer sleep quality, higher score of anxiety and depression, and lower quality of life (in terms of physical subcomponent) compared with the control group. Moreover, although age, marital status, education status, time of cancer diagnosis, menopausal status, surgical method did not have any effect on sleep quality in patient group; low income, accompanying chronic diseases, and increased levels of anxiety and depression worsened sleep quality and increased the risk.
Conclusion: In patients with breast cancer, poor sleep quality, score of anxiety and depression were higher, and worsened the quality of life. In addition, low income, presence of concomitant chronic diseases, and anxiety score posed an increased risk for poor sleep quality. Therefore, physical and mental evaluation of breast cancer patients during and after treatment should not be ignored.

Keywords: Anxiety, breast cancer, depression, quality of life, sleep
Key Message: Sleep quality was found to be worse in women diagnosed with breast cancer compared to those without breast cancer. In order to prevent and reduce the negative effects of sleep quality in women diagnosed with breast cancer, mental health and quality of life should be taken into consideration as well as sleep quality.

How to cite this URL:
Emre N, Yılmaz S. Sleep quality, mental health, and quality of life in women with breast cancer. Indian J Cancer [Epub ahead of print] [cited 2022 Dec 4]. Available from:

  Introduction Top

Breast cancer is the most common cancer in women, affecting 2.1 million women each year and is the most common cause of cancer-related deaths among women. In 2018, it has been estimated that 627,000 women have died of reasons related to breast cancer, and this accounts for approximately 15% of all cancer deaths among women. Although the incidence of breast cancer is reported to be higher in more developed countries, global rates keep on increasing.[1],[2] According to GLOBOCAN 2018 report, 208,8849 new cases with breast cancer have been defined all around the world.[2] In our country, breast cancer is placed on the top among all women's cancers. In Turkey, 17,183 women have been diagnosed with breast cancer in the previous year.[3]

Advances in early diagnosis and treatment of cancer have led to an increase in the 10-year survival in almost 80% of patients with breast cancer. Thus, optimizing the quality of life in patients becomes more and more important, because these patients are not completely symptom-free and may come up against a number of different psychological and physical symptoms such as sleep disorders, depression, anxiety, fatigue, and cognitive dysfunction.[4],[5] Recent studies have shown that sleep disorders are a common complaint in patients with breast cancer, and most of these patients suffer from anxiety, depression, low self-esteem, and pain. Therefore, it is important to manage low sleep quality, and it should be prevented by identifying related factors at different time courses of diagnosis and treatment.[6],[7]

In addition, it has been reported that women with breast cancer may experience psychiatric disorders such as depression and anxiety during any time of the disease, regardless of the stage and treatment process.[8]

In studies that investigate the relationship between sleep patterns and anxiety and depression, the onset of sleep disorders has surfaced at the same time at which symptoms have appeared.[9] As a result, untreated insomnia has been shown to negatively affect the mood, physical symptoms, pain sensitivity, fatigue, and health-related quality of life. In this study, our aim was to investigate the sleep quality of patients with breast cancer, compare their results with the healthy control group, and evaluate the relationship between quality of life and mental health.

  Materials and Methods Top

This study was designed as a descriptive–cross-sectional study at Pamukkale University Faculty of Medicine between April and July 2019. All women aged between 18 and 65 years who were admitted to general surgery department, were diagnosed with breast cancer, had surgery, spent 3 months after surgery, were in remission of disease, were not receiving active radiotherapy chemotherapy drugs, were willing to participate in the study, had no communication problems, and did not have any psychological and cognitive impairments were included in the study. Exclusion criteria were local recurrence, distant metastasis, or secondary malignancies and using drugs that could affect sleep quality. Cancer patients whose disease was in remission were included in the study.

Patients who were not receiving active radiotherapy or chemotherapy drugs were included in the study. The control group consisted of healthy women matching the patient group by age and gender within the same dates and those who were patients' relatives, patients' attendant, university staff, and those who agreed to participate in the study. Participants were informed about the study, and written consent was obtained from those who wanted to participate. Prior to the study, the Local Ethics Committee of the relevant university approved the study with confirmation number 03 and 05 February 2019.

