Introduction
Breast cancer remains the most common cancer among women worldwide, touching the lives of millions each year (1, 2). In 2020 alone, more than 2.26 million new cases were diagnosed globally (3). While rates have stabilized or even declined in some high-income countries, developing nations—including Iran—have seen a concerning rise in new breast cancer cases (2).
In Iran, breast cancer accounts for roughly 12.5% of all cancer diagnoses in women (4). What makes the situation more alarming is that women here tend to face this disease at a younger age compared to other parts of the world—often 5 to 10 years earlier (5, 6). Many of these women are in the prime of their lives, building careers, raising families, or dreaming of starting one.
Globally, breast cancer is the most common cancer among women of childbearing age, representing nearly half of all cancers in women aged 25 to 49 (7). Over 15% of breast cancer cases affect women under 40 (8), many of whom have young children at home or hopes of becoming mothers in the future (9). While advances in treatment have dramatically improved survival rates—with more than 91% of women surviving at least five years after diagnosis (5, 10)—the journey doesn’t end with medical treatment. The emotional, social, and reproductive impacts of breast cancer often linger, particularly for young women still in their reproductive years (8, 10, and 11). For these women, concerns about fertility, the ability to conceive, raising children, and the health of future offspring can be overwhelming (12). Many grapple with questions: Will I be able to have children? Will my illness or treatment affect my child? How do I navigate motherhood while managing my own health? In cultures like Iran’s, where motherhood and family play a central role in a woman’s identity, these concerns are even more profound. The emotional strain, paired with fears about infertility, pregnancy complications, and the health of future children, can significantly affect mental well-being and quality of life (13).
Despite these challenges, reproductive health concerns are often overlooked in cancer care. Understanding the specific fears and needs of young women with breast cancer—especially within the context of Iranian society—is essential for providing compassionate, comprehensive care. This study aimed to explore these concerns among young women with breast cancer in northwest Iran and to better understand both the measurable factors and the deeper, personal experiences shaping their reproductive worries.
Data Collection
Quantitative Phase:
Participants completed a structured questionnaire capturing demographic details, medical history, and reproductive concerns. Reproductive concerns were assessed using the well-established Reproductive Concerns after Cancer (RCAC) scale (10), which evaluates six key areas:
Reproductive potential: Fears about being unable to conceive
Partner disclosure: Anxiety around discussing reproductive issues with a spouse
Child health: Concerns about how their illness might affect existing or future children
Personal health: Worries about being physically able to care for a child
Acceptance: Emotional difficulty accepting infertility
Pregnancy: Fears regarding potential pregnancy risks after cancer
Each question was rated on a 5-point Likert scale, with higher scores reflecting greater concern. The overall score ranged from 18 to 90, providing a broad picture of each woman’s reproductive worries. The RCAC scale’s reliability (Cronbach’s alpha > 0.75) and content validity were confirmed by expert review prior to use.
Qualitative Phase:
To dive deeper into the emotional and cultural roots of these concerns—especially around personal health and caregiving—we conducted one-on-one, semi-structured interviews with 30 women from the initial group. Participants were encouraged to share their thoughts and feelings openly, with interviews guided by broad, open-ended questions and gentle prompts for elaboration. The conversations lasted between 45 and 90 minutes, depending on each woman’s comfort and energy levels, and were conducted at a time and place of their choosing to ensure privacy and emotional safety. All interviews were conducted by the same trained researcher, ensuring consistency. The discussions were audio-recorded, transcribed word-for-word, and analyzed until no new themes emerged—a process known as data saturation.
Data Analysis
Quantitative data were analyzed using SPSS software (version 25), applying t-tests, logistic regression, and Fisher’s exact tests. Statistical significance was defined as a p-value < 0.05.
Qualitative data were analyzed using conventional content analysis, following the framework established by Graneheim and Lundman (14). Through careful coding and categorization, we identified recurring themes that reflected the women’s lived experiences and cultural context.
Ethical Considerations
The study received ethical approval from the Ardabil University of Medical Sciences Ethics Committee (Approval Code: IR.ARUMS.REC.2019.098). Participation was entirely voluntary, and women were free to withdraw at any time without consequences. All participants provided written informed consent, and their privacy and confidentiality were fully protected throughout the study.
3. Results
The women in this study were between 18 and 45 years old, with an average age of 37.5 years. Most (67.6%) had one or two children, while 9.4% had no children. For mothers, the youngest child was, on average, just over five years old—highlighting how many participants were still raising very young children while facing breast cancer.
