DOI: https://doi.org/10.21203/rs.3.rs-1789695/v2
Cancer is the second leading cause of death worldwide. In Peru, cancer represented 20% of deaths nationwide between 1986 and 2015, where the types of cancer with the highest incidence include prostate, breast, and stomach cancer. Cancer diagnosis is a complex communicative process that is associated with the idea of death and suffering, especially those in advanced stages. Regarding the psychological factor, cancer is associated with an increase in depressive symptoms, anxiety, and stress. These represent an obstacle to recovery from the disease and can affect the quality of life of cancer patients. This study aims to determine the association between quality of life and depressive symptoms, anxiety, stress, and emotional distress in Peruvian cancer patients.
A cross-sectional study was conducted on 500 literate National Institute of Neoplastic Diseases cancer patients over 18 years of age. Additionally, descriptive statistical analyses and Poisson association measures of mental health and quality of life factors were performed.
A prevalence of anxious symptoms (27.5%), depressive symptoms (20.4%), symptoms of moderate-severe stress (83.2%), and emotional discomfort (57.4%) has been identified. Regarding the Poisson regression model, cancer patients with 12 or more years of education were less likely to have emotional distress symptoms. Cancer patients with a low or average mental quality of life are twice as likely to present signs of moderate or severe stress. Notably, neither the type of cancer or the clinical stage presented significant values for any of the mental health problems, mental quality of life, and physical quality of life. The comorbidity sub-analysis has identified that as the number of comorbid mental health problems increases, the probability of having a low mental quality of life and physical quality of life increases.
Emotional distress and stress are factors associated with the quality of life of cancer patients. Other covariates such as high educational level are factors related to mental health problems. Likewise, the results directly affect the development of public policies and effective health strategies in this type of population.
Cancer is the second leading cause of death worldwide since approximately one of every six deaths is caused by this disease [1]. By 2020, more than 19 million new cases and almost 10 million deaths were reported worldwide [2]. By 2040, annual cases are estimated to increase by 29.5 million and the number of deaths by 16.4 million [3]. Moreover, the cost attributable to treatment for this disease globally is estimated at $1.16 trillion annually [4]. Low- and middle-income countries account for almost 70% of deaths and have the highest incidence of some cancers such as breast and cervix uteri cancer [5, 6]. Among the main causes of death from cancer are tobacco consumption, high body mass index, alcohol consumption, and an inadequate diet [5]. Cancer has become a public health problem, as advanced cancer overwhelms health systems, including those with poorly integrated technical and professional capacity at different levels of care [7].
In Peru during 2018, 66,627 new cases of cancer and 33,098 deaths were reported, in addition to an increase in annual deaths from cancer [8]. An analysis of mortality due to disease carried out between 1986 and 2015 showed that cancer accounted for 20% of deaths nationwide [9]. The types of cancer with the highest incidence in Peruvians [8] are prostate (11.4%), breast (10.5%), and stomach (8.6%) cancers, with prostate cancer being the most frequent in men (24.7%) and breast cancer as the most common in women (19.5%), while stomach cancer is the main cause of death in the general population (13.9%). Based on age group, leukemia is the most prevalent cancer in childhood, stomach and cervical cancer in adolescence and young adulthood, and stomach and lung cancer in adults over 50 years of age [10].
Disclosing of cancer diagnosis is part of a doctor-patient communication process in which information is provided about the disease, stages, treatment plans, and others [11]. Receiving the news of the diagnosis is very complex for the patient and their family, as cancer is associated with ideas of death and suffering [12]. Early stages of cancer are treated with surgery or radiotherapy, while more advanced stages require more invasive treatments such as targeted drug therapy, immunotherapy, or chemotherapy [13, 14]. In that sense, the stage and type of treatment added to other factors such as the type of cancer, age, sex, and social and environmental conditions (residing in rural areas, being illiterate, and having lower economic income) influence the deterioration of the functioning at the physical and psychological level of the patients that affects various areas like family, work, social activities, affective, sexual, among others [15]. Among the physical complaints that patients most frequently reported are fatigue, pain, and insomnia, and in hospitalized patients, symptoms like pain, nausea, dyspnea, loss of appetite, drowsiness, and constipation can be added [16–19]. As for the psychological factor, ample evidence showed that knowing about the diagnosis of cancer is associated with an increase in depressive symptoms, anxiety, and stress [20–23]. Moreover, hospitalized patients have a higher prevalence of symptoms of depression, anxiety, and stress of these health problems, compared to outpatients [16, 24]. Other factors related to increased symptoms of depression, anxiety, and stress in cancer patients include the high costs and economic expenses related to the treatment of the disease [20, 25, 26].
