Research Article

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

DOI:

10.3791/69060

⸱

October 31st, 2025

 ,  ,  ,  ,  , 
1Operating Room, Tumor Hospital Affiliated to Nantong University, 2Department of Breast Surgery, Tumor Hospital Affiliated to Nantong University, 3Department of Anesthesiology, Tumor Hospital Affiliated to Nantong University, 4Nursing Department, Tumor Hospital Affiliated to Nantong University

In This Article

Summary

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This protocol aims to assess the clustered care model in postoperative radiotherapy for breast cancer to improve patients' quality of life by reducing skin lesions, alleviating psychological burden, and improving nutritional status, with the potential for clinical implementation.

Abstract

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Postoperative radiotherapy for breast cancer (BC) often leads to complications such as skin injury, pain, and psychological distress. Ultimately, the quality of life of the patient is compromised. Structured nursing interventions are designed to mitigate these effects and support recovery. A total of 76 patients undergoing BC postoperative radiotherapy between January 2023 and September 2024 were enrolled. Patients were randomly assigned to receive either conventional nursing interventions (n = 38) or cluster nursing (n = 38. The protocol included systematic education on skin care, continuous monitoring of radiation-induced skin changes, pain assessment and management using the visual analog scale (VAS), self-rating anxiety scale (SAS), and self-rating depression scale (SDS). The health survey short form (SF-36) was used to evaluate patients' quality of life, and the nutritional status and nursing satisfaction of the two groups were statistically analyzed. After nursing intervention, the severity grading of radiological skin injury was reduced in the observation group than in the control group (P < 0.05). The scores, including VAS, SAS, and SDS, were lower in the test population (P < 0.05). In this population, nutritional status improved. A higher SF-36 score indicated better quality of life in the intervention group (P < 0.05). The structured cluster care approach effectively regulates the psychological condition of post-BC patients. It also improves the dietary intake ability of patients and their quality of life.

Introduction

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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 erosion3,4.

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 confidence6,7. 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.

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Protocol

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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 met11, 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), respectively16,17. 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.

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Results

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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 th...

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Discussion

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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 health20,21. 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 literat...

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Disclosures

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Authors do not declare any conflict of interest.

Acknowledgements

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This work was supported by the Nantong Science and Technology Plan Project (JC2021084) and Nantong Social Welfare and Public Health Project - Clinical Medicine Research Center (HS2022002).

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
Hyaluronic acid-containing repair cream Fengchen, Qingdao, China9004-61-9
Normal salineAmsino Medical Kunshan Co Ltd, Jiang Su Sheng, ChinaASO559
Silver-based dressings Exciton technologies, Edmonton, Canadaexsalt SD&
Whey proteinSigma AldrichW3501

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Tags

Postoperative RadiotherapyNursing InterventionsSkin Injury ManagementPain AssessmentPsychological DistressQuality Of LifeNutritional Status

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