Psycho-Oncology

Psycho-Oncology 23: 10141020 (2014)

Published online 3 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3523

Social support and health-related quality of life in women

with breast cancer: a longitudinal study
Janni Leung1*, Nancy A. Pachana2 and Deirdre McLaughlin1
1
2

The University of Queensland, School of Population Health, Brisbane, Queensland, Australia

The University of Queensland, School of Psychology, Brisbane, Queensland, Australia

*Correspondence to: School of

Abstract
Population Health, The University
Objectives: A breast cancer diagnosis is a distressing event that impacts on physical and psychological
of Queensland, Herston Rd,
functioning. This study examined the longitudinal relationships among a diagnosis of breast cancer,
Herston, Brisbane, Queensland
social support, and health-related quality of life (HRQOL).
4006, Australia. E-mail: j.
Methods: Participants were 412 women from the 19461951 birth cohort of the Australian
leung1@uq.edu.au
Longitudinal Study on Womens Health who self-reported a new diagnosis of breast cancer between
1998 and 2007. The three surveys of longitudinal data analyzed included data 3 years before diagnosis,
at diagnosis (baseline), and 3 years after diagnosis (follow-up). Social support was measured using the
19-item Medical Outcomes Study Social Support Survey; HRQOL was measured using the Medical
Outcomes Study 36-item Short-Form Health Survey.
Results: Compared with pre-diagnosis HRQOL, women newly diagnosed with breast cancer
reported signicantly poorer HRQOL in subscales related to pain, physical functioning, and health
and vitality. At 3-year follow-up, HRQOL had improved in most domains to levels consistent with
pre-diagnosis. Levels of social support remained stable across time. The structural equation model
showed that social support was positively predictive of better physical and mental HRQOL at
3-year follow-up.
Conclusions: Longitudinal analyses indicate that social support appears to be an important predictor of HRQOL in women diagnosed with breast cancer. In particular, positive emotional and informational support that may normally be provided by a partner is important in maintaining HRQOL.
Identication of those lacking social support, especially patients without partners, will enable them
Received: 26 July 2013
to be guided to appropriate support networks and programs.
Revised: 25 February 2014
Copyright 2014 John Wiley & Sons, Ltd.
Accepted: 26 February 2014

Introduction
Breast cancer is the second most prevalent cancer among
women and is one of the leading causes of death in women
worldwide [1]. Despite this, advances in screening and diagnostic procedures mean that most breast cancers can be
diagnosed at an early stage, leading to effective treatments
and improved survival rates [2]. Nonetheless, a diagnosis
of breast cancer is a distressing event that affects physical
and psychological functioning and impacts on lifestyle
and relationships with family and friends [35]. Breast
cancer treatments, including systemic adjuvant therapy,
lead to long-term worsened quality of life in breast cancer
survivors [5]. Furthermore, treatment-related changes to
womens physical appearance may affect self-image, and
other effects of treatment, including fatigue, nausea, and
pain, may decrease opportunities for social interactions
and limit the ability of women with breast cancer to continue their normal lifestyle and social activities [6]. This
in turn curtails their opportunities to maintain supportive
social networks and to receive appropriate emotional and
instrumental support.
Copyright 2014 John Wiley & Sons, Ltd.

Social support has been identied as being protective

for health and in particular for reducing cancer-related distress [79]. Studies have found that social support is associated with better adjustment to disease and better quality
of life; however, the subjective appropriateness of the support offered is important [10,11]. Not all social relationships are sources of support; although women possess
extensive and robust social networks, these can come at
a price (such as maintaining the networks and managing
expectations of providing support to others) [10,12]. The
stress-buffering model of social support focuses on the
perceived availability, quality, and appropriateness of support [13]. In particular, this model suggests that when
confronted with a situation of high stress, the availability
of appropriate levels of subjective support is more important than the number of contacts in the social network.
Perceived social support in health-related contexts has
been categorized as (a) emotional/informational support,
(b) tangible support, (c) affectionate support, and (d) positive social interaction [14]. The provision of satisfactory
emotional and informational support has been associated
with better health and lower symptom intensity in women

