Self Eciency And Symptom Control of Cancer Patients

Objective: This cross-sectional study was planned to evaluate the self-ecacy and symptom control of cancer patients and to determine the factors affecting them. Methods: The sample of the study consisted of 329 cancer patients who were treated in the Medical Oncology Clinic of a university hospital between April and June 2019 and accepted to participate in the study. Data were collected using the Patient Characteristics Information Form, Cancer Behavioral Inventory-Short Version (CBI-SV), and Edmonton Symptom Assessment Scale (ESAS). Percentage, mean, Mann Whitney U test, Kruskal Wallis analysis of variance were used in the analysis of the data. Results: The mean CBI-SV score of the patients was 79.10±17.55. It was determined that the highest mean score of ESAS of the patients was in the symptom of fatigue (3.53±2.81). Some symptoms were statistically lower in patients with good income, working, and non-smokers. Also it was determined that the self-ecacy levels of the patients with good income and quitting smoking were higher (p<0.05). At the same time, as the patients' self-ecacy scores increased, the severity of the symptoms they experienced decreased statistically (p<0.05). Conclusion: It was found that the patients' self-ecacy score was above the moderate level, the most intense symptom experienced by the patients was fatigue, and the severity of the symptoms decreased as the patients' self-ecacy level increased. In line with these results; the symptoms, self-ecacy perceptions and affecting factors of cancer patients should be evaluated by nurses at regular intervals, and care and consultancy services should be provided.


Introduction
Cancer, one of the most important health problems of today, is one of the diseases that affect human life biologically, psychologically, socially and economically. As the exposure to environmental carcinogens increases with the developing technology, the number of cancer cases is also increasing. At the same time, with the development of cancer diagnosis possibilities and the increase in the opportunities to bene t from health institutions, more cancer cases are diagnosed every year. It has been announced that 19. million people were newly diagnosed with cancer worldwide in 2020, and 9.9 million people died from cancer. According to the latest statistics, it has been declared that the total incidence of cancer in Turkey is 210.2 per hundred thousand; a total of 163,417 people were diagnosed with new cancer [1,2,3].
With the diagnosis of the disease, many patients have to be treated with one or more of many treatment approaches such as surgical treatment, chemotherapy, radiotherapy, hormone therapy and biotherapy.
Among these treatment approaches, chemotherapy can cause many complaints such as fatigue, nauseavomiting, loss of appetite, skin and nail changes, which cause deterioration in the patient's quality of life, according to the chemotherapy protocol applied during the treatment [4,5]. This may affect the selfe cacy of the individual by causing physical and psychological discomfort in patients [4,5,6,7,8].
Self-e cacy, which is de ned as the belief that an individual can successfully perform the behavior aimed at promoting health, is stated to be the most important factor affecting the participation of individuals in their individual care and health-promoting practices. As individuals' self-e cacy increases, they feel healthier both physically and psychologically [8,9]. In this context; it is very important to determine the degree of symptoms experienced by cancer patients, to determine how much they bother the person and to evaluate their self-e cacy in coping with these symptoms in order to increase the quality of life by maintaining the treatment effectively. Studies show that as individuals' self-e cacy perceptions increase, they are better able to tolerate their physical and psychological symptoms. In the literature, the number of studies determining the symptom severity, self-e cacy level and affecting factors of cancer patients is almost non-existent. It is very important to determine self-e cacy perceptions along with the symptoms experienced by cancer patients, especially in order to cope with this di cult and complex situation that cancer patients are in [4,6,7,8]. Therefore, this study was planned to evaluate the self-e cacy and symptom control of cancer patients.

