Worldwide, breast cancer remains the most prevalent cancer among women, both in developed and developing countries contributing to global morbidity and mortality. Approximately, 25% of breast cancer patients are over the age of 65, and nearly 10.6% of the cases are in women aged 80 years and older.¹

The average age at diagnosis is 61 years, and the majority of women who die from breast cancer are aged 65 years or older, with geriatric patients experiencing unique challenges following mastectomy, including heightened risks of lymphedema, infection, and psychological distress, such as anxiety and depression.² Notably, elderly women face barriers due to social isolation, physical frailty, and inadequate post-operative support, further emphasizing the need for targeted interventions.³

These statistics emphasize a growing need to address the specific healthcare and support needs of the geriatric population affected by breast cancer. Notably, the United States reports the highest incidence rates globally, with 128.6 cases per 100,000 in white women and 112.6 per 100,000 in African American women.⁴ In Egypt, approximately 46,000 incident cases are forecasted for 2050.³ Although this incidence rate in Egypt is lower than the global figures, mortality is higher at an age-standardized rate of 20.4/100,000.⁵

Risk factors for breast cancer encompass a complex interplay of biological, environmental, and lifestyle determinants, including advancing age, hormonal influences, diet, obesity, tobacco use^1,6, and urbanization-associated factors and the adoption of Western lifestyles.⁷ This population experiences distinct post-mastectomy challenges, including increased psychological distress, such as anxiety and depression, and a heightened risk of complications like lymphedema, infection, and fatigue.⁸

Surgery remains the cornerstone of breast cancer treatment, particularly mastectomy, which is frequently combined with other therapies such as chemotherapy, radiation, and hormonal therapy.⁹ Despite improvements in survival rates due to advancements in treatment, women who undergo mastectomy still face substantial psychological distress, with increased rates of depression and anxiety, which can significantly impact recovery.¹⁰ Psychological distress is particularly prominent in older women, who also experience challenges such as social isolation and physical frailty, which can further complicate post-surgical recovery.¹¹ Research suggests that structured discharge education programs significantly improve self-care practices and reduce psychological distress, including anxiety and depression, in post-mastectomy patients.^12,13 However, much of this research has focused on younger populations, highlighting the need for tailored interventions for older women, who face unique challenges in managing their health. Geriatric oncology nursing emphasizes the importance of education to empower patients in managing their recovery and reducing distress. However, studies evaluating the effectiveness of targeted educational programs for elderly women post-mastectomy remain scarce.¹⁴

One critical gap in the current healthcare system is the insufficient post-operative care and self-care education provided to older women after mastectomy. Many geriatric patients face difficulties in managing post-surgical complications that can significantly affect their quality of life.¹⁵ Self-care practices, including manual lymphatic drainage, skin care, exercise, and infection prevention, are essential for post-mastectomy recovery, but many older women lack the knowledge and support to effectively manage these aspects of their care.¹⁶ Given the brief hospital stays and the rising demand for home-based care, discharge education, particularly through telecommunication, has emerged as a vital means to support patients during recovery.¹⁷

Despite these findings, there remains a lack of targeted interventions addressing the specific needs of elderly women undergoing mastectomy. This demographic not only requires comprehensive education on self-care practices, such as lymphatic drainage and infection prevention, but also psychological support to navigate the emotional toll of their diagnosis and treatment.¹⁸ This study aims to bridge this gap by evaluating the impact of a proposed discharge education plan on self-care practices and anxiety levels in elderly post-mastectomy patients, contributing to a growing body of evidence that underscores the value of structured patient education.

Discharge education plans have demonstrated significant benefits across surgical populations, improving self-care practices, reducing re-admissions, and enhancing psychological well-being. For example, studies have shown that discharge education can alleviate anxiety, improve self-efficacy, and decrease the severity of post-operative symptoms in cardiac and general surgery patients.¹⁹ Web-based education programs and structured discharge plans have proven particularly effective, offering patients and caregivers the tools to better manage recovery and address potential complications early.²⁰

Given the physical and emotional toll of mastectomy, targeted self-care education is crucial for elderly women. It helps them manage post-surgical recovery, reduces anxiety, and improves overall quality of life.²¹ In conclusion, this study will address the significant gap in current healthcare practice by providing targeted self-care education for older women after mastectomy.

The hypothesis posits that discharge education will lead to improved self-care practices and reduced anxiety levels in this population, ultimately enhancing their post-operative recovery and quality of life.

