{'fraction_non_alphanumeric': 0.02137546468401487, 'fraction_numerical': 0.015038864481243664, 'mean_word_length': 4.825295275590551, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Depression and Anxiety as Predictors of Perceived Quality of Life in Breast Cancer Survivors

Breast cancer is one of the hundred types of cancer1. Mainly breast cancer occurs in women but men can also be victims of it2. According to The National Cancer Institute a cancer survivor is an individual who survives from the time of diagnosis until he or she gains the balance of his or her life. The caregivers, family members and friends are also impacted by survivorship experience3. The women survival rate from breast cancer is very low in Pakistan4.


INTRODUCTION
Breast cancer is one of the hundred types of cancer 1 . Mainly breast cancer occurs in women but men can also be victims of it 2 . According to The National Cancer Institute a cancer survivor is an individual who survives from the time of diagnosis until he or she gains the balance of his or her life. The caregivers, family members and friends are also impacted by survivorship experience 3 . The women survival rate from breast cancer is very low in Pakistan 4 .
Depression and anxiety are common psychological consequences of cancer 5 . Research indicated a significant negative effect of depression on Quality of Life (QoL) in cancer patients 6 . The extended, abnormal and severe anxiety reactions affect patients' normal functioning and social life 7 . Breast cancer has a great effect on a woman's QoL and self-esteem. Ferrans defines QoL as an individual's sense of wellbeing that originates from satisfaction or dissatisfaction with his or her important aspects of life 8 .
There is extensive literature suggesting a crucial role of psychological comorbidities in influencing patients' QoL. A study suggested that chemotherapy and tamoxifen is significant predictor of poorer QoL 9 . A study concluded that lower income & education, unemployment and poor health care services were related with QoL 10 . Age also affects QoL as older BCS reported lower QoL and higher level of education appeared to reduce depression 11 . Depression and anxiety as significant predictors of quality of life and as major psychological conditions were studied in BCS 12 . Literature concluded that BCS experienced higher level of anxiety and depression in Pakistan. The results revealed that poor QoL was related with depression in BCS 13 .
The objective of the study was to investigate the role of depression and anxiety in influencing perceived QoL in BCS in order to understand the psychological consequences of a life threatening illness. The study also aimed to examine the role of socio-demographic factors in influencing depression and anxiety levels among BCS. The current study further tried to explore whether there is a reciprocal/causal relationship between depression, anxiety and QoL?. As studying QoL in BCS may help to find out the long term impacts of breast cancer and can help to improve the QoL of BCS in future.

MATERIALS & METHODS
The present study followed cross sectional within group research design. The sample comprised of 52 female BCS from INMOL and Jinnah hospital, Lahore, after fulfilling required formal ethical procedures. Purposive sampling was used to recruit participants on the following inclusion/ exclusion criteria; Participants on regular follow-ups at public sector hospitals, post one year of successful chemotherapy, recruited as referrals from the medical professionals. No age range was set to include a diverse population. Patients with complications were excluded after being screened from the doctors. Patients with minimum basic schooling equivalent to primary school level, who could read and write, were included in the study. The BCS with any recurrence of cancer and having any other type of cancer were excluded. This study was conducted over a period of two months from 1 st March, 2014 to7 May, 2014. The individual assessment was conducted in one session in the absence of family members, when BCS visited outdoor of hospital for their follow up. The measurements included self report questionnaires that were also translated into Urdu for those who cannot speak and comprehend English. Demographics and medical information was taken from their medical reports. All formalities and ethical considerations were fulfilled including participant's consent form and information sheet.
A 14 items Hospital Anxiety and Depression Scale (HADS) developed by Zigmond and Snaith was used to measure depression and anxiety. It has two subscales, depression (7 items, á=0.70) and anxiety (7 items, á= 0.74). All items rated on 4 point scale as some items are rated on 0 to 3 scale and others are rated on 3 to 0 scale. For each scale the scores range is 0 to 21, the high scores means high level of distress. Total score will be achieved by adding two subscales. High scores show high depression and anxiety 14 . In the present study the reliability of HADS was 72.
The Quality of Life Index (QLI) Cancer Version III by Ferrans and Powers was used; it measures importance and satisfaction with various areas of life. All items rated on 6 point scale (1-6) 8 . Scores range from 0-30 and calculated by weighting each satisfaction item by its corresponding importance item 15 . Total scores and four subscales scores are calculated. The reliability of QLI in BCS was reported .95 & .97 16 . In the present study the reliability of QLI was 89.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study.

