Factors influencing surgical choice and surgerical anxiety in patients with pulmonary nodules smaller than 8mm

doi:10.21203/rs.3.rs-1611698/v1

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Factors influencing surgical choice and surgerical anxiety in patients with pulmonary nodules smaller than 8mm

https://doi.org/10.21203/rs.3.rs-1611698/v1

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Background: The detection of pulmonary nodules has a great impact on people's lives and mental health. The 2018 NCCN guidelines recommend follow-up treatment for nodules ≤8mm, but many patients with small nodules choose surgery. We wanted to explore why these patients had surgery and what caused their anxiety.

Methods: We cross-sectionally surveyed patients with small nodules who decided to undergo surgery in a local grade 3 hospital, using a questionnaire.

Results: 338 patients responded, but only 234 were included in the final analysis. 68.81% of patients reported clinically significant anxiety about pulmonary nodules, as measured by the IES-R. Poor performance in activities of daily living (ADL) (P=0.022, 95% CI: 1.237-15.857) was associated with the highest positive rate (92.31%). Other factors such as presence of solid nodules (P=0.015, 95% CI: 1.26-8.335), multifocal disease (P=0.006, 95% CI: 1.317-5.373) and family history of lung cancer (P=0.048, 95% CI: 1.015-21.307) were also associated with distress.

Conclusion: Current ability to perform activities of daily living, presence of solid and multiple nodules, and a family history of lung cancer make patients who choose surgery more likely to experience pain.

Pulmonary nodules

Clinically significant anxiety

Surgical choice

Less than 8 mm.

Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo computed tomography (CT) screening, even more patients will be found to have nodules.[1] Although Ground Glass Nodules (GGN) are mostly early non-invasive or minimally invasive adenocarcinomas (MIA), they bring a huge burden to the patient, especially in the form of psychological distress.[2] Given the serious implications of pulmonary nodules, clinicians should better understand the experiences and concerns of patients with pulmonary nodules and be prepared to discuss them.[3, 4] According to the 2020 NCCN guidelines, long-term follow-up is recommended for pulmonary nodules ≤ 8mm, and surgical treatment is not recommended. However, some patients still choose surgical treatment.

Almost everyone with a nodule has a risk of suffering psychological harm and has anxiety about nodule removal surgery. Recognizing the growing emphasis on patient-centered care, the American Thoracic Society recently called for more research to explore the impact of nodule monitoring on patients.[5] Patients with small nodules will generally choose conservative treatment and adhere to follow-up. Only a minority of patients will choose surgical treatment. Therefore, we wanted to explore the factors influencing preoperative anxiety and the reasons as to why people choose surgery for nodules smaller than 8mm in the local area.

We attempt to characterize the psychosocial impact of nodular surveillance and evaluation more fully by surveying patients with small pulmonary nodules at treatment sites in the local area. We hypothesized that patients would be influenced by their own condition, the nature of their nodules and level of anxiety when choosing a treatment.

Study Population

We selected patients in the local area as the study subjects. Inclusion criteria for participants: 1) ASA grade ≤Ⅲ; 2) Be aware and able to express basic information normally; 3) Age 18–90; 4) nodules less than 8mm; 5) hospitalized for surgery. Exclusion criteria: 1) Do not agree to participate in the research; 2) Patients already diagnosed with lung cancer; 3) History of psychotropic drugs (including opioids, NSAIDs, sedatives, and antidepressants) and alcohol abuse.

Survey Instrument

We designed a self-management questionnaire covering four aspects: (1) patient characteristics, (2) nodule-specific knowledge, (3) patient-clinician communication, (4) nodule-specific distress. In these aspects, we conducted a series of pilot tests at the local hospital to test the content, relevance, and understandability of the questionnaire. Five patients were randomly selected for an in-depth investigation to gather the factors that might influence their choice of surgical treatment and perioperative anxiety. Furthermore, the trial conducted by Dr. Freiman et al. at Dartmouth-Hitchcock Medical Center was referred to. The final survey tool consisted of 28 items, including validated scales and new questions.[4]

Survey Administration

Data were collected from inpatients in the local hospital from October 2021 to February 2022. The data were collected by professionals in the form of a questionnaire. Patients were able to scan a QR code and access its contents (Fig. 1).

