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ORIGINAL ARTICLE
Year : 2023 | Volume
: 9
| Issue : 3 | Page : 307-313
Characteristics and correlation analysis of negative emotions, quality of life, and chinese medicine syndromes in patients with lung cancer after surgery: A cross-sectional study
Cong-Meng Zhang1, Yi-Feng Gu1, Sheng-Ping Shen2, Yi-Chao Wang1, Ao Qi1, Ling-Zi Su1, Jia-Lin Yao1, Jia-Qi Li1, Wen-Xiao Yang1, Qin Wang1, Li-Jing Jiao1, Xiong Qin3, Ya-Bin Gong1, Ling Xu1
1 Department of Oncology, Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital, Shanghai, China
2 Department of Oncology, Shanghai Chest Hospital, Affiliated Chest Hospital of Shanghai Jiao Tong University, Shanghai, China
3 Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai, China
Correspondence Address:
prof. Ling Xu
Department of Oncology, Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital, No. 110 Ganhe Road, Hongkou 200437, Shanghai
China
Prof. Ya-Bin Gong
Department of Oncology, Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital, No. 110 Ganhe Road, Hongkou 200437, Shanghai
China
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2311-8571.385512
Objective: The objective of the study was to observe and analyze the characteristics of negative emotions and quality of life (QoL) in patients with nonsmall cell lung cancer (NSCLC) from 1 to 3 months after surgery, and summarize their population characteristics after surgery. Materials and Methods: The consolidation rehabilitation period was defined as 1 to 3 months after surgery. The main observation indicators were the general Hospital Anxiety and Depression Scale, the European Organization for the Research and Treatment of Cancer Core QoL Questionnaire (EORTC QLQ-C30), and EORTC QLQ-Lung Cancer-13. The secondary observation indicators were peripheral blood cytokines and immune function indicators. Statistical methods such as one-way analysis of variance and logistic regression were used to analyze the characteristics of this part of the population. Results: Among patients who underwent lung surgery, the overall incidence of anxiety during consolidation recovery was 13.66%, and that of depression was 10.38%. The scores of fatigue, pain, dyspnea, insomnia, and loss of appetite were significantly higher than those of other symptoms (P = 0.000). The presence of anxiety was associated with the site of surgery (P < 0.05) and the presence of depression was associated with emotional functioning and dyspnea (P < 0.05). Conclusions: The occurrence of negative emotions in the postoperative NSCLC population is related to gender, and the degree of emotions is negatively correlated with QoL and positively correlated with the degree of symptoms. The main relevant syndromes are the pulmonary and meridian categories.
Keywords: Chinese medicine syndromes, lung cancer, negative emotions, postoperative, quality of life, rehabilitation
Lung cancer is one of the most common malignant tumors worldwide. Surgical resection is the treatment choice for early-stage nonsmall cell lung cancer (NSCLC); however, the stress responses and neurological dysfunction brought about by surgery, accompanied by nausea, vomiting, pain, loss of appetite, insomnia, and other symptoms, seriously affect the patients' quality of life (QoL). In addition, owing to the dual effects of cancer diagnosis and surgery, postoperative patients with lung cancer may face even more severe problems of negative emotions.
Negative emotions, represented by depression and anxiety, are the most prevalent, with 8.9%–33% of lung cancer survivors reporting having experienced depression and 19.7%–34% having felt anxious.[1] With the shift in the medical paradigm, the biopsychosocial model is gaining increasing attention. In addition to the treatment against the tumor itself, the relationship between negative emotions and the incidence and prognosis of tumors is being increasingly emphasized.
This study summarized the population characteristics of postoperative patients with NSCLC through a cross-sectional study of the QoL and negative emotions of those patients and revealed the correlation between negative emotions and QoL in the postoperative patients.
Materials and MethodsStudy design
A cross-sectional study was conducted to investigate the status of patients with lung cancer during the consolidation recovery period (1 to 3 months postoperatively).
Settings
The NSCLC patients who had undergone radical surgical resection at the Oncology Department of Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital and Shanghai Pulmonary Hospital from June 2020 to January 2022 were recruited. All procedures were carried out in compliance with the guidelines approved by the Ethics Committee of the Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital, and the approval number is No. 2020-038.
