Introduction
Palliative radiotherapy (RT) has been utilized as an
effective and standard treatment modality to reduce
symptoms for locally advanced and metastatic cancer
disease since the 1900s. Palliative RT provides pain relief,
hemostasis for bleeding tumoral lesions, amelioration
of obstructive symptoms, or recovery of neurological
symptoms due to tumors in any site of the body.[]
Various recent studies have focused on patients with
incurable cancer who have palliative RT in their final
months.[-]
The previous studies reported the incidence of adjustment
disorder, anxiety, and depression in cancer
patients as 40?50%.[-] These disorders may cause
social isolation, treatment compliance disorder, long
rehabilitation period, suicide risk, impairment in quality
of life (QoL), and even shorter survival in oncology
patients.[,] Thus, the evaluation of patients in terms
of any psychosocial morbidity should be a step of palliative
care that should not be missed.
Negative expectations about something important
and an inability to change the likelihood of that
outcome bring out feelings of helplessness and hopelessness.
Patients diagnosed with cancer may experience
these emotions severely due to the disease"s
unpredictable nature. In addition, these patients often
suffer from increased pessimism while they lose
their ability to look ahead due to the uncertainty of
their future.
Hopelessness is a common psychological symptom
in cancer patients, such as depression and impaired
QoL.[,] Cancer patients with depression and high
hopelessness have an increased risk of suicide.[,]
Although death is an inevitable reality, it is denied
by many people. Cancer patients who are faced with
came up against the disease and treatment processes
can focus on death. Death anxiety is a state of worry
and panic that arise as a consequence of expectancy
of death and a sense of regret for not being able
to accomplish objectives.[] Advanced stage cancer
patients may have distressed thoughts about death,
fear of death, and suffering among these patients may
be as high as 80%.[] Psycho-oncologists have defined
the situation of patients who are aware of the
deterioration in their health status while trying to arrest
of their lives in the best possible way as "double
awareness."[]
Loneliness is an essential part of QoL and is defined
as "an unpleasant experience that occurs when a person's
network of relationships is felt to be deficient in some important way."[] Although social isolation
and loneliness are thought to be related, they are separate
concepts.[] A socially isolated person may not
feel lonely, or someone with adequate social support
may still feel lonely. Social isolation can be defined as a
lack of relationships; however, loneliness is a subjective
and negative experience.[]
This study aimed to investigate death anxiety, hopelessness,
and loneliness levels of distant metastatic
cancer patients who underwent palliative RT in the radiation
oncology department (ROD). The relation between
QoL and death anxiety, hopelessness, and loneliness
levels was also evaluated. In addition, possible
predisposing characteristics of patients for high levels
of death anxiety, hopelessness, and loneliness were investigated.
Methods
Study Population
The target population of this study was the cancer patients
who are suffering from distant metastatic malignancies
and who received treatment in a palliative
intent in the ROD of our institute. Among these patients,
the ones with performance status of ECOG 0-3
and literate were offered to participate in this study. Informed
consent was obtained from all participants. All
patients were receiving palliative RT targeting primary
tumor site or metastatic lesions due to pain, bleeding,
or compression symptoms. RT was delivered with
6-18 MV X-rays, using three-dimensional conformal
RT technique, in 10 fractions, to a total dose of 30 Gy.
In addition to age, gender, education, marital status,
housing, and caregiver information, clinical data such
as primary site, stage, date of diagnosis, previous treatments,
and current height-weight information of each
patient were recorded on a special follow-up form by
the radiation oncologist.
Scales
The scales are provided printed for each patient, and
they were allowed to fill out the forms in a sufficient
time. A psychiatrist from our institute assessed the
filled scales.
The Medical Outcomes Study 36-Item Short-Form
(SF-36)
It is a health screening form widely utilizing for evaluating
QoL in clinical practice and research. It was developed
in 1992,[] and the validity and reliability of
the Turkish version of SF-36 were studied by Kocyigit et al.[] The form consists of eight health concepts:
Physical functioning (10 items), bodily pain (2 items),
role limitations due to physical health problems (4
items), role limitations due to personal or emotional
problems (4 items), emotional well-being (5 items),
social functioning (2 items), energy/fatigue (4 items),
and general health perceptions (5 items). Scores for
each domain range from 0 to 100; the lowest score represents
the worst health condition.