Financial strain was common. More than half of the women reported that their household income was insufficient to meet basic living needs. Self-rated health was also concerning, with nearly half (47.5%) describing their health as poor. The average age at breast cancer diagnosis was 34.9 years—meaning many were diagnosed during the prime of their reproductive years. In terms of treatment, two-thirds (65.5%) underwent lumpectomy, while the most common additional therapy was a combination of chemotherapy and radiotherapy (39%). The overall level of reproductive concerns among participants was moderate to high, with an average score of 48.5 out of a possible 75. Women who received more intensive treatments, such as chemotherapy, reported significantly higher levels of reproductive worry, while employed women tended to report fewer concerns (see Table 1).
Table 1
Distribution and Mean score of perceived reproductivity concerns in terms of demographic variables and disease-related variables in patients with breast cancer
| | Category | N (%) /Mean | Mean ± SD | P value |
|---|
Age | < 30 | 17 (12.4) | 48.18 ± 6.63 | 0.97 |
30–40 | 59 (42.3) | 48.59 ± 6.41 |
> 40 | 63 (45.3) | 48.44 ± 5.71 |
Age at the time of diagnosis | | 34.9 ± 6 | | |
Level of education | Elementary and secondary | 84(60.4) | 48.54 ± 5.7 | 0.98 |
High school | 38 (27.3) | 48.3 ± 6.5 |
University | 17 (12.2) | 48.5 ± 6.6 |
Partner level of education | Elementary and secondary | 59 (42.4) | 48.4 ± 5 | 0.83 |
High school | 46 (33.1) | 47.9 ± 5 |
University | 20 (14.4) | 47.6 ± 6 |
No response | 14 (10.1) | | |
Number of children | Without child | 13 (9.4) | 52.46 ± 6.6 | 0.02 |
1–2 child | 94 (67.6) | 48.55 ± 5.9 |
≥ 3 child | 27 (19.4) | 47.07 ± 5.5 |
No response | 5 (3.6) | - |
Job | Housekeeper | 128 (92.1) | 48.59 ± 6 | 0.57 |
Occupied | 11 (7.9) | 47.45 ± 6.1 |
Menstrual status | Menstrual | 73 (52.5) | 47.6 ± 5 | 0.07 |
Menopause | 66 (47.5) | 49.4 ± 6 |
Prevention method | Natural | 68 (48.9) | 47.94 ± 6.17 | 0.62 |
LD Tablet | 9 (6.5) | 47.0 ± 5.29 |
IUD | 16 (11.5) | 47.06 ± 4.26 |
Condom | 2 (1.4) | 51.0 ± 4.23 |
No prevention | 23 (16.5) | 49.48 ± 5.96 |
No response | 21 (15.1) | - | - |
Diagnosis stage | Local | 104 (74.8) | 48.16 ± 6.16 | 0.17 |
Advanced localization | 29 (20.8) | 50.10 ± 5.87 |
Metastatic | 3 (2.2) | 44.67 ± 3.51 |
No response | 3 (2.2) | - | - |
Type of surgery | Lumpectomy | 91 (65.5) | 48.15 ± 6.30 | 0.56 |
Unilateral mastectomy | 34 (24.5) | 49.38 ± 5.33 |
Non-surgical | 10 (7.1) | 49.30 ± 7.21 |
No response | 4 (2.9) | - |
Adjuvant therapies | No | 39 (28.05) | 45.26 ± 4.51 | < 0.001 |
Yes | 100 (71.95) | 49.7 ± 6.16 |
Chemotherapy | 37 (37.0) | 48.14 ± 5.34 | < 0.001 |
Hormone therapy | 6 (6.0) | 50.00 ± 2.36 |
Chemotherapy + Radiotherapy | 39 (39.0) | 50.54 ± 6.72 |
Chemotherapy + Radiotherapy + Hormonotherapy | 15 (15.0) | 48.73 ± 5.27 |
Chemotherapy + Hormonotherapy | 3 (3.0) | 62.00 ± 2.64 |
Adequacy of income | Inadequate | 72 (51.8) | 49.28 ± 5.65 | 0.19 |
Enough | 51 (36.7) | 47.29 ± 6.77 |
Too much need | 16 (11.5) | 48.81 ± 5.04 |
Patients' self-assessment of their level of health | Good | 36 (25.9) | 46.22 ± 5.97 | 0.03 |
Medium | 37 (26.6) | 49.27 ± 6.44 |
Weak | 66 (47.5) | 49.30 ± 5.63 |
| LD: Low-Dose Birth Control, IUD: Intrauterine Device |
The most significant worries centered on “personal health”, followed by concerns about fertility and child health. The area of least concern involved disclosing reproductive issues to partners. Importantly, women with higher education levels, as well as those whose partners had more education, expressed fewer personal health concerns—possibly reflecting better access to health information and resources. (Respectively (P = 0.049) (P = 0.048))
Having children also influenced reproductive concerns. Women with more children reported lower levels of worry about fertility and acceptance, while childless women reported the highest levels of concern in these areas (P = 0.02 and P < 0.001, respectively). (Table 2).
