Factors affecting depression, anxiety, and quality of life in patients receiving radiotherapy for gastric cancer

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RESEARCH ARTICLE

Hippokratia 2024, 28(2): 56-64

Cihan YB1, Ozturk O2
1Department of Radiation Oncology, Kayseri City Hospital
2Department of Statistics, Hacettepe University
Turkey

Abstract

Aim: This study aimed to evaluate the quality of life, anxiety, and depression levels in gastric cancer patients receiving radiotherapy. We also investigated the impact of demographic, clinical, pathological, and laboratory data on the quality of life, anxiety, and depression levels.

Methods: We designed this prospective observational study that enrolled gastric cancer patients treated in the Radiation Oncology Department of Kayseri City Education and Research Hospital. Patients were requested to complete questionnaires on the first day of their adjuvant radiotherapy and six months after treatment completion. We utilized the clinical data collection form, the European Cancer Treatment and Organization Committee Quality of Life Questionnaire (EORTC QLQ-C30), and the Hospital Anxiety and Depression Scale (HADS) scale forms, and we analyzed statistically the data obtained.

Results: Fifty-one gastric cancer patients with a mean age of 67.1 years and 64 % males were included in the study. We found no statistically significant difference when comparing HADS scores with demographic, clinical, and pathological data. When we compared the mean scores of the EORTC QLQ-C30 with the clinicopathological characteristics of the patients, the difference was significant between gender, radiotherapy, and chemotherapy. When we performed subgroup analysis for the scales examined on the first day of radiotherapy and six months later, we found the results to be significant for fatigue, pain, financial difficulty, global health, and dyspnea for chemotherapy; role function, dyspnea, constipation, and financial situation for radiotherapy; and role function, pain, dyspnea, and insomnia for gender.

Conclusion: We demonstrated that gender, radiotherapy, and chemotherapy affected the quality of life in patients with gastric cancer, but we found no relationship between depression, anxiety, and quality of life. HIPPOKRATIA 2024, 28 (2):56-64.

Keywords: Radiotherapy, gastric cancer, quality of life, depression, anxiety

Corresponding author: Yasemin Benderli Cihan, Kayseri City Education and Research Hospital, Department of Radiation Oncology, Şeker District, 77 Muhsinyazıcıoğlu Boulevard, 38080 Kocasinan/Kayseri, Turkey, tel: +903523157700, -01, -02, fax: +903523157986, H/P: +905362169987, e-mail: cihany@erciyes.edu.tr

Introduction

Gastric cancer (GC) rates fifth most common malignancy in the world, with 6.8 %1. In clinical practice, many patients are diagnosed at an advanced stage due to generally non-specific symptoms2. Surgical intervention can be curative in the early stages; however, more than two-thirds of patients present with a locally advanced or metastatic stage at initial diagnosis. In locally advanced diseases, a combined treatment modality utilizing surgery, chemotherapy, and radiotherapy is applied3,4. The prognosis of GC is generally poor, and the five-year survival rate is quite low3.

The symptoms of GC, its treatment, and disease- or treatment-related complications may cause a decline in the individual’s functional performance and work capability, inducing social isolation, negatively affecting family relationships, and causing undesirable lifestyle changes. These interactions negatively affect those individuals’ quality of life (QoL)4-7. It is documented that improving the patient’s QoL reduces hospitalizations and emergency visits. Thus, many scales have been developed to evaluate physical and mental problems; the most commonly used are the European Committee on the Treatment and Organization of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Hospital Anxiety and Depression Scale (HADS).

Scales used to evaluate QoL consist of general and disease-specific scales. EORTC QLQ-C30 is a widely used scale that patients can apply on their own and, in a short time, allows them to evaluate concurrently the positive and negative aspects of their health status. The scale evaluates general health status, functionality (physical, role, cognitive, emotional, social, and global life), and detailed patient symptoms such as fatigue, nausea, vomiting, dyspnea, decreased appetite, constipation, and diarrhea4-10. Also, many scales have been developed to evaluate mental health, with one of the most utilized being the HADS. It was first developed in English by Zigmond and Snaith in 1983 and consists of 14 questions in total: seven questions about depression and seven questions about anxiety symptoms11.

The goals of comprehensive care for cancer patients could only be achieved by ensuring people’s physical, mental, and social well-being. Therefore, our study determined the GC patients’ QoL levels and mental status utilizing the EORTC QLQ-C30 and HADS, respectively, aiming to investigate the relationship between the participants’ QoL levels, anxiety and depression scores, and clinical and laboratory data.

Methods

We designed this prospective observational study that enrolled GC patients who received adjuvant radiotherapy in the Radiation Oncology Department of Kayseri City Education and Research Hospital after obtaining ethical approval from the Erciyes University Ethics Committee (No 2015/466). Fifty-one patients constituted the study’s population after meeting the inclusion criteria: age over 18 years, gastric cancer diagnosis, Karnofsky Performance score ≥50, ability to answer questions, no sensory loss, neurological/psychiatric disorders, or perception problems that could prevent filling out the survey, at least one of the patient’s kins or carers to be literate, and to agree to participate in the study voluntarily.

