According to the World Health Organization’s International Agency for Research on Cancer (IARC) report, in 2020, new cancer cases and death rates in China ranked first in the world, and the age-standardized incidence of cancer in women was on the rise (1, 2). Survival rates for women with cancer are statistically about 50% higher than those for men (1). This longer survival period with cancer makes the psychological vulnerability of female cancer patients more pronounced as they face cancer treatment and carry the disease for longer. Oona et al. showed that the severity of psychological problems in female cancer patients was significantly higher than that in males (3). During cancer diagnosis, treatment, and recovery, psychological distress can occur on a continuum from normal fear, worry, or sadness to severe anxiety, depression, and existential despair (4). With the transformation of the traditional medical model into a biopsychosocial medical model, the psychological problems of cancer patients have received increasingly more attention from the medical community (5). Therefore, how to help female cancer patients maintain a healthy psychological state deserves to be explored more thoroughly. Previous studies have focused on the current status and influencing factors of personal control and mental disorders in female cancer patients, but few studies have focused on the important impact of demoralization on the psychological problems of female cancer patients.

Both demoralization and depression are common in cancer and are characterized by disturbed sleep and appetite and suicidal ideation. Depression is featured by anhedonia. Depression patients strive to experience expected and perfect joy while demoralization patients can still experience perfect joy (6). Demoralization is a mental state in which the patient has a persistent inability to cope along with feelings of helplessness, despair, meaninglessness, subjective incompetence, and decreased self-esteem against a background of internally or externally induced stress (7). Demoralization is a common psychological problem among cancer patients (8), with a prevalence of up to 13%-18% (8). Oona et al. showed that the degree of demoralization in female cancer patients was significantly higher than that in males (3); thus, early identification and effective intervention are of great clinical significance for female cancer patients. Yu et al.’s study systematically identified, evaluated, and synthesized the relationship between demoralization and related factors in cancer patients based on bio-psychosocial models (9) but lacked a detailed analysis of the specific effects of subtle symptoms within demoralization. Vehling et al. (10) explored the co-occurrence and independence between the demoralization and other psychiatric disorders and described the impact of demoralization on the single symptom of suicidal ideation; however, the study lacked research on the importance of each symptom of demoralization and their interactions. In addition, previous studies have used structural equations, latent category analysis, or total scores to determine the severity of demoralization. It’s a pity that both the traditional latent categorical and latent dimensional models of mental disorder view symptoms as responses to the underlying disease entity rather than factors contributing to mental disorders (11). Therefore, the latent variable can be seen as a mediator that transfers effects from stressors to symptoms. Accordingly, in latent variable models, external variables are typically modeled as conditionally independent symptoms, given the latent variable (12). There are other methods that ignore the causal relationship between observed indicators, such as the reflective model relies on the assumption that there is no direct causal relationship between variables, however, causal relations between observables are likely to exist in many psychological constructs (13).These methods do not allow one to observe subtle correlations between specific psychological symptoms (e.g., meaninglessness, worthlessness, and discouragement).In other words, it is difficult to adopt precise psychological treatments for different symptom subtypes of demoralization using traditional methods.

In recent years, network analysis has been increasingly used in the fields of psychology and psychiatry (14). In this method, each network consists of nodes and edges. Nodes represent symptoms, domains, or constructs, while edges represent partial correlations between these nodes (15). The thickness and saturation of the edges correspond to the strength of the partial correlation: The stronger the correlation is, the thicker and more saturated the edges become (16). Network analysis also provides indicators for centrality, indicating the importance of any symptom in the network. These indicators can be used to identify core symptoms in the network (17). Core symptoms have the strongest correlation with other symptoms. By accurately identifying core symptoms, determining the interconnections between core symptoms and other symptoms, and targeting the development of effective interventions, we can more accurately prevent the occurrence of serious consequences. Yang et al.’s study applied network analysis to explore the network correlates for fear of cancer recurrence, anxiety, and depression in breast cancer patients (14). However, the authors’ approach of constructing networks for multiple psychological variables may have diminished the advantages of network analysis in allowing precise measurements. Another German study investigated the interrelationship and relative importance of demoralization symptoms in patients using network analysis (18), but this study included all cancer groups and did not examine the specific population of women, making the results lack specificity. In addition, the study population included only German cancer patients. Thus, due to differences between cancer types and cultures, the results may not be applicable to Chinese female cancer patients.