Outcome Measures

The primary outcome of this trial was pulmonary nodule specific distress, as measured by the Impacted of Event Scale-Revised (IES-R). The scale consists of two subscales: avoidance scale (actively staying away from reminders of the nodule) and intrusion scale (intrusive thoughts). The degree of vicarious trauma can be obtained by adding the avoidance scale and the intrusion scale.[6, 7] IES-R consists of 16 questions, each with a score of 0 to 4, and an overall score of 0 to 64, with 0 to 8 being subclinical; 9–25 mild; 26–43 moderate; over 44 severe. We defined moderate or severe nodular distress as significant.[4, 8]

Based on the patient-centered communication model, we hypothesized that high quality doctor-patient communication and the psychological stress caused by positive pulmonary nodules test had an important influence on the choice of surgical treatment for patients with small nodules. Our experience was that many patients overestimate their risk of cancer, and these patients seem to suffer more than those who think they are at low risk. Finally, we hypothesized that high quality clinical communication and problems associated with nodular monitoring affected patients' choice of surgical treatment.[1]

Statistical Analyses

All analyses were performed using IBM SPSS Statistics 26 software. The Chi-square test was used to assess the association between patient characteristics and nodule specific distress. All tests for significance were two-tailed. The multivariate logistic regression model included variables identified as potential confounders (self-care ability, nodule nature, presence of multiple lesions, and family history of lung cancer). Odds ratios (OR) were calculated and reported with a 95% confidence interval (CI).

Information was collected on 338 patients, 234 with nodules smaller than 8mm. Their mean age was 59.3 (SD = 12.3). There was no significant difference between male and female patients, and female patients accounted for 54.70%. Most patients (68.80%) did not smoke, and about a third of them (31.62%) earned enough money to pay for the surgery(Table 1). This reflects the low socioeconomic status of our sample and high levels of economic insecurity.

Table 1

Characteristics of Survey Respondents (n = 234)
Characteristics of patients	Value
Mean age ± SD, y	59 ± 12
Gender
Male	45.30%
Female	54.70%
Highest level of education
Primary and below	57.26%
junior high school	23.08%
High school/technical secondary school	9.83%
Junior College/Bachelor	9.83%
Enough money on your own salary to cover expenses
Wasn't Enough	47.01%
Enough	31.62%
Secrecy	21.37%
Fere
Yes	94.87%
No	5.13%
quantity of children
0	2.14%
1	26.92%
2	49.15%
≥ 3	21.79%
ADL
All depend on	1.71%
Some rely on	14.96%
A little rely on	22.65%
Don't need to rely on	60.68%
Current or past smoking history
Smoking, never quit	16.67%
Quit smoking	14.53%
No smoking	68.80%
CT examination demonstrates the nature of pulmonary nodules
Solid nodule	35.90%
Part-solid nodule	50.00%
GGN	14.10%
Pulmonary nodule morphology
Round, quasi-round	34.19%
Having irregular, polygonal or flat, straight edges	35.04%
Be unaware of	30.77%
Number of lesions
Single lesion	70.51%
Multifoci diseases	29.49%
Family history of lung
Yes	10.26%
No	89.74%
ADL, Activity of Daily Living; SD, standard deviation.

Distress associated with nodules was common. 8.97% of patients had subclinical distress and anxiety. Most patients reported nodular distress: 22.22% mild and 68.81% clinically significant distress (52.14% moderate and 16.67% severe). Certain factors were significant in both bivariate and multivariate analysis, including difficulty in performing ADL (P = 0.022, 95% CI: 1.237–15.857) with the highest positive rate (92.31%). People who lose the ability to take care of themselves in daily life are more likely to have anxiety, not only need to face the pressure of life, but also face the trouble of disease. Presence of solid nodules (P = 0.015, 95% CI: 1.26–8.335), multifocal disease (P = 0.006, 95% CI: 1.317–5.373) and family history of lung cancer (P = 0.048, 95% CI: 1.015–21.307) were also important(Table 2,3). Other features were not significantly associated with clinically significant distress in the bivariate analysis and were not included in the majority analysis.

Table 2

Univariate analysis of clinical pain of pulmonary nodules.
		Clinically significant distress		Positive rate	P value
		no	yes	Positive rate	P value
Gender	Female	41	87	67.97%	0.762
Gender	Male	32	74	69.81%	0.762
Age	༜60	30	83	73.45%	0.138
Age	≥ 60	43	78	64.46%	0.138
BMI	༜24	41	89	68.46%	0.900
BMI	≥ 24	32	72	69.23%	0.900
Education bakeground	Junior high school and above	35	65	65.00%	0.278
Education bakeground	Junior high school the following	38	96	71.64%	0.278
ADL	Yes	70	125	64.10%	0.001
ADL	No	3	36	92.31%	0.001
Nodules nature	GGN	15	18	54.55%	0.003
	Part-solid nodule	43	74	63.25%
	Solid nodule	15	69	82.14%
Smoking history	No	52	109	67.70%	0.589
Smoking history	Yes	21	52	71.23%	0.589
Multifoci diseases	No	58	107	64.85%	0.043
Multifoci diseases	Yes	15	54	78.26%	0.043
Partner	No	3	9	75.00%	0.634
Partner	Yes	70	152	68.47%	0.634
Family history of lung cancer	No	71	139	66.19%	0.011
Family history of lung cancer	Yes	2	22	91.67%	0.011
ADL, Activity of Daily Living

