Anxiety, depression, and coping styles among cervical cancer patients during radiotherapy and their correlations with uncertainty in illness

Abstract

BACKGROUND

Currently, there is limited research examining the relationship between anxiety, depression, coping styles, and illness uncertainty in patients with cervical cancer (CC) undergoing radiotherapy. Addressing this gap could provide valuable insights and more reliable evidence for clinical practice targeting this patient population.

AIM

To analyze the anxiety, depression, and coping styles of patients with CC undergoing radiotherapy and explore their correlations with illness uncertainty.

METHODS

A total of 200 patients with CC undergoing radiotherapy at The First Affiliated Hospital of Soochow University between June 2018 and June 2022 were enrolled. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS), comprising subscales for anxiety (HADS-A) and depression (HADS-D). Coping styles were evaluated using the Jalowiec Coping Scale (JCS-60), comprising dimensions such as confrontive, evasive, optimistic, fatalistic, emotive, palliative, supportive, and self-reliant. Illness uncertainty was measured using the Mishel Uncertainty in Illness Scale (MUIS), encompassing ambiguity, complexity, information deficit, and unpredictability. Correlations among anxiety, depression, coping styles, and illness uncertainty were analyzed.

RESULTS

During radiotherapy, the mean scores were 7.12 ± 3.39 for HADS-A, 6.68 ± 3.49 for HADS-D, 1.52 ± 0.23 for JCS-60, and 93.40 ± 7.44 for MUIS. Anxiety (HADS-A ≥ 8) was present in 39.5% of patients, depression (HADS-D ≥ 8) in 41.0%, and both in 14.0%. Anxiety was significantly positively correlated with ambiguity, unpredictability, and total MUIS score (P < 0.05). Depression was significantly positively correlated with ambiguity, information deficit, unpredictability, and total MUIS score (P < 0.05). Most patients adopted an optimistic coping style, whereas the emotive style was least utilized. Evasive, fatalistic, and emotive coping styles were significantly positively correlated with illness uncertainty, whereas the self-reliant style was significantly negatively correlated with unpredictability (P < 0.05).

CONCLUSION

Anxiety, depression, and coping styles in patients with CC undergoing radiotherapy correlate significantly with their level of illness uncertainty. Medical staff should address patients’ psychological status and coping strategies by providing targeted information to reduce negative emotions, foster adaptive coping styles, and decrease illness uncertainty.

Key Words: Cervical cancer; Radiotherapy; Anxiety; Depression; Coping styles; Uncertainty in illness

Core Tip: This study comprehensively analyzed anxiety, depression, and coping styles and their association with illness uncertainty in patients with cervical cancer (CC) undergoing radiotherapy. The study enrolled 200 patients with CC undergoing radiotherapy. Several key findings of this study include a 39.5% prevalence of anxiety and a 41.0% prevalence of depression among the patients. Anxiety, depression, and several coping styles correlated significantly with the level of illness uncertainty during radiotherapy. These findings highlight the importance of healthcare providers in addressing patients’ emotional states and coping strategies and providing customized psychological support plans tailored to help patients alleviate negative emotions and develop healthy coping strategies, thereby reducing their illness uncertainty. This study provides novel insights and empirical data to inform nursing care and clinical decision-making for patients with CC.

INTRODUCTION

Cervical cancer (CC) is a leading cause of cancer-related mortality among women, ranking behind only breast, colorectal, and lung cancers in terms of lethality[1,2]. In the United States alone, approximately 100000 women receive treatment for cervical precancerous lesions annually, with approximately 15000 new CC cases and 4000 deaths yearly[3]. Persistent infection with high-risk human papillomavirus (HPV) types is closely associated with CC development, accounting for as many as 99.7% of cases[4,5]. Although HPV infection is common, certain risk factors increase the likelihood of persistent infection progressing to CC, including smoking, high parity, multiple sexual partners, co-infection with other sexually transmitted infections, and long-term use of oral contraceptives[6].

Treatment choices for CC primarily depend on the stage and extent of disease progression and may involve surgery, radiotherapy, chemotherapy, or a combination of these modalities[7,8]. Radiotherapy, as a primary treatment option for CC, can cause various adverse reactions, including diarrhea, skin toxicity, abdominal cramps, and pelvic pain[9]. Subsequently, these side effects may precipitate negative emotions, such as anxiety and depression, in the patients. Furthermore, the daily limitations imposed by both the disease and its treatment can contribute to the accumulation of psychological distress[10,11].

