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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 92-96

Evaluation of distress among cancer patients in Bengaluru City: A cross-sectional study


1 Department of Public Health Dentistry, Yogita Dental College and Hospital, Ratnagiri, Maharashtra, India
2 Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India

Date of Submission24-Dec-2019
Date of Decision27-Jan-2020
Date of Acceptance31-Jan-2020
Date of Web Publication2-Mar-2020

Correspondence Address:
Dr. Anuradha Sadanand Bandiwadekar
Department of Public Health Dentistry, Yogita Dental College and Hospital, Khed, Ratnagiri - 415 709, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_134_19

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  Abstract 


Background: Distress is common among people affected by cancer. Distress can influence the quality of life and participation in medical treatment. Although not everyone wants to openly discuss their feelings and emotional distress, research shows that early advice, support, education, and intervention can avoid the demand for intensive intervention. Aims: This study aimed to evaluate the extent and source of distress among cancer patients using the National Comprehensive Cancer Networks Distress Thermometer (DT). Materials and Methods: A cross-sectional descriptive study was carried out at a tertiary care hospital, Bengaluru. A study was conducted among 384 cancer patients attending a tertiary care hospital, Bengaluru, from June to August 2012, after obtaining the consent. The DT consisted of a 48-item questionnaire representing the problems commonly experienced by cancer patients. The patients were asked to mark any sources of distress. Mann–Whitney U-test, Kruskal–Wallis, and Spearman's rho were employed using SPSS software 16.0 version. Results: Out of 384 cancer patients, 88 (22.92%) had a distress score of 7. Age and socioeconomic status were significantly associated with distress, whereas gender was not. Practical problems, family problems, emotional problems, religious concerns, and physical problems were significantly associated with the distress. Statistically significant difference was noted between patients with head-and-neck cancer against other cancers with regard to practical problems, religious concerns, and physical problems. Conclusion: This study documents a significant level of distress among cancer patients. Hence, there is a need to develop appropriate coping strategies in cancer patients.

Keywords: Cancer, distress, Distress Thermometer


How to cite this article:
Bandiwadekar AS, Shanbhag N, Puranik MP. Evaluation of distress among cancer patients in Bengaluru City: A cross-sectional study. J Indian Assoc Public Health Dent 2020;18:92-6

How to cite this URL:
Bandiwadekar AS, Shanbhag N, Puranik MP. Evaluation of distress among cancer patients in Bengaluru City: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Dec 5];18:92-6. Available from: https://www.jiaphd.org/text.asp?2020/18/1/92/279813



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  Introduction Top


Cancer is a major health problem in many parts of the world, especially in developing countries.[1] Life is never exactly the same again once a cancer diagnosis has been made.[2] Everything about cancer is stressful.[3] Patients living with cancer feel many different emotions, including anxiety and distress. Patients may have feelings of anxiety and distress while being screened for a cancer, waiting for the results of tests, receiving a cancer diagnosis, being treated for cancer, or worrying that cancer will recur.

Anxiety and distress may affect a patient's ability to cope with a cancer diagnosis or treatment. Even mild anxiety can affect the quality of life for cancer patients and their families and may need to be treated.[4] About one-third of the patients newly diagnosed with cancer experience psychological distress.[5] In spite of the prevalence of distress among the cancer patients, distress often goes undetected by oncology professionals.[6]

The ability to screen for distress has become an important issue for clinicians and researchers in the field of oncology, as a result of an increased recognition of the distress experienced during the cancer journey, with the overall level of clinically significant distress seeming to be between 25% and 30% of patients.[7] Screening methods and tools for distress measurement are available, but still not routinely used. Given the prevalence rates of distress in cancer patients worldwide, the International Psycho-Oncology Society endorsed distress as the 6th vital sign in June 2009.[8] An early assessment and evaluation of psychological morbidity in terms of assessment of distress and anxiety has become an essential component of optimal cancer care.[9] The literature on screening for distress has been somewhat static for the past 20 years. Gaps still exist, and more research around understudied groups and the need for refinement of tools and measures remain essential.

Cancer prevalence in India is estimated to be around 2.5 million, with over 8,00,000 new cases and 5,50,000 deaths occurring each year.[10] The age-standardized cancer incidence rate per 1,00,000 population is 12.6 in India.[11] There are not many reported researches available pertaining to screening of distress and its assessment and management among cancer patients in India. This demonstrates the growing need for investigating the screening and treatments for distress.[8] Hence, this study was conducted to evaluate the extent and source of distress among cancer patients visiting a tertiary care hospital, Bengaluru, and to recommend appropriate strategies for management.