The abovementioned problems faced by people with cancer can be an obstacle to their recovery from cancer and can affect their quality of life [22]. Various factors can generate changes in the quality of life, either negatively or positively, depending on the individual, social, type, stage, and treatment characteristics of the patients. For example, psychological problems, such as anxiety, depression, and stress; unmet needs; and an advanced stage of illness are negatively associated with quality of life [27–30]. People with cancer may have comorbidities, which are additional conditions or disorders that coexist with the primary disease [31, 32]. Such comorbidities affect the development and treatment of cancer patients [32]. Also, cancer patients may have more than one comorbidity, including a combination of depression and anxiety [33, 34]. This comorbidity of mental health problems allows us to consider transdiagnostic intervention as a viable alternative in the care of nuclear vulnerabilities in cancer patients [35, 36]. On the other hand, the high level of education, high monthly income, adequate care, interventions, and early treatment favor the quality of life of cancer patients [28, 37]. Therefore, it must be ensured that patients receive psychoeducation and palliative care to reduce physical and psychological symptoms [38, 39]. Based on the exposed evidence, the aforementioned sociodemographic factors are considered for the statistical analysis of this study.
Our study aims to determine the association between quality of life with depressive symptoms, anxiety, stress, and emotional distress among Peruvian cancer patients.
Study design
This cross-sectional study was conducted on oncology patients in a Peruvian public institution specializing in cancer.
Setting
The application of the study protocols was performed for 2 months (July and August 2018) by psychologists and psycho-pedagogues of the Mental Health Unit of the “National Institute of Neoplastic Diseases” (INEN, acronym in Spanish) who were previously trained in the administration of psychometric tests. The tests were administered to each of the patients with confirmed cancer separately, in areas of mental health, hospitalization, and oncology outpatient clinics: breast and mixed tumors, gynecology, medical oncology, abdominal, head and neck, urology, thorax, neuro-oncology, and orthopedics.
Participants
The study sample included 500 participants using the following inclusion criteria: being cancer patients of the National Institute of Neoplastic Diseases, being older than 18 years of age, and having the ability to read and write. Also, patients presenting physical discomfort during the application of the tests and those with cognitive disabilities that limit comprehension and ability to complete the instruments administered for this study were excluded from the study. Due to the nature of the sample, the sampling was purposive and non-probabilistic.
The sample size was calculated based on Poisson regression, assuming a small effect size (PR = 1.2), a probability error of 0.05, and a power of 95%. A total of 453 participants were estimated, to which an additional 10% was added based on the probability of rejection, noncompliance with inclusion criteria, and missing data. Thus, a total of 500 participants were included for the study.
Variables
Anxious symptoms
Anxiety symptoms were assessed using Beck Anxiety Inventory (BAI). Anxiety in BAI can be defined based on the criteria for anxiety described in the DSM-III, which are different from depressive symptoms [40]. Likewise, to differentiate anxious symptoms from depressive symptoms we can define anxiety as fear, tension, and apprehension usually associated with anticipatory ideas of what may happen in the future and the activation of the autonomic nervous system [41]. The BAI is a 21-item self-applied scale created by Beck et al. in 1988, which measures the severity of anxiety symptoms in adults and adolescents in psychiatric populations [42]. The BAI is evaluated using a scale from 0 to 3 (0 = Not at all, 1 = Slightly, 2 = Moderately, and 3 = Severely), so the minimum score is 0 and the maximum is 63 points. The questions refer to the last week and the current moment; administration can take approximately 15 minutes. It shows a high internal consistency (α = 0.93) and evidence of internal structure [43]. Anxiety symptoms according to their scores are classified as normal (0–9), low anxiety (10–18), moderate anxiety (19–29), and severe anxiety (30–63) [44].
Perceived stress
The self-reported perceived stress scale with 10 items (PSS-10) was used to assess perceived psychological stress. Perceived stress was defined as the level of stress that the subject experiences as a function of objective stressful events, coping processes, and personality factors, among others [45]. PSS-10 is composed using a scale from 0 to 4 (0 = Never, 1 = Almost never, 2 = Occasionally, 3 = Often, and 4 = Very often). Psychometric studies of this test have been conducted in different countries, obtaining adequate scores for two-factor models [46–48]. Moderate and severe stress symptoms are defined using a cutoff value of 14 and higher [49].
