Research ArticleClinical Studies
Open Access

The Impact of State-trait Anxiety Inventory (STAI) Self-evaluation versus 25-year Outcome: A Prospective Follow-up Study in Patients With Breast Cancer Symptoms

MATTI ESKELINEN, RIIKA KOSKELA, TUOMAS SELANDER, KAI KAARNIRANTA, PAULA OLLONEN and MAARET ESKELINEN
Anticancer Research May 2025, 45 (5) 2161-2169; DOI: https://doi.org/10.21873/anticanres.17590

Abstract

Background/Aim: This study evaluated whether self-evaluation using the State-Trait Anxiety Inventory (STAI) questionnaire could predict long-term outcomes – specifically 25-year relapse-free survival (RFS) and overall survival (OS) – in patients presenting with breast cancer (BC) symptoms.

Patients and Methods: A total of 115 patients with BC symptoms completed the STAI questionnaire pre-diagnosis. Associations between STAI scoring and long-term outcomes were analyzed using Kaplan–Meier and Cox proportional hazards models.

Results: STAI scores correlated significantly with Beck Depression Inventory (BDI) (r=0.634, p<0.001) and Montgomery–Asberg Depression Rating Scale (MADRS) (r=0.550, p<0.001). A lower STAI score (<36) was associated with improved 25-year RFS (hazard ratio=2.753, p=0.02). The 25-year RFS rate was 80% for patients with low STAI scores versus 54% for those with higher scores. OS was also higher in the low-STAI group (80% vs. 65.9%), though the difference did not reach statistical significance (p=0.100).

Conclusion: Although widely used to assess anxiety, STAI’s long-term prognostic relevance in patients with BC symptoms has been largely overlooked. This 25-year prospective study is the first to demonstrate that lower STAI scores significantly predict better RFS. Given its correlation with established depression inventories, STAI could offer additional diagnostic and prognostic value. Integrating STAI assessments into the diagnostic workflow for patients with BC symptoms may improve long-term risk stratification and personalized care planning.

Keywords:

Introduction

Breast carcinoma (BC) is one of the most common malignant neoplasms worldwide and the most common carcinoma in women (1-4). The stage of the disease at diagnosis is closely associated with the outcome, which emphasizes the importance of early diagnosis by non-invasive methods with high diagnostic accuracy (DA) and prediction of recurrence and outcome to improve the relapse-free survival (RFS) and overall survival (OS) of patients with BC (5-8). Most of the current screening programs for BC are based on the use of mammography combined with clinical examination (9). Such diagnostic and prediction programs could be supported by quality of life (QoL) models (10-13), but until now, the data on QoL models in BC diagnosis and prediction setting are rarely considered and reported (10-13). Although, QoL-based models look promising, only few recent studies assess the outcome of the QoL-based models, where clinical features of the patients are integrated with the results of QoL scoring in patients with BC symptoms (10-14).

Prompted by the increasing number of studies on QoL assessment in different clinical situations (10, 11, 15-26), the authors aimed to evaluate the prognostic value of the STAI model in relation to RFS and OS in patients with BC symptoms diagnosed at the Breast Cancer Diagnostic Unit (BCDU). To date, no previous have assessed the long-term outcomes associated with the STAI scores using survival analysis models.

Patients and Methods

Patients. The study cohort included 115 patients with BC symptoms diagnosed in BCDU, Kuopio University Hospital (KUH), Finland, of whom 34 (29.6%) were patients with BC and 81 non-BC patients (70.4%) (Table I). The study patients had BC symptoms, and the detailed description of the study protocol is shown in earlier reports by Ollonen et al. (27-30).

View this table:
Table I.

The baseline data of three study groups; the healthy study participants (HSP), breast carcinoma (BC), benign breast disease (BBD).

Spielberger State-Trait Anxiety inventory (STAI). Each STAI item yields a Likert-type score of 0 to 4 and the STAI score with 20 variables ranges from 0 to 80. The 20 items refer to how a person generally feels, with a higher total score reflecting greater anxiety (31). The total STAI score was used as a continuous variable, with a cut-off point of 36 used to distinguish between low and high anxiety levels.

Beck Depression Inventory (BDI). The BDI score was used as a continuous variable with a cut-off value of 8. A detailed description of the protocol is shown in earlier reports (13, 32, 33).

Montgomery-Asberg Depression Rating Scale (MADRS). The MADRS score was used as a continuous variable with a cut-off value of 25. A detailed description of the protocol is shown in earlier reports (14, 34, 35).

