Assessment of psychological distress among cancer patients undergoing radiotherapy in Saudi Arabia

Background

Cancer patients live with the burden of the disease and its treatment. Receiving a diagnosis of cancer is associated with psychological symptoms secondary to significant distress such as feeling of pain, hopelessness, fear, anxiety, and depression.¹ They also experience psychological distress due to the consequence of illness.² Previous reports show that the most common psychiatric disorders experienced by cancer patients are fatigue, anxiety, depression and adjustment disorder after the use of adjuvant therapy.^3–5 Evidence suggest that the occurrence of some psychological symptoms elevates in patients under radiotherapy.⁶

Radiotherapy is now one of the most effective means for local or regional control of cancer.⁷ Cancer patients receive radiotherapy either as their primary treatment or as adjuvant treatment along with chemotherapy and/or surgery.^7,8 About 45% of patients with malignancy require radiotherapy.⁷ Approximately, 50% of these patients are treated with the goal of curing or improving the survival rate by increasing the local control, whereas the other 50% receive palliative treatment.⁹ Previous studies also show that the period of radiotherapy may provide a valuable opportunity for screening and intervening for psychological distress.^10–12 Identifying patients suffering from psychological symptoms in the earliest period is necessary to provide appropriate care and interventions.¹⁰

Psychological distress is prevalent in cancer patients and has been associated with poor survival of cancer patients.^13–15 It can occur at any time during the course of the disease and may worsen over time.^14,16 Identification of factors associated with poor psychosocial outcomes in cancer patients who were treated with radiotherapy might aid the health care team in identifying who might be in need of additional psychosocial support. Several studies show that younger cancer patients, female patients or patients in general who perceive that their treatment is palliative may be more likely to suffer from psychological distress.^17–20 Furthermore, other demographic factors such as ethnicity and cancer type may influence the level of psychological distress.^12,20,21

Although psychological distress among cancer patients is expected, various studies have shown that anxiety and depression are significant and prevalent problems that affect patient quality of life.^22,23 In Saudi Arabia, studies show that social and emotional functions were the lowest and most troubling symptoms among cancer patients.^24,25 In fact, evidence indicates that patients with first-year after cancer diagnosis be likely to have a poor emotional well-being, social function and general health.²⁴ Given the importance of psychological assessment of cancer patients, only few studies in Saudi Arabia have been conducted to explore the psychological morbidity. Compared to Western countries, studies related to psycho-oncology particularly patients undergoing radiotherapy are a neglected or isolated subject. Furthermore, cancer patients under psychological distress have reduced compliance with treatment and prolonged hospitalizations.^22,26 Identifying cancer patients who may be more likely to suffer from psychological distress over the cancer trajectory is essential to targeting the proper interventions and providing the best care.

Based on the authors' knowledge and literature search, there is a scarcity of research studies which encompass the level of psychological distress among patients undergoing radiotherapy. The primary objective of this study is to assess the level of emotional and physical distress, depressive symptoms, and social concerns of cancer patients undergoing radiotherapy in Saudi Arabia. A secondary objective is to identify demographic and clinical characteristics associated with distress, depression and social concerns.

Methods

Design and setting

A descriptive cross-sectional study was performed at five different public tertiary-level hospitals in Saudi Arabia, from November 2015 to April 2016. These hospitals were selected because they are the largest referral hospitals for cancer patients and established by the Ministry of Health (MOH) of Saudi Arabia. Cancer patients in Saudi Arabia who go through radiation therapy mostly takes place in outpatient clinics and usually take 5 days a week to 8 week depending on the cancer type and location.

Study population

Patients had to be at least 18 years of age and above, with a confirmed diagnosis of cancer-based from patients’ medical records; receiving radiotherapy; and able to speak and understand either Arabic or English. All patients previously diagnosed with psychiatric condition were excluded from the study.

Ethical consideration

Ethical approval was obtained from the College of Applied Medical Science at King Saud University (CAMS 49-36/37) and from each of the selected hospitals prior to distribution of the survey questionnaires.

