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Title: Conceptualizing problems with symptoms, function, health behavior, health-seeking skills, and financial strain in breast cancer survivors using hierarchical clustering
Authors: Liu, X
Chen, Y
Cheng, ASK 
Zeng, Y 
Ullah, S
Feuerstein, M
Issue Date: 2021
Source: Journal of cancer survivorship, 2021, Online first,
Abstract: Purpose: Determine whether a diverse set of problems experienced by breast cancer survivors (BCS) following curative treatment can be formulated into a reduced number of clusters, potentially simplifying the conceptualization of these problems.
Method: Female BCS were recruited from four cancer hospitals in China. The Chinese translation of the Cancer Survivor Profile (CSPro) was used to measure 18 common problem areas, as supported by epidemiological and phenomenological research. The Functional Assessment of Cancer Therapy–Breast (FACT-B) was used to measure quality of life, as a validation of any observed groupings. Hierarchical clustering using multiple distance criteria and aggregation methods to detect patterns of problems was used.
Results: A total of 1008 BCS (mean 46.51 years old) living in both urban and rural areas were investigated. Hierarchical cluster analysis identified two major clusters of problems. One set was classified as “functional limitations,” while the other cluster was labeled “multi-problems.” Those who fell into the multi-problem cluster experienced poorer quality of life.
Conclusion: Eighteen non-medical problems were broken down into two major clusters: (1) limitations in higher level functions required of daily life and (2) limitations in health care–seeking skills, problems with certain symptoms, unhealthy behaviors, and financial problems related to cancer. The breakdown of problem areas into these two clusters may help identify common mechanisms. Implications for Cancer Survivors: In the future, the search for common clusters and the mechanisms for the many problems that breast cancer survivors and other cancer survivors can experience following primary treatment may improve how we help manage these problems in the future.
Keywords: Breast cancer survivors
Economic burden
Functional limitations
Health-seeking skills
Hierarchical cluster analysis
Symptom burden
Publisher: Springer
Journal: Journal of cancer survivorship 
ISSN: 1932-2259
EISSN: 1932-2267
DOI: 10.1007/s11764-021-01068-w
Rights: © The Author(s) 2021
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
The following publication Liu, X., Chen, Y., Cheng, A.S. et al. Conceptualizing problems with symptoms, function, health behavior, health-seeking skills, and financial strain in breast cancer survivors using hierarchical clustering. J Cancer Surviv (2021) is available at
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