Discussion
This study showed that the incidence of CRF in CC patients was high. 283 patients had CRF of different degrees, and the incidence of CRF is as high as 99%, of which the incidence of mild and moderate CRF is 53.2%, and the incidence of severe CRF is 46.8%. The CPMs of severe CRF is Logit(P)=1.276-0.947 Monthly income+0.989 Long-term passive smoking-0.952 Physical exercise+1.512 Diagnosis type+1.040 Coping style-0.726 PSS-2.350 SOC. In addition to demographic and clinical characteristics, patients’ psychological conditions were more influential in the CPMs, similar to Meglio’s model of breast cancer CRF10.
Long term passive smoking, tumor recurrence, avoidance and yielding are risk factors for severe CRF in CC patients. The concentrations of many carcinogenic and toxic chemicals in second-hand smoke are higher than those inhaled by smokers themselves, which may lead to some malignant diseases, and the patients whose husbands do not smoke have worse negative emotions and sleep quality than those who smoke24. When the tumor relapses, the patient will fear the disease, and the psychological defense line will collapse. Patients will doubt the possibility of curing the disease, affecting their confidence in treatment, and their mental health will be poor25. CC patients who adopted avoidance and surrender coping styles had a higher risk of serious CRF than those who adopted facing coping style. They did not care about the development of the disease and did not seek help actively. These patients had no confidence in the prognosis and was resigned to fate, which might increase the their negative mood and thus aggravated CRF26.
Monthly income, physical exercise, PSS, and SOC are protective factors for severe CRF in CC patients. After CC was diagnosed, patients usually needed to receive comprehensive treatment, and the medical cost was high. Patients with higher income had more and better treatment options and less psychological pressure, so the risk of CRF was relatively low27. Exercise can improve the blood oxygen content of the body, accelerate the metabolism of the body, stimulate the central nervous system, and then improve the mental state of patients, so as to eliminate fatigue28. The social support provided by role relationship is a valuable resource, which helps to stabilize and develop positive self-esteem and self-confidence, enhancing the patient’s ability to withstand pressure, and reduce the possibility of negative extreme emotions29. There were physiological and psychological stressors in the diagnosis and treatment of cancer. SOC can strengthen the management of stressors, that is, use existing resources to successfully deal with stressors. Therefore, a high level of SOC can promote the good physical and mental health of cancer patients30.
The areas under the ROC curve of both groups were greater than 0.8, indicating that the CPMs of severe CRF for CC patients constructed can better distinguish mild/moderate CRF patients from severe CRF patients31. In the consistency test of the two groups, the calibration curves were well fitted (P <0.05), indicating that the probability of severe CRF predicted by the model was consistent with the actual probability of severe CRF in CC patients, and the accuracy of the model prediction was high. The DCA analysis showed that the net benefit of applying the model to most thresholds in the model building group and the model validation group was good. In addition, this study visualized the CPMs in the form of Nomogram, which was more intuitive and convenient for calculation, and was conducive to the practical application of the model in clinical practice. According to the best cut-off value 0.444 in ROC curve, CC patients can be divided into high-risk group and low-risk group of CRF. For patients whose prediction probability is close to or higher than the optimal threshold, early intervention can be carried out according to their coping style, social support, psychological consistency, etc.
The patients’ SOC improved after MBSR (from 55.07 to 59.95), and the effect lasted until 6 months (64.17). The facing dimension score increased after MBSR (from 19.20 to 21.15), and also maintained at 6 months (20.95). At the same time, the yielding dimension score decreased after MBSR (from 12.10 to 10.85) and continuous decreased to 8.90 at 6 months. The CRF after MBSR were significantly improved (from 37.70 to 31.25), and maintained at 6 months (31.25 months). These results fully indicated that online MBSR can effectively improve the SOC, coping style, and CRF of CC patients, and the intervention effect lasted for a short time, with scores significantly lower than those of the control group. Previous studies have proved that MBSR has achieved good results in promoting positive psychology and improving negative emotions and also tried to explore the lasting effect of MBSR through longitudinal research at different time points. Salvador proved that MBSR could improve the psychological distress, general well-being, and fatigue-related quality of life32. Gaboury showed that up to 12 months after MBSR, anxiety, depression, emotion-oriented coping, sleep and function significantly improved33. Elimimian showed cancer survivors who participated in an 8-week MBSR reported persistent benefits with reduced anxiety, depression, and improved mental health over 24 months of follow-up34. Green indicated mindfulness meditation had the potential to decrease stress and burnout by decreasing self-judgment and over-identification with experience, and by increasing resiliency, compassion, and emotional regulation35. The above researches fully proved the good intervention effect of MBSR, which may be due to the mechanism of mindfulness, that is, when patients were threatened, injured or wasted by specific events beyond their ability, individuals will actively reassess stress events, redefine or construct stress events, thus triggering positive emotions that can relieve stress, and ultimately achieve internal balance and understanding36. Although Carlson proved social support improved to a lesser degree after MBSR37, our study showed that MBSR had no significant impact on social support of CC patients. This may be because social support usually emphasizes the emotion and help provided by personal social networks, and tends to external factors. MBSR, as an internal resource, requires the subject to actively explore and develop themselves.
Limitations: first, influenced by the COVID-19, the time of arrival and the way of visiting the hospital of the research objects had changed, therefore, the missed follow-up rate was lightly high; second, the tracking of the intervention effect was only 6 months, and the evaluation results cannot reflect the long-term intervention effects. Strengths: first, the model constructed in this study can help clinical workers to identify high-risk groups of CRF, and provide a reference for taking targeted intervention programs; second, we conducted an intervention study based on the model and proved the effectiveness, which was a complete study.