Depressive symptoms
The Beck Depression Inventory-Second Edition (BDI-II) was used to assess depressive symptoms and is defined in the specific subtype of depression of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) [50]. The BDI-II is an inventory created by Beck that assesses the severity of depressive symptoms in psychiatric patients and in adolescents and adults (13–80 years) during the last 2 weeks [50]. The BDI-II consists of 21 items and 4 response alternatives ordered from the least to the greatest severity. The response alternatives are scored from 0 to 3 (0 = Not at all, 1 = Slightly, 2 = Moderately, and 3 = Severely), with a maximum and minimum scores of 63 and 0, respectively. This inventory presents high internal consistency (α = 0.94) and evidence of internal structure [51]. Depressive symptoms are classified based on their scores as mild depression (14–19), moderate depression (20–28), and severe depression (29–63) [52].
Emotional distress
Emotional distress was assessed using the Hospital Anxiety and Depression Scale (HADS). The National Comprehensive Cancer Network (NCCN) defines distress as an unpleasant multidetermined emotional experience of a psychological, social, and spiritual nature that can interfere with the ability to effectively cope with cancer, its physical symptoms, and its treatment [53]. This emotional response ranges from common normal feelings of vulnerability, sadness, and fear to problems that become disabling, such as depression, anxiety, panic, social isolation, and spiritual crisis [53]. The HADS was created by Zigmond and Snaith in 1983 [54] and was translated from English into Spanish by Tejero et al. in 1986 [55]. This tool consists of 14 items and two subscales (each with 7 items) that assess symptoms of anxiety and depression at a cognitive and discomfort emotional level in patients with somatic illnesses during the last week. The HADS has a Likert-type response option from 0 to 3, so the scores on each subscale range from 0 to 21. For both scales, if they exceed 8 points, it is considered a “case” and scores higher than 11 points are a “probable case” [54]. However, a meta-analysis study suggests that cancer patients consider a cutoff point scores greater than 15 for the total HADS (sensitivity, 0.87; specificity, 0.88) [56].
Quality of life
The quality of life was assessed using the 12-item short form questionnaire (SF-12). The SF-12 assesses eight domains of quality of life: the first four related to physical health (general health, physical functioning, physical role, and body pain) and the other four related to mental health (vitality, social functioning, emotional role, and mental health) [57]. The response options to the SF-12 items are dichotomous (yes or no) and Likert-type. Response options are scored, weighed, and summed to produce physical and mental component scores ranging from 0 to 100, with higher scores indicating better quality of life in that domain. The SF-12 scoring was performed using the STATA package developed by Bruun [58].
Covariates
Other sociodemographic variables assessed in the study included the following: sex (women/men), age grouped into four groups of approximately 15 years each (17–29, 30–44, 45–59, and 60 years and older); type of care (outpatient clinic, outpatient, and hospitalization), civil status (with a current partner, separated or widower, and single), educational years (primary education [at least 6 years old], secondary education [7–11 years], and superior education [12 to more years]), and employment status (employed and unemployed). Moreover, the variable types of cancer (focused/unfocused) are considered, prioritizing cancers with the highest mortality worldwide with sufficient frequency (lung cancer [bronchi, lungs, and trachea], colorectal cancer, gastric cancer, breast cancer, cervical cancer, and other focal types of cancer) [36]. Additionally, the clinical stage variable (early stages [0, I], advanced stages [II, III, IV], and there is no record) and comorbidity of mental health problems (number of mental health problems that participants have) were included.
Characteristics of the participants
In the descriptive analysis, the frequencies and percentages of all sociodemographic variables and the prevalence of depressive, anxiety, and stress symptoms have been reported. Furthermore, an analysis of the prevalence of moderate to severe symptoms of mental health problems (anxiety, depression, stress, and emotional distress) and the quality of life in relation to clinical stage and the types of cancer with the highest overall mortality was performed.