Instruments

Two surveys instruments were administered. The first part of the questionnaire was the demographic and clinical characteristics data that include age, gender, marital status, level of educational attainment, employment status, primary cancer type, age when diagnosed with cancer, number of children and a self-rating of their overall health status. The participants were asked to rate their overall health status and responded using a 5-point adjectival scale ranging from poor (0) to excellent (4).

The second part of the questionnaire was the Psycho-Oncology Screening Tool (POST) is a validated screening instrument used to identify the level of distress of cancer patients undergoing radiotherapy. It is a 33-item self-reported survey designed to evaluate emotional and physical distress, depressive symptoms, social concerns, willingness to receive psychosocial services, and level of support.²⁷ The POST is only one-page and can be completed by the participants in fewer than 5 mins. The POST consists of three components. The first component (which measures emotional and physical distress) consists of six VASs rating fatigue, anxiety, confusion, depression, anger, and pain. Study participants were asked to indicate their symptom level over the past week by drawing a vertical mark across a horizontal 100-mm line that included a left-side anchor of “None” and a right-side anchor of “Most possible.” The researcher measured the distance from the start of the line to the point where the respondent’s mark crossed the horizontal line to get a numerical rating that corresponded to the number of millimeters for each VAS. In addition to individual item VAS scores (range 0–100), a total physical and emotional distress score was calculated by summing the six VAS scores (total score range from 0 to 600).

The second component of the POST consists of two subscales: one that measures depression and the other that measures social concerns. The Depressive Symptoms Subscale is a list of 14 items assessing the somatic, cognitive, and emotional symptoms of depression to which patients responded either yes or no (yes = 1 point, no = 0 points). The total Depressive Symptoms Subscale score is calculated by summing the 14 item scores (range 0–14). The Social Concerns Subscale included a list of 13 yes or no items (yes = 1 point, no = 0 points) divided into practical concerns (six items), family/social concerns (five items), and spiritual/religious concerns (two items). The social concerns items were summed to create a total score ranging from 0 to 13.

The third component consists of four questions that assess patient interest in receiving psychosocial assistance. The first two questions ask whether the respondent would be interested in individual and/or group services. The last two questions assess the respondent’s sources of support, as well as the perceived adequacy of the support.

For this study, to ensure the cultural appropriateness and adaptation of the instrument, a forward-translation and back-translation methods were performed. One of the authors (EA) and professional language translator emphasize a conceptual language translation such as using a simple, clear and concise question for the patients. All of the authors including the professional language translator compared the translated instrument to the original English version and approved the Arabic version of the instrument. The Arabic-translated questionnaire was pilot-tested on a sample of patients (n=30) to ensure the clarity, understandability and cultural relevance of the items. Patients’ medical record number was saved and recorded to ensure that all patients from the pilot study were not included in the larger study. After the pilot testing, the Arabic instrument was modified and adjustments were made as necessary for scoring a better response from the participating subject prior to data gathering. Adjustments were done such as deleting question relating to God and making the translated questionnaire easy to understand for the respondents. The Cronbach’s alpha coefficients of the three components that have been used were 0.73 (Physical and Emotional), 0.71 (Depressive Symptoms Scale) and 0.70 (Social Concerns).

Procedure

Prior to the distribution of the questionnaire, the researcher explained the purpose of the study to the patients and that their participation was voluntary. All patients who agreed had provided written informed consent to participate and to review their medical records. We distributed 50 survey questionnaires in each hospital and patients were recruited using a convenience sampling during their visits for radiotherapy. The participants were assisted by a trained researcher and an oncology nurse while answering the questionnaire. In order to ensure anonymity, no names or other identifiable information were included in the questionnaires or database. Also, researchers checked medical records to confirm the validity of diagnosis, age of diagnosis, treatment method, and stage of disease.

