|Year : 2021 | Volume
| Issue : 4 | Page : 393-402
Factors Related to Resilience, Anxiety/Depression, and Quality of Life in Patients with Colorectal Cancer Undergoing Chemotherapy in Japan
Graduate School of Nursing, Osaka Medical College, Takatsuki, Osaka, Japan
|Date of Submission||20-Oct-2020|
|Date of Acceptance||06-Jan-2021|
|Date of Web Publication||31-May-2021|
MD Saori Tamura
Graduate School of Nursing, Osaka Medical College, Takatsuki, Osaka
Source of Support: None, Conflict of Interest: None
Objective: This study clarifies the relationship between resilience and anxiety and depression, quality of life (QOL), and other related factors that influence colorectal cancer patients undergoing chemotherapy. Methods: This cross-sectional study focused on outpatients with colorectal cancer undergoing chemotherapy. A questionnaire including the Connor-Davidson Resilience Scale, Hospital Anxiety and Depression Scale, the MOS 12-item Short-Form Health Survey, and items based on a literature review was administered between August 2019 and August 2020. SPSS version 26 was used for data analysis. Correlation analysis and t-test were applied. In addition, Amos version 26 was used and structural equation modeling was applied to create a causal model. Results: A total of 121 participants (94.5%) were included in the study. The goodness of fit (GFI) of the causal model was GFI = 0.94, adjusted GFI = 0.906, comparative fit index = 0.997, and root mean square error of approximation = 0.011. Resilience had a negative effect on anxiety and depression and a positive effect on QOL. Depression had a negative effect on QOL. Conclusions: The results of this study indicate that resilience is a predictor of anxiety, depression, and QOL in colorectal cancer patients undergoing chemotherapy. Therefore, I believe that it is important to enhance resilience in order to maintain and improve patients’ mental health and QOL. In addition, since resilience was affected by cancer metastasis and the presence of metastasis was a predictor of resilience, it is a challenge to explore interventions to enhance resilience, especially in patients with metastasis.
Keywords: Anxiety, chemotherapy, colorectal cancer, depression, quality of life, resilience
|How to cite this article:|
Tamura S. Factors Related to Resilience, Anxiety/Depression, and Quality of Life in Patients with Colorectal Cancer Undergoing Chemotherapy in Japan. Asia Pac J Oncol Nurs 2021;8:393-402
|How to cite this URL:|
Tamura S. Factors Related to Resilience, Anxiety/Depression, and Quality of Life in Patients with Colorectal Cancer Undergoing Chemotherapy in Japan. Asia Pac J Oncol Nurs [serial online] 2021 [cited 2021 Jun 20];8:393-402. Available from: https://www.apjon.org/text.asp?2021/8/4/393/316628
| Introduction|| |
The prevalence of colorectal cancer is the third highest worldwide among all cancer types. In Japan, its prevalence is the highest among all cancer types. This occurrence rate of colorectal cancer has been increasing along with the rise in population and aging. The response rate to treatment for colorectal cancer has been improving along with the development of new anticancer drugs, and colorectal cancer can be cured with tumor resection and adjuvant chemotherapy, improving the 5-year survival rate. Even if conditions of patients worsen and they suffer unresectable recurrent colorectal cancer, chemotherapy has further prolonged the survival rate., These conditions have increased the length of treatment periods as well as the number of colorectal cancer patients undergoing chemotherapy.
It has been reported that patients with colorectal cancer, undergoing chemotherapy, experience peripheral neuropathy, a side effect known to be difficult to control and face difficulties in adjusting their lifestyles to prevent worsening of symptoms due to side effects. Previous studies found that patients with colorectal cancer, undergoing chemotherapy, experienced higher levels of anxiety and depression than those not administered for chemotherapy., Studies have noted declining treatment adherence and quality of life (QOL) in patients with stronger feelings of anxiety and depression., This highlights the importance of reducing anxiety and depression among such patients for the continuance of treatment and maintenance or improvement of QOL.
