Cluster Care Model: Optimizing Patient Outcomes in Post-Surgical Breast Cancer Radiotherapy

The prevalence of breast cancer (BC) is ever-increasing, with an element of social stigma to discuss it openly¹. However, the onset of BC and the effectiveness of treatment can be accurately identified. It also requires timely hospital visits. BC patients with surgery and radiotherapy still have a high proportion of ideal prognosis². The primary goal of radiotherapy is to prevent chest wall recurrence and regional lymph node metastasis in patients. However, long duration and high dose of the operation lead to adverse reactions, including skin damage. In the case of mild skin damage, patients still face discomfort, such as itching and a burning sensation. In severe cases, they complain of ulceration and erosion^3,4.

Due to the special location of the tumor, patients are prone to panic and other complex psychological problems in the face of the disease. The uncertainty regarding treatment leads to discomfort and a painful psychological state. It negatively impacts patients' psychology and sleep, resulting in poor psychological adjustment and adaptation, and some of them even continue to have psychological problems after the treatment ends⁵. Without proper and timely management, patients feel helpless and powerless when facing reality and lose their confidence^6,7. Some studies have reported⁸ that the negative emotions generated by cancer patients after surgery adversely affect their quality of life and physical recovery. Despite improvement in the disease after surgery, the changes in body function due to psychological problems are irreversible. At the same time, the difficulty of the curative nature of the disease, combined with the subsequent continuous conservative treatment, aggravates the psychological burden of patients. These factors also influence compliance by the patients to continue with the treatment. It further worsens their quality of life. Regarding the nutritional mix of the postoperative radiotherapy diet, some patients lack relevant knowledge, which can lead to malnutrition due to substandard nutritional intake. Indeed, different postoperative care measures can directly affect the quality of daily diet⁹. To meet the high care needs of patients at all stages, continuous improvement of the care system is essential to enhance the quality of life for patients.

Based on evidence-based practices, the clustered care model integrates multiple proven nursing strategies into a structured protocol to deliver systematic, scientific, and patient-centered care¹⁰. We hypothesized that implementing this model in patients undergoing postoperative radiotherapy for BC would reduce treatment-related skin injury and pain, alleviate psychological distress, improve nutritional status, and ultimately enhance overall quality of life. To test this hypothesis, we applied the intensive care intervention protocol, monitored relevant nursing indicators, and evaluated its effectiveness through clinical outcomes and patient-reported measures.

The Ethics Committee of the Tumor Hospital Affiliated to Nantong University, Nantong, Jiangsu, China, reviewed and approved this investigation (Approval No. 2025-027-010). The Declaration of Helsinki and relevant institutional guidelines were adhered to in all procedures involving human participants. The consumables used are listed in the Table of Materials.

1. Data collection

Seventy-six patients admitted to the hospital for BC postoperative radiotherapy from January 2023 to September 2024 were selected as the subjects. Written informed consent was taken from every patient. Among the study population, 38 patients who received conventional nursing interventions were regarded as the control group, while 38 patients who received intensive care interventions were recorded as the observation group. The general data of both groups showed no statistically significant differences (p > 0.05, Table 1).

2. Inclusion and exclusion criteria

The patients included when the diagnostic criteria for BC were met^11, and radiation therapy was performed after surgery. Patients and families were fully informed and completed signed consent forms. The expected survival time was greater than six months. The patients were excluded when severe cognitive or communication impairment was found, or the patients were chemotherapy intolerant, or any comorbid hematologic and other somatic disorders were reported.

3. Control group (Conventional nursing intervention)

The control group received conventional postoperative radiotherapy care, including:

1. Skin care
   Patients were instructed to maintain the cleanliness and dryness of the irradiated skin, avoiding friction and using non-irritating skincare products. For mild erythema or pruritus, alcohol-free moisturizers were recommended. Dry desquamation was considered when peeling or flaking occurred without exudation. Moist desquamation was established if the epidermis was lost and the wound was oozing, wet, and painful, with a high risk of infection¹².
2. Health education
   Radiotherapy procedures were explained to the patients. Potential adverse reactions and management strategies were explained to patients and families.
3. Psychological support
   Basic psychological counseling was provided to encourage emotional expression. No systematic psychological interventions were implemented.
4. Dietary guidance
   A high-protein, vitamin-rich diet was recommended. Spicy and irritating foods were suggested to be avoided. No personalized nutrition plans were developed.