Statistical analysis

All data were entered and analyzed using SPSS 22 (Chicago, IL, USA). Patient characteristics were summarized using descriptive statistics. All continuous data were presented as mean ± SD while categorical data were presented as frequencies and percentages (%). All numeric variables were tested using independent t-test and ANOVA. Pearson correlation coefficient was used to examine the correlation between variables. Linear regression was done to determine the predictors associated between emotional and physical distress, depression and social concerns and other parameters. The dependent variables used are emotional and physical distress, depression and social concerns, while the independent variables are demographic characteristics and clinical data of the participants. Non-binary independent variables such as age, marital status and age diagnosed with cancer were dichotomized and coded as “1” and “2.” The group categories were: under and over 45, primary and secondary versus bachelor and above, employed versus unemployed, good, fair and poor versus very good and excellent overall health status. Cancer type was dichotomized according to groups of breast and colorectal cancers. These cancers were selected because they are the most prevalent cancer types in Saudi Arabia. Other type of cancer was dropped also in the analysis because of the small sample in the study. A p-value below 0.05 was considered statistically significant.

Results

Characteristics of the study sample

Out of 250 questionnaires distributed, 148 respondents (59.19%) took part in the study. The demographics and clinical characteristics of the study sample are presented in Table 1. The respondents were relatively young with a mean age of 46.2±9.26. Only 7% of the participants were 61 or older. The majority of the participants were male (n=88, 58.1%), Saudi nationals (n=128, 85%), employed (n=98, 66.2%) and married (n=128, 86.5%). Almost half of the participants rated their overall health as good (n=75, 50.7%), while 36.2% rated it as very good to excellent and 12.9% reported their overall health as poor to fair.

Table 1 Demographic and clinical characteristic of participants

Level of psychological distress of patients undergoing radiotherapy

Table 2 presents the mean, SDs, and ranges of the POST instrument in which high scores indicate higher level of distress. Participants demonstrated substantial level of physical and emotional distress, depression and social concerns. For the first component of the POST assessing physical and emotional distress, patients’ demonstrated distress among the six individual VAS scores (range 0–100). The individual VAS scores were Fatigue (62.16±11.2), Anxiety (66.48±13.24), Confusion (68.51±13.62), Depression (67.83±13.72), Anger (68.10±14.34), and Pain (64.10±17.24). The mean total (sum of the six scales) individual VAS’s scores was (342.07±78.9) (range 0–600). Regarding the second component of the POST, participants had a mean of 7.75 (SD=1.74) depression characteristics from the Depression Subscale (range 0–14) and a mean of 7.27 (SD=1.68) social concerns from the Social Concerns Subscale (range 0–13). From the third POST component, 78% of the participants were interested in talking to a social worker or behavioral health specialist, while 69% were interested in participating in a support group offered at the cancer center. The majority of the participants had adequate support in coping with their illness and treatment (n=104, 70%) and 40% of the participants reported that family was the most common source of support.

Table 2 Mean, SDs, and ranges of scores of different measures

Association of psychological distress of cancer patients undergoing radiotherapy

Table 3 shows the association of psychological distress of cancer patients undergoing radiotherapy on the parameters included in the present study. In level of Physical and Emotional distress had significant inverse correlation with marital status (P<0.05), and number of children (P<0.001). There was a moderate, positive association found between overall health status and Physical and Emotional distress of patients (r=0.043, n=148, P<0.001). In Depressive symptoms domains, only employment status made a significant association found on the study parameters (r=−0.10, n=148, P<0.05). Meanwhile, employment status (r=−0.26, n=148, P<0.001) and number of children (r=−0.27, n=148, P<0.001) show moderate, inverse association (P<0.001) with social concerns. Other parameters were found no significant associations.

Table 3 Association of level of psychological distress of cancer patients undergoing radiotherapy

Factors associated with psychological distress of patients undergoing radiotherapy

Table 4 presents the predictors of psychological distress of cancer patients undergoing radiotherapy included in the present study. Preliminary analyses were conducted to ensure no violations of the normality, linearity and multicollinearity. In the final model, five variables emerged as significant predictor of physical and emotional distress of cancer patients undergoing radiotherapy. Age was a significant predictor of psychological distress (P<0.05). Younger patients complained of more physical and emotional distress symptoms than older patients. Age diagnosis of cancer as considered a predictor of physical and emotional distress recording a higher beta value (beta=0.28, P<0.05) followed by overall health status of patients (beta=0.22, P<0.05).