Several studies have highlighted the significant psychological impact of CC treatment. Ding et al[12] found that 72.7% of 802 patients with CC undergoing radiotherapy and/or chemotherapy developed depression, with adverse reactions directly contributing to its occurrence. Similarly, Mungase et al[13] reported that patients with cancer undergoing radiotherapy experienced depression, anxiety, and stress, correlating negatively with their resilience.

Understanding the role of illness uncertainty is crucial for addressing the psychological challenges of patients with CC. Negative emotions experienced by patients with CC can impair their psychological adaptability and coping ability. Conversely, their coping strategies influence their psychological well-being and perception of illness uncertainty[14]. Illness uncertainty refers to patients’ limited understanding of their disease, which manifests as ambiguity in symptoms, complexity in treatment and care, insufficient information about diagnosis and severity, and unpredictability of disease progression and prognosis. Such uncertainty can lead to negative emotions and adversely affect patients’ coping mechanisms[15]. Despite the significant impact of anxiety, depression, coping styles, and illness uncertainty on patients with CC undergoing radiotherapy, few studies have explored the correlations among these factors. This study aimed to address this by analyzing these relationships, thereby providing valuable insights for clinical practice in managing patients with CC.

MATERIALS AND METHODS

Inclusion and exclusion criteria

A total of 200 patients with CC admitted to The First Affiliated Hospital of Soochow University between June 2018 and June 2022 were enrolled. The inclusion and exclusion criteria were as follows.

Inclusion criteria: (1) Patients diagnosed with CC through imaging studies, cervical smear, and biopsy; (2) Patients undergoing radiotherapy for the first time; (3) Patients who were conscious, able to communicate normally, and had a stable mood; and (4) Patients with complete clinical data.

Exclusion criteria: (1) Patients who had previously undergone radiotherapy or chemotherapy; (2) Patients with comorbid conditions, including cardiac, pulmonary, or renal insufficiency; (3) Patients with other malignant tumors, coagulation disorders, or autoimmune deficiencies; and (4) Pregnant or lactating women.

Detection indicators

Anxiety and depression assessment: The Hospital Anxiety and Depression Scale (HADS)[16] was used to evaluate the patients’ levels of anxiety and depression. The HADS comprises 14 items divided into two subscales: One for anxiety (HADS-A) and one for depression (HADS-D), each containing seven items. Responses were scored on a 4-point Likert scale ranging from 0 to 3, with a maximum score of 21 for each subscale. According to the original criteria: (1) 0–7 points: No symptoms; (2) 8–10 points: Suspicion of symptoms; and (3) 11–21 points: Presence of symptoms. The optimal cut-off values for anxiety and depression can vary between 8 and 10 points. However, many recent studies have used a cut-off value of 8 points. Therefore, for comparison, this study also adopted a cut-off value of 8 points for both anxiety and depression.

Assessment of coping styles: The Jalowiec Coping Scale (JCS-60)[17] was used to evaluate the patients’ coping styles. The JCS-60 comprises 60 items that are categorized into eight distinct coping styles: (1) Confrontive; (2) Evasive; (3) Optimistic; (4) Fatalistic; (5) Emotive; (6) Palliative; (7) Supportive; and (8) Self-reliant. Each item was rated on a 4-point Likert scale: (1) 0: Never; (2) 1: Rarely; (3) 2: Sometimes; and (4) 3: Frequently. The items were distributed among the eight coping styles as follows: (1) Confrontive: 10 items; (2) Evasive: 13 items; (3) Optimistic: 9 items; (4) Fatalistic: 4 items; (5) Emotive: 5 items; (6) Palliative: 7 items; (7) Supportive: 5 items; and (8) Self-reliant: 7 items. To calculate the score for each coping style, the sum of the scores for all items within that style was divided by the number of items in that category, resulting in a score of 0–3 for each coping style. A higher score indicates a more frequent use of that particular coping strategy.

