Associations of diagnostic awareness with psychosocial symptoms and survival time in patients with advanced lung cancer

doi:10.21203/rs.3.rs-4468001/v1

Download PDF

Research Article

Associations of diagnostic awareness with psychosocial symptoms and survival time in patients with advanced lung cancer

https://doi.org/10.21203/rs.3.rs-4468001/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 13 Oct, 2024

Read the published version in The International Journal of Psychiatry in Medicine →

Version 1

posted

You are reading this latest preprint version

Background

Disclosing diagnosis to lung cancer patients is a critical issue. The psychosocial consequences of diagnostic awareness and its impact on life expectancy are issues of curiosity. We intended to evaluate the effects of diagnostic awareness on psychosocial symptomatology and survival time in advanced lung cancer patients.

Methods

This prospective cohort study was conducted on 126 advanced lung cancer patients admitted to the oncology department between Feb 2016 and Aug 2021. A face-to-face survey, including questions on age, gender, marital/employment statuses, comorbidities, and symptom checklist (SCL-90-R) assessment, was applied to patients. Diagnostic awareness was recorded by asking patients about comorbidities and obtaining confirmation from their relatives. Survival data was collected from the national death notification system on Feb 2023, and survival time was calculated from admission until Feb 2023.

Results

Of the patients, 104 were males, and 86 were non-survivors. Survival time and scores of SCL-90-R subscale dimensions were compared between diagnosis-aware (79.4%) and diagnosis-unaware groups (20.6%). Somatization, depression, psychoticism, additional scales, general symptoms, Positive Symptom Total, and Positive Symptom Distress Index scores were significantly higher in the diagnosis-unaware group (p=0.00, p=0.01, p=0.01, p=0.00, p=0.01, p=0.02, p=0.01, respectively). No significant associations were found between survival time and diagnostic awareness, gender, and marital/employment statuses.

Conclusions

Advanced lung cancer patients aware of such a serious disease experienced less psychosocial burden. However, no significant difference was found in survival time between diagnosis-aware and diagnosis-unaware patients. The diagnosis should be disclosed to lung cancer patients after the confirmation of diagnosis.

Lung cancer

diagnosis knowledge

palliative care

depression

psychological stress

survival

Lung cancer is the most common cancer worldwide after breast cancer and remains the leading cause of cancer-related deaths by 20% [1, 2]. Patients are often diagnosed at an advanced stage; thus, treatment options are limited, and survival is poor [3]. Therefore, it is difficult to disclose the diagnosis to lung cancer patients as well as the diagnosis acceptance of patients. The patients must cope with stressors, including urgent treatment decisions, adverse effects of treatment, and uncertainty regarding the future after diagnosis [4, 5]. Furthermore, the cost associated with cancer and its treatment in a resource-poor setting can enhance psychological distress (PD).

The National Comprehensive Cancer Network (NCCN) guidelines state that PD is a multidimensional, unpleasant emotional experience that affects psychological, physical, social, and religious well-being [6]. Zabora et al reported that lung cancer patients experienced more PD compared with other cancer patients [7]. Psychosocial stressors (e.g., treatment complications, poor relative support and financial difficulties) increase morbidity and mortality while reducing quality of life (QoL) [8].

Western medical societies emphasize full disclosure of cancer diagnosis and prognosis with respect for autonomy, which is the basis of ethical practices. However, surveys of cancer patients and physicians who are Native Americans, Japanese, Europeans, and members of various ethnic American groups (including European Americans, Mexicans, Chinese, Koreans, Africans, and Hispanics) reveal that comprehensive and accurate disclosure is undesirable [9]. Spiritual, social, and cultural factors contribute to perspectives on this issue in the Middle East and Mediterranean region [10, 11]. Still today, disclosing the diagnosis to cancer patients in Türkiye is a dilemma for healthcare professionals [12, 13].

We evaluated the effects of advanced lung cancer patients’ diagnostic awareness (DA) on psychosocial symptoms. In addition, we compared survival time between diagnosis-aware and diagnosis-unaware groups.