RESULTS
Descriptive statistics of demographic characteristics of BCS showed that the mean age of participants is 47.23 with SD=9.21. The participants were categorized according to the marital status as 76% participants were married, 26% BCS had 3 children, 48% participants were educated till primary level and 98% were unemployed. 57% participants belonged to urban areas, 65% lived in nuclear family system and 55% were not satisfied with their financial conditions. The descriptive statistics of medical factors indicated that mean age of onset of breast cancer was 43.46 years with SD=9.37. The mean age of breast cancer diagnosis was 43.67 years with SD=9.39. 88% BCS had 1-4 years duration of illness and treatment. 38% BCS had stage 1 and 34% BCS had stage 2 of breast cancer. 88% survivors visited the hospital for follow up after 1-6 months. It is showed that 73% survivors come for their regular follow up during 1-2 years immediately after the completion of chemotherapy. 30% BCS had hypertension and 15% BCS had hypertension and diabetes (both) as co-morbidity. 58% BCS used Tamoxifen medicine during survivorship period.
The levels of depression and anxiety among breast cancer survivors are presented in Table 1   Results (in Table 2) indicated significant negative correlation of depression and anxiety with overall QoL, HF, PSP, SOC, and FAM which means that depressed and anxious BCS inclined to be less satisfied with their QoL or vice versa. There is a significant positive relationship between depression and anxiety which indicated that anxious BCS are more likely to be depressed because depression and anxiety are often co-morbid. The significant positive correlation between overall QoL and its domains (i.e. HF, SOC, PSP, FAM) showed that BCS tend to be more satisfied with their overall QoL if they were satisfied with their HF, SOC, PSP and FAM life.
The results of multiple hierarchical regression analysis are presented in Table 3. Table  3) indicated that number of children and level of education were the significant strongest predictors of depression among all demographic variables. It is suggested that low level of education and less number of children make BCS more depressed. Marital status, monthly income, number of dependents and financial satisfaction did not emerge as significant predictors of depression. The analysis indicated that overall QoL and HF, SOC, PSP, FAM did not predict depression and anxiety among BSC. Table 4 shows a multiple linear regression analysis that was carried out to explore that do depression and anxiety predict quality of life.

A hierarchical multiple regression analysis (in
These results (in Table 4) revealed that depression and anxiety emerged as significant predictors of overall QoL, HF and PSP. It means that lower the level of anxiety and depression leads to the higher level of QoL. Both depression and anxiety did not emerge as significant predictors of SOC and FAM well being.

DISCUSSION
The current research was conducted to investigate depression and anxiety as predictors of QoL and to explore whether there is a reciprocal association among depression, anxiety and QoL.
Findings of the present research suggested that depressed and anxious BCS inclined to be less satisfied with their QoL or vice versa. These findings are similar with the earlier researches 13,[17][18][19] . These findings suggested that anxiety and depression are negatively related with QoL among BCS.
The present study indicated that BCS after one year of chemotherapy experienced mild to moderate level of depression and normal to mild anxiety and improved QoL. These results are similar with the earlier findings 17 . One reason for these consistent findings can be the time since chemotherapy. The immediate psychological consequences (especially depression and anxiety) of chemotherapy can be reduced with the passage of time.
There are many factors (e.g. physical activity, exercise, social support) that can contribute in reduction of the depression and anxiety levels with the passage of time. A previous study concluded that BCS who had increased physical activity level after diagnosis had better QoL and low intensity of depression 20 . A meta-analysis concluded that exercise lead towards a little improvement in depressive symptoms 21 . A study concluded that BCS with better social support had improved depressive symptoms and better QoL 22 .
The findings of present research indicated that number of children and education level was the significant stronger predictors of depression among BCS. These findings are similar with earlier researches [23][24][25]11 . The current study showed that age, marital status, occupational status, monthly income and financial satisfaction did not predict depression among BCS. The results further exposed that there was no demographic predictor of anxiety among BCS. These results are similar with the previous research 26 . The current research indicated that QoL did not predict anxiety and depression. These results are inconsistent with the literature. A study concluded that QoL has negative outcomes like anxiety & depression in BCS 27 . The present study indicated that anxiety and depression significantly predicted overall QoL, HF and PSP well being. These findings are similar with the earlier findings which suggested that anxiety and depression were considered as indicators of QoL 28 . Therefore, present study could not find out the bidirectional relationship between anxiety, depression and QoL. According to Wilson and Cleary model there is reciprocal relationship between anxiety, depression and QoL. But it is difficult to say that which one is the predictor or which one is outcome. There is ongoing debate on this issue 29 .

CONCLUSION
The study found that anxiety and depression are significant psychological issues that need to be screened and identified for a formal assessment and management in any life threatening chronic condition. Anxiety and depression can have a considerable negative influence on the overall QoL of BCS and significantly affect their psychological well-being. Efforts need to focus on adding quality and not just quantity to life.