2.3.1 Study type and sample size calculation.

Employing a cross-sectional framework, this study conducted a retrospective analysis of cohort data. As reported in the existing literature [9], the prevalence rate of anxiety in breast cancer patients was 35.21%, which was set as 35% in this study. The sample size was estimated according to the formula , p = 35%, allowable error d = 0.1, 95% confidence limit, α = 0.05, u(α/2)=1.96. This study utilized a consecutive sampling strategy. Based on the statistically estimated sample size, patients who received implanted venous access port (IVAP) placement and completed chemotherapy at our Breast Center between January 1, 2019, and December 31, 2023, were enrolled. According to the inclusion and exclusion criteria of the study, a total of 920 eligible patients were screened out. Non-respondents comprised 68 cases (Deceased patients (N = 4); Patients diagnosed with other malignancies, severe systemic diseases (N = 5); Breast cancer recurrence and metastasis during follow-up (N = 21); Patients unable to provide valid responses due to insufficient literacy (N = 16); Refuse to answer (N = 19); Suffering from severe mental disorders or cognitive impairments (N = 3)). A total of 76 questionnaires were excluded as invalid due to the following reasons: Patients lost to follow-up (N = 17); Patients opted for IVAP maintenance at other hospitals (N = 34); Patients opted for IVAP disease surveillance at other hospitals (N = 14); Patients with incomplete data entry (resulting in unavailable clinical catheterization information) (N = 11), and a total of 776 respondents completed the survey, with a response rate of 84.3%, see Fig 1.

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Fig 1. Flowchart of Study Participant Selection.

https://doi.org/10.1371/journal.pone.0332826.g001

2.3.2 General information questionnaire.

Ordinary circumstances, sociological data, disease data and infusion port information were collected through the general data questionnaire. Ordinary circumstances include age, education, employment, culture, place of residence, menopause, Body Mass Index (BMI), etc. Sociological data include employment status, monthly income per capita, marital status, payment method of medical expenses, ethnicity, etc. Disease data include diagnosis, disease stage, surgical method, chemotherapy regimen, post-chemotherapy period, current physical condition, underlying disease, etc. The conditions of infusion port include catheter length (cm), placement site, port placement time, X-ray positioning, local bleeding or bruising, selection of maintenance hospital at infusion port, maintenance cost, maintenance cycle, other venous access routes were used during the port placement period, etc.

In terms of “traction sensation” [10,11], it is defined as a persistent or activity-induced tightness, pulling or constricting sensation perceived by breast cancer patients during the indwelling of an implantable venous port (IVAP) at the catheter site or in the surrounding tissues, often accompanied by local discomfort or limited movement. This subjective feeling may be related to the mechanical stimulation of the catheter on the surrounding tissues, fibrotic response or increased neural sensitivity, and it is an important factor affecting the patient’s psychological state (such as anxiety) and quality of daily life. The “foreign body sensation” [12,10] refers to the series of physiological and psychological reactions that an individual experiences when perceiving the existence of objects that do not belong to their normal tissues within or on their body surface. In medical contexts (such as patients with PICC or IVAP catheterization), foreign body sensation not only involves the physical perception of the catheter’s presence but also the emotional, cognitive and behavioral responses it triggers.

2.3.3 Self-rating anxiety scale (SAS).

Compiled by William W.K. Zung et al. [13] in 1971, it is mainly used to analyze the subjective symptoms and feelings of patients, and is applicable to adults with anxiety symptoms. SAS is mainly assessed according to the frequency of symptoms defined for the project, which is divided into 4 levels, with 15 positive scores and 5 reverse scores. The score of 20 items is added to obtain a rough score, and the integer part is the standard score after multiplying the coefficient 1.25. SAS has a cut-off value of 50, 50–59 is mild anxiety, 60–69 is moderate anxiety, and 70 or more is severe anxiety.

The SAS scale has been widely verified in the generalized breast cancer population, and its reliability and validity are good (usually α > 0.80). It has been widely used to assess the anxiety levels of patients with breast cancer and other malignant tumors. In recent domestic and international studies, SAS has been employed to investigate the psychological states of breast cancer patients before surgery, during the perioperative period, and during chemotherapy. The SAS score during the perioperative period can serve as an important indicator of intervention effectiveness [14]. Additionally, SAS has been utilized for breast cancer patients receiving chemotherapy through IVAP/PICC to evaluate the impact of different nursing models on anxiety [15]. Regarding the psychometric properties of the scale, the Cronbach’s α of the original Zung SAS ranges from 0.81 to 0.92, and domestic large-sample studies on breast cancer patients report an α coefficient of approximately 0.88 [16], suggesting good consistency among the items. The SAS consists of 20 items, is concise and easy to understand, and is a self-rating scale, which can avoid social desirability bias caused by face-to-face interviews. It is suitable for rapid screening of anxiety status during outpatient follow-up or chemotherapy breaks. Therefore, SAS is applicable for the investigation and research of breast cancer patients undergoing chemotherapy through port-a-cath.