Recent studies have shown that anxiety and depression are low in cancer patients with high resilience,, and that mental health is related to resilience. This suggests that resilience is an important concept for maintaining mental health in cancer patients. Resilience is the mental strength to return to the original state and is a factor when people face difficult situations in life. Resilience is considered to be acquired throughout life, suggesting that resilience may be a key element in maintaining the mental health and QOL of patients with colorectal cancer undergoing chemotherapy.
Previous studies have shown the relationship between resilience and psychological distress,,, resilience and QOL,, and resilience and social support, in cancer patients. However, no study has been found to clarify the relationship between cancer patients’ resilience and anxiety and depression, QOL, and the factors that affect them. No studies on colorectal cancer have been conducted yet, except for those involving patients with terminal illnesses or permanent stomas., It can be assumed that the number of colorectal cancer patients undergoing chemotherapy will increase; thus, it is important to explore support for maintaining their mental health and QOL. Therefore, the purpose of this study was to determine the relationship between resilience and anxiety and depression, QOL, and related factors in colorectal cancer patients undergoing chemotherapy.
The research framework adopted by the study is illustrated in [Figure 1]. This framework was created based on a systematic review conducted by the present researchers and that by Eicher. Resilience is defined to be related to anxiety/depression, and QOL, and anxiety and depression are related to QOL. As previous studies have reported that personal factors and disease-related factors are related to resilience,, and that resilience is also related to anxiety and depression in patients with colorectal cancer, resilience in this study is regarded also to be related to depression. Further, it has been reported that the QOL of patients with colorectal cancer is related to anxiety/depression,, age, and fatigue. Thus, the present study considers that personal and disease-related factors are also related to QOL [Figure 1].
- High resilience in a colorectal cancer patient undergoing chemotherapy will cause lower anxiety and depression and a better QOL
- The higher the anxiety and depression in the patient, the lower the QOL
- Individual and disease-related factors affect patients’ resilience, anxiety and depression, and QOL.
Research setting and population
This study is a cross-sectional study. Colorectal cancer patients undergoing outpatient chemotherapy at university hospitals and general hospitals in the Kinki region of Japan, who participated in the study, after signing their consent. Inclusion criteria for the subjects were as follows: persons of age 20 years or above, those who have been informed of the diagnosis of primary or recurrent colorectal cancer at least 6 weeks in advance, and those who have completed one course of chemotherapy before participation in the study. Patients who were only administered oral anticancer drugs, who were diagnosed to suffer from strong anxiety and depressive symptoms, have been diagnosed with mental illness, display cognitive decline, and those who were evaluated to be Performance Status 3 or higher of the Eastern Cooperative Oncology Group were excluded from the study.
Participant recruitment process
A convenient sampling method was used for this study. The researcher asked the physician in charge to select the patients – based on the inclusion and exclusion criteria – who visited the chemotherapy facility of the hospital during the study period. The researchers explained the outline of the study and ethical considerations to the selected patients in writing. Questionnaires were distributed to the patients who agreed to participate.
For calculating the sample size, GPower 3.1 (Heinrich-Heine-Universitaet Duesseldorf, Duesseldorf, Germany) was used for the correlation coefficient, and previous studies for the covariance structure analysis. With the correlation coefficient, the calculation by a two-sided test, and effect size of 0.3, a = 0.05, 1−b = 0.8, yielded a sample size of 82.
For the performing structural equation modeling, a few studies have reported a sample size of 92, whereas others have reported that at least 100 were required.,, Based on these sizes, it was decided to set the sample size to 120 or more. Data were collected until the number of valid responses reached 120.
The Japanese version of the Connor-Davidson Resilience Scale (CD-RISC) was used for this study. The CD-RISC consists of 25 items with four-point scale questions, assigning 0 for “not applicable at all” to 4 for “almost always applicable,” with the maximum total score being 100 points. A higher score is considered to express better resilience. The reliability and validity of CD-RISC have been established with a Cronbach’s alpha coefficient of 0.93 and an intraclass correlation coefficient of 0.86.