Statistical analysis. Baseline data are shown as means and percentages. Group differences were analyzed by two-sided chi-square and non-parametric Kruskal–Wallis tests. RFS was calculated from the time of diagnosis to the occurrence of the first relapse, contralateral BC, or metastatic disease. OS was assessed as the time from the date of diagnosis to the date of last follow-up or death of the patient. The effect of the STAI on the RFS and OS were calculated using the Kaplan–Meier survival analysis and the difference between the groups was assessed using the log-rank test. The p-values and the hazard ratios (HRs) with their 95% confidence intervals (CI) were calculated using the Cox proportional hazard model. Pearson’s method was used to test for correlation between STAI scores and BDI and MADRS scale values. Data were analyzed using the IBM SPSS statistical software (IBM SPSS Statistics for Windows, version 26.0, IBM Corporation Armonk, NY, USA). p-Values <0.05 were considered as statistically significant.

Results

The baseline data of the study groups are presented in Table I. Although the patients in the BC group were slightly older than those in the benign breast disease (BBD) and healthy study participants (HSP) groups (51.5 versus 47.5 and 45.7 years, respectively), the age difference was not statistically significant (p=0.12). The mean STAI score values were quite similar across the study groups (p= 0.780, Table I) and the HSP, BBD, and BC groups differed only slightly from each other in reproductive health-related factors (Table I).

The STAI score values correlated significantly with BDI score values (r=0.634, p<0.001) (Figure 1) and MADRS score values (r=0.550, p<0.001) (Figure 2), In addition, BDI and MADRS scores correlated significantly in patients with BC symptoms (r=0.812, p<0.001) (Figure 3).

Figure 1.
Figure 1.

Scatter plot of state-trait anxiety inventory (STAI) score levels versus Beck Depression Inventory (BDI) score levels in patients with breast cancer symptoms (r=0.634, p<0.001).

Figure 2.
Figure 2.

Scatter plot of state-trait anxiety inventory (STAI) score levels versus Montgomery-Asberg depression rating scale (MADRS) score levels in patients with breast cancer symptoms (r=0.550, p<0.001).

Figure 3.
Figure 3.

Scatter plot of Beck Depression Inventory (BDI) score levels versus Montgomery-Asberg depression rating scale (MADRS) score levels in patients with breast cancer symptoms (r=0.812, p<0.001).

In the Kaplan–Meier survival analysis, an STAI score under 36 was a significant favorable predictor of RFS in patients with BC symptoms (log-rank p=0.016, Figure 4). Also, in the Cox regression analysis, a low STAI score (<36) was identified as a significant favorable predictor of RFS (HR=2.753, 95%CI=1.17-6.51, p=0.021, Table II) in patients with BC symptoms. A similar pattern was observed in the BC and BBD groups (HR=2.76 and HR=4.14, Table II). The 25-year relapse rate differed significantly between patients with low STAI scores (<36) and those with high STAI scores (≥36) (80% versus 54%, log-rank p-value=0.016). The 25-year OS was also higher in the low STAI group (<36), but the difference did not reach statistical significance (80% versus 65.9%, log-rank p-value=0.100) (Figure 5 and Table III).

Figure 4.
Figure 4.

Relapse-free survival (RFS) curves in patients with breast cancer symptoms (n=115) according to state-trait anxiety inventory (STAI) score. The STAI score was a continuous variable in the analysis of the study patients. The STAI score has a statistically significant effect on RFS by the log-rank test (p=0.016).

View this table:
Table II.

Relapse-free survival (RFS) ratios for healthy study participants (HSP, n=28), patients with benign breast disease (BBD, n=53), and patients with breast cancer (BC, n=34), as well as for the combined group (All), stratified by low (<36) and high (≥36) State-Trait Anxiety Inventory (STAI) scores.

Figure 5.
Figure 5.

Overall survival (OS) curves in patients with breast cancer symptoms (n=115) according to state-trait anxiety inventory (STAI) score. The STAI score was a continuous variable in the analysis of the study patients.

View this table:
Table III.

The overall survival (OS) ratios for the healthy study participants (HSP, n=28), patients with benign breast disease (BBD, n=53), and patients with breast cancer (BC, n=34), as well as the combined group (All) stratified by low (<36) versus high (≥36) State-Trait Anxiety Inventory (STAI) scores.

Discussion

The Ollonen et al. study (27) investigated the impact of stressful and adverse life events in patients with BC symptoms in a prospective study in Finland. All study patients were interviewed and completed BDI, MADRS, and STAI questionnaires. Authors reported a significantly enhanced stress load (p=0.02) and more severe life losses (p< 0.001) in patients with BC versus non-BC patients. In addition, authors suggested that severe stress and significant life losses could enhance BC risk, potentially due to stress-induced disruptions in immune system function, predisposing to neoplasia. The same authors also studied the association of psychiatric symptoms and anxiety/depression with the risk of BC in a prospective case-control study (28). All study patients were interviewed and completed BDI, MADRS, and STAI questionnaires and the Forsen Inventory was used to evaluate the history of psychiatric symptoms in the patients with BC symptoms in the six years prior to admission. However, their study found no significant overall association between anxiety, depression, and history of psychiatric symptoms and an increased BC risk.