Assessment of illness uncertainty: The Mishel Uncertainty in Illness Scale (MUIS)[18] was used to assess the level of illness uncertainty among patients. The MUIS comprises 33 items divided into four dimensions: (1) Ambiguity (13 items): Unclear disease symptoms; (2) Complexity (8 items): Complexity of treatment and care procedures; (3) Information deficit (7 items): Lack of information regarding disease diagnosis and severity; and (4) Unpredictability (5 items): Unpredictability of the disease process and prognosis. These dimensions represent the primary sources of illness uncertainty. Noteworthy, the 15^th item within the complexity dimension was excluded during scoring. The scale uses a 5-point Likert scale, yielding a total score of 32–160. Higher scores indicate greater uncertainty levels. The total MUIS scores are interpreted as follows: (1) 32–74.7 points: Low-level uncertainty; (2) 74.8–117.4 points: Medium-level uncertainty; and (3) 117.5–160 points: High-level uncertainty.

Statistical analysis

All statistical analyses were performed using Statistical Package for the Social Sciences software version 23.0 (SPSS Inc., Chicago, IL, United States). Continuous variables were expressed as mean ± SE of the mean. Pearson’s correlation coefficient was used to assess the relationships between anxiety, depression, coping styles, and levels of illness uncertainty. A P value < 0.05 was considered statistically significant.

RESULTS

Anxiety and depression scores of patients with CC undergoing radiotherapy

The anxiety and depression levels of the 200 patients with CC undergoing radiotherapy were assessed using the HADS-A and HADS-D scales, respectively. The findings were as follows: (1) Anxiety (HADS-A): The mean score was 7.12 ± 3.39, with 39.5% of the patients scoring ≥ 8, indicating anxiety; (2) Depression (HADS-D): The mean score was 6.68 ± 3.49, with 41.0% of the patients scoring ≥ 8, indicating depression; and (3) Combined anxiety and depression: The combined mean score was 13.80 ± 5.04, with 14.0% of the patients exhibiting both anxiety and depression symptoms (Table 1).

Table 1 Scores of anxiety and depression among cervical cancer patients during radiotherapy.

Indicators	Scoring range	Average score
HADS-A	1-18	7.12 ± 3.39
HADS-D	1-19	6.68 ± 3.49
Total	3-30	13.80 ± 5.04

HADS: Hospital Anxiety and Depression Scale.

Scores of coping styles among patients with CC undergoing radiotherapy

The coping styles of the patients were evaluated using the JCS-60. The scores for each coping style, presented in descending order, were as follows: (1) Optimistic: 2.08 ± 0.66; (2) Confrontive: 1.69 ± 0.73; (3) Self-reliant: 1.68 ± 0.61; (4) Supportive: 1.59 ± 0.64; (5) Evasive: 1.55 ± 0.60; (6) Fatalistic: 1.38 ± 0.72; (7) Palliative: 1.21 ± 0.57; and (8) Emotive: 0.96 ± 0.60. The combined mean score of all coping styles was 1.52 ± 0.23. These results indicate that the optimistic coping style was most frequently adopted among patients with CC undergoing radiotherapy, suggesting a generally positive approach to coping with their illness. In contrast, the emotive coping style had the lowest score, indicating minimal utilization as a coping mechanism in this patient population (Table 2).

Table 2 Coping style scores of cervical cancer patients during radiotherapy.

Indicators	Average score
Optimistic	2.08 ± 0.66
Confrontive	1.69 ± 0.73
Self-reliant	1.68 ± 0.61
Supportive	1.59 ± 0.64
Evasive	1.55 ± 0.60
Fatalistic	1.38 ± 0.72
Palliative	1.21 ± 0.57
Emotive	0.96 ± 0.60
Total	1.52 ± 0.23

Uncertainty in illness scores among patients with CC undergoing radiotherapy

The level of illness uncertainty among the patients was evaluated using the MUIS. The mean scores for each dimension were as follows: (1) Ambiguity: 41.01 ± 5.56; (2) Complexity: 17.14 ± 2.80; (3) Information deficit: 19.08 ± 3.44; and (4) Unpredictability: 16.18 ± 2.51. The total MUIS score was 93.40 ± 7.44. These results suggest that the overall level of illness uncertainty among patients with CC undergoing radiotherapy was moderate (Table 3).

Table 3 Uncertainty in illness scores in cervical cancer patients during radiotherapy.