Templer"s Death Anxiety Scale (TDS)
There are 15 questions answered as "yes" or "no" in
the form. It was developed in 1970.[] Scores of 7
and above indicate death anxiety. The validity and reliability
of the Turkish version of TDS were reported
by Ertufan.[]
Beck Hopelessness Scale (BHS)
It is a 20-item, true or false questionnaire designed
to quantify hopes for the future.[] The validity and
reliability of the Turkish version of BHS were studied
by Seber et al.[] The BHS scores range from 0 to 20,
and higher scores indicate greater levels of hopelessness
which is categorized as minimal (0-3), mild (4-8),
moderate (9-14), and severe (≥15).
University of California, Los Angeles Loneliness
Scale (ULS)
It has a 4-point Likert-type rating with a total of 20
items and was developed by Russell et al. in 1980.[]
The validity and reliability of the Turkish version of
ULS were studied by Demir.[] Scores are categorized
as low (20-34), moderate (35-48), and high (≥49).
Higher scores indicating higher levels of loneliness.
Statistical Analysis and Ethical Considerations
The categorical characteristics of the patients were
presented with numbers and percentages, whereas
the continuous characteristics were presented with
median (minimum-maximum) due to the non-parametric
distribution. The scale scores were evaluated
with Kolmogorov-Smirnov and Shapiro-Wilk
normality tests and presented with mean±standard
deviation. The correlations between scale scores in
each other and other continuous variables were evaluated
with the Pearson test. The score means were
compared with independent samples t-test between
two groups. The median scores in the three groups
were compared with the Kruskal-Wallis test. An
overall 5% type-I error level was used to infer statistical
significance.
The protocol of the present study was reviewed
and approved by the Institutional Human Research
Ethics Committee (protocol no.: 379?23/12/2019).
All procedures were performed in terms of the ethical
standards of the Institutional Research Committee
in alliance with the 1964 Helsinki Declaration and its
later amendments.
Results
Patient Characteristics
Thirty-three (82.5%) male and 7 (17.5%) female patients
were involved in the study. The median age of
all patients was 60 (43-87). More than half of the patients
(52.5%) were diagnosed with lung cancer. Sixteen
(40%) patients did not have metastatic disease
at the time of diagnosis, but then with a progressive
disease, all had at least one metastatic site at the time
of the study. Ten (25%) patients were treatment naïve
when they were consulted for palliative RT. Between
diagnosis and palliative RT, the median time was 9.6
(0.26-72.57) months. The sites that were treated with
palliative RT were 18 (45%) bone metastasis, 14 (35%)
brain metastasis, 7 (17.5%) lung tumor, and 1(2.5%)
rectum tumor. The sociodemographic features (marital
status, number of kids, educational status, housing,
and caregiver), BMI, performance status, chronic
disease, or psychiatric drug use information of all patients
are given in Table 1. The BMI profiles of the
patients were as follows: 3 (7.5%) patients under 20,
19 (47.5%) patients between 20 and 24.9, 11 (27.5%)
patients between 25 and 29.9, and 7 (17.5%) patients
over or equal to 30.
Table 1 The sociodemographic and clinical characteristics
of the patients
Scale Results
The mean scores of SF-36, TDS, BHS, and ULS are
shown in Table 2. Eighteen (45%) patients had a
high death anxiety score (≥7). According to BHS,
11(27.5%) patients had moderate, and 13 (32.5%) patients
had mild hopelessness where no patients with
severe scores were recorded. More than half of the patients
(57.5%) had moderate and 6 (15%) patients had
high ULS scores.
Table 2 The mean scores of short-form 36 sub-concepts,
Templer"s Death Anxiety Scale, Beck Hopelessness
Scale, and UCLA Loneliness Scale
We evaluated the relations of SF-36 results with
TDS, ULS, and BHS. Remarkable correlations were
detected, which are shown in detail in Table 3. TDS,
BHS, and ULS scores were positively correlated with
each other which was statistically significant (p=0.006,
p=0.001, and p<0.001). All of the scale scores were negatively
correlated with emotional well-being (p=0.001
and p<0.001) and general health perceptions (p=0.038 and p<0.001) which were also statistically significant.