Sample of the study
The study is a descriptive and cross-sectional study. Ethics committee permission (08.04.2019/TUFM-SREC 2019/166) and permission from the institution where the research was conducted were obtained in order to conduct the research. Before the study, the purpose and scope of the study were explained to the patients included in the sample group and their verbal consent was obtained. The population of the study consisted of all cancer patients treated in the Medical Oncology Clinic of a university hospital between April and June 2019. The sample of the study is a total of 329 cancer patients accepted to participate in the study.
Before starting data collection, patients were informed about the purpose of the study and that the con dentiality of the data would be protected. The study was carried out by face-to-face interview method with patients who were treated in the Medical Oncology clinic. It took approximately 10 minutes for the patients who agreed to participate in the study to ll out the personal information form and questionnaire.
Research data were collected by using face-to-face interviews with patients, a Questionnaire Form containing Patient-Related Characteristics prepared by the researchers in line with the literature, Cancer Behavior Inventory-Short Version (CBI-SV) and Edmonton Symptom Assessment Scale (ESAS).

Patient Characteristics Information Form
The form was prepared by the researchers in line with the literature and consists of two parts [6,7,9]. In the rst part, the patient's personal characteristics (gender, age, marital status, educational status, smoking and alcohol use, etc.), in the second part, the characteristics of the disease (diagnosis of the disease, time of diagnosis, surgical treatment, radiotherapy status, etc.) questions are included.

Cancer Behavioral Inventory-Short Version
Cancer Behavior Inventory-Short Version (CBI-SV) was developed by Heitzmann et al. in 2011 and its validity and reliability were veri ed by İyigün et al. in 2017 [8]. The CBI-SV is derived from the 33-item "Cancer Behavior Inventory-Long Version 2.0". This inventory is a 12-item one-dimensional measurement tool designed to assess cancer patients' self-e cacy in coping with their disease. Each item of this 12item scale is scored between 1 and 9. The scale score is calculated as the sum of all items. High scores obtained from the scale indicate high self-e cacy in coping with disease [10].

Edmonton Symptom Assessment Scale
Edmonton Symptom Assessment Scale (ESAS) was developed by Bruera et al. (1991) [11] and its validity and reliability were evaluated by Kurt and Unsar in 2009 [7]. Scale helps evaluate nine common symptoms in cancer patients. These symptoms are pain, fatigue, nausea, sadness, anxiety, drowsiness, lappetite, sense of well-being, shortness of breath and other problems. Three additional symptoms (skin and nail changes, stomatite or sore mouth, numbness in the hands) were added into the other problems section of the scale by the researchers in line with the literature information. The severity of each symptom is assessed by numerical numbers from 0 to 10. A score of 0 indicates that there is no symptom, a score of 10 indicates that the symptom is felt very severely, and the severity of the symptom increases from 0 to 10.

Statistical analysis
Analysis of the research data was done by using the SPSS 22 statistical program. Characteristics of the patient, factors affecting their self-e cacy and symptoms presented as percentages and averages. The Mann Whitney U test was used for the comparisons of the data that did not show normal distribution, and the Kruskal Wallis analysis of variance was used for the comparisons of the three groups. Statistical signi cance level was accepted as p<0.05.