Indicators	Scoring range	Score
Ambiguity	24-54	41.01 ± 5.56
Complexity	10-26	17.14 ± 2.80
Deficit information	10-29	19.08 ± 3.44
Unpredictability	9-24	16.18 ± 2.51
Uncertainty in illness	72-112	93.40 ± 7.44

Correlation analysis of anxiety, depression, and illness uncertainty

Pearson correlation analyses were used to assess the relationships between anxiety, depression, and the level of illness uncertainty among the 200 patients with CC undergoing radiotherapy. The results indicated that the HADS-A score (anxiety) was significantly positively correlated with the ambiguity dimension, the unpredictability dimension, and the total MUIS score (P < 0.001). Similarly, the HADS-D score (depression) was significantly positively correlated with ambiguity, information deficit, unpredictability, and the total illness uncertainty score (P < 0.001). These findings suggest that higher levels of anxiety and depression are associated with greater illness uncertainty among patients with CC undergoing radiotherapy (Table 4).

Table 4 Correlation analysis between anxiety and depression and the level of illness uncertainty.

Indicators	Ambiguity		Complexity		Deficit information		Unpredictability		Uncertainty in illness
	r value	P value	r value	P value	r value	P value	r value	P value	r value	P value
HADS-A	0.461	< 0.001	0.061	0.393	0.115	0.105	0.324	< 0.001	0.328	< 0.001
HADS-D	0.363	< 0.001	0.117	0.099	0.311	< 0.001	0.281	< 0.001	0.400	< 0.001

HADS: Hospital Anxiety and Depression Scale.

Correlation analysis between coping styles and illness uncertainty

Pearson correlation coefficients were calculated to assess the relationships between different coping styles and levels of illness uncertainty among the 200 patients with CC undergoing radiotherapy.

No significant correlations: The confrontive, optimistic, palliative, and supportive coping styles correlated insignificantly with any dimension of illness uncertainty (P > 0.05).

Positive correlations with negative coping styles

Evasive coping style: It showed significant positive correlations with all dimensions of illness uncertainty and the total MUIS score (P < 0.05).

Fatalistic coping style: It showed significant positive correlations with all dimensions of illness uncertainty and the total illness uncertainty score (P < 0.05).

Emotive coping style: It showed significant positive correlations with complexity, information deficit, unpredictability, and the total illness uncertainty score (P < 0.05).

Negative correlation with self-reliant coping style

Self-reliant coping style: It showed a significant negative correlation with the unpredictability dimension of illness uncertainty (P < 0.001).

These results indicate that patients adopting negative coping strategies, such as evasive, fatalistic, and emotive styles, are more likely to experience higher levels of illness uncertainty. In contrast, those employing a self-reliant coping style may perceive less unpredictability in their illness (Table 5).

Table 5 Correlation analysis between coping styles and uncertainty in illness level.

Indicators	Ambiguity		Complexity		Deficit information		Unpredictability		Uncertainty in illness
	r value	P value	r value	P value	r value	P value	r value	P value	r value	P value
Confrontive	-0.065	0.636	-0.041	0.568	0.066	0.355	-0.035	0.624	-0.052	0.466
Evasive	0.140	0.048	0.193	0.006	0.309	< 0.001	0.188	0.008	0.286	< 0.001
Optimistic	0.052	0.467	-0.047	0.510	0.013	0.855	0.041	0.569	0.004	0.954
Fatalistic	0.306	< 0.001	0.249	< 0.001	0.404	< 0.001	0.371	< 0.001	0.363	< 0.001
Emotive	0.138	0.052	0.260	< 0.001	0.212	0.003	0.320	< 0.001	0.191	0.007
Palliative	-0.037	0.600	0.135	0.056	-0.056	0.427	-0.072	0.312	-0.056	0.428
Supportive	-0.077	0.279	0.121	0.087	0.123	0.083	-0.091	0.200	0.131	0.065
Self-reliant	0.074	0.299	0.108	0.130	0.124	0.079	-0.272	< 0.001	0.130	0.068

DISCUSSION

Our study revealed that among the 200 patients with CC undergoing radiotherapy, 39.5% exhibited anxiety, 41.0% showed signs of depression, and 14.0% experienced both conditions. Consistent with our findings, Zhao et al[19] reported that anxiety and depression were highly prevalent among patients with CC, with rates of 44.9% and 36.1%, respectively. Similarly, another study involving 224 patients with CC revealed even higher prevalence rates of depression and anxiety, with 52.2% and 65.6% of the participants, respectively. These findings highlight the critical need for greater attention to the elevated risk of depression and anxiety in this patient population in clinical settings[20]. Such psychological distress may be closely associated with factors, such as greater tumor burden, unfavorable survival outcomes, and, to some extent, dissatisfaction with body image changes experienced during and after treatment, a particularly relevant concern for female patients[21].