3.2.1 Impact of demographic factors on anxiety in patients with IVAP.

The work situation, physical condition, underlying diseases, and type of chemotherapy are significant factors influencing anxiety in patients with port placement (P < 0.05). No statistically significant differences were observed in other demographic characteristics, as shown in Table 1.

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Table 1. Demographic Characteristics and Their Association with Anxiety Scores (N = 776).

https://doi.org/10.1371/journal.pone.0332826.t001

3.2.2 Impact of port-related factors on anxiety levels in patients with IVAP.

Redness and swelling, poor wound healing, pulling sensation, swelling sensation, pain, foreign body sensation, itching or allergy, catheter blockage in the infusion port, and wound dehiscence are associated with the anxiety levels of patients with infusion ports (P < 0.05), as shown in Table 2.

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Table 2. Impact of different port placement conditions on patients’ anxiety with IVAP.

https://doi.org/10.1371/journal.pone.0332826.t002

3.2.3 Impact of catheter maintenance practices on anxiety in patients with IVAP.

During the period of port usage, the utilization of other venous access methods is associated with the anxiety levels of patients with infusion ports (P < 0.05), as shown in Table 3. Note: The reasons and proportions for the use of other venous access during the port placement period are as follows: There were 16 patients with emergency condition (10.39%), 92 patients (59.74%) faced a lack of conditions for using infusion ports at local hospitals, 22 patients (14.29%) with high cost, 12 patients (7.79%) expressed fear of pain associated with puncturing without damage needles, and 12 patients (7.79%) were unable to use their infusion ports due to complications that temporarily rendered them unusable.

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Table 3. Impact of different port maintenance conditions on patients’ anxiety with IVAP.

https://doi.org/10.1371/journal.pone.0332826.t003

4.2.1 Treatment-related physical symptomatology.

Grusdat et al. [21] found that after the diagnosis of breast cancer, women showed a decline in physical function and mental health, alongside pronounced symptoms of fatigue. Furthermore, there is a significant trend of deterioration following treatment. The findings of this study indicate that changes in quality of life and poor physical condition can impact patients’ emotional states and mental health. In this research, 4.62% of patients feel that their physical condition is poor, indicating that some patients may continue to experience significant physical discomfort after the completion of treatment. Furthermore, the severity of anxiety is correlated with a deterioration in overall health status, the more serious the anxiety, the worse the overall health status. This finding aligns with current relevant guidelines [22,23], which demonstrate that cancer-related fatigue (CRF) represents one of the most prevalent and persistent symptoms among breast cancer patients, frequently coexisting with significant psychological distress (e.g., anxiety, depression). These guidelines explicitly emphasize that both fatigue and emotional disturbances may persist throughout the entire treatment course and extended recovery phase.

Specifically regarding phenomena observed in this study, chemotherapy-induced adverse effects in breast cancer patients persist throughout the treatment continuum and recovery period. Beyond causing physical discomfort, these effects—particularly body image disturbances secondary to alopecia and illness experiences associated with long-term implantable port utilization—induce varied levels of psychological distress. In addition to causing physical discomfort, these side effects also lead to psychological trauma due to changes in appearance from hair loss and the ongoing experience of illness associated with long-term indwelling infusion ports. On the other hand, some patients with stable-stage breast cancer who have completed chemotherapy still experience poor physical condition and weakness, leading to a delay in their physical rehabilitation. In clinical practice, medical personnels need to further strengthen the management of physical symptoms and anxiety for these patients following chemotherapy with implanted venous access ports. This also underscores the importance of continuity in nursing care.

4.2.2 Port-site complications: Wound dehiscence, pulling sensation and foreign body sensation.

Although the advantages of intravenous infusion ports are prominent compared to traditional venous pathways, they can still lead to corresponding complications and discomfort. This may increase patients’ physical unease and economic burden, ultimately resulting in adverse emotional responses. Domestic researchers focused on the occurrence and treatment of complications such as thrombus, infection, catheter blockage, catheter end displacement, catheter rupture, wound bleeding, and pinch-off syndrome in their studies on implantable intravenous infusion ports. In contrast, there has been relatively less attention paid to patients’ feelings following catheter placement [24]. In this study, 25.0% of patients experienced a noticeable pulling sensation after the placement of the port, and 28.1% had foreign body sensation. It is noteworthy that, on the one hand, patients often experience anxiety and unease due to complications associated with infusion ports, fearing potential impacts on their physical health [25]. On the other hand, in the process of communication with patients, researchers in this study found that patients felt obvious pulling sensation and foreign body sensation after catheter insertion, which directly affected their sleeping posture, shoulder and neck activities, arm activities, etc., thereby affecting their daily lives and leading to adverse emotional responses among patients. In addition, the patients’ insufficient understanding of venous access ports may lead to their concerns.

