Interaction of Anxiety and Hypertension on Quality of Life among Gynecological Cancer Patients: A cross-sectional study

DOI: https://doi.org/10.21203/rs.3.rs-2100862/v1

Abstract

Gynecological cancer patients are prone to anxiety, accompanied by hypertension symptoms, which seriously affect the quality of life (QOL). The study was to explore the interaction of anxiety and hypertension on QOL, and the moderating effect of social support in the impact of anxiety and hypertension on QOL of gynecological cancer patients. A cross-sectional study was conducted in 2020, and 566 patients have been collected from the Affiliated Hospital of China Medical University. The Self-Rating Anxiety Scale (SAS), the Functional Assessment of Cancer Therapy Genera tool (FACT-G), and the Multidimensional Scale of Perceived Social Support Scale (MSPSS) were used. The interaction was analyzed by additive model, and the moderating effect was conducted by regression analysis and the simple slope analysis. We found that 68.8% of patients had poor QOL due to the interaction between anxiety and hypertension. The relative excess risk ratio (RERI) was 22.238 (95%CI:44.119–88.596); the attribution ratio (AP) was 0.688 (95%CI:0.234–1.142); The interaction index (S) was 3.466 (95%CI: 0.823–14.435). The interaction items of social support and anxiety were negatively correlated with QOL (β=-0.219, P < 0.01) and explained an additional 4.0% variance (F = 68.649, Adjusted R2 = 0.399, ΔR2 = 0.040, P < 0.01); Social support and blood pressure interaction item was not associated with QOL (β = 0.013, F = 55.138, Adjusted R2 = 0.365, ΔR2 = 0.001, P = 0.730). When anxiety and hypertension coexist, the QOL was seriously decreased. Social support played a moderating role in the impact of anxiety on QOL. Medical staffs should take intervention measures to improve patients’ social support to reduce the impact of anxiety on QOL.

Introduction

Gynecological tumors are common diseases in women, including cervical cancer, endometrial cancer, ovarian cancer and other malignant tumors, and both incidence rate and mortality were high [1]. Surgery combined with chemotherapy is an effective method to treat gynecological tumors. Although its prognosis and survival rate have been significantly improved, it inevitably brings physical pain and psychological changes to patients. The quality of life (QOL) is often better than the survival rate in reflecting the treatment of cancer patients [2]. QOL is defined as the “individual’s perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [3]. QOL evaluation is an important outcome indicator of cancer research, reflecting the changes of physiological, social, psychological and emotional aspects of patients after illness [4]. The special disease track, the loss of female characteristics after surgery and the accompanying symptoms of gynecologic cancer patients, such as sexual health, fertility and sexual desire problems, seriously affect the QOL of patients [5]. In addition to cancer surgical treatment and other physiological factors, the negative psychological factors also have a negative impact on the QOL. Cancer patients not only suffer from physical pain, but also face complex psycho-social problems, which will seriously affect the QOL [6].

Among the psychological factors affecting the QOL, cancer-related anxiety is more common in the incidence of emotional disorders [7]. Sudden onset of disease or partial organ loss caused by tumor resection will affect the patients’ self-esteem and self-confidence, hence affect the patients’ self recognition, and cause severe anxiety. Previous studies have shown that the anxiety of female tumor patients in the preoperative and postoperative chemotherapy period is widespread and the incidence is high [8]. In many kinds of cancer patients, the anxiety level of female patients is significantly higher than that of male patients, and gynecological cancer patients are one of the highest anxiety groups [9, 10]. Studies have shown that the incidence of anxiety in gynecologic cancer patients is 23.7–42% [1113]. Cancer patients have obvious psychological stress reaction or psychological disorder, especially anxiety, which will affect coping style, treatment compliance, immune function and reduce QOL [14]. A meta-analysis showed that anxiety affect 10% of cancer patients at any stage of cancer [15]. About 75% of patients with obvious anxiety did not receive any psychological or drug-related treatment systematically or never [16], leading to the obstruction of anti-cancer decision-making, poor treatment compliance, prolonged disease recovery time, and the QOL [17]. In cancer patients, the most common cardiovascular disease is hypertension. The study showed that compared with the normal population, the incidence rate of anxiety in patients who knew hypertension was higher [18]. Patients with hypertension may be excessively nervous due to their lack of understanding of the disease and worry about the adverse effects of anti hypertensive drug treatment, resulting in poor mood and anxiety. This psychological state in turn will aggravate the condition of hypertension, weaken the anti hypertensive effect of drugs, and cause a vicious circle between hypertension and anxiety. The epidemiological investigation on hypertension and anxiety comorbidity showed that the prevalence of anxiety complicated with hypertension in China is 11.6% − 38.5% [19]. A survey in Ghana found that 56.0% of hypertensive patients had anxiety [20]. Hypertension can affect the QOL of the elderly population, and has a greater impact on elderly women [21]. However, few studies have discussed the interaction effect of hypertension and anxiety on the QOL.

