https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Anxiety and Depression Levels with Risk Factors of Breast Cancer Patients in Erbil City – Iraq ABSTRACT INTRODUCTION Breast cancer appears to be becoming more common around the world. It is the most common type of cancer in women in the Middle East and the West [1]. Urologi- cal (21.3%), hematological (18.0%), head and neck malignancies (15.0%), and breast (14.0%) cancer are the most prevalent can- cer diagnoses [2].Globally, breast cancer is still the most frequent cancer among women and accounts for 14 to 42 percent of all female cancers in the Arab world. Its treatment can be a difficult experience for women, affecting their self-image and sex- ual relationships that can result in psycho- logical reactions such as denial, rage, or acute dread toward their condition and treatment. Patients with breast cancer are at an increased risk of acquiring Background and objectives: Breast cancer appears to be becoming more common world- wide. It is the most common type of cancer in women in the Middle East and the Western countries. Patients with breast cancer are at a high risk of developing psychological prob- lems such as anxiety and depression. This study aimed to evaluate the severity of anxiety and depression levels in breast cancer patients and their risk factors for breast cancer. Methods: A quantitative descriptive study design was conducted at Rizgary Teaching Hos- pital and Nanakali Oncology Hospital in Erbil City in the Kurdistan Region of Iraq from 1st September 2020 to 5th August 2021. The duration of data collection was four months and purposive sampling was used to select 298 patients who were admitted to both hospitals. A questionnaire format was used to gather the data, and the Hospital Anxiety and Depres- sion Scale (HADS) standardized questionnaire was utilized to measure the level of anxiety and depression. Results: The average age of the patients was 45.28±9.17 years, 80.5% were married, 60.7% of the studied sample had a low socio-economic status. Almost a third (30.5%) of the participants had severe anxiety and 60.4% had severe depression. Concerning the risk factors of breast cancer, 82.2% of patients were obese, 91.9% did not do exercise, 35.6% had breast cancer family history, 93.6% were non-smoker, and 6.4% of them were smok- ers. Conclusion: According to the findings, the majority of breast cancer patients suffer from anxiety and depression, and obesity is one of the risk factors for breast cancer. Keywords: Anxiety; Depression; Breast cancer; Risk factors. Mosleh Saber Kareem; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: mosleh.kareem@hmu.edu.krd) Diyar Hussain Taher; Department of psychiatry, College of Medicine, Hawler Medical University, Erbil, Iraq. 76 Erbil Journal of Nursing & Midwifery Received: 29/08/2021 Accepted: 14/ 11/2021 Published: 30/11/2021 mailto:Mosleh.kareem@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article psychological problems such as depression and anxiety [3], and the treatment can cause patients a lot of sadness [4]. Breast cancer is one of the most researched onco- logical illnesses in terms of its impact on quality of life. The patients frequently ex- perience high levels of anxiety and sad- ness, lowering their quality of life [5]. The diagnosis and treatment of this malignancy are well known for causing severe psycho- logical suffering and discomfort, which is found to be present in more than 30% of cancer patients. Breast cancer patients have a high level of anguish following their diagnosis, which included sadness and anx- iety. The amount of anxiety decreases over time. However, while anxiety and depres- sion are both common in breast cancer pa- tients, their effects on suffering differ. Anxi- ety, which is linked to a sense of uncertain- ty, appears to have a larger role in breast cancer patients' discomfort. Depression, on the other hand, which is characterized by negative emotions, does not correlate with the level of perceived distress in cancer patients. In contrast to depression, anxiety is frequently overlooked in the treatment of breast cancer patients' psychological