In summary, to understand the interactions and relative importance of the symptoms of demoralization in Chinese female cancer patients, we need more in-depth investigations to overcome the limitations of previous studies. The present study attempts to explore the core symptoms, bridge symptoms between different psychological subgroups, and interactions between the symptoms of demoralization in Chinese female cancer patients using the approach of a network structure model. To our knowledge, this is the first study to use network analysis to explore demoralization among Chinese female cancer patients.

Demoralization is an important psychological problem in female cancer patients. Thus, it is critical to understand the complex interactions between specific symptoms in female cancer patients with demoralization to ensure accurate intervention and treatment of their psychological symptoms. To the best of our knowledge, this is the first study based on network analysis to explore the network structure relationships between specific symptoms of demoralization in Chinese female cancer patients. Through network analysis, this study identified core symptoms and bridge symptoms in the network, while focusing on symptoms in the network with the strongest edge connections.

The results showed that “Discouragement (C3)” is the most central symptom of demoralization among female cancer patients, which is manifested by the patient’s internalized feelings of disheartenment. The long cycle of cancer treatment, the need to face a variety of adverse reactions during chemotherapy or radiotherapy, uncertain treatment effects, and the fear of disease development place significant psychological pressure on patients, which can easily lead to depression and discouragement. In addition, female personality traits make such individuals more sensitive to negative events. Studies show that women’s emotional reactions are generally stronger than those of males, making them more prone to serious psychological burdens in the face of diseases (29, 30). This study confirms that “Irritable (B2)” is the most severe symptom of demoralization, “Discouragement (C3)” is the most central symptom in the network. Moreover, we were surprised to find that “Irritable (B2)” is not only the most severe symptom, but also the most prevalent symptom. And the ranking of the top three symptoms in severity is exactly the same as the top three symptoms in prevalence. The results showed inconsistency between the most severe symptoms, most prevalent symptoms and the most central symptoms, presumably due to the fact that “Irritable (B2)”, although the most prevalent and severe problem in women with cancer, has little effect on other symptoms of demoralization. “Discouragement (C3)”, on the other hand, although not the most prevalent symptom, had the strongest influence on other symptoms, suggesting that healthcare professionals should focus on the severity of “Discouragement(C3)” when assessing the mental health status of female cancer patients. The study also found that the symptom most closely connected with “Discouragement (C3)” is “Loneliness (C4)”, which means that “Loneliness (C4)” often appears together with “Discouragement (C3)”and is common in female cancer patients, with both playing a synergistic role in demoralization. The results show that both “Discouragement (C3)” and “Loneliness (C4)” are among the most predictable symptoms. According to the definition of predictability, effective interventions targeting “Loneliness (C4)” can also weaken the degree of “Discouragement (C3)”. A synergistic intervention targeting both symptoms may further improve demoralization. Medical staff should focus on the dual health education of patients and their families, encouraging family members to provide support and companion to patients, which can alleviate patients’ loneliness and frustration.

The second strongest symptom was “No self-worth (A3)”, which indicates a sense of meaninglessness in the face of the illness. Women often take on heavy family-oriented responsibilities such as housework and raising children, but the burden of disease can make them lose this role. Some patients can no longer continue to share the burden with their families, and their physical condition makes them more dependent on their family members for care, increasing the family’s burden (31). In society, most female patients cannot continue to engage in social labor to obtain remuneration for physical reasons. The survey results also show that the proportion of unemployed female cancer patients is significantly higher than that of employed and retired patients. Not being able to create economic benefits for one’s family but having to pay high medical expenses for a long period of time, alongside increased financial and energy burdens on the family can make a patient feel frustrated with her current situation. Due to this frustration, the patient can feel guilty about her family and believe that she no longer has living value (8). It is suggested that healthcare professionals encourage patients to undertake appropriate family and social responsibilities and actively participate in healthcare decision-making. Patients should also establish reasonable goals, formulate life plans, and reflect upon their self-worth through goal realization.