Only the ULS score was negatively correlated with
physical functioning (p=0.007). TDS and ULS scores
were negatively correlated with role limitations due to
physical health problems (p=0.039 and p=0.035) and
social functioning (p=0.015 and p=0.043). BHS and
ULS scores were negatively correlated with energy/fatigue
level (p<0.001 and p=0.001). Only BHS score was
negatively correlated with bodily pain level (p=0.010).
Table 3 The correlations between TDS, BHS, ULS, SF-36 scores, and continuous variables of the patients
A statistically significant positive correlation was
detected between educational status and ULS score
(correlation coefficient=0.351, p=0.026). The median
scores of ULS for primary school, high school, and
college graduated patients were 38 (20-57), 43 (26-55),
and 46 (45-55), respectively (p=0.046) (Fig. 1a).
Fig. 1. (a) UCLA loneliness scale (ULS) box plot for
education level. The median scores of ULS for
primary school, high school, and college graduated
patients were 38 (20-57), 43 (26-55), and
46 (45-55), respectively (p=0.046). (b) Templer"s
death anxiety scale (TDS) box plot for gender.
The mean TDS scores of males are 7.42±3.88 and
of females are 4.43±2.87 (p=0.030). (c) TDS box
plot for ECOG performance status. The median
TDS scores of ECOG 1, 2, and 3 patients were 6
(4-14), 4.5 (1-11), and 9.5 (3-15) (p=0.034).
ECOG: Eastern Cooperative Oncology Group.
The mean TDS scores were statistically significantly
different between male and female patients. It
was higher in male patients (7.42±3.88 vs. 4.43±2.87,
p=0.030). Furthermore, the median TDS scores was
higher in the ECOG 3 group (p=0.034) (Fig. 1b, c). The
median TDS scores of ECOG 1, 2, and 3 patients were
6 (4-14), 4.5 (1-11), and 9.5 (3-15).
BMI was the only clinical feature with a statistically
significant negative correlation with TDS, BHS, and
ULS scores (p=0.007, p=0.025, and p=0.020). As a result
of the comparison of scale scores between patients
whose BMI <26 and ≥26, higher TDS, BHS, and ULS
scores were observed in the BMI <26 group (p=0.046,
p=0.033, and p=0.024) (Table 4).
Table 4 The comparison of scale results of patients with
body mass index below and above 26
Discussion
A total of 40 advanced cancer patients" data were evaluated
in the present study. About 45% of patients had high
death anxiety, 27.5% had moderate hopelessness, 32.5%
had mild hopelessness, 57.5% had moderate loneliness,
and 15% had high loneliness. Increasing death anxiety,
hopelessness, and loneliness were all associated with
poorer QoL. The predisposing factors of death anxiety
were male gender and poor ECOG performance status,
while higher education level was the only factor related to
loneliness. The negative correlation of BMI with all scores
was remarkable. BMI was not investigated as a factor in
previous similar studies to the best of our knowledge.
Through the current multimodal treatment methods,
it has become possible to achieve extended survival times in metastatic cancer patients. With prolonged
survival, the QoL of patients becomes an even
more remarkable issue. The median overall survival
(mOS) varies according to the primary cancer site.
While the mOS was reported up to 57 months for
metastatic prostate cancer and 41.8 months for breast
cancer, it is limited to 30 months for lung and colorectal
cancers.[-] The majority of the patients in
the present study were lung, prostate, and colorectal
cancer patients.
