4.1 Supportive care needs of patients with breast cancer receiving chemotherapy is at the higher level
Efforts for the continuous improvement of clinical nursing quality focus on systematically understanding the needs of patients with tumors, exploring ways to provide the most appropriate professional support and care services, helping patients to manage physical and mental pain, and maximizing the quality of life of patients . The results of this study showed that the average score of supportive care needs of breast cancer patients with chemotherapy was ( 2.80 ± 0.46 ) points, which was higher than that of Cai et al.  in the longitudinal study of breast cancer patients with postoperative chemotherapy ( 2.23 ± 0.74 ) points. The score was similar to that of ( 2.80 ± 0.59 ) points in gastric cancer patients investigated by Chen et al. . It is suggested that the supportive care needs of patients with breast cancer receiving chemotherapy are high, and support care by medical staff is urgently needed.
In addition, among the five dimensions of the SCNS scale, the health system services and information needs dimension yielded the highest average score and unmet rate; these findings are consistent with the conclusions of current domestic studies [18, 19]. This evidence shows that the health system services and information needs are the most common unmet and urgent needs of patients with breast cancer receiving chemotherapy [18, 19]. Yu et al. retrospectively analyzed the information of 1,586 online consultations of 247 patients with breast cancer in China within 6 months following operation. They found that the information needs of patients during chemotherapy were high; this was mainly reflected in the process of chemotherapy, management of treatment-related adverse effects, infusion tube-related problems, and consultation of examination reports. It is suggested that medical staff should actively integrate traditional follow-up and mobile health, use the needs of patients with different characteristics for guidance, carry out diversified health education support (e.g., centralized answering, video publicity during hospitalization, peer education, family synchronization education), and set up multi-disciplinary teams for breast cancer. These measures would assist in the integration of medical resources and provide one-stop, high-quality diagnosis and treatment services for patients. In addition, further investigation is warranted for the development of localized personalized survivorship care plan tools, optimization of the process of supportive care, and timely assessment of the effects. This approach would ultimately lead to personalized, continuous, and coordinated care .
Among the breast cancer patients undergoing chemotherapy, patients living in rural areas had higher demand for supportive care. In addition, the hierarchical regression results of this study showed that residence was the influencing factor of supportive care needs of breast cancer patients receiving chemotherapy (P < 0.05). These high needs may be related to the fact that 60% of patients resided in rural areas, the lack of economic support, or family burden restricting the realization of these needs. Wang et al. reported significant differences between urban and rural areas in the supportive care needs of patients with breast cancer. The needs of patients residing in rural areas were significantly higher than those of patients residing in urban areas. This difference was mainly related to two factors: 1) the unbalanced allocation of medical and health resources between urban and rural areas in the development of the medical system in China; and 2) fewer opportunities for general practitioners or community nurses in rural areas to receive care training. The key to solving this problem lies in the continuous improvement of China's medical insurance system and medical service system. In addition, medical staff should try their best to help such patients control medication costs, contact charitable assistance and other organizations to give patients material support.
The hierarchical regression analysis showed that the Number of chemotherapy cycles is an influencing factor of supportive care needs of patients with breast cancer receiving chemotherapy; this result is consistent with the conclusions stated by Chen et al.. The reason for this relationship may be that most patients with breast cancer receiving postoperative chemotherapy have limited knowledge and self-management skills regarding this type of treatment. In addition, some patients exhibit poor psychological adjustment; hence, their supportive care needs is high. However, with the increasing Number of chemotherapy cycles, the disease knowledge and skills of patients with breast cancer are increasing, the psychological uncertainty is decreasing, and the supportive care needs is reduced. Therefore, it is recommended that medical staff assess the supportive care needs of patients with breast cancer receiving their first cycle of chemotherapy and provide them with tailored health education. In addition, the focus of health education should be adjusted according to changes in the Number of chemotherapy cycles.