well-being. Based on the current findings, a greater emphasis on assisting breast cancer patients in reducing their worry in the fu- ture is critical in lowering their perceived degree of discomfort [6]. Breast cancer pa- tients may be uniquely susceptible to de- pression, anxiety, and resultant distress due to decreased estrogen levels second- ary to hormone therapy and chemothera- py. It is important to routinely assess breast cancer sufferers for distress, and in collaboration with their primary care physi- cians, for signs and symptoms of insomnia, depression, anxiety, and distress. Counsel- ling, mindful meditation and pharmacologi- cal interventions have helped many breast cancer survivors. The rate of depression in breast cancer patients (4.5%–46%) is higher than rates in most other cancer types, also anxiety rates are (14.7%) very high in people with breast cancer. During the first year following a diagnosis, pa- tients are at the highest risk for major de- pressive disorder, especially for younger patients and those who have received chemotherapy. These high rates of depres- sion may be due to a multi-factor including body image issues, physical effects of treatment, loss of sexual function, ongoing fatigue, and perpetual concern about re- currence. Anxiety rates are also very high in breast cancer patients. One large cohort study found pure anxiety symptoms in 14.7% [7]. According to the study done by Kameran et al. (2012) in Erbil city – Iraq, increased levels of melancholy and anxiety following a breast cancer diagnosis under- score the need for specialized psychiatric services [8].Breast cancer risk factors in- clude both social and biological aspects including women's age, menarche at a young age, delayed first birth and meno- pause, nulliparity, short-term lactation, birth control pills, obesity, excessive fat consumption, hormone replacements Moreover, several epidemiological and clinical investigations have identified wom- en with a family history of breast cancer as significant risk factors for the disease. On the other hand, the majority of breast can- cer intervention literature suggests that modifiable risk factors can be avoided by promoting a healthy diet, regular physical activity, regulating alcohol consumption, and controlling weight, all of which are likely to reduce breast cancer incidence over time [9]. One study in South India dis- covered that urban regions have a higher incidence of breast cancer than rural ones. This study also found that the risk of breast cancer increased when the proportion of overweight or obese women in both pre- menopausal and post-menopausal women increased. The majority of breast cancer 77 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article the level of anxiety and depression. . HADS included 14 questions, 7 questions for anx- iety and 7 questions for depression. Each question had 4 responses ranked from 0 to 3, and the client selected one response that was appropriate to their situation. Normal scores ranged from 0 to 7, border- line abnormal scores ranged from 8 to 10, and abnormal scores ranged from 11 to 21 [11]. The ethical permissions for perform- ing this study came from the College of Nursing's ethical committee at Hawler Medical University. The goal of the study was described to the patients before their interview, and a verbal agreement was ob- tained. Patients were informed that they could withdraw from the study at any time. The data were entered into SPSS (version 23) for analysis, and the frequen- cy, percentage, mean and standard devia- tion, t-test, and Chi-square test were used to analyze the data. Table 1 shows that 41.6 percent of the par- ticipants were between the ages of 36 and 45. The participants' mean age (SD) was 45.28 ± 9.17. Regarding the educational level and occupation, most (29.5 %) of the studied sample graduated from an inter- mediate school and three quarters (74.8 %) of patients had unskilled manual occu- pations (housewives). The majority (80.5%) of the study sample was married, more than half (60.7%) had low economic status, and most (66.8%) most lived in an urban area. Table 2 illustrates that almost a third