Sample and procedure
This cross-sectional study was conducted in University of Health Sciences, Bagcilar Research and Training Hospital, Medical Oncology Clinic and Chemotherapy Unit, between 15 June and 15 October 2020. This study included consecutively selected 216 eligible cancer patients, who receiving treatment or visiting the oncology center for routine follow-up examinations. To be eligible for study participation, patients had to be (a) diagnosed with any cancer type, (b) aged between 18 and 75 years, (c) able to complete questionnaire in Turkish language, and (d) able to provide informed consent. Reasons for exclusion were pregnancy, illiteracy, substance abuse, declared inability to complete questionnaires, serious psychiatric disorders that hindered judgement, and patients with any issues interfering with giving informed consent. The aim of the study was explained to the participants and invited to voluntarily participate, and informed consent forms were obtained before they were included in the study. This research was approved by the University of Health Sciences, Bagcilar Research and Training Hospital’s ethical committee (reference 2020.06.1.11.082) and was conducted in accordance with the Declaration of Helsinki. The study protocol was also approved by the Turkish Ministry of Health, General Directorate of Health Services (reference ES-2020-05-07T13_40_22). The Patient Health Questionnaire-15 (PHQ-15), Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), The Depression, Anxiety and Stress Scale-21 (DASS-21), the Brief Resilience Scale (BRS), the Stressful Life Events List due to Pandemic and, demographic and clinical characteristics were administered to the participants with face to face interweaving by author XXX who senior social worker trained for the study.
Demographic and clinical characteristics form.
Age, gender, marital status, education, employment status, economic well-being, comorbidity (hypertension, diabetes, coronary heart disease, chronic obstructive lung disease, chronic kidney disease, and other), and history of psychiatric disorders were assessed via self‐report. Clinical characteristics included type of cancer, time since diagnosis, types of treatment currently or previously received, present treatment, and metastasis; this information was obtained from participants’ medical charts.
Stressful Events List due to Pandemic.
The scale was prepared by authors, using the Stressful Life Events Screening Questionnaire14 and review of the literature, and used to measure the stressful life event burden during the pandemic. The scale, answers are 0-no, 1-yes consisting of 18 questions and total scores ranging from 0 to 18. Higher scores on the scale are associated with stressful event burden. Cronbach’s alpha internal consistency coefficient was determined as 0.73. A positive and significant relationship was found between the total score of the scale and depression (r = .35), anxiety (r = .32), stress (r = .32), PCL-5 total score (r = .41), and PHQ-15 total score (r = .38) (see Supplementary Table 1).
Patient Health Questionnaire (PHQ-15).
Somatic symptoms were measured using the PHQ-15 scale, which includes the 15 most common somatic symptoms. This scale assesses how much participants were bothered by health symptoms such as "abdominal pain", "back pain" on a scale of 0=not bothered at all to 2=bothered a lot. A total somatic symptom score was calculated, with possible scores ranging from 0 to 30, and scores scaled to account for the additional item asked only of female participants relating to menstrual pain and problems. Higher scores on the PHQ-15 are strongly associated with somatic symptoms. Somatic symptom severity were calculated in four categories based on the PHQ-15 score ‘minimal’ (0–4), ‘mild’ (5–9), ‘moderate’ (10–14), or ‘severe’ (≥15).15 The Turkish validity-reliability study was conducted by Yazıcı Güleç et al. (2012).16 In this study, Cronbach’s alpha of the PHQ-15 was 0.86.
Post-traumatic stress disorder checklist for DSM–5 (PCL-5).
The PCL-5 is a 20-item measure that assesses PTSD symptomatology: intrusions, avoidance, negative alterations in cognitions and mood (NACM), and hyperarousal. Participants responded to the items on 5-point Likert-type scales (0 = not at all to 4 = extremely) in relation to their experience of COVID-19 outbreak, with total scores ranging from 0 to 80.17. The Turkish version of PCL-5 was used, which has been shown to be reliable and valid. In this study, used ≥47 as a cut-off point to diagnose possible PTSD.18 Among the current sample, the PCL-5 and subscales evidenced a Cronbach’s alpha of α=.96 for PCL-5, α=.89 for intrusions, α=.87 for avoidance, α=.91 for NACM, and α=.92 for hyperarousal.
The Depression Anxiety Stress Scales-21 (DASS-21).
DASS-21 is a 21-item, selfreport questionnaire designed to measure the severity of a range of depression, anxiety and stress symptoms. Each item of the DASS corresponds to one of the three subscales (depression, anxiety, and stress) with 7 items per subscale. The scale is a 4-point Likert from 0 (never) to 3 (almost always) and evaluates symptoms from last week.19,20 DASS-21 raw scores were doubled for comparability to full-length (42 items) DASS scores. The depression score results were classified as normal (0-9), mild (10-12), moderate (13-20), severe (21-27), and extremely severe (28-42). The anxiety score results are classified as normal (0-6), mild (7-9), moderate (10-14), severe (15-19), and extreme severe (20-42). The stress score results were classified as normal (0-10), mild (11-18), moderate (19-26), severe (27-34), and extreme severe (35-42).21 Among the current sample, the DASS-21and subscales evidenced a Cronbach’s alpha of α=.93 for DASS-21, α=.86 for depression, α=.78 for anxiety and α=.83 for stress.
Brief Resilience Scale (BRS).
The BRS includes six items. The respondents were asked to indicate how well each statement described their behaviour and actions on a 5-point Likert-type scale, ranging from “1” = does not describe me at all to “5” = describes me very well. As Item 2 (I have a hard time making it through stressful events), Item 4 (It is hard for me to snap back when something bad happens) and Item 6 (I tend to take a long time to get over set-backs in my life) were reverse-coded, the data collected were recoded prior to analysis. High scores obtained from the scale after the items coded in reverse order are translated in the scale indicate high psychological resilience.22 The factor loads for the items were found between 0.68 and 0.91 in Turkish sample.23 In this study, Cronbach’s alpha of the BRS was 0.69.
Descriptive statistics were presented in median values and interquartile ranges (IQR) (25% to 75%) for the quantitative variables, and frequencies and percentages for the categorical variables. Normality tests were carried out by using one-sample Kolmogorov–Smirnov and Shapiro-Wilk tests and through histogram graphs. The Mann–Whitney U test was utilized for comparing the continuous variables among two groups. Kruskal-Wallis test was used to evaluate possible differences between the more than two groups and the level of significance was determined after the Dunn multiple comparison tests with Bonferroni correction test. Multiple linear regression model was used with backward elimination technique to investigate potentially predictive factors for the somatic distress. The variables evaluated were determined as significant variables derived from our results and literature review, in accordance with clinical experience. The variables used for the models are as follows; age (years), gender, education levels (years), additional chronic disease, history of psychiatric disorders, present treatment (any treatment, follow-up), metastasis anxiety, stressful life events, BRS, and intrusions. The tests for assumptions-linearity, homoscedasticity, and multicollinearity were carried out by the authors (assumptions met). All the analyses were 2-sided with alpha of 0.05, and performed with SPSS statistical software (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.).