Table 2
Comparison of patients' mean scores in the six dimensions of perceived reproductivity concerns in terms of some variables
| | | Reproductivity potential | Disclosing the problem | Child health | Personal health | Acceptance | Becoming pregnant |
|---|
| | | Mean ± SD |
Total score in subscales | | 57/1±60/8 | 58/1±22/7 | 63/2±55/8 | 95/1±97/8 | 72/1±57/7 | 48/1±59/7 |
Number of children | Without child | 8.92 ± 1.7 | 7.6 ± 2.1 | 9.3 ± 2.2 | 8.4 ± 1 | 9.6 ± 1.6 | 8.3 ± 1.9 |
1–2 child | 8.7 ± 1.6 | 7.2 ± 1.5 | 8.4 ± 2.6 | 9.1 ± 1.8 | 7.4 ± 1.6 | 7.5 ± 1.4 |
≥ 3 child | 7.8 ± 1.1 | 6.9 ± 1.3 | 8.8 ± 2.8 | 8.8 ± 2.4 | 7.2 ± 1.5 | 7.3 ± 1.3 |
P value | 0.03 | 0.40 | 0.42 | 0.35 | 0.001 | 0.12 |
Adjuvant therapy | yes | 8.69 ± 1.5 | 7.4 ± 1.7 | 8.9 ± 2.8 | 9.34 ± 1.8 | 7.4 ± 1.7 | 7.8 ± 1.4 |
no | 8.31 ± 1.6 | 6.6 ± 0.87 | 7.6 ± 1.8 | 7.9 ± 1.8 | 7.6 ± 1.6 | 7.1 ± 1.3 |
P value | 0.24 | 0.001 | 0.01 | 0.001 | 0.64 | 0.01 |
Adequacy of income | Inadequate | 8.6 ± 1.5 | 7.4 ± 1.7 | 8.7 ± 2.7 | 9.4 ± 1.9 | 7.5 ± 1.6 | 7.5 ± 1.3 |
enough | 8.6 ± 1.6 | 6.9 ± 1.4 | 8.3 ± 2.6 | 8.3 ± 1.8 | 7.4 ± 1.6 | 7.6 ± 1.7 |
Those who underwent comprehensive treatment (surgery, chemotherapy, radiotherapy, and hormone therapy) were significantly more concerned about both their own health (P = 0.001) and their children’s health (P = 0.008). Higher income was associated with fewer personal health concerns (P = 0.025). When asked directly, 61.6% of women identified infertility as their biggest fear, followed closely by the fear of not being able to care for their children (47.4%).
Regression analysis revealed that younger age, the age of the youngest child, and age at diagnosis were significant predictors of reproductive concerns (see Table 3).
Table 3
predictive factors of reproductivity concerns in patients with breast cancer
| | B | Sig. | Exp(B) |
|---|
Age | -0.483 | 0.004 | 0.617 |
Level of education | 1.349 | 0.086 | 3.855 |
Occupation | -0.233 | 0.894 | 0.792 |
Husband education | -0.687 | 0.204 | 0.503 |
Menstrual status | -0.269 | 0.665 | 0.764 |
Number of children | -0.384 | 0.523 | 0.681 |
Last child age | 0.152 | 0.042 | 1.164 |
Breastfeeding history | 0.271 | 0.346 | 1.311 |
Age at diagnosis | 0.367 | 0.010 | 1.444 |
Cancer stage | 0.769 | 0.321 | 2.157 |
Type of surgery | 0.133 | 0.762 | 1.143 |
Other treatment | 0.101 | 0.589 | 1.106 |
In the second phase, qualitative interviews provided deeper insight into these fears. Two major themes emerged:
1. Living under the Shadow of Fear
Women described overwhelming anxiety about their children’s future, their own health, and their ability to protect and raise their children. Common worries included:
Fears of not being present to raise their children due to illness or death
Feeling inadequate as a mother
Anxiety about their children’s social well-being and safety
Patient Voices:
I’m always worried I’ll be so consumed by my illness that I won’t raise my children properly, and they’ll grow up alone.