4. Intervention group (Cluster nursing intervention)

The intervention group received evidence-based cluster care in addition to conventional care, including:

1. Systematic skin management
   Skin assessment was conducted prior to radiotherapy. Patients were instructed to wear loose, cotton clothing and avoid contact with metal in the radiation field. During radiotherapy, daily skin monitoring was carried out. Dry desquamation was managed with normal saline compresses applied twice daily, with each session lasting 15 min. Moist desquamation was treated with silver-based dressings combined with topical anti-inflammatory agents. For post-radiotherapy, hyaluronic acid-containing repair cream) was recommended for skin barrier restoration.
2. Structured psychological intervention
   For cognitive behavioral therapy (CBT), weekly group sessions were held for 60 min to modify negative cognitions and enhance treatment confidence. In mindfulness-based stress reduction (MBSR), daily guided mindfulness breathing exercises for 10 min were conducted to reduce anxiety. In addition to these measures, family members also participated (as a family support program) through structured meetings to strengthen social support systems.
3. Individualized nutritional support
   In this case, the nutritional risk screening (NRS) 2002 scale was administered. For the patients with scores ≥3, personalized diet plans were developed. Specifically, the patients were counseled to maintain an energy intake of 25-30 kcal/kg, with a protein requirement of 1.2-1.5 g/kg/day from lean poultry, fish, soy, legumes, and whey¹³. To add vitamins, minerals, and antioxidants, seasonal fruits, vegetables, nuts, and flaxseed were also recommended to be included in the diet. To maintain hydration, 1.5-2.0 L/day water intake was advised. Compliance was monitored weekly by a dietitian. Weekly assessment of body weight and serum albumin levels was also considered for the dynamic plan adjustments.
4. Pain and symptom management
   For the pain control assessment, the VAS score was calculated. It was calculated on the scale of 0 to 10, where 0 means no pain. The patient was asked to point at the scale. VAS ≥4 was assigned in case of non-pharmacological interventions (cold compresses, music therapy) combined for moderate-severe pain. To manage fatigue, a progressive exercise program was implemented (30 min daily walking).

5. Outcomes measures

Skin lesions were assessed using the Radiation Oncology Collaborative Group's grading scale for acute radiation lesions of the skin¹⁴. Grade 0 indicated no skin changes; grade I referred to localized edema and mild erythema with dry lesions and blister formation, burning sensation, and pruritus. Grade II was assigned if wet lesions significantly fused and erythema was visible, with vesicles, neutrophilic edema, and superficial ulcers observed. Grade III showed severe local erythema with skin tissue necrosis, showing ulcerative manifestations.

VAS was used to assess the pain of both groups before and after nursing intervention¹⁵. The specific scoring criteria were plotted on a crossline scale, with 0 being no pain to 10 being unbearable severe pain.

For the analysis of psychological factors, anxiety and depression were scored by the Zung Self-Rating Anxiety Score (SAS), while depression was measured through the Zung Self-Rating Depression Scale (SDS), respectively^16,17. Both scales were measured at 20 items. For each score, a raw total (from 20 to 80) was obtained through the instrument (questionnaire). Raw scores were multiplied by 1.25 to yield an index score (25-100). SAS scores were categorized as normal (>45), mild-moderate (45-59), marked-severe (60-74), and extreme (>75). An SDS score of <50 showed a normal level, 50-59, mild depression, 60-69, moderate depression, and >70, severe depression.

