Status quo and factors of depression and anxiety in patients with non-muscle invasive bladder cancer after plasma electrocision

Abstract

BACKGROUND

Bladder cancer is a type of cancer with a high incidence in men. Plasma electrosurgery (PES) is often used in the treatment of bladder cancer. Postoperative complications often cause depression and anxiety in patients after surgery.

AIM

To investigate the current state of depression and anxiety after PES in patients with non-muscle-invasive bladder cancer and analyze the factors affecting them.

METHODS

A retrospective study was conducted to compare the baseline data of patients by collecting their medical history and grouping them according to their mental status into negative and normal groups. Logistic regression analysis was used to explore the risk factors affecting the occurrence of anxiety and depression after surgery in patients with bladder cancer.

RESULTS

Comparative analyses of baseline differences showed that the patients in the negative and normal groups differed in terms of their first surgery, economic status, educational level, and marital status. A logistic regression analysis showed that it affected the occurrence of anxiety in patients with bladder cancer, and the results showed that whether the risk factors were whether or not it was the first surgery, monthly income between 3000 and 3000-6000, secondary or junior high school education level, single, divorced, and widowed statuses.

CONCLUSION

The risk factors affecting the onset of anxiety and depression in bladder cancer patients after PES are the number of surgeries, economic status, level of education, and marital status. This study provides a reference for the clinical treatment and prognosis of bladder cancer patients in the future.

Key Words: Bladder cancer; Anxiety; Depression; Analysis of influencing factors; Plasma electrocision

Core Tip: This study provides a theoretical basis for the clinical treatment and rehabilitation of bladder cancer patients. In the future, we should pay more attention to the mental health status of bladder cancer patients and their risk factors in order to provide more comprehensive and effective treatment and rehabilitation programmes.

INTRODUCTION

Bladder cancer is a malignant tumor of the bladder mucosa[1]. It is the most common malignant tumor of the urinary system. The latest statistics show that the incidence rate of bladder cancer has shown a significant rising trend, with men being the main group with bladder cancer[2]. Bladder cancer is a type of malignant tumor with a high recurrence rate, and the factors that cause its onset are more complicated, including intrinsic genetic and extrinsic environmental factors[3]. In the modern clinical treatment of non-muscle invasive bladder cancer[4]. With the continuous progress of human civilization, the incidence of malignant bladder tumors has increased in China in recent years. Smoking, alcohol consumption, long-term exposure to chemical products, and occupational exposure to toxic substances are the main risk factors for malignant bladder tumors. In China, the population, especially the male population, has a significant impact on the incidence of malignant bladder tumors owing to the high rates of smoking and alcohol consumption[5].

The clinical treatment of bladder cancer mainly involves resection of tumor lesions, prevention of tumor recurrence, prevention of recurrent tumor progression, prolongation of patient survival time, and improvement of patient quality of life as the main objectives. Plasma electrosurgery (PES) is a common surgical treatment option. However, previous studies have shown that PES has some limitations. This procedure is prone to trigger an occlusive nerve reflex, resulting in bladder perforation, which requires a high level of skill on the part of the operator. Moreover, some patients show signs of urinary tract irritation, such as frequent urination and urgency after surgery. Second, because of the thermal cutting of electrodesiccation, the cut surface often forms a large number of scabs, postoperative edema, degeneration, or even necrosis of local tissues. If the ureteral orifice, the bladder neck, and its surrounding tissues are edematous and necrotic, it can be secondary to urinary obstruction, and necrotic tissues induce the body to produce inflammatory factors that can cause bladder irritation, such as frequency, urgency, and painful urination.

Previous studies have found that many cancer patients are prone to anxiety and depression during treatment[6]. About 15%-25% of patients with cancer suffer from comorbid depression each year, which is four times more prevalent than in the general population. Nearly 20% of cancer patients experience severe anxiety[7]. Depression in patients with cancer often has serious consequences, including treatment abandonment and suicide tendencies. Recent studies have identified depression as an independent risk factor for predicting mortality in patients with cancer[8,9]. However, the increased prevalence of depression is not solely caused by a single psychosocial stressor during cancer diagnosis. Surgical treatment modalities, prognostic outcomes, and financial stress are also major risk factors for comorbid depression in patients with cancer[10]. There is a lack of research exploring the factors influencing the occurrence of depression and anxiety after PES in patients with non-muscle invasive bladder cancer at this stage of the study.