Social support, quality of life, and breast cancer

with breast cancer [15]. Both tangible support, in the form

of a psycho-educational program, and affectionate support, from family and friends, have been associated with
better well-being and improved health-related quality of
life (HRQOL) among breast cancer patients [1618].
Although previous studies have reported that positive
social support can enhance adjustment to breast cancer
and improve HRQOL [1820], these studies are largely
cross-sectional. Little evidence has been presented that
examines either the longitudinal impact of social support
on HRQOL in women with breast cancer or changes over
time in social support and HRQOL throughout the course
of the disease. A small number of previous studies that
have reported on patterns of social support associated with
breast cancer have found that levels of social support
uctuated over time [21,22]. However, these studies did
not have information on pre-diagnosis levels of social
support, and analyses were based on short follow-up times
(up to 6 months). Given the increasing incidence and
higher survival rate from breast cancer in recent years, a
focus on factors associated with HRQOL, especially from
a longitudinal perspective, can provide valuable insight to
inform the development of strategies to support women
during this distressing experience.
The aim of this study is to examine the impact of a
breast cancer diagnosis on social support and quality of
life over time. Additionally, this paper will examine the
role of social support as a predictor of better HRQOL in
women newly diagnosed with breast cancer. Consistent
with previously reported cross-sectional research, it is
expected that women with high levels of social support
will report higher HRQOL scores.

Method
Participants
The Australian Longitudinal Study on Womens Health
(ALSWH) is a prospective study of the health and wellbeing of three cohorts of women who were aged 1823 years
(19731978 birth cohort), 4550 years (19461951 birth
cohort), and 7075 years (19211926 birth cohort) when
recruited in 1996. The study sample was selected randomly
from the Medicare Australia database (which covers all
citizens and permanent residents of Australia, including
refugees and immigrants), with intentional oversampling
of women living in rural and remote areas in order to achieve
an adequate sample size in this population. The project uses
mailed questionnaires to collect self-report data on health
and related variables every 3 years. Details of the ALSWH
recruitment and study design have been fully described elsewhere [23], and details of the study can be found at www.
alswh.org.au. Participation is voluntary, and the ALSWH
is approved by the University of Newcastle and University
of Queensland Human Research ethics committees.
Copyright 2014 John Wiley & Sons, Ltd.

1015

Data for these analyses are drawn from surveys 1 to 6

(1996 to 2010) of the 19461951 birth cohort. Because
of uncertainties about the accuracy of the Medicare
Australia database, response rates to the initial invitation
cannot be exactly specied. However, it has been
estimated that 5356% of women in this birth cohort
responded with 14,072 women responding to survey 1
[24]. Of the total eligible women at each survey, responses
to subsequent surveys were 12,338 (90.7%) at survey 2
(1998), 11,226 (84.3%) at survey 3 (2001), 10,905
(84.0%) at survey 4 (2004), 10,638 (83.8%) at survey 5
(2007), and 10,011 (83.3%) at survey 6 (2010).
Participants were women who responded yes to the
following question in survey 2 (1998), survey 4 (2004), or
survey 5 (2007): In the past three years, have you been
diagnosed or treated for breast cancer. A baseline breast
cancer diagnosis was a positive response at any of the three
surveys. This self-report item has been validated against
Cancer Registry data with 93% sensitivity and 98%
specicity [25]. Pre-diagnosis data were drawn from the
survey immediately preceding the baseline (breast cancer
diagnosis) survey, and follow-up data were drawn from
the survey immediately after the baseline survey. A total
of 519 women reported a new diagnosis of breast cancer
between 1998 and 2007: 82 in 1998, 199 in 2004, and
238 in 2007. There were 433 women (83%) who completed
the follow-up survey, in which 21 (5%) had missing data.
The nal sample included 412 women newly diagnosed
with breast cancer who had valid data. Missing data were
excluded pair-wise for statistical analyses.

Measures
Social support was measured by the 19-item Medical
Outcomes Study Social Support Survey [14], with a stem
question that asks, How often is each of the following
kinds of support available to you if you need it? Each
item was answered on a ve-point scale, ranging from
none of the time to all of the time. Scores were from 1
to 5 with higher scores indicating greater levels of social
support. The original four functional support subscales included (1) emotional/informational support (eight items),
(2) tangible support (four items), (3) affectionate support
(three items), and (4) positive social interaction (three
items), and an additional item [14]. Emotional support is
the expression of positive affect, empathic understanding,
and the encouragement of expressions of feelings (e.g.,
share your most private worries and fears with); informational support is the offering of advice, information, guidance, or feedback that can provide a solution to a problem
(e.g., turn to for suggestions about how to deal with a personal problem); positive social interaction is companionship or the availability of other persons to share leisure
and recreational activities (e.g., have a good time with);
affectionate support is the expression of love and affection
Psycho-Oncology 23: 10141020 (2014)
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J. Leung et al.

