Introduction
Cancer treatment has three main modalities, namely
surgery, radiotherapy and chemotherapy. The chemotherapy
is an intense and a cyclic treatment and has
many side effects, such as hair loss, nausea, vomiting,
loss of appetite, diare and immunsuppression. Long treatment periods, recurrent hospitalizations, and the
side effects of chemotherapy, in addition to the knowledge
of cancer, affect the psyche of the patients.
Depression and anxiety affect 20% and 10% of the
cancer patients receiving curative or palliative treatment,
respectively.[] Two-thirds of patients with cancer
and depression also have clinically significant anxiety.[] Depression rates vary according to the type of
cancer. Lung cancer (13%), gynecologic cancer (11%),
breast cancer (9%), colorectal cancer (7%) and genitourinary
system cancer (6%) are the most common.
[] The highest levels of anxiety are reported in lung,
gynecologic and hematological cancers.[] This difference
between types of cancer is thought to be related
to the prognosis of patients, pain levels and body image
changes, in addition to disease-specific neuropsychiatric
effects and treatment-related neuropsychiatric
side effects.[]
Pain is one of the symptoms that negatively affect
the quality of life in cancer patients and causes the
patient to develop secondary problems concerning
physical, psychological and sociological aspects. The
pain leads to negative effects not only on the patient
but also on the close environment. In the recognition
and treatment of pain, it is necessary to consider the
emotional, cognitive and behavioral dimensions, as
well as the perceptual aspect. Pain may sometimes be
a symptom of a psychiatric disorder, and sometimes as
a physical disorder leads to a disorder in the person's
spiritual world. Although the factors involved in the
occurrence of pain are largely similar in most people, it
is noteworthy that past experiences, social and psychological
factors determine the response to pain and vary
considerably between individuals.
Anxiety symptoms, such as motor tension, persistent
danger and immediate startle, displeasure and
fearful waiting, are common in painful patients. Therefore,
it should be considered that psychological factors
play an important role in pain severity and continuity
in individuals with cancer pain.[]
Illness perception was proposed to be one of the
significant causes of psychological distress in cancer
patients in the early follow-up period.[] However,
few researchers have examined the relationship between
patients" illness and treatment beliefs or causal
attributions of symptoms and distress during the
treatment phase in cancer patients. In one study, it
was reported that distress during the treatment phase
was associated with more negative illness beliefs and
a likelihood of reporting more severe side effects.[]
However, cancer differs from other chronic illnesses
in that its treatment often produces more symptoms
than does the illness itself. In this study, we aimed to
investigate the effects of illness perception on anxiety
and depression in cancer patients receiving chemotherapy
treatment.
Methods
Sample and Settings
This study was conducted at a single center-Gaziantep
University Faculty of Medicine, Oncology Hospital.
The protocol and informed consent documentation
were reviewed and approved by the Independent
Ethics Committee of the University and agreed with
the ethical principles of the Declaration of Helsinki. In
total, 182 patients who were receiving chemotherapy
in our hospital between March 1, 2019, and March 31,
2019, were included in this cross-sectional study. The
inclusion criteria for the patients were as follows: (1) 18
years and over (2) having a histopathologically proven
cancer diagnosis (3) receiving intravenous chemotherapy
and (4) no obvious mental abnormalities, psychological
disorder, and cognitive impairment. The
exclusion criteria were as follows: (1) have not agreed
to participate in this study and (2) non-communicable
patients. The following information was recorded: age,
gender, marital status, educational level, working status,
diagnosis of cancer subtype and disease stage.
Study Measures
Participants completed a standardized questionnaire
assessing the socio-demographic factors, degree of
pain, anxiety and depression, and illness perception.
Thus, the following measures were used:
Socio-Demographic Characteristics
We developed the socio-demographic and medical
questionnaire to assess general information (e.g. age,
gender, education level and employment status), personal
information about patient"s relationships with
their partners (e.g. marital status), and general information
about their cancer diagnosis (e.g. type of diagnosis,
disease"s stage).