Anxiety and depression
The Japanese version of the Hospital Anxiety and Depression Scale (HADS) was also used. The HADS was developed by Zigmond and Snaith to measure anxiety and depression in patients with physical symptoms. The reliability and validity of HADS have been established for Japanese outpatients of gastroenterology clinics. The HADS consisted of 14 items (7 items for anxiety and 7 items for depression); the scores of all the items were then summed. The Cronbach’s alpha coefficients were 0.8 or higher for anxiety and 0.7 or higher for depression.
Quality of life
The QOL was measured with the Japanese version of the MOS 12-item Short-Form Health Survey (SF-12),, covering three areas, “physical health,” “mental health,” and “role-social health,” as well as an inquiry of the health status of the past month. The higher the score, the better the QOL. As there is a national standard value established for the SF-12 and it is possible to convert this from the raw MOS score, the present study used the national standard value. The reliability by the parallel test method was 0.88–0.91.
Factors identified through literature as being related to resilience were classified into personal and disease-related factors. While the former included age, gender, living with family, with a spouse, with children, financial difficulties, educational background, type of social support (mental, evaluation, instrument, and information), and self-disclosure of cancer, the latter included the cancer stage, metastasis, length of time after the diagnosis of cancer, physical symptoms, details of the physical symptoms, comorbidities, and surgical treatment.
Date management and analysis
The data were analyzed using SPSS version 26 (International Business Machines Corporation, New York, USA). Correlation coefficients were calculated to identify the relationships between the resilience of patients with colorectal cancer undergoing chemotherapy and the reported scores of anxiety and depression and QOL. Furthermore, t-tests were utilized to interpret the relationship between patient resilience, anxiety and depression, and QOL as dependent variables and personal factors and disease-related factors as independent variables. In order to identify the relationship between patient resilience, anxiety and depression, QOL, and personal and disease-related factors that showed significant trends through t-test and ANOVA, a causal model using Amos version 26 (International Business Machines Corporation, New York, USA) was created; the analysis utilized structural equation modeling.
This study was approved by the Ethics Committee of Osaka Medical College (Approval No. Nurse-126 (2743)) and the Ethical Review Board established at the Saiju Moriguchi-Keijinkai Hospital. The participants were informed of the research plan and provided with assurances that their participation was voluntary and that their personal information would be kept confidential during and after the project. Participants provided written informed consent.
| Results|| |
The researchers handed out questionnaires to a total of 128 patients, of which 7 did not respond; thus, 121 responses were analyzed (94.5%). The demographic characteristics of the participants were as follows: the mean age was 63.8 years (standard deviation [SD]: 10.7), 71 were male (58.7%) and 50 were female (41.3%), and 29 patients (24.0%) had no metastasis and 92 (76.0%) had metastasis [Table 1].
|Table 1: Demographics and Clinical information of the participants (n=121)|
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Relationship between resilience and anxiety/depression and quality of life
The mean score for CD-RISC was 60.7 (SD: 16.4). Other mean values are shown in [Table 2].
|Table 2: Descriptive statistics for Resilience, anxiety/depression, and QOL (n=121)|
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The correlations between resilience, anxiety and depression, and the QOL subscales of physical health, mental health, and role-social health were as follows: resilience and anxiety (r = −0.224, P < 0.05) and depression (r = −0.340, P < 0.01) had significant negative correlations, and higher resilience scores were associated with lower anxiety and depression scores. In addition, resilience and QOL had a significant positive correlation only for the subscale mental health (r = 0.459, P < 0.01), and higher resilience scores were also higher mental health scores.
