Social Relationships and Its Association With Affective Symptoms of Women With Breast Cancer: a Scoping Review

Background: Problems in affective and cognitive functioning are among the most common concurrent symptoms that breast cancer patients report. Social relationships may provide some explanations of the clinical variability in affective-cognitive symptoms. Evidence suggests that social relationships (functional and structural aspects) can be associated with patients’ affective-cognitive symptoms; however, such an association has not been well studied in the context of breast cancer. The purpose of this scoping review was to address the following question: What social relationships are associated with affective-cognitive symptoms of women with breast cancer? This scoping review used the framework proposed by Arksey and O’Malley and PRISMA-Sc. Extracted data included research aims, design, sample, type and measures of social relationships (functional and structural), and the association between social relationships and affective-cognitive symptoms. Results: Of sixty-ve included studies, none of them focused on cognitive symptoms of breast cancer patients; thus, in this review, we focused on only the affective symptoms of breast cancer patients and their association with patients’ both aspects of social relationships. Conclusion: Our ndings reveal that positive social relationships benet in mitigating affective symptoms of women with breast cancer. Thus, health care providers need to educate patients about the importance of building solid social relationships and encourage them to participate in a supportive network of friends and family members.


Background
With advances in medical treatments, breast cancer mortality rates have steadily declined in recent years, resulting in an increase in 5-year survival rates. (1) According to the report from American Cancer Society in 2017, the overall survival rates have increased from 68-89% for White women and from 55-81% for Black women. (2) Resultantly, cancer is no longer viewed as an incurable acute disease. Instead, it follows the trajectories of chronic diseases that is characterized by periods of remission and exacerbation of symptoms.(3) Women with breast cancer often experience symptoms that co-occur (i.e., symptom clusters) during the disease trajectory.(3) For example, patients experience affective and cognitive problems (symptoms) concurrently. The co-occurrence of these symptoms is called a psychoneurological symptom cluster.(4) Further, these two symptoms within a psychoneurological cluster are strongly related to each other. (4,5) Problems in affective and cognitive functioning are among the most common concurrent symptoms that breast cancer patients report. (4,5) Cognitive symptoms include changes in memory, concentration, processing speed, executive function, and language, whereas affective symptoms include mood changes such as anxiety and depression. (4,5) Factors that contribute to affective-cognitive (i.e., psychoneurological) symptoms were identi ed as stress, hypothalamic-pituitary-adrenocortical axis dysfunction, cytokine dysregulation, telomere shortening, or DNA damage(4); however, these factors do not su ciently explain the variability in cognitive-affective symptoms. For example, some patients have reported persistent and high levels of mood disturbance and cognitive impairment for several years or more following cancer treatment.(6) This nding suggests a need to investigate other potential factors that can explain their clinical variabilities.
Social relationships may provide some explanations of the clinical variability in affective-cognitive symptoms. Social relationships can be characterized as aspects, structural and functional. The structural aspect re ects the size, scope, and connectedness of social relations (e.g., social integration), while the functional aspect covers the interpersonal interaction within the structure of the social relations (e.g., social support). (7) Both aspects of social relationships can in uence patients' affective and cognitive symptoms. Recent systematic reviews have reported that the older populations showed a greater decline in their cognition when their social relationship was functionally and structurally poor. (8,9) Additionally, patients who had greater social support and cohesive relationships with their family members showed fewer depressive symptoms. (10,11) Evidence suggests that social relationships can be associated with fewer patients' affective-cognitive symptoms. One study has reported that breast cancer survivors demonstrated higher levels of depressive symptoms over the trajectory of their illness when they received lower levels of social support. (12) In addition, those with less social support showed cytokine dysregulation which is recognized as a contributing factor for cognitive symptoms. (12,13) Other studies have reported that social relationships play an important role in the protection against affective symptoms (14,15), ultimately improving survival outcomes of breast cancer patients. (15) Social relationships (functional and structural aspects) appear to be associated with fewer affective-cognitive symptoms in breast cancer patients; however, such association has not been well studied.

