Mediating role of fear of progression between sensory processing sensitivity and stigma in lung cancer patients: a cross-sectional study^†

Data of a total of 242 patients with lung cancer hospitalized in Yunnan Cancer Hospital treated from August 2022 to December 2022 were collected by convenient sampling method. All participants completed the Chinese version of the Highly Sensitive Person Scale (HSPS), Fear of Progression Questionnaire-Short Form (FoP-Q-SF), and the Cataldo Lung Cancer Stigma Scale (CLCSS).

Inclusion criteria: (1) patients with pathological diagnosis of lung malignancy; (2) age ≥18 years; (3) normal cognition, clear language expression, able to complete the questionnaire independently; and (4) the patients gave informed consent and volunteered to participate in the study.

Exclusion criteria: (1) the pathological stage was carcinoma in situ and (2) current or previous history of mental illness or family history, or substantial brain organ lesions.

The study was approved by the ethics committee before implementation, and all subjects were informed of the purpose and content of the study by the researcher before filling out the questionnaire. Subjects spent 10 min filling out a questionnaire that included general information, the HSPS, FoP-Q-SF, and The CLCSS. The team members who have received unified training managed the questionnaires and collected them on the spot after the subjects filled out the questionnaires. If there was any wrong selection or missing selection after inspection, the group members asked the subject to fill in again after checking.

The HSPS was developed by Aron and Aron,⁸ which has 27-item including environment stimuli, caffeine, body sense, and other moods. The 3 factors of SPS, ease of excitation (EOE) assesses an individual becoming mentally overwhelmed by external and internal; aesthetic sensitivity (AES) assesses aesthetic awareness; and low sensory threshold (LST) assesses unpleasant sensory arousal to external stimuli. In the current study, Cronbach’s α was 0.89.

FOP-Q-SF is a reliable and valid instrument comprising 12 items.¹³ These use a Likert scale ranging from 1 (never) to 5 (very often), and total scores ranging from 12 to 60. Psychological dysfunction appeared in patients with total scores of >34, indicating the necessity for corresponding intervention. The estimates of reliability have been shown to be high, with a Cronbach’s α value of 0.87.

The CLCSS is a reliable and valid measure of health-related stigma in lung cancer patients,¹⁴ which has 31-item and 4 factors: stigma and shame, social isolation, discrimination, and smoking and coefficient α ranging from 0.75 to 0.97 for the subscales.

This study had two parts of data analysis: (1) The first section aimed to verify the association between SPS, FoP, and stigma using Pearson analysis. (2) The second section is a mediation analysis of FoP between SPS and stigma, and the hypothetical model depicted in Figure 1. We used bootstrap analysis to test the indirect effect (a × b), which is significant if the 95% confidence intervals (CI) do not include 0.

Figure 1.

The coefficient “a” is the effect of the independent variable SPS on dependent variable stigma; The coefficient “b” between the mediating variable FoP on dependent variable; The coefficient “c” is the total effect between SPS and stigma; The coefficient “c’” is the direct effect between SPS and stigma without FoP.

This study used t-test to examine the difference of all scale scores in demographic characteristics (Table 1). Nationality (t = 2.065, P < 0.05), gender (t = -4.44, P < 0.001), and smoking history (t = -3.388, P < 0.01) have differences in FoP, smoking history (t = 3.803, P < 0.001), residence (t = 4.297, P < 0.001), monthly income (t = 3.699, P < 0.001), and education level (t = 2.289, P < 0.05) have differences in CLCSS, and only gender (t = -2.789, P < 0.01) has difference in HSPS.

The relationships between all scale scores were analyzed using Pearson correlation analysis (Table 2). CLCSS was positively correlated with FoP (Pearson correlation = 0.217, P < 0.01) and HSPS (Pearson correlation = 0.187, P < 0.01), FoP was positively correlated with HSPS (Pearson correlation = 0.199, P < 0.01).