1016

(e.g., love and make you feel wanted); and tangible

support is the offering of material aid or behavioral assistance (e.g., take you to the doctor if you need it). Psychometric testing and scale validation in the current sample
was previously conducted [26]. Factor analysis and parallel
analysis in the current sample revealed three factors
(Cronbachs alphas 0.900.96), supporting the combination
of the affectionate support and positive social interaction
subscales, and the inclusion of the additional item in the
emotional/informational support subscale [26]. Consequently, in our sample, the three subscales of social support
that can be measured separately are mean emotional/informational support (EMI), mean affectionate support/positive
social interaction (AFF), and mean tangible support (TAN).
Health-related quality of life was measured using the
Medical Outcomes Study 36-item Short-Form Health
Survey (SF-36) [27]. The SF-36 assesses general physical
and psychological health and well-being over the preceding 4 weeks. The survey covers eight dimensions of
physical and mental health: physical functioning, role
limitations due to physical or emotional problems, bodily
pain, general health perceptions, vitality, social functioning, and emotional well-being or mental health. The
responses to items within each dimension are summed
and linearly transformed to produce scores ranging from
0 to 100 with higher scores indicating better health.
Sociodemographic characteristics examined included
marital status (single/divorced/widowed and married/
cohabiting), education (no formal, high school, and trade/
certicate/degree), country of birth (Australia, other
English-speaking countries, and non-English-speaking
countries), and area of residence (major cities, inner
regional, outer regional, remote, and very remote).

Statistical analysis
Statistical analyses were conducted using SPSS 19 (IBM
Corp, Armonk, NY, USA). The womens social support
was compared over time, from the survey before diagnosis
of breast cancer (pre-diagnosis) to the survey at which
breast cancer was diagnosed (baseline) and at 3 years follow-up. Repeated-measures analyses of variance
(ANOVAs) were conducted to compare levels of social support over time. Within-subject contrasts were conducted to
compare pre-diagnosis social support with baseline social
support and baseline social support with social support
reported at follow-up. Similarly, repeated-measures
ANOVAs were conducted to compare HRQOL over time.
One-way between-subject ANOVAs were conducted to
compare social support and HRQOL by sociodemographics
(marital status, education, country of birth, and area of
residence) at baseline. The bivariate associations between
baseline social support and follow-up HRQOL were estimated using Pearsons correlation. Partial correlation was
used to estimate the association between social support
Copyright 2014 John Wiley & Sons, Ltd.

and HRQOL adjusting for sociodemographic characteristics

found to be signicantly associated with both social support
and HRQOL.
Structural equation modeling in Amos 17 was used to
model the effects of social support on both physical and
mental HRQOL outcome in the same model. Social
support and HRQOL variables were standardized. Paths
were entered between latent variables from baseline social
support to physical and mental HRQOL. The observations
on bodily pain, general health, physical functioning, and
role physical were loaded onto the latent variable physical
HRQOL. The observations on mental health, role
emotional, social functioning, and vitality were loaded
onto the latent variable mental HRQOL. The three social
support subscales, EMI, AFF, and TAN, were loaded onto
the latent variable social support. Covariance paths were
entered between the three social support subscales.
Sociodemographic characteristics were controlled for by
entering the observed characteristics with paths to latent
social support, physical, and mental HRQOL. A good
model t is indicated by a root mean square error of
approximation 0.05, and normed-t index and comparative t index >0.90.

Results
Social support and quality of life over time
Women newly diagnosed with breast cancer had moderately high levels of EMI, AFF, and TAN social support
overall, indicated by a mean of 3.974.16 out of a vepoint scale at baseline (Table 1). Repeated-measures
ANOVA results showed that there was no change in social
support pre-diagnosis, at baseline, and after breast cancer
diagnosis.
Compared with pre-diagnosis HRQOL, women newly
diagnosed with breast cancer had signicantly worse quality
of life on the subscales of bodily pain, general health,
physical functioning, role physical, and vitality. However,
compared with when they were newly diagnosed, at follow-up, the women had increased scores in some domains
of HRQOL. Specically, signicant improvements were
observed in their general health, role physical, role emotional, social functioning, and vitality (Table 1).