2.1 Participants

Of the 16.203 advanced lung cancer patients admitted to the oncology department of the lung cancer center between Feb 2016 and Aug 2021, 126 patients participated in this study. Inclusion criteria were having an advanced lung cancer diagnosis defined with a biopsy and willingness to participate in the study. The patients with cognitive impairment and unwillingness to participate in the study were excluded.

2.2 Measures

Symptom checklist (SCL-90-R) scale is a self-statement psychometric questionnaire, including 90 questions and five answer options [14]. The Likert-type scale method signed as 0-1-2-3-4 from “none” to “overmuch” is used in SCL-90-R. Nine dimensions of psychological symptoms, including obsessive-compulsive symptoms, depression, hostility, anxiety, phobic reaction, paranoid delusions, interpersonal sensibility, somatization, and psychoticism are evaluated by the cluster of questions. The additional scales assess feelings of guilt and sleep-eating disorders. General symptoms are defined as psychological symptoms included in SCL-90-R and additional scales. The Positive Symptom Total (PST) and Positive Symptom Distress Index (PSDI) are valuable global indices in revealing the levels of general symptoms. PST is the absolute total number of the questions except those signed with the “0” option. PST indicates how many symptoms an individual perceives. PSDI is the average score obtained by dividing the sum of the questions’ scores (1–4 points) other than those signed as “0” by PST [15, 16]. PSDI measures the intensity of the symptoms. SCL-90-R subscale dimensions, additional scales, PST, and PSDI were used to assess the psychological symptoms in this study.

2.3 Procedure

A face-to-face survey, including questions on age, gender, marital status., employment status, and SCL-90-R assessment was applied to the patients by a specialized nurse in the oncology department. DA was defined as a patient’s knowledge of diagnosis. Awareness was assessed during anamnesis; each patient was asked about comorbidities. Then, awareness was confirmed by a discussion with their relatives. Information on survival time was collected from the national death notification system in Feb 2023. Survival time was calculated as days from admission to the hospital until Feb 2023.

2.4 Endpoint

Diagnosis-aware and diagnosis-unaware patients were compared regarding SCL-90-R subscale dimensions and survival time.

2.5 Statistical analysis

Data analysis was performed by using the IBM SPSS Statistics 24.00 program. Mann-Whitney U test was used to compare the non-normally distributed variables according to the two category variables, and the Chi-square independence test was used to compare two categorical variables. The Spearman correlation coefficient was calculated between continuous variables.

The average age of 126 patients was 62 ± 8.9 (year). Of the patients, 79.4% (n:100) were aware of the diagnosis, 82.5% (n:104) were male, and 68.3% (n:86) were non-survivors. The average of the survival time was 435 ± 407.4 (day) (shown in Table 1).

Table 1

Demographic, diagnostic awareness, and survival information of patients with advanced lung cancer
n = 126		n	%
Age (year)	Mean ± SD	62 ± 8.9
Age (year)	Min-max	41–83
Gender	Male	104	82.5
Gender	Female	22	17.5
Marital status	Married	97	77.0
	Single	12	9.5
	Widowed	17	13.5
Employment status	Employed	70	55.6
Employment status	Unemployed	56	44.4
Diagnostic awareness	Available	100	79.4
Diagnostic awareness	Non-available	26	20.6
Survival	Survivor	40	31.7
Survival	Non-survivor	86	68.3
Survival time (day) n = 86	Mean ± SD	435 ± 407.4
Survival time (day) n = 86	Min-max	2-2717
n: Number of patients, %: Percentage of patients, SD: Standard deviation

Somatization, depression, psychoticism, additional scales, general symptoms, and PST and PSDI scores were significantly higher in diagnosis-unaware patients than in diagnosis-aware patients. (p = 0.00, p = 0.01, p = 0.01, p = 0.00, p = 0.01, p = 0.02, p = 0.01, respectively) (shown in Table 2).