4.2 Self-management efficacy of patients with breast cancer receiving chemotherapy is at the medium level
With the gradual extension of the survival time of patients with breast cancer, the actual level and advantages of self-management efficacy in the management of chronic disease have become increasingly prominent . As the core concept of chronic disease management, it reflects the confidence of patients in their ability to self-manage the disease. The results of this study showed that the self-management efficacy scores of patients with breast cancer receiving chemotherapy were at the medium level (91.71 ± 12.16) points. Notably, these values were higher than those recorded by Qian et al.  (87.46 ± 26.43) points. This shows that the subjective confidence of patients with breast cancer chemotherapy for the self-management of disease increases with the progress of treatment. In this study, the total score of self-management efficacy of patients with breast cancer receiving chemotherapy was lower than that reported by Yang et al. in a study of patients with head and neck cancer receiving radiotherapy, this score was (99.06 ± 18.07) points. The reason for this may be that the confidence of patients in coping with the disease varies depending on the type of disease. For example, breast cancer and its treatment destroy the secondary sex characteristics of women, and is more likely to cause psychological problems (e.g., physical pain and low self-esteem) seriously affecting the confidence of patients to actively respond to diseases (i.e., self-management efficacy) compared with head and neck malignant tumors .
Moreover, the results showed that the average scores of the three dimensions of self-management efficacy from high to low were positive attitude, self-decompression, and self-decision making. The average score of self-decision making items was the lowest, indicating that patients with breast cancer receiving chemotherapy did not have strong autonomy in the selection of treatment regimens and decision to accept relevant treatment. The potential reasons for this are provided below. Firstly, in China, the clinical workload is heavy and the communication time between doctors and patients is limited. Therefore, the prognosis of the treatment plan cannot be thoroughly explained, resulting in information asymmetry between doctors and patients and compromising the ability of patients to participate in treatment decisions. Secondly, some treating physicians do not determine whether patients prefer to participate in treatment decision making, pay less attention to complaints expressed by patients, spend limited time to encourage them to participate in treatment decision making, and prioritize communication with relatives of patients regarding the disease and treatment . Therefore, decision making may be influenced by the views of family members, thereby limiting the participation of patients in this process. It is suggested that medical staff should fully evaluate the decision-making expectations and preferences of patients with breast cancer receiving chemotherapy (particularly those with low self-management efficacy level), actively mobilize relatives of patients with breast cancer, empower patients to actively participate in disease management and treatment decisions, and develop localized and intelligent decision-making aids for patients with breast cancer in China . These measures would improve the treatment decision-making process.
4.3 Effect of self-management efficacy on supportive care needs
The results of this study showed that the total score and score of each dimension of self-management efficacy of patients with breast cancer receiving chemotherapy were negatively correlated with the total score and score of each dimension of supportive care needs (P < 0.05). These data suggest that higher self-management efficacy of patients is associated with a lower degree of supportive care needs. This is consistent with the conclusions reported by Dong et al.  and Bagnasco et al.  showed that patients with diabetes and high self-management efficacy could actively seek external social support resources and participate in the self-management of diabetes; hence, their supportive care needs by medical staff was relatively low. In addition, hierarchical regression analysis in this study showed that self-management efficacy was the main influencing factor of supportive care needs of patients with breast cancer receiving chemotherapy (P < 0.05), and could explain 29.8% of the variation in supportive care needs. Thus, improving the self-management efficacy of patients is important for reducing their supportive care needs.
Therefore, it is suggested that medical staff should assess the level of self-management efficacy in patients with breast cancer receiving chemotherapy. This approach would improve the self-management efficacy and self-management skills of patients (i.e., problem solving, self-decision making, resource utilization, partnership with medical staff, action planning and self-tailoring) through self-management education. Moreover, medical staff should also focus on improving their professional skills, as well as expanding and extending non-drug therapy (e.g., meditation, relaxation, yoga, music therapy, acupoint pressing, and acupuncture) to help patients cope with adverse effects during chemotherapy .