Geriatric patients receiving a proposed discharge education plan will exhibit improved self-care practices and reduced anxiety levels post-mastectomy compared to those receiving routine care.

This study employed a randomized clinical trial to evaluate the effect of a discharge education plan on self-care practices and anxiety levels among geriatric patients post-mastectomy.

It included 80 geriatric female patients undergoing modified radical mastectomy at the Oncology Center in Damanhur Governorate, Egypt, affiliated with the Ministry of Health and Population (MOHP). Participants were equally assigned to a study group (n = 40) and a control group (n = 40). The sample size was determined using G*Power statistical software, considering an expected large effect size (0.8), a power of 80%, and a significance level of P < 0.05. Based on these parameters, the minimum required sample size was 34 participants per group. To accommodate potential dropouts, the final sample size was set at 40 per group, totaling 80 participants.

Inclusion criteria ensured participants were aged 60 years or older, able to communicate effectively, had no prior upper limb injuries or surgeries, and had not received chemotherapy or radiotherapy before surgery. Eligible patients were also required to be available during the data collection period.

Exclusion criteria included a history of upper limb disorders, previous mastectomy, or ongoing cancer treatments (chemotherapy/radiotherapy). These criteria were applied to control for confounding variables that could influence outcomes, such as pre-existing conditions affecting post-surgical recovery or anxiety levels.

Participants were assigned to the study or control groups through a simple randomization process. Each eligible patient was sequentially numbered and allocated alternately to the study group (discharge education plan) and the control group (routine care).

Three tools were used for data collection.

The sociodemographic profiles of the participants are assessed and compared between the study and control groups in Table 1.

The majority of the participants in both groups were aged 60 to 65 years (35% in the study group and 37.5% in the control group). Married participants constituted 42.5% of the study group compared to 62.5% of the control group. Illiteracy was observed in 32.5% of the study group and 17.5% of the control group. A higher proportion of the control group (62.5%) lived with family compared to the study group (42.5%). Urban dwellers comprised 55.0% of the control group and 27.5% of the study group. Only 10.0% of the study group were currently working, compared to 52.5 % of the control group. A majority in both groups reported sufficient monthly income (72.5% in the study group and 67.5% in the control group).

These sociodemographic factors are pertinent to understanding the baseline characteristics of the participants and the potential influence of individual differences on self-care practices and anxiety levels.

Table 2 presents the health profile and breast cancer history of the patients. Chronic comorbidities were prevalent in both groups, affecting 75.0% of the study group and 62.5% of the control group; however, this difference was not statistically significant (P=0.21). Among the reported comorbidities, diabetes mellitus was the most frequent, exhibiting a significantly higher prevalence in the control group (60.0%) compared to the study group (36.7%) (P=0.037). The prevalence of other chronic conditions, including heart disease, respiratory illness, osteoporosis, gout, and arthritis, did not differ significantly in the 2 groups.

Medication adherence rates were approximately similar in both the study (66.7%) and control (72.0%) groups (P=0.65). A family history of cancer was reported more frequently in the control group (22.5%) than in the study group (10.0%), although the difference was not statistically significant (P=0.12). Among the participants with a family history of cancer, the relationship to the affected relative (first- versus second-degree) did not differ significantly in the 2 groups (P=0.83).

Regarding symptom management behaviors, all the participants in both groups reported consulting a physician upon experiencing symptoms (100.0%; P=1.00). Other coping responses, such as prayer, acceptance, denial, and fear/anxiety, showed slight variations between the groups, but these differences were not statistically significant (P-values ranging from 0.09 to 0.58). Surgical duration was comparable between the study and control groups, with no significant difference observed (P=0.46).

Table 3 indicates significant differences for BMI (P<0.01) and regular exercising (P<0.01), which are important indicators of physical health disparities between the 2 groups. The categories for duration (P=0.33) and type (P=0.48) of Exercises showed no statistically significant difference.

Table 4 demonstrates the impact of the nursing intervention program on mean self-care practice scores among the studied geriatric patients. The discharge education plan significantly improved self-care practices in the study group compared to the control group. The total self-care practice score in the study group was significantly higher than that of the control group (P<0.001). All self-care practice domains showed significant improvements (P<0.001).

