Anxiety, Perceived Stress and Self-Efficacy of Elderly Oncology Patients
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Citation: Anxiety, Perceived Stress and Self-Efficacy of Elderly Oncology Patients. American Research Journal of Geriatrics and Aging; V1, I1; pp: 1-7.
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Abstract:
The results revealed that the group of patients with cancer had a significantly higher value of perceived stress compared to the control group (279.62 vs. 125.05, F = 33.222, p <0.0001). Moreover, the self-efficacy scores were significantly lower in the study group (28.89 vs. 31.13, F = 5.893, p <0.016), and for anxiety-trait, significantly increased compared to the control group (49.43 vs. 43.12, F = 4.895, p< 0.028).
In women from the study group, self-efficacy was significantly lower compared to the control group (28.38 vs.30.72, F = 6.995, p <0.009, F = 6.995), while the perceived stress was higher (269.15 vs. 114.70, F = 30.377, p<0.0001). Men with cancer scored significantly higher in trait anxiety (53.10 vs 39.68, F = 29.66, p <0.0001), state anxiety (48.033 vs 37.44, F = 6.811, p<0.012) and perceived stress (300.23 vs 150.72, F = 19.855, p <0.0001).
These results plead in favor of a significant relationship between the psycho -behavioral patterns and the presence of cancer in the elderly and also represent an argument for the inclusion of clinical psychologists in the multidisciplinary team caring for these patients.
Description:
INTRODUCTION
In the last decades, the incidence of cancer has reached an
unprecedented level (1). World Health Organization (WHO) estimates an increase
of approximately 70% new cancer cases per year, in the next 20 years, with the potential
to reach a global incidence of 22 million (2).
In Romania, the age-indexed incidence of cancer has been
reported to be 224.2 at 100000 (3), with a number of deaths attributable to
cancer having consistently reached in the last decade over 50,000 each year.
Many cancer cases are discovered in a late phase, which brings into light the
need to invest additional resources for cancer prevention, including the design
of optimal strategies for cancer screening.
Currently, cancer is largely reported in literature to be
caused my multiple factors, such as genetic configuration (4-6), or
environmental and psycho-behavioral variables (7). In this sense, the
integrative vision of cancer brings a lot of benefits for understanding the
indestructible and bidirectional link between psychological factors and the
nervous, endocrine and immune systems. This relationship was reported in 1975
by Dr. Robert Ader, under the concept of “psychoneuroimmunology” (8). Since
then, many papers argued in favor of the relationship between stress and cancer
as being mediated by the efficiency of the immune system, which is in turn
influenced by cognitive and affective factors (11).
Among cognitive
factors, self-efficacy plays a key role, many experts emphasizing the strong
relationship between self-efficacy, cancer prevention and the adaptation to
cancer (9-11). Self-efficacy can help an individual to better adjust to cancer
and to the side effects of therapy, leading to improved sense of disease
control (12, 13). Literature data show a direct proportionality between
self-efficacy and the strength of the immune system (14). Inversely, low
self-efficacy is reported to be associated with the defective functioning of
the immune system, particularly of the cytotoxic T and NK cells (15). Based on
self-regulation and self-efficacy theories, instruments such as the Cancer
Behavior Inventory were developed as a measure of self-efficacy strategies for
coping with cancer (16-18).
In what concerns negative affectivity, its role in the
development of somatic diseases, particularly cancer, was also thoroughly
reported (19-20) Anxiety, both as a trait and as a state, can generate
vulnerability to cancer, through the chronic high secretion of corresponding
hormones, such as cortisol and cathecolamines, which in turn lead to a
premature exhaustion of the immune system.
Taking into account the variable age, the most exposed
population with cancer is over 65 years old. The incidence of cancer gets a
peak in the age interval 75-90 (20), and the prevalence of metastasis is
agedependent, reaching a level of 63% for 75-year-old patients (21). In this
context, the issue of psycho-behavioral determination of cancer disease is more
relevant in elderly patients than in other age groups, to the extent that certain
protective and risk factors tend to remain unchanged over time. In elderly
cancer patients, in addition to low self-efficacy, trait anxiety and stress
perception could play an important role in cancer etiopathogenesis (22, 23).
Furthermore, the psychological ”configuration” could be important in how the
elderly cancer patient relates to the disease. In the literature, there is a
growing concern about this topic, but in Romania the interest for this subject
is still low. From this point of view, identifying correlations between these
variables and the occurrence and prognosis of cancer is a potentially low
cost-benefit objective that would facilitate the more specific psychological
intervention on higher exposure groups.
