The research team, led by Hameed Adnan Hameed of Al-Maarif University’s College of Pharmacy together with colleagues from the Anbar Oncology Center, Beni-Suef University in Egypt, and Qassim University in Saudi Arabia, set out to answer a deceptively simple question: which postoperative treatment pathway for breast cancer delivers the best psychological value for money? Iraq’s healthcare system suffers from serious fiscal and organizational constraints, and breast cancer management imposes a significant financial and psychosocial burden on both institutions and patients. Although psychological outcomes are recognized as relevant to treatment adherence, quality of life, and survival, they had not previously been examined within an economic evaluation in Iraq.

The study examined a cross-sectional cohort of 437 women, drawn from an initial screening population of 535 through consecutive sampling, all of whom underwent surgery for breast cancer in 2025. Patients were classified into four treatment groups: surgery alone (214 women), surgery plus monoclonal antibody therapy (91), surgery plus radiotherapy (49), and surgery plus both radiotherapy and monoclonal antibody therapy (83). Costs were disaggregated in US dollars from institutional ledgers, providing a grounded picture of what each pathway actually costs the provider rather than relying on estimates or modeled figures.

Psychological outcomes were measured using three widely validated instruments: the Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder scale (GAD-7), and the Patient Health Questionnaire for depression (PHQ-9). For the economic analysis, scores were reversed onto a symptoms-avoided scale, allowing the researchers to frame psychological benefit as an outcome that could be weighed against cost. Incremental cost-effectiveness ratios were then calculated in both crude and regression-adjusted models, with covariates including cancer stage, metastatic status, comorbidity, and income. Uncertainty was quantified across willingness-to-pay thresholds ranging from zero to 10,000 US dollars, using bootstrapping with 2,000 iterations and cost-effectiveness acceptability curves.

The results on the psychological side were striking for their uniformity. Statistical testing found no significant differences between the four treatment groups on any of the three measures: the PHQ-9 comparison yielded a Kruskal-Wallis statistic of 3.71 with a p-value of 0.295, the GAD-7 comparison a statistic of 1.31 with p equal to 0.727, and the perceived stress scale a statistic of 1.02 with p equal to 0.796. In other words, whether a woman received surgery alone or the most intensive combination of surgery, radiotherapy, and biologic therapy, her reported levels of depression, anxiety, and stress were statistically indistinguishable.

That uniformity, however, concealed alarming absolute levels of distress. Severe depression was observed in between 21.7 and 34.7 percent of patients across the groups, while moderate-to-severe anxiety affected between 47.0 and 61.2 percent. These figures suggest that psychological morbidity in this population is not a marginal concern but a pervasive one, affecting roughly half or more of all postoperative breast cancer patients regardless of the treatment they received. For a health system already strained by fiscal and organizational problems, the data point to a large unmet need that current treatment pathways are not addressing.

Costs, by contrast, varied considerably across the pathways, with a Kruskal-Wallis statistic of 75.80 and a p-value below 0.001. Surgery alone cost an average of 3,791 US dollars, surgery plus radiotherapy 4,210 dollars, and surgery plus radiotherapy and monoclonal antibody therapy 5,556 dollars. When the researchers combined these costs with the psychological outcomes, the biologic-containing strategies were consistently dominated in economic terms—meaning they cost more without delivering measurable additional psychological benefit. The cost-effectiveness acceptability curves plateaued at only 40 to 60 percent acceptability regardless of the willingness-to-pay threshold, indicating persistent uncertainty about whether any of the escalation options could be considered a psychologically worthwhile investment.

Perhaps the most consequential finding emerged from the regression-adjusted analyses. When the researchers controlled for stage, comorbidity, and income, metastatic status emerged as the strongest factor associated with psychological distress, with standardized coefficients ranging from −1.67 to −4.09, all statistically significant at p below 0.01. The intensity of treatment itself was not the main driver of distress; the presence of metastatic disease was. This distinction matters because it redirects attention away from treatment escalation as a lever for psychological improvement and toward targeted psychosocial support for the patients facing the most advanced disease.

The authors argue that these findings carry direct policy implications for Iraqi oncology practice. They recommend the incorporation of routine psychological screening into standard care, the provision of dedicated psychosocial support for metastatic patients, and the development of health technology assessment infrastructure to inform resource allocation in conflict-affected settings. In a system where every additional dollar of spending must be justified, the study suggests that money spent on mental health services for the most vulnerable patients may yield more value than automatic escalation of biomedical treatment for all.

The study, which was registered with ClinicalTrials.gov under identifier NCT07109063 and received no external funding, also highlights a broader methodological lesson. By embedding patient-reported psychological measures directly into an economic evaluation, the researchers demonstrated that cost-effectiveness analysis in oncology need not be limited to survival or tumor response metrics. In settings where psychological distress is widespread and resources are scarce, measuring what patients actually feel—and what it costs to change it—may be the only way to allocate limited funds wisely. The work was conducted in accordance with the Declaration of Helsinki, with ethical approval from the Anbar Oncology Center institutional review board and written informed consent from all participants, and it is published open access under a Creative Commons license.

Subject of Research: Cost-effectiveness of postoperative breast cancer treatment pathways and psychological outcomes in Iraq

Article Title: Economic evaluation of psychological outcomes across postoperative breast cancer treatment pathways in a conflict-affected setting: a cross-sectional study from Iraq

Article References: Hameed, H. A., Al Aboosi, I., Abdullah, M. I., Ahmed, A. T., Boules, M. E., Hussein, R. R. S., & Kassem, L. M. (2026). Economic evaluation of psychological outcomes across postoperative breast cancer treatment pathways in a conflict-affected setting: a cross-sectional study from Iraq. Discover Psychology. https://doi.org/10.1007/s44202-026-00894-2

Image Credits: AI Generated

DOI: 10.1007/s44202-026-00894-2

Keywords: breast cancer, cost-effectiveness, psychological distress, Iraq, depression, anxiety, perceived stress, metastasis, health technology assessment, conflict-affected settings, psycho-oncology, patient-reported outcomes