Table 5 presents the distribution of anxiety levels within the intervention and control groups at baseline and post-intervention. The intervention group demonstrated a statistically significant shift in anxiety categories following the intervention. Specifically, a marked reduction in severe and extreme anxiety was observed, with these categories disappearing entirely post-intervention (P<0.001 for both). Concurrently, the proportion of patients experiencing mild anxiety increased significantly from 2.5% to 80.0% (P<0.001). This indicates a substantial positive effect of the structured nursing intervention on reducing psychological distress and promoting emotional regulation among breast cancer patients

In contrast, the control group showed no statistically significant changes in most anxiety categories. The pre- and post-intervention differences in mild (P=0.50), moderate (P=1.00), and severe (P=0.22) anxiety levels were not significant. While a trend towards a reduction in extreme anxiety was noted (from 90.0% to 77.5%), this change was not statistically significant (P=0.06).

Table 6 provides a basic comparison between anxiety levels (mild and moderate) and the total self-care practice scores. Participants with mild anxiety had a slightly higher mean self-care practice score (356.75 ± 7.402) compared to those with moderate anxiety (353.28 ± 9.586). The scores suggest that participants with lower anxiety levels demonstrated better adherence to self-care practices. However, the P-value of 0.270 indicates no statistically significant difference was found between the mild and moderate anxiety groups in terms of self-care practices.

Breast cancer remains a global health challenge, ranking as one of the most common malignancies affecting women and a leading cause of mortality worldwide. Its impact is especially pronounced among older populations, where age serves as a significant risk factor.¹ Women aged 60 to 69 years have a notably higher probability of developing breast cancer compared to younger demographics, with the risk escalating further among women aged 70 and above. These statistics highlight the importance of targeted interventions for this vulnerable group to address their unique post-treatment needs and improve quality of life.^26,27

This study evaluated the effectiveness of a discharge education plan in improving self-care practices and reducing anxiety levels among elderly women post-mastectomy.

The results revealed significant improvements in the intervention group, suggesting that such structured educational interventions can play a pivotal role in enhancing both physical recovery and psychological well-being.

The observed improvements in self-care practices align with findings from previous research, such as the study done by Cui et al.²⁸ that emphasized the importance of tailored educational interventions in enhancing adherence to post-operative care routines. In addition, our findings are in line with the results reported by Speyer et al.²⁹ that demonstrated substantial compliance with self-care regimens, including arm care and follow-ups, among patients who received focused education. Similarly, Gautam et al.³⁰ confirmed that post-mastectomy training programs led to good self-care practices, such as arm care and arm exercises, which were associated with better quality of life scores. These findings underscore the effectiveness of patient-centered approaches in bridging knowledge and encouraging proactive health behaviors.

However, the findings contrast with the results reported by Kilbreath et al.³¹, who reported limited improvements in physical outcomes, such as upper limb strength, following educational programs. These discrepancies may be attributed to differences in participant demographics, with Kilbreath’s study focusing on younger women who might have faced fewer physical recovery barriers compared to the elderly cohort in the current study. Additionally, the inclusion of psychological support in the discharge education plan might have contributed to better outcomes in the present study, as emotional well-being is a critical determinant of adherence and recovery.

The structured nature of the discharge education plan, incorporating visual aids, hands-on demonstrations, and iterative reinforcement, emerged as a key strength. These strategies effectively addressed barriers such as high illiteracy rates among the participants, ensuring the accessibility and practicality of self-care instructions. Moreover, the phased delivery of the intervention allowed for consistent reinforcement, fostering better knowledge retention and skill application. These findings resonate with the principles of Bandura’s Social Cognitive Theory, which posits that guided mastery experiences and reinforcement enhance self-efficacy and behavior change. The inclusion of demonstration and re-demonstration of exercises during the education sessions likely enhanced patients' confidence in their ability to perform these tasks. Observing and practicing under guided supervision seem to have reinforced learning and bolstered self-efficacy, contributing to improved adherence to self-care practices.³² By enabling patients to practice self-care under professional supervision, the education plan likely boosted their confidence and ability to manage post-operative challenges.

The psychological benefits observed in the intervention group were notable, with significant reductions in anxiety levels post-intervention. These findings align with those reported by Sawant et al.³³, who demonstrated the role of pre-operative education in mitigating fear and enhancing coping mechanisms. The supportive patient-provider relationship established during the educational sessions likely contributed to this outcome, alleviating uncertainties and fostering a sense of empowerment. Additionally, the incorporation of relaxation and breathing exercises may have directly influenced anxiety reduction, as highlighted by Caruso et al.³⁴ in their work on psychosocial interventions for cancer patients.