For patients with anxiety and hypertension coexisting, it is inevitable that their QOL will be affected. In order to balance the impact of stressful life events, some studies have emphasized the importance of social support on the QOL of patients with mental illness [22]. Social support refers to the spiritual or material help and support system given by the outside world, and a good social support system helps to promote mental health [23]. Huang et al. found that social support was a moderator of depression on QOL in breast cancer patients, which can significantly alleviate the impact of depression on QOL [24]. Panayiotou et al. found that social support helps buffer the negative impact of anxiety on QOL [25]. Anyway social support directly and indirectly regulates the influence of variables to play its role, that is, the “buffer hypothesis”, which has been widely confirmed [26]. Therefore, this paper chose social support as the moderating variable in gynecologic tumor patients with hypertension and anxiety.

The purposes of this study are as follows: 1) This study analyzed the effect of the interaction of anxiety and hypertension on the QOL. 2) For patients with anxiety and hypertension, it also aims to test whether the social support could moderate the impact of anxiety and hypertension on QOL, and to provide the theoretical basis for improving the QOL of gynecological cancer patients.

Materials And Methods

Study Design and Sample

Since December 2019 to July 2020, a total of 566 patients with gynecological cancer have been collected from the Affiliated Hospital of China Medical University in Liaoning, Shenyang. Inclusion criteria: during the investigation, the condition was relatively stable, with clear consciousness and no serious complications; voluntary participants; the expected survival time was > 9 months.

Assessment of Anxiety symptoms

Zung’s Self-Rating Anxiety Scale (SAS) was used [27]. The SAS considered both emotional and physical symptoms, including 20 items, of which 15 were negative experiences and 5 were positive experiences. Add all the items together to form a rough score, which is multiplied by 1.25 and rounded to get the standard score to evaluate anxiety. The index score of 45 (original score = 36) was set as the cut-off point for clinical significant anxiety in our study [28]. The Cronbach’s alpha of it was 0.918 which proved that the scale had good reliability.

Assessment of Quality of Life

The Functional Assessment of Cancer Therapy Genera (FACT-G) tool is applicable to all cancer sites, and is included as the common cancer core questionnaire for specific instruments of each fact cancer site [29]. The FACT-G is a cancer-targeted QOL measure that includes physical well-being, social well-being, emotional well-being, and functional well-being. The scale consists of 27 items with a total score range of 0 to 108. In this study, the Cronbach’s alpha of global scale was 0.899 which proved that the scale had good reliability.

Assessment of Perceived Social Support

The Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess perceived social support as perceived by the respondents from family, friends and significant others [30]. The MSPSS is a subjective assessment of social support adequacy with 12-item with a total score range of 12–84. In this study, the Cronbach’s alpha of global scale was 0.963 which proved that the scale had good reliability.

