A correlational study of reproductive concerns with self-disclosure and mental resilience in breast cancer patients of childbearing age in China

Objective The current study aimed to investigate the prevalence of reproductive concerns in breast cancer patients of Chinese women of childbearing age, to explore the effects of self-disclosure and mental resilience on reproductive concerns, and to explore the relationships among the three variables. Correlation research design was used.274 women suffering from breast cancer with age (M=38.10, SD=6.44) were taken from two tertiary hospitals in Guangzhou. The participants were asked to ll out a set of self-reported questionnaires including the Sociodemographic data, Reproductive Concerns after Cancer scale (RCACs), the Distress Disclosure Index (DDI), and the 14-Item Resilience scale (RS-14). The mediation analysis was tested using SPSS (Process-plugin) and the bootstrap method. A total of 252 valid questionnaires were collected in this study. 36.1% of the patients scored highly in at least one dimension of reproductive concerns, with Child's health and Personal health being the top two concerns. Correlation analysis revealed that there was a signicant positive relationship between self-disclosure and mental resilience. Self-disclosure and mental resilience had a negative relationship with reproductive concerns, respectively. The results of the mediation analysis showed that there was a mediational role of mental resilience between self-disclosure and reproductive concerns. It was levels of


Introduction
In recent years, the incidence of breast cancer in Chinese women is rising and showing a younger trend. [1] Among women with breast cancer, 25% are diagnosed in their reproductive years. [2] With the introduction of late marriage and late childbirth and the opening up of the two-child policy, many women are still willing to have children after a cancer diagnosis. [3] However, due to the uncertainty of fertility caused by cancer treatment, the characteristics of the disease itself, and the side effects in the treatment process, female cancer patients may experience a range of reproductive concerns, including the fear of infertility, the negative impact of infertility on relationships, the risk of birth defects or cancer in children, and concerns about poor health affecting the ability to raise children. [4,5] Several papers indicated reproductive concerns are common among cancer survivors. [6,7] These concerns persist after diagnosis and treatment and may worsen during survivorship with researches indicating that concerns about infertility remain constant or even increase over time [8,9] and reproductive concerns can independently predict depressive symptoms later in survivorship (12 years on average) in breast cancer patients younger than 45 at the time of diagnosis. [10] Other researches also con rmed that reproductive concerns are associated with poorer psychosocial health outcomes and poorer quality of life in survivorship. [11][12][13] Assisted reproduction, as a fertility protection technology, has been gradually applied in the fertility care of cancer patients, and to some extent alleviated the concerns of patients. [11][12][13] However, it is not widely used in clinical practice, especially for women, due to the expensive cost, ethics, and some other issues. [15] It is reported that female cancer survivors experience reproductive concerns associated with unmet access to information and services related to their fertility. [7,16] Several interventions with the main purpose of providing information related to fertility, such as fertility counseling [14] and web-based texting send evidence-based information on reproductive health issues, [17] have been carried out. However, studies of the effectiveness of these interventions have produced mixed results. Sinha et al. found that fertility counseling for women newly diagnosed with cancer can reduce anxiety, pain, and reproductive concerns. [18] While Young et al. reported that compared with patients who did not receive fertility counseling before cancer treatment, those who received fertility counseling before cancer treatment were 1.2 times more likely to subsequently have moderate to high reproductive concerns. [19] Regardless of the outcome of fertility counseling, one thing is certain that fertility counseling gives patients more information about post-cancer fertility. But what does this information bring to the patient? Whether there is more or less reproductive stress is uncertain.Therefore, further exploration of other interventions is needed.
Self-disclosure is the transmission of personally relevant and revealing information to another person, which can include factual thoughts or feelings as well as nonverbal, behavioral communication. [20] The importance of self-disclosure has been emphasized, there are frequent claims that open communication and self-disclosure are bene cial to patient adaptation. Zhen and colleagues revealed that self-disclosure eased the depression of the ood victims. [21] Another group showed that cancer survivors with higher levels of self-disclosure have more positive effects and more posttraumatic growth. [22] Zhang et al. performed a randomized controlled trial of a guided self-disclosure intervention to facilitate bene t nding in Chinese breast cancer patients, like the above results, this study also achieved the expected good results. [23] However, evidence on the impact of self-disclosure on reproductive concerns is scant, with only one study showing a negative correlation between reproductive concerns and self-disclosure. [24] Therefore, more research is needed to verify the relationship between reproductive concerns and self-disclosure.
Mental resilience is considered as a dynamic process in which individuals show effective adaptation in the face of stress and adversity. [25] Individuals with high mental resilience can nd the psychosocial, cultural, and material resources to maintain their happiness and make concentrated use of them to achieve a good state of mental adaptation. [26] Some studies have also con rmed the negative correlation between resilience and stress [27][28][29][30] . Therefore, we hypothesize that patients with high mental resilience may have more positive cognition and better adaptability in the face of post-cancer fertility problems, thus effectively alleviating their post-cancer reproductive concerns.
At present, there are few reports on relationships among mental resilience, self-disclosure, and reproductive concerns.
We would like to explore the relationships among the three variables. Self-disclosure can signi cantly predict more external protective factors, such as social support and intimate relationship. [31,32] While these factors are bene cial for enhancing mental resilience. [33,34] So, self-disclosure may promote mental resilience. Therefore, we hypothesize that (1) self-disclosure is positively correlated with mental resilience and negatively correlated with reproductive concerns, (2) mental resilience plays a mediating role between self-disclosure and reproductive concerns.The model was shown in