If I were healthy, I could meet their needs, but I just can’t anymore.
My illness isolates us. I can’t take my daughter to parties or outside much.
I feel guilty that my illness interferes with raising my children.
I’m afraid I might die, and my children will end up with a stepmother.
These fears contributed to feelings of being an inadequate mother, unable to protect or nurture their children as they desired.
2. Restrictions and Financial Strain
Disease-related fatigue, pain, and disability—especially after surgery—made daily caregiving difficult. Additionally, many women described the financial burden of treatment draining household resources, making it even harder to care for their families.
Patient Voices:
I want to hug my daughter and take her out, but my hands won’t let me.
I get tired so quickly—I can’t cook or play with them like before.
Most of our money goes toward my treatment.
These physical and financial limitations left many women feeling powerless to meet their children’s needs, deepening their concerns about motherhood and family life (see Table 4).
Table 4
Categorizing the roots of personal health concerns
Main categories | Subcategory | Basic concepts | Code |
|---|
Living under shadow of fear (perceived fears and negative emotions) | Fear concerning the uncertain future prospects of their children | The apprehension of potential physical separation from their child due to their illness | Being separated from children due to necessary treatment follow-up |
The mother's concern about her children living with a stepmother |
The mother's fear of her children becoming motherless |
Fear of hereditary cancer risk |
The mental strain induced by the costs of treatment | The mother's discomfort due to not being able to meet her children's welfare needs because of medical expenses |
Feeling pressured to support the family financially while undergoing treatment |
Experiencing adverse sentiments regarding one's role as a mother | The perception that a mother cannot fulfill her maternal role |
Drawing comparisons between one's physical health and that of healthy mothers |
Restrictions | Physical disability and its limitations | The inability to care for and protect children due to physical limitations resulting from illness | Inability to use the hand on the side of mastectomy |
Pain in the arm on the side of the mastectomy |
Edema in the arm on the mastectomy side |
Inability to carry the child with the hand |
Interference of disease follow-up with children's care |
Resource limitations | Financial difficulties stemming from medical expenses impacting the care of children | most of our income are spent on my treatment |
Absence of cohesive support systems | Inability to provide an optimal caregiving environment for children |
| 4. Discussion |
For young women, a breast cancer diagnosis can feel like life stops—and for many, fears about fertility, parenting, and their children’s future quickly rise to the surface. Our study reflects these deeply personal concerns, with reproductive worries reported at moderate to high levels.The greatest anxieties focused on personal health, reproductive potential, and child health, echoing findings from Sweden, Portugal, and other studies (15–19). Women who have not yet started or completed their families often experience heightened fears about fertility loss (20), which can worsen depression (21) and diminish quality of life (22).
Education played a protective role. Women with higher levels of education, and those with educated partners, reported fewer personal health worries—possibly due to better understanding of treatment options (23, 24), improved self-care, and greater access to resources (23–25). The number of children also influenced reproductive concerns. Women without children or with fewer children reported more intense worries about fertility and social acceptance, consistent with previous studies (15, 26–28). The innate desire to become a mother—or to expand one’s family—makes the threat of infertility especially distressing (17, 26). It has been shown that the unfulfilled desire to become a parent is associated with mental health disorders (27). Intensive treatments like chemotherapy and radiotherapy, known for their potential to harm fertility, were linked to higher reproductive concerns (15, 29). Financial challenges further amplified these fears, particularly among women from lower-income households who struggled with both treatment costs and providing for their families.
Our qualitative findings gave voice to the profound emotional struggles behind these statistics. Many women expressed fears of being unable to fulfill their role as mothers, protect their children, or shield them from social harm—an especially heavy burden in cultures like Iran’s, where motherhood is deeply valued. Limitations from fatigue, pain, and disability, alongside financial strain, made daily caregiving feel like an impossible task. Similar challenges have been documented in other studies, emphasizing the need for broader social and healthcare support (30).
5. Conclusion
Reproductive concerns are more than just medical side effects—they touch the heart of a woman’s identity, dreams, and role as a mother. Young women with breast cancer face not only fears about their health but also worries about their future fertility, ability to care for children, and family well-being. Healthcare providers must recognize these intertwined concerns and address them holistically. This means:
Creating formal support networks for young breast cancer patients
Offering resources to reduce financial and emotional strain
Providing clear, compassionate education about fertility preservation and caregiving support
Ensuring psychological services are available, especially for women with lower socioeconomic status or limited educational backgrounds
Supporting these women isn’t just about managing cancer—it’s about safeguarding their hopes, families, and futures.