Table 2

Comparison of symptom checklist (SCL-90-R) subscale dimensions between diagnosis-aware and diagnosis-unaware patients with advanced lung cancer
Subscale dimensions	Diagnostic awareness	n	Mean	SD	Rank average	Z	p
Somatization	A	100	0.9	0.8	58.6	-2.937	0.00*
Somatization	NA	26	1.2	0.7	82.2	-2.937	0.00*
Obsessive-compulsive symptoms	A	100	0.6	0.7	60.8	-1.618	0.11
Obsessive-compulsive symptoms	NA	26	0.8	0.7	73.8	-1.618	0.11
Interpersonal sensibility	A	100	0.6	0.8	60.8	-1.655	0.10
Interpersonal sensibility	NA	26	0.8	0.7	74	-1.655	0.10
Depression	A	100	0.7	0.7	58.9	-2.784	0.01*
Depression	NA	26	1.1	0.8	81.2	-2.784	0.01*
Anxiety	A	100	0.5	0.7	61.1	-1.461	0.14
Anxiety	NA	26	0.7	0.6	72.8	-1.461	0.14
Hostility	A	100	0.5	0.7	60.5	-1.819	0.07
Hostility	NA	26	0.9	1	74.9	-1.819	0.07
Phobic reaction	A	100	0.4	0.7	61.7	-1.130	0.26
Phobic reaction	NA	26	0.6	0.8	70.4	-1.130	0.26
Paranoid delusions	A	100	0.5	0.7	61.5	-1.238	0.22
Paranoid delusions	NA	26	0.6	0.7	71.2	-1.238	0.22
Psychotic symptoms	A	100	0.4	0.6	59.4	-2.551	0.01*
Psychotic symptoms	NA	26	0.6	0.6	79.5	-2.551	0.01*
Additional scales	A	100	0.9	0.7	58.7	-2.892	0.00*
Additional scales	NA	26	1.4	0.7	81.9	-2.892	0.00*
General symptoms	A	100	0.6	0.7	59	-2.701	0.01*
General symptoms	NA	26	0.9	0.6	80.7	-2.701	0.01*
PST	A	100	29.4	20.9	59.5	-2.400	0.02*
PST	NA	26	40.1	23.1	78.8	-2.400	0.02*
PSDI	A	100	1.6	0.6	59.1	-2.633	0.01*
PSDI	NA	26	1.9	0.5	80.3	-2.633	0.01*
A: Available, NA: Non-available, SD: Standard deviation, PST: Positive Symptom Total, PSDI: Positive Symptom Distress Index, Z: Mann-Whitney U test, *p < 0.05: Significant value

No significant correlations were found between the survival time and DA, gender, marital status, and employment status in the non-survivor patients (p = 0.12, p = 0.91, p = 0.82, p = 0.10, respectively). A negative and poor association was found between survival time and age (r=-0.262, p = 0.02) (shown in Table 3).

Table 3

Effects of gender, marital status, employment status, diagnostic awareness, and age on survival time of non-survivor advanced lung cancer patients
n = 32		n	Survival time (day)
n = 32		n	Mean	SD	Rank average	Z	p
Gender	Male	72	436.7	418.2	43.4	-0.111	0.91
Gender	Female	14	426.8	360.4	44.2	-0.111	0.91
Marital status	Married	65	425.9	409.8	43.2	-0.226	0.82
Marital status	Single/Widowed	21	463.5	408.3	44.6	-0.226	0.82
Employment status	Available	50	364.6	316.8	39.7	-1.641	0.10
Employment status	Non-available	36	533	495.5	48.7	-1.641	0.10
Diagnostic awareness	Available	66	472.8	434.4	45.8	-1.574	0.12
Diagnostic awareness	Non-available	20	310.7	275	35.8	-1.574	0.12
Age		r= -0.262					0.02*
n: Number of patients, SD: Standard deviation, Z: Mann Whitney U test, r: Spearman correlation, *p < 0.05: Significant value