The quality of patients' life was evaluated using the 36-Item Short Form Health Survey (SF-36), which covers four functional dimensions (cognitive, bodily, social, and role), with a standard score of 100 for each dimension, and a high score indicating a better quality of life¹⁸. Nutritional status was evaluated using the Nutrition Risk Screening Scale (NRS)¹⁹, which assesses disease severity, nutritional impairment, and age standard range, with a score of 2-7 and ≥3 points indicating malnutrition. Nursing satisfaction was evaluated at a total score of 100 through a self-administered nursing satisfaction questionnaire. The score was analyzed as 80-100, 60-80, and <60 for very satisfied, basically satisfied, and dissatisfied, respectively. Satisfaction with care was evaluated using the formula (very satisfied + basically satisfied) / total number of cases × 100%.

6. Statistical analysis

Comparisons between groups of counting data were made by chi-square test, expressed as (rate); the measurement data conformed to normal distribution were assessed by t-test and paired t-test, expressed as mean ± standard deviation. SPSS 22.0 software was used for statistical analysis. P< 0.05 defines a statistically significant difference.

Skin damage grading situation
After the nursing intervention, there were 14 cases (36.84%) of grade 0, 7 cases (18.42%) of grade I, 14 cases (36.84%) of grade II, and 3 cases (7.89%) of grade III skin lesions in the control group (Table 2). In the observation group, there were 22 cases (57.89%) of grade 0, 11 cases (28.95%) of grade I, 4 cases (10.53%) of grade II, and 1 case (2.63%) of grade III skin damage. This data shows that the severity grading of radiological skin injury in the observation group was significantly lower (p < .05) than that in the control group.

Comparison of VAS scores before and after nursing intervention
Before the nursing intervention, there was no difference in VAS scores between the two groups (p > .05), and patients in both groups reported experiencing pain. After nursing intervention, the VAS score dropped to 4.55 ± 0.50 in the control group, and even lower (1.18 ± 0.39) in the observation group, with statistical significance (Figure 1).

Changes in SAS and SDS scores before and after nursing intervention
Before nursing intervention, there was no difference in SAS and SDS scores between the two groups (p > 0.05). After nursing intervention, SAS and SDS scores, respectively, were 45.05 ± 7.45 and 49.42 ± 9.33 in the control group and 32.76 ± 6.46 and 35.50 ± 5.24 in the observation group, respectively (Figure 2A,B). It showed that nursing intervention improved the psychological status of the study population.

Nutritional status before and after nursing intervention
The data in Figure 3 shows that the control and study populations did not vary based on their nutritional status before nursing intervention (p > 0.05). Nursing intervention showed a higher nutritional score (2.26 ± 0.79) compared to the control group (1.18 ± 0.51).

Quality of life after nursing intervention
The quality of life, as measured in cognitive, bodily, social, and role, was higher (with statistical significance) in the intervention group than the control group (Figure 4), affirming the effectiveness of the intervention.

Nursing satisfaction survey in both groups
Patient satisfaction in the control group was significantly lower (31/38; 81.58%) than that in the intervention group (36/38; 94.74%) with statistical significance (Table 3).

DATA AVAILABILITY:
Raw data associated with this study are provided in Supplementary File 1.

Figure 1: Comparison of VAS scores before and after nursing intervention. Compared with before the nursing intervention. Mean values with standard deviations have been given. *p < 0.05 compared with the observation (control) group. Please click here to view a larger version of this figure.

Figure 2: Changes in Self-rating anxiety score (SAS) and Self-rating depression score (SDS) before and after nursing intervention. (A) Comparison of SAS scores. (B) Comparison of SDS scores. Compared with before the nursing intervention. Mean values with standard deviations have been given. *p < 0.05 compared with the observation (control) group. Please click here to view a larger version of this figure.

Figure 3: Nutritional status before and after nursing intervention. Mean values with standard deviations have been given. *p < 0.05 compared with the observation (control) group. Please click here to view a larger version of this figure.

Figure 4: Changes in quality-of-life scores for each function. (A) Comparison of cognitive function scores. (B) Comparison of somatic function scores. (C) Comparison of social function scores. (D) Comparison of role scores. Mean values with standard deviations have been given. *p< 0.05 compared with the observation (control) group. Please click here to view a larger version of this figure.

Table 1: General information of the Control, Observation, or Intervention groups. Please click here to download this Table.

Table 2: Skin damage grading of the populations (Control and Observation/Intervention groups). Please click here to download this Table.