Materials And Methods
Participants and procedure This is a cross-sectional study based on several self-reported questionnaires. A convenience sampling method was carried out in two tertiary hospitals in Guangzhou from November 2019 to August 2020. The inclusion criteria for the target population are as follows:(1) the patient was pathologically diagnosed with breast cancer;(2) surgery or neoadjuvant chemotherapy has been performed;(3) between the ages of 18 and 49;(3) having normal cognitive abilities; (4) willing to participate in the investigation. The exclusion criteria were as follows:(1) not knowing the diagnoses of their diseases, (2) Combined with other types of cancers.274 questionnaires were issued, of which 252 were valid, with an effective recovery rate of 91.97%. The study was approved by the institutional review board.

Measures
The sociodemographic characteristics were designed by the researchers after consulting the literature, including age, marital status, educational level, number of children, recurrence of cancer, family history of tumor, occupational status, medical burden, fertility intention after cancer diagnosis, therapy method, the time since the rst diagnosis.
Reproductive concerns were measured by the Reproductive Concerns After Cancer scale (RCACs). The scale was developed by Gorman et al [35] in 2013, with a total of 18 items. The scale is divided into six dimensions: Becoming pregnant, concerns about Fertility potential, Partner disclosure, Child's health, Personal health, and Acceptance. Likert 5 scoring method is adopted for each item, in which items 5, 10, and 15 are scored in reverse. The higher the score, the more anxious the patient was about fertility. The total Cronbach's coe cient of the Chinese version of the RCAC scale was 0.792, and the Cronbach's coe cient of each dimension was 0.720~0.864. [36] For each dimension, a mean value of 4 indicates a high level of reproductive concerns. [35] The level of self-disclosure was measured using the Distress Disclosure Index (DDI) developed by Hessling et al [37] in 2001. A ve-point Likert scale from 1 to 5 is used for each item. Items 2, 4, 5, 8, 9, and 10 are scored in reverse. The higher the DDI score indicating the higher the degree of self-disclosure. This scale was revised in Chinese by Li Xinmin et al. [38] in 2009 with good internal consistency reliability (α=0.886). The 14-Item Resilience Scale (RS-14) [39] was used to measure mental resilience, containing two factors, namely "personal competence" and "positive cognition". Likert 7 rating scale was used for each item, with a total score ranging from 14 to 98 points. The higher the score, the better resilience. The Cronbach's α of the Chinese version of the RS-14 scale was acceptable (α=0.93).
Statistical analysis SPSS 26.0 software and the PROCESS plug-in was used for data analysis. Measurement data were expressed as mean standard deviation and counting data in the form of percentages. Two independent sample T-tests and ANOVA tests were used to compare reproductive concern scores between/among groups. Pearson correlation analysis was conducted to explore the correlations among reproductive concerns, mental resilience, and self-disclosure. PROCESS V3.5 (Model 4) was used to analyze the mediating effect of mental resilience between self-disclosure and reproductive concerns. The 95% con dence interval (CI) was calculated by 5000 bootstrap samples. If the 95% CI of the mediation path does not contain 0, the indirect effects are considered statistically signi cant.

Results
Common method deviation test Before data analysis, Harman single factor test was used to conduct a common method deviation test for all items of the scale used in this study. The results showed that there were 9 factors eigenvalue greater than 1, and the variation explained by the rst factor was 22.733%, less than 40% [40] , indicating that the data in this study were not signi cantly affected by common method deviation.  2.0% reported a high level in the dimensions "Fertility potential," and "Becoming pregnant." To our surprise, none of the subjects showed a high level in the remaining two dimensions"Partner disclosure" and "Acceptance".See Table 2 for more details.

Correlation analysis
The mean scores of reproductive concerns and its dimensions, self-disclosure, and mental resilience, and the results of the Pearson's coe cient correlation analysis of these variables are shown in Table 3. It can be observed that organizational self-disclosure was positively associated with mental resilience and negatively associated with reproductive concerns and its dimensions except for acceptance. Notably, mental resilience was negatively associated with reproductive concerns and its dimensions (becoming pregnant, concerns about fertility potential, partner disclosure, child's health, personal health) except acceptance.  Table 5.