of the women had a high level of anxiety (30.5 %) and most (64.4 %) of them suffered from high depression levels. Table 3 shows some of the risk factors of breast cancers. Concerning the age of the partici- pants, less than half (41.6%) were in the age group of 36-45 years, the risk factors of breast cancer. The majority (82.2 %) of the women were obese. Concerning cases were found in women aged 40–49, who were mostly housewives. Breast can- cer risk was shown to be 8 times greater among unmarried women, 3 times higher among nulliparous women, 2 times higher among postmenopausal women, and 10 times higher among those who never nursed. In comparison to married, non- nulliparous, premenopausal, women who breastfed, who have not been exposed to hormonal contraceptives, and women without any ovarian diseases, women who were exposed to hormonal contraceptives were 1.5 times more likely and women with ovarian diseases were 4.5 times more likely to be diagnosed with breast cancer [10]. A quantitative descriptive study design was conducted at the Oncology Department of Rizgary Teaching Hospital and Nanakali On- cology Hospital in Erbil City in the Kurdistan region of Iraq from 1st September 2020 to 5th August 2021. The duration of data col- lection was four months, and 298 patients in both hospitals were selected as a pur- posive sample. A questionnaire format was modified and developed for the data col- lection. The sample selection was based on the following criteria: female breast can- cer, undergoing treatments, new cases, no psychiatric diagnosis, ability to communi- cate verbally. The exclusion criteria includ- ed refusal of participation, metastasis, age (66 years and above). ). The data was gath- ered by the same researcher using an inter- view technique in the Kurdish language. Each patient's interview lasted 25-30 minutes and was divided into three parts: Part One included participants' socio- demographic characteristics, Part Two ex- amined the breast cancer risk factors, and Part Three consisted of the Hospital Anxie- ty and Depression Scale (HADS) standardized questionnaire to measure 78 Erbil Journal of Nursing & Midwifery METHODS RESULTS https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article the daily exercise, the data showed that a high percentage (91.9%) of participants did not do daily exercise. Less than half (35.6%) of the study sample had a family history of breast cancer, while more than half (51.7%) had a family history of other types of cancer. 86.2 % of the study sample had menarche between13-15 years of age, and more than half (57.4 %) were married at the age of 13-24 years old. 84.2 % of wom- en had children, and 15.8 % were childless. Regarding the type of child's feeding, 75.8 % of the participants breastfed their chil- dren. Concerning contraceptive medica- tion, 76.5% of them did not take any con- traceptive medication. A high percentage (93.6%) of the study sample was non- smokers. Almost all (93.6% ) of respond- ents did not do breast self–examination, and 78.9 % of them were diagnosed with breast cancer before the menopausal peri- od. 79 Table1: Socio-demographic characteristics of patients (n=298) (%) No. Variables (14.1) 42 26-35 Age Group/years (41.6) 124 36-45 (27.9) 83 46-55 (16.4) 49 56-65 (29.2) 87 Primary school (or can read and write) Educational level (29.5) 88 Intermediate school (14.8) 44 High school or vocational (5) 15 Diploma (institute) (8.1) 24 Bachelor degree (college) (12.4) 37 Master degree or equivalent, e.g., higher diploma (1) 3 PhD or equivalent (74.8) 223 Unskilled manual occupations Jobs (9.7) 29 Skilled manual and non-manual occupations (13.4) 40 Associate professional occupations (2.1) 6 Skilled professional or senior managerial occupations (80.5) 240 Married Marital Status (9.7) 29 Single (2.7) 8 Divorced (7.1) 21 Widow (60.7) 181 Low Socio-economic status (28.9) 86 Middle (10.4) 31 High (66.8) 199 Urban Residency (21.1) 63 Suburban (12.1) 36 Rural https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article 80 Erbil Journal of Nursing & Midwifery Table 2: Levels of anxiety and depression among breast cancer patients (n=298) Levels Anxiety