Psychological distress in thyroid cancer patients: Influencing factors and intervention strategies

Abstract

Thyroid cancer is a common endocrine malignancy with a rising incidence. Patients often suffer from mental pain due to concerns about recurrence, treatment-related side-effect, and body image changes. Demographic factors like age, gender, physiological factors such as somatic symptoms and disease stage, cognitive-regulatory factors including negative and positive thinking, and social factors like work, economy, education level, and social support all influence their mental state. Existing interventions, including nursing, psychological, and traditional Chinese medicine-based methods, have some benefits but face limitations like short-term effectiveness and lack of standardization. Future research should focus on creating better-defined, long-term, and widely applicable intervention programs and explore positive psychology-based approaches to improve patients' mental well-being and quality of life.

Key Words: Thyroid cancer; Psychological distress; Influencing factors; Intervention strategies; Positive psychology

Core Tip: Thyroid cancer patients often experience mental pain. This review sums up its influencing factors like demographics, physiology, and social aspects. Current interventions have flaws. Future research should focus on better-designed, long-term interventions and positive psychology-based methods to improve patients’ mental health.

INTRODUCTION

Thyroid cancer is not only the most common endocrine malignancy[1], but also the solid malignant tumor with the fastest-growing incidence rate in recent years[2]. In 2023, approximately 600000 new cases of thyroid cancer were reported globally, ranking 9^th among common malignancies. Notably, the age-standardized incidence rate of thyroid cancer in women is about three times that in men, making it the 5^th most common malignancy in women[3]. Surgery is the primary treatment for thyroid cancer, followed by radiotherapy and endocrine therapy based on individual conditions. Although thyroid cancer has a low mortality rate and a relatively good prognosis, its recurrence rate is as high as 30%, and recurrence can even occur 20 years after the initial diagnosis[4]. Consequently, patients often experience psychological problems due to concerns about disease recurrence.

Moreover, traditional open-thyroid resection inevitably leaves a “suicide-like” scar in the anterior cervical region. This scar can easily trigger a psychological stress response[5] and even a sense of stigma[6] in patients after surgery. Additionally, postoperative endocrine and radiotherapy disrupt the normal fertility plans of female patients, leading to issues such as social sensitivity, hostility, and fertility-related anxiety among women of child-bearing age. Some scholars have pointed out that the combined stress of cancer diagnosis and surgery can cause thyroid cancer patients to experience depression and behavioral withdrawal, which affects their quality of life and disease prognosis[7,8].

Mental pain, also known as psychological distress. Ridner[9] described psychological distress as the impact of negative emotions on people’s functional levels and disruptions to daily life. Gundelach and Henry[10] defined psychological distress in cancer patients as a series of negative emotional reactions that occur after a cancer diagnosis. However, this definition is a general description of psychological distress and is not conducive to analyzing its influencing factors. The imprecise definition of psychological distress causes problems. It leads to inconsistent diagnosis, with some patients’ distress being misjudged. This affects treatment, as inappropriate care may be provided. In research, it’s hard to compare results across studies[11]. Currently, the definition of psychological distress most widely accepted by scholars at home and abroad is proposed by the National Comprehensive Cancer Network: Psychological distress is an unpleasant emotional experience caused by multiple factors, encompassing psychological (cognitive, behavioral, emotional), social, and spiritual aspects[12]. It can affect a patient’s ability to actively cope with cancer (somatic symptoms, treatment), and may progress from common feelings such as sadness, vulnerability, and fear to depression, anxiety, phobia, social isolation, existential crisis, and spiritual crisis[12].

Given the complexity of psychological distress in thyroid cancer patients and the existing research gaps, this mini review aims to comprehensively explore the influencing factors of psychological distress in thyroid cancer patients. By synthesizing domestic and foreign research, it seeks to clarify the key factors and their interactions, providing a solid foundation for developing more effective and targeted intervention strategies in the future.