Table 4 Predictors of psychological distress of cancer patients undergoing radiotherapy

Marital status emerged as significant predictor of depressive symptoms and social concerns (P<0.05). Employment status was linearly correlated with domains of depressive symptoms and social concerns (P<0.001) recording a higher beta value (beta=0.38, P=0.001). Unemployed patients felt more anxious and had a social issue than patients who were employed (P<0.001). The patients’ type of cancer was found to be significantly correlated with domains of depressive symptoms. For example, breast cancer patients felt more depressed (P<0.05) and distressed (P<0.05) than patients with other types of cancer. The age of patients diagnosed with cancer was found to be significantly correlated with social concerns (P<0.001). The results showed that patients who were diagnosed with cancer at a younger age experienced had more social concerns (P<0.05). As can be seen in Table 3, physical and emotional distress and social concerns (P=0.001) significantly correlated with the number of children of the patients. The analysis shows that physical and emotional distress (P<0.001) as well-social concerns (P<0.05) greatly impacts the overall health status of patients undergoing radiotherapy.

Discussion

This study examined the level of psychological distress of patients undergoing radiotherapy in Saudi Arabia. It has identified that majority of the participants were younger and quietly highly educated patients. In addition, almost 50% of the respondents were diagnosed with cancer below the age of 40's. This indicates that the prevalence of cancer in Saudi Arabia increased considerably among younger age group. An alternate explanation is that cancer in Saudi Arabia is a sensitive issue and most patients do not want to participate and discuss their condition particularly older patients. We believe that this has impacted the level of resources, support, and concerns patients experienced in the study.

Our study found substantial level of distress, depression, and social concerns among cancer patients undergoing radiotherapy. The level of fatigue found in our study was comparable to the previous study conducted in India and Malaysia.^28,29 Fatigue was found as one of the most common symptoms among patients undergoing radiotherapy in Arabic and Western countries.^30–33 Previous study reported that fatigue was commonly mixed with depression and anxiety which form one symptom cluster among cancer patients.^34,35 The level of depression and anxiety found in our study was high compared with the level of fatigue. The level of depression and anxiety found in the current study was above average might be because of the demographic characteristics of our study sample. Specifically, majority of the respondents were in younger age and diagnose their condition below age of 40's which could be linked to high levels of depression.^36,37 Symptoms of depression were also observed among cancer patients undergoing chemotherapy.^38,39 Most cancer patients experience multiple symptoms due to the nature of their disease and its treatment.⁴⁰ It is recommended that approximately half of all new cancer patients should receive radiotherapy.⁴¹ The delivery of radiation to control tumors provides side effects which often results in deterioration of the physical and psychosocial conditions of these patients.^40,42

Our findings also show several demographic factors associated with the level of distress, depression, and social concerns. Younger age was associated with greater distress and social concerns than older cancer patients. The high level of psychological distress among younger cancer patients was also found in a study in Korea in which anxiety or depression was greater among patients below 65 years old than patients more than 65 years old.³⁷ However, a study from Norway identified greater levels of anxiety among middle-aged cancer patients and lower levels of anxiety patients under 30 and over 70 years old.¹⁹ This discrepancy supports our findings that age was a significant predictor in psychological distress of cancer patients undergoing radiotherapy as well as in other studies.^17,43–45 For example, in a 5-year observational study done by Burgess et al, shows a dropping point of prevalence of depression and anxiety among breast cancer patients for the first to fifth year.⁴⁴ From 48% of prevalence of depression and anxiety to 15% in the fifth year.⁴⁴ A possible reason for this finding is that the impact of cancer among younger patients is generally unexpected and they may find it difficult to accept the nature of disease and its treatment. For example, young breast cancer patients having mastectomy or breast surgery and early menopause caused by the treatments may find it more difficult to accept changes in the body and that can be a distressing experience. Previous studies have reported older age was strongly correlated with less psychological distress and a strong moderator of resilience than younger cancer patients.^46,47 Resilience is a person’s capacity to handle hardships and stressors in life.⁴⁸ Viewed in this context, older patients are capable of recovery and may have developed skills during their lifetime to recover toward psychological distress. Thus, younger cancer patients may be in particular need of support and interventions that will increase their resilience and help lessen the psychological distress during cancer treatment. This may effectively prolong the goal of cancer treatment beyond patients’ survival.