Depression No. (%) No. (%) Normal 137 (46) 65 (21.8) Borderline Abnormal (Borderline Case) 70 (23.5) 41 (13.8) Abnormal (Case) Total 91 298 (30.5) (100) 192 298 (64.4) (100) Table 3: Risk factors of breast cancer among 298 female breast cancers (n=298) (%) No. Risk factors (14.1) 42 26-35 Ageing (41.6) 124 36-45 (27.9) 83 46-55 (16.4) 49 56-65 Mean ± SD = 45.28 ± 9.17 (2) 6 Underweight Body Mass Index (15.8) 47 Normal (82.2) 245 Obesity (8.1) 24 Yes Daily exercise before breast cancer (91.9) 274 No (35.6) 106 Yes Family history of breast cancer (64.4) 192 No (51.7) 154 Yes Family history of all types of cancer (48.3) 144 No (11.1) 33 10-12 Menarche/ years (86.2) 257 13-15 (2.7) 8 16-18 (57.4) 171 13-24 Age of marriage/years (28.1) 84 25-36 (4.4) 13 37 and above (10.1) 30 Single (84.2) 251 Yes Do you have children (15.8) 47 No (Infertility, Single) (75.8) 226 Yes Breastfeeding (24.2) 72 No (23.5) 70 Yes Did you use contraceptive drugs? (76.5) 228 No (6.4) 19 Yes Smoking before breast cancer (93.6) 279 No (21.1) 63 Yes Breast self-examination (78.9) 235 No (81.5) 243 Pre-menopause Menopausal period (18.5) 55 Post-menopause https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Table 4 shows that there was a significant association between the levels of anxiety and risk factors of breast cancer such as menopause , sleep after diagnosis and cigarette smoking. The same table shows that there were no statistically significant differences between anxiety levels and Body Mass Index, sleep before the diagnosis, exercise and breastfeeding. 81 Erbil Journal of Nursing & Midwifery Table 4: Association between risk factors of breast cancer and their levels of anxiety (n=298) Anxiety Levels and Risk factors Normal Borderline Case Case Total P- value No. (%) No. (%) No. (%) Menopause period Pre-menopause 102 (34.2) 59 (19.7) 82 (27.5) 243 0.009 Post-menopause 35 (11.7) 11 (3.6) 9 (3) 55 Body Mass Index Underweight (BMI<18.5) 3 (1) 1 (0.3) 2 (0.6) 6 0.231 Normal (BMI≥18.5 and<25) 18 (6) 8 (2.7) 21 (7) 47 Obesity (BMI≥25) 116 (39) 61 (20.5) 68 (22.8) 245 Sleep/Hour before breast cancer 1-3 hours 13 (4.3) 13 (4.3) 13 (4.3) 39 0.065 4-6 hours 20 (6.7) 14 (4.7) 23 (7.7) 57 7 and above 104 (34.9) 43 (14.4) 55 (18.4) 202 Sleep/Hour after breast cancer 1-3 hours 12 (4) 6 (2) 14 (4.6) 32 0.044 4-6 hours 78 (26.1) 47 (15.7) 61 (20.4) 186 7 and above 47 (15.7) 17 (5.7) 16 (5.3) 80 Smoking before breast cancer Yes 7 (2.3) 9 (3) 3 (1) 19 0.034 No 130 (43.6) 61 (20.4) 88 (29.5) 279 Daily exercise before breast cancer Yes 13 (4.3) 1 (0.3) 10 (3.3) 24 0.061 No 124 (41.6) 69 (23.1) 81 (27.1) 274 Total 137 (45.9) 70 (23.6) 91 (30.5) 298 Breast Feeding Yes 107 (35.9) 55 (18.4) 64 (21.5) 226 0.337 No 30 (10.1) 15 (5) 27 (9) 72 Total 137 (45.9) 70 (23.6) 91 (30.5) 298 https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article The same table shows that there were no statistically significant differences between depression levels and Body Mass Index, sleep before diagnosis, exercise and breastfeeding. Table 5 shows that there were significant statistical associations between the levels of depression and risk factors of breast cancer such as menopause and sleep after diagnosis. 82 Erbil Journal of Nursing & Midwifery Table 5: Association between risk factors of breast cancer and their levels of depression (n=298) Depression Levels and Risk factors Normal Borderline Case Case Total P- value No. (%) No. (%) No. (%) Menopause period Pre-menopausal 55 (18.4) 25 (8.3) 163 (54.7) 243 0.001 Post-menopausal 10 (3.3) 16 (5.3) 29 (9.7) 55 Body Mass Index Underweight (BMI<18.5) 3 (1) 1 (0.3) 2 (0.7) 6 0.345 Normal (BMI≥18.5 and<25) 11 (3.7) 4 (1.3) 32 (10.7) 47 Obesity (BMI≥25) 51 (17.1) 36 (12) 158 (53.1) 245 Sleep/Hour before breast cancer 1-3 hours= poor sleep 8 (2.7) 6 (2) 25 (8.4) 39 0.143 4-6 hours= fair sleep 8 (2.7) 4 (1.3) 45 (15.1) 57 7 and above =Good 49 (16.4) 31 (10.4) 122 (40.1) 202 Sleep/Hour after got breast cancer 1-3 hours 1 (0.3) 3 (1) 28 (9.4) 32 0.001 4-6 hours 33 (11) 27 (9) 126 (42.3) 186 7 and above 31 (10.4) 11 (3.7) 38 (12.7) 80 Smoking Yes 2 (0.7) 3 (1) 14 (4.7) 19 0.469 No 63 (21.1) 38 (12.7) 178 (59.7) 279 Exercise