Factors related to resilience, anxiety/depression, and quality of life
[Table 3] and [Table 4] show the results of the t-test as factors related to resilience, anxiety and depression, and QOL. Resilience was shown to be related to education level (P = 0.046), metastasis (P = 0.041), and surgery (P = 0.047). Anxiety was related to financial difficulties (P = 0.004), self-disclosure of cancer (P = 0.021), poor concentration (P < 0.001), and pain (P = 0.048). Depression was related to gender (P =0.005), education level (P = 0.010), financial difficulties (P = 0.001), number of types of social support (P = 0.015), and fatigue (P < 0.001).Physical health, a subscale of QOL, was significantly related to fatigue (P = 0.004) and pain (P = 0.003). Mental health was substantially dependent on education level (P = 0.006) and poor appetite (P = 0.018). Furthermore, role-social health was related to financial difficulties (P = 0.008) and poor appetite (P = 0.010).
|Table 3: Personal factors related to resilience, anxiety/depression, and QOL|
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|Table 4: Disease-related factors related to resilience, anxiety/depression, and QOL (n=121)|
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Creation of a causal model
Based on the correlation of resilience with anxiety and depression and QOL, as well as the results of the t-tests [Table 3] and [Table 4], a causal model was created using the factors that exhibited relationships [Figure 2].
|Figure 2: Resilience model for patients with colorectal cancer undergoing chemotherapy. χ2 = 50.706, df = 50, goodness of fit = 0.94, adjusted goodness of fit = 0.906, comparative fit index = 0.997, root mean square error of approximation = 0.011. Arrows indicate the direction of influence. *P < 0.05, P < 0.01, ‡P < 0.001. e1–e6: Error variable|
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The goodness of fit (GFI) of the model was GFI = 0.94, adjusted GFI = 0.906, comparative fit index = 0.997, and root mean square error of approximation = 0.011. Significant differences were found in all pass coefficients [Table 5]. Resilience had a negative effect on anxiety (b = −0.18, P = 0.032) and depression (b = −0.16, P = 0.024). It also had a positive effect on mental health (b = 0.32, P < 0.001). Anxiety had a positive effect on depression (b = 0.48, P < 0.001). Depression had a negative effect on physical health (b = −0.18, P = 0.04), mental health (b = −0.41, P < 0.001), and role-social health (b = −0.28, P = 0.001).
Influencing factors included in the model were cancer metastasis, gender, number of types of social support, self-disclosure of having cancer, fatigue, and poor concentration.
Resilience was negatively affected by cancer metastasis (b = −0.19, P = 0.038), and resilience scores were lower when metastasis was present. Anxiety was negatively affected by self-disclosure of cancer (b = −0.20, P = 0.015) and positively affected by poor concentration (b = 0.32, P < 0.001). Anxiety scores were significantly lower when cancer self-disclosure was possible and significantly higher when poor concentration was present. Depression was influenced by gender, number of types of support, and fatigue (fatigue). Males had significantly higher depression scores than females (b = −0.22, P = 0.001). The presence of more types of social support in terms of instrumental/emotional/informational/evaluative support had a negative impact on depression (b = −0.17, P = 0.016). In addition, fatigue had a positive effect on depression (b = 0.17, P = 0.016), and depression scores were significantly higher when fatigue was present.
| Discussion|| |
This study clarified the causal relationship between resilience and anxiety and depression and QOL in colorectal cancer patients undergoing chemotherapy. It also developed a causal model that included individual and disease-related factors affecting the three main variables (i.e., resilience, anxiety/depression, and QOL).
Relationship between resilience and anxiety/depression, and quality of life, and factors affecting resilience
The results of this study showed that resilience negatively affected anxiety and depression, and depression negatively affected QOL in colorectal cancer patients undergoing chemotherapy. As shown in [Figure 2], the causal relationship between resilience and anxiety and depression and QOL was identified, and resilience was found to be a predictor of mental health on the anxiety and depression and QOL subscales. Therefore, it can be said that resilience plays an important role as a predictor of mental health and QOL in colorectal cancer patients undergoing chemotherapy. Moreover, since previous studies have only reported that resilience is a predictor of anxiety, depression, and QOL in patients with illnesses such as breast, lung, or gastric cancer,,,, the findings of this study are unique. These findings suggest that it is important to enhance resilience in order to improve and maintain the mental health and QOL of colorectal cancer patients undergoing chemotherapy.
The mean resilience score of the participants in this study was 60.7 (SD: 16.4). Previous studies reported that resilience scores of the general population, when CD-RISC was used, was 80.7, and a meta-analysis of resilience scores using CD-RISC for cancer patients was 72.0.