Data Collection Forms

Patients were requested to complete questionnaire forms on the first day of their adjuvant radiotherapy and six months after treatment completion. We defined as dependent variables the EORTC QLQ-C30 and HADS scales and as independent variables age, gender, type of surgery, pathological diagnosis, surgical margin, depth of invasion, number of lymph nodes removed, presence of metastases, depth of tumor invasion, chemotherapy, and laboratory data.

EORTC QLQ-C30

This scale allows more objective data collection to evaluate individuals’ symptoms, is widely used worldwide, and consists of three parts: functional scale, symptom scale, and general health status scale totaling 30 questions. The functional scale consists of 15 questions concerning physical, role, emotional, cognitive, and social functions. The symptom scale consists of 13 questions regarding specific symptoms affecting the patient’s QoL (fatigue, nausea, vomiting, pain, dyspnea, insomnia, loss of appetite, constipation, diarrhea) and financial difficulties. The last two questions represent the general health status and display the patients’ evaluation of their own QoL. There are four possible answers for each question: not at all, a little, quite a bit, and a lot, accounting for 1-4 points, respectively6. Cankurtaran et al conducted the Turkish validity and reliability of the 3.0 version of the scale on 114 different types of cancer patients and reported the scale’s Cronbach α coefficient to vary between 0.56 and 0.85, the overall QoL being 0.81, physical function 0.81, role function 0.83, emotional function 0.85, and social function 0.7412.

HADS scale

HADS evaluates the patient’s mental health status consisting of 14 items: seven questioning anxiety symptoms and seven depression symptoms. Scale’s odd-numbered questions record anxiety, while even-numbered questions measure depression. Patient’s responses are estimated in a four-point Likert format and score between 0-3. Patients are defined as not having anxiety when their anxiety score is 0-10 and having anxiety with 11 or more points. Similarly, they are defined as not having depression when scoring 0-7 points for depression and having depression when they get eight or more points. The Turkish HADS validity and reliability study was conducted by Aydemir et al, and it is widely used to screen for symptoms of anxiety and depression13. 

Statistical Analysis

We used the independent sample t-test and Mann-Whitney U test to compare the means of quantitative variables in two groups, and the dependent sample t-test and Wilcoxon signed-rank test were used to compare the means of quantitative variables in groups. We analyzed the data using the statistical cloud software TURCOSA (Turcosa Statistical Solutions Ltd. Sti, www.turcosa.com.tr). We set the significance level at p <0.05.

Results

Table 1 shows the demographic, clinical, and pathological data of the 51 evaluated patients. The average age of the participants was 67.1 years, and 64 % were male patients. The surveys conducted in the first and sixth months observed an increase in the anxiety rate. The anxiety scores of the cohort were 8.33 on average in the first survey and 8.96 six months after completion of radiotherapy, while the depression scores averaged 10.22 and 9.67 in the first and second measurements, respectively (Table 2). When the distribution of EORTC QLQ-C30 mean scores was examined, the highest score in the surveys conducted on the first day of radiotherapy was documented in social, cognitive, and role functions. In contrast, the lowest score was recorded in nausea, vomiting, loss of appetite, constipation, diarrhea, and financial difficulties. In the surveys conducted six months later, the highest score was recorded in physical, role, cognitive, and social functions, and the lowest score was documented in nausea and vomiting (Table 2).

When data regarding anxiety and depression obtained through the HADS questionnaire scale conducted on the first day of radiotherapy and six months after completion of radiotherapy was compared between gender (Table 3) and variables regarding clinical and pathological data (Table 4), no significant differences were found (all p >0.05).

According to the Student-t test results, the scale average scores recorded on the first day of radiotherapy regarding patients who received chemotherapy were statistically significantly higher than those who did not receive chemotherapy in the variables fatigue (p =0.026) and pain (p =0.020) (Table 5). When comparing the first day and six months later (dependent Student-t test), the scale score averages were significantly higher after six months compared to the first day regarding fatigue (p =0.028), financial difficulty (p =0.041) for patients who did not receive chemotherapy, and dyspnea (p =0.020) for patients who received chemotherapy. In addition, the global health scale averages were significantly lower after six months compared to the first day (p =0.047) for chemotherapy patients (Table 5).

Table 6 shows a comparison (dependent student-t test) of the measurements of the EORTC QLQ-C30 questionnaire scale on the first day and six months after completion of radiotherapy and found the difference between role function (decreased, p =0.026), dyspnea (increased, p =0.016), constipation (increased, p =0.029), and financial situation (deteriorated, p =0.040) to be significant. When the EORTC QLQ-C30 questionnaire scale results on the first day and six months were compared separately for each gender, a significant decrease in role function (p =0.005) and a significant increase in dyspnoea (p =0.011) were found after six months for male and a significant increase in pain (p =0.036) for female patients (Table 7). When male and female were compared, there was only a difference in pain (p =0.019) and insomnia (p =0.029) on the first day of radiotherapy.

