Anxiety, depression and quality of life among Chinese breast cancer patients
during adjuvant therapy
Winnie K.W. So a, * , Gene Marsh b , W.M. Ling c , F.Y. Leung d , Joe C.K. Lo e , Maggie Yeung f , George K.H. Li g a Department of Nursing Studies, The University of Hong Kong, Hong Kong SAR, China b School of Nursing, University of Colorado Health Science Center, USA c Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China d Infection Control Unit, Princess Margaret Hospital, Hong Kong SAR, China e Department of Oncology, Princess Margaret Hospital, Hong Kong SAR, China f Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong SAR, China g Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China Keywords: Anxiety Depression Quality of life Adjuvant therapy Chemotherapy Radiotherapy Breast cancer a b s t r a c t Purpose: The aim of the study was to examine anxiety and depression and their effects on the quality of life (QOL) of patients with breast cancer undergoing chemotherapy or radiotherapy. Methods: A cross-sectional descriptive design was used. Data were collected from a self-report survey derived from the Hospital Anxiety and Depression Scale (HADS)-Cantonese/Chinese version, the Func- tional Assessment of Cancer Therapy for Breast Cancer (FACT-B)-Chinese version, and from demographic and clinical characteristics. Chi-square tests and the General Linear Model (GLM) were used for secondary data analysis. Sample: The study group consisted of 218 women (18 years old) who were midway through chemo- therapy or radiotherapy for stage IIII breast cancer. All subjects were recruited from the outpatient sections of the Departments of Clinical Oncology or Breast Centers of the four Hong Kong public hospitals. Results: The percentage of participants with anxiety (c 2 6.56, p 0.01) or depression (c 2 7.26, p 0.007) was higher in the chemotherapy group. More participants in the chemotherapy group had both anxiety and depression than those in the radiotherapy group, though no statistically signicant difference was reported. Anxiety and depression had detrimental effects on the overall and other domains of QOL of these women undergoing adjuvant therapy for breast cancer. Conclusion: This study should increase nurses awareness of the importance of integrating psychological symptom assessment into nursing assessment procedures, and enhance their clinical sensitivity in identifying high-risk groups of patients undergoing specic cancer treatments. 2009 Elsevier Ltd. All rights reserved. Introduction Breast cancer is the most commonly diagnosed cancer among women in Hong Kong, with the incidence rate increasing every year (Hong Kong Cancer Registry, n.d.). In 2006, there were approxi- mately 2600 newcases and the life-time risk for females was up to 1 in every 20 (Hong Kong Cancer Registry, n.d.). The treatment modalities for primary breast cancer include surgery, chemotherapy, radiotherapy and hormonal therapy, all four of which can be used alone or in combination (Dow, 2004). Surgery is a primary treatment for breast cancer, whereas adjuvant therapies such as chemotherapy and radiotherapy are commonly used after primary treatment in order to inhibit metastasis and enhance long-term survival rates (National Cancer Institute, 2002). Despite advances in cancer treatment which have increased breast- cancer survival rates, the aggressiveness of the therapy increases the exposure of patients to treatment side-effects. In fact, cancer and treatment-related symptoms are major stressors in patients with breast cancer undergoing treatment for the disease (Jim et al., 2007). Of all the symptoms, anxiety and depression are the most prevalent psychological symptoms perceived by cancer patients (Takahashi et al., 2008), the prevalence rate ranging from 13% to 54% (Burgess et al., 2005; Gaston-Johansson et al., 1999; Hopwood * Corresponding author at: Dr Winnie K.W. So, Department of Nursing Studies, The University of Hong Kong, 4/F., William M.W. Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China. Tel.: 852 2819 2684; fax: 852 2872 6079. E-mail address: wkw@hku.hk (W.K.W. So). Contents lists available at ScienceDirect European Journal of Oncology Nursing j ournal homepage: www. el sevi er. com/ l ocat e/ ej on 1462-3889/$ see front matter 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2009.07.005 European Journal of Oncology Nursing 14 (2010) 1722 et al., 2007; Takahashi et al., 2008; Zabora et al., 2001). A large variation in the prevalence of anxiety and depression may be due to the use of different measurement tools and heterogeneous samples. Also, the fewstudies that have taken place have only used small samples to examine the psychological symptoms of patients undergoing either chemotherapy or radiotherapy (Byar et al., 2006; Farrell et al., 2005). To the best of the authors knowledge, no study has compared the prevalence of psychological symptoms in different types of