The third strongest symptom was “Don’t want to live (A5)”, which highlights the patient’s painful feelings of despair in the face of cancer and indicates a loss of self- efficacy and will to live. According to the survey, the incidence of suicidal ideation in female cancer patients is slightly higher than that among males (32), which may be influenced by the traditional concept of male superiority over females in China (33). Women in China occupy a vulnerable position, have weak recourse, and lack the awareness to utilize social resources, making them able to seek relief only through suicide (32). Secondly, the cycle of cancer diagnosis, treatment and rehabilitation is long, and adverse reactions increase with prolonged treatment time, making it impossible for patients to perceive a hope of recovery. For patients, these large physical and psychological burdens and a sense of guilt for one’s family can lead to a complete loss of the will to survive. “Don’t want to live (A5)” is also one of the most predictable symptoms. The most closely connected symptom is “No meaning of survival (A4)”, suggesting that medical staff’s intervention in “No meaning of survival (A4)” can reduce the degree of “Don’t want to live (A5)” and thus improve the patient’s will to live (34).

In addition to the core symptoms, network analysis can also infer how the dimensions of Demoralization interact with each other. The results showed that “Hopeless (D4)” had the highest bridge strength, followed by “Discouragement (C3)”, “No self-worth (A3)”, “Poor spirits (E2)”, and “Vulnerability (B3)”, which were identified as bridge symptoms in all dimensions. The edge weights showed that the most closely connected dimensions for demoralization were “Loss of meaning” and “Sense of failure”, which were connected by the bridge symptom “No self-worth” and the symptom “Worthless” (A3—E6, edge weight=0.27). This result suggests that losing a sense of meaning and purpose in life is likely to lead to a strong sense of failure for patients and as a result of self-denial. Deckx et al. (35) found that most cancer survivors experience a moderate level of loneliness, which makes them more concerned about themselves, overly concerned about the meaning of life’s existence, and prone to feelings of uselessness when they perceive that they are not wanted. Secondly, the vast majority of the subjects in this study were female breast cancer patients, and most of the participants were in the stage of chemoradiotherapy. Patients experience symptoms such as hair loss and edema, which can lead to serious disturbances in one’s own image. Patients can also lose important organs and face reduced femininity due to surgery, causing them to have a strong sense of inferiority and failure (36), and believe that life has lost its meaning. Healthcare professionals should especially pay attention to the postoperative psychological state of patients (37) and encourage family members to actively communicate with patients and enhance each patient’s sense of meaning in life by establishing spiritual connections. Such professionals could instruct patients to wear wigs and prosthetic breasts and engage in other forms of self-image management to improve their sense of self-worth. This measure could avoid transitioning from the bridge symptom “No self-worth (A3)” to the symptom “Worthless (E6)”, which may lead to a sense of failure.

The bridge symptom “Poor spirits” and the symptom “Loss of emotional control” (E2-D1, edge weight = 0.22) ranked second in terms of closeness of connection; these symptoms belong to the “Sense of failure” and “Helplessness” dimensions, respectively. Previous research (38–40) found a strong association between physical symptoms such as fatigue and a fear of cancer recurrence among cancer survivors, as patients may misinterpret their fatigue as a sign of cancer recurrence or progression. However, fighting the disease commonly leads to fatigue, causing the patient to fear cancer recurrence and resulting in a poor mental state. This factor also confirms the results of this study. This phenomenon suggests that when a patient’s mental state is obviously poor, it may be a critical period for therapeutic intervention, which can be achieved through physical therapy to alleviate the patient’s fatigue, analgesic therapy to improve the patient’s sleep quality, and dynamic health education to eliminate the patient’s fear of relapse, so as to prevent the patient from being unable to cope with the disease, leading to the occurrence of “Loss of emotional control (D1)”.

The third most closely connected symptoms were “Discouragement” and “Vulnerability” (C3-B3, edge weight = 0.14), which were bridge symptoms of each other, belonging to the dimensions of “Disheartenment” and “Dysphoria”, respectively. This result shows that the two dimensions influence each other through a mutual cause-and-effect relationship. The “Discouragement (C3)” symptom highlights the patient’s negative attitude towards the cancer diagnosis and further triggers negative coping behaviors, leading the patient to acquire a “Vulnerability (B3)” state of mind, which corresponds to a lower level of mental resilience. As Qian’s research (41) shows, “positive attitudes towards reality and the future” and “taking positive actions” play a significant role in improving patients’ resilience. Studies have found that middle-aged women with cancer have lower levels of resilience than men (41), which makes this population more psychologically vulnerable when faced with cancer. If the corresponding emotions are not attended to, they can lead to resentment, as the patient may feel guilty about her family while at the same time believing that she is not valued. This ambivalence of both guilt and dissatisfaction can cause patients to become more sensitive, vulnerable, and subject to bursts of intense negative emotions. In the process of treatment, medical staff should pay special attention to the identification and treatment of “Discouragement (C3)” and “Vulnerability (B3)” to avoid the interactions between bridge symptoms that can produce more serious psychological symptoms. Professional medical measures such as individualized cognitive behavioral therapy can be taken to improve the patient’s mental resilience level and prevent the generation of negative emotions.