Mental health and quality of life outcomes
Mental health outcomes were defined as variables of anxiety, stress, depression, and emotional distress. These results were dichotomized based on the scores: mild perceived stress (0–13) and moderate to severe perceived stress (14–40), normal to mild depressive symptoms (0–18) and moderate to severe depressive symptoms (19 and above), normal to mild anxiety symptoms (0–18) and moderate to severe symptoms (19 and above), and no emotional distress (0–10) and probable cases of emotional distress (11 or more). On the other hand, quality of life outcomes includes two dimensions: the mental quality of life and physical quality of life. The scores obtained were divided into tertiles that were then dichotomized into low-medium and high (high quality of life was used as the baseline category to facilitate interpretation). Moderate to severe symptoms and low-medium quality of life were viewed as clinically significant for cancer patients and those in need of mental health support (outcomes). A sub-analysis of the comorbidity of mental health problems for the mental quality of life and physical quality of life was performed.
Additionally, generalized linear models with the Poisson family were used to calculate the raw (rPR) and adjusted (aPR) prevalence ratios and their 95% confidence intervals (95% CI) between each covariate and dichotomous health outcomes: the mind and the quality of life. To determine the covariates that would enter the adjusted model, it was taken as a criterion that in the crude model they had a p-value of less than 0.05 to be added to the multivariable model.
Topics of ethics
The study protocol was approved by the INEN Research Ethics Committee and the Research Review Committee (N°239-2018-CIE/INEN). Study participants were invited to participate in the research according to conventional ethical requirements. Subsequently, a signed written informed consent has been obtained from all of the study participants, and a questionnaire has been provided, which consisted of sociodemographic questions and psychometric tests.
Characteristics of the participants
Initially, 500 participants were evaluated, but those who lacked information on the outcome of interest (n = 27, 5.3%) or were foreigners (n = 8, 1.6%) were excluded from the study. No missing values were found. Our study included a total of 465 participants. Most of the participants were women (75.7%), their ages ranged between 17 and 84 years (mean = 45.9; SD = 14.4); they were currently in a relationship (48.1%), had focal cancer (77.6%), were in an advanced stage of cancer (63.87%), and were unemployed (78.3%); and most of them were housewives. The characteristics of the participants are presented in Table 1. Moreover, a prevalence of anxious symptoms (27.5%), depressive symptoms (20.4%), moderate-severe stress symptoms (83.2%), and emotional distress (57.41%) was identified. Our study finds that 87.1% of the participants had some mental health problems.
|
n |
% |
||
|---|---|---|---|
|
Sex |
Men |
113 |
24.2% |
|
Women |
352 |
75.5% |
|
|
Age, years |
17–29 |
72 |
15.5% |
|
30–44 |
141 |
30.3% |
|
|
45–59 |
164 |
35.2% |
|
|
60 to more |
88 |
18.9% |
|
|
Type of care |
Outpatient clinic |
185 |
39.7% |
|
Outpatient |
154 |
33.0% |
|
|
Hospitalization |
126 |
27.0% |
|
|
Civil status |
With current partner |
224 |
48.1% |
|
Separated or widower |
74 |
15.9% |
|
|
Single |
167 |
35.8% |
|
|
Educational years |
At least 6 years old |
78 |
16.7% |
|
7 to 11 years |
214 |
45.9% |
|
|
12 to more |
173 |
37.1% |
|
|
Employment status |
Employed |
364 |
78.1% |
|
Unemployed |
101 |
21.7% |
|
|
Clinical stage |
Early stage |
68 |
14.62% |
|
Advanced stage |
297 |
63.87% |
|
|
No stage |
100 |
21.51% |
|
|
Type of cancer |
Unfocused |
104 |
22.4% |
|
Focused |
361 |
77.60% |
|
|
Focal type of cancer |
Colorectal cancer |
15 |
4.16% |
|
Breast cancer |
137 |
37.95% |
|
|
Cervical cancer |
69 |
19.11% |
|
|
Gastric cancer |
19 |
5.26% |
|
|
Lung cancer |
14 |
3.88% |
|
|
Otros |
107 |
29.64% |
|
|
Anxious symptoms |
No |
337 |
72.47% |
|
Yes |
128 |
27.53% |
|
|
Depressive symptoms |
No |
370 |
79.57% |
|
Yes |
95 |
20.43% |
|
|
Moderate-severe stress |
No |
78 |
16.77% |
|
Yes |
387 |
83.23% |
|
|
Emotional distress |
No |
198 |
42.58% |
|
Yes |
267 |
57.42% |
|
|
Comorbidity of mental health problems |
None |
60 |
12.90% |
|
One mental health problem |
143 |
30.75% |
|
|
Two or more mental health problems |
262 |
56.35% |
Mental health and quality of life
A regression model showed that study participants with cancer who had at least 12 years of education (college or higher technical education) were 33% less likely to have emotional distress, compared to those with basic education (aPR = 0.67, 95% CI = 0.48–0.94) (see Table 2). Notably, neither the type of cancer (unfocused and focused) nor the clinical stage (early stage, advanced stage, and no stage) presented significant values for any of the mental health problems (anxious symptoms, stress, depressive symptoms, and emotional distress).