Considering the aim of the study, we performed an extensive literature research and in the light of clinical experiment, patient and control groups were asked to complete sociodemographic and clinical data collection form, Pittsburgh Sleep Quality Index (PSQI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Quality of Life Survey (SF-12 [12-Item Short Form Survey]). The questionnaires were conducted by the same researcher with the participants who accepted the study, using face-to-face interview technique.


Pittsburgh Sleep Quality Index (PSQI): PSQI has been developed by Buysse et al.[10] and the validity and reliability of the Turkish version have been measured by Ağargün et al.[11] In total, it consists of 24 questions and seven components. Each question is scored from 0 to 3. The sum of the scores for the seven components gives the total PSQI score. In PSQI, the last five questions are not used for scoring, and the total PSQI score can range between 0 and 21. Although a score of 5 and below indicates “good sleep quality,” a score higher than 5 is considered “poor sleep quality.”

Beck Anxiety Inventory (BAI): This is a Likert-type scale consisting of 21 items. The validity and reliability of Turkish version have been measured by Ulusoy et al.[12] It is used to assess the frequency of anxiety symptoms. The scoring of the scale can range from 0 to 63, and a score less than 8 means none to minimal anxiety levels, 8–15 means mild anxiety, 16–25 means moderate, and a score greater than 25 shows severe anxiety.

Beck Depression Inventory (BDI): This inventory is a Likert-type scale and it consists of 21 items on a 4-point scale. Its Turkish version has been validated, and the reliability has been measured by Hisli.[13] BDI was used to measure the severity of depression. The scale is scored between 0 and 63, and is classified as follows: <10 means none, 10–18 means mild, 19–29 means moderate, and 30–63 means severe depression.

Quality of Life Survey (SF-12): SF-12 is a survey consisting of 12 questions all selected from the SF-36 (36-Item Short Form Survey) Health Questionnaire, and it assesses the quality of life for the past 4 weeks, without focusing on a particular age and disease group. The survey has subscales that evaluate physical components summary (PCS) and mental components summary (MCS). In addition, the survey consists of subcomponents such as physical functionality, physical role, pain, general health, emotional role, mental health, and social functionality.[14]

Statistical analysis

The data were analyzed using SPSS Version 21.0 (Statistical Package for Social Sciences) package program. Continuous variables were presented as mean ± standard deviation and categorical variables as numbers and percentages. Because the parametric test assumptions were not provided, Mann–Whitney U test was used to compare the differences between the groups. Moreover, the relationships between continuous variables were analyzed using Spearman correlation analysis, and the differences between categorical variables were analyzed using Chi-square analysis. In addition, logistic regression analysis and multiple logistic regression were performed to identify the determinants of sleep quality. In all statistical tests, the statistical significance was determined as P < 0.05.

  Results Top

A total of 125 women patients diagnosed with breast cancer, and age-matching 125 healthy women who met the inclusion criteria were included in this study. The mean age of the patient and control groups was 51 (31–65) and 48 (30–65) years, respectively. There was no statistically significant difference between the patient and the control groups in terms of sociodemographic characteristics, except the presence of chronic diseases in family history. [Table 1] shows the sociodemographic characteristics of the patient and control groups.
Table 1: Sociodemographic characteristics of the patient and control groups

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Of the 118 (47.2%) patients with poor sleep quality, 76 (60.8%) were with breast cancer, and 42 (33.6%) were healthy controls. The PSQI total and subscale scores and SF-12, BAI, and BDI scores of the patient and control groups are presented in [Table 2]. There was a significant difference between the patient and the control groups in terms of PSQI and all subscale scores, except for sleep quality and types of sleep medications. Anxiety and depression scores were significantly higher in the patient group than in the control group. Although the mental health was not significantly different between the patient and control groups in terms of quality of life, the physical dimension showed a significant difference.
Table 2: The total and subscale scores of the Pittsburgh Sleep Quality Index of the patient and control groups, and the differences between anxiety, depression, and quality of life

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Pittsburgh sleep quality was strongly associated with anxiety and depression. Although the sleep quality was strongly affected by the physical dimension of the quality of life, it was weakly affected by the mental dimension [Table 3].
Table 3: The Relationship between Pittsburgh Sleep Quality Index and quality of life and mental health

