Methods

In terms of objective, the present study was basic research, and in terms of data collection, it was descriptive-correlational of the path analysis modeling type. The statistical population comprised all married women with breast cancer referred to the Mehr Golestan Center in Gorgan city during the year 1403 (2025.2024), from whom 230 individuals were selected as the study sample using convenience sampling. Inclusion criteria included being married, not having specific psychiatric disorders or current use of psychotropic medications, willingness to participate in the study, an age range between 30 and 55 years, and at least one year elapsed since cancer diagnosis. The collected data were analyzed using path analysis modeling via AMOS 24 software. Data collection instruments included the Marital Quality of Life Scale (RDAS), the Relationship Attachment Anxiety Scale (RAAS), and the Collett-Focht Death Anxiety Scale (CL-FODS).

Results

To assess the model fit, various fit indices were employed. The resulting indices were: Chi-square to degrees of freedom ratio (χ²/df): 2.857, Root Mean Square Error of Approximation (RMSEA): 0.068, Goodness of Fit Index (GFI): 0.909, Adjusted Goodness of Fit Index (AGFI): 0.918, Incremental Fit Index (IFI): 0.915, Comparative Fit Index (CFI): 0.919, and Parsimonious Goodness of Fit Index (PGFI): 0.795. The R² index indicates the variance explained by the endogenous latent variables. The coefficient of determination for MQL in the study model is 0.57, suggesting that the exogenous and mediating variables can predict 57% of the variance in MQL. According to the results, the direct relationship between secure attachment and MQL was β=0.34 (t=4.98); the direct relationship between avoidant attachment and MQL was β=0.07 (t=1.88); the direct relationship between preoccupied attachment and MQL was β=−0.35 (t=−7.13); the direct relationship between death anxiety and MQL was β=−0.37 (t=−5.03); the direct relationship between secure attachment and death anxiety was β=−0.28 (t=−4.50); the direct relationship between avoidant attachment and death anxiety was β=0.42 (t=6.89); and the direct relationship between preoccupied attachment and death anxiety was β=0.34 (t=4.87).
To examine the mediating role of death anxiety in the relationship between attachment styles and MQL in women with breast cancer, the bootstrapping test was utilized, and the results showed that death anxiety plays a significant mediating role in the relationship between attachment styles and MQL in women with breast cancer.

Discussion and Conclusion

The results of the statistical analysis provide compelling evidence that death anxiety significantly mediates the relationship between attachment styles and MQL in women with breast cancer. Specifically, the indirect effect of secure attachment via death anxiety was negative, suggesting that higher secure attachment is associated with lower death anxiety, which in turn is linked to higher MQL. Conversely, the indirect effects of avoidant and preoccupied attachment styles on MQL were positive, implying that these insecure attachment patterns accompany higher levels of death anxiety, and this anxiety contributes to predicting lower MQL. Women with secure attachment generally possess greater capacity for emotion regulation, seeking and accepting support, and maintaining emotional closeness with their spouses [15, 29]. These capabilities can mitigate the intensity of death-related fears and allow them to remain emotionally engaged in their marital relationship despite their illness [30]. In contrast, avoidant attachment is characterized by discomfort with dependence, emotional distancing, and suppression of vulnerability. When confronted with the existential threat posed by cancer, women with this attachment style may outwardly minimize or deny their fears, but internally experience unresolved death anxiety. This hidden distress can undermine relationship quality by reducing emotional openness and limiting the capacity for shared coping. The mediation results suggest that higher death anxiety in this group exacerbates marital strain by decreasing emotional intimacy or avoiding discussions about illness-related fears. Preoccupied attachment, characterized by high sensitivity to relational cues and fear of rejection, might intensify the emotional impact of death anxiety. Women with this attachment pattern may interpret their illness as a trigger for spousal rejection or withdrawal. The combination of existential fear and relational insecurity can lead to increased emotional needs, dependency, or excessive reassurance-seeking-patterns that, over time, can erode marital satisfaction and exhaust mutual support.

Ethical Considerations

This study was conducted in compliance with the ethical codes for human research. Furthermore, the present study was approved by the Ethics Committee of Islamic Azad University, Chalus Branch, with the ethics code IR.IAU.CHALUS.REC.1404.001.

Funding

There is no funding support.

Authors’ Contribution

The present article is extracted from the doctoral dissertation in psychology of the first author. All authors contributed equally to the conceptualization and writing of the article. Each author reviewed and approved the final manuscript, agreeing on all aspects of the work.

Conflict of Interest

Authors declared no conflict of interest.

Acknowledgments

The researchers thank all individuals who assisted in this research through their participation in this study.