Table 3

Factors associated with clinically significant distress in patients with pulmonary nodules.
		P value	OR	OR 95% CI
ADL	Yes		1
ADL	No	0.022	4.429	1.237–15.857
Family history of lung cancer	No		1
Family history of lung cancer	Yes	0.048	4.65	1.015–21.307
Nodules nature	GGN		1
	Part-solid nodule	0.691	1.18	0.522–2.671
	Solid nodule	0.015	3.241	1.26–8.335
Multifoci diseases	No		1
Multifoci diseases	Yes	0.006	2.66	1.317–5.373
OR, odds ratio; CI, confidence interval.ADL; Activity of Daily Living.

In addition, most patients (about 60%-80%) who decided to have surgery said they remembered their doctor's clinical communication clearly. The rest said they did not understand or remember what the doctor said.(Table 2) Among the problems associated with pulmonary nodules, the risk of cancer(51.78%), surgery(41.72%), and death(53.83%) have a significant psychological impact on most patients(Fig. 2). From this, it can be seen that the sample population has a high degree of similarity in possible cancer and death. And based on years of clinical experience of clinicians, most patients equate cancer with death. What they don't know is the likelihood of indolent tumors (tumors that grow slowly and are unlikely to cause problems in your lifetime). Some patients feel uneasy about pulmonary nodules(29.29%) and the overall lack of medical knowledge(23.96%)(Fig. 3).

As far as we know, patient assessments and misconceptions about nodules are common. Patients' perceived cancer risk was more strongly linked to pain than actual cancer. [1] This highlights the importance of improving clinical communication to correct patient misestimates of pulmonary nodules. The confirmation of these data helps quantify the impact of nodule detection on patients' physical and mental health.[9, 10] However, our findings differ from those in the literature, showing significant differences in specific distress and financial distress and tobacco use after nodule detection.

This study found that poor performance in ADL, presence of solid and multiple pulmonary nodules and a family history of lung cancer affected patients' moods to varying degrees. The average age of the subjects in our study is about 60 years old, belonging to the older group, which has more underlying diseases than the younger age group. Patients who lacked the ability to take care of themselves showed greater anxiety after pulmonary nodules were detected accidentally. They also showed obvious anxiety after learning that their nodules were more likely to be cancerous. Although most patients have little knowledge of nodules, they understand that the presence of solid and multiple nodules means more likelihood of malignancy. Surprisingly, there was no clear correlation between smoking and non-smoking and anxiety. In fact, there were positive health aspects to the test as well, with about a third of patients who were asked about their smoking history finding pulmonary nodules and indicating that they wanted to quit, although everyone's definition of quitting and whether they could stick to it varied. Perhaps a deeper exploration of this area might reveal subtle differences in patients' smoking histories. [11]

In our experience, patients often misestimate the risk of nodules, and although patients know the cause of their distress, the uncontrollable and unknown nature of their nodules is the main cause of their anxiety.[12, 13] This demonstrates the great benefit of helping patients through the nodule monitoring period. A recent study by Slatore et al. suggests that this suffering may be alleviated with high-quality clinical communication.[14] As noted in studies of communication about abnormal Papanicolaou tests,[15] doctors may not mention cancer because they want to avoid arousing fears that might not come up, but patients tend to worry about cancer whether the doctor brings it up or not. So doctors should explicitly discuss cancer risks unless the patient explicitly asks not to be told. The American College of Chest Physicians recommends that all patients with pulmonary nodules adopt a shared decision-making approach. Clearly explaining the treatment process helps patients understand and reduce their feelings of anxiety. In 1986, nine-year compulsory education was implemented in China, so there was no primary education for patients above 50 in the local area. Therefore, most patients could seek advice from their children to decide whether to choose surgery. Therefore, communication with young people in patients' families would often get unexpected results.

As more and more pulmonary nodules are detected, it highlights the importance of clinical communication. The ability to explain the risk of pulmonary nodules to patients from a professional perspective and enlighten patients is an essential component of being a good clinician. These simple communication strategies could help improve the lives of countless patients found to have pulmonary nodules each year.