Table 3: Statistics of nursing satisfaction survey after nursing intervention in both groups. Please click here to download this Table.

Supplementary File 1: Raw data generated during the study. Please click here to download this File.

Radiotherapy alone or in combination with chemotherapy causes various physical changes to BC patients, rendering psychological pressure to women in many ways, affecting their ability to take care of themselves, and further threatening their physical and mental health^20,21. Clustered care is the integration of a series of clinical treatment and care models to provide care to patients, minimizing physical and emotional damage. By reviewing a large amount of literature and data, nursing staff can gain a deeper understanding of professional nursing knowledge and tailor a scientific and rational multi-care approach to patients' specific clinical realities²². Improving patients' disease-related knowledge enables them to fully understand their condition and reduces their uncertainty about treatment, which has a complementary effect on their quality of life²³. Therefore, this study was conducted to analyze whether patients had achieved an overlay of care effects with pre- and post-collective care intervention data.

The findings of this study demonstrated that structured nursing interventions yield better improvements across the clinical spectrum of BC patients undergoing radiotherapy. The observation or intervention group experienced significantly fewer high-grade skin injuries (grade II and III desquamation), reflecting an effective attenuation of radiation-induced skin toxicity. These outcomes align with a prior study that emphasizes the importance of proactive skin care education, timely assessment, and appropriate nursing measures in reducing the incidence and severity of radiotherapy-induced dermatitis²⁴.

A lower VAS score showed better pain management in the intervention population (mean ~1.8) compared to the control group (mean ~4.55). It explains the importance of nursing in symptom management and providing non-pharmacological comfort strategies that complement analgesics and enhance patient experience²⁵.

The effect of nursing care on the psychosocial status of the patients was evident by SAS and SDS scores. These results corroborate earlier findings where a reduction in mood disturbance, anxiety, and depression was reported as a function of the Korean nurse-led program²⁶. It has also been reported²³ that quality of life is negatively correlated with non-adaptive cognitive emotion regulation, and positively correlated with adaptive cognitive emotion regulation. Yet, alternative methods, such as 'Mindfulness-based stress reduction' (MBSR) program, have also been proposed in a broader and specific perspective (https://dhwp rograms.dukehealth.org/programs-training/public/mindfulness-based-stress-reduction/). Similarly, music therapy has also been reported to reduce neuroexcitation levels and adjust the emotional status of patients to better manage postoperative radiotherapy^26,27.

Ensuring adequate nutrition supports wound healing, treatment tolerance, and improves cognitive, physical, social, and role functioning, reflecting comprehensive patient-centered care^28,29.

The nutritional status of patients has been described as having a conductive impact on early postoperative recovery^30,31. The data related to the nutritional status of BC patients showed that an integrated approach involving pain management, psychological counseling, and better nutrition alleviates radiotherapy-related complications and improves patients' quality of life. Clustered care, which provides individualized nutritional counseling, improved both the appetite and nutritional status of patients³².

Nonetheless, the clinical implications of this study are substantial. The nursing intervention model presented here could be seamlessly integrated into oncology care protocols and guidelines. In resource-limited or rural settings, where access to specialists may be constrained, empowered nursing personnel can deliver high-impact care, potentially lowering healthcare burdens and improving equity. The model may also translate to other cancer populations undergoing radiotherapy, where skin toxicity and psychological distress are similarly prevalent.

However, the generalization of the study should be considered with caution. First, the sample size of this study was not too large (n = 76). Secondly, long-term follow-ups were not included, and hence, the effects on chronic skin changes were not studied. In addition, the reliance on self-reported scales (VAS, SAS, SDS) brought subjectivity. Therefore, more quantitative analysis is required to strengthen these findings. Future studies involving larger datasets from multiple centers are required, particularly to analyze the economic burden of such a level of nursing support. The availability of staff and hospital facilities also needs to be evaluated systematically.

In conclusion, this study demonstrated that the clustered care model was effective for breast cancer patients. The intervention provided relief to the patients in terms of skin lesions, psychological status, and nutritional status. Future studies involving multiple centers and large datasets can strengthen the findings and improve the model.