Resilience of the participants in this study was negatively affected by the presence of metastases. Cancer patients with metastasis have to undergo chemotherapy for a long period of time, until treatment is successful, which negatively affects their motivation to seek treatment. Moreover, patients with metastatic cancer experience high levels of physical and mental distress due to the prolonged side effects and symptoms associated with the disease and continued chemotherapy., On the other hand, patients undergoing adjuvant chemotherapy combined with surgery perceive the treatment positively. For this reason, I believe that differences in the pathology and course of treatment affected the resilience. Therefore, nurses are required to anticipate and intervene in the treatment of patients with colorectal cancer who have metastases and are undergoing chemotherapy. Therefore, by focusing on patients with metastatic colorectal cancer undergoing chemotherapy and clarifying the relationship between resilience and anxieties, depression, and quality of life, as well as the factors that influence these relationships, we can identify predictors that are characteristic of patients with metastatic colorectal cancer and suggest specific assistance. I believe that this study will be useful in identifying predictive factors characteristic of patients with metastatic colorectal cancer and in suggesting specific assistance.
Factors affecting anxiety/depression and quality of life
The anxiety of the participants in this study was negatively affected by self-disclosure of cancer and the findings of this study are unique. Self-disclosure of cancer helps them gain new support, reduce loneliness, and feel closer to acquaintance by sharing their experience with cancer diagnosis and treatment. Therefore, this study’s findings suggest that cancer patients can mitigate their anxiety by self-disclosure of cancer. In addition, anxiety was positively affected by poor concentration, which is known to be caused by chemo brain and fatigue, which are side effects of chemotherapy. Patients’ perception of changes between, before, and after treatment, for example, taking longer to do household chores, compared to before led to increased anxiety.
The participants’ depression was affected by the number of types of social support and fatigue. In previous studies, the amount of social support was found to have a negative effect on depression in breast cancer patients.
In this study, regarding social support, which includes the four functions of instrumental/emotional/informational/evaluative support, it was found that patients who had more of these functions had lower depression. Therefore, not only the amount of support but also the social support from various aspects is important for reducing depression. Previous studies have reported that fatigue is more strongly associated with depression than other physical symptoms. In the present study, fatigue was found to have a positive effect on depression. However, it had a negative effect on physical health, a subscale of q QOL. Since fatigue is considered to be one of the most difficult physical symptoms to control, managing it is the key to preventing or reducing depression and improving physical health.
Strengths and limitations
Resilience, anxiety and depression, and QOL are affected differently by cancer type and treatment method. Therefore, limiting the number of subjects and treatment methods in this study allowed an analysis of the relevant factors suited to the subjects and provided suggestions for detailed assistance. In addition, the inclusion of general as well as university hospitals to the target facilities supplemented the generalization of the results. However, the limitation of this study is that the sample size is smaller than other quantitative studies.
| Conclusions|| |
This study shows that resilience in colorectal cancer patients undergoing chemotherapy helps alleviate anxiety and depression and improve QOL. This study identified predictors of resilience, anxiety and depression, and QOL. To prevent or reduce anxiety and depression and maintain QOL in colorectal cancer patients undergoing chemotherapy, it is important to provide support to enhance resilience. It is also necessary to assess patients’ metastasis, self-disclosure of cancer, types of social support, and physical symptoms before receiving chemotherapy. Subsequently, it is also important to explore the interventions that help increase the resilience of such patients.
I wish to express our appreciation to the patients and staff of participating hospitals for their cooperation in conducting this study. This study is a part of a doctoral dissertation written by the author at the Graduate School of Nursing, Osaka Medical University, in Japan. I also wish to thank Professor Kumi Suzuki for valuable advice from research planning to writing the dissertation. I further wish to express my appreciation to Associate Professors Yuri Ito and Emiko Kusano, Professor Norito Yasuda for advice on the analysis, and Professor Yuko Tomari of Kansai Medical University for advice on the research planning.
Financial support and sponsorship
The work was supported by Grants of the Osaka Cancer Society.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]