Anxiety and depression symptoms among ovarian cancer patients in China: a cross-sectional study†
Article Category: Original article
Publié en ligne: 05 janv. 2021
Pages: 321 - 327
Reçu: 27 avr. 2020
Accepté: 11 juin 2020
DOI: https://doi.org/10.2478/fon-2020-0041
Mots clés
© 2020 Jing Chen et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The International Cancer Research Agency (IARC), the American Cancer Society (ACS), and the International Union for Cancer Control (UICC) reported in the third edition of the “Atlas of Cancer” that the number of new cancer cases in the world will reach 29 million in 2040, and the cancer burden is expected to increase by 60%, of which China reports the largest number of new cancer cases (4.3 million cases, 24% of the total) and deaths (2.9 million cases, 30% of the total).1 As of the end of 2017, malignant tumors have become the first major mortality rate of urban residents (26.11%) and the second-highest mortality rate of rural residents (23.07%) in China.2 Among female patients, ovarian cancer has the second-highest incidence of cancer, and the mortality rate ranks first in gynecological malignant tumors.3 According to the latest statistics in China, 52,000 new cases of ovarian cancer have been detected, and about 22,000 deaths have occurred. Due to a lack of effective screening methods, nearly 75% of the patients get it diagnosed only in late stages. The 5-year survival rate is only 41.8%.4,5 Different stages have different survival rates, 90% in the early stage, but only 30% in the advanced stage.6 However, it is difficult to diagnose ovarian cancer at an early stage (I/II) due to the nonspecific symptoms, and there is no recommended screening test. So, the majority of ovarian cancer patients are diagnosed only at an advanced stage.
As a result of high incidence rates in advanced stages and high mortality of the disease, patients who are suffering from ovarian cancer have to tolerate not only the physical pain but also the enormous psychological pressure and a huge financial burden.7,8 Some studies have indicated that depression and anxiety are two common types of psychological disorders in cancer patients.9,10,11 Anxiety is often described as the emotion of fear, involving the feelings of tension, nervousness, worry, apprehension, and dread for something perceived as threatening in the further. Depression has been defined as an emotion of sadness, hopelessness, lack of energy, and gloom.12 Among many types of cancer patients, the degree of anxiety in female patients was significantly higher than in male patients, and gynecological cancer patients were found to have the highest level of anxiety.13 In the past, a poor mental state is often regarded as a normal phenomenon accompanied by the disease, which led medical workers to ignore these symptoms. But anxiety, depression, and other adverse psychological states will not only affect the patient's subjective feelings and quality of life but also the disease progression and prognosis.14 Especially for patients with gynecological oncology, the disease often causes the loss of function or organism that represents female characteristics, which make the patients feel ashamed. So gynecological cancer patients are more likely to suffer from a poor mental state and interruption treatment than other cancer patients.15 Several previous studies have shown that a monitoring coping style is related to reduce the psychological impact on ovarian cancer.16,17 So, identifying the influencing factors associated with poor psychological status is important to develop appropriate target interventions for ovarian cancer patients.18,19 Therefore, we conducted this cross-sectional study to assess the prevalence of depression and anxiety in ovarian cancer patients in western China and analyze the related influencing factors.
We carried out a cross-sectional study to assess the symptoms of anxiety and depression among ovarian cancer patients and influencing factors. According to the epidemiology of sample size estimates, the required sample size is 10 times the research factors and the number of related factors in our study is 14. Meantime, considering the 20% loss rate, 168 participants are needed to be enrolled. Pre-survey showed that the prevalence of cancer-related anxiety and depression was about 50%, and the actual sample should be more than 240 cases.
Inclusion criteria were (a) being pathologically diagnosed as epithelial ovarian cancer; (b) able to read and understand the questionnaire in Chinese; (c) with clear consciousness; and (d) above 18 years old. Exclusion criteria were patients (a) with a history of the psychiatric disease; (b) unable or unwilling to fill in the informed consent or communicate with study staff; and (c) complicated with other kinds of cancers.