This study uses a retrospective design by analyzing the incidence of depression and anxiety after PES in patients with non-muscle invasive bladder cancer. It clarifies the current status of the occurrence of depression and the factors influencing the occurrence of depression in patients with bladder cancer through the use of logistic regression. It shows that providing a scientific basis for the prevention and treatment of the occurrence of depression and anxiety in patients with bladder cancer and improving patient prognosis is possible.

MATERIALS AND METHODS

Researchers and study design

One hundred and twenty patients with bladder cancer who visited the Department of Urology between May 2020 and May 2023 and were diagnosed by two attending physicians were included in the main study population. The patients’ medical history data were collected during the consultation period, their psychological status was assessed at the time of discharge, and they completed the depression and anxiety scales to assess the occurrence of depression and anxiety.

The diagnostic criteria for bladder cancer were based on the Chinese Bladder Cancer Guidelines 2022 Edition, and the clinical diagnosis was made based on the patients’ medical history, symptoms, and signs, combined with laboratory examination, imaging examination, urine cytology, urine tumor marker examination, and cystoscopy. Inclusion criteria of the study subjects: (1) Patients were clinically diagnosed as non-muscle invasive bladder cancer; (2) Preoperative urological imaging [ultrasound, plain computed tomography (CT) and enhanced CT, etc.] did not show any combination of urological, other primary or secondary tumors; (3) No lymph node metastasis or distant metastasis of tumor was seen; (4) Pathological staging of the patient’s cancer was based on the classification of the bladder cancer according to the World Health Organization’s Bladder Cancer Nausea Level Classification published in 2004. Uroepithelial cancer nausea grading system issued by the World Health Organization in 2004; and (5) Patients who had regular bladder perfusion therapy after surgery and received timely follow-up examinations on time; and patients who underwent cystoscopy for one year.

All the patients underwent PES. Treatment process: After anesthesia and truncal position, the perineum was routinely disinfected and toweled, and the bladder was inserted smoothly under the direct vision of F25.6 circon-electrosurgical scope. After passing through, we saw that the mucous membrane of the bladder was congested, and the openings of the bladder were clear bilaterally with the spraying of urine and clear color, and we saw a new organism in the right side of the bladder behind the opening of the ureter, which was about 1.0 cm × 0.8 cm in size and was tipped, and we gave the power of electrocutaneous excision of 90 W and electrocoagulation of 100 W to electrically resect the bladder tumor and its surrounding mucosa in the range of 1 cm, deep to the muscle layer, complete hemostasis, removal of the tumor, F20 three-lumen catheter retained catheterization, injection of 20 mL of water, the operation went smoothly, the postoperative anamnesis, the specimen was sent for pathological examination.

Measure index

Self-rating Anxiety Scale: The Self-rating Anxiety Scale (SAS) is a self-reported measure of anxiety used primarily in adults. The scale consists of 20 items. Each item was scored out of a total of four points, ranging from one to four. This is then multiplied by 1.25 to obtain a standardized score. The SAS contains 20 items reflecting subjective feelings of anxiety, and each item is rated on a four-point scale according to the frequency of symptom occurrence, with 15 positive and five negative ratings. 1 means “none or very little of the time”; 2 means “a small percentage of the time”; 3 means “quite a lot of the time"; 4 means “present the vast majority or all of the time”.

Self-Rating Depression Scale: The Self-Rating Depression Scale (SDS) is a self-report measure of the severity of depressive symptoms in adults developed by Zung in 1965 and consists of 20 items rated on a four-point Likert scale ranging from 1 to 4 (i.e., none to all). The total score on the SDS index is obtained by summing the scores for each of the 20 items to obtain a total score, which is then normalized to a score by multiplying by 1.25. The SDS measures the severity of depressive symptoms in adults. With reference to the results of the national norm, the final criterion for the SDS was a total score of ≥ 53 for depressive symptoms and < 53 for no depressive symptoms[11].

Statistical analysis

A database was set up, and the data were entered using Epidata after double-checking. Data were entered after double-checking. SPSS software (version 26.0) was used to analyze the data. Count data were analyzed using the χ² test. Measurement data were expressed as mean ± SD. The two groups before and after the intervention were compared using repeated-measures ANOVA, the two groups were compared using the two independent samples t-test, and the two groups within the groups were compared using the least significant difference procedure. Statistical significance was set at P < 0.05.