INFLUENCING FACTORS OF PSYCHOLOGICAL DISTRESS IN THYROID CANCER PATIENTS

Demographic factors

Age: Thyroid cancer is the most common malignancy among young cancer patients[13]. Wells et al[14] found that young head-and-neck cancer patients had higher scores of psychological distress. However, some scholars’ research showed that there was no significant correlation between the scores of psychological distress in thyroid cancer patients and their age[15,16]. Young patients have a relatively high probability of developing thyroid cancer. They usually have less life experience, greater work and family pressures, and a stronger sense of disease uncertainty. On the other hand, elderly patients have poorer regulatory and coping abilities[17]. Moreover, psychological distress is affected by multiple factors such as disease treatment methods and prognosis, in addition to age[18,19]. Therefore, more research is needed to verify whether there are differences in the level of psychological distress among thyroid cancer patients of different ages.

Gender: Thyroid cancer occurs more frequently in women. Influenced by cultural characteristics, female patients often shoulder more responsibilities in raising children and doing housework, making them more likely to experience psychological distress after treatment[20,21]. However, some research results indicate that although female patients show more anxiety, depression, and fatigue symptoms, there is no significant difference in the level of psychological distress between female and male patients[22]. This may be because although the incidence of thyroid cancer in men is lower than that in women, their risk of cancer metastasis and recurrence is higher[23]. Disease-related factors may interfere with the impact of gender on the level of psychological distress. Future research can further explore the gender factor on the basis of balancing disease-related factors. Female thyroid cancer patients are more prone to negative emotions and should be the key population for clinical medical staff to implement psychological nursing. However, more research is needed to confirm whether gender is an influencing factor of psychological distress in thyroid cancer patients.

Physiological factors

Somatic symptom-related factors: To prevent disease recurrence, thyroid cancer patients need to receive lifelong hormone replacement therapy after treatment. The drug treatment often causes patients to experience a high level of fatigue, which significantly affects their level of psychological distress[24]. Fatigue can interfere with patients’ normal work and life, thus increasing their psychological distress. In addition, unstable hormone levels can also affect patients’ emotions. In clinical work, caregivers should promptly inquire about patients’ feelings, observe their behaviors, and provide guidance on preventing and intervening in fatigue symptoms. Research shows that a decline in attention and memory is one of the common problems leading to psychological distress in thyroid cancer patients[25]. This may be because treatment with 131I or hormone interruption can cause hormonal disorders in patients, affecting their cognitive and memory abilities, reducing their quality of life, and thus increasing their level of psychological distress. Lee et al[26] found that during the preparation period for 131I treatment, due to hormone interruption and hormone deficiency in the body, thyroid cancer patients may experience various adverse reactions such as loss of appetite, limited mobility, and lethargy, which seriously affect their daily life and home environment. Without timely medical guidance, patients often show a high level of psychological distress. During the 131I isolation treatment period, due to the isolation environment and drug side-effects, patients may experience problems such as sleep disorders, nausea, and vomiting, leading to insecurity and various negative emotions, and an increase in the level of psychological distress[27].

Disease-stage-related factors: Research shows that newly-diagnosed thyroid cancer patients have a relatively high level of psychological distress, with 43.3% of patients having significant psychological distress problems. The diagnosis of cancer is a strong negative stimulus for patients, which can trigger a series of stress responses and affect their physical and mental health[28]. Roerink et al[29] found that thyroid cancer patients still showed a high level of psychological distress for a long time after treatment. This is because thyroid cancer survivors still have to face some long-lasting special problems after treatment, such as drug side-effects, fear of cancer recurrence, and unstable thyroid hormone levels. Evidently, thyroid cancer patients experience relatively severe psychological distress throughout the disease process. Clinical medical staff should pay attention to this, detect problems in a timely manner, and provide targeted guidance. Research shows that patients receiving 131I treatment have more psychological distress problems. This may be because during the 131I treatment period, patients need to be isolated. The separation from their families and the side-effects of the treatment can cause patients to experience negative emotions such as loneliness, fear, anxiety, and depression, resulting in a high level of psychological distress[30,31]. In addition, patients with local recurrence of thyroid cancer have more serious psychological distress problems. This may be because most patients are informed by medical staff at the initial diagnosis that the prognosis of thyroid cancer is very good and may not even affect their lifespan. Therefore, when cancer recurrence occurs, patients are more likely to experience negative emotions such as fear, anger, and despair, and have more concerns about the prognosis of the disease and the risk of recurrence[32,33]. Medical staff should actively pay attention to the psychological changes of patients, conduct health education according to the characteristics of patients at different disease stages, and provide sufficient and multi-faceted support to help patients maintain good physical and mental health.