Fleer et al. (15) assessed anxiety using the STAI method in patients with testicular cancer (TeC) with orchidectomy (n=15, group 1) versus orchidectomy plus chemotherapy (n=37, group 2) followed up one, three, and 12 months after treatment. Although, the study groups reported similar levels of anxiety, the authors concluded that highly anxious patients with TeC could benefit from a multidisciplinary intervention.

Fafouti et al. (10) investigated the association between psychiatric symptoms and anxiety/depression in BC patients (n=109) versus healthy women (n=71). All study patients completed SCL-90-R, MADRS, and STAI questionnaires (10). The authors found that SCL-90-R, MADRS, and STAI scores were significantly higher in patients with BC versus non-BC women in regression analysis. The authors concluded that anxiety/depression and psychiatric symptoms are more frequent in patients with BC compared to non-BC women. Therefore, patients with BC should be closely followed up in order to identify and timely treat any mental health problems that may arise.

The Bruno et al. (17) study evaluated 117 patients diagnosed at BCDU, of whom 24 were patients with BC, and 93 non-BC patients; 44 patients with benign breast disease (BBD) and 49 healthy women. However, the results of this study do not support a specific link between STAI scores and BC risk.

Gogou et al. (17) studied prospectively QoL and STAI anxiety in 90 patients with cancer undergoing radiotherapy (RT). They found that QoL of patients with cancer correlated with symptoms (r=−0.684, p=0.0005) and the STAI scores inversely correlated with QoL (r=−0.253, p=0.0017). The authors concluded that there is a significant association between symptoms, anxiety, and QoL following RT.

Chirico et al. (19) assessed the role of anxiety and coping in 110 patients with BC. The patients with BC were randomized to control group versus the Reiki treatment group. The authors suggested that STAI anxiety and coping with cancer are significantly associated with Reiki treatment results.

Biro et al. (20) investigated STAI anxiety and depression (BDI and Hamilton inventory) in 46 patients with BC undergoing endocrine therapy. BC patients received adjuvant endocrine therapy (ET) (tamoxifen with or without LHRH analog or aromatase inhibitor) or were observed only (control group). At baseline, and at 6, 12, and 24 months thereafter, depression, anxiety, and QoL measurements were performed. No differences were found regarding anxiety, depression, and QoL. However, baseline QoL variables in this study proved to be predictors of anxiety and depression.

Kuosmanen et al. (21) investigated rectus sheath block (RSB) analgesia in 56 patients with midline laparotomy (MLa). The QoL survey with an 11-point numeric rating scale (NRS) and Brief Pain Inventory (BPI) was conducted preoperatively and at one and four weeks and 12 months postoperatively. The authors concluded, that QoL survey with NRS and BPI scales may assist in planning appropriate postoperative analgesia in MLa patients.

Saimanen et al. (22) assessed QoL in 110 cholecystectomy (ChC) patients using the RAND-36 survey performed preoperatively and following surgery. RAND-36 scores improved in several RAND-36 domains in patients with ChC with a similar postoperative course over the 3-year study period. The linear mixed effect model was used to test the overall significance of the RAND-36 survey during the follow-up period and the overall p-values were statistically significant for the domains of vitality, mental health, role physical, and bodily pain. The authors concluded that the RAND-36-Item Health Survey is a comprehensive test for analyzing QoL status after ChC.

Susini et al. (24) evaluated psychological outcomes with STAI survey of 131 patients with BC randomized to day care (DC) treatment versus regular treatment of BC. The DC treatment significantly reduced anxiety (p=0.05) and depression (p=0.01) and enhanced cost savings of BC treatment in comparison to regular treatment. The authors concluded that the DC treatment is feasible option for the treatment of BC, with low anxiety and depression scores, high patients’ satisfaction and substantial financial savings.

Kontoangelos et al. (26) studied the correlation of psychosomatic factors and personality traits in 80 patients with melanoma using the psychometric instruments; BDI, the psychopathology questionnaire (SCL-90), Eysenck personality questionnaire (EPQ) and hostility questionnaire (HDHQ). The patients in an advanced stage of melanoma scored statistically significantly higher anxiety scores than the patients in the initial stage of melanoma (5.17±3.60 vs. 2.86±2.04, p<0.01). The authors concluded that enhanced anxiety in melanoma patients with advanced-stage disease should be considered when planning their treatment.