Results
The mean age of cancer patients participating in the study was 60.10±12.10 years; 53.2% were male, 89.4% were married, and 67.8% were primary/secondary school graduates. 59.3% of the patients stated that they did not smoke, 79.9% did not use alcohol, 79.1% of them stated that their income was at a medium level, 79.6% were not working, 97.3% had health insurance. At the same time, it was determined that the patients were diagnosed with cancer an average of 2.36±2.65 years ago, 27.1% of the patients had lung cancer, 52% had surgery related to the diagnosis of cancer, and 43.2% received radiotherapy treatment ( Table 1). The mean BDI-CV self-e cacy scale score of the patients was 79.10±17.55, which was above the moderate level. Mean ESAS pain score of the patients 2.01±2.57, mean fatigue score 3.53±2.81, mean nausea score 1.33±2.29, mean depression score 1.92±2.33, mean anxiety score 2.00±2.41, mean drowsiness score 2.46±2.78, mean appetite score 2.57±3.02, the mean score of feeling well-being was 2.70±2.49, the mean score of dyspnea was 1.50±2.50, the mean score of changes in the skin and nails was 1.71±2.62, the mean score of sores in the stomatite or mouth sore was 1.25±2.14, and the mean score of numbness in the hands was 1.72±2.35. The highest mean score on ESAS of the patients was found in the symptom of fatigue (3.53±2.81) and the lowest mean score in the symptom of mouth sore (1.25±2.14) ( Table 2).
A statistically signi cant difference was found between the genders of the patients participating in our study and ESAS score of shortness of breath and the score of numbness in the hands and feet (p<0.05).
The mean shortness of breath score of male patients was higher than female patients (p=0.042). The mean scores of numbness symptoms in the hands were higher in female patients than in male patients (p<0.01). (Table 3).
In our study, a statistically signi cant difference was found between the education status of the patients and the BDI-CV self-e cacy scale mean score (p<0.05). High school graduate patients' self-e cacy scores were higher than primary/secondary school graduate patients' (p=0.029). (Table 3).
A statistically signi cant difference was found between the income status of the patients participating in our study and the BDI-CV self-e cacy scale mean score, fatigue and sense of well-being symptom ESAS scores (p<0.05). Patients with good income status had higher self-e cacy scores than patients with poor income status (p=0.004). Patients with low income status had higher ESAS fatigue symptom scores than patients with good income status (p=0.021). Patients with good income status had a higher feeling of well-being than patients with low income status (p=0.039) ( Table 3).
A statistically signi cant difference was found between the working status of the patients participating in our study and the symptoms of ESAS fatigue, anxiety, drowsiness, appetite and sense of well-being (p<0.05). Fatigue, anxiety, drowsiness, appetite, and sense of well-being symptoms were worse in nonworking patients compared to working patients (p<0.01, p=0.048, p=0.033, p=0.002, p=0.013, respectively) ( Table 3).
In our study, a statistically signi cant difference was found between the smoking status of the patients and the BDI-CV self-e cacy scale mean score, ESAS fatigue, sense of well-being and shortness of breath symptoms (p<0.05). Patients who quit smoking had higher self-e cacy scores than patients who did not smoke (p=0.003). Fatigue symptoms were worse in smokers than in non-smokers and ex-smokers (p=0.002). The feeling of well-being score was worse in smokers than in patients who quit smoking (p=0.005). The symptoms of shortness of breath were worse in patients who quit smoking compared to patients who did not smoke (p=0.006) ( Table 3).
In our study, a statistically signi cant difference was found between the alcohol use status of the patients and the symptoms of ESAS shortness of breath (p<0.05). The symptoms of shortness of breath were worse in patients who stopped using alcohol compared to patients who did not use alcohol (p=0.021) ( Table 3).
A statistically signi cant difference was found between the patients who participated in our study and the ESAS score of pain and numbness symptoms in the hands (p<0.05). While the pain symptom of the patients who did not have surgery was worse than the patients who had surgery (p=0.041), the numbness symptom of the hands was worse in the patients who had surgery compared to the patients who did not have surgery (p<0.01) ( Table 3).
In this study, a statistically negative correlation was found between BDI-CV self-e cacy score and ESAS pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, shortness of breath, skin and nail changes, and stomatite or sore mouth. As the patients' BDI-CV self-e cacy scores increased, their symptoms decreased (Table 4).
In this study, a statistically positive correlation was found between age and ESAS depression, appetite, and shortness of breath symptoms. As the mean age of the patients increased, the symptoms of depression, appetite and shortness of breath increased (Table 4).
In this study, a statistically signi cant positive correlation was found between the ECOG performance scores of the patients and ESAS pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, shortness of breath, skin and nail changes, and stomatite or sore mouth symptoms. As the ECOG performance scores of the patients increased, their symptoms also increased (Table 4).
In this study, a statistically signi cant positive correlation was found between the time of diagnosis and the symptoms of sore mouth and numbness in the hands. As the time until the diagnosis is made increased, the symptoms of mouth sores and numbness in the hands also increased (Table 4).