According to the JCS-60 data, optimism was the most prevalent coping style among the patients, whereas the emotive coping style was the least adopted. This may be because most of the patients were at stage IIb or above. In many cases, initial symptoms such as vaginal bleeding were effectively controlled shortly after treatment began, significantly relieving symptoms. Consequently, these patients maintained a relatively high level of hope and approached their situation with optimism[22].

The emotive coping style, considered a negative coping strategy, fails to alleviate psychological stress and may exacerbate psychological distress. This likely explains its limited adoption among the patients[23]. Thieme et al[24] reported that the optimism level among female patients with cancer was marginally higher than the corresponding average in the general population. Optimism was significantly positively correlated with quality of life and negatively correlated with anxiety and depression. This may be because female patients with cancer who maintain an optimistic attitude are better able to adapt to their illness. Kim et al[25] reported that patients with gynecological cancer undergoing chemotherapy effectively alleviated depressive emotions through active cognitive restructuring, suggesting a close relationship between positive coping styles and the mitigation of negative emotions. Nevertheless, further in-depth analysis is warranted to fully understand this correlation. Furthermore, tailoring personalized psychological support programs for patients with diverse coping styles holds great promise in fostering positive coping strategies, subsequently facilitating their enhanced adaptation to the disease and their successful navigation out of psychological distress. Nevertheless, the development and detailed formulation of such programs require further experimental exploration and in-depth analysis.

Our MUIS data indicated that the total illness uncertainty score among the patients with CC undergoing radiotherapy was at a moderate level (93.40 ± 7.44 points). Gu et al[26] recruited 284 patients with CC. Notably, 78.6% of these patients exhibited a moderate-to-high level of disease-related uncertainty. This finding strongly suggests that most patients experience a relatively elevated level of uncertainty about their illness, consistent with our findings. Our correlation analysis revealed that anxiety was significantly positively correlated with ambiguity, unpredictability, and the total illness uncertainty score (P < 0.05). Depression was also significant positively correlated with ambiguity, information deficit, unpredictability, and the total illness uncertainty score (P < 0.05). These findings align with those of Wang et al[27], who reported a bidirectional interdependence between illness uncertainty and anxiety and depression in patients with lung cancer. Similarly, Cruz-Castellanos et al[28] noted that illness uncertainty in patients with advanced lung cancer can increase psychological distress, corroborating our results.

It is well-established that the impact of illness uncertainty on patients primarily stems from their cognitive appraisals and coping strategies. Furthermore, our study revealed that evasive, fatalistic, and emotive coping styles were significantly positively correlated with illness uncertainty (P < 0.05). In contrast, the self-reliant coping style was significantly negatively correlated with unpredictability (P < 0.05). These results suggest that patients adopting negative coping strategies may experience higher levels of illness uncertainty, whereas those adopting self-reliant approaches may perceive less unpredictability in their illness.

Evasive, fatalistic, and emotive coping styles are considered negative coping modalities characterized by a lack of active pursuit of useful disease-related information and a tendency toward compromise. Although these approaches may temporarily alleviate psychological stress, they are detrimental to long-term physical and mental rehabilitation. The significant negative correlation between the self-reliant coping style and unpredictability may be attributed to patients actively seeking effective disease-related information, enhancing their understanding of the disease and helping reduce illness uncertainty. Lauver et al[29] reported that effective clinical interventions can reduce illness uncertainty among patients with CC, facilitate the adoption of positive coping strategies, and effectively alleviate psychological distress. This underscores the close association between illness uncertainty, coping styles, and psychological status, consistent with our findings.

CONCLUSION

In summary, anxiety, depression, and negative coping styles, specifically evasive, fatalistic, and emotive, among patients with CC undergoing radiotherapy are significantly positively correlated with illness uncertainty. Medical staff should be vigilant regarding patients’ emotional states and coping strategies. By providing targeted interventions, healthcare professionals can help patients alleviate their psychological distress and promote the adoption of positive coping styles, consequently reducing their sense of illness uncertainty. This approach enhances patients’ psychological well-being and may contribute to improved treatment outcomes.