  Materials and Methods Top


This cross-sectional, descriptive study was conducted to evaluate the extent and source of distress among cancer patients attending a tertiary care hospital, Bengaluru, between June and August 2012. Ethical clearance was obtained from the institutional ethical committee. Informed consent was obtained from the study participants after explaining the need and purpose of the study.

Inclusion criteria

All patients diagnosed with cancer and seeking treatment at a tertiary care hospital, Bengaluru, during June–August 2012, were included in the study.

Exclusion criteria

Patients were excluded from the study if they were unable to consent, were too unwell to participate, had cognitive impairment, were already under psychiatric treatment for current psychological problems, and were not able to read and mark or respond verbally to Distress Thermometer (DT) Problem List (PL) were excluded from the study.

Tool used

The DT is a brief screening tool for cancer patients to assess distress. It has been developed by the National Comprehensive Cancer Networks, USA. The DT is a single-item, 11-point visual analog scale measuring psychological distress during the past week. The DT ranges from no distress (0) to extreme distress (10). The appendant PL consists of 48 items representing problems commonly experienced by cancer patients in the following five categories: practical problems, family problems, emotional problems, religious/spiritual concerns, and physical problems.[12]

In this study, the DT PL in English language was translated to Kannada language and was translated back to English language to ensure the linguistic validity of the PL.

Data collection procedure

A total of 384 cancer patients (135 males and 249 females) were included in the study. The age ranged from 26 to 80 years. An interview was conducted with distribution of pro forma and pencil to the participants, which they were able to complete in the waiting room. Demographic data were obtained, and medical charts were reviewed to obtain information about disease stage and treatment characteristics. The respondents were asked to indicate whether they experienced it during the last 7 days or not for each item in DT scale.

Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version no. 16.0, SPSS Inc., Chicago, Illinois. Statistical significance was considered at P < 0.05. Descriptive statistics and inferential statistics were computed. Mann–Whitney U-test, Kruskal–Wallis test, and Spearman's rho were employed.


  Results Top


Among the cancer patients, majority were in the age group of 40–49 years (102, 26.56%); 135 (35.16%) were males and 249 (64.84%) were females. Out of the 384 cancer patients, 88 (22.92%) had a distress score of 7. The number of patients suffering from clinical relevant distress ranged from 362 (94.27%; cutoff score of ≥ 4) to 205 (53.39%; cutoff score of ≥7) [Table 1].
Table 1: Distribution of the cancer patients according to the frequency distribution of Distress Thermometer scores

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Among the 384 cancer patients, 203 (52.86%) belonged to other cancer group and 181 (47.14%) belonged to head-and-neck cancer group. A statistically significant difference was not observed between patients with head-and-neck cancer against other cancers with regard to DT scores [Table 2].
Table 2: Mean distress scores among cancer patients

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In this study, age and socioeconomic status were significantly associated with distress, whereas gender was not. Among practical problems, 230 (59.90%) reported financial followed by child care (229, 59.64%) as the source of problem. Regarding family/social problems, 136 (35.42%) patients reported dealing with children followed by dealing with partner (128, 33.33%) as the source of problem. Regarding emotional problem, 289 (75.26%) reported fears followed by depression (210, 54.69%) as a source of problem. Regarding physical problem, 292 (76.04%) reported sleep followed by eating (240, 62.50%) as a source of problem. Regarding religious/spiritual concern, 377 (98.18%) reported trust in god/religion followed by meaning of life (279, 72.66%) as a source of problem. Practical, family, emotional, physical, and religious/spiritual concerns significantly correlated with the DT score.

Statistically significant difference was noted for practical problems. The mean values of practical problems for head-and-neck cancer and other cancer were 1.75 and 2.04, respectively. Similarly, statistically significant difference was noted for religious/spiritual concerns. The mean values of religious/spiritual concerns for head-and-neck cancer and other cancer were 1.63 and 1.77, respectively. Statistically significant difference was noted for physical problems. The mean values of physical problems for head-and-neck cancer and other cancer were 4.90 and 4.13, respectively [Table 3].
Table 3: Means of various domains of problem list (region wise) among cancer patients

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  Discussion Top


The stress associated with a diagnosis of cancer has been shown to induce considerable psychological morbidity, with 25%–50% of all cancer patients indicating significant levels of distress. The paucity of data regarding distress intensity and sources of distress for cancer patients inhibits the development of clinical programs to reduce distress. The general consensus among professional associations and governmental agencies is that the standard of care for all cancer patients should include screening for distress and the provision of psychosocial care for those cancer patients identified as being in need.[6] A few studies are reported in literature in this regard.

