Correlation research between fear of disease progression and quality of life in patients with lung cancer
Introduction
Cancer has become the second leading cause of mortality, with nearly 1/6 of deaths worldwide caused by the disease (1). Lung cancer has the highest incidence rate among cancer patients in China (2), comprising close to 20% of all malignancies (3). Fear of disease progression, or “fear of progress” (FoP) (4) in cancer, is a psychological state in which patients are afraid of the possibility of metastasis or recurrence of the disease. One study showed that the FoP score of breast cancer patients in China is mostly moderate (5). Poor quality of life (QOL) is a common problem in all cancer patients, and this problem is more prominent in lung cancer, mainly including physical, social, emotional, and functional status. It has become a vital consideration in understanding the long-term impact of cancer and its treatment (6), and studies have shown that FoP has a direct impact on QOL in people with interstitial lung disease and prostate cancer patients (7,8). Due to the FoP, patients will have large emotional fluctuations, which will eventually affect the treatment effect and quality of life. At present, there are few studies on FoP in lung cancer patients in China (9), and in this study we hoped to develop an understanding of its relationship with QOL in lung cancer patients to increase awareness in medical settings and the community. We present the following article in accordance with the SURGE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-21-2821/rc).
Methods
Study population
A questionnaire survey was conducted on 110 patients with primary lung cancer in the Thoracic Oncology Department of the Fifth Affiliated Hospital of Sun Yat-sen University from December 2019 to January 2020. The inclusion criteria were: (I) age >18 years old, with self-judgment ability; (II) patients were hospitalized for ≥1 day; (III) hospitalized patients with a pathological diagnosis of lung cancer; (IV) patients were conscious, had basic language communication skills, and had the ability to complete the questionnaire survey; (V) patients had a high degree of cooperation and voluntarily accepted the survey and informed consent of their families. The exclusion criteria were: (I) patient’s age was less than 18 years old; (II) patients were unconscious and unable to complete the questionnaire; (III) patients were hospitalized repeatedly.
Study methods
The sampling method was used in this study. Comprehensive quality control measures have been taken in the whole process of investigation (including design, investigation and analysis stages), such as rationalization and standardization of problem establishment, pre investigation, and timely study and solve the problems in the investigation. Trained investigators were selected to conduct clinical investigations using a unified questionnaire. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics board of the Fifth Affiliated Hospital of Sun Yat-sen University (K247-1) and written informed consent was obtained from all patients.
Patient general information questionnaire
The questionnaire included the general information of patients, as well as blood type, occupation, monthly income, medical burden, place of residence, religious belief, main caregivers, family companionship, mood state, efforts for serious illness, and the decision maker for existing treatment plans.
Simplified Chinese scale for fear of disease progression in cancer patients (FoP-Q-SF)
The scale was developed by Mehnert of Germany on the basis of FoP-Q in 2006 (10), and the simplified Chinese version of the scale (FoP-Q-SF) adopts a Likert 5-point scoring method, with a total of 11 items (11). The evaluation method adopts patient self-evaluation, with a score of 11–55 points, and the higher the patient’s score, the stronger their fear of disease progression. The Internal consistency Cronbach’s α coefficient is 0.883 in the original FoP-Q-SF total table, and the test-retest reliability was 0.85 after modifying the original scale. The FoP-Q-SF has good reliability and validity and is suitable for the detection of disease progression fear in lung cancer patients.
QOL scale for cancer patients (FACT-G)
This is a specific scale for various tumor patients formed by combining common and specific templates and is especially used to measure the QOL. The scale is mainly divided into four dimensions: physiological, social, emotional, and functional status, with a total of 23 items (12). In this study, a Likert scoring method was adopted for all items of the FACT-G, most of which were positive items, while reverse items were GP1-GP7, GE1, and GE3-GE6. The total score of patients ranged from high to low and indicated that the QOL of patients with lung cancer ranged from good to poor. The value reliability of internal consistency in each field in the original scale α is 0.85, and the test-retest reliability was 0.902 after modifying the original scale. FACT-G has good reliability and validity, and is suitable for the detection of QOL in patients with lung cancer.
Statistical analysis
After the data were collected, SPSS25.0 statistical software was used for descriptive statistics, independent sample t-test, one-way analysis of variance (ANOVA), Pearson correlation analysis, and multiple linear regression in the data analysis.