Cognitive-regulatory factors

Negative cognition: Research has found that negative cognitive regulation in the face of disease can increase the level of psychological distress in patients[34]. The diagnosis of cancer and somatic symptoms are heavy burdens for patients, and patients’ perception of the disease is an important influencing factor of psychological distress. Negative cognition can cause patients to experience negative emotions such as anxiety, helplessness, despair, and depression, thus affecting their quality of life and the degree of psychological distress[31]. Therefore, it is necessary to provide psychological support and cognitive intervention for patients in the early stage of disease diagnosis.

Positive cognition: Research shows that some patients gradually experience post-traumatic growth during the late stage of disease treatment, and their level of psychological distress decreases[35]. This may be because as the treatment progresses, patients begin to re-think about life, adjust their lifestyle, and the way they interact with others. A more positive attitude towards the disease can help patients better understand the disease, cope with difficulties, and conduct self-counseling when problems arise, thus reducing distress[36].

Social economical status

Work status: Research shows that work and academic situations are important influencing factors of psychological distress in thyroid cancer patients[37]. This can be attributed to multiple aspects. Firstly, thyroid cancer predominantly affects middle-aged and young individuals. For this group, work often represents not only a source of income but also a crucial part of their social identity and self-worth. The diagnosis and treatment of thyroid cancer can disrupt their work-related routines, career development plans, and social connections in the workplace. For example, the need for surgery, radiotherapy, or long-term medication may lead to absences from work, reduced work efficiency, or even job loss in some cases[38]. These work-related disruptions can cause significant stress and anxiety among patients, thus contributing to their psychological distress. Secondly, the relatively good prognosis of thyroid cancer makes patients eager to return to work as a way to regain a sense of normalcy and control over their lives. However, the process of returning to work may be accompanied by various challenges, such as concerns about how colleagues will react to their illness, whether they can still perform their job duties effectively, and potential discrimination in the workplace. These concerns further exacerbate their psychological burden[30]. Therefore, thyroid cancer patients have a greater demand for returning to work after recovery[39]. In clinical practice, it is necessary to analyze the causes of psychological distress in patients based on their background characteristics and provide targeted counseling.

Economy: Studies have shown that economic problem is one of the most important causes of psychological distress in thyroid cancer patients[24,30]. The long-term course of thyroid cancer requires patients to bear the economic pressure of various treatments, lifelong medication, and regular re-examinations. Thus, medical staff and social institutions should pay attention to the economic problems of patients, provide them with multi-faceted support and resources, and help patients actively face and solve difficulties.

Educational level: Research indicates that patients with a lower educational level tend to have a higher level of psychological distress[37,40,41]. This may be due to their relatively poor information-gathering ability and limited access to social resources. However, Fan et al[42] research showed that patients with a higher educational level have a relatively high incidence of thyroid cancer, which may be related to factors such as greater work pressure, lifestyle, and higher disease detection rates during physical examinations. Therefore, high-educated patients are also a group that cannot be ignored among thyroid cancer patients. Clinical medical staff should not only provide psychological counseling for low-educated patients but also pay attention to disease recurrence prevention and health education for high-educated patients.

Social support: Wang et al[43] found that the more social support patients received for their psychological distress, the lower their level of psychological distress. Social support plays a crucial role in the treatment and continuous care of patients. Caregivers should choose appropriate forms and provide timely and effective support to patients at the right time to help them relieve distress symptoms and improve their quality of life. Research shows that thyroid cancer patients generally have demands for health education in aspects such as disease recurrence, complication observation and treatment, and pregnancy guidance. However, their satisfaction with information needs such as treatment plans and continuous nursing is relatively low, which has an adverse impact on the prognosis of the disease and the patients’ quality of life, and thus affects their mental health[44]. Currently, the overall nursing and continuous nursing models for thyroid cancer patients are not yet perfect, and patients have certain difficulties and limitations in obtaining information support. Medical staff can combine new forms such as information technology to actively explore new models of information support and continuous nursing, provide patients with long-term and targeted information support, meet their information and psychological needs, and thus reduce their level of psychological distress. The influencing factors of psychological distress in patients with thyroid cancer are shown in Table 1.