Visual Analogue Scale (VAS): The VAS was a
straight horizontal, 10 cm line and was anchored on
the left with "no pain" and on the right with "pain as
bad as it could be." The patient reported pain intensity
by drawing a vertical mark at the appropriate interval
on the horizontal line. The pain intensity score was determined
by measuring the distance, in millimeters,
from the left side of the line to the place marked by the
patient. The VAS is considered to be one of the beststudied
pain intensity scales concerning validity, reliability,
and sensitivity.[]
The Hospital Anxiety and Depression Scale
(HADS): HADS was developed in 1983 by Zigmond et
al.[9] HADS is a 14-item scale which is divided into two dimensions-anxiety (seven items-question 1, 3, 5,
7, 9, 11, 13) and depression (seven items-question-2,
4, 6, 8, 10, 12, 14). The items are scored from 0 to 3,
with higher scores indicating greater levels of anxiety
and depression. The scale distinguishes between probable
and possible pathology-a score of between 0 and 7
indicates normal situation, 8 and 10 indicates possible
pathology (borderline), and a score between 11 and 21
indicates probable pathology (abnormally). The HADS
has been validated among a population of people with
cancer [] and is the most frequently used screening
tool for psychological distress in cancer care. In our
study, we used the Turkish version, which was adapted
by Aydemir et al.[]
Illness Perception: This was assessed using the
Brief Illness Perception Questionnaire (B-IPQ). It is
an eight-item instrument assessing cognitive and emotional
perceptions of the illness, and in addition, nineth
item is the casual item, which asks patients to list the
three most important cancer-causing factors.[] The
questions were related to the following aspects: (i)
consequences (how much does your illness affect your
life?); (ii) timeline (how long do you think your illness
will continue?); (iii) personal control (how much control
do you feel you have over your illness?); (iv) treatment
control (how much do you think your treatment
can help your illness?); (v) identity (how much do you
experience symptoms from your illness?); (vi) concern
(how concerned are you about your illness?); (vii) coherence
(how well do you feel you understand your
illness?); and (viii) emotions (how much does your illness
affect you emotionally?). Each question is rated on
a linear 0-10 point scale. Higher scores indicate more
negative illness representations, except for questions 3,
4, and 7; higher scores indicate more positive illness
perception. Differently, ninth item responses can be
grouped into categories, such as stress, lifestyle, hereditary,
determined by the particular illness studied. Categorical
analysis can then be performed, either on just
the top listed cause or all three listed causes. We used
the Turkish version of the questionnaire form.[]
Statistic Analysis
In the analysis of the data, descriptive statistics were
used for demographic variables. The conformity of the
variables to the normal distribution was examined by
Kolmogorov-Smirnov and Shapiro Wilk tests and it
was determined that all variables were not distributed
normally. The Mann-Whitney U test was used to compare
the two groups and Kruskal-Wallis analysis was
used for three or more groups. Spearman correlation analysis was used for the correlation between variables.
The strength of agreement is evaluated by correlation
coefficient (<0.00 is poor; 0.00-0.20 is slight, 0.21-0.40
is fair, 0.41-0.60 is moderate, 0.61-0.80 is substantial,
0.81-1.00 is almost perfect). A p-value<0.05 was
considered to indicate statistical significant. Statistical
analysis was performed using SPSS 22.0 software
(SPSS, Chicago, IL, USA).
Results
A total of 182 patients involved in this study. The demographic
and clinical characteristics of the participants
are shown in Table 1. The mean age was 53.57 years
(range, 22-87 years). There were 103 (56.59%) female
and 79 (43.41%) male patients. At the time of the interview,
the majority of patients were married (n=152,
83.52%). Their educational levels were low (81.3% were
illiterate or primary school level). All patients were receiving
intravenous chemotherapy. The majority of the
patients had metastatic stage disease (n=116, 63.74%).
Six of the patients were working. Breast and gastrointestinal
tract cancer were the dominant diagnosis
(n=55, 30.22%; n=51, 28.02%). With scores of 8 or
above, we found that 51.1% of the sample to have possible
clinical levels of anxiety, and 52.2% had possible
clinical levels of depression (Table 1). According to the
possible and probable distinction of clinical pathology,
the present sample had possible clinical levels of anxiety
and depression of 25.3% and 26.4%, respectively,
and probable clinical levels of anxiety and depression
of 25.8% for both.
Table 1: Demographic and clinical characteristics of the
patients (n=182)
Table 2 was described as the VAS, positive and negative
illness perception, anxiety and depression scores.