In a meta-analysis,[] 13 studies that evaluate
loneliness among cancer patients by ULS were reviewed,
and the mean score was reported as 38.26,
corresponding to moderate loneliness, which was in
line with our result (39.1). This meta-analysis also argued
that the level of loneliness increased over time after cancer diagnosis and that the lack of social support
was associated with loneliness.[] On the contrary,
our results did not reveal any relationship between the
time from diagnosis and the level of loneliness. This
result may be attributed to the target population in
the meta-analysis, which includes all stages unlike our
study evaluating only metastatic patients treated with
palliative intent. The only variable we found to have
a statistically significant association with loneliness in
the present study was educational attainment in the
present study. Similarly, Avci and Kumcagiz[] also
detected that the level of loneliness increased with the
increase in education level in their study with breast
cancer patients, although this was not statistically significant
(p=0.085). In the study of Boer et al.,[] in
which they evaluated the link between QoL and loneliness
in cancer patients, social functioning, emotional
limitations, mental health, and vitality were found
significantly related to loneliness level (p<0.001 for
all). These results were in line with our study. The additional
correlation of physical functioning, physical
limitations, and general health with the ULS score in
the present study can be attributed to the sample consisting
of metastatic patients only.
The present study's findings indicated that individuals
diagnosed with various forms of cancer, most of
whom were men, experienced more death anxiety. The
fact that the majority of our sample was composed of
men may have contributed to this finding. Other studies
from Eastern countries have revealed that women
experience more death anxiety than males among cancer
patients.[,] However, it is also reported that
men are more likely to contemplate death than women.
[] According to a meta-analysis encompassing 22
studies and 2474 individuals, the estimated pooled
mean for death anxiety in cancer patients was 6.84 (CI
95%: 5.98, 7.69). It has been shown that the type of cancer,
gender, marital status, and geographic location all
influence death fear. Death anxiety rates vary according to cultural norms, religiosity, an individual's access
to medical care, and regional disparities in health systems.[] Similar to our study, a study investigating
the relationship between death anxiety and QoL in advanced
cancer patients was reported from Canada. The
study evaluated death anxiety by the Death and Dying
Distress Scale, which they developed, and social, functional,
physical, and emotional well-being by the 46-
item Functional Assessment of Chronic Illness Therapy-
Palliative Care scale. They found that functional,
physical, and emotional well-being were negatively
correlated with death anxiety.[]
In some prior research, hopelessness was associated
with an increased risk of incidence and mortality
of serious illnesses such as myocardial infarction and
cancer.[] There is a study with a 10-year follow-up
period reporting that helplessness and hopelessness are
effective in disease-free survival in patients with breast
cancer.[] Gustavsson-Lilius et al. found considerable
gender differences in their study of 155 cancer patients
in which they investigated the effects of optimism,
hopelessness, and partner support on QoL. Female
patients" optimistic assessments were connected with
high levels of partner support, and together they predicted
improved QoL. For male patients, a low level of
hopelessness was the primary predictor of good QoL.
[] In our study, hopelessness levels did not differ
between genders or according to other sociodemographic
features. The hopelessness level was lower only
in patients with BMI <26. The effect of hopelessness on
QoL was demonstrated by its negative correlation with
energy/fatigue, general health perceptions, bodily pain,
and emotional well-being scores.
Another remarkable finding of our study was that
individuals with a lower BMI were more likely to suffer
from death anxiety, hopelessness, and loneliness. Just
a few research studies examine the psychological distress
experienced by cancer patients who have a low
BMI. Weight loss in cancer patients may occur due to
the clinical course of the disease, treatment side effects,
as well as psychological distress. In addition, low BMI
in individuals with advanced cancer may predispose
them to psychological problems. Negative feelings
about body image may serve as a reminder to cancer
patients of their impending demise. The perceived
threat can trigger fear reactions. Cachexia is connected
with increased despair and anxiety, as well as a worse
QoL among cancer patients.[,]
Symptom control may occur weeks to months after
the completion of palliative RT. Thus, patients who will
be offered palliative RT should be carefully selected.
Considering the side effects of RT, palliative RT may
not be indicated in patients with poor performance,
whose informed consent cannot be obtained, and
transportation is not possible, who have multiple progressive
diseases, and who have a short life expectancy.
[] In the light of these criteria, patients with a performance
status of ECOG 0-3 and literate patients were
included in our study. The results indicated that the
patients with ECOG 3 performance status had higher
levels of death anxiety than ECOG 0-2 patients.