The main finding was that somatization, depression, psychoticism, additional scales, and general symptoms were less common in patients with DA. The PST and PSDI scores were significantly lower in the diagnosis-aware group. Many studies found associations between DA and lower levels of PD and depression, as supported by this study [17–21]. We consider that DA allows patients to understand the disease and cope with cancer-related stressors. However, the psychological consequences of cancer patients' DA are still a controversial issue today. Some studies reported that DA had no effect on PD, depression, and anxiety levels [22–24]. In contrast, other studies showed correlations between DA and PD, somatization, and anxiety [25–27]. These different outcomes may be related to differences in coping strategies, spirituality, medical care received, and culture.

This study also showed that sleep and eating disorders, psychotic symptoms, and feelings of guilt were more common in diagnosis-unaware patients. We speculate that the relatives of these patients possess some unshared information, vagueness and unrealistic feelings. Also, the relatives’ pretending that everything is normal may increase patients’ psychotic symptoms by contributing to inappropriate reactions, beliefs, perceptions, and predictions. Uncertainties about the disease diagnosis and prognosis lead to more significant PD. Moreover, diagnosis-unaware patients cannot interpret the treatment process, resulting in more significant PD.

Previous studies revealed that lung cancer patients with DA had a longer survival time than patients without DA [28, 29]. In this study, patients with DA insignificantly survived longer than another group. DA increases treatment compliance and enables coping with stressors, which contributes to prolonged survival [30]. Also, DA reduces depression and anxiety rates, which are associated with poor survival [17, 19, 31]. Patients with depression have lower fighting spirit scores, representing one of the essential psychosocial factors for coping with the disease and extending longevity [32].

As perceived financial difficulties increase, the QoL index (including social/economic, health/physical, psychological/spiritual, family, and general function scores) decreases [33]. The decrease in QoL is a critical factor that negatively affects survival. The fact that the mean survival time was higher in the unemployed patients compared to the employed patients (533-day vs 364.6-day, p = 0.10) in our study supported this condition. Patients who did not work presumably had no financial concerns and were more financially secure, allowing more focus on treatment. Accordingly, we suggest that government-funded socioeconomic support would be beneficial for cancer patients. DA will also enable patients to benefit from governmental support.

Hope is not entirely lost when patients accept the fatal nature of the disease [34]. Healthcare professionals can support this hope by answering each patient’s disease-related questions sensitively and honestly. Along with explanations of the diagnosis and treatment, Healthcare professionals should describe the range of possible prognoses (from worst to best) [35]. The number of patients with DA was three-fold higher than patients without DA. This finding showed a more common tendency to disclose the diagnosis to lung cancer patients in Türkiye.

This study has some limitations. DA was assessed during anamnesis; each patient was asked about comorbidities, which were confirmed by discussion with their relatives. Although the overall patient population was large, the number of participants was small due to unwillingness to participate in the study. We considered only DA as the independent variable; however, we could have performed a comprehensive study by considering the prognosis and the final of the disease as independent variables.

This study indicated that DA enabled a low psychosocial burden on patients with advanced lung cancer. In this respect, healthcare professionals should disclose the cancer diagnosis to patients appropriately and openly. Thus, the patient's treatment compliance and the ability to cope with cancer-related stressors increase, resulting in prolonged survival. However, further studies with larger sample sizes are required to confirm these outcomes on this issue.

Ethics Approval and Consent to Participate

This protocol of the study was reviewed and approved by the local Ethics Committee of University of Health Sciences, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital (No: 2020-15). Written consent form was obtained from participants to participate in the study.

Consent for Publication

The authors consented to submission for publication.

Availability of Data and Materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Competing Interests

The authors have no competing interests to declare.

Funding

The funder had no role in the design, data collection, data analysis, and reporting of this study.

Authors’ Contributions

HA conceived and designed the study. HA, STO, YB, and AB collected and processed the data. HA and DD analyzed and interpreted the data. HA searched the literature and wrote the paper. All authors made the critical review and approved the final manuscript.