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In [Table 4], the risks affecting sleep quality in patients with breast cancer were analyzed with logistic regression analysis. Although the age, marital status, educational status, the time at which the patient was diagnosed with cancer, menopausal state, and surgical method do not pose a risk for sleep quality, low income status (odds ratio [OR] = 2.564; 95% confidence interval [CI]: 1.226–5.364; P = 0.012), presence of concomitant chronic diseases (OR = 3.077; 95% [CI]: 1.414–6.697; P = 0.005), anxiety score (OR = 1.10; 95% [CI]: 1.053–1.159; P < 0.001) and depression score (OR = 1.086; 95% [CI]: 1.035–1.139; P = 0.001) increase the risk of poor sleep quality. [Table 5] presents the factors affecting the sleep quality in breast cancer patients with multiple logistic regression.
Table 4: The risks affecting the sleep quality in patients with breast cancer

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Table 5: Factors affecting sleep quality in patients with breast cancer with multiple logistic regression

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  Discussion Top

In this day and age, breast cancer remains the most common malignancy in women worldwide.[15] In this study, we found that sleep quality was highly correlated with mental health and quality of life in breast cancer patients, and compared with the healthy control group, they had poorer sleep quality, higher score of anxiety and depression, and lower quality of life (with regard to physical subcomponent). Studies in the literature have shown that psychological problems in breast cancer patients increase the development of poor sleep quality, which in turn negatively affects the quality of life. It is stated that the frequency of sleep disorders and accompanying anxiety and depression in breast cancer patients is higher than in the healthy woman population.[16],[17],[18]

Karakoyun-Celik et al.[19] have reported that anxiety and depression negatively affect the quality of life in women with breast cancer, which negatively affects the patient's fight against cancer. The results of our study are consistent with studies showing that poor sleep is a risk factor for the development and maintenance of mental health and confirm that people with poor sleep quality experience physical, cognitive, and mental depression. In addition, it has been shown that disturbed sleep increases symptom severity, and it may reflect the overall effect of sleep on emotion regulation capacity.[9] In studies investigating the relationship between quality of life and subjective sleep, sleep disorders have been associated with poor quality of life. A relationship between sleep quality and quality of life in patients and healthy control groups has also been observed.[20],[21],[22] These results support the results of our study.

Although the factors that increase sleep problems in humans are stated as being a woman, advanced age, and multiple accompanying health problems;[23] in patients with cancer, the stage of cancer, the time elapsed since diagnosis, and treatment are other factors that may affect sleep quality.[17] Nevertheless, it has been reported that the psychological state of the person affects the sleep quality, and it leads to sleep problems in cancer patients.[24],[25] However, we found that the age, age of going through menopause, time at which the patient was diagnosed with cancer, and surgical method did not have any effect on sleep quality in our patients. Although it has been shown that age affects sleep quality depending on the menopausal status of the patient,[7] there are studies showing that age does not affect sleep quality, similar to our results.[25]

In addition, we showed that low income and concomitant chronic diseases posed a risk for insomnia in patients with breast cancer. Similarly, Fekih-Romdhane et al.[7] have reported that low socioeconomic status worsened sleep quality. This finding may be attributed to the financial burden of the disease and the increase in levels of anxiety. However, being a woman and having breast cancer and related disorders are unalterable risk factors for insomnia. In addition, it has been reported that continuous sleep disorders, depression, and anxiety in patients with breast cancer can affect the patient's recovery period and her compliance with treatment as well as quality of life and may exacerbate symptoms.[6],[26] Therefore, good-quality sleep, psychological well-being, and a good quality of life are considered important factors during the recovery period after treatment in patients with breast cancer.

The main limitation of the study was that a relatively less number of patients and controls were included in the study. Another limitation of the study was its cross-sectional nature. We think that it is important to conduct longitudinal prospective studies in the future and to evaluate the sleep quality of women by months or even years following the diagnosis.

  Conclusion Top

To conclude, a high percentage of women with breast cancer had a poor sleep quality. The sleep quality of these patients was mostly affected by socioeconomic status and accompanying chronic diseases. On the other hand, sleep quality was found to be highly associated with mental health and quality of life. Therefore, a holistic assessment should be made to prevent or reduce the negative effects of poor sleep quality on patients, and other factors such as health and quality of life should be taken into account.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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