OBJECTIVE AND
HYPOTHESIS
The primary objective of this study was to identify several
unfavorable psychological patterns associated with the increased cancer
vulnerability of the elderly and whether they can directly influence the
evolution of the disease to healing or relapse.
The first hypothesis was that elderly cancer patients would
experience a high level of anxiety-trait and perceived stress, as well as a
lower level of self-efficacy.
The second hypothesis assumes that gender differences may be
significant among cancer patients, in the sense that women, in comparison to
men, experience a higher level of state– and trait anxiety and lower
self-efficacy.
MATERIAL AND METHOD
The design of the study was transversal. The study included
176 patients over the age of 65, from whom 89 patients underwent chemotherapy
for cancer disease at the Oncological Institute ”Alexandru Trestioreanu” -
Bucharest (the case group) and 87 with similar demographic characteristics, but
without cancer (the control group), were in the care of a family doctor. The case
group comprised 59 women (66.30%) and 30 males (33.70%), with a mean age of
71.2 years (± 5.81). The control group comprised 62 women (71.27%) and 25 males
(28.73%), with a mean age of 73.2 years (±4.03).
The study was conducted with the approval of the Ethics
Committee of the hosting hospital. Each person included in the study signed an
informed consent sheet. The standardized questionnaires applied to both groups
were:
State-Trait Anxiety
Inventory (24, 25): has the advantage to provide high validity in
investigating anxiety in both patients from medical, neuropsychiatric and
surgery services and normal adults (26). Each scale - state anxiety (STAI 1)
and trait anxiety (STAI 2) - has 20 questions, which reflect the perception of
anxiety in threatening circumstances, or in general. The answers are provided
on a 4–point Likert scale, from 1-“almost never” to 4-“almost always”. The
range of global scores for each scale is 20–80, the higher scores indicating
greater anxiety. A cut point of 39–40 has been suggested to detect clinically
significant symptoms for STAI 1 (at .783 sensitivity and .712 specificity),
whereas a cut point of 44 seems optimal for STAI 2 (at .935 sensitivity and
.574 specificity = 57.4) (27).
Self-Efficacy Scale
(SES) (28): comprises 10 items and is designed to evaluate the individuals’
beliefs about their ability to cope with the difficulties encountered in
solving everyday tasks. The answers are provided on a 4-point Likert scale,
from 1-“not at all true” to 4-“exactly true”. The global self-efficacy score
can be interpreted by allocating it into one of the following classes: very low
self-efficacy: <25 points; low self-efficacy: 26-29 points; medium self-efficacy: 30-33 points; high self-efficacy: 34-37 points, and very high self-efficacy: >38
points. In our study we took into account in the statistical interpretation the
values corresponding to a global SES score <33.
Holmes-Rahe Scale for
Perceived Stress (29): is based on the authors’ assumption that every event
causing a change in lifestyle may be perceived as a stress generator. In
authors’ view, the correlation between recent life changes and the occurrence
of somatic disease is highly significant, suggesting the use of this instrument
as a screening tool to measure the stress load. The three thresholds for
perceived stress considered by Holmes-Rahe’s Scale test are:
150 points or less = a low amount. of life change and low
susceptibility to stress-induced health breakdown; 150 to 300 points = 50%
chance of health breakdown in the next 2 years; 300 points or more = 80% chance
of health breakdown in the next 2 years. In our study, we included in the
statistical analysis the scores of perceived stress > 150 points.
The statistical analysis was conducted running the SPSS
software, more specifically the one-way ANOVA for the distribution of trait
anxiety, state anxiety, self-efficacy and perceived stress.
RESULTS
The case group of patients had a higher perceived level of
stress, compared to the control group (279.62 vs.125,05) (F = 33.222, p <
0.0001).
DISCUSSIONS AND
CONCLUSIONS
Elderly cancer patients in our study, irrespective of their gender, seem to experience a high level of perceived stress and low self-efficacy, both occurring on a background of high trait anxiety. At the same time, several effects proved to be gender-specific: men diagnosed with cancer had higher trait and state anxiety scores, compared to women suffering from cancer. Also, the presence of cancer was associated to low self–efficacy especially in women, whereas stress perception was not influenced by the participants’ gender.
These results are subject to several study limitations: the
design of the study was transversal, the number of participants was rather low
and the questionnaires were self-administered, which brings into discussion the
possible risks brought by misinterpretation of items or social desirability.