In advanced cancer patients, sociodemographic
characteristics and psychological characteristics of the
patient may predispose to hopelessness, depression, the
desire for hastened death, and physical distress due to the
disease. Patients requiring particular intervention can be
identified by evaluating the patient in terms of these factors.
The stress chain can be prevented by interventions
to protect the sense of meaning and hope in these individuals
and strengthen their self-esteem.[,-]
When assessing the results of our study, it should be
considered that this is a single-center study with a limited
number of patients. If it had been planned as a multicenter
study, it would have been considered that regional
sociocultural features might not have affected the results.
Conclusion
More than half of the palliative RT patients suffer
from hopelessness, loneliness, and death anxiety. This
circumstance is related to poorer QoL. The levels of
hopelessness, loneliness, and death anxiety were statistically
significantly higher in patients with BMI <26.
Advanced cancer patients must be evaluated about
psychological symptoms and supported if needed to
improve QoL and palliative care.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by
the Süleyman Demirel University Faculty of Medicine Clinical
Research Ethics Committee (No: 379, Date: 23/12/2019).
Financial Support: None declared.
Authorship contributions: Concept - Z.A.K., G.Ö.Ü.; Design
- Z.A.K., G.Ö.Ü.; Supervision - Z.A.K., G.Ö.Ü.; Funding
- Z.A.K., G.Ö.Ü., E.E.Ö.; Materials - Z.A.K., G.Ö.Ü.;
Data collection and/or processing - Z.A.K., G.Ö.Ü.; Data
analysis and/or interpretation - Z.A.K., G.Ö.Ü.; Literature
search - Z.A.K., G.Ö.Ü.; Writing - Z.A.K., G.Ö.Ü.; Critical
review - Z.A.K., G.Ö.Ü., E.E.Ö.
References
Jones J. A brief history of palliative radiation oncology.
In: Lutz S, Chow E, Hoskin P, editors. Radiation Oncology
in Palliative Cancer Care. 1st ed. Hoboken, NJ:
Wiley-Blackwell; 2013. p. 3-14.
Kapadia NS, Mamet R, Zornosa C, Niland JC, D"Amico
TA, Hayman JA. Radiation therapy at the end of life
in patients with incurable nonsmall cell lung cancer.
Cancer 2012;118(17):4339-45.
Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz
TA, Shih YC. Use of radiation therapy in the last
30 days of life among a large population-based cohort
of elderly patients in the United States. J Clin Oncol
2013;31(1):80-7.
Toole M, Lutz S, Johnstone PA. Radiation oncology
quality: aggressiveness of cancer care near the end of
life. J Am Coll Radiol 2012;9(3):199-202.
Grassi L, Gritti P, Rigatelli M, Gala C. Psychosocial
problems secondary to cancer: an Italian multicentre
survey of consultation-liaison psychiatry in oncology.
Italian Consultation-Liaison Group. Eur J Cancer
2000;36(5):579-85.
Kissane DW, Grabsch B, Love A, Clarke DM, Bloch S,
Smith GC. Psychiatric disorder in women with early
stage and advanced breast cancer: a comparative analysis.
Aust N Z J Psychiatry 2004;38(5):320-6.
Singer S, Szalai C, Briest S, Brown A, Dietz A, Einenkel
J, et al. Co-morbid mental health conditions in cancer
patients at working age--prevalence, risk profiles, and
care uptake. Psychooncology 2013;22(10):2291-7.
Mitchell AJ, Meader N, Davies E, Clover K, Carter GL,
Loscalzo MJ, et al. Meta-analysis of screening and case
finding tools for depression in cancer: evidence based
recommendations for clinical practice on behalf of the
Depression in Cancer Care consensus group. J Affect
Disord 2012;140(2):149-60.
Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L,
Johansen C, et al. Prevalence of depression, anxiety,
and adjustment disorder in oncological, haematological,
and palliative-care settings: a meta-analysis
of 94 interview-based studies. The Lancet Oncol
2011;12(2):160-74.
Götze H, Brähler E, Gansera L, Polze N, Köhler N.