Discussion
In this study, the reproductive concerns score of breast cancer patients of childbearing age was 47.63±9.10, which is in line with the result of Ba´rtolo et al... [13] 36.1% of the participants reported a high level of reproductive concerns in ≥1 dimension of the RCAC, and at least two dimensions of high levels were reported by 4.8%, signi cantly lower than the results reported by Ljungman et al.: 58% scored high in at least one dimension, and 22% scored high in at least two. [7] This may be because our participants were older, and the percentage of patients without children is small (8.7%).
While, when it comes to types of concerns, our results are consistent with those of Ljungman et al. [7] Child's health and Personal health are the two dimensions that get the most attention. This gives clinical workers a clue that even if patients do not want to have more children, they still have high-level concerns about Child's health and Personal health, which means that some aspects of reproductive concerns are common among women of childbearing age with breast cancer.
To our surprise, none of the participants showed a high level of concern in terms of Partner disclosure and Acceptance, even among patients who had fertility intentions after diagnosis. The reason may be that most of the patients are in the early stage of treatment, and the patients and their families may pay more attention to the treatment of the disease, thus temporarily reducing the need for fertility.
The results of correlation analysis in this study showed that self-disclosure of breast cancer patients of childbearing age was negatively correlated with reproductive concerns (r=-.417, P 0.01). .. [24] Breast cancer patients of childbearing age face unique physical and mental challenges. Changes in menstruation, decreased fertility, potential health-related problems after pregnancy, and genetic risks for offspring can all be of concern to patients. [41,42] Self-disclosure can not only help patients gain insight into their inner feelings and enhance their self-knowledge but also help them obtain more social support. [32] There was a signi cant negative correlation between reproductive concerns and social support in breast cancer patients. [43] From this perspective, we proposed that social support helps alleviate reproductive concerns. It means that self-disclosure might indirectly affect patients' reproductive concerns by increasing their social support.
Therefore, clinicians should be aware that patients with breast cancer of childbearing age may face psychological distress caused by reproductive, and it is of great signi cance for them to express their inner feelings and information.
While, in this study, the score of self-disclosure of breast cancer patients of childbearing age was 39.75±7.64, lower than the average level of female self-disclosure of 42.21±9.16, [44] and this result is supported by the research of Wang et al. [45] To our knowledge, few studies have investigated the factors that in uence self-disclosure in breast cancer patients.
The psychological trauma caused by cancer, the change of body image brought by treatment, or the fear of aggravating the psychological burden on the family may all be factors that lead to the disorder of disclosure. We suggest that the in uencing factors and intervention measures of self-disclosure in breast cancer patients of childbearing age should be further explored in future studies.
Mediating analysis was used to clarify the relationships among mental resilience, self-disclosure, and reproductive concerns, and the results con rmed that mental resilience mediated the relationship between self-disclosure and reproductive concerns. Among them, self-disclosure can have a direct impact on mental resilience, which means that the higher the degree of self-disclosure, the better the mental resilience, which is consistent with the result of Yamashita. [46] The self-disclosure process model proposed by Chaudoir et al. [47] indicates that positive self-disclosure not only enables patients to release their repressed emotions but also can increase others' understanding of them, promote intimate relationships, obtain social support, and other bene cial resources. And these are all good factors for improving mental resilience. Individuals with a high level of mental resilience have strong adaptability and can adopt more positive coping styles when faced with adversity and pressure. [48] Therefore, breast cancer patients with high mental resilience may have a higher psychological tolerance to stress events such as decreased fertility and poor disease progression and are more likely to adopt an optimistic attitude and positive coping style to relieve their inner pressure.
Taken together, high levels of self-disclosure and good mental resilience can help to relieve the reproductive concerns of patients, and self-disclosure can also help to strengthen mental resilience.

Study limitations
This study is a cross-sectional observational study, unable to determine the causal relationship between self-disclosure and mental resilience, and the use of convenient sampling in this study may make the sample less representative.

Clinical implications
This study suggests that self-disclosure may play a role in improving patients' mental resilience and alleviating their reproductive concerns. But breast cancer patients may tend to hide and be reluctant to disclose under the in uence of multiple factors, which is not a good phenomenon. In total, this study provides a theoretical basis for the development of self-disclosure interventions for breast cancer patients with fertility concerns, but how to make interventions more effective is challenging. Clinical staff may need to consider personalization factors when developing self-disclosure measures.

Conclusion
This study preliminarily elucidated that self-disclosure is bene cial to relieve and improve mental resilience in breast cancer patients, this study preliminarily clari ed that self-disclosure is bene cial to relieve reproductive concerns and improve mental resilience of breast cancer patients, which provides a reference basis for the development of fertility care for breast cancer patients. As reproductive concerns are common among cancer patients of all kinds, similar studies should be conducted in patients with other cancer types. Con icts of interest/Competing interests The authors declare that they have no con icts of interest.

Declarations
Ethics approval This study is in full compliance with institutional review board guidelines for the protection of human subjects.
Consent to participate Informed consent was obtained from all individual participants included in the study.
Consent for publication Informed consent for publication was obtained from all participants.
Availability of data and material The datasets used or analysed during the current study are available from the corresponding author on reasonable request.
Code availability Not applicable.
Authors' contributions Conceptualization and design:Zhang Lili, Yu Ya and Liu Suting; data curation: Yu Ya,Liu Suting and Ye Yanxin; manuscript writing and editing: Yu Ya and Zhang Lili. All authors have read and approved the nal manuscript.