Results
Patients
A total of 110 questionnaires were distributed and 102 valid questionnaires were recovered, indicating a recovery rate of 92.7%. Patients comprised of 45 females (44.1%) and 57 males (55.9%); there were 88 cases (86.3%) of non-small cell carcinoma and 14 cases (13.7%) of small cell carcinoma; and the age range was 25–79 years old, of which those between 51–70 years old (47.1%) accounted for most respondents. Most patients were married (97, 95.1%), and their educational level was concentrated in high school and above (70, 68.6%). See Table 1 for details.
Table 1
| Characteristics | Cases (n) | Percentage (%) | Fear disease progression score | F/t | P |
|---|---|---|---|---|---|
| Sex | −0.60 | 0.55 | |||
| Male | 57 | 55.9 | 25.18±5.49 | ||
| Female | 45 | 44.1 | 25.91±6.75 | ||
| Age (years) | 0.87 | 0.46 | |||
| 18–30 | 3 | 2.9 | 27.00±6.25 | ||
| 31–55 | 36 | 35.3 | 25.44±6.09 | ||
| 56–70 | 48 | 47.1 | 26.13±5.96 | ||
| >70 | 15 | 14.7 | 23.33±6.34 | ||
| Medical insurance | −0.08 | 0.93 | |||
| Yes | 101 | 99 | 25.50±6.09 | ||
| No | 1 | 1 | 26.00 | ||
| Pleural effusion | 1.61 | 0.11 | |||
| Yes | 6 | 5.9 | 29.33±6.12 | ||
| No | 96 | 94.1 | 25.26±6.00 | ||
| Marriage | 0.35 | 0.56 | |||
| Yes | 5 | 4.9 | 25.43±6.11 | ||
| No | 97 | 95.1 | 25.28±4.79 | ||
| Degree of education | 1.47 | 0.23 | |||
| Junior high school and below | 18 | 17.6 | 24.89±6.05 | ||
| High school | 37 | 36.3 | 24.65±5.70 | ||
| Junior college | 33 | 32.4 | 25.52±6.53 | ||
| College and above | 14 | 13.7 | 28.5±5.49 | ||
| Chemotherapy | 0.58 | 0.57 | |||
| Yes | 82 | 80.4 | 25.56±5.64 | ||
| No | 20 | 19.6 | 24.8±7.67 | ||
| Radiotherapy | 0.45 | 0.65 | |||
| Yes | 34 | 33.3 | 25.88±5.51 | ||
| No | 68 | 66.8 | 25.31±6.34 | ||
| Targeted therapy | −0.69 | 0.49 | |||
| Yes | 42 | 41.2 | 25±6.74 | ||
| No | 60 | 58.8 | 25.85±5.56 | ||
| Immunotherapy | −0.73 | 0.94 | |||
| Yes | 13 | 12.7 | 25.38±4.03 | ||
| No | 89 | 87.3 | 25.52±6.31 | ||
| Blood type | 4.51 | 0.005** | |||
| A | 33 | 32.4 | 22.55±7.22 | ||
| B | 24 | 23.5 | 27.71±5.07 | ||
| AB | 12 | 11.8 | 56.42±4.3 | ||
| O | 33 | 32.4 | 26.52±4.97 | ||
| Monthly income | 9.76 | 0.00** | |||
| ≤3,000 | 34 | 33.3 | 28.26±5.8 | ||
| 3,000–5,000 | 34 | 33.3 | 36.79±4.17 | ||
| 5,001–10,000 | 27 | 26.5 | 20.93±6.21 | ||
| ≥10,000 | 7 | 6.9 | 24.43±5.29 | ||
| Medical burden | 1.31 | 0.28 | |||
| No burden at all | 4 | 3.9 | 24±2.31 | ||
| Basically no burden | 14 | 13.7 | 23±9.22 | ||
| Have a certain burden | 42 | 41.2 | 26.55±5.01 | ||
| Have a heavy burden | 42 | 41.2 | 25.43±5.88 | ||
| Residence | 0.05 | 0.96 | |||
| City | 16 | 15.7 | 25.51±6.16 | ||
| Countryside | 86 | 84.3 | 25.44±5.67 | ||
| Occupation | 1.82 | 0.17 | |||
| Worker | 21 | 20.6 | 25.67±7.1 | ||
| Farmer | 13 | 12.7 | 25.69±4.99 | ||