In this study, we used SPS as an independent variable, stigma as a dependent variable, FoP as a mediating variable. In addition, 6 demographic variables, including nationality, gender, smoking history, place of residence, monthly income, and education level were used as covariables to construct the mediating model. Figure 2 shows the mediating analysis model of SPS, FoP, and stigma. Tables 3 and 4 respectively demonstrate the analysis procedure and total, direct, and indirect effects. Bootstrap analysis showed that the indirect effect was significant (a × b = 0.025, 95% CI [0.004, 0.054]), and the proportion of mediating effect (ab/c) in the relationship between independent variable and dependent variable is 21% (ab = 0.025, c = 0.120). Accordingly, FoP plays a significant mediating role in the relationship between SPS and stigma.

Figure 2.

Mediating role of FoP between SPS and Stigma.

Note: FoP, Fear of Progression Questionnaire-Short Form; SPS, sensory processing sensitivity; ^*P < 0.05, ^**P < 0.01, ^***P < 0.001; the results were obtained by controlling for demographic variables.

The current study found that high level of SPS were associated with high stigma among lung cancer patients. Previous studies have shown that lung cancer stigma negatively affects psychological health and complicates doctor–patient communication,^15,16 which is a barrier to medical help-seeking behavior in lung cancer patients.¹⁷ Other studies reported stigma strong association with adverse outcomes, such as depression, anxiety, and lower quality of life.^18–20 For lung cancer patients, the diagnosis, treatment, and hospitalization of disease are worse experiences, according to the SPS theory, in such a poor environment, SPS is bound to be associated with negative outcomes. Thus, if we can reduce the impact of negative environment or enhance the effect of positive environment, SPS does not necessarily lead to bad outcomes.

The preliminary analysis of this study showed that SPS, stigma, and FoP were pairwise significantly correlated, which could be used for further mediation analysis. Mediating analysis results indicate that FoP played a mediating role between SPS and stigma, the indirect effect size of 0.025, accounting for 21% of the total effect. SPS not only directly predicts the level of stigma but also predicts stigma through FoP in lung patients. Previous studies suggested that SPS, stigma, and FoP can all reduce quality of life and mental health.^21–26 For person with high SPS, facing great stress, such as cancer, is more likely to harm their physical health.²⁷ Thus, individuals with greater SPS may instinctively take the negative action in response to these events, such as FoP, when an individual’s FoP reaches a certain level, it will harm their physical and mental health and further aggravate the stigma.

From the characteristics of SPS, people with higher SPS are more susceptible to undesirable stimuli, moreover, diagnosis of cancer and the disturbance of the hospital environment are strong negative stimuli for them. In the face of such stimuli, cancer patients with greater SPS not only have higher stigma, but also further aggravate stigma through higher FoP.

These findings have clinic values, which help us realize the negative role of FoP among SPS and stigma, and suggest that medical staff should identify patients who have higher SPS and help them reduce the harm caused by FoP through psychological interventions, such as resilience and mindfulness therapy, to further weaken the stigma of cancer patients, thereby to help them achieve a better quality of life and a healthier life. A study that indicated that higher SPS students reported lower well-being, but they responded more positively to the intervention of resilience.²⁸ Another study suggested that the improvement of dispositional mindfulness may be effective for the psychological and physical problems of people with high SPS.¹¹ Thus, our study deemed that psychological interventions such as resilience and mindfulness can help higher SPS patients reduce the problems associated with FoP and thus reduce stigma.

SPS is a relatively new theory, and researchers have not found any studies on SPS in lung cancer patients. In this study, lung cancer patients were combined with SPS. On the other hand, this study is the first to combine SPS, FoP, and stigma to construct a mediation model.

Our study has several limitations. First, our participants were recruited only from lung cancer patients in Yunnan Province, and did not include patients with other types of cancer. Future studies could segment cancer types and be implemented in different cities. It is worth mentioning that in other SPS literature, there are few studies based on cancer patient samples, our study just enriched the sample types of SPS literature. Second, this study was just a cross-sectional study, it only collected the mental state of lung cancer patients at a certain time period, and did not track them longitudinally. Accordingly, it is necessary for future studies to longitudinally explore the relationship between SPS, FoP, and stigma.