RESULTS

General information on the study population

A total of 120 participants were included in this study and categorized into the passive psychological state group (n = 55) and regular group (n = 75) based on depression and anxiety scores. Although the two groups of patients did not show significant differences in indicators such as sex, age, and work status, they showed statistical differences in indicators such as whether it was the first operation, economic status, education level, and marital status (P < 0.05). No significant difference was found in the baseline data between the study groups, proving their comparability (Table 1).

Table 1 General information on the study population.

		Passive group	Regular group	χ2/t	P value
Gender (n)	Male	45	60	2.671	0.775
	Female	10	15
Age (yr)		56.18 ± 2.50	55.50 ± 0.55
Place of residence	Urban	20	25	1.824	0.556
	Countryside	35	50
First surgery	Yes	11	41	14.743	0.001
	No	44	34
Economic status (yuan/month)	< 3000	20	15	21.834	< 0.001
	3000-6000	29	42
	> 6000	6	18
Education	Below junior high school	12	19	14.823	< 0.001
	High school/secondary school	33	26
	University/college and above	10	30
Occupational status	Active	23	35	2.781	0.056
	Retired	21	33
	Unemployed	4	7
Marital status	Married	6	56	8.958	< 0.001
	Unmarried	11	7
	Divorced/widowed	38	12

Logistic regression analysis affecting the occurrence of anxiety and depression in bladder cancer patients

Table 2 shows the distribution of variables with significant differences between the mental status disorder and conventional groups. Tables 3 and 4 show the logistic regression analyses affecting the occurrences of depression and anxiety in patients with bladder cancer, respectively. The results show that whether it is the first surgery, monthly income between 3000 and 6000, secondary or junior high school education level, and single, divorced, and widowed status are risk factors for these conditions.

Table 2 Table of assignments.

Variable	Assignment
Whether first surgery	No = 0; yes = 1
Economic status	> 6000 = 0; 3000 = 1; 3000-6000 = 2
Education level	University/college and above = 0, high school/secondary school = 1, below junior high school = 2
Marital status	Married = 0; unmarried = 1; divorced/widowed = 2

Table 3 Logistic regression analysis affecting the occurrence of depression.

Variable	OR	95%CI	Wald χ2	P value
First surgery 1 vs 0	9.21	3.7-18.3	19.13	< 0.001
Economic status 1 vs 0	4.5	3.1-10.8	14.7	< 0.001
Economic status 2 vs 0	7.3	3.1-19.2	20.3	< 0.001
Education level 1 vs 0	5.1	2.4-13.3	19.2	< 0.001
Education level 2 vs 0	0.34	0.22-2.31	1.0	0.033
Married 1 vs 0	1.21	1.02-0.55	23.5	< 0.001
Married 2 vs 0	2.61	1.9-21.0	15.1	< 0.001

OR: Odds ratio; CI: Confidence interval.

Table 4 Logistic regression analysis affecting the occurrence of anxiety.

Variable	OR	95%CI	Wald χ2	P value
First surgery 1 vs 0	12.88	4.4-30.7	20.92	< 0.001
Economic status 1 vs 0	0.75	0.31-10.8	14.7	< 0.001
Economic status 2 vs 0	3.21	2.5-21.6	20.3	< 0.001
Education level 1 vs 0	3.30	2.88-15.2	13.9	< 0.001
Education level 2 vs 0	1.29	1.11-9.03	3.9	0.08
Married 1 vs 0	6.72	3.21-29.9	3.90	0.12
Married 2 vs 0	2.14	1.92-34.0	15.1	< 0.001

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

With the development of society and the increase in environmental pollution, the number of cancer patients has shown an increasing trend every year. With the change in the medical model, the clinical treatment for cancer patients is not limited to symptomatic treatment but also focuses on the psychological health of cancer patients. In this study, we took bladder cancer patients as the main research object and analyzed the current situation and factors affecting the occurrence of depression and anxiety after PES in patients with non-muscle invasive bladder cancer. The results of the study found that among the 130 patients with bladder cancer, 55 (45.83%) had a negative psychological status. Logistic regression analysis showed that the first surgery, economic status, education level, and marital status were risk factors affecting the development of anxiety and depression in patients with bladder cancer.