Psychological distress and quality of life of palliative
cancer patients and their caring relatives during home
care. Support Care Cancer 2014;22(10):2775-82.
Mystakidou K, Tsilika E, Parpa E, Pathiaki M,
Galanos A, Galanos A, et al. The relationship between
quality of life and levels of hopelessness
and depression in palliative care. Depress Anxiety
2008;25(9):730-6.
Rodin G, Lo C, Mikulincer M, Donner A, Gagliese L,
Zimmermann C. Pathways to distress: the multiple determinants
of depression, hopelessness, and the desire
for hastened death in metastatic cancer patients. Soc
Sci Med 2009;68(3):562-9.
Costantini A, Pompili M, Innamorati M, Zezza MC,
Di Carlo A, Sher L, et al. Psychiatric pathology and
suicide risk in patients with cancer. Journal of J Psychosoc
Oncol 2014;32(4):383-95.
Abdel-Khalek AM. Death anxiety in clinical and
non-clinical groups. Death Stud 2005;29(3):251-9.
Cherny NI, Coyle N, Foley KM. Suffering in the advanced
cancer patient: a definition and taxonomy. J
Palliat Care 1994;10(2):57-70.
Rodin G, Zimmermann C. Psychoanalytic reflections
on mortality: a reconsideration. J Am Acad Psychoanal
Dyn Psychiatry 2008;36(1):181-96.
Peplau L, Perlman D. Perspectiveson loneliness. In:
Peplau LA, Perlman D, editors. Loneliness: A sourcebook,
of current theory, research and therapy. New
York: Wiley; 1982; p. 1-18.
Tomaka J, Thompson S, Palacios R. The relation of
social isolation, loneliness, and social support to disease
outcomes among the elderly. J Aging Health
2006;18(3):359-84.
Dykstra PA. Older adult loneliness: myths and realities.
Eur J Ageing 2009;6(2):91-100.
Ware JE Jr, Sherbourne CD. The MOS 36-item shortform
health survey (SF-36). I. Conceptual framework
and item selection. Med Care 1992;30(6):473-83.
Kocyigit H, Aydemir O, Olmez N, Memis A. Kısa
Form36"nın (KF-36) Türkçe versiyonunun güvenilirliği
ve geçerliliği. İlaç ve Tedavi Dergisi 1999;12:102-6.
Templer DI. The construction and validation of a
death anxiety scale. J Gen Psychol 1970;82:165-77.
Ertufan H. Validity and reliability study of death anxiety
and fear scales on a group of medical students.
Master"s thesis. Istanbul University; 2000.
Beck AT, Weissman A, Lester D, Trexler L. The measurement
of pessimism: the hopelessness scale. J Consult
Clin Psychol 1974;42(6):861-5.
Seber G, Dilbaz N, Kaptanoglu C, Tekin D. Umutsuzluk
ölçeği: geçerlilik ve güvenirliği. Kriz Dergisi
1993;1(3):139-42.
Russell D, Peplau LA, Cutrona CE. The revised UCLA
Loneliness Scale: concurrent and discriminant validity
evidence. J Pers Soc Psychol 1980;39(3):472-80.
Demir A. UCLA yalnızlık ölçeğinin geçerlik ve güvenirliği.
Psikoloji Dergisi 1989;7(23):14-8.
Udayakumar S, Parmar A, Leighl NB, Everest L, Arciero
VS, Santos SD, et al. Pembrolizumab alone or with
chemotherapy for metastatic non-small-cell lung cancer: A systematic review and network meta-analysis.
Crit Rev Oncol Hematol 2022;173:103660.
Christensen T, Berg T, Nielsen LB, Andersson M, Jensen
MB, Knoop A. Dual HER2 blockade in the firstline
treatment of metastatic breast cancer - A retrospective
population-based observational study in
Danish patients. Breast 2020;51:34-9.
Mori K, Mostafaei H, Sari Motlagh R, Pradere B, Quhal
F, Laukhtina E, et al. Systemic therapies for metastatic
hormone-sensitive prostate cancer: network
meta-analysis. BJU Int 2022;129(4):423-33.