|
Anxious symptoms |
Moderate-severe stress |
Depressive symptoms |
Emotional distress |
|||
|---|---|---|---|---|---|---|
|
rPR (95% CI) |
rPR (95% CI) |
rPR (95% CI) |
rPR (95% CI) |
aPR(95% CI)* |
||
|
Sex |
Men |
Ref. |
Ref. |
Ref. |
Ref. |
Ref. |
|
Women |
1.55 (0.98–2.45) |
1.16 (0.91–1.47) |
2.02 (1.13–3.64) |
1.36 (1.00–1.84) |
1.34 (0.98–1.81) |
|
|
Age, years |
17–29 |
Ref. |
Ref. |
Ref. |
Ref. |
- |
|
30–44 |
1.25 (0.72–2.16) |
0.93 (0.68–1.26) |
1.26 (0.69–2.29) |
1.07 (0.74–1.56) |
- |
|
|
45–59 |
1.24 (0.73–2.13) |
0.94 (0.70–1.26) |
0.82 (0.44–1.53) |
1.02 (0.70–1.48) |
- |
|
|
60 to more |
0.68 (0.34–1.35) |
0.90 (0.64–1.26) |
0.82 (0.40–1.67) |
1.02 (0.68–1.55) |
- |
|
|
Type of care |
Outpatient clinic |
Ref. |
Ref. |
Ref. |
Ref. |
- |
|
Outpatient |
1.04 (0.69–1.55) |
0.98 (0.77–1.24) |
1.57 (0.99–2.46) |
1.25 (0.95–1.65) |
- |
|
|
Hospitalization |
0.87 (0.56–1.37) |
1.00 (0.78–1.29) |
0.85 (0.48–1.49) |
1.04 (0.77–1.42) |
- |
|
|
Civil status |
With current partner |
Ref. |
Ref. |
Ref. |
Ref. |
- |
|
Separated or widower |
0.90 (0.53–1.55) |
0.98 (0.73–1.31) |
0.76 (0.39–1.47) |
0.93 (0.65–1.33) |
- |
|
|
Single |
1.27 (0.88–1.84) |
1.02 (0.82–1.27) |
1.22 (0.80–1.88) |
1.00 (0.77–1.30) |
- |
|
|
Educational years |
At least 6 years old |
Ref. |
Ref. |
Ref. |
Ref. |
Ref. |
|
7 to 11 years |
0.89 (0.56–1.41) |
0.87 (0.66–1.15) |
1.05 (0.61–1.82) |
0.78 (0.57–1.06) |
0.80 (0.59–1.10) |
|
|
12 to more |
0.77 (0.46–1.24) |
0.90 (0.67–1.19) |
0.77 (0.42–1.40) |
0.66 (0.47–0.92) |
0.67 (0.48–0.94) |
|
|
Employment status |
Employed |
Ref. |
Ref. |
Ref. |
Ref. |
- |
|
Unemployed |
0.71 (0.44–1.13) |
0.92 (0.72–1.18) |
0.96 (0.59–1.57) |
0.73 (0.53–1.01) |
- |
|
|
Clinical stage |
Early stage |
Ref. |
Ref. |
Ref |
Ref. |
- |
|
Advance stage |
1.00 (0.61–1.65) |
0.90 (0.68–1.19) |
1.14 (0.63–2.08) |
0.91 (0.65–1.26) |
- |
|
|
No stage |
0.93 (0.52–1.68) |
0.96 (0.69–1.33) |
0.90 (0.43–1.83) |
0.85 (0.57–1.27) |
- |
|
|
Type of cancer |
Unfocused |
Ref. |
Ref. |
Ref. |
Ref. |
- |
|
Focused |
1.03 (0.68–1.56) |
0.96 (0.76–1.22) |
1.23 (0.74–2.06) |
1.09 (0.81–1.46) |
- |
|
| Note: rPR = raw prevalence ratio. aPR = adjusted prevalence ratio. 95% CI = 95% confidence interval. *Model adjusted for emotional distress adjusted by sex and educational years. Values in bold are significant (p < 0.05) | ||||||
|
Mental quality of life (low-middle) |
Physical quality of life (low-middle) |
||||
|---|---|---|---|---|---|
|
rPR (95% CI) |
aPR (95% CI)* |
rPR (95% CI) |
aPR (95% CI)** |
||
|
Sex |
Men |
Ref. |
Ref. |
Ref. |
- |
|
Women |
1.37 (1.03–1.81) |
1.17 (0.88–1.56) |
1.06 (0.82–1.38) |
- |
|
|
Age, years |
17–29 |
Ref. |
- |
Ref. |
- |
|
30–44 |
1.03 (0.73–1.46) |
- |
1.39 (0.96–2.03) |
- |
|
|
45–59 |
1.02 (0.72–1.42) |
- |
1.33 (0.92–1.93) |
- |
|
|
60 to more |
0.92 (0.62–1.36) |
- |
1.33 (0.88–1.99) |
- |
|
|
Type of care |
Outpatient clinic |
Ref. |
- |
Ref. |
- |
|
Outpatient |
0.97 (0.75–1.26) |
- |
0.99 (0.76–1.29) |
- |
|
|
Hospitalization |
0.99 (0.75–1.30) |
- |
1.05 (0.80–1.38) |
- |
|
|
Civil status |
With current partner |
Ref. |
- |
Ref. |
- |
|
Separated or widower |
0.97 (0.69–1.35) |
- |
0.91(0.65–1.26) |
- |
|
|
Single |
1.12 (0.88–1.42) |
- |
0.92 (0.72–1.17) |
- |
|
|
Educational years |
At least 6 years old |
Ref. |
- |
Ref. |
- |
|
7 to 11 years |
0.86 (0.63–1.16) |
- |
0.87 (0.64–1.19) |
- |
|
|
12 to more |
0.82 (0.60–1.12) |