In this study, distress was assessed using the DT with PL. Majority of the patients in this study belonged to a distress score of 7. While in other studies, the corresponding score was 5[13],[14] and 2.[15]

In most of the studies, cutoff scores of ≥4[9], 13, [16],[17],[18],[19] and ≥5[20],[21],[22],[23],[24] were employed. As identified by cutoff points, 94.2% had a cutoff score of ≥4, whereas 53% had a cutoff score of ≥7, similar to other studies.[13] In this study, analysis of the problem checklist indicates that the majority of problems were of physical, followed by emotional, practical, religious/spiritual, and family/social problems. These findings were in line with those of other studies.[13],[14],[25]

In this study, among physical problems, majority reported problems related to sleep (76.04%) and eating (62.50%). Among emotional problems, majority reported problems related to fears (75.26%) and depression (54.69%). Among practical problems, majority reported problems related to financial constraints (59.90%) and child care (59.64%). Regarding religious/spiritual problems, majority reported concerns related to trust in god/religion (98.18%) and meaning of life (72.66%). Regarding family/social problems, majority reported problems related to dealing with children (35.42%) and dealing with partner (33.33%).

Practical problems, family problems, emotional problems, religious concerns, and physical problems were significantly correlated with distress and are in line with those of other studies.[13],[14],[15],[17],[18],[20] Whereas in other studies, the majority of problems were emotional, followed by practical and family/social.[6],[17] In other studies physical followed by emotional[20],[22] and family followed by emotional, physical problems indicates the majority of problems.[9] Whereas, in other studies, majority of the problems were of physical followed by practical and family problems.[5]

There was no significant difference between the patients reporting with head-and-neck and other cancers for overall PL scores. Whereas, significant differences were observed between these groups for the domains of practical, religious, and physical problems. Headandneck cancer patients had significantly higher mean values in physical domain when compared to those with other cancers. whereas a reverse trend was noted for practical and religious domains.

It can be inferred that among various domains, cancer patients experience more of physical problems than other domains. In this study, patients with head-and-neck cancer seemed to have more impact on physical domain than other domains. In this study, statistically significant difference was not observed between patients with head-and-neck cancer against other cancers with regard to DT scores. Whereas, another study demonstrated that DT scores were not significantly related to cancer type.[17]

Distress scores decrease with increase in age,[16],[20] with minimum variation in younger age group and maximum variation in older groups. Whereas, in other studies, the reported DT scores were not significantly related to age.[15],[17],[19],[24],[26] In this study, age was significantly associated with distress. Significant difference among age groups was noted with maximum distress with patients aged <30 years and least among patients aged >80 years.[16]

Various studies reported that males and females did not differ regarding the DT score.[13],[15],[16],[17],[26] Whereas, another study showed that the DT cutoff score of 4 was related significantly only to gender, with women more likely to report scores above the cutoff score[18] and scoring higher (4.9) on the DT than males with a mean level of 4.5.[19],[20] In this study, gender was not significantly associated with distress score.


  Conclusion Top


This study has furnished basic information about the level and source of distress among cancer patients. Oncology patients may have psychosocial needs that could easily go unnoticed in the absence of screening. This study demonstrates the significant level of distress among cancer patients by using DT screening tool. Screening and appropriate intervention for psychosocial concerns are just the beginning of a truly integrative model of cancer care. In addition, prospective and systematic screening may address psychosocial problems before they become time consuming and disruptive to the medical treatment plan. Hence, there is a need to help these patients to cope up with distress by developing appropriate strategies.

Suggestions and recommendations

Education and training

  • Continuous quality improvement projects should include distress management programs/services provided by the institution
  • Recognition and documentation processes for distress should be a part of patient care at all stages of the disease in all clinical settings
  • Oncology care providers need knowledge and skills in assessing and managing patient distress
  • Education and training programs should be developed to ensure that clinicians can acquire these skills
  • Patients and their families should be informed that distress management is an integral part of total cancer care.


Screening and assessment

  • Distress screening should be performed at the initial visit and at appropriate intervals during treatment
  • In addition, screening should be performed when clinically indicated, especially when disease status has changed
  • Assessment of the psychosocial domain should be included in clinical health outcome measurements
  • The level and nature of a patient's distress should be identified and treated promptly.


Further research

  • Longitudinal studies are needed to assess the sensitivity of DT to the changing stages of cancer
  • Studies are needed to assess the level of distress before, during, and after the treatment of cancer patients
  • Screening methods need further testing, and barriers on the part of the patient and oncologist that impede the identification of the most distressed patients should be identified
  • Studies are required to measure the functional impairment along with the distress level.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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