Participants
Inclusion criteria included: (1) underwent surgical resection of an occupying lung lesion, (2) 4 ± 1 weeks after radical surgical resection of the lung, and (3) being able to cooperate with clinical data investigation. Patients with incomplete clinical data were excluded. The study was approved by the Ethics Committee of Shanghai Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital, and the informed consent form was signed by all the participants.
Variables
Patients' general medical history data (gender, age, surgical site, procedure, and pathology type) were collected. The pathological diagnosis was based on the 2015 World Health Organization (WHO) classification criteria.[2] The Hospital Anxiety and Depression Scale (HADS) was used to assess negative emotions.[3] The Chinese version of the European Organization for the Research and Treatment of Cancer Core QoL Questionnaire (EORTC QLQ-C30) and EORTC QLQ-Lung Cancer-13 (EORTC QLQ-LC13) (version 4) was used to assess the patients' QoL.[4] The symptoms in the EORTC QLQ-C30 and LC13 were categorized into different groups with reference to the clinical terminology of the traditional Chinese medical diagnosis and treatment:[5] insomnia and sore mouth or tongue were categorized in the heart system; nausea, vomiting, appetite loss, constipation, diarrhea, and dysphagia were categorized in the spleen and stomach system; fatigue, dyspnea, cough, and hemoptysis were in the lung system; pain, pain in the chest, peripheral neuropathy, pain in the arm or shoulder, and pain in other parts were in the meridian system; and alopecia was in the liver and kidney system. Patients' peripheral blood inflammatory indicators were collected, including interleukin (IL)-1β, IL-2 receptor, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF-α).
Data sources/measurement
Each eligible participant was contacted by the investigator within 1 week of signing the informed consent form. The investigator collected basic information about the participant at that time and checked they had completed the HADS, EORTC QLQ-C30, and EORTC QLQ-LC13. Participants visited the hospital within 7 days of signing the informed consent form to collect a blood sample for blood inflammatory indicators. To avoid survey bias, data were collected by trained independent questionnaire collectors.
Study size
The incidence of negative emotions was expected to be 26% in the consolidation recovery period,[6] with a two-tailed α of 0.05, 80% power, and 20% tolerance error of specificity. A sample size of 84 cases was calculated using PASS 15.0 for Windows.
Statistical analysis
All collected clinical data were entered into the computer using the database for all data entries; after completion, SPSS 26.0 (IBM SPSS statistics, kmont, New York, USA.) was applied for statistical processing. Quantitative variables were expressed as means ± standard deviation. Count variables were expressed as quantities and percentages, and the specific methods of statistical analysis were as follows: (1) quantitative variables: one-way analysis of variance was used to compare the scores of each subscale; and (2) count variables: Chi-square test, Fisher's exact test, and so on.
Patients were categorized by the HADS-Anxiety (HADS-A) scores into the presence and absence of anxiety or depression; the presence was assigned a value of 1 and the absence a value of 0. Logistic regression was adopted to analyze the relationship between anxiety and depression, clinical symptoms, QoL, gender, and the surgical site. The regression method was used as the independent variable screening method.
ResultsA total of 183 patients were eventually observed [Figure 1], and their general data are presented in [Table 1].
Table 1: Demographic and baseline disease characteristics for patients during the consolidation rehabilitation period (n=183)Occurrence of anxiety and depression
A HADS-A or HADS-Depression score of 7 was used as the cutoff value, and >7 indicated the presence of anxiety or depression. The incidence of anxiety in the consolidation recovery period was 13.66%, and that of depression was 10.38% [Table 2].
Quality of life
The QLQ-C30 scale scores of the 183 patients in the consolidation recovery period displayed no significant differences in the scores of the functional domains (P > 0.05), while the symptom domains of fatigue, dyspnea, insomnia, and pain were significantly higher than the other symptoms (P < 0.05). The QLQ-LC13 scale suggested that the main symptom was cough, followed by dyspnea, pain in the chest, and pain in the arm or shoulder (P < 0.05). Syndromes were distributed across the pulmonary and meridian categories [Table 3].
Table 3: Scores of quality of life questionnaire and quality of life questionnaire-lung cancer (mean±standard deviation)Factors associated with anxiety and depression during consolidation recovery
Univariate logistic regression analysis established that the occurrence of anxiety was correlated with the site of surgery, fatigue, dyspnea, peripheral neuropathy, alopecia, pain in the chest, pain in the arm or shoulder, and pain in other areas (P < 0.05). Symptoms were distributed across the pulmonary and meridian categories.