Discussion
Cancer is a life-threatening, di cult and complex disease. Cancer patients are faced with many symptoms during and after treatment. These symptoms negatively affect the patients' life quality, reduce their self-e cacy perceptions and impair their compliance with treatment. Therefore; it is very important to determine the degree of symptoms experienced by cancer patients, to determine how much they disturb the patients and to evaluate their self-e cacy in coping with these symptoms [4,8].
In our study, the mean BDI-CV self-e cacy score of the patients was found to be 79.10±17.55, above the moderate level. In a randomized controlled study with cancer patients receiving chemotherapy, while the mean BDI-CV self-e cacy score of the patients in the experimental group was 78.1±13.2; the mean BDI-CV self-e cacy score of the patients in the control group was found to be 80.90±12.10 [12]. In studies conducted with breast cancer patients, the self-e cacy level of patients was found to be moderate [13,14]. In another study conducted with patients with gastric and colorectal cancer, the self-e cacy level of the patients was found to be moderate [15]. This situation can be explained by the diagnosis and treatment received by cancer patients and the severity of the symptoms they experience.
In our study, it was determined that the highest mean score of ESAS of the patients was in the symptom of fatigue. In studies conducted with cancer patients receiving chemotherapy, the most intense symptom experienced by patients was found to be fatigue [12,16,17]. In another study conducted with palliative care patients, it was determined that the most common symptoms felt by patients on the rst day of hospitalization were fatigue, loss of appetite, and feeling well [18]. It is seen that the results of our study are similar to the literature. Patients also experience fatigue as a result of many symptoms such as loss of appetite, insomnia, etc. For this reason, it is thought that most of the patients experience the symptom of fatigue more severely as a common problem.
While the symptoms of dyspnea were worse in male patients who participated in our study compared to female patients; hand numbness symptoms were worse in female patients than in male patients. In a study conducted with colorectal cancer patients receiving chemotherapy, it was found that the symptoms of female patients were more severe [19]. It is an expected result that most of the male patients in our study experienced the symptom of dyspnea, since they were diagnosed with lung cancer. At the same time, female patients had worse symptoms of numbness in the hands and that can be explained by the fact that women feel this symptom more because they are more active in housework.
High school graduate patients participating in our study had better self-e cacy scores than primary/secondary school graduates. In a study conducted with patients with breast cancer, it was found that the physical symptoms of secondary school graduates were higher and the attitudes of maintaining a positive attitude and reducing stress were more inadequate. [14] Self-e cacy, which is de ned as an individual's belief that he or she can successfully perform the behavior aimed at improving his or her health, is a feature that can be developed with training. In this context, in our study, it is thought that as the education level of the patients increases, the self-e cacy levels of the individuals also increase.
In our study, patients with good income had better self-e cacy scores than patients with low income. Fatigue symptoms were worse in patients with poor income compared to patients with good income status. In a study conducted with patients with breast cancer, no signi cant difference was found between the self-e cacy scores of patients and their income, but their quality of life was found to be affected by income status [14]. This situation can be explained by the fact that individuals with a good income can afford the treatment and self-care costs and receive treatment in better facilities, thus positively affecting their self-e cacy.
In our study, patients who quit smoking had better self-e cacy scores than non-smokers. Fatigue symptoms of smokers were worse compared to non-smokers and ex-smokers; symptom of well-being of smokers were worse compared to patients who quit smoking and also the symptoms of dyspnea were worse in patients who quit smoking compared to non-smokers. At the same time, the symptoms of dyspnea were worse in patients who stopped using alcohol in our study compared to patients who did not use alcohol. Smoking and drinking alcohol are very harmful habits that cause cancer and its progression. The fact that patients who continued these harmful habits in our study had worse symptoms, explains this situation. At the same time, the better self-e cacy scores of the patients who quit smoking in our study and the fact that individuals take important initiatives such as getting rid of harmful habits can be explained by the 'belief that individuals can successfully perform the behavior aimed at improving their health', which is also included in the de nition of self-e cacy.