| Cadre | 8 | 7.8 | 24.8±10.05 | ||
| Medical staff | 2 | 2.0 | 23 | ||
| Teacher | 14 | 13.7 | 22.29±6.27 | ||
| Merchant | 10 | 9.8 | 26±5.14 | ||
| Others | 34 | 33.3 | 26.79±4.67 | ||
| Religious belief | 0.005 | 0.99 | |||
| Yes | 4 | 3.9 | 25.75±3.10 | ||
| No | 98 | 96.1 | 25.49±6.16 | ||
| Primary caregiver | 3.16 | 0.007** | |||
| Mate | 73 | 71.6 | 25.27±5.74 | ||
| Children | 13 | 12.7 | 28.66±5.28 | ||
| Parents | 1 | 1.0 | 25 | ||
| Brothers and sisters | 1 | 1.0 | 35 | ||
| Medical staff | 9 | 8.8 | 26.67±5.77 | ||
| Escort | 1 | 1.0 | 19 | ||
| Others | 4 | 3.9 | 16.25±6.19 | ||
| Family company | 2.93 | 0.038* | |||
| All day | 67 | 60.9 | 26.54±5.11 | ||
| Visit every day | 24 | 21.8 | 22.54±7.69 | ||
| 2–3 times a week | 7 | 6.4 | 26.71±6.8 | ||
| Once a week | 4 | 3.6 | 23.76±3.78 | ||
| Mood | 8.34 | 0.00** | |||
| Very good | 11 | 10.8 | 22.45±3.59 | ||
| Good | 45 | 44.1 | 23.2±6.5 | ||
| General | 38 | 37.3 | 28.32±4.85 | ||
| Range | 8 | 7.8 | 29.25±3.66 | ||
| What degree of effort do you think you should make when you are seriously ill? | 0.47 | 0.63 | |||
| Save lives as much as possible | 82 | 80.4 | 25.78±6.38 | ||
| It depends on the patient | 17 | 16.7 | 24.47±4.62 | ||
| Artificial methods should not be used to maintain vegetative life | 3 | 2.9 | 23.67±4.04 | ||
| Histology | 3.11 | 0.84 | |||
| Small cell lung cancer | 14 | 13.7 | 25.86±7.51 | ||
| Non-small cell lung cancer | 88 | 86.3 | 25.44±5.84 | ||
| Non-small cell lung cancer | 1.02 | 0.36 | |||
| Adenocarcinoma | 74 | 72.5 | 25.48±5.88 | ||
| Squamous cell carcinoma | 10 | 9.8 | 23.70±7.23 | ||
| Others | 16 | 17.7 | 27.67±6.42 | ||
| Stage | 0.54 | 0.58 | |||
| Stage II and below | 9 | 8.7 | 27.22±6.61 | ||
| Stage III | 65 | 63.8 | 25.11±5.91 | ||
| Stage IV | 28 | 27.5 | 25.86±6.32 | ||
*, indicates P<0.05; **, indicates P<0.01.
FoP in cancer patients
Univariate analysis showed that there were statistically significant differences in the level of FoP among lung cancer patients in terms of their monthly income, blood type, medical insurance type, main caregivers, family companionship, and mood (P<0.05), see Table 1 for details.
Multiple stepwise regression analysis of FoP
Taking the statistically significant factors obtained from the univariate analysis of FoP as the independent variable and the total score of FoP as the dependent variable, the FoP was analyzed by multiple stepwise regression. The results showed that the monthly income, mood state and blood type of lung cancer patients all affected the FoP (P<0.01), and the total coefficient of certainty was 0.291, indicating these three variables could explain 29.1% of the variation of the total FoP score. The assignment of independent variables of FoP and the results of multivariate analysis are shown in Tables 2,3.