Data analysis

SPSS Statistics 21.0 software was used for statistical analysis. Chi square test was used to compare the count data. The significant variables in univariate analysis were used as independent variables, and multiple logistic regression was performed. By using Delta method, the excel table compiled by Andersson et al. [31] was introduced to calculate the related indexes of additive interaction. The OR value obtained by logistic regression model in the interaction calculation process was used as the estimation value of relative risk (RR). Additive interaction index: (1) the relative excess risk due to interact (RERI) was used to evaluate the difference between the combined effect of factor A and factor B and the sum of factors A and B alone; (2) the attributable proportion due to interaction (AP) was used to evaluate the proportion of interaction between two factors when two factors A and B exist at the same time; (3) the synergy index (S): the confidence interval of S is greater than 1 [3234]. Correlations among variables were examined by Pearson’s correlation. Hierarchical regression analysis was used to prove the relationship of variables and to examine the moderating effect. Finally, the simple slope analysis was conducted to visualize the interaction term [35]. Significance level was α = 0.05, and a two-tailed P < 0.05 was considered to have statistical significance.

Results

Basic information

566 cases were investigated with an average age of (56.34±9.78) years. The average score of QOL was 72.69±18.10. There were 304 cases with good QOL(>72.69) and 262 cases with poor QOL(≤72.69). 253 cases had anxiety (44.7%); 192 cases had hypertension (33.9%); 113 cases had anxiety with hypertension (20.0%). The difference of QOL between the two groups was statistically significant (P<0.01). The details are shown in Table 1.

Table 1 Comparison of basic conditions of patients with different QOL (N=566)

Variables

Good

Poor

χ2

P

Marital status

 

 

0.681

0.409

Married/cohabited

33

23

 

 

Single /separated

271

239

 

 

Education level

 

 

4.722

0.094

Junior high school and below

170

170

 

 

High/Technical secondary school

116

80

 

 

Bachelor degree or above

18

12

 

 

Monthly income (RMB)

 

 

6.112

0.047

<2000

78

62

 

 

2000-4000

163

164

 

 

>4000

63

36

 

 

Habitation

 

 

3.636

0.057

Rural 

199

191

 

 

Urban

105

71

 

 

Hypertension

 

 

56.254

<0.001

No

243

131

 

 

Yes

61

131

 

 

Stage of cancer

 

 

5.034

0.081

163

122

 

 

61

73

 

 

Ⅲ+Ⅳ

80

67

 

 

BMI

 

 

11.391

0.001

<24

178

189

 

 

≥24

126

73

 

 

Anxiety symptoms

 

 

144.458

<0.001

No

239

74

 

 

Yes

65

188

 

 

PSS

 

 

61.869

<0.001

Low/Moderate

49

122

 

 

High

255

140

 

 

Notes: “Good” includes “fairly good” and “very good”, “Bad” includes “fairly bad” and “very bad” responses.

Multivariate logistic regression analysis of the factors affecting the QOL 

Taking the QOL as the dependent variable, the variables with P<0.1 in the single factor were included in the multiple logistic regression. The results showed that the factors that entered the equation were monthly income (RMB), hypertension, anxiety, and social support. Monthly income >4000 yuan and social support were the protective factors for the QOL, and hypertension and anxiety were the risk factors for the QOL. The details were shown in Table 2.

Table 2 Multiple logistic regression analysis of QOL

Factors

B

S.E.

Wald χ2

P

OR

95%CI

Monthly income (RMB)

 

 

 

 

 

 

2000-4000 v s<2000

-0.068

0.283

0.058

0.810

0.934

0.537-1.625

>4000 vs 2000

-0.890

0.367

5.889

0.015

0.411

0.200-0.843

BMI 

-0.078

0.223

0.123

0.726

0.925

0.597-1.433

Hypertension

1.229

0.221

30.888

<0.001

3.419

2.216-5.273

Anxiety 

1.945

0.230

71.584

<0.001

6.994

4.457-10.975

PSS

-0.692

0.242

8.189

0.004

0.501

0.312-0.804

Constant

-0.832

0.389

4.575

0.032

0.435

 

 

Calculation of additive interaction index of anxiety and hypertension on QOL

As shown in Table 3, 113 patients (20.0%) were anxiety with hypertension. The reference were no anxiety and no hypertension. The OR value of hypertension without anxiety on QOL was 3.112 (95%CI:1.778-5.447); The OR value of anxiety without hypertension on QOL was 7.978 (95%CI:4.939-12.886); The OR value of hypertension and anxiety on QOL was 32.327 (95%CI: 16.848-62.026). The interaction between anxiety and hypertension was significant. The relative excess risk ratio (RERI) was 22.238 (95%CI:44.119-88.596); the attribution ratio (AP) was 0.688 (95%CI:0.234-1.142); The interaction index (S) was 3.466 (95%CI: 0.823-14.435). AP was 0.688, indicating that 68.8% of the patients with poor QOL due to the interaction between anxiety and hypertension. 