Acknowledgements

The author(s) thank the oncology nurse, Rana Uslu, for applying the surveys.

Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2021: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49.
Thandra KC, Barsouk A, Saginala K, Aluru JS, Barsouk A. Epidemiology of lung cancer. Contemp Oncol (Pozn). 2021;25(1):45–52.
Tichanek F, Försti A, Hemminki O, Hemminki A, Hemminki K. Survival in Lung Cancer in the Nordic Countries Through A Half Century. Clin Epidemiol. 2023;15:503–10.
Teunissen SC, Wesker W, Kruitwagen C, de Haes HCJM, Voest EE, de Graeff A. Symptom prevalance in patients with incurable cancer: A systematic review. J Pain Symptom Manage. 2007;34(1):94–104.
Nipp RD, Zullig LL, Samsa G, Peppercorn JM, Schrag D, Taylor DH Jr. Identifying cancer patients who alter care or lifestyle due to treatment-related financial distress. Psycho-Oncol. 2016;25(6):719–25.
Riba MB, Donovan KA, Andersen B, Braun I, Breitbart WS, Brewer BW, et al. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(10):1229–49.
Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-Oncol. 2001;10(1):19–28.
Yao J, Novosel M, Bellampalli S, Kapo J, Joseph J, Prsic E. Lung Cancer Supportive Care and Symptom Management. Hematol Oncol Clin North Am. 2023;37(3):609–22.
Mitchell JL. Cross-cultural issues in the disclosure of cancer. Cancer Pract. 1998;6(3):153–60.
Gordon DR, Paci E. Disclosure practices and cultural narratives: understanding concealment and silence around cancer in Tuscany, Italy. Soc Sci Med. 1997;44(10):1433–52.
Younge D, Moreau P, Ezzat A, Gray A. Communicating with cancer patients in Saudi Arabia. Ann N Y Acad Sci. 1997;809:309–16.
Butow PN, Tattersall MH, Goldstein D. Communication with cancer patients in culturally diverse societies. Ann N Y Acad Sci. 1997;809:317–29.
Bozcuk H, Erdoğan V, Eken C, Ciplak E, Samur M, Ozdoğan M, et al. Does awareness of the diagnosis make any difference in quality of life? Determinants of emotional functioning in a group of cancer patients in Turkey. Support Care Cancer. 2002;10(1):51–7.
Reisch T, Vijayananda S, Gekle W, Tschacher W. A qualitative follow-up assessment two years after inpatient crisis intervention. Psychiatr Prax. 2004;31(1):16–22.
Cunha I, Brissos S, Dinis M, Mendes I, Nobre A, Passão V. Comparison between the results of the Symptom Check List 90-R of two different populations with temporal lobe epilepsy. Epilepsy Behav. 2003;4(6):733–39.
Numan N. Exploration of adverse psychological symptoms in Yemeni khat users by the Symptoms Check List-90. Addiction. 2004;99(1):61–5.
Tian X, Tang L, Yi LJ, Qin X-P, Chen G-H, Jiménez-Herrera MF. Mindfulness Affects the Level of Psychological Distress in Patients with Lung Cancer via Illness Perception and Perceived Stress: A Cross-Sectional Survey Study. Front Psychol. 2022;13:857659.
Deenadayalan SK, Balakrishnan K, Chidambaram S. Factors associated with knowledge of diagnosis, prognosis & distress in cancer patients receiving palliative care - A retrospective cohort analysis. Indian J Med Res. 2023;157(6):568–76.
Kállay E, Pintea S, Dégi CL. Does knowledge of diagnosis really affect rates of depression in cancer patients? Psycho-oncol. 2016;25(12):1418–23.
Chittem M, Norman P, Harris PR. Illness representations and psychological distress in Indian patients with cancer: does being aware of one’s cancer diagnosis make a difference? Psycho-oncol. 2015;24(12):1694–700.