Table 1 Related influencing factors, research details and main conclusions of psychological distress in patients with thyroid cancer.

Study	Study details	Key findings	Risk factor categories
Demographic	Examined age[12-17], gender[18-21]	Age: Relationship with psychological distress in thyroid cancer patients unclear; more research needed; Gender: Influence on distress level uncertain; Female patients more prone to negative emotions	Age, gender
Physiological	Looked at somatic symptoms[25,29-31] and disease stages[32-36]	Somatic symptoms: Hormone replacement and 131I treatment cause fatigue, cognitive decline, etc., increasing distress; Disease stages: Newly diagnosed, treated, 131I-treated, and recurrent patients all experience high psychological distress due to diagnosis shock, side effects, fear of recurrence	Somatic symptoms, disease stages
Cognitive-regulatory	Analyzed negative/positive cognition[37-39]	Negative cognition: Increases psychological distress through negative emotions like anxiety and despair; Positive cognition: Leads to post-traumatic growth, reducing distress by helping patients adjust and cope	Negative cognition, positive cognition
Social economical status	Studied work status[22,23], economy[24,25], education [22,26-28], social support, info-need satisfaction [40,41]	Work status: Work and academic situations impact distress as patients want to return to work; Economy: Economic problems are a major cause of distress; Education: Lower-educated have higher distress; High-educated also a group to note; Social support: More support is associated with lower distress levels; Information need satisfaction: Low satisfaction with treatment plans and continuous nursing affects prognosis and mental health; New info support and nursing models needed	Work, economy, education, social support, info-need satisfaction

INTERVENTION STRATEGIES FOR THE MENTAL HEALTH OF THYROID CANCER PATIENTS

Currently, most of the research by foreign scholars on the mental pain of thyroid cancer patients focuses on cross-sectional surveys and analyses of influencing factors, while there are relatively few intervention studies. Domestic scholars pay more attention to negative emotions such as anxiety and depression in patients. Some scholars have made preliminary attempts at intervening in the psychological distress of thyroid cancer patients, which are summarized as follows.

Nursing intervention methods

At present, nursing interventions for the postoperative psychological status of thyroid cancer patients mainly focus on the construction of different programs, with holistic nursing, comprehensive nursing, and incentive-based nursing being the main approaches[45]. These methods advocate the use of a patient-centered medical model that takes into account the psychological, physiological, and social functions of patients to promote their mental health.

Evidence-based nursing, which is based on scientific research evidence and combined with the specific situation of patients, can improve the postoperative psychological state of thyroid cancer patients. Ji et al[46] found that applying evidence-based nursing to thyroid cancer surgery patients helps reduce their negative emotions. Cui and Li[47] demonstrated that implementing evidence-based nursing in the care of thyroid cancer patients, providing psychological support during the peri-operative period, and conducting individualized interventions for patients with negative psychological states can significantly improve their quality of life.

Evidence-based nursing, a globally recognized approach, has shown remarkable efficacy in improving the postoperative psychological state of thyroid cancer patients. A study[45] focused on a cohort of thyroid cancer patients. The nurses implemented evidence-based nursing protocols that included preoperative psychological assessment, personalized care plans based on patients’ psychological profiles, and post-operative follow-up support. Through this approach, patients reported a significant reduction in anxiety and depression levels. In European, some hospitals adopted evidence-based nursing models that integrated family-centered care. They involved family members in the nursing process, providing them with education on how to support patients’ psychological well-being. This not only improved patients’ mental health but also enhanced the overall quality of care[48]. A South Korea study[49] used evidence-based nursing to develop a unique self-management support program for thyroid cancer patients. This program encouraged patients to actively participate in their own care, and the results showed that patients had better psychological adaptation and a higher quality of life during the recovery period.

Traditional Chinese medicine intervention methods

Emotional factors play a crucial role in the development of thyroid cancer[50]. Researches pointed out that emotional abnormalities are one of the causes of many postoperative symptoms in thyroid cancer patients and are also a major symptom that patients experience after surgery[27,51]. Therefore, in the field of traditional Chinese medicine, scholars attach great importance to the study of patients’ emotions. Previous studies have reported that methods such as external application of Xiaozhong Fang combined with Sizhi San, self-formulated ointment prescriptions, and acupuncture have been successfully used to regulate the physical discomfort of thyroid cancer patients after surgery and relieve their psychological anxiety[52-55]. The review by Xia[56] pointed out that used Chaimai Decoction to soothe the liver, relieve depression, and regulate qi movement, alleviating the postoperative anxiety, depression, and other negative emotions of thyroid cancer patients.