Table 3 Analysis of interaction between anxiety symptoms and hypertension on QOL

Anxiety

Hypertension

QOL

β

P

OR/RR

95%CI

Good 

Poor

-

-

192

42

-

 

 

 

-

+

47

32

1.135

<0.001

3.112

1.778-5.447

+

-

51

89

2.077

<0.001

7.978

4.939-12.886

+

+

14

99

3.476

<0.001

32.327

16.848-62.026

RERI

 

 

 

 

 

    22.238

44.119-88.596

AP

 

 

 

 

 

0.688

0.234-1.142

S

 

 

 

 

 

3.446

0.823-14.435

 

Correlations among continuous variables

As shown in Table 4, anxiety was negatively correlated with QOL and PSS, and positively correlated with BP (P<0.01). BP was negatively correlated with PSS and QOL (P<0.01). PSS was positively correlated with QOL (P<0.01 ). 

Table4 Correlations among study variables

Variables

Mean±SD

1

2

3

4

Anxiety

47.43±14.45

 

 

 

 

BP

124.94±23.25

0.140**

 

 

 

PSS

68.11±12.12

-0.539**

-0.246**

 

 

QOL

72.69±18.10

-0.473**

-0.349**

0.560**

1

Notes: **P<0.01.QOL: quality of life, PSS: perceived social support, BP: blood pressure.

 

Hierarchical regression analysis

As shown in Table 5, age, monthly income (RMB), and BMI were added in the first step. In the second block, anxiety and PSS were added. Finally, the PSS&Anxiety interaction term were added in the last block. The PSS&Anxiety interaction term was negatively correlated with QOL (β=-0.219, P<0.01), and explained an extra 4.0% of the variance (F= 68.649, Adjusted R2=0.399, ΔR2=0.040, P<0.01); The PSS&BP interaction term was not associated with QOL (β=0.013, F=55.138, Adjusted R2=0.365, ΔR2=0.001, P=0.730).

Table5 Hierarchical linear regression for anxiety symptoms and PSS with quality of life

Variables

Quality of Life 

Block 1

Block 2

Block 3

Age

0.052

0.021

0.004

Monthly income (RMB)

0.057

0.101**

0.082*

BMI

0.110**

-0.026

-0.047

Anxiety 

 

-0.256**

-0.220**

PSS

 

0.430**

0.373**

PSS&Anxiety 

 

 

-0.219**

F

3.546*

64.673**

63.459**

Adjusted R2

0.013

0.360

0.399

ΔR2

0.019

0.347

0.040

Notes: *P<0.05, **P<0.01.

Simple slope analysis

In Figure 1, simple slope analysis showed that the association between anxiety and QOL was gradually decreased in the low (-1SD below the mean, B=0.110, β=0.093, P<0.05), mean (B=-0.269, β=-0.229, P<0.01) and high (+1SD above the mean, B=-0.648, β=-0.552, P<0.01) groups of PSS.

Discussion

The results of this study showed that anxiety and hypertension were the influencing factors of the QOL of patients with gynecological tumors. Anxiety made gynecological cancer patients have a low evaluation of their overall health, often showing physical symptoms, and their social function was significantly reduced. Foreign scholars also pointed out that anxiety and other emotions had a greater impact on the psychological level than the physical function [36].Therefore, the QOL of patients with anxiety symptoms was poor. Hypertension will also affect the QOL of patients with gynecological tumors, which has been concluded in previous studies [21]. Hypertension will not only cause blood pressure to lose its balance, thus leading to various blood pressure diseases, but also may lead to multiple organ dysfunction, seriously affecting the QOL of patients, and even causing life danger [37].

