Education moderates the structural architecture and plasticity of post-traumatic stress disorder symptoms in breast cancer survivors: A network analysis

Hongman Li; Ying Xiong; Qihan Zhang; Qiaoling Chen; Siqi Wu; Yiguo Deng; Ziqing Huo; Luhong Wen; Weiwei Tong; Jiaying Li; Zengjie Ye

doi:10.1016/j.ejon.2026.103188

Education moderates the structural architecture and plasticity of post-traumatic stress disorder symptoms in breast cancer survivors: A network analysis

Eur J Oncol Nurs. 2026 Apr 6:82:103188. doi: 10.1016/j.ejon.2026.103188. Online ahead of print.

Authors

Hongman Li¹, Ying Xiong², Qihan Zhang¹, Qiaoling Chen², Siqi Wu¹, Yiguo Deng¹, Ziqing Huo¹, Luhong Wen¹, Weiwei Tong¹, Jiaying Li³, Zengjie Ye⁴

Affiliations

¹ School of Nursing, Guangzhou Medical University, Guangzhou, Guangdong Province, China.
² School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China.
³ The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China. Electronic address: jiayingli1@cuhk.edu.hk.
⁴ School of Nursing, Guangzhou Medical University, Guangzhou, Guangdong Province, China. Electronic address: zengjieye@qq.com.

PMID: 41962526
DOI: 10.1016/j.ejon.2026.103188

Abstract

Purpose: Many breast cancer survivors develop post-traumatic stress disorder (PTSD) symptoms. Educational level has been associated with differences in mental health outcomes, but its role in the structure and plasticity of PTSD symptom networks remains unclear. To compare PTSD symptom network structure and network plasticity between breast cancer patients with low versus high educational attainment.

Methods: In this cross-sectional study (n = 677) drawn from the "Be Resilient to Breast Cancer" project, participants were classified into low-education (n = 323) and high-education (n = 354) groups. Network structure, global strength, and network plasticity were compared between low- and high-education groups using the Network Comparison Test. Bayesian network analysis was conducted to examine potential causal relationships.

Results: In the low-education group, "ongoing thoughts triggered by various things" was the most central symptom (Str = 2.000), whereas "unintentional thoughts" showed the highest centrality in the high-education group (Str = 0.826). The low-education group exhibited higher plasticity (plasticity index = 0.158), while the high-education group had lower plasticity (plasticity index = 0.147, p = 0.073, ES = 2.794).

Conclusions: Educational level moderates plasticity of PTSD symptom networks among breast cancer survivors. Lower education is associated with higher network plasticity, more negative connections, and a different pattern of central and potentially causal symptoms compared with higher education.

Keywords: Be resilient to breast cancer; Breast cancer; Network analysis; Post-traumatic stress disorder.