Despite these limitations, our results plead in favor of the
efficacy of early and continuous psychological and social support in cancer
care. As consistently reported in literature, both stress perception and
increased anxiety related to cancer could be diminished if the patient is
offered personalized psychological counseling. In selected cases, the provision
of cognitive-behavioral psychotherapy, encouraging the development of more
appropriate coping strategies or motivational counseling, could equally address
these symptoms and also increase self efficacy.
These goals can be achieved, as a whole, through the
multidisciplinary approach of the cancer patient, and specifically through the
inclusion of a psycho-oncologist in the medical team. This kind of specialist
could have clear, well-defined responsibilities in providing psychosocial
support to the cancer patient from the very beginning of the treatment, as well
as in offering psychological counseling to the patient’s family.
As a long-time strategy, specialists recommend the integration
of the psychosocial component of care into the routine oncology care (30, 31,
32, 33). As literature data show, for the specific participants having taken
part in this study, the involvement of the psycho-oncologist in reducing the
level of perceived stress, the decrease of the state of anxiety and the
increase of self-efficacy may bring huge benefits, both in terms of therapeutic
compliance, overcoming the side effects of therapy and in increasing their
quality of life (34).
ACKNOWLEDGMENTS
The authors would like to express their warm gratitude to the Executive Board and to the Ethical Commission of the Oncological Institute “Alexandru Trestioreanu” – Bucharest.
References
1. Siegel R., Naishadham D, Deepa N. Cancer Statistics, 2013. CA Cancer J Clin. 2013 Jan; 63(1):11-30. doi: 10.3322/caac.21166.
2. WHO. Cancer. Available from: http://www.who.int/en/news-room/fact-sheets/detail/cancer, accessed on Apr 20th, 2018.
3. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. 2014. Lyon, France: International Agency for Research on Cancer. Available from: http://globocan.iarc.fr, accessed on January 16th, 2015.
4. Bernstein C, Prasad AR, Nfonsam V, Bernstein H. DNA Damage, DNA repair and cancer. In Chen C (Ed.) New Research Directions in DNA repair. 2013 (pp.413-465). InTech Open. doi:10.5772/53919.
5. Ferguson LR, Chen H, Collins AR, Connell M, Damia G, Dasgupta S, et al. Genomic instability in human cancer: Molecular insights and opportunities for therapeutic attack and prevention through diet and nutrition. Semin Cancer Biol. 2015; 35 Suppl (Suppl): S5–S24. doi:10.1016/j.semcancer.2015.03.005.
6. Roukos DH. Genome-wide association studies: how predictable is a person’s cancer risk? Expert Rev Anticancer Ther. 2009 Apr;9(4):389-92. doi: 10.1586/era.09.12.
7. Stewart BW, Wild CP (Eds.). Cancer etiology. In World Cancer Report 2014. 2014 (pp.16– 54) (World Health Organization) (ISBN 9283204298).
8. Ader R, Cohen N. Behaviorally-conditioned immunosuppression. Psychosom Med. 1975 Jul-Aug; 37(4):333-40.
9. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. 1986. Englewood Cliffs, NJ: Prentice-Hall.
10. Lev EL. Bandura’s theory of self-efficacy: Applications to oncology. Sch Inq Nurs Pract. 1997 Spring; 11(1):21-37; discussion 39-43.
11. Marks DF, Murray M, Evans, B, Vida Estacio E. Health Psychology: Theory, Research and Practice. 2015. Sage Publications (ISBN 978-1-446-29507-6).
12. Bubulac L, Gatej ER, Rizeanu S. The effects of self efficacy on the level of perceived stress: a correlational study. Rom J Psych Studies. 2018; 6(1):29-35.
13. Rizeanu S. Stress, emotional intelligence and locus control over job satisfaction. Romanian J Exp Appl Psychol. 2016; 7 (Special issue 1) (Psiworld 2015 Proceedings):413-6.
14. Wiedenfeld SA, O’Leary A, Bandura A, Brown S, Levine S, Raska K. Impact of perceived self-efficacy in coping with stressors on components of the immune system. J Pers Soc Psychol. 1990 Nov; 59(5):1082-94.
15. Taneichi H, Asakura M, Sairenchi T,Haruyama Y, Wada K, Muto T. Low self-efficacy is a risk factor for depression among male Japanese workers: a cohort study, Ind Health. 2013; 51(4):452–8.