In this study, 68.8% of patients had poor QOL due to the interaction between anxiety and hypertension. It shows that the interaction of anxiety and hypertension has a serious impact on the QOL of patients with gynecological tumors, and the impact of two factors is significantly greater than that of a single factor. Possible causes may be there is an interactive relationship between hypertension and anxiety [38]. Longitudinal data and theoretical literature indicate that anxiety may precede hypertension [39]. Anxiety patients are in low mood or pessimism for a long time due to unstable mood, which will lead to unstable blood pressure and high blood pressure. In particular, severe anxiety will lead to a sharp rise in blood pressure and even hypertension crisis. Research also showed that the change process of hypertension patients’ condition will participate in and affect the generation of anxiety, and the fluctuation range of blood pressure and heart rate variability are positively related to the severity of anxiety [40]. Therefore, hypertension will lead to anxiety, and anxiety will aggravate the condition of hypertension, leading to a vicious circle between hypertension and anxiety, which will affect the prognosis of the disease, cause serious physical and mental consequences. This was also the reason why the patient’s QOL was seriously reduced when the two coexist.

The results of this study show that social support has a regulatory role in the impact of anxiety on the QOL of gynecological cancer patients, and social support can alleviate the impact of anxiety on the QOL of patients. Research has confirmed that social support can be used as personal and internal resources to cope with and adapt to stress situations, enabling people to explain and deal with diseases, difficulties, hopes and rehabilitation [41]. Social support is closely related to the physiological and psychological aspects of long-term survival of gynecological cancer patients [42]. At the same time, social support is an important factor in predicting the QOL of cancer patients [43]. The key reason why social support plays a “buffer” role may be that “individuals think that providing appropriate support to others will reduce stress and physiological reactions”. This can explain why the more social support patients feel during treatment, the more beneficial it is to improve anxiety [44]. Research also shows that only when social support is needed, can social support relieve the anxiety of cancer patients [45]. This may explain why in our study, the relationship between anxiety and QOL is not obvious with lower social support, but it is only with higher social support that it plays a regulatory role. Based on the above theory, when gynecological cancer patients have anxiety, higher social support can improve their impact on QOL by reducing the possibility of anxiety. The results of this study show that social support has no regulatory role in the impact of hypertension on the QOL of patients with gynecological tumors, which may be related to the pathogenesis of hypertension, and drug control of blood pressure will achieve better results.

Limitations and implications

Limitations of this study: This study was a cross-sectional study, so we could not get the causal relationship between variables; More variables that may affect the quality of life should be included; Self filled questionnaire will bring bias problems to this study, such as recall bias, measurement bias, etc.

Our study found that anxiety and hypertension have a negative impact on the QOL of gynecological cancer patients, and the interaction of anxiety and hypertension has a greater impact on the QOL of patients with gynecological tumors than that of single factor. At the same time, social support alleviates the impact of anxiety on the QOL of gynecological cancer patients. It is suggested that medical staff should pay more attention to patients with anxiety and hypertension, and take intervention measures to improve the social support of gynecological cancer patients, so as to improve the QOL

Declarations

Acknowledgments

The authors would acknowledge the services of staffs in the the Affiliated Hospital of China Medical University in Liaoning, Shenyang, who helped to get the written informed consent about the conduct of this survey and distribute the questionnaires to the gynecological cancer patients.

Authors’ contributions

ZHG: Data collection and curation, literature survey, drafting initial manuscript. CXY: Conceptual design and methodology. LT: Formal analysis. HW: Supervision, project administration, reviewing and editing. The final manuscript was read and approved by all authors. All authors read and approved the final manuscript.

Funding

This work was supported by the National Key R&D Program of China (Grant #2018YFC1311600).

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due the data also forms part of an ongoing study but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study design was approved by the Committee on Human Experimentation of China Medical University (ChiCTR2000040122). All methods were carried out in accordance with Declaration of Helsinki. Written informed consent was obtained from each participant. Information collected from all participants was kept confidential and anonymous.

Consent for publication

Not applicable.

Competing interests

We declare that we have no financial or personal relationship with other people or organizations, will not have inappropriate impact on our work, and there is no professional or other personal interest of any nature or kind in any product, service and/or company.

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