The mean VAS scores were 3.6 (range, 0-10). According
to B-IPQ, the mean positive IPQ scores were 21.02
(range, 7-30), negative IPQ scores were 27.29 (range,
0-50). The mean anxiety scores were 7.87 (range, 0-19),
while for the depression, it was 7.96 (range, 0-20). As
the educational level of the patients decreased, anxiety
and depression scores increased (p=0.019, p=0.003; respectively).
While anxiety scores were high in female
gender patients, there were no differences in depression
scores (p=0.009, p=0.062). There was no difference
in anxiety and depression in terms of marital status,
disease stage and diagnostic subgroups. According
to VAS analyses, there was no correlation between VAS
scores and education level, marital status, diagnosis
subgroup and disease stage. VAS score was higher in
the female patients (p=0.001). Patients with low education
levels and the metastatic stage had a higher rate of negative illness perception (p=0.006, p=0.032, respectively)
(Table 3).
Table 2: The pain visual analogue scale (VAS), positive and negative illness perception, anxiety and depression scores
Table 3: Association of the demographic and clinical characteristics of the patients with visual analogue scale (VAS), positive
and negative illness perception, anxiety and depression scores
Positive illness perception parameters, such as (i)
personal control (question 3-how much control do
you feel you have over your illness?) and (ii) treatment
control (question 4-how much do you think your treatment
can help your illness?), were both not correlated
with anxiety scores (p=0.120, p=0.070, respectively).
According to the evaluation of depression scores, personal
control was negatively correlated (p<0.005) and
no relation was found with treatment control (p=0.062). The mean score of coherence, which is a parameter of
positive illness perception, was 7.51 (0 to 10). Coherence
was not correlated with anxiety and depression
scores. In contrast, the following were positively correlated
with anxiety and depression scores (p<0.005,
for all): negative illness perception as (i) consequences
(question 1-how much does your illness affect your
life?), (ii) timeline (question 2-how long do you think
your illness will continue?), (iii) identity (question
5-how much do you experience symptoms from your
illness?), (iv) concern (question 6-how concerned are
you about your illness?), and (v) emotions (question
8-how much does your illness affect you emotionally?).
VAS was positively correlated with negative illness perception
(p<0.005, for all) and was not correlated with
positive illness perception (Table 4).
Table 4: Correlation of Brief Illness Perception Questionnaire (B-IPQ), Visual Analoge Scale (VAS) with anxiety and depression
score: Spearman's rho correlation test
Discussion
The objective of cancer treatment is to cure cancer, prolong
life when cure is not possible, and give palliation.
The overall impact of chemotherapy on cancer survival
can be difficult to estimate since improved cancer
screening, prevention strategies, and detection all
influence statistics on cancer incidence and mortality.
Although chemotherapy may prolong survival modestly
in advanced cancer [], conventional cytotoxic
chemotherapy has proven unable to cure most cancers
after they have metastasized. Cancer and its treatment
may have a severe impact on individuals, affecting all
areas of functioning, causing a variety of problems and
affecting various quality of life (QOL) issues. In this
study, we aimed to examine the correlation between
illness perception, pain and distress during chemotherapy
treatment in cancer patients.
Patients may experience anxiety and depression due
to the negative effects of cancer and treatment. In this
case, the individual's level of perception decreases, his/
her ability to share emotions and coping strategies decreases,
social interaction and social support becomes
difficult, patients" fighting power decreases and treatment
response deteriorates over time. In one study, it
was stated that the long duration and uncontrollable
side effects of chemotherapy treatment increased the
level of anxiety and depression and adversely affected
the quality of life.[]
The demographic characteristics of the patients are
associated with anxiety and depression. In one study,
it was reported that female patients had higher levels
of anxiety than male patients.[] In our study, the female
sex anxiety rate was high (p=0.009). Depression was not statistically significant concerning gender
(p=0.062). Regarding social support, the likelihood of
being married had a positive effect on anxiety and depression.
In our study, although the scoring was higher
in the unmarried group than married group (anxiety:
8.53±5.06 versus 7.74±4.21, depression: 8.87±3.96 versus
7.78±4.48), no statistically significant difference
was found (p=0.543, p=0.136, respectively).
The level of education was also an important factor.
In one study, patients with low-level education had
a higher prevalence of depression than patients with
over six years of education (p<0.001).[] In our study,
anxiety and depression rates were higher in the illiterate
group (anxiety: 8.81±4.52, depression: 9.28±4.35) and statistically significant differences were found
(p=0.019, p=0.003, respectively).