As the self-e cacy scores of the patients participating in our study increased, the severity of the symptoms they experienced decreased. In a study conducted with colorectal cancer patients receiving chemotherapy, it was found that the severity of their symptoms decreased as the patients' self-e cacy scores increased [19]. Self-e cacy is a feature that supports behaviors aimed at improving the health of individuals. This can be explained by the fact that individuals with increased self-e cacy make more efforts to protect and improve their health, reducing the severity of the symptoms experienced and feeling better.
In our study, as the mean age of the patients increased; the symptoms of sadness, loss of appetite and shortness of breath worsened. In a study evaluating the symptoms of cancer patients, it was determined that both psychological and general well-being worsened as the age of the patients increased [20]. In a study conducted with colorectal cancer patients receiving chemotherapy, it was found that the symptoms of patients over the age of 60 were more severe [19]. This situation can be explained by the deterioration in the body's defense mechanism against health problems and health problems added with increasing age.
In our study, non-working patients had worse symptoms of fatigue, anxiety, insomnia, anorexia, and wellbeing compared with working patients. At the same time, it has been shown that as the performance scores of cancer patients in this study worsened, the severity of the symptoms also increased. In a study conducted with advanced cancer patients, it was found that the physical condition of the patients affected the patients' self-e cacy. As the performance status of the patients decreased, their self-e cacy also decreased [9]. In another study conducted with outpatient chemotherapy patients, it was stated that especially female patients may experience a lower risk of self-e cacy as their physical functionality decreases [21]. This situation; This can be explained by the fact that cancer patients who experience fewer symptoms can perform their physical functions, work, perform their duties, and thus have better self-e cacy scores as their performance improves.
In our study, as the time taken for patients to be diagnosed increased, the symptoms of mouth sores and numbness in the hands worsened. At the same time, in our study, patients who did not have surgery had worse pain symptoms than patients who underwent surgery and the numbness symptom in the hands was worse in the patients who had surgery compared to the patients who did not. In another study, in which the symptoms of cancer patients were evaluated, it was found that as the time of diagnosis of the patients increased, the general well-being of the patients was better [20]. As the time taken for patients to be diagnosed increases, the process of living with the disease and the duration of exposure to treatment opportunities and treatment side effects increase in this process. The increase in the severity of some symptoms as the time taken for patients to be diagnosed increases in our study explains this situation. At the same time, the severity of symptoms is reduced with treatment opportunities. The decrease in the severity of pain with the operation of the patients who experience pain explains this situation.

Conclusion
It was found that the self-e cacy score of the patients was above the moderate level, the most intense symptom experienced by the patients was fatigue and the severity of the symptoms decreased as the self-e cacy level of the patients increased. Some of the symptoms are lower in patients with a good income, working, not smoking and using alcohol. Also it was determined that the self-e cacy levels of the patients with good income and who quit smoking were higher. In line with these results; the symptoms, self-e cacy perceptions and in uencing factors of cancer patients should be evaluated by nurses at regular intervals. At the same time, it can be recommended to provide counseling services that can improve the care and self-e cacy perceptions of patients that will provide symptom control.

Limitation
These research data can be generalized only to patients who were treated in the institution where the research was conducted, since it was applied to patients who applied to the Medical Oncology Clinic of the Faculty of Medicine between the dates of the study, who met the inclusion criteria and who volunteered to do so.

Declarations
Funding Not supported Con ict of interest There are no con icts and interest was reported by the authors.
Availability of data and material: The data that support the ndings of this study are available from the corresponding author upon reasonable request.  Tables   Due to technical limitations, table 3 is only available as a download in the Supplemental Files section.