- |
0.88 (0.64–1.21) |
- |
|
|
Employmentl status |
Umemployed |
Ref. |
- |
Ref. |
- |
|
Employed |
0.85 (0.64–1.13) |
- |
0.92 (0.70–1.21) |
- |
|
|
Clinical stage |
Early stage |
Ref. |
- |
Ref. |
- |
|
Advance stage |
1.22 (0.87–1.72) |
- |
1.09(0.78–1.51) |
- |
|
|
No stage |
1.09 (1.10–1.64) |
- |
1.00 (0.68–1.47) |
- |
|
|
Type of cancer |
Unfocused |
Ref. |
- |
Ref. |
- |
|
Focused |
1.20 (0.91–1.59) |
- |
1.15 (0.87–1.52) |
- |
|
|
Anxious symptoms |
No |
Ref. |
Ref. |
Ref. |
Ref. |
|
Yes |
1.57(1.25–1.98) |
1.10 (0.83–1.43) |
1.27 (1.01–1.61) |
1.02 (0.76–1.35) |
|
|
Depressive symptoms |
No |
Ref. |
Ref |
Ref. |
- |
|
Yes |
1.52(1.19–1.95) |
1.11 (0.83–1.48) |
1.29 (0.99–1.67) |
- |
|
|
Moderate-severe stress |
No |
Ref. |
Ref. |
Ref. |
- |
|
Yes |
2.92(1.85–4.59) |
2.30 (1.42–3.69) |
1.36 (0.98–1.90) |
- |
|
|
Emotional distress |
No |
Ref |
Ref. |
Ref. |
Ref. |
|
Yes |
1.90(1.48–2.43) |
1.46 (1.10–1.96) |
1.49 (1.18–1.89) |
1.39 (1.05–1.85) |
|
| Note: rPR = raw prevalence ratio. aPR = adjusted prevalence ratio. 95% CI = 95% confidence interval. *Multiple Poisson regression for mental quality of life adjusted by sex, anxious symptoms, depressive symptoms, stress, and emotional distress. **Multiple Poisson regression for physical quality of life adjusted by anxious symptoms and emotional distress. Values in bold were significant (p < 0.05) | |||||
|
Mental quality of life (low-middle) |
Physical quality of life(low-middle) |
||||
|---|---|---|---|---|---|
|
rPR (95% CI) |
aPR (95%CI)* |
rPR (95% CI) |
aPR (95% CI)* |
||
|
Comorbidity of mental health problems |
None |
Ref. |
Ref. |
Ref. |
- |
|
One |
2.59 (1.41–4.76) |
2.55 (1.38–4.69) |
1.17 (0.76–1.80) |
1.17 (0.76–1.80) |
|
|
Two or more |
4.27 (2.39–7.64) |
4.13 (2.30–7.41) |
1.67 (1.12–2.48) |
1.68 (1.13–2.50) |
|
| Note: rPR = raw prevalence ratio. aPR = adjusted prevalence ratio. 95% CI = 95% confidence interval. *Multiple Poisson regression adjusted by sex. Values in bold were significant (p < 0.05) | |||||
Main findings and significance of the results
A high prevalence of depressive symptoms (20.4%), anxiety (27.5%), emotional distress (57.4%), and moderate-severe stress (83.2%) has been identified. A meta-analysis on the prevalence of depression and anxiety in cancer patients from low- and middle-income countries has identified similar values (prevalence of depression [21%] and anxiety disorder [18%]) [59]. For the rest of the variables, only cross-sectional studies were found with different results, such as the prevalence of emotional distress in ovarian cancer patients (18%), adult cancer patients (26%), patients with intracranial neoplasms (48.4%), and breast cancer patients (66.5%) [60–63]. Moreover, the results of stress prevalence in cross-sectional studies were diverse, reporting a prevalence of 70% and 78.1% in Iranian cancer patients and breast cancer patients, respectively [64, 65].
Based on our research, no significant association has been found between cancer type and cancer stage in relation to mental health problems. The empirical evidence is mixed, although the literature suggests that cancer patients are heterogeneous and present different mental health problems according to the type and stage of cancer [15, 59, 66, 67]. Other studies have found no significant differences between different types of cancer [29]. These mixed results may be attributed to the different sociocultural contexts in which diagnosis occurs, the sample size of the studies (mostly small), and the instruments used for measurement. Possibly, other factors, such as being aware of cancer, are more important than the specific site. Studies have identified that being aware of having a chronic illness increases the likelihood of having mental health problems [68, 69].