Social support by sociodemographic characteristics

Analysis of variance results by sociodemographic characteristics showed that at baseline, women who were
married/cohabiting reported higher EMI, AFF, and TAN
support scores and had better HRQOL scores (Table 2).
Therefore, marital status was included as a control variable
in the analysis between social support and HRQOL. There
were no signicant differences in social support scores by
education, country of birth, and area of residence.
Psycho-Oncology 23: 10141020 (2014)
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Social support, quality of life, and breast cancer

1017

Table 1. Social support and health-related quality of life at pre-diagnosis, at baseline diagnosis, and at 3-year follow-up after breast cancer
diagnosis
Before diagnosis
M

[95% CI]

Social support (N = 124)

EMI
3.98
[3.80, 4.16]
AFF
4.20
[4.03, 4.37]
TAN
4.01
[3.80, 4.22]
Health-related quality of life (N = 345)
Bodily pain
68.08
[65.40, 70.76]
General health
69.74
[67.42, 72.06]
Physical functioning
80.84
[78.70, 82.98]
Role physical
73.90
[69.97, 77.83]
Mental health
73.42
[71.46, 75.37]
Role emotional
77.38
[73.49, 81.28]
Social functioning
79.45
[76.81, 82.08]
Vitality
57.89
[55.56, 60.22]

Baseline
(1)

M
3.97
4.16
4.10

*
***
**
**

65.12
63.70
77.80
65.18
72.60
73.80
77.04
55.86

Follow-up
M

[95% CI]

[3.79, 4.16]
[3.98, 4.34]
[3.90, 4.29]
[62.38,
[61.21,
[75.49,
[60.61,
[70.49,
[69.63,
[74.15,
[53.30,

4.00
4.16
4.01

67.85]
66.18]
80.11]
69.74]
74.70]
77.96]
79.93]
58.41]

67.24
67.22
78.48
72.73
74.05
79.99
82.14
58.55

[95% CI]

Repeated-measures ANOVA

[3.82, 4.18]
[3.99, 4.32]
[3.81, 4.22]
[64.61,
[64.70,
[76.15,
[68.61,
[72.07,
[76.20,
[79.60,
[56.14,

69.88]
69.74]
80.82]
76.84]
76.03]
83.78]
84.68]
60.96]

Partial eta squared

0.06
0.30
0.66

<0.01
<0.01
0.01

(2)

**
**
**
**
*

2.73
15.84
5.86
7.59
1.37
4.07
6.07
3.44

0.01
0.05
0.02
0.02
<0.01
0.01
0.02
0.01

***
**
**
*
**
*

Repeated within-subject contrasts were (1) before diagnosis versus baseline and (2) baseline versus follow-up.
CI, condence interval; ANOVA, analysis of variance; EMI, emotional/informational support; AFF, affectionate/positive social interaction support; TAN, tangible support.
*p < 0.05, **p < 0.01, ***p < 0.001.

Table 2. Social support at baseline and health-related quality of life at follow-up by marital status at baseline
Single/divorced/widowed
M
Social support (N = 412)
EMI
3.51
AFF
3.43
TAN
3.25
Health-related quality of life (N = 358)
Bodily pain
62.27
General health
61.11
Physical functioning
70.38
Role physical
72.57
Mental health
69.33
Role emotional
62.33
Social functioning
75.17
Vitality
52.13

[95% CI]

[3.28, 3.73]
[3.20, 3.65]
[3.01, 3.49]
[56.10,
[55.55,
[65.94,
[67.19,
[60.00,
[52.49,
[68.87,
[46.57,

68.44]
66.66]
74.82]
77.96]
78.66]
72.18]
81.47]
57.70]

Married/cohabiting
M

[95% CI]

4.06
4.28
4.16
68.06
69.01
74.76
79.91
82.73
74.73
83.42
60.00

[3.96, 4.16]
[4.18, 4.38]
[4.05, 4.26]
[65.22,
[66.36,
[72.62,
[77.41,
[78.80,
[70.32,
[80.72,
[57.44,

70.91]
71.66]
76.90]
82.40]
86.66]
79.14]
86.13]
62.56]

One-way ANOVA
F
22.43
61.20
58.56
3.24
7.13
3.37
6.75
8.70
6.10
7.01
7.37

Eta squared

***
***
***

**
*
**
*
**
**

0.05
0.13
0.13
0.01
0.02
0.01
0.02
0.02
0.02
0.02
0.02

CI, condence interval; ANOVA, analysis of variance; EMI, emotional/informational support; AFF, affectionate/positive social interaction support; TAN, tangible support.
*p < 0.05, **p < 0.01, ***p < 0.001.