Purpose
The purpose of this scoping review was to address the following question: What social relationships are associated with affective-cognitive symptoms of women with breast cancer? This will lay the foundation for studies that explicate the mechanism of affective-cognitive symptoms in breast cancer patients. This understanding will also allow clinicians to identify patients more precisely at risk for affective-cognitive symptoms associated with social relationships and will contribute to the development of strategies to prevent and manage these symptoms.

Methods
We followed the ve methodological stages of scoping review developed by Arksey and O'Malley(16). This review was conducted based on the following stages: 1) identifying the research question, 2) identifying relevant studies, 3) selecting studies, 4) charting the data, and 5) collating, summarizing, and reporting the results. We reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). (17) Figure 1 presents study selection by owchart as per PRISMA guidelines.

Stage 1. Identifying research questions
We identi ed a research question using the PCO model(16): "What social relationships ("C", concept) are associated with affective-cognitive symptoms ("O", outcome) of women with breast cancer ("P", population)?" We limited our study population of women with breast cancer aged 18 years and above because of different trajectories and manifestations of cognitive symptoms that children with cancer show compared with adults.(18) Table 1 describes eligibility criteria for the studies that were included in this scoping review. Studies that did not assess the association between social relationships and patients' affective-cognitive symptom.
Studies that were explicitly about individuals with cognitive de cits attributed to non-cancer causes such as psychiatric or neurological illness, dementia, stroke, brain injury or delirium. were excluded if they did not clearly meet inclusion criteria, and of those, 3,291 references were deemed irrelevant and excluded. Upon the completion of screening titles and abstracts, any disagreements were resolved by discussion. One hundred thirty-eight citations were identi ed for full text assessment. At the full text review stage, articles were independently read by two different members of team (YY, YL, GS). During the full-text review, each study was reviewed independently to determine the nal sample. Full-text studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were noted. Disagreement between the team members were resolved through discussion. 65 articles were con rmed to be included in the nal set for data extraction (Figure 1).

Stage 4. Charting the data
Our team developed a data extraction tool and determined which data should be extracted from studies to answer the research question. Two team members (YY, GS) independently piloted data abstraction from the rst fteen included studies using the data charting form. Then, they discussed the process and their results to con rm whether their approaches to data extraction were consistent. Questions arising when piloting the extract data form were discussed with the other team members (YL, TN). After piloting the form, two team members (YY, GS) independently recorded the following data from selected studies on the data charting form: 1) authors, 2) country of study, 3) year of publication, 4) study design, 5) sample characteristics (sample size, age, and type of cancer treatment), 6) type of social relationships 7) affective-cognitive symptoms and measurements, and 8) key ndings (the association between social relationships and affective-cognitive symptoms).

Association between social relationships and affective symptoms
In this review, social relationships were classi ed as functional and structural aspects of social relations. Of the included 65 studies, 60 focused on functional aspects of social relationships, and the remaining 5 reported on structural aspects of social relationships. Interestingly, none of the included 65 studies examined the association between social relationships and cognitive symptoms of breast cancer patients; thus, in this paper, we focused only on the affective symptoms of breast cancer patients and their association with patients' social relationships.

Functional aspects of social relationships
Social support, satisfaction of social support, quality of the relationship, social constraints, and family functioning (including family con ict and family stress) are functional social relationships included in this review.