Osterlund P, Salminen T, Soveri LM, Kallio R, Kellokumpu
I, Lamminmäki A, et al; Members of The
RAXO study group are collaborators of this study and
are listed in Appendix Table 4B. Repeated centralized
multidisciplinary team assessment of resectability,
clinical behavior, and outcomes in 1086 Finnish
metastatic colorectal cancer patients (RAXO): A nationwide
prospective intervention study. Lancet Reg
Health Eur 2021;3:100049.
Deckx L, van den Akker M, Buntinx F. Risk factors
for loneliness in patients with cancer: a systematic literature
review and meta-analysis. Eur J Oncol Nurs
2014;18(5):466-77.
Avci IA, Kumcagiz H. Marital adjustment and loneliness
status of women with mastectomy and husbands
reactions. Asian Pac J Cancer Prev 2011;12(2):453-9.
Boer H, Elving W, Seydel E. Psychosocial factors and
mental health in cancer patients: opportunities for
health promotion. Psychology Health & Medicine
1998;3:71-9.
Suhail K, Akram S. Correlates of death anxiety in Pakistan.
Death Stud 2002;26(1):39-50.
Tang PL, Chiou CP, Lin HS, Wang C, Liand SL. Correlates
of death anxiety among Taiwanese cancer patients.
Cancer Nurs 2011;34(4):286-92.
Drolet JL. Transcending death during early adulthood:
symbolic immortality, death anxiety, and purpose in
life. J Clin Psychol 1990;46(2):148-60.
Soleimani MA, Bahrami N, Allen KA, Alimoradi
Z. Death anxiety in patients with cancer: A systematic
review and meta-analysis. Eur J Oncol Nurs
2020;48:101803.
Lo C, Hales S, Zimmermann C, Gagliese L, Rydall A,
Rodin G. Measuring death-related anxiety in advanced
cancer: preliminary psychometrics of the Death and
Dying Distress Scale. J Pediatr Hematol Oncol 2011;33
Suppl 2:S140-5.
Everson SA, Goldberg DE, Kaplan GA, Cohen RD,
Pukkala E, Tuomilehto J, et al. Hopelessness and risk
of mortality and incidence of myocardial infarction
and cancer. Psychosom Med 1996;58(2):113-21.
Watson M, Homewood J, Haviland J, Bliss JM. Influence
of psychological response on breast cancer survival:
10-year follow-up of a population-based cohort.
Eur J Cancer 2005;41(12):1710-4.
Gustavsson-Lilius M, Julkunen J, Hietanen P. Quality
of life in cancer patients: The role of optimism,
hopelessness, and partner support. Qual Life Res
2007;16(1):75-87.
Couch M, Lai V, Cannon T, Guttridge D, Zanation
A, George J, et al. Cancer cachexia syndrome in head
and neck cancer patients: part I. Diagnosis, impact on
quality of life and survival, and treatment. Head Neck
2007;29(4):401-11.
Nipp RD, Fuchs G, El-Jawahri A, Mario J, Troschel
FM, Greer JA, et al. Sarcopenia Is Associated with
Quality of Life and Depression in Patients with Advanced
Cancer. Oncologist 2018;23(1):97-104.
Jones JA, Lutz ST, Chow E, Johnstone PA. Palliative
radiotherapy at the end of life: a critical review. CA
Cancer J Clin 2014;64(5):296-310.
Schofield P, Jefford M, Carey M, Thomson K, Evans
M, Baravelli C, et al. Preparing patients for threatening
medical treatments: effects of a chemotherapy educational
DVD on anxiety, unmet needs, and self-efficacy.
Support Care Cancer 2008;16(1):37-45.
Breitbart W. Spirituality and meaning in supportive
care: spirituality- and meaning-centered group psychotherapy
interventions in advanced cancer. Support
Care Cancer 2002;10(4):272-80.
Duggleby WD, Degner L, Williams A, Wright K, Cooper
D, Popkin D, et al. Living with hope: initial evaluation
of a psychosocial hope intervention for older
palliative home care patients. J Pain Symptom Manage
2007;33(3):247-57.
