This relatively large-scale multi-center, cross-sectional study of patients with oral cancer was conducted in the northeastern region of china, which was the first study to examine the effects of stigma, hope and social support on QoL in China. Our findings revealed that a majority of Chinese oral cancer patients was suffering from impaired QoL. Mean score of QoL among Chinese patients with oral cancer was 90.85±20.15, which is much lower than patients of other countries. Tulio et al. indicated that in Brazil, mean score of FACT-H&N was 96.6±20.5 [32]. In Williams’ research, the median of FACT-H&N was 110.20 in America [33]. Dominika et al. reported that in Poland, the mean score of FACT-H&N was 109.19 [34]. Despite the fact that there is continual progress in diagnosis and treatment technology and more convenient to obtain quality care in China, our results found that Chinese patients with oral cancer still suffered from poor QoL. Therefore, it’s very important to found out essential influencing factors and targeted solutions to improve their QoL.
Among all the demographic and clinical variables, there are some variables related to QoL including marital status, residence area, educational level, undergone mandibulectomy and distant metastasis. These factors in combination explained 9.9% of the variance in QoL of patients with oral cancer. Findings of our study shows that patients with a college or above educational level had a higher score of QoL, which echoed the findings of Liu’s study [35]. On the one hand, individuals with higher education level was proved to be positively related to high resilience [36], resilient patients are always considered to possess stronger capabilities to rebound from frustration and tragedy [37]. On the other hand, patients with higher education have more access to obtain disease-related knowledge and have a better understanding of their condition. This result indicated that more communications between medical workers and patients are essential for improving patient’s QoL. Moreover, as the result showed, patients with distant metastasis had the lowest QoL in this study. However, metastasis is one of the main causes of oral cancer patients’ death which is the worst negative events of cancer patients [38]. Not only the oral cancer, but metastasis has been confirmed as adverse influential factor in many other cancers in several studies [39-41].
One of the core findings in this study was that stigma alone explained more than one-third of the variance on QoL. Specifically, stigma was found to be significant negatively associated with QoL,which was consistent with previous studies [42,43]. Treatment for oral cancer is complex, which can lead to functionality issues such as dysphagia and breathing difficulties, as well as a cosmetic burden with facial disfigurement. However, facial disfigurement always together with the development of shame and a perception of stigma [14]. The sense of inner shame plays a crucial role in these patients’ self-evaluation processes. High stigma not only has a negative impact on follow-up treatments including treatment compliance, seeking treatment behaviors, self-esteem and social adaptation, but also harmful to patients’ recovery which seriously impairing patients’ QoL. Noticeably, the mean score of stigmas of the participants in this study were found to be higher than their counterparts in other countries [44-46], which may partly explain why Chinese patients with oral cancer experienced poor QoL. However, to our knowledge there are no other published clinical interventions addressing stigma in oral cancer patients so far [45]. Therefore, future studies should focus more on positive psychological factors when stigma impacting oral cancer patients’ QoL.
In this study, perceived social support and hope were found to be positively associated with QoL of patients with oral cancer. Patients with high level of hope were likely to experience high QoL that is consistent of the previous study [47]. Furthermore, higher level of hope was confirmed to associated with lower rates of alcohol and cigarette abuse, more frequent exercising and better nutrition which were critical factors in preventing cancer recurrence and increasing QoL [48]. Hope is a positive coping resource for people experiencing difficult situations. Reasonably, oral cancer patients with higher level of hope experienced higher QoL because they are more confident in both daily life and disease conditions. Thus, enhancing the level of hope was one of the important strategies to increase the QoL of patients with oral cancer in China. In addition, we also found that social support was a predictive factor of QoL and positively associated with QoL. Previous study has shown that the absence of social support after diagnosis and during treatment was associated with development of depression and anxiety, and eventually affected the treatment effect [50]. However, Li et al. demonstrated that the psychological comfort that cancer patients obtained from family and friends was benefit for clinical treatments and recovery [15]. Likewise, Hodges also indicated in their study that social support was positively relate to patients’ QoL and promoted well-being, and ultimately improve the QoL [51]. Therefore, more social support from family and friends are essential to improve the overall QoL.
The most important value of this study is that we identified the stigma was significant negatively associated with QoL in oral cancer patients. In addition, our study also has added to the evidence that positive resources, hope and social support, were positively associated with QoL in oral cancer patients. Based on our findings, some implications should be mentioned. Firstly, Chinese medical institutions and government should pay more attention to oral cancer patients with low level of QoL. Secondly, it was important for clinicians and nurses to pay more attention to patients with distant metastasis. Thirdly, more attention should be paid to patients with high stigma. There are some studies confirmed that contact with health professionals and the community [52], peer counselling [53], skill building and empowerment [54] were efficient for decrease the stigma. Thus, future research should focus more on longitudinal studies to determine whether reducing stigma is beneficial to improving QoL. Last but not least, some studies have provided the concrete measures and advices to implement psycho-social interventions to enhance QoL in cancer patients. For example, Berg mentioned that hope-based interventions can increase psychological strength, enhance coping with physical symptoms in their research [48]. Cramer also indicated in their study that yoga was an effective measure to improving mental health among patients with breast cancer [40]. However, up to now, psychological counseling and intervention in clinical setting have not been enough. Overall, health care organizations should realize that the importance of positive psychological strengths for oral cancer patients to combat severe diseases. And more target intervention strategies should be conducted in future researches.
Nonetheless, there were some limitations in our study. First, because of the cross-sectional design and self- reported measures, no causal conclusions could be drawn between psycho-social resources and QoL. Secondly, this study was conducted in one city from a province of the northeastern region of china. Representativeness of sample might be affected. Thirdly, a control group should be included in our study. Thus, the interpretation of the results would be more convincing. Lastly, several potential factors, such as recurrence, pathological stage, may affect QoL of patients with oral cancer, that we didn’t included in our study. A lager and longitudinal study should be implied to future researches.