before breast cancer Yes 8 (8.1) 5 (1.7) 11 (3.7) 24 0.14 No 57 (19.1) 36 (12) 181 (60.7) 274 Breast feeding Yes 49 (16.4) 37 (12.4) 140 (46.9) 226 0.063 No 16 (5.3) 4 (1.3) 52 (17.4) 72 https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article the majority of the studied patients were obese. Weight gain before menopause and being overweight or obese after meno- pause are both linked to an increased risk of breast cancer [1, 18]. Regarding breast self-examination, the majority of the par- ticipants did not do breast self- examination monthly. These results are consistent with the study conducted in In- dia in 2020 [10]. furthermore, the majority of studied patients were affected during the pre-menopausal period, which is in agreement with the study done by Chen et. al. in China [18]. The present study shows that less than half of the study sam- ple had a family history of breast cancer and most of the study sample had a nega- tive family history of breast cancer. These results are in concordance with the WHO (2021), which shows that breast cancer is more likely in families with a history of the disease, but the majority of women diag- nosed with the disease have no known family history of the disease. The absence of a known family history does not always imply that a woman is at a lower risk. [14]. According to the data collected in this study, there were no statistically significant differences between anxiety levels and ex- ercise, similar to the study by Sunil et al. (2012). Similarly, the combined data from 53 epidemiological studies showed no rela- tionship between smoking and breast can- cer [13]. The findings of this study revealed that anxiety and depression symptoms were common in studied breast cancer sufferers. Over half (60.4) percent of women had depression and 30.5 percent had anxiety symptoms based on HADS questionnaires. The prevalence of depres- sion and anxiety in patients with breast cancer in our study was similar to the pre- vious studies [3,15]. According to the find- ings of this study, there was no statistically significant relationship between the severity of depression and the According to our knowledge, this is the first study to look at anxiety, depression, and breast cancer risk factors in breast cancer patients. Patients with breast can- cer have a variety of symptoms related to the disease and its treatment and may have various psychological problems. In this study, anxiety and depression in breast cancer patients were chosen for examination. Regarding the age of the participants, less than half of the study sample was in the age group of 36-45 years. This is supported by the study done by Majid et .al (2009) and other researchers [1, 13, 3,17]. The majority of the participants in the study were mar- ried, which is consistent with the study done by Huang (2019) and others [12, 3, 17, 18]. According to the results of this study, the majority of the participants completed secondary school and lived in urban areas, which is compatible with the results of a study conducted by Tsaras, et al. (2018) [3, 17]. The findings of the present study indicate that the majority of the respondents were mar- ried, housewives, had low socioeconomic status and were pre-menopausal. These results are compatible with the results of a study conducted in Egypt by Alagizy (2020) [17]. In this study, data on socio- economic status were collected from breast cancer patients to investigate the relationship between economic position and anxiety and depression. The percent- age of women who were anxious or de- pressed was directly related to their soci- oeconomic level and treatment costs. In addition, extra expenses were needed to buy the medications, because sometimes they were not available in hospitals. At that time, Iraq faced many problems such as; economic crisis and COVID -19. Regarding risk factors of breast cancer; 83 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article smoking. . For the rest of the variables, there were no statistically significant differences between anxiety and Body Mass Index, sleep before diagnosis, exer- cise and breastfeeding. There were signifi- cant associations