Effect of number of operations on the psychological status of bladder cancer patients

Bladder cancer has a very high recurrence rate, and the recurrence rate of early-stage bladder cancer patients is 10%-30%. Some bladder cancer patients need to undergo a second surgery after PES[12]. Previous studies have found that most patients have significantly greater expectations for the first surgery than for the second and that multiple surgical treatments have made patients more anxious[13]. In the present study, non-first surgery was not only a factor influencing patients’ anxiety but also a factor influencing patients’ depression[14]. In addition, the adverse effects of electrosurgery are a factor in anxiety and depression. In recent years, most studies have found that post-electrosurgery patients often have urethral inflammation, urinary frequency, urgency, urinary pain, and other complications that greatly affect their quality of life[15]. Patients who underwent multiple surgeries had higher surgical risks and adverse reactions. Repeated post-operative reactions are also a type of torture for patients, affecting their sleep and work, and they are more prone to depression and anxiety than patients who have undergone their first surgery[16].

Effect of educational level on the psychological state of bladder cancer patients

For patients with cancer, the costs of surgery and chemotherapy are high. Patients with bladder cancer often require more than one year of chemotherapy after surgery, and the huge financial burden makes some patients face great economic pressure in addition to the pressure caused by the disease[17]. Therefore, financial pressure is more serious for patients with low monthly incomes. Previous studies found that some patients discontinued treatment mainly because of financial pressure[18]. In this study, we found that financial stress caused anxiety and depression in patients with bladder cancer. Therefore, when treating patients with financial difficulties, special attention should be paid to their psychological health, and the government should provide certain subsidies to cancer patients to help them treat the disease.

Effect of educational level on the psychological state of bladder cancer patients

Educational level affects how a person thinks about difficult events. Most studies have shown a significant correlation between the level of education and the state of depression[19]. It has been found that people with low levels of education are prone to depression, and those with high levels of education are generally more financially and socially resourceful and more concerned about their own health or physical condition and it can be concluded that between those with different levels of education. Differences in depression can start early in life, and those with low levels of education are more likely to have grown up in a poor environment with poor home occupations, diet, exercise habits, and access to healthcare, which are factors that can exacerbate their risk of depression as they grow older[20].

Effect of marital status on the psychological state of bladder cancer patients

The present study showed that the marital status of patients was also a major factor influencing depression and anxiety. This may be related to the atmosphere of home care for cancer patients during and after surgery[21]. Bladder cancer is a urological tumor; therefore, spouses are more important in patient care than in other kinship relationships[22]. When cancer is diagnosed, both the patient and the family are under a great deal of stress. Throughout the process, from diagnosis to treatment, the spouse usually takes on most of the emotional, financial, or functional support needed by the patient and plays a very important role in the prognosis and quality of life of cancer patients. In fact, married patients with cancer have higher survival rates than nonmarried patients.

Suggested strategies

To address the mental health problems of patients with non-muscle invasive bladder cancer, we propose the following strategies: First, strengthening preoperative psychological intervention; providing patients with assessment, counseling, and guidance on coping strategies through professional mental health teams; and helping them establish a positive mindset and coping mechanisms. Second, to enhance the knowledge of patients and their families about bladder cancer and its treatment, knowledge about bladder cancer should be popularized through health education and lectures so that patients can better understand the condition and reduce unnecessary fear and anxiety. Meanwhile, a sound postoperative psychological rehabilitation system should be established. Personalized rehabilitation plans, including cognitive-behavioral therapy, group counseling, and relaxation training, should be designed according to the specific conditions of the patients to alleviate their psychological pressure and improve their quality of life. We must also pay attention to patients’ economic situations by enhancing the medical insurance system and setting up special funds to reduce their financial burden so that they can focus more on treatment and rehabilitation. Finally, we need to strengthen the training and education of healthcare professionals to enhance their understanding of and ability to deal with the mental health problems of patients with cancer. This step will ensure that patients can receive timely and effective psychological support. Through the integrated implementation of these strategies, we expect to improve the mental health status of patients with non-muscle-invasive bladder cancer and promote their full recovery.

Strengths and limitations of this study

In this study, the occurrence of depression and anxiety in patients with bladder cancer was statistically analyzed, mainly using retrospective studies, and the history of patient pairs was complete, which provided a better description of the current status and influencing factors. However, unlike cohort studies, retrospective studies lack direct causal links. In addition, our study did not include a large sample of people to explore due to the stringent screening criteria for the study population. In the future, larger samples should be explored to ensure the robustness of the results.

CONCLUSION

This retrospective study analyzed morbidity-influencing factors affecting anxiety and depression in patients with bladder cancer after PES. In the future clinical treatment of patients with bladder cancer, attention should also be paid to their mental health, and recommendations and evidence should be provided for a good clinical prognosis.