The occurrence of depression during consolidation was correlated with gender, physical functioning, emotional functioning, cognitive functioning, global QoL, fatigue, insomnia, dyspnea, peripheral neuropathy, alopecia, pain in the arm or shoulder, and pain in other areas (P < 0.05). The associated symptoms were mainly distributed in the pulmonary, cardiac, and meridian categories of syndromes. It is suggested that women are more likely to experience depression than men. With the scores of physical, emotional, and cognitive function, and global QoL getting lower and the symptoms of fatigue, insomnia, dyspnea, peripheral neuropathy, alopecia, pain in the arm or shoulder, pain in other areas being more severe, the patient is more likely to be depressed [Table 4]. No significant association was observed between ILs and anxiety or depression [Table 5].
Table 4: Single-factor logistic analysis of related factors of anxiety and depression
Table 5: Results of multifactor logistic regression analysis between anxiety, depression, and interleukin
Table 6: Multifactor logistic regression of related factors of anxiety and depressionFurther multifactorial logistic regression analysis revealed that the site of surgery was an associated factor for the occurrence of anxiety (P < 0.05). For depression, the emotional functioning score was a protective factor (odds ratio [OR]: 0.942, 95% confidence interval [CI]: 0.900–0.987). The dyspnea score was also a risk factor (OR: 1.015, 95% CI: 1.008–1.122) [Table 6].
DiscussionWith the increasing awareness of cancer being a physical and mental illness, people are paying more attention to symptom management and the impact of negative emotions on the long-term survival and prognosis of patients with lung cancer.[7] This study established that the majority of postoperative patients with lung cancer had anxiety and depression, as well as decreased QoL at 1 month postoperatively. The occurrence of anxiety and depression in postoperative patients with lung cancer was negatively correlated with the functional domain scores and positively correlated with the symptom scores. The related symptoms were mainly concentrated in the pulmonary and meridian symptom groups.
A cross-sectional study of 1002 patients with a variety of solid tumors with the survival of 5 and 10 years or more determined the following: the occurrence of moderate-to-severe depression and anxiety was found in 17% and 9% of cancer survivors, respectively; women had higher rates of anxiety and depression than men; the older the age of patients, the higher the rate of anxiety and depression would be; the variables financial problems, global QoL, and cognitive function had the strongest association with depression and anxiety.[8] A cross-sectional study at Guang'anmen Hospital in China documented that 34.2% of inpatients with lung cancer had anxiety, and 58.1% had depression. Furthermore, insomnia is a common factor of anxiety and depression, while constipation and gender are independent factors.[9] However, to the best of our knowledge, there has not been a large research sample to determine the incidence of anxiety and depression and related factors for this specific population after lung cancer surgery. The current study determined that the rates of anxiety and depression in the study population differed significantly from those at Guang'anmen Hospital. According to the analysis, the majority of patients with lung cancer who had undergone surgery were in the early and middle stages, and this group had a stronger confidence in the treatment; most of their symptoms came from the surgery rather than cancer itself, which led to a lower incidence of anxiety and depression. The multifactor analysis also suggested that the operative style and dyspnea were the common influencing factors of anxiety and depression; different surgical procedures had different effects on lung function and respiration. The larger the area of lung tissue excision, the more severe the lung function impairment. This result also explained why the incidence of anxiety and depression differed from other studies. Therefore, because the occurrence of anxiety and depression in patients after lung cancer surgery has its own unique reasons, clinical workers should pay more attention to reduce surgical trauma as far as possible, carrying out postoperative rehabilitation as soon as possible, and improving the symptoms caused by surgery.
In addition, a study of 217 patients with lung cancer documented higher serum levels of TNF-α, IL-1β, IL-6, and IL-17 in patients with elevated HADS scores compared with healthy people.[10] This suggests that these four indicators are related to the incidence of anxiety and depression. The results of the current study indicated that IL-1β and IL-10 expression levels might be higher in those with anxiety or depression in postoperative patients with lung cancer. The reason for the difference is that the effective collection rate of serum samples was significantly low, which greatly reduced the statistical sample size.