Our study identified that the main factors associated with low mental quality of life and low physical quality of life in people with cancer were nonspecific indicators of mental health such as having severe-moderate stress and emotional distress. Several cross-sectional studies have previously identified an inverse relationship between quality of life stress and emotional distress in cancer patients [68–70]. Moreover, a longitudinal study suggests that increased perceived stress would predict a reduction in quality of life over time [71]. These results can also be interpreted from a transdiagnostic model with an understanding of pathology as a continuum [72].
One of these models is the hierarchical taxonomy of psychopathology, which posits the distress subfactor (emotional distress and stress) as the highest-order component within the range of emotional disorders [73]. Therefore, it supported that core distress factors are better predictors of poor mental quality of life, rather than specific symptoms/disorders (i.e., depression and anxiety), and assumes that comorbidity of mental health problems is associated with clinical severity and functional impairment [73].
Gender has been identified as a risk factor for the presence of depressive symptoms. There is ample evidence that gender is a predictor of the presence of depressive symptoms. A global meta-analysis reported that women have a prevalence of 31% compared to a prevalence of 26% in men [74]. This may be due to a variety of biological and hormonal factors in women that increase the risk of having intense emotional symptoms [75]. However, as studies have shown that men had higher symptoms [76], this may be due to social patterns. In a society with traditional gender norms, masculinity involves hiding concerns and not expressing feelings of vulnerability [77]. The cancer diagnosis can undermine perceptions of masculinity, coupled with poor control of the effects of the disease, leading to further deterioration of their health in the long term [78], while women are considered to be better at identifying emotions [79, 80]. So they would be better able to self-identify symptoms of sadness and emotional distress and therefore present a higher rate of positive cases.
A higher level of education was identified as a protective factor for emotional distress symptoms. The literature exposes contrary positions, as one systematic review reported that educational level does not predict long-term emotional distress [81]. Other studies using the distress thermometer instrument, which has acceptable diagnostic performance for measuring emotional distress [82], found that lower educational levels are associated with greater distress and patients with lower educational levels are more likely to develop emotional distress [83–86]. Another possible explanation is that educational level is a predictor of income level in Peru, and evidence showed that a high-income level is a predictor of the presence of emotional problems, such as depressive symptoms [87].