between depression and risk factors of breast cancer such as breast surgery, menopause period, sleep after diagnosis and having a child. The Body Mass Index, sleep before diagnosis, exer- cise and breastfeeding were not associated with depression levels. The study results indicate that the patients should be guided to psycho-education programs that can significantly reduce anxiety and depres- sion. Furthermore, the availability of a psy- chiatric nurse or a clinical psychologist who can provide adequate psycho-oncological therapy to patients who are most likely to develop psychopathological issues would be very beneficial for cancer care in the region. They are currently not available but very much needed and recommended by the author of this research. The authors report no conflicts of interest and any sources of financial support. [1] Majid RA, Mohammed HA, Saeed HM, Safar BM, Rashid RM, Hughson MD. Breast cancer in Kurdish women of northern Iraq: inci- dence, clinical stage, and case-control analy- sis of parity and family risk. BMC women's health. 2009;9(1):1-6. [2] Jadoon NA, Munir W, Shahzad MA, Choudhry ZS. Assessment of depression and anxiety in adult cancer outpatients: a cross- sectional study. BMC Cancer. 2010;10(1):1-7. [3] Tsaras K, Papathanasiou IV, Mitsi D, Veneti A, Kelesi M, Zyga S, et al. Assessment of de- pression and anxiety in breast cancer pa- tients: prevalence and associated factors. Asian Pacific journal of cancer prevention. 2018;19(6):1661. [4] Akel R, El Darsa H, Anouti B, Mukherji D, Temraz S, Raslan R, et al. Anxiety, socio-demographic characteristics of pa- tients. These findings matched those of research conducted in Taiwan [16]. Fur- thermore, the present study revealed no significant difference between anxiety and depression levels and demographic characteristics of participants as in the research of Alagizy et al. [17]. The pre- sent study showed that there was a sig- nificant association between the levels of anxiety and risk factors of breast cancer such as menopause period, sleep after diagnosis and cigarette smoking. On the other side, there were no statistically sig- nificant differences between anxiety lev- els and Body Mass Index, sleep before diagnosis, exercise and breastfeeding. The present study results illustrated a significant association between the levels of depression and risk factors of breast cancer such as breast surgery, meno- pause period, sleep after diagnosis and having a child. Examining depression lev- els and Body Mass Index, sleep before diagnosis, exercise and breastfeeding re- vealed that there was no statistically sig- nificant association between them. The differences between this study's findings and other studies could be attributed to the questionnaire technique, sample size, culture, religion, ethnicity, and eco- nomic level. According to the findings, the majority of the patients showed severe anxiety and depression symptoms. In general, there was no statistically significant relation- ship between anxiety and depression lev- els and socio-demographic factors; only the age group was statistically significant. There were significant differences be- tween the anxiety and risk factors of breast cancer such as menopause period, sleep after diagnosis and cigarette 84 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICT OF INTERESTS REFERENCES https://doi.org/10.15218/ejnm.2021.09 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article [14] WHO. Breast cancer, 2021. https:// www.who.int/news-room/fact-sheets/ detail/breast-cancer. [15] Civilotti C, Botto R, Maran DA, Leonardis BD, Bianciotto B, Stanizzo MR. Anxiety and De- pression in Women Newly Diagnosed with Breast Cancer and Waiting for Surgery: Prev- alence and Associations with Socio- Demographic Variables. Medicina Journal- scientific journal of the Lithuanian University of Health Sciences 2021;57(5):454. https:// www.mdpi.com/1648-9144/57/5/454. [16] Su J-A, Yeh D-C, Chang C-C, Lin T-C, Lai C-H, Hu P-Y, et al. Depression and family support in breast cancer patients. Neuropsychiatric disease and treatment. 2017; 13:2389. 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