The studies to date investigating the impact of STAI self-evaluation on BC risk have not considered STAI self-evaluation versus long-term outcome of patients with BC symptoms (31). In a previous study, Eskelinen et al. (13) investigated the impact of BDI scale as a predictor of long-term outcome among patients admitted to the BCDU. In the multivariate Cox proportional hazard model, the BDI score significantly forecasted the 25-year RFS and OS in women with or without BC. In addition, in the Kaplan–Meier survival analysis the BDI score forecasted the 25-year RFS and OS in BC and non-BC patients (log-rank, p=0.036). Authors concluded, that BDI is a significant predictor of long-term outcome among patients admitted to the BCDU. The same authors studied the MADRS inventory in patients with BC symptoms admitted to the BCDU in Finland (14). The effect of MADRS inventory on the RFS/OS were calculated using the Kaplan–Meier survival method and the difference between the groups was assessed using the log-rank test. The RFS and OS were estimated for the study groups with the low MADRS score (<25) versus the high MADRS score (≥25). In the Cox proportional hazard model, the MADRS score significantly predicted the 25-year RFS and OS in the patients with BC and non-BC women (HR=2.26, p=0.006; HR=2.46, p=0.008, respectively). In addition, in the Kaplan–Meier survival analysis the total MADRS score predicted the 25-year RFS and OS (log-rank, p=0.005; p=0.006, respectively). The authors concluded, that since depression (MADRS) can affect the QoL of patients with BC symptoms, the patients with BC symptoms should be closely monitored to identify the moderate/severe depression and timely treat any mental health problems that may arise.

Taken together, the aim of the study was to investigate the characteristics of the STAI model in 115 patients with BC symptoms and to examine its association with RFS and OS in patients with BC symptoms diagnosed at BCDU. The results showed that STAI score correlates with the 25-year RFS and OS in patients with BC symptoms. The present data indicate that the currently available patient reported outcome measure (PROM) STAI seem to have the potential to enhance the DA of QoL-testing in patients with BC symptoms. Since we observed significant correlations between STAI score and MADRS and BDI score values, one can assume that, of the three QoL inventories tested in the present study, the correlations between STAI and both BDI and MADRS scores are interesting and novel observations.

Anxiety and stress in patients with BC symptoms before and during visit at BCDU have been recognized as a problem, but the cascade of anxiety-related endocrine and metabolic events during BC diagnosis remains still obscure (36, 37). Stress response is defined as the hormonal and metabolic changes that accompany injury and trauma and encompasses a variety of immunological and metabolic events (36-39). In response to stressogenic stimuli, certain neuroendocrine events, including the activation of the sympathetic nervous system and the hypothalamic-pituitary axis, react to anxiety and stress (36, 37). However, recently published studies demonstrated cytokine and immune system alterations following surgery in MLa patients (38) and in patients with ChC (39). Apart from this effect, it would be of great interest to evaluate the immunological and metabolic events during stress and anxiety in patients with BC symptoms.

Conclusion

To date, studies investigating the impact of QoL on outcomes in patients with BC symptoms have not considered STAI score levels. Until now, the lack of long-term follow-up time in patients with BC symptoms has delayed the advance in accurately evaluating RFS and OS. In the present study, the 25-year follow-up of patients with BC symptoms allowed for a comprehensive assessment of long-term outcomes and their association with STAI scores using survival models. The present study showed that the total STAI score significantly correlates with 25-year RFS in patients with BC symptoms and therefore, incorporating STAI assessments into the diagnostic decision-making process may enhance risk stratification and long-term outcome prediction in this patient population.

Footnotes

  • Authors’ Contributions

    All Authors contributed to the collection and analysis of data, drafting and revising the manuscript, and read and approved the final article.

  • Conflicts of Interest

    The Authors report no conflicts of interest or financial ties regarding this study.

  • Funding

    The study was funded by the North Savo Regional Fund (Pohjois-Savon Maakuntarahasto).

  • Artificial Intelligence (AI) Disclosure

    No artificial intelligence (AI) tools, including large language models or machine learning software, were used in the preparation, analysis, or presentation of this manuscript.

  • Received March 25, 2025.
  • Revision received April 10, 2025.
  • Accepted April 11, 2025.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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The Impact of State-trait Anxiety Inventory (STAI) Self-evaluation versus 25-year Outcome: A Prospective Follow-up Study in Patients With Breast Cancer Symptoms
MATTI ESKELINEN, RIIKA KOSKELA, TUOMAS SELANDER, KAI KAARNIRANTA, PAULA OLLONEN, MAARET ESKELINEN
Anticancer Research May 2025, 45 (5) 2161-2169; DOI: 10.21873/anticanres.17590
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