The study did not have a longitudinal component and lacked dynamic data on patients who were followed up and experienced peak pain at the onset of nodule discovery. Moreover, as the area was limited to the Linhai City, the conclusions may not apply to the general population. Although we chose small nodules, they were also the patients who decided to have surgery. Therefore, it indicates that the detection of nodules seriously affects patients' physical and mental health, and perioperative anxiety is very common in this patient group.

Current ability to perform activities of daily living, presence of solid and multiple nodules, and a family history of lung cancer make patients who choose surgery more likely to experience pain.

CRediT authorship contribution statement

Hongbin Qiu: Conceptualization, Writing–original draft. Yingqiao Lou: Visualization, Investigation. Congcong Xu: Conceptualization, Methodology, Software. Pasan Witharana: Writing–review & editing. Dong Chen: Software, Validation. Kanghao Zhu: Conceptualization, Software. Jiawei Li: Conceptualization, Methodology. Baofu Chen: Supervision. Jianfei Shen: Project administration.

Acknowledgement

Not applicable.

Funding source

Not applicable.

Ethics approval and consent to participate

This study obtained the ethical approval of Taizhou Hospital Research Ethics Committee. All experimental protocols are approved by designated agencies and licensing committees. Informed consent of all subjects and/or their legal guardians has been obtained. All the methods were carried out in accordance with relevant guidelines and regulation.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The data used and/or analysed during the current study are available from the corresponding author on reasonable request.

Slatore CG, Wiener RS, Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It, CHEST (2017), doi: 10.1016/j.chest.2017.10.013.
Wentao Fang, Yangwei Xiang, Chenxi Zhong et al. The IASLC/ATS/ERS classification of lung adenocarcinoma-a surgical point of view. J Thorac Dis 2014;6(S5):S552-S560.
Wiener RS, Gould MK, Woloshin S, Schwartz LM, Clark JA. What do you mean, a spot?: a qualitative analysis of patients’ reactions to discussions with their physicians about pulmonary nodules. Chest. 2013;143(3):672–677.
Marc R. Freiman, MD, MS, a Jack A. Clark, PhD, Christopher G et al. Patients’ Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey. Journal of Thoracic Oncology. 2016;11(5):700–708.
Slatore CG, Horeweg N, Jett JR, et al. An official American Thoracic Society research statement: a research framework for pulmonary nodule evaluation and management. Am J Respir Crit Care Med. 2015;192:500–514.
Landsbergen KM, Prins JB, Brunner HG, Hoogerbrugge N. Shortened time interval between colorectal cancer diagnosis and risk testing for hereditary colorectal cancer is not related to higher psychological distress. Fam Cancer. 2011;10:51–57.
Fiscella K, Whitley E, Hendren S, et al. Patient navigation for breast and colorectal cancer treatment: a randomized trial. Cancer Epidemiol Biomarkers Prev. 2012;21:1673–1681.
Corcoran K, Fischer J, eds. Measures for Clinical Practice and Research: A Sourcebook. 5th ed. Oxford, UK: Oxford University Press; 2013.
Sullivan DR, Golden SE, Ganzini L, Hansen L, Slatore CG. ‘I still don’t know diddly’: a longitudinal qualitative study of patients’ knowledge and distress while under-going evaluation of incidental pulmonary nodules. NPJ Prim Care Respir Med. 2015;25:15028.
Lemonnier I, Baumann C, Jolly D, et al. Solitary pulmonary nodules: consequences for patient quality of life. Qual Life Res. 2011;20:101–109.
Renda Soylemez Wiener MD MPH, Michael K. Gould MD MS et al. ‘The thing is not knowing’: patients’ perspectives on surveillance of an indeterminate pulmonary nodule 2012 Blackwell Publishing Ltd Health Expectations. 2012;18:355–365.
Dall’Era MA. Patient and disease factors affecting the choice and adherence to active surveillance. Curr Opin Urol. 2015;25:272–276.
Brett J, Austoker J. Women who are recalled for further investigation for breast screening: psychological consequences 3 years after recall and factors affecting reattendance. J Public Health Med. 2001;23:292–300.
Slatore CG, Golden SE, Ganzini L, Wiener RS, Au DH. Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules. A cohort study. Ann Am Thorac Soc. 2015;12:184–192.
Simon MA, Cofta-Woerpel L, Randhawa V, John P, Makoul G, Spring B. Using the word‘cancer’ in communication about an abnormal Pap test:finding common ground with patient-provider communication. Patient Educ Couns. 2010;81(1):106–112.

No competing interests reported.

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Factors influencing surgical choice and surgerical anxiety in patients with pulmonary nodules smaller than 8mm

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