Discussion

We examined in this prospective study the effects of sociodemographic, clinical, and laboratory data on the QoL, anxiety, and depression of gastric cancer patients treated with adjuvant radiotherapy. The anxiety values measured on the first day of radiotherapy increased at the end of treatment, while there was no similar increase in the depression values. We observed that the QoL was negatively affected and improved after the treatment completion. It was considered that the effect on the QoL recorded on the first day of adjuvant radiotherapy could be due to earlier surgery and the side effects of the chemotherapy concurrently received. We also observed that the QoL tended to improve as soon as the treatment was completed. There are many studies in the literature investigating the relationship between chronic diseases and anxiety depression disorders, demonstrating that depression and anxiety disorders frequently accompany chronic diseases. This association is meaningful regarding individual and public health in terms of disrupting the course of the disease in individuals, increasing treatment costs, negatively affecting treatment compliance, and causing untimely deaths9,11,14,15.

There are studies examining the relationship between patients’ quality of life, depression status, and treatment compliance and its effects on disease mortality and morbidity16-18. In their study, Park et al investigated patients with advanced gastric cancer receiving second-line chemotherapy with the EORTC QLQ-C30 and HADS scales before, during, and after chemotherapy and reported that both QoL and anxiety depression disorder improved after treatment ended. Choi et al studied the quality of life and anxiety depression levels in 565 patients who underwent endoscopic submucosal dissection or surgery for early-stage gastric cancer and observed more symptoms affecting QoL, such as fatigue, nausea, vomiting, loss of appetite, diarrhea, and pain in the surgery group. They reported no difference between the groups in HADS results7. Matsushita et al examined the EORTC QLQ-C30 and HADS scales in patients with operated gastrointestinal tumors at different times (before surgery, before discharge, and six months after discharge) and found that both scales were affected in the presence of advanced cancer stages and postoperative complications. As a result, they reported that QoL varies over time and is affected by various clinical factors8. Hu et al found that QoL was worse in patients with locally advanced gastric cancer and in patients who underwent total gastrectomy. They reported that the QoL improved within the first year10. Baundry et al reported that anxiety, depression, and QoL are affected in esophagogastric cancer9. The findings obtained in our study are consistent with the above literature.

In our study, when we examined the distribution of EORTC C-30 cancer QoL scale mean scores, the highest score in the first-day surveys was in social, cognitive, and role functions, while in the surveys conducted six months later, the highest score was in cognitive and social functions. Gender, chemotherapy, and radiotherapy were the factors affecting the QoL. There is no relationship between other clinical, pathological, and laboratory parameters. Guo et al looked at clinical conditions, symptoms, anthropometric parameters, and laboratory data that could affect the QoL in 2,322 stomach cancer patients and reported that only nutritional status affected the QoL19. Park et al examined the possible changes in EORTC QLQ-C30 for patients who underwent distal gastrectomy and total gastrectomy before and in the first, second, and third years after surgery. In the second and third postoperative years, physical functionality, role function, and fatigue were worse in the total gastrectomy group than in the distal gastrectomy group, emphasizing that the QoL should be improved in patients who undergo total gastrectomy20.

Some side effects experienced by gastric cancer patients receiving radiotherapy and chemotherapy, such as nausea, vomiting, anorexia, fatigue, anorexia, and esophagitis, are seen during treatment. The surgical techniques applied, concurrent chemotherapy drugs, additional diseases in the patient, age, gender, etc., may cause an increase in the frequency and severity of these side effects. After treatment completion, side effects decrease or completely disappear21-22. In our study, a difference was detected between fatigue, pain, dyspnea, global health, and financial difficulty from the EORTC QLQ-C30 life scales with chemotherapy; a difference between role function, dyspnea, constipation, and financial situation with radiotherapy; and a difference between role function, pain, dyspnea, insomnia in gender. It was postulated that these symptoms (pain, dyspnea, anorexia, financial difficulty, general well-being, insomnia, dyspnea, and constipation) were attributed as a direct consequence of radiotherapy and chemotherapy. Cascinu et al reported in their study that QoL improved due to reduced symptoms in patients with gastric cancer who responded better to  chemotherapy18.

Conclusion

Our study is one of the few studies examining QoL, depression, anxiety, and clinical and laboratory data in patients with gastric cancer. It was observed that gender, radiotherapy, and chemotherapy negatively affect the QoL in patients with stomach cancer. The study’s limitations include that it was conducted with a particular patient group in a single center and the potential bias influencing the accuracy of information gathered via questionnaires. However, the fact that the patients filled out the questionnaires and were followed up by a single physician is a strong aspect of the study. In order to reach a clearer conclusion, more prospective, large-scale studies are needed.

Conflict of interest

The authors have no conflicts of interests to declare.

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