We adopted the Hospital Anxiety and Depression Scale (HADS)20 to measure the degree of anxiety and depression symptoms. This 14-item questionnaire includes two subscales, such as anxiety subscales (seven items) and depression subscales (seven items). Responses for each question ranges from 0 to 3 (0 = completely not; 1 = a little; 2 = somewhat; and 3 = very much). The total score point ranges from 0 to 21. The higher the score is, the more severe the anxiety and depression symptom is. The score “<8” is within the normal range, “8–10” suggests possible clinical anxiety or depression, and “>10” indicates probable anxiety or depression mood disorder. The instrument has been widely used in China with sufficient reliability. The internal reliability alpha values for the symptoms of anxiety and depression are 0.828 and 0.901, respectively, in the current study.
Coping style was measured by the 20-item Simplified Coping Style Questionnaire (SCSQ).21 Each item is rated as four points on the Likert scale (0 = never do; 1 = seldom do; 2 = often do; and 3 = always do). This instrument is a self-report questionnaire that contains 20 items and consists of two subscales: positive and negative coping. The high score of each dimension indicated frequent usage of this type of coping. The internal reliability alpha values for the positive and negative coping styles were 0.793 and 0.835, respectively, in the current study.
This survey was conducted from March 2016 to March 2017 and was demonstrated in West China Second University Hospital, Sichuan University, China.
The survey data were entered into Epidata 2.1, and specialized software was used for managing data Endnote X8. This program facilitates interactive entry and data correction and maintains consistent and accurate trial data. SPSS 17.0 software package was used for statistical analyses. A chi-squared test or
We surveyed 483 patients and eliminated 13 questionnaires because some patients’ diagnoses were not clear, and the effective questionnaire recovery rate of this study was 95.4%. Finally, a total of 270 hospitalized ovarian cancer patients were enrolled in the study. Table 1 presented the patients’ characteristics of demographic and clinical variables. Among 270 ovarian cancer patients, there were 148 (54.81%) patients who were 45–60 years old, and patients in the age range 18–82 years (53.54 ± 5.49, 95.18%) were married. A total of 65.55% of patients graduated from primary and high school, and only 52 patients (19.26%) earned more than 5,000 Yuan per month. The majority of ovarian cancer patients were under stage-III, accounting for 72.22%, 197 patients (72.96%) spent 20,000–40,000 Yuan when they were hospitalized.
Clinical and social-demographic data of patients (
| Variable | Number ( | Percentage (%) |
|---|---|---|
| 18–44 | 87 | 32.22 |
| 45–60 | 148 | 54.81 |
| ≥60 | 35 | 12.97 |
| Unmarried | 13 | 4.82 |
| Married | 257 | 95.18 |
| Primary or high school | 177 | 65.55 |
| Bachelor degree or master | 93 | 34.45 |
| ≤3,000 | 115 | 42.59 |
| 3,000–5,000 | 103 | 38.15 |
| ≥5,000 | 52 | 19.26 |
| III | 195 | 72.22 |
| IV | 75 | 27.78 |
| 20,000–40,000 | 197 | 72.96 |
| ≥40,000 | 73 | 27.04 |
The prevalence of cancer-related depression was 47.03% and cancer-related anxiety was 57.77% among the 270 ovarian cancer patients. Approximately 90.38% of cancer-related anxiety and 91.33% of cancer-related depression were both mild (Table 2).
The incidence of cancer-related anxiety and depression (
| Variable | Distribution | Morbidity (%) | |||
|---|---|---|---|---|---|
| Degree | Constituent ratio (%) | ||||
| 156 | 57.77 | ||||
| Mild | 141 | 90.38 | |||
| Moderate | 13 | 8.33 | |||
| Severe | 2 | 1.29 | |||
| 127 | 47.03 | ||||
| Mild | 116 | 91.33 | |||
| Moderate | 10 | 7.88 | |||
| Severe | 1 | 0.79 | |||
As shown in Tables 3 and 4, the prevalence of cancer-related depression and anxiety was associated with education level and income, there were statistically significant differences in education level (depression:
Relationship between various factors and cancer-related anxiety and depression.