adjuvant therapy. Further research using larger homogeneous samples to examine possible cases of anxiety and/or depression during chemotherapy or radiotherapy is essential to close the knowledge gap. Quality of life (QOL) has been used as a primary outcome measure in recent decades. It is a complex multi-dimensional assessment of the physical, psychological and social well-being of individuals (Akin et al., 2008). The adverse effects of different cancer- or treatment-related symptoms and types of treatment have been associated with QOL (Albert et al., 2004; Groenvold et al., 2007; Safaee et al., 2008; Schreier and Williams, 2004; Takahashi et al., 2008). Anxiety and depression have both been shown to be negatively associated with the QOL of breast-cancer patients after diagnosis, at the start of treatment and post-treatment (Weitzner et al., 1997; Longman et al., 1999; Schreier and Williams, 2004; Wong and Fielding, 2007). Nevertheless, the co-occurrence of anxiety and depression and the combined effect of the two psychological symptoms on the quality of life of breast-cancer patients remain unclear. Aim The aimof the study was to examine anxiety and depression and their effects on the QOL of patients with breast cancer undergoing chemotherapy or radiotherapy. The research questions involved are as follows: 1) What is the prevalence of anxiety and depression in patients undergoing adjuvant therapy for breast cancer? 2) Are patients undergoing chemotherapy more likely to have anxiety and/or depression than those receiving radiotherapy? 3) Do anxiety and/or depression in this population affect QOL? Methods Design This study used a cross-sectional descriptive design. Sample and settings Potential subjects were recruited fromthe outpatient sections of the Departments of Clinical Oncology or Breast Centers of the four local public hospitals. Eligibility criteria included: Chinese women who 1) were 18 years old or older, 2) had undergone surgery for breast cancer, 3) were midway in their course of curative treatment by chemotherapy or radiotherapy, and 4) were diagnosed with stage IIII breast cancer. Those who 1) had difculty in under- standing the questionnaire or communicating in Cantonese, 2) had a history of psychiatric disorder, or 3) had metastatic brain disease were all excluded from the study. Instruments The original self-report survey consisted of six parts. Details of the instrument are reported elsewhere (So, 2007). In the present paper, three parts of the survey were used for analysis and discussion: 1) demographic and clinical characteristics, 2) anxiety and depression, and 3) quality of life. Demographic and clinical characteristics. The demographic data consisted of age, income, marital status, educational level, employment status, religious belief, family history of cancer, stage of disease, comorbidity, duration of illness, type of current treat- ment, time since initial treatment and type of surgery received. Anxiety and depression. The Hospital Anxiety and Depression Scale (HADS)-Cantonese/Chinese version is a screening tool for measuring the severity of anxiety and depression (Zigmond and Snaith, 1983). The Cantonese/Chinese version was developed by Lam et al. (1995) and translated from the original version of the HADS developed by Zigmond and Snaith (1983). The scale consists of 14 items and two subscales (anxiety and depression) with seven items in each subscale. Each item is scored on a 4-point Likert-type scale (03). Total scores for each subscale are calculated by simple summation of individual items, a higher score indicating more distress. Consistent with the original version of HADS, the Cantonese/Chinese version has been used for measuring the level of psychological distress in various populations, including general hospital in-patients (Leung et al., 1999) and the elderly (Lam et al., 1995). The results showed that the scale had good internal consistency and external validity with favorable sensitivity and specicity in screening for patients with psychiatric disorders. In this study, the Cronbachs alpha coefcients for the anxiety and depression subscales were 0.806 and 0.724 respectively. Quality of life. The Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B)-Chinese version was used to assess the degree of the participants QOL (FACIT Functional Assessment of Chronic Illness Therapy, n.d.) The scale consists of 36 items divided into ve domains: the physical, emotional, social, functional well- being and breast cancer subscales. Each item was rated on a ve- point scale (0 not at all; 1 a little bit; 2 somewhat; 3 quite a bit; 4 very much). In this way, the total score and the subscale score for well-being are calculated. Higher scores indicate better functional status. Internal consistency and content validity were demonstrated in a sample of 60 Chinese patients with breast cancer (Mak et al., 2007), where the Cronbachs alpha coefcient for