Social support
Forty-nine studies examined the association between social support and affective symptoms among breast cancer patients. Of those 49 studies, four did not nd any associations of affective symptoms with social support (19)(20)(21)(22), whereas one showed that patients' affective symptoms can be changed depending on the source of provided support was. (19) A reduction in patients' depression was reported when patients received peer support from patients who are newly diagnosed with cancer rather than from patients who are undergoing active treatment. (19) Among 45 studies that reported signi cant association with affective symptoms, 33 investigated the association of patients' affective symptoms with the quantity of social support that patients received. The quantity of social support refers to the amount of social support that is available to patients (e.g., frequency of meetings). (23) Patients showed lower levels of anxiety, depression, worry, mood disturbances, and psychological/mental distress when they received a greater quantity of social support. (12,22, Furthermore, some studies reported that the quantity of social support can predict the levels of patients' affective symptoms including their emotional well-being. (47)(48)(49)(50)(51)(52)(53)(54) In addition to the quantity of social support, seven studies reported an association between type of social support and affective symptoms. Emotional (i.e., subjective) support, de ned as support that includes the provision of care, empathy, and trust, was found to be most helpful to decrease patients' depression and anxiety. (36,46,52,55) In other words, as patients received stronger emotional/subjective support, their experience of affective symptoms decreased.
Some longitudinal studies showed that emotional/subjective support can function as a predictor of patients' anxiety and depression. (32,56,57) Additionally, improvements in affective symptoms occurred when tangible support such as material support/assistance (e.g., brochures) was provided. (32,36,52,55,56) In six studies, patients' affective symptoms were affected by source and satisfaction of social support received in six studies. When patients received support from their family members, including a spouse or children, they reported less anxiety and depression.(41, 58-61) However, one study showed less depression and anxiety when support was received from friends compared to support from family.(62) In addition, higher satisfaction with support received was associated with the lower levels of patients' anxiety and depression. (30,58,(63)(64)(65)(66) A study reported that patients showed less affective symptoms when they were more satis ed with support from family than from friends.(62) Patients' affective symptoms were not related to whether they were satis ed with their friend's support but were related to the amount of support received from a friend.

Social support and/or social constraints
Three studies have examined the association of patients' depression with social constraints.(67-69) Patients who perceived social constraints from family (including spouse/partners) or friends showed higher depressive symptoms.
However, patients showed lower depression when they had decreased family/friend social constraints. Patients reported no change in depression when social constraints increased. (68, 69) Also, lower depression was reported when patients received greater social support.

Social support and Family functioning
One study found that both patients' anxiety and depression decreased when they had greater social support and a better-functioning family.(70) Furthermore, family functioning predicted the levels of patients' anxiety and depression. (70) In line with this nding, three other studies also found higher depression in patients when they perceived poor/ineffective family functioning. Speci cally, depression greatly increased when patients experienced inappropriate responses from family(71), con icts between its members (i.e., family con ict) (72), and stress due to the demands on the family (i.e., family stress). (73)

Quality of relationships
Four studies investigated the quality of relationships with patients' partners/spouses that patients perceived and assessed its association with their affective symptoms. Of those four, two of them failed to show any signi cant associations of affective symptoms with the quality of couple/marital relationships. (74,75) However, one study showed that anxiety was not associated with patient's reported relationship quality but with the partner's reported relationship quality. (75) The other two studies showed that patients' psychological distress and mood disturbance increased when patients reported unsatisfying relationships with their spouse/partners.(76, 77) Speci cally, one study found that lower mood disturbance was reported when patients have a partner relationship with greater cohesion and expression (i.e., open communication) as well as more constructive con icts. (77) The authors interpreted constructive con icts as an indicator of greater engagement in the relationship with partners. In other words, constructive con icts can occur due to greater discussion/understanding of each other's speci c needs, and this constructive con ict can help reduce patients' mood disturbances.

Structural aspects of social relationships
Structural aspects of social relationships refers to the structure of social networks, such as the size and the linkage between members within a social network. (7) This review included social integration as the structural social relationships (Table 2).

Social integration
In this review, one randomized controlled trial that investigated the effect of psychoeducational intervention examined the association between social integration and affective symptoms of breast cancer patients.