Unlike other studies [,], the present study failed
to the difference in anxiety and depression depending
on the type of cancer. Failing to see differences in the
type of cancer in our study was surprising but might
be explained by the variability within the sample, representing
diverse types of cancer resulting in few cases
behind each group.
The prevalence rates of depression/anxiety may be
different in patients with different tumor sites. Some
researchers have suggested that patients with breast
and lung cancers have a high risk of depression.[]
Symptoms of depression were found to occur in 3-55% of the breast cancer patients, while anxiety was found
in 18-33%.[] In another study, the depression prevalence
was high in lung, esophagus and cervix cancer.
[17] In our study, the patients with breast and female
genitourinary tract cancers had a high risk of anxiety
and depression scores. This result may be due to the
concern of women"s sexuality loss of function.
Disease stage was not influenced neither anxiety
(p=0.742) nor depression (p=0.582). Most of the patients
did not know their disease stages, which may explain
that anxiety and depression were not influenced
by the disease stage because information about patients"
disease stage was obtained from their medical records.
The pain is affected by the individual"s life experiences.
People with negative thoughts about cancer pain
may have more severe pain. Emotional reactions occur
due to social isolation. All these changes result in increased
stress levels, tension, anger and pain.[] In our
study, only gender differences were found concerning
demographic characteristics and pain (p=0.001). Pain
scores were higher in patients with anxiety and depression
scores of 11 and more (Mean score 5.13±3.17,
4.89±2.98, respectively, for both p=0.001).
Illness perception has been linked to depressive
symptoms. In a sample of colorectal cancer patients, the
authors found that individuals who attributed a higher
number of symptoms to their illness (identity), held
more negative beliefs regarding the timeline of their
illness, endorsed more perceived consequences, and reported
lower treatment control were at increased risk
for depressive symptoms. Similar relationships between
illness perception and depressive symptoms have been
documented in advanced cancer patients.[] In another
study with breast cancer patients, the illness perception had a significant effect on anxiety and depression.[]
We found the same correlation in our study. Patients
who had a lower positive illness perception exhibited
more anxiety and depression. Coherence, one of the
positive illness perception items, was a generally high
score in our patient (7.51±3.06). When the patients felt
that they understood their illness sufficiently, they gave
a high score, which means the sense of positive disease
as in personal and treatment control. Understanding
the disease is important to cope with the disease. In
our study, there was no significant correlation between
coherence and anxiety and depression. This may be related
to our precision to provide information that leads
to understanding their illnesses at a high level. As a
different situation, patients with higher negative illness
perception scores showed higher anxiety and depression
scores. In this context, it was found that the illness
perception in patients receiving chemotherapy had a
significant effect on anxiety and depression.
Our study has several limitations. First, this study
was designed the cross-sectionally, and for this reason,
the cancer patients were seen at one point in time. Second,
the mixed convenience sample was included in
this study, and there was a variety of cancer diagnoses.
This could be problematic because cancer encompasses
a diverse array of illnesses with the particular difficulties
patients face varying across cancer sites. Third, the
majority of patients had a low educational level. Thus,
we cannot generalize the findings obtained in this study.
Conclusion
Anxiety and depression were strongly associated with
illness perception, pain and educational level in cancer patients during chemotherapy treatment. Oncologists
and chemotherapy nurses should pay more attentive to
the signs and symptoms of anxiety and depression and
offer specific supportive therapy to each patient.
Peer-review:Externally peer-reviewed.
Conflict of Interest: The authors declare that they have no
conflict of interest.
Ethics Committee Approval: The protocol and informed
consent documentation were reviewed and approved by the
Independent Ethics Committee of the University and agreed
with the ethical principles of the Declaration of Helsinki.
Financial Support: Financial and material support was not
recevied.
Authorship contributions: Concept - H.Y.Ç., G.E.; Design
- H.Y.Ç., G.E.; Supervision - H.Y.Ç., G.E.; Funding - H.Y.Ç.;
Materials ? H.Y.Ç.; Data collection and/or processing - H.Y.Ç.;
Data analysis and/or interpretation - H.Y.Ç.; Literature search
- H.Y.Ç.; Writing - H.Y.Ç.; Critical review - H.Y.Ç., G.E.
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