the subscales ranged between 0.524 and 0.872 and for the entire scale was 0.725. Procedure The study was approved by the ethical committee of the study institutions, and conducted in 20062007. Potential subjects were approached by a research nurse midway through their regime of chemotherapy and in the third to sixth week of radiotherapy. Data were collected by face-to-face interview. Medical records were reviewed by the research nurses for the purpose of recording demographic and clinical variables. Data analysis Demographic and clinical variables were grouped by type of current treatment, and chi-squared (dichotomous variables) or t- tests (continuous variables) were used to determine if differences occurred that were due to different types of current treatment. The mean scores for anxiety, depression and QOL were grouped by type of current treatment, and a t-test performed. Chi-squared analysis was used to examine whether there was a signicant relationship between psychological symptoms and the type of cancer treatment being received by the subjects. A general linear model (GLM) was used to investigate whether the degree of QOL showed signicant difference among participants with different psychological W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 18 symptoms after adjustment for confounding variables. Interaction effects between the dichotomous variables were examined, but insignicant results were found. The six dependent variables were the overall QOL, physical well- being (PWB), social/family well-being (SFWB), emotional well- being (EWB), functional well-being (FWB) and breast cancer subscale (BCS). The two independent variables were the anxiety (HAD-A) and depression (HAD-D) subscales of HADS. Confounding variables for adjustment included age (continuous), stage of disease (stage I, II or III), type of treatment (chemotherapy or radiotherapy), and type of surgery received (mastectomy (MRM) or breast conservation treatment (BCT)/breast reconstruction). A p-value of 0.05 or less was considered as statistically signicant. Results Recruitment and response Subjects were recruited from an original study examining the symptom cluster and QOL of breast-cancer patients undergoing adjuvant therapy (So, 2007). The response rate then was about 80% (283 out of 354). For the present paper, 218 of these patients took part in a secondary analysis. Patient characteristics Information on demographic and clinical characteristics grou- ped by type of cancer treatment is presented in Table 1. Overall, the mean age was 51.7 (SD10.32) and the mean duration of illness was 7.35 (SD16.02). A large number of the subjects were married (77.1%), had completed a secondary education (64.7%), were not employed (73.9%), did not have a family history of cancer, and had undergone mastectomy (74.3%). More than half of the subjects were diagnosed with stage II cancer (52.8%). There was no signicant difference in the demographic and clinical characteristics of the two groups (Table 1). Prevalence of anxiety and/or depression The percentage of participants suffering from anxiety, depres- sion or both was compared with the type of current treatment (Table 2). Signicance differences were found between anxiety and type of treatment (c 2 6.56, p 0.01), and between depression and treatment (c 2 7.26, p 0.007). More participants in the chemotherapy group [n (%) 25 (19.2)] suffered from both anxiety and depression than in the radiotherapy group [n (%) 9 (10.2)], though no statistically signicant difference was found. Effect of anxiety and/or depression on QOL GLM was performed to examine whether the psychological symptoms had signicant adverse effects on the overall QOL and the ve domains of QOL (Table 3). Statistically signicant effects of HAD-D were reported in all dependent variables after being adjusted for age, stage of disease, type of treatment and type of surgery. Participants with depression were signicantly associated with poorer overall QOL (b 18.47, p <0.001) and all ve domains of QOL (p 0.001). Statistically signicant effects of HAD-A were reported in overall QOL (b 13.22, p <0.001), PWB (p 0.017), EWB (p <0.001), FWB (p 0.044) and BCS (p <0.001). Participants with anxiety were more likely to have poorer overall QOL and other domains of QOL except SFWB. It was also found that participants with both anxiety and depressionwould see a decrease of 31.6 units in their overall QOL when compared with those in the non-case anxiety or depression groups. See Table 3. Table 1 Demographic and clinical characteristics of the participants grouped by types of cancer treatment (N218). Characteristics All subjects Chemotherapy Radiotherapy c 2 p-value N (%) N (%) N (%) N (%) 218 (100) 130 (59.6) 88 (40.4) Marital status Single/divorced/widowed 50 (22.9) 27 (20.8) 23 (26.1) 0.855 0.355 Cohabitation/married 168 (77.1) 103 (79.2) 65 (73.9) Education levels No formal / primary 77 (35.3) 44 (33.8) 33 (37.5) 