The type of cancer was significantly associated with distress and depression symptoms. Breast cancer patients feel more depressed (P=0.046) and distressed (P=0.017) than patients with colorectal cancer. Our results were contrary to a previous study conducted in the United States that examines the variations of anxiety and depression among the most common cancer types.⁴⁹ In that study, lung, gynecological, and hematological cancer patients reported the highest levels of distress at the time of cancer diagnosis. However, a review study done by Stiegelis et al found no significant correlation between cancer site and psychological distress.⁵⁰ Future studies are needed that assess patients’ cancer type and other identified predictors such as physical, behavioral and social stressors because this might reflect differences in prognosis, treatments or potentially in models of care of cancer patients undergoing radiotherapy. Stressors are nutritional deficiencies, emotional resentments and frustrations, relationship/marriage difficulties and lack of social support. They may also provide a better understanding of the daily challenges and concerns of individuals diagnosed with cancer, while providing the information for clinicians, researchers, and policy makers to meet the needs of this patient population. Another highlight of this study is the domains of physical and emotional distress as well as social concerns that significantly influence the overall or global health status of cancer patients undergoing radiotherapy. This finding implies the psychosocial impact of the disease and its treatment among cancer patients. A need for psychosocial support focusing on managing and adopting coping strategies with the disease and its treatment might help patients in developing higher risk of emotional disturbances.⁵¹

The present study stresses the importance of support services or psychosocial care for cancer patients. Approximately, 80% of the participants were interested in talking to a social worker or behavioral health specialist, while 69% were interested in attending a support group offered at the cancer center. With regard to intervention strategies used to reduce anxiety and/or depression, a combination of psychological education and supportive psychotherapy may be effective to support cancer patients undergoing radiotherapy. In Finland, breast cancer patients thought they would have felt more supported if they had received more information about their disease.⁵² Furthermore, communication between the patient and the physician and treatment team remains a keystone of care particularly with cancer patients. Identifying patients in need of psychosocial intervention by screening for psychological distress or available social support could enhance any effect on well-being.

Limitations

The present study is limited in terms of sample size. We believe that cancer patients’ particularly older patients conceal their feelings, and as well as the relative who were the ones who decide for their patients do not want to disclose the patient’s situation. Other variables like comorbid conditions and concomitant medications were not assessed which consider another limitation of the study. In addition, the assessment tool was developed from the Western nation, and may not be applicable in Saudi Arabia because of the norms in Saudi Arabia may differ on the scales. However, the instrument was translated in the Arabic language by a professional language translator and modified pilot tested with an acceptable level of Cronbach Alpha. Future research should investigate in more detail these differences between cancer types. Lastly, convenience sampling was used to select the participants, probably may restrict the generalizability of the findings of the study and do not reflect the psychological distress of cancer patients undergoing radiotherapy in Saudi Arabia. However, these findings may form a preliminary database that might be useful for health authorities in assessing the current level of psychological distress among cancer patients undergoing radiotherapy in Saudi Arabia. Such studies may help in developing or enhancing psychosocial intervention programs for cancer patients undergoing radiotherapy in the whole country at a larger level. This might also serve as a criterion for good functioning or comparison if it is possible.

Conclusion

Cancer patients undergoing radiotherapy in Saudi Arabia demonstrate substantial level of physical and emotional distress, depression, and social concerns. Furthermore, many are interested in accessing support services. Though the present study covers a small sample size, the results may provide preliminary information on the likely presence of psychological distress among cancer patients undergoing radiotherapy in Saudi Arabia. Addressing these issues can not only improve quality of life but also adherence to cancer treatments. Patients who were young and have certain primary cancers may demonstrate greater susceptibility to these issues. Routine screening should be performed and psychosocial support services should be available for these patients. Future studies should include the level of distress before and after radiotherapy and differences between cancer types. Further research might investigate the efficacy of psychosocial support therapy and efforts to improve methods reducing psychological distress among cancer patients undergoing radiotherapy.