Therefore, for patients with implanted venous infusion ports, clinical attention should be directed towards the complications associated with the infusion port as well as the subjective feelings of the patients. Prior to port placement, medical personnels should not only inform patients about common complications related to the infusion port but also discuss potential changes in comfort levels that may arise from its use. Additionally, a standardized protocol for managing complications related to the infusion port should be established. Regular psychological assessments tailored to this patient group are essential, along with comprehensive health education initiatives. It is crucial to implement holistic management throughout the entire course of treatment for patients with infusion ports in order to alleviate anxiety stemming from complications and discomfort associated with their use.

4.2.3 Use of other venous access.

Among the 776 breast cancer patients in this survey, 622 (81.1%) patients who did not use other venous access had no anxiety (49.67 ± 10.24), and 154 (19.9%) patients had used other venous access due to other physical discomfort or anti-tumor treatment during hospitalization, indicating that this group of people had mild anxiety. Among them, 10.91% patients had used other venous access once or twice, and the score of anxiety scale was 53.37 ± 14.05. 3.47% of the patients had used other venous access 3 ~ 5 times, and the score of anxiety scale was (53.96 ± 12.15); 5.52% of the patients had used other venous access more than 5 times, and the anxiety scale score was (51.95 ± 11.71).

The analysis of the reasons for using other venous access in this group of patients indicates that, in special scenarios, medical personnels must establish venous access rapidly. The use of an infusion port requires adherence to strict operational process, this procedure requires dedicated time for: strict aseptic technique throughout; pre-use port inspection/complication assessment; understanding port depth/thickness; selecting the correct non-coring (Huber) needle; aspirating blood and flushing after puncture; securing with a sterile transparent dressing shaped for close skin contact; and finally connecting to IV access. Compared to these, the infusion process using peripheral intravenous catheters and scalp veins is relatively straightforward, demonstrating a significant advantage in terms of time efficiency. The lack of access to infusion ports in local hospitals was the main reason for the use of other venous access, accounting for 59.74%, which may be related to the fact that 533 (68.7%) patients in this study were from rural areas. Due to the influence of geographical conditions and medical conditions, domestic township hospitals may not yet have implemented the techniques for port placement and maintenance of infusion ports, so these patients requiring intravenous infusion therapy are left with no choice but to opt for other venous access. In terms of costs, Fang et al. [8] indicated that the overall expenses associated with IVAP are higher than those of PICC. In this study, the total expenditure on catheter maintenance (including travel expenses and maintenance costs) indicates that only 7.86% of patients incurred total costs within 100 yuan, while 18.30% of patients had expenses amounting to 400 yuan or more. Furthermore, among the surveyed subjects, 39.18% of patients reported a monthly household income per capita below 2000 yuan, indicating that to a large extent, when patients experience other physical discomforts before the scheduled maintenance time for their infusion ports, they are more willing to choose other venous access to solve the current medical problems. In addition, patients at infusion port will experience more pain and discomfort during non-damaging needle punctures, which will not only increase patients’ anxiety, but even lead them to evading therapeutic measures [26]. In this study, 7.79% of patients opted for other venous access due to for this reason. This further underscores the necessity for clinical medical staff to enhance their assessment of patients’ pain and psychological state when dealing with infusion port patients. When appropriate, it is essential to implement safe and effective methods that can alleviate pain associated with non-invasive needle punctures, thereby improving patient comfort.

4.2.4 Surgery and chemotherapy implementation sequence.

The systemic chemotherapy for early-stage breast cancer is categorized into neoadjuvant chemotherapy and adjuvant chemotherapy following surgery. This study indicates that among 766 patients, 57.73% received postoperative adjuvant chemotherapy, while 42.27% underwent neoadjuvant chemotherapy. The results reveal that patients who received postoperative adjuvant chemotherapy exhibited more severe anxiety symptoms, which is consistent with findings from scholars both domestically and internationally [27]. The study of Yang et al. [28] indicates that postoperative patients must endure the pain caused by various treatments, as well as the fear associated with their illness, which was the most serious period of patients’ anxiety. On one hand, the impairment of body image resulting from surgery is likely a key factor influencing patients’ emotional well-being. On the other hand, following surgery, patients often experience a decline in overall bodily function. Coupled with adverse physical conditions and the toxic side effects of chemotherapy drugs,such as gastrointestinal reactions, hair loss, and insomnia, etc., these pronounced somatic symptoms make patients more susceptible to feelings of anxiety.

Therefore, for patients with postoperative adjuvant chemotherapy, clinical interventions can be implemented to assist breast cancer patients in alleviating discomfort caused by surgery and reducing the occurrence of chemotherapy side effects, thereby promoting their physical recovery. At the same time, attention should be paid to the psychological care of patients undergoing postoperative chemotherapy, providing targeted nursing interventions helps patients to accurately understand their condition, actively cope with the negative emotions associated with surgery and chemotherapy, and alleviate anxiety-related psychological disorders [29].