Spiritual Well-Being Moderates the Association Between Attachment Insecurity and Death Anxiety in Chinese Patients With Metastatic Breast Cancer: Indirect Pathways Through Distress and Depressive Symptoms.

OBJECTIVES: This study aimed to determine the prevalence of death anxiety and examine its psychological correlates within a hypothesized psycho-social-spiritual framework among Chinese patients with metastatic breast cancer. METHODS: Consecutive inpatients with metastatic breast cancer were recruited from the Breast Cancer Department at Peking University Cancer Hospital (Beijing, China) between January 2022 and March 2025. Of 412 consented patients, 400 completed all questionnaires (response rate: 97.1%). Measures included the Chinese Death and Dying Distress Scale (DADDS), Patient Health Questionnaire-9 (PHQ-9), Distress Thermometer (DT), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), Brief Experiences in Close Relationships scale (ECR-M16), and Quality of Life at the End of Life in Cancer (QUAL-EC). RESULTS: Death anxiety was common: 37.5% reported mild symptoms and 19.0% reported moderate-to-severe levels. In multivariable ordinal logistic regression, higher death anxiety severity was associated with greater depressive symptoms (PHQ-9), greater general distress (DT), higher attachment insecurity (ECR-M16), and poorer end-of-life preparation (all p<0.001). In a theoretically informed path model, attachment insecurity showed a direct association with death anxiety and an indirect association through distress and depressive symptoms; spiritual well-being moderated the attachment insecurity-death anxiety association after adjusting for distress and depression (interaction p=0.017). CONCLUSION: In this cross-sectional sample of Chinese patients with metastatic breast cancer, death anxiety was prevalent and was significantly associated with attachment insecurity, distress, depressive symptoms, and poorer end-of-life preparation. Higher spiritual well-being may buffer the association between attachment insecurity and death anxiety among patients with greater attachment vulnerability, highlighting the potential value of targeted psycho-social-spiritual assessment and supportive intervention.