Discussion
Sixty-ve studies met the inclusion criteria and informed this review. None of the included studies examined the association of social relationships with patients' cognitive symptoms, thus including studies that investigated the association of social relationships with affective symptoms. Of those 65 studies, four studies completely failed to show signi cant associations of affective symptoms with any aspects of social relationships.; (20)(21)(22)74) We found that most patients who participated in those four studies were primarily treated with surgery, which could be interpreted as showing very early stage breast cancer. In contrast/However, in patients with advanced cancer (metastatic disease), social relationships play an important role in promoting their affective symptoms. (33,60,63,77) This nding suggests that patients with advanced stage cancer can bene t from social relationships in managing their affective symptoms compared with those with early stages of cancer.
In this review, social relationships were divided into their function and structural aspects. Functional aspects of social relationships include four variables: social support, social constraints, family functioning, and quality of relationship.
Social support refers to aid provided (e.g., emotional or instrumental) through contact with one's social networks (e.g., friends or family),(7, 79) whereas social constraints are social conditions that hinder individuals' expression of stressors due to unsupportive, misunderstood, or isolated responses from others.(84) Our ndings clearly show that patients' affective symptoms can be improved depending on the quantity (e.g., time spent or availability), type (e.g., tangible aid or empathy), source (i.e., who provided support), and satisfaction from the support that they received. Contrary to such positive impact, patients showed greater affective symptoms when they perceived negative social interactions (i.e., social constraints) and poor family functioning. Compared with other functional aspects, ndings regarding the quality of social relationships are not consistent. Some studies reported that the quality of relationships is associated with patients' affective symptoms(76, 77), but others do not. (74,75) Furthermore, one study showed that patients who reported greater con icts in relationships with partners also reported lower mood disturbances. (77) Future studies would bene t from ensuring consistency and speci city in de ning and measuring quality of social relationships.
Similarly, structural aspects of social relationships also show an association with patients' affective symptoms. All ve included studies showed that having a support person, not living alone, and building close relationships with others are factors that lower patients' affective symptoms. It is possible that patients with larger social networks and greater social integration may increase the odds that patients will have friends and family who survive as peer and familiar support.(85) This support can be bene cial while patients are managing symptoms from disease and/or treatment.(85) Additional research is needed to understand how structural and functional aspects of social relationships interact and in uence patients' affective symptoms. This understanding may help identify important concepts for models that promote social relationships in breast cancer patients that will help improve their affective symptoms.

Implication for Practice
Most interventions for those with affective symptoms have primarily focused on managing their internal clinical characteristics. However, our ndings reveal that positive social relationships bene t in mitigating affective symptoms of women with breast cancer. Thus, health care providers need to educate patients about the importance of building solid social relationships and encourage them to participate in a supportive network of friends and family members.
Patients with advanced cancer may nd it highly bene cial to have access to support groups that are relevant to their speci c needs. This type of support may help mitigate patients' affective symptoms.
It is also important to assess whether patients have anyone to talk to or attend appointments with them. This type of assessment may be helpful in preventing, and furthermore, mitigating their affective symptoms. Additionally, establishing a social system to support coordination of various types of social relationships from healthcare professionals may yield positive affective outcomes in breast cancer patients. More expanded studies on the impact of social relationships on affective symptoms of breast cancer patients are recommended.

Limitations
Our study goal was to nd literature hat examined the association between social relationships and cognitive symptoms among breast cancer patients. The review of literature yielded that there are no published studies that study this association based on our review criteria. During the literature search, we found several studies that investigated this association in healthy older adults.(8, 9) However, no studies have been conducted in the context of breast cancer. We only included articles that explore the association between social relationships and affective symptoms of breast cancer patients. Future research is needed that considers the effect of social relationships on cognitive symptoms in breast cancer is needed to advance our knowledge in cancer symptom science.
Approximately half of the included studies did not report confounding factors (e.g., sociodemographic) and did not adjust for these factors This is an important limitation because the associations between social relationships and a patients' affective symptoms could differ depending on confounding factors. Thus, it is essential to report and adjust for confounding factors using statistical methods. Availability of data and material: All data generated or analyzed during this study are included in this published article and its supplementary information les. Figure 1 PRISMA-ScR ow diagram for the study selection process Supplementary Files