16. Heitzmann CA, Merluzzi TV, Jean-Pierre P, Roscoe JA, Kirsh KL, Passik SD. Assessing self-efficacy for coping with cancer: development and psychometric analysis of the brief version of the Cancer Behavior Inventory (CBI-B). Psychooncology. 2011 Mar; 20(3):302-12. doi: 10.1002/pon.1735.
17. Merluzzi TV, Martinez Sanchez MA. Assessment of self-efficacy and coping with cancer: development and validation of the cancer behavior inventory. Health Psychol. 1997 Mar; 16(2):163-70.
18. Merluzzi TV, Nairn RC, Hegde K, Martinez Sanchez MA, Dunn L. Self-efficacy for coping with cancer: revision of the Cancer Behavior Inventory (version 2.0). Psychooncology. 2001 May-Jun; 10(3):206-17.
19. Watson D, Pennebaker JW. Health complaints, stress, and distress: exploring the central role of negative affectivity. Psychol Rev. 1989 Apr; 96(2):234-54.
20. Reiche EM, Nunes SO, Morimoto HK. Stress, depression, the immune system, and cancer. Lancet Oncol 2004; 5(10): 617–25.
21. Harding C, Pompei F, Wilson R. Peak and decline in cancer incidence, mortality, and prevalence at old ages. Cancer. 2012 Mar 1; 118(5):1371–86. doi: 10.1002/cncr.26376.
22. Stanta G, Campagner L, Cavallieri F, Giarelli L. Cancer of the oldest old. What we have learned from autopsy studies, Clin Geriatr Med. 1997 Feb;13(1):55-68.
23. Nordin K, Glimelius B. Predicting delayed anxiety and depression in patients with gastrointestinal cancer. Br J Cancer. 1999;79(3/4): 525-9. doi: 10.1038/sj.bjc.6690082.
24. Spielberger, CD. Theory and research on anxiety. In Spielberger CD (Ed.). Anxiety and Behavior. 1966 (pp.3- 20). New York: Academic Press.
25. Spielberger CD, Gorsuch RL, Lushene R., Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. 1983. Palo Alto CA: Consulting Psychologists Press.
26. Spielberger CD, Reheiser EC. Measuring anxiety, anger, depression, and curiosity as emotional states and personality traits with the STAI, STAXI, and STPI. In Hilsenroth MJ, Segal DL. (Eds.) Comprehensive Handbook of Psychological Assessment (vol.2). 2004 (pp.70-86). Hoboken, NJ: Wiley.
27. Knight RG, Waal-Manning HJ, Spears GF. Some norms and reliability data for the State-Trait Anxiety Inventory and the Zung Self-Rating Depression scale. Br J Clin Psychol. 1983; 22(Pt 4): 245–9.
28. Schwarzer R, Jerusalem M. Generalized Self-Efficacy Scale. In Weinman J, Wright S, Johnston M. (Eds.), Measures In Health Psychology: A User’s Portfolio. Causal and Control Beliefs. 1995 (pp.35-37). Windsor, UK: NFER-NELSON.
29. Holmes TH, Rahe RH (1967). The Social Readjustment Rating Scale. J Psychosom Res. 1967 Aug;11(2):213-8.
30. Anand P, Kunnumakkara AB, Sundaram C, Harikumar KB, Tharakan ST, Lai OS, et al. Cancer is a preventable disease that requires major lifestyle changes. Pharm Res. 2008 Sep; 25(9):2097-116. doi: 10.1007/s11095- 008-9661-9.
31. Boinon D, Sultan S, Charles C, Stulz A, Guillemeau C, Delaloge S, et al. Changes in psychological adjustment over the course of treatment for breast cancer: the predictive role of social sharing and social support. Psychooncology. 2014 Mar;23(3):291-8. doi: 10.1002/pon.3420.
32. Fobair P, Stearns NN, Christ G, Dozier-Hall D, Newman NW, Zabora J, et al. Historical threads in the development of oncology social work. J Psychosoc Oncol. 2009;27(2):155-215. doi: 10.1080/07347330902775301.
33. Forsythe LP, Alfano CM, Leach CR, Ganz PA, Stefanek ME, Rowland JH.Who provides psychosocial follow-up care for post-treatment cancer survivors? A survey of medical oncologists and primary care physicians, J Clin Oncol. 2012 Aug 10;30(23):2897-905. doi: 10.1200/JCO.2011.39.9832.
34. Misea S, Rizeanu S. Importanța terapiilor suportive în ameliorarea tulburărilor depresive în rândul
adolescenților bolnavi de cancer. Revista de Studii Psihologice, 2016; 4 (22): 187-93.