| Variable | Number ( | Anxiety | Depression | ||||||
|---|---|---|---|---|---|---|---|---|---|
| % | χ2 | % | χ2 | ||||||
| 1.043 | 0.594 | 1.673 | 0.433 | ||||||
| 18–44 | 87 | 49 | 56.32 | 36 | 41.37 | ||||
| 45–60 | 148 | 84 | 56.75 | 74 | 50.00 | ||||
| ≥60 | 35 | 23 | 65.71 | 17 | 48.57 | ||||
| 0.079 | 1.000 | 1.153 | 0.395 | ||||||
| Unmarried | 13 | 8 | 61.53 | 8 | 61.53 | ||||
| Married | 257 | 148 | 57.58 | 119 | 46.30 | ||||
| 7.087 | 0.009* | 17.398 | <0.001* | ||||||
| Primary or high school | 177 | 92 | 51.97 | 67 | 37.85 | ||||
| Bachelor degree or master | 93 | 64 | 68.81 | 60 | 64.51 | ||||
| 11.003 | 0.004* | 9.394 | 0.009* | ||||||
| ≤3,000 | 115 | 57 | 49.56 | 46 | 40.00 | ||||
| 3,000–5,000 | 103 | 59 | 57.28 | 47 | 45.63 | ||||
| ≥5,000 | 52 | 40 | 76.92 | 34 | 65.38 | ||||
| 0.328 | 0.587 | 0.373 | 0.589 | ||||||
| III | 195 | 110 | 56.41 | 89 | 45.64 | ||||
| IV | 75 | 46 | 61.33 | 38 | 50.66 | ||||
| 0.365 | 0.580 | 0.009 | 1.000 | ||||||
| 20,000–40,000 | 197 | 116 | 58.88 | 93 | 47.20 | ||||
| ≥40,000 | 73 | 40 | 54.79 | 34 | 46.57 | ||||
Relationship between coping style and cancer-related depression and anxiety.
| Variable | Active style | Negative style | |||||
|---|---|---|---|---|---|---|---|
| 2.77 | 0.006* | −6.019 | <0.001* | ||||
| Yes | 156 | 20.60 ± 5.224 | 13.07 ± 3.943 | ||||
| No | 114 | 22.68 ± 7.075 | 10.18 ± 3.940 | ||||
| 2.15 | 0.032* | −4.906 | <0.001* | ||||
| Yes | 127 | 20.63 ± 4.577 | 13.11 ± 3.776 | ||||
| No | 143 | 22.23 ± 7.198 | 10.73 ± 4.138 |
Binary logistic regression showed that there were statistically significant differences in education level (OR = 0.307, 95% CI = 0.157–0.603), active style (OR = 0.903, 95% CI = 0.859–0.948), and negative style (OR = 1.298, 95% CI = 1.195–1.410) in cancer-related depression (Table 5). The multivariate analysis also showed that cancer-related anxiety was associated with education level (OR = 0.189, 95% CI = 0.096–0.371), active style (OR = 0.926, 95% CI = 0.883–0.971), and negative style (OR = 1.248, 95% CI = 1.155–1.348) (Table 6).
Multivariate analysis of factors associated with cancer-related depression.
| Variable | OR | 95% CI | ||
|---|---|---|---|---|
| Lower | Upper | |||
| Age, years | 0.302 | 1.263 | 0.811 | 1.965 |
| Marital status | 0.469 | 0.614 | 0.164 | 2.299 |
| Education level | 0.001* | 0.307 | 0.157 | 0.603 |
| Income | 0.852 | 0.864 | 0.381 | 1.958 |
| Cancer staging | 0.990 | 1.013 | 0.131 | 7.831 |
| Medical costs | 0.900 | 0.875 | 0.111 | 6.904 |
| Active style | <0.001* | 0.903 | 0.859 | 0.948 |
| Negative style | <0.001* | 1.298 | 1.195 | 1.410 |
Multivariate analysis of factors associated with cancer-related anxiety.