The fourth most closely connected dimensions were “Helplessness” and “Loss of meaning”, which were connected by the bridge symptom “Hopeless” and the symptom “No meaning of survival” (D4-A4, edge weight = 0.12). If the patient’s long-term helplessness is not sufficiently resolved, it will eventually lead to a loss of purpose and meaning of life accompanied by a loss of hope for survival (18). The study also found that the symptom “Hopeless (D4)” is not only the fourth strongest symptom in the network but also a bridge symptom, which means that the intervention of the “Hopeless (D4)” symptom can not only weaken most of the connections in the network but also avoid the development of the “Hopeless (D4)” emotion to “No meaning of survival (A4)”. This factor also requires the attention of healthcare professionals.

Regarding the interactions between bridge symptoms in the network structure model, the results also show that the dimensions of “Loss of meaning and Sense of failure”, “Sense of failure and Helplessness”, and “Helplessness and Loss of meaning” are mutually connected by bridge symptoms. Together, these three strongest bridge symptoms form a “Loss of meaning–Sense of failure–Helplessness–Loss of meaning” cycle, indicating that negative demoralization-based emotions will gradually increase and produce stronger negative emotions, eventually leading to a loss of the patient’s willingness to live. This result suggests that healthcare professionals can view “Loss of meaning–Sense of failure–Helplessness–Loss of meaning” as a whole when intervening in female cancer patients with demoralization. Through family narrative therapy, mutual support groups, and other interventions, patients can be encouraged to share their experiences in successfully overcoming the disease. This type of sharing can provide help to others by increasing one’s sense of meaning in survival and reducing feelings of failure, thus breaking the undesirable cycle of “Loss of meaning-Sense of failure–Helplessness–Loss of meaning”.

First, this study adopted a self-reporting method, which may have introduced a self-reporting bias. Secondly, because this was a cross-sectional study, the interpretations of causal relationships are limited. Furthermore, despite some studies showing more optimistic results, there are still a number of studies that clearly show that cross-sectional networks are not necessarily decisive symptom predictors of changes in overall treatment symptoms, even in large datasets (42). Although centrality indices may seem intuitive, easily applicable, and frequently used, the possible problems with interpreting these indices in the context of mental networks have not been examined (43). In future work, longitudinal studies could be used to explore the changes in various dimensions of demoralization among cancer patients over a longer diagnosis period. In addition, due to time constraints, the participants in this study were all from eastern China, with no samples from central and western regions. In the future, multi-center studies with larger samples could be carried out to improve the generalizability of the results and thus more accurately explore the interactive relationships between the symptoms of demoralization among female cancer patients.

In this study, we analyzed the interactions between symptoms of demoralization using a network structure model and found that the demoralization symptoms of “Discouragement (C3)”, “No self-worth (A3)”, “Hopeless (D4)”, and “Vulnerability (B3)” were both the most central symptoms and those with the highest bridge strength. We suggest that these symptoms represent the core symptoms leading to demoralization and that these core symptoms can influence each other. In future clinical work, the above-mentioned core symptoms and bridge symptoms should be identified, and precise interventions should be carried out to counteract the strongest interactions between symptoms to improve the psychological care effects for female cancer patients.

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.

The studies involving humans were approved by Medical Ethics Committee of Jiangsu University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

YG: Data curation, Investigation, Writing – original draft, Writing – review & editing. BS: Data curation, Writing – review & editing. JT: Supervision, Writing – review & editing. CL: Supervision, Writing – review & editing. ZB: Supervision, Writing – review & editing. XW: Data curation, Writing – review & editing. TF: Data curation, Writing – review & editing. QZ: Data curation, Writing – review & editing. LL: Data curation, Writing – review & editing. WS: Data curation, Writing – review & editing.