Lai C, Luciani M, Galli F, Morelli E, Prete FD, Ginobbi P, et al. Spirituality and Awareness of Diagnoses in Terminally Ill Patients With Cancer. Am J Hosp Palliat Care. 2017;34(6):505–9.
Costantini A, Grassi L, Picardi A, Brunetti S, Caruso R, Nanni MG, et al. Awareness of cancer, satisfaction with care, emotional distress, and adjustment to illness: an Italian multicenter study. Psycho-oncol. 2015;24(9):1088–96.
Chandra PS, Chaturvedi SK, Kumar A, Subbakrishna DK, Channabasavanna SM, Anantha N. Awareness of diagnosis and psychiatric morbidity among cancer patients – a study from South India. J Psychosom Res. 1998;45(3):257–61.
Qian H, Hou L. Psychological impact of revealing a diagnosis of lung cancer to patients in China. J Thorac Dis. 2016;8(10):2879–84.
Arai D, Sato T, Nakachi I, Fujisawa D, Takeuchi M, Sato Y, et al. Longitudinal Assessment of Prognostic Understanding in Patients with Advanced Lung Cancer and Its Association with Their Psychological Distress. Oncologist. 2021;26(12):e2265–73.
Yanwei L, Dongying L, Zhuchen Y, Ling L, Yu Z, Zhanyu P. A double-edged sword: Should stage IV non-small cell lung cancer patients be informed of their cancer diagnosis? Eur J Cancer Care (Engl). 2017;26(6).
Erbil P, Razavi D, Farvacques C, Bilge N, Paesmans P, Houtte PV. Cancer patients psychological adjustment and perception of illness: cultural differences between Belgium and Turkey. Support Care Cancer. 1996;4(6):455–61.
Lee H, Ko HJ, Kim A-S, Kim S-M, Moon H, Choi H-I.. Effect of Prognosis Awareness on the Survival and Quality of Life of Terminally Ill Cancer Patients: A Prospective Cohort Study. Korean J Fam Med. 2020;41(2):91–7.
Su T, He C, Li X, Xiao L, He J, Bai Y, et al. Association between early informed diagnosis and survival time in patients with lung cancer. Psycho-oncol. 2020;29(5):878–85.
Kim J, Roh JK, Yoon JS, Lee SJ, Lee DY. Associations between Depression, Anxiety, Hostility and Fighting Spirit among Cancer Patients in a Cancer Center in Korea. Cancer Res Treat. 2003;35(5):411–8.
Wang YH, Li JQ, Shi JF, Que J-Y, Liu J-J, Lappin JM, et al. Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. Mol Psychiatry. 2020;25(7):1487–99.
Kim J, Roh JK, Yoon JS, Lee SJ, Lee DY. Associations between Depression, Anxiety, Hostility and Fighting Spirit among Cancer Patients in a Cancer Center in Korea. Cancer Res Treat. 2003;35(5):411–8.
Gupta D, Lis CG, Grutsch JF. Perceived cancer-related financial difficulty: implications for patient satisfaction with quality of life in advanced cancer. Support Care Cancer. 2007;15(9):1051–6.
Borneman T, Irish T, Sidhu R, Koczywas M, Cristea M. Death awareness, feelings of uncertainty, and hope in advanced lung cancer patients: can they coexist? Int J Palliat Nurs. 2014;20(6):271–7.
Villalobos M, Siegle A, Hagelskamp L, Jung C, Thomas M. Communication along Milestones in Lung Cancer Patients with Advanced Disease. Oncol Res Treat. 2019;42(1–2):41–6.

No competing interests reported.

Download PDF

Journal Publication

published 13 Oct, 2024

Read the published version in The International Journal of Psychiatry in Medicine →

Version 1

posted

You are reading this latest preprint version

Associations of diagnostic awareness with psychosocial symptoms and survival time in patients with advanced lung cancer

Status:

Journal Publication

Version 1

Abstract

1 Introduction

2 Methods

2.1 Participants

2.2 Measures

2.3 Procedure

2.4 Endpoint

2.5 Statistical analysis

3 Results

4 Discussion

5 Conclusions

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1