0.307 0.580 Secondary or above 141 (64.7) 86 (66.2) 55 (62.5) Employment status Employed 49 (23.3) 28 (22.0) 21 (25.3) 0.297 0.586 Not employed 161 (73.9) 99 (78.0) 62 (74.7) Monthly household income 10,000 87 (40.8) 51 (39.5) 36 (42.9) 1.444 0.486 10,00130,000 96 (44.0) 62 (48.1) 34 (40.5) >30,000 30 (13.8) 16 (12.4) 14 (16.7) Religious belief Yes 104 (47.7) 60 (46.2) 44 (50.0) 0.311 0.577 No 114 (52.3) 70 (53.8) 44 (50.0) Stage of disease Stage I 33 (15.1) 17 (13.1) 16 (18.2) 1.359 0.507 Stage II 115 (52.8) 72 (55.4) 43 (48.9) Stage III 70 (32.1) 41 (31.5) 29 (33.0) Type of surgery received Mastectomy (MRM) 162 (74.3) 102 (78.5) 60 (68.2) 2.905 0.088 Breast conservation treatment (BCT)/MRMbreast reconstruction 56 (25.7) 28 (21.5) 28 (31.8) Family history of cancer Yes 24 (11.0) 10 (7.7) 14 (15.9) 3.616 0.057 No 194 (89.0) 120 (92.3) 74 (84.1) Characteristics M (SD) M (SD) M (SD) t p-value Age 51.70 (10.32) 50.99 (9.22) 52.75 (11.73) 1.179 0.240 Charlson index 2.12 (0.38) 2.08 (0.31) 2.17 (0.46) 1.535 0.127 Time since diagnosis (months) 7.35 (16.02) 6.70 (16.70) 8.31 (14.99) 0.727 0.468 Time since initial treatment started (weeks) 8.43 (50.52) 20.61 (62.91) 21.97 (22.27) 0.194 0.847 W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 19 Discussion Prevalence of anxiety and/or depression The results of the study showed that more than half of the participants had anxiety or depression and 15.6% had both of these psychological symptoms. The ndings reect those reported in other studies (Hopwood et al., 2007; Takahashi et al., 2008), and indicate the importance of assessing the mental health of such patients throughout the process of cancer treatment. Since this study excluded patients with a history of psychological disorder, the symptoms of anxiety and depression are likely to be caused by cancer or by its treatment. However, this study measured the symptoms at one point in time. More research is needed to examine the onset time of the symptoms, their causes and their patterns in the whole process of cancer treatment. The study found that the prevalence of psychological symp- tom(s) was higher in those subjects undergoing chemotherapy than in those receiving radiotherapy. Possible reasons include severe treatment side-effects from chemotherapy (Rao et al., 2009) and poorer self-esteem through side-effects involving changes in physical appearance. Also, the main purpose of chemotherapy is to reduce the risk of recurrence of cancer, whereas that of radio- therapy is to eliminate localized cancer cells (National Cancer Institute, 2002). Uncertainty about the recurrence of cancer in patients undergoing chemotherapy may cause higher levels of anxiety and depression (van den Beuken-van Everdingen et al., 2008). Further studies are needed to investigate whether these factors lead to anxiety and depression in the same patient population. Effect of anxiety and/or depression on QOL A signicant relation was observed between the groups in their overall and ve domain results on the FACT-B, except social/family well-being. Participants with depression experienced overall a poorer level of QOL and other domains of QOL than those in the non-case group. Those in the anxiety case group had signicantly poorer overall QOL, PWB, EWB, FWB and BCS than those in the non- case group. The ndings provide evidence that psychological symptoms could have profound effects on the physio-psycho-social well-being of patients during cancer treatment. The results of this study show that anxiety did not have a signicant adverse effect on the SFWB of the participants. This may be due to the provision of social and family support not being affected by anxiety exclusively. In other words, when cancer patients have adequate support from their family and friends, healthcare professionals and the society around them, their SFWB can be maintained. Limitations The cross-sectional design of this study provided information about the prevalence of psychological symptoms at one point in time. The pattern and intensity of the symptoms over time were not evaluated. In future research, baseline data before treatment should be collected so that whether or not the risk of anxiety or depression is directly associated with cancer treatment can be investigated. Also, longitudinal studies are recommended to capture more in- depth information about the psychological symptoms experienced Table 2 A comparison of anxiety and depression grouped by types of cancer treatment (N218). All subjects Chemotherapy Radiotherapy c 2 p-Value N (%) N (%) N (%) Anxiety Yes a 46 (21.1) 35 (26.9) 11 (12.5) 6.56 0.010 No b 172 (78.9) 95 (73.1) 77 (87.5) Depression Yes c 75 (34.4) 54 (41.5) 21 (23.9) 7.26 0.007 No d 143 (65.6) 76 (58.5) 67 (76.1) Anxiety and depression Yes e 34 (15.6) 25 (19.2) 9 (10.2) 3.23 0.072 No f 184 (84.4) 105 (80.8) 79 (89.8) a Anxiety subscale score >7. b Anxiety subscale score 7. c Depression subscale score >7. d Depression