Regarding the relationship between geriatric women’s self-care practices and their anxiety levels following the implementation of the discharge plan, the present study found no significant correlation between self-care practices and anxiety levels (Table 5). However, it was observed that higher mean scores for self-care practices were more frequently associated with women experiencing mild anxiety. This finding is consistent with a Turkish study conducted by Erbay et al.³⁵, which demonstrated that relaxation exercises helped reduce anxiety levels and other side effects of chemotherapy in patients undergoing a radical mastectomy, particularly those receiving chemotherapy for the first time. Similarly, a study by Taso et al.³⁶ in Taiwan found no significant relationship between anxiety and yoga exercise programs in relation to fatigue among women with breast cancer.

Despite its notable contributions, the study has several limitations that must be addressed to enhance the robustness and applicability of its findings. One key limitation is the sample's focus on geriatric women, which restricts the generalizability of the results to other demographic groups, including younger women and individuals from diverse socio-economic backgrounds. Furthermore, the study did not fully control for potential confounding variables, such as variations in familial support and socio-economic disparities, which could have influenced both adherence to self-care practices and psychological outcomes. To build on these findings, future research should employ stratified analyses or multivariable models to account for these confounding factors, thereby providing a more nuanced and comprehensive understanding of the intervention’s broader impact.

Clinically, the study highlights the critical role that discharge education plays in improving post-operative outcomes. However, to scale this intervention effectively, healthcare systems must prioritize the training of nursing staff in culturally sensitive and contextually appropriate educational delivery. This ensures that education is tailored to meet the specific needs of diverse patient populations. Additionally, the integration of digital tools, such as telehealth platforms and mobile applications, could improve accessibility, particularly for rural or underserved communities. By offering remote support, these digital solutions ensure continuity of care and help address gaps in access to in-person resources. Furthermore, the establishment of peer support programs and community-based initiatives could enhance the intervention’s impact, promoting a collaborative environment conducive to recovery and self-management.

The broader implications of this research emphasize the importance of long-term evaluations of discharge education programs. While the study demonstrated short-term benefits in self-care and anxiety reduction, it remains crucial to examine the sustainability of these outcomes over time. Longitudinal studies are needed to explore the intervention’s effects on key indicators such as quality of life, healthcare utilization, and overall survival. Expanding the scope of future research to include more diverse populations, such as men with breast cancer, patients undergoing different cancer treatments, or individuals recovering from various types of surgery, would strengthen the external validity of the findings and increase the adaptability of the intervention across different patient groups. Younger patients, in particular, may benefit from customized approaches that address their unique needs and recovery goals.

Looking forward, research should focus on several key areas: first, assessing the long-term sustainability of improved self-care practices and anxiety reduction over six months to a year; second, evaluating the cost-effectiveness of structured education plans, particularly in terms of their impact on reducing complications and hospital readmissions; and finally, exploring the integration of technology, such as telehealth and mobile applications, to deliver education and monitor adherence remotely. By addressing these areas, future studies can further refine and expand upon the findings of this research, leading to more effective and scalable interventions in post-operative care.

The results of the study showed that the discharge education plan significantly improved self-care practices and reduced anxiety levels in the intervention group compared to controls, demonstrating its effectiveness in enhancing post-operative recovery and psychological well-being.

The results reinforce the value of tailored educational strategies in enhancing recovery and improving quality of life for breast cancer patients across various healthcare settings. They also highlight the importance of integrating structured discharge education into routine nursing practice. By equipping patients with the necessary knowledge and skills for effective post-operative care, this intervention not only contributes to better patient outcomes but also has the potential to reduce healthcare costs by preventing complications and readmissions.

To maximize the benefits of this intervention, it is crucial for nursing staff to be trained in delivering individualized education. This should include the use of visual aids and culturally appropriate materials to meet the diverse needs of patients. Furthermore, incorporating digital platforms for follow-up care and educational delivery could improve accessibility, particularly for patients in rural or resource-constrained settings. Ultimately, this approach holds the potential to significantly enhance the overall quality of care and patient satisfaction in post-operative settings.

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the College of Nursing Research Ethics Committee at Damanhur University with approval reference number (50-e), dated [18-11-2021].

All participants were fully informed about the study’s purpose, procedures, potential risks, and benefits. Written informed consent was obtained from each participant before inclusion. To accommodate participants with limited literacy, the consent form was explained verbally in simple, comprehensible terms, and participants were encouraged to ask questions before signing. Family members were also allowed to be present during the consent process for additional support.

Participants' data were anonymized and securely stored. Identifiable information was not shared or disclosed outside the research team. Participants were informed of their right to withdraw from the study at any stage without any penalty or impact on their medical care.