Table 2
| Independent variable | Assignment method |
|---|---|
| Did you receive immunotherapy | Yes =1, no =2 |
| Did you receive chemotherapy | Yes =1, no =2 |
| Medical burden | No burden at all =1, basically no burden =2, have a certain burden =3, have a heavy burden =4 |
| Blood type | A =1, B =2, AB =3, O =4 |
| Occupation | Worker =1, farmer =2, cadre =3, medical staff =4, teacher =5, merchant =6, others =7 |
| Monthly income (Yuan) | ≤3,000 =1, 3,001–5,000 =2, 5,001–10,000 =3, ≥10,000 =4 |
| Primary caregiver | Mate =1, children =2, parents =3, brothers and sisters =4, medical staff =5, escort =6, others =7 |
| Family company | All day =1, visit every day =2, 2–3 times a week =3, once a week =4 |
| Mood state | Very good =1, good =2, general =3, range =4 |
Table 3
| Independent variable | Nonstandard coefficient | Standardized partial regression coefficient | T value | P value | |
|---|---|---|---|---|---|
| B | Standard error | ||||
| Constant | 20.4 | 2.73 | – | 7.47 | 0.00** |
| Mood state | 2.701 | 0.678 | 0.352 | 3.986 | 0.00** |
| Very good | – | ||||
| Good | 0.745 | 1.846 | – | 13.57 | 0.00** |
| General | 5.861 | 1.879 | 0.47 | 3.119 | 0.002** |
| Range | 6.795 | 2.55 | 0.303 | 2.665 | 0.009** |
| Monthly income (Yuan) | −1.707 | 0.587 | −0.264 | −2.91 | 0.004** |
| ≤3,000 | – | ||||
| 3,001–5,000 | −1.265 | 1.309 | −0.099 | −0.966 | 0.336 |
| 5,001–10,000 | −7.133 | 1.391 | −0.522 | −5.128 | 0.00** |
| ≥10,000 | −3.63 | 2.239 | −0.152 | −1.621 | 0.108 |
| Blood type | |||||
| A | – | ||||
| B | 5.163 | 1.546 | 0.363 | 3.339 | 0.001** |
| O | 3.97 | 1.419 | 0.308 | 2.797 | 0.006** |
| AB | 3.871 | 1.943 | 0.207 | 1.992 | 0.049* |
Regression equation R2=0.291, adjusted R2=0.269, f=13.382, P<0.01. *, indicates P<0.05; **, indicates P<0.01.
QOL in patients with lung cancer
The total standardized QOL score of lung cancer patients was 56.15±21.69. The standardized scores of the four dimensions of QOL were physiological dimension (108.5±28.52), emotional dimension (58.73±23.96), functional dimension (57.11±25.15), and social/family dimension (32.95±30.21), see Table 4.
Table 4
| Dimension | Score range | Minimum score | Maximum score | Original score, | Standardized score, |
|---|---|---|---|---|---|
| Physiological condition | 0–28 | 4 | 27 | 19.53±5.13 | 108.5±28.52 |
| Social/family status | 0–24 | 0 | 18 | 11.58±6.94 | 32.95±30.21 |
| Emotional state | 0–16 | 5 | 16 | 11.46±2.64 | 58.73±23.96 |
| Functional status | 0–24 | 1 | 17 | 10.14±4.03 | 57.11±25.15 |
| Scale score (total) | 0–92 | 28 | 72 | 52.71±9.54 | 56.15±21.69 |
Progress of phobia in patients with lung cancer
The FoP score of the 102 patients was 25.5±6.06, which indicated a medium level. Among them, 18 patients had mild disease (17.65%), 69 had moderate disease (67.65%), and 15 had severe lung cancer (14.7%). The top three items with the highest scores are shown in Table 5.
Table 5
| Top three of FoP items with the highest scores | Item score () | Very | Quite | Some | A little | Not at all | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | ||||||
| I’m worried about what will happen to my family if something happens to me | 3.31±0.96 | 3.0 | 2.8 | 52 | 50.9 | 28 | 27.5 | 12 | 11.8 | 7 | 7 | ||||
| I’m worried that the medicine will affect my body | 2.74±1.09 | 0 | 0 | 32 | 31.4 | 29 | 28.4 | 23 | 22.5 | 18 | 17.7 | ||||
| The idea that I might not be able to work because of illness annoys me | 2.59±0.80 | 0 | 0 | 12 | 11.8 | 44 | 43.1 | 38 | 37.3 | 8 | 7.8 | ||||
FoP, fear of progress.
Correlation between fear, disease progression, and QOLI in patients with lung cancer
The QOL score of lung cancer patients was significantly negatively correlated with the total score of FoP (r=−0.382). Among them, the QOLI was positively correlated with the scores of social/family dimensions in the FoP (r=0.77), and negatively correlated with the scores of physiological dimensions (r=−0.271), emotional dimensions (r=−0.289), and functional dimensions (r=−0.242) in the FoP, as shown in Table 6.
Table 6
| Dimension | r | P |
|---|---|---|
| Physiological condition | −0.271 | 0.006** |
| Social/family status | 0.77 | 0.443 |
| Emotional state | −0.289 | 0.003** |
| Functional status | −0.242 | 0.014* |
| Scale score (total) | −0.382 | 0.000** |
*, indicates P<0.05; **, indicates P<0.01.