subscale score 7. e Anxiety subscale score >7 and depressive subscale score >7. f Anxiety subscale score 7 and/or depressive subscale score 7. Table 3 Parameter estimates of the overall and ve domains of QOL 1 using GLM test. QOL HADS 2 Beta SE t p-Value 95%CI Overall QOL a HAD-A 3 cases 13.219 2.999 4.407 <0.001 19.131, 7.306 HAD-D 4 cases 18.465 2.634 7.010 <0.001 23.658, 13.272 Physical well-being b HAD-A cases 2.863 1.188 2.410 0.017 5.206, 0.521 HAD-D cases 4.725 1.044 4.528 <0.001 6.783, 2.668 Social/family well-being c HAD-A cases 0.923 0.995 0.928 0.354 1.038, 2.885 HAD-D cases 2.935 0.874 3.358 0.001 4.685, 1.212 Emotional well-being d HAD-A cases 5.523 0.788 7.008 <0.001 7.076, 3.969 HAD-D cases 3.992 0.692 5.768 <0.001 5.357, 2.628 Functional well-being e HAD-A cases 2.058 1.014 2.030 0.044 4.057, 0.059 HAD-D cases 3.945 0.891 4.430 <0.001 5.701, 2.190 Breast cancer subscale f HAD-A cases 3.698 0.873 4.237 <0.001 5.418, 1.977 HAD-D cases 2.867 0.767 3.741 <0.001 4.378, 1.356 Note. 1 Functional Assessment of Cancer Therapy for Breast Cancer (FACTdB)-Chinese version. 2 Hospital Anxiety and Depression Scales (HADS), 3 Anxiety subscale of HADS, 4 Depression subscale of HADS. Inuence of signicance variables on the overall QOL and QOL domains after adjusted for age, stage of disease, types of current treatment and type of surgery received. a Adjusted R squared 0.403; corrected model: F 21.818, p <0.001. b Adjusted R squared 0.275; corrected model: F 12.690, p <0.001. c Adjusted R squared 0.391; corrected model: F 28.708, p <0.001. d Adjusted R squared 0.407; corrected model: F 22.210, p <0.001. e Adjusted R squared 0.193; corrected model: F 8.381, p <0.001. f Adjusted R squared 0.245; corrected model: F 11.020, p <0.001. W.K.W. So et al. / European Journal of Oncology Nursing 14 (2010) 1722 20 by groups of cancer patients. This study only focused on examining anxiety, depression and QOL. Other factors that may be associated with the overall and other domains of QOL were not investigated. This might in future be another research area helping to close the knowledge gap. Implications The ndings of the study have several implications. In Chinese culture, the virtues of tolerance and harmony are emphasized (Bond, 1991). One of the characteristics of Chinese people is to avoid extremes and maintain harmony through the balance of feelings aroused (Wu, n.d.). Conicts should not therefore be openly expressed, to maintain harmony between different people. Chal- lenging an expert is inappropriate as this may induce conicts with the expert (Chen, 2001). These cultural beliefs may inhibit Chinese patients from openly expressing their queries and emotions to healthcare professionals. Thus, it is vital to incorporate the measurement of anxiety and depression in nursing assessment procedures. Once psychological symptoms are detected, patients can be referred to the clinical psychologist or psychiatrist promptly for further examination. Additionally, psychological symptoms may reduce the efcacy of chemotherapy incases of breast cancer (Su et al., 2005). Although the mechanism of how psychological distress alters the efcacy of the treatment is poorly understood, evidence suggests that psychological distress may cause stress which alters hormonal and neuronal secretions and affects the biological activity of breast cancer cells (Drell et al., 2003). Therefore, the early detection of psychological symptoms and provision of effective symptom management may well maintain the effectiveness of the cancer treatment. Results can also help nurses to offer better support to breast- cancer patients who are at risk of psychological symptoms during the course of cancer treatment. For example, nurses may use the ndings to tailor the information they provide to prepare patients more adequately for treatment. Nurses can also perform symptom- distress assessments periodically and implement effective symptom-relieving strategies for those in need. Conclusion Anxiety, depression and QOL in patients undergoing chemo- therapy or radiotherapy for breast cancer were examined in this study. The prevalence of anxiety and/or depression was higher in patients undergoing chemotherapy. The ndings provide evidence that psychological symptoms have a detrimental effect on various aspects of a patients QOL. Nurses awareness of the importance of integrating psychological symptom assessment into their proce- dures should therefore be increased, and their clinical sensitivity in identifying high-risk groups of patients undergoing specic cancer treatments should be enhanced. Conict of interest statement None of the authors have any conicts of interests. Acknowledgements The University of Hong Kong and the University of Colorado funded this study. The authors would like to thank Prof Joan K. Magilvy, Dr Paula Nelson-Martin, Dr Ellyn E. Mathews and Prof Sarah H. 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