Latent profile analysis of perceived stress and influencing factors in colorectal cancer patients^†

Colorectal cancer, also known as colon cancer, is a malignant tumor of the digestive tract and is most commonly manifested by changes in bowel habits and stool consistency in the early stages. With the background of socioeconomic transition, sedentary lifestyles, and a shift toward a Westernized diet, the incidence of colorectal cancer has been rapidly increasing and has become the second most common malignant tumor in China.¹ The primary treatment for colorectal cancer is surgery, complemented by radiation and chemotherapy.

Throughout the entire treatment process, patients face significant pressures from the disease itself, medical expenses, and the impact on their family and work.² Perceived stress refers to the psychological state of confusion or threat that individuals experience after cognitive evaluation of stressful events, leading to a state of tension and loss of control.³ A survey conducted by Huang⁴ on 251 colorectal cancer patients found that only 3.2% of patients fell within the normal range of stress perception, with the majority of patients perceiving high levels of stress. This is related to their concerns about postoperative complications, the economic costs of disease treatment, rehabilitation, and ostomy supplies, as well as self-management factors. Existing studies have found that the factors influencing stress in colorectal cancer patients are complex and highly heterogeneous.^5,6 Latent profile analysis, which is individual-oriented, distinguishes homogeneous individuals with similar characteristics into different categories with significant features based on their scores on scale items, maximizing the differences between category groups. This analytical approach has been widely applied in psychology, behavioral science, and medical fields due to its unique advantages.⁷ Based on the exploration of the stress perception types in colorectal cancer patients, this study further analyzed the characteristics of the influencing factors of different stress perception types, so as to provide a theoretical basis for developing interventions to reduce economic toxicity and psychological stress in patients.

There is heterogeneity in the perceived stress among colorectal cancer patients. This study utilized latent profile analysis to classify the perceived stress of colorectal cancer patients into “Low Stress-Stable Type,” “Moderate Stress-Uncontrolled Type,” and “High Stress-Tense Type.” The “High Stress-Tense Type” accounted for 56.9% of the total population, indicating that a majority of colorectal cancer patients experience a significant level of perceived stress, which is consistent with the findings of Sheng.⁶

Our study found that patients in the “High Stress-Tense Type” (C3) scored the highest in item 1 (“Feeling uneasy about unexpected events”). This may be attributed to the common association of cancer with mortality. When diagnosed with cancer without mental preparedness, patients may worry about their physical condition, treatment process, and future life, leading to anxiety and feelings of unease. Patients in the “Low Stress-Stable Type” (C1) and “Moderate Stress-Uncontrolled Type” (C2) scored the highest in item 12 (“Feeling preoccupied with things that must be done”). This could be due to the significant impact of colorectal cancer diagnosis and treatment on the psychological and emotional state of patients. Anxiety, depression, fear, and stress may make patients more sensitive and urgent about unfinished tasks. They may seek to alleviate these negative emotions and strive for a sense of positive control by completing certain tasks.

The influencing factors of the latent categories of perceived stress among colorectal cancer patients are as follows:

Male colorectal cancer patients perceive higher levels of stress. The results of this study indicate that the stress levels of male patients are higher than those of female patients. Existing research has focused more on stress in female patients,^16,17 often overlooking the psychological assessment of male patients. In reality, men may face greater psychological pressure. First, men are often associated with a strong and fearless image. The diagnosis and treatment of colorectal cancer may impact their self-identity and self-esteem, exacerbating their psychological burden. Second, influenced by social and cultural beliefs, men are expected to be strong and self-reliant. They may be reluctant to express emotions, seek psychological support, or seek medical help, making it easier for them to internalize psychological stress. In many societies, men are often expected to be the financial pillar of the family, providing economic support and stability. When they are unable to work due to illness or their financial situation is affected, they may face greater pressure from societal expectations and internal sources. Therefore, healthcare providers can assist patients in coping with psychological stress by listening, expressing concern, and providing emotional support. Building a trusting relationship with patients, encouraging them to express emotions, offering emotional comfort and coping strategies, and guiding them to seek professional psychological counseling or support groups¹⁸ can be beneficial.

In terms of social aspects, after stoma surgery, patients face changes in body image and self-esteem, which may lead to avoidance of social and group activities and increase psychological pressure. They require additional psychological support and counseling. In the workplace, some patients may be unable to work due to the stoma or face discrimination and awkwardness, posing significant psychological challenges. In daily life, stoma surgery alters patients’ diet, exercise abilities, personal hygiene habits, and other aspects. Additionally, due to the issues related to the stoma, patients require long-term assisted care from caregivers, which can affect caregivers’ work and life, further increasing the psychological burden on patients. In terms of treatment costs, after stoma surgery, patients need to purchase related medical supplies such as stoma bags and baseplates, which require regular replacement and consumption, increasing the financial burden on patients.

Therefore, nurses can teach patients self-management skills for the stoma, dietary adjustments, and strategies to reduce related complications through a healthy lifestyle. This can better alleviate the economic burden and help patients cope with the psychological pressure associated with stoma discomfort.²²

(4) Colorectal cancer patients with lower economic toxicity levels perceive higher levels of stress. Economic toxicity is an important driver of psychological stress, and Sharp et al.²³ found that economic stress is associated with increased risk of adverse psychological outcomes; consistent with the findings, people with low economic toxicity scores tended to experience high levels of stress. The treatment of colorectal cancer typically involves procedures such as surgery, chemotherapy, radiation therapy, and medication, all of which can incur significant medical expenses. If patients do not have sufficient medical insurance coverage or social welfare support, the economic burden can be substantial, leading to immense stress for patients and their families.

Furthermore, some patients may undergo a monitoring period after treatment, as well as face the risks of disease progression and recurrence. The economic burden associated with continued treatment and monitoring, along with the uncertainty of the disease, can contribute to psychological pressure and anxiety for patients.²⁴

The perceived stress of colorectal cancer patients can be categorized into 3 types: “low stress-stable type,” “moderate stress-uncontrolled type,” and “high stresstense type.” Nursing staff should focus on assessing male patients, those with a monthly household income of ≤3000 RMB, patients with stomas, and those with low economic toxicity score. Based on the assessment results, comprehensive support should be provided, including economic assistance, psychological counseling, and social policy support, to alleviate the burden on patients and their families and improve their mental health and quality of life. This study is only a cross-sectional survey, the sample size is small, and the sample is only derived from the Sichuan region, with certain geographical limitations. Moreover, the impact of other unincluded variables needs further validation, and the expanded sample size should be investigated in the future and further studied on other variables.