Discussion
A total of 102 questionnaires were collected in this study, of which the proportion of men and women was 57:45. Most patients were middle-aged and elderly, and more than 60% had intermediate and higher education. Most had non-small cell lung cancer, which were mostly advanced adenocarcinoma.
As We all know, anti-tumor treatment and drug side effects are inevitable. However, excessive worry, what we call fear of disease progression, will aggravate this subjective feeling of patients themselves. Finding out the objective factors affecting the progress of fear disease will help patients maintain a good attitude and accept everything calmly. The mood status of patients affected the FoP, with those in good mood and with a cheerful personality having a lower score and stronger tolerance for the disease (13). The monthly income of lung cancer patients also affected the FoP, with those with high income often receiving better and more timely treatment, and attracting a lower score. These findings show it is necessary for legislators to improve medical insurance and related policies for cancer patients to reduce the financial burden on patients (14).
The blood type of lung cancer patients also affected the FoP score. The results of this study showed that those with type B, AB, and O blood were more significantly afraid of disease progression than patients with type A. This result differs from those of previous studies and may be related to the controversial blood group theory (15), which suggests people with type O blood may have a lower risk of disease than other blood types.
In this study, while most patients experienced FoP, the score was 25.5±6.06 points, which is considered a moderate level, and is basically consistent with the results of previous studies. In Table 5, the top three items with the highest scores in the questionnaire were the impact of the disease on patient’s families, side effects of drugs, and work troubles. This may be because: (I) Chinese society generally has a strong concept of family, and not being a burden to family is important (16). At the same time, the complications or death caused by disease progression bring irreparable psychological and economic trauma to the families of patients (17). (II) Chemotherapy drugs used by cancer patients often cause adverse reactions (18), and bring further fear and potential resistance to the treatment. (III) Both illness and its treatment may disrupt the normal working lives of patients (19), and increase the economic burden of patients and their families (20).
Table 6 shows that the distribution of FoP in patients with lung cancer was significantly negatively correlated with the QOL score (r=−0.382, P<0.05), indicating that the higher the level of FoP, the lower the QOL. The FoP score was significantly negatively correlated with the scores of physiological dimension, emotional dimension, and functional dimension (r=−0.271, −0.289, −0.242, P<0.05), which mimic the results of other studies (21). This may be due to (I) the patients’ lack of knowledge of cancer, doubts about the possibility of a cure, or fear of the adverse reactions of treatment. These adverse psychological emotions increased the psychological burden of patients and affect their QOL. (II) The emotional, social, and economic support of patients was difficult to address, which may also affect their rehabilitation process. To address this, medical staff should take measures to increase the confidence of patients and to reduce FoP, such as reiterating the importance of family and social support to family members, providing ongoing counselling online and via telephone, and maintaining continuous care (22). The QOL score of patients was (56.15±21.69), which was at the medium level (23). It can be seen from Table 4 that the physiological dimension score of patients with lung cancer was the highest (108.5±28.52 points), while that of society or family was the lowest (32.95±30.21 points), indicating that lung cancer caused considerable work, social, and family stress. In this study, following their illness, patients found it difficult to engage in their original work, resulting in reduced interpersonal communication and gradual alienation from society, which produced a variety of negative psychological emotions. Therefore, while using chemotherapy, radiotherapy, and other means to treat them, medical staff should attach great importance to the psychological status of patients (24), and encourage patients, families, and all involved parties to maintain close connections with those recovering from the disease.
In general, the fear of disease progression in patients with lung cancer seriously affects their QOL. With the continuous progress of medical treatment, physical disease rehabilitation is not the only factor medical workers should be concerned with, and the humanistic care of patients should be considered a crucial component of healing. Medical workers should pay more attention to patients’ FoP and provide more health education, psychological counseling, social support, alleviate fear of disease progression for lung cancer patients to improve their QOL. This study has not investigated the impact of fear of disease recurrence on patients’ QOL, and further research in this field is required.
Acknowledgments
Funding: None.
Footnote
Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-21-2821/rc
Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-21-2821/dss
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-21-2821/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by ethics board of the Fifth Affiliated Hospital of Sun Yat-sen University (K247-1) and written informed consent was obtained from all patients.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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(English Language Editor: B. Draper)