Correlation between social support and quality of life

Pearsons correlation results showed that the social support
subscales were highly correlated (Table 3). Therefore, the
combined effects of the three social support subscales were
examined in the multivariate analysis. Higher baseline
social support scores were associated with higher physical
and mental HRQOL scores at follow-up. This indicated that
better social support was associated with better quality of
life. The effects of EMI and AFF support appeared to be
slightly stronger than the effect of TAN support at
predicting HRQOL at follow-up. Partial correlation results
were consistent after controlling for marital status.

Structural equation model

The structural equation model results showed a good
model t (root mean square error of approximation = 0.02,
Copyright 2014 John Wiley & Sons, Ltd.

normed-t index= 0.92, and comparative t index = 0.93).

In women with newly diagnosed breast cancer at baseline,
more social support overall was predictive of better
HRQOL, both physical and mental, at follow-up (Figure 1).
The effect was slightly stronger for mental HRQOL.

Discussion
Findings from this study indicate that, over time, a diagnosis of breast cancer impacted negatively on HRQOL, but
not on perceived social support, which remained stable.
Those aspects of HRQOL, which were susceptible to
treatment effects (bodily pain, general health, physical
functioning, and vitality), were most likely to be impaired
at time of diagnosis. The correlational results suggested
that emotional/informational support and affectionate
support/positive social interaction, rather than tangible
Psycho-Oncology 23: 10141020 (2014)
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J. Leung et al.

1018

Table 3. Correlation between social support at baseline breast

cancer diagnosis and health-related quality of life at 3-year follow-up
Baseline social support
EMI
Baseline social support
EMI

AFF
0.85**
TAN
0.72**
Follow-up health-related quality of life
Bodily pain
0.27**
General health
0.24**
Physical functioning
0.20**
Role physical
0.22**
Mental health
0.27**
Role emotional
0.18**
Social functioning
0.22**
Vitality
0.25**

AFF

TAN

0.71**

0.25**
0.23**
0.19**
0.23**
0.29**
0.24**
0.28**
0.25**

0.18**
0.18**
0.13*
0.18**
0.21**
0.19**
0.18**
0.19**

EMI, emotional/informational support; AFF, affectionate/positive social interaction

support; TAN, tangible support.
*p < 0.05 **p < 0.01.

support, were more important in improving quality of life

after diagnosis. Better social support at time of diagnosis
predicted better physical and mental HRQOL at subsequent follow-up.
A diagnosis of breast cancer, while no doubt a stressful
and distressing event, did not impact on existing levels of
social support in the women in this study over time. The
women had moderately high levels on all three aspects
of social support prior to diagnosis, and there was little
variation at the two subsequent measurement points. The
stability of social support in the current analyses is inconsistent with the results from previous studies that showed
levels of social support, which either decreased within
6 months [21] or increased in the rst 12 weeks of a social
support intervention and then decreased [22]. Neither of
these studies had pre-diagnosis measures, however, and
their measurement time frame was relatively short. The
current study is the rst to examine the long-term effects
of a breast cancer diagnosis on womens social support

and HRQOL employing a 6-year longitudinal design.