| Variable | OR | 95% CI | ||
|---|---|---|---|---|
| Lower | Upper | |||
| Age, years | 0.080 | 1.487 | 0.954 | 2.318 |
| Marital status | 0.581 | 1.462 | 0.379 | 5.648 |
| Education level | <0.001* | 0.189 | 0.096 | 0.371 |
| Income | 0.593 | 1.378 | 0.616 | 3.083 |
| Cancer staging | 0.264 | 3.371 | 0.400 | 28.430 |
| Medical costs | 0.281 | 0.307 | 0.036 | 2.631 |
| Active style | 0.002* | 0.926 | 0.883 | 0.971 |
| Negative style | <0.001* | 1.248 | 1.155 | 1.348 |
We find that the prevalence of ovarian cancer-related depression was 47.03% while cancer-related anxiety was 57.77%. Chun found that the prevalence of ovarian cancer-related depression was 47% and the anxiety was 51.5%, which was similar to the present study (Liu et al., 2017). But Price et al. performed a prospective cohort study, which enrolled 798 Australian ovarian cancer patients, and reported that the clinical anxiety was 15% and depression was only 5.9%.22 And a meta-analysis indicated that the prevalence of symptoms of depression and anxiety in Chinese cancer patients was 54.90% and 49.69%,23 respectively, which was not limited to ovarian cancer. Moreover, a systematic review has shown that the prevalence of depression and anxiety in women with ovarian cancer is significantly higher than healthy females.24 Therefore, it suggests that Chinese ovarian cancer patients have relatively higher levels of anxiety and depression. Besides, in our study, the ovarian cancer-related anxiety level was slightly higher than the depression level. It is consistent with the results of Mielcarek et al. (2016), which also found that the level of anxiety was higher than the level of depression in patients from Poland with advanced ovarian cancer, and the prevalence of pathological anxiety was the highest (74%) before surgery.25 All the patients who participated in our study were in the advanced-stage of ovarian cancer, too. Another study showed that the prevalence of depression in Chinese patients with malignant tumors was 54.90%.23 Hu Hong reviewed 35 studies involving cancer-related depression in China, where a total of 7,445 cases of cancer patients were included, and found that the prevalence of cancer depression was ranged from 19% to 95%.26 So, there is no doubt that the sample size, stage of cancer, and choice of assessment tools are the factors that lead to the different results between our study and previous studies. In developed countries, the improved recognition of the psychological impact of ovarian cancer may lead workers to seek mental treatment and other social supports actively.
In our study, we also found that education and coping styles were independent influencing factors. Binary logistic regression analysis showed that education level, active style, and negative style were the influencing factors with cancer-related anxiety and depression. Liu et al. found that ovarian cancer patients with higher education levels were tended to have a lower prevalence of cancer-related depression.10 But another study reported the opposite result which was consistent with the findings of our study. The reason may be that the patients with higher educational levels often took the initiative to get cancer-relevant information, but the poor prognosis of ovarian cancer gave rise to the symptoms of depression and anxiety.27 Patients with lower educational levels were dependent on medical institutions and medical staff more and cooperate with the diagnosis and treatment actively. Wang found that the symptoms of depression and anxiety in ovarian cancer patients were positively correlated with negative coping and negatively correlated with positive coping which were consistent with the findings of our study.28 The reason may be that coping style has played a regulatory and mediating role between stress and psychological response. Previous studies have shown that patients who are actively coping with problems are prone to optimism emotion.29 Several studies have provided evidence of the influence of positive psychological factors in cancer patients,30,31,32 and a meta-analysis has shown that psychological intervention can significantly reduce the anxiety and depression of ovarian cancer patients.33 This means that clinical staff should make more efforts to provide health education on coping styles and psychological interventions to ovarian cancer patients.
Our findings highlight that about half of the ovarian cancer patients suffered from cancer-related depression and anxiety, while more than 90% of depression and anxiety were mild. Among their education level, coping styles were significant and independent determinants. It is essential to ensure that the health care system provides efficient health education, psychological intervention, and support. In particular, clinical staff should pay more attention to the mood of ovarian cancer patients, early detection of cancer-related depression and anxiety, and promote the mental health of ovarian cancer patients.