Psychological support and information support

Wu et al[57] conducted psychological and behavioral interventions on 60 thyroid cancer patients undergoing 131I treatment. Before 131I treatment, nurses conducted in-depth interviews with each patient to understand their feelings, reactions, and opinions regarding the treatment and to assess the degree of their psychological distress. In terms of information support, the latest disease-related knowledge and successful case introductions were provided to patients. For emotional support, psychological guidance was given to patients through various channels such as the Internet, and patient experience exchange meetings were held to enhance patients’ sense of belonging and encourage them to bravely face the current situation of the disease. The results showed that the psychological distress level of patients in the experimental group was significantly reduced, and their quality of life improved. Timely and effective information and emotional support from medical staff can reduce patients’ feelings of loneliness and helplessness, help them adopt positive disease-coping strategies, thus improving their psychological state and enhancing their quality of life[58]. In Greece, Giannoula et al[59] carried out a study where nurses provided personalized care plans for thyroid cancer patients. They used a mobile-app-based system to send patients daily reminders about treatment schedules, along with positive affirmations and tips for managing stress. This was an innovative approach to both information and emotional support, which enhanced patients’ self-management and psychological well-being.

However, currently, the information and psychological support interventions for thyroid cancer patients are still in the initial stage, with problems such as short-term duration and a lack of theoretical basis for intervention programs. A more systematic and full-course care model for thyroid cancer patients needs to be further explored.

Health education

Wu et al[60] implemented seamless health education for patients undergoing 131I treatment through various forms such as WeChat, telephone follow-up, and health manuals. The intervention period ranged from the time of booking 131I treatment after surgery to one month after discharge. The results showed that the psychological distress level of patients in the intervention group was significantly reduced. Giordano et al[61] studied the psychological status of patients with differentiated thyroid cancer before, during, and 40 days after I-131 radionuclide therapy and found that timely psychological assessment and appropriate support can help reduce patients’ anxiety and depression and improve workplace safety. The results indicated that the psychological distress of patients in the intervention group was also significantly alleviated[62]. Evidently, health education is an effective means of relieving the psychological distress of thyroid cancer patients. It can help patients better understand the disease, adjust their mentality and coping methods, and reduce their fear of treatment. Moreover, diversified health education forms such as peer education can compensate for the lack of companionship, communication, and care during the isolation treatment period, expand the resources and channels for patients to obtain information, and thus help patients more smoothly navigate through various stages of the disease. However, current intervention programs have issues such as uneven qualifications of health educators, insufficient continuous care, and a lack of standardized implementation processes and plans, which require further exploration and improvement.

CONCLUSION

In recent years, the psychological distress of thyroid cancer patients has received increasing attention. However, several issues remain. Firstly, the unclear definition of psychological distress has led to significant differences in assessment tools used in current research, resulting in poor comparability of research findings. Secondly, there is a lack of research on the current status and influencing factors of psychological distress in thyroid cancer patients, especially in domestic studies. Consequently, many uncertainties still exist. Thirdly, there are few and non-standardized targeted intervention programs for the psychological distress of thyroid cancer patients. Although some Chinese scholars have made preliminary attempts, these interventions mainly focus on in-hospital patients during the peri-operative period or those undergoing 131I treatment. They suffer from short-term intervention durations, a lack of theoretical basis, poor reproducibility of the programs, and significant regional limitations. Therefore, further exploration is needed to develop standardized, continuous, and generalizable intervention programs for the psychological distress of thyroid cancer patients. The postoperative psychological status of thyroid cancer patients has gained certain attention, and some achievements have been made in both Western and traditional Chinese medicine fields. However, most current research approaches this topic from a negative perspective. Given the relatively good prognosis of thyroid cancer, it provides a practical basis for positively guiding patients and stimulating their positive emotions. Thus, future research could start from the perspective of positive psychology to adjust the postoperative psychological status of thyroid cancer patients and improve their quality of life.