Surgery is the treatment choice for lung cancer. While significantly improving the survival of patients, it is accompanied by risks and impacts on postoperative QoL.[11] Koch established that the most significant symptoms among patients with lung cancer who had undergone surgery were fatigue and dyspnea,[12] and investigations confirmed that fatigue and pain were also the main symptoms in those undergoing treatment.[13] For patients with lung cancer undergoing lobectomy, the 15 domains of the QLQ-C30 can be improved through appropriate care and exercise 1 year postoperatively and present individual changes. Age, preoperative QoL score, perioperative complications, and type of surgery in patients with lung cancer significantly influence the QoL in the early postoperative period and its trend over time.[14] Surgical treatment removes part of the lung tissue, which changes the local physiological structure and reduces the lung ventilation area, resulting in impaired lung function. The need for repeated intraoperative traction and tracheal intubation, which compress and stimulate the lung tissue and airways, leads to inflammatory exudation of these. In addition, postoperative patients have incomplete sputum excretion owing to painful trauma and the inability to cough, which further leads to complications such as secondary infection and pulmonary atelectasis. All of the above are causes of cough, shortness of breath, and dyspnea after pulmonary surgery,[15],[16] and the QoL of the postoperative patients is further affected and decreased. The present study further confirmed that the QoL of patients after pulmonary surgery decreased, and that there was a correlation between their negative emotions and QoL.
Negative emotions are mainly related to the psychological stress or trauma faced by patients. The impact of surgery on self-care, socialization, and work, and the financial stress of treatment change the patient's previous comfortable psychological environment and increase the risk of negative emotions. Postoperative symptoms are also an important influence on the development and severity of negative emotions. Research has confirmed that the QoL of anxious and depressed patients with lung cancer was significantly lower, and the degree of anxiety and depression had a negative effect on both the QLQ-C30 and QLQ-LC13 functional scales and the symptom scale.[17] The results of the present study are largely consistent with these findings. The correlation between anxiety and depression, QoL, and symptoms was further confirmed. This study additionally found that serum IL-1β and IL-10 expression might be higher in individuals with anxiety and depression. In their respective studies, Song and Xin, Li et al., and Shi confirmed that inflammatory cytokines such as IL-6, IL-1β, and TNF-α could promote negative emotions such as anxiety and depression by affecting the hypothalamic–pituitary–adrenal axis.[18],[19],[20]
The current study established that the postoperative patients experienced cough, shortness of breath, chest pain, or other somatic pain as the main symptoms, which mainly belong to pulmonary and meridian syndromes. Negative emotions were positively correlated with the severity of these symptoms; this is also largely consistent with other research. Dong et al. demonstrated a significant positive correlation between the level of anxiety and depression and pain, and symptoms such as cough, hemoptysis, and shortness of breath also increased the risk of negative emotions in postoperative patients.[21] In Chinese Medicine Theory, lung surgery injures the lung body and damages the meridians; hence, the postoperative patient is prone to the lung system and meridian syndromes. “The lungs are the main source of qi, and the meridians are the pathways through which qi and blood flow.” As stated in the Su Wen – Ju Tong Lun, “The circulation of qi in the meridians does not stop, the circumference does not stop.” “Surgical trauma makes the flow of qi unstable. Most diseases are born from abnormalities of qi.” Emotion is susceptible to qi, which is consistent with the results of the current study in which the pulmonary and meridian system groups were closely related to patients' anxiety and depression.
However, some of the results were inconsistent with existing research. Some studies have documented that sociodemographic characteristics, such as gender, age, marital status, and education level, are also important influences on the occurrence of negative emotions.[22] In the current study, only females were found to be more prone to negative emotions, which may be due to the fact that they are more likely to be stimulated by the external environment to develop negative emotions than males. The factors influencing negative emotions in patients with lung cancer also include the mode of surgery, degree of tumor differentiation, and tumor stage.[23] Therefore, the results should be validated using a larger sample.
ConclusionsThe occurrence of negative emotions in the postoperative NSCLC population is related to gender; the degree of emotions is negatively correlated with QoL and positively correlated with the degree of symptoms. The main relevant syndromes are the pulmonary and meridian categories.
Financial support and sponsorship
This study was supported by the National Natural Science Foundation of China (No. 81973810); Shanghai Science and Technology Commission “Science and Technology Innovation Action Plan” medical innovation research special project (No. 22Y31920400); and Clinical Collaboration Pilot Project of Traditional Chinese and Western Medicine from Shanghai Municipal Health Commission (ZXYXZ-201901).
Conflicts of interest
There are no conflicts of interest.
References
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