Relevance in public health
Quality of life is a relevant outcome within the course of cancer disease [11, 12, 16, 26–30, 68], so healthcare systems should develop interventions and strategies to care for the quality of life of cancer patients. Our study helps to prioritize which mental health problems were associated with poor quality of life (i.e., stress and emotional distress). Therefore, we suggest that future studies focused on mental health problems could be based on the transdiagnostic approach and offer further support for these interventions in cancer patients. Interventions based on a transdiagnostic approach have been shown to have several public health advantages by grouping people with common emotional distress symptoms, associated with a negative impact on their quality of life [88]. Furthermore, the transdiagnostic approach allows for a low-cost and short-duration implementation that will optimize mental health care by improving the quality of life for a wide range of cancer patients [88, 89].
Our study also serves as an input for cancer insurance policies in low- and middle-income countries, as it reveals a high prevalence and comorbidity of mental health problems. Consequently, it would allow them to plan actions to promote a culture of prevention, early detection, and treatment, thereby restoring patients’ quality of life. Additionally, establishing psychological and psychiatric care plans for cancer patients within their policies is suggested.
In Peru, since 2015, the Ministry of Health and INEN have implemented a budgetary program for the control and promotion of mental health that focuses on the application of psychological support strategies for cancer patients [90, 91]. During the COVID-19 pandemic, mental health support and self-care strategies for cancer patients were strengthened. One of the main objectives of the program is the improvement of the quality of life through a psychosocial support team [92, 93]. Our results support the need to further strengthen this type of health strategy.
Strengths and limitations
This study has some methodological limitations. First, this study has a cross-sectional design that consists of making a single measurement over some time and analyzing the relationship between variables [94], so making statements about the causal relationship between variables is not possible. Nevertheless, these results are important because they show what associated factors are important for the mental health and quality of life of cancer patients. Second, cancer patients are influenced by their family and social environment, which can increase their risk of mental health problems [69], but assessing patients and relatives is not possible, so this could introduce a measurement bias. Third, the results are not generalizable to other cancer populations in Peru, because our study is non-probabilistic. Fourth, the sample size is small, so regression analyses cannot be performed for each cancer diagnosis (i.e., gastric cancer, cervical cancer, or others).
Our study identifies that the main factors associated with the physical quality of life and the mental quality of life are emotional distress and stress. Additionally, the greater the comorbidity of mental health problems is associated with a lower quality of life (physical and mental). Also, the variable high educational level was found to be a factor associated with emotional distress. A high prevalence of mental health problems was found in cancer patients.
Our findings have direct implications for the public health of cancer patients. On the one hand, continuing to develop health policies and strategies to strengthen their mental health and quality of life is necessary. Furthermore, our study raises the need to prioritize interventions focused on reducing symptoms of emotional distress and stress.
The authors have no conflict of interest to declare when conducting the study, analyzing the data, or writing the manuscript.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The database can be accessed by requesting it from the authors.
The authors thank the support of the members of the Oncological Mental Health Functional Team; evaluating clinical psychologists: Rosa Argüelles Torres, Giovanna Galarza Torres, Flor Arrunátegui Reyes, Hernán Bernedo Del Carpio, Antonio Conso Machuca, Oscar Villanueva Cortés, Sarita Angulo Rubio, and Yvo Fernández Montoro; the Psychology Interns team of the period 2018; and all patients of the INEN that responded to the evaluation. Also, we thank Daniel Rivas for the linguistic revision of the article.
The protocol of this study was approved by the INEN Research Ethics Committee and the Research Review Committee (N°239-2018-CIE/INEN).Study participants were invited to participate in the research according to conventional ethical requirements. Subsequently, a signed written informed consent has been obtained from the study participants, and questionnaires were provided, which consisted of sociodemographic questions and psychometric tests. Necessary ethical care was maintained following the guidelines of the Declaration of Helsinki.
Not applicable.
David Villarreal-Zegarra: Formal analysis, methodology, supervision, validation, writing – original version, and approval of the final version.
Sofía C. Malaquias-Obregon: Formal analysis, investigation, validation, writing – original version, and approval of the final version.
Jackeline García-Serna: Investigation, validation, writing – original version, and approval of the final version.
Milagros Cabrera-Alva: Investigation, validation, writing – original version, and approval of the final version.
Ana L. Vilela-Estrada: Conceptualization, data curation, investigation, methodology, validation, writing – review and editing, and approval of the final version.
Anthony Copez-Lonzoy: Conceptualization, methodology, validation, writing – review and editing, and approval of the final version.