Consistent with these results was the stability over time
of the womens mental health. Prior research has shown
that poor mental health is associated with lower levels of
social support, possibly either through withdrawal from
existing networks or resistance to approaches from within
the network [9,28]. However, the impact of diagnosis was
clearly evident on HRQOL, particularly in those areas of
quality of life functioning that would be most affected by
treatment side effects (pain, general health, and vitality).
Despite this, by 3-year post-diagnosis, the women had
returned to pre-diagnosis functioning on most aspects of
HRQOL.
The positive effect of social support on HRQOL is consistent with previous cross-sectional studies [1719] and
with the stress-buffering model of social support [12].
Our ndings indicate that certain aspects of social support
such as the provision of emotional, affectionate, and informational support were more inuential on HRQOL than
the provision of instrumental support. When confronted
with a high stress situation, such as a diagnosis of breast
cancer, the stress-buffering model suggests that the receipt
of subjectively appropriate support optimizes outcomes.
For women who are managing a distressing diagnosis
and concomitant treatment, the most appropriate subjective support may be emotionally focused and most likely
provided by husbands or other intimate partners [20].
The importance of spousal support for women with
breast cancer was highlighted in our ndings. Married or
partnered women had higher levels of social support on
the three measured dimensions and better HRQOL. This
is consistent with previous research among women with
breast cancer, which has shown that spousal support is associated with improved emotional and physical well-being
and better quality of life [20].
Our ndings raise a number of issues relating to the
treatment and support provided to women diagnosed with
breast cancer. Those women who face diagnosis and
subsequent treatment without a partner, or other adequate

Figure 1. Structural equation model of social support at baseline predicting health-related quality of life at 3-year follow-up. Standardized
estimates for signicant paths at p < 0.001 are presented. EMI, emotional/informational support; AFF, affectionate/positive social interaction
support; TAN, tangible support
Copyright 2014 John Wiley & Sons, Ltd.

Psycho-Oncology 23: 10141020 (2014)

DOI: 10.1002/pon

Social support, quality of life, and breast cancer

support provider, are at clear risk of impaired HRQOL.

Treatments that focus wholly on the physical aspects of
breast cancer and that exclude psychological and social
aspects leave patients vulnerable to continuing distress.
This is an important ethical issue that needs to be
addressed when health professionals and their patients
are discussing treatment options and available support
and counseling programs. Further, access to breast cancer
support groups and other assistance-providing agencies
may be affected by a range of factors including area of
residence, mobility, and nancial constraints. Women
experiencing these additional barriers may be doubly
disadvantaged if their available social support is
inadequate.
There are a number of limitations in our study. Other
possible variables that may be associated with both social
support and HRQOL, such as stage of breast cancer at
diagnosis and timing and efcacy of treatment, were not
available in the dataset. We did not have a cancer-specic
measure of HRQOL (e.g., Functional Assessment of
Cancer Therapy) in our dataset, and rather have used a
generic instrument (SF-36) to examine HRQOL, which
should be taken into consideration in the interpretation
of our ndings. Our results reect the overall effects of social support, rather than specic effects of social support
for women with different stages of cancer and with varying responses to their treatments. We did not have information on the womens subjective feelings about the
social support they were receiving. Previous research in
breast cancer patients has shown that unwanted support
can have adverse psychological effects [29]. The women
who provided data for this paper generally reported good
mental health at the three time points, and women with
poor psychological health may be underrepresented. As
negative affect can result in poorer self-assessment and
lower social support, the results may reect this possible
bias. The majority of participants in the current study were

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Copyright 2014 John Wiley & Sons, Ltd.

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1019

Australian born; as the need for social support after breast

cancer treatment differs by cultural background [30], our
results may not be generalizable to women of other
cultural background. However, our oversampling of
women residing in rural areas has provided an adequate
sample size in this group; so our results can be generalized
to women with breast cancer living in both urban and rural
areas of Australia.
Health care support staff should inquire about the levels
of social support available to women diagnosed with
breast cancer. Although tangible support in the form of
assistance with activities such as transportation to medical
appointments is a useful and perhaps obvious form of
social support for women diagnosed with breast cancer,
our data suggest that emotional/informational support
and affectionate/positive social interaction were as
important, if not more important, to quality of life. Thus,
encouragement of activities and behaviors to promote
companionship and quality time with those who can provide these types of support should be stressed, particularly
for those patients who do not have partners. In this way,
the negative effects of a diagnosis of breast cancer on
quality of life post-diagnosis can be ameliorated.

Acknowledgements
The research on which this paper is based was conducted as part of
the ALSWH by investigators at the University of Newcastle and the
University of Queensland. The study was approved by the University of Newcastle and University of Queensland Human Research
ethics committees. We are grateful to the Australian Government
Department of Health and Ageing for funding and to the women
who provided the survey data. The funding source had no role in
the design, conduct, and reporting of the study.

Conict of interest
The authors have declared no conicts of interest.

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