Self-perceived burden and influencing factors in patients with cervical cancer administered with radiotherapy

Abstract

BACKGROUND

Cervical cancer is the fourth commonest malignancy in women around the world. It represents the second most commonly diagnosed cancer in South East Asian women, and an important cancer death cause in women of developing nations. Data collected in 2018 revealed 5690000 cervical cancer cases worldwide, 85% of which occurred in developing countries.

AIM

To assess self-perceived burden (SPB) and related influencing factors in cervical cancer patients undergoing radiotherapy.

METHODS

Patients were prospectively included by convenient sampling at The Fifth Affiliated Hospital of Sun Yat-Sen University, China between March 2018 and March 2019. The survey was completed using a self-designed general information questionnaire, the SPB scale for cancer patients, and the self-care self-efficacy scale, Strategies Used by People to Promote Health, which were delivered to patients with cervical cancer undergoing radiotherapy. Measurement data are expressed as the mean ± SD. Enumeration data are expressed as frequencies or percentages. Caregivers were the spouse, offspring, and other in 46.4, 40.9, and 12.7%, respectively, and the majority were male (59.1%). As for pathological type, 90 and 20 cases had squamous and adenocarcinoma/adenosquamous carcinomas, respectively. Stage IV disease was found in 12 (10.9%) patients.

RESULTS

A total of 115 questionnaires were released, and five patients were excluded for too long evaluation time (n = 2) and the inability to confirm the questionnaire contents (n = 3). Finally, a total of 110 questionnaires were collected. They were aged 31-79 years, with the 40-59 age group being most represented (65.4% of all cases). Most patients were married (91.8%) and an overwhelming number had no religion (92.7%). Total SPB score was 43.13 ± 16.65. SPB was associated with the place of residence, monthly family income, payment method, transfer status, the presence of radiotherapy complications, and the presence of pain (P < 0.05). The SPB and self-care self-efficacy were negatively correlated (P < 0.01). In multivariate analysis, self-care self-efficacy, place of residence, monthly family income, payment method, degree of radiation dermatitis, and radiation proctitis were influencing factors of SPB (P < 0.05).

CONCLUSION

Patients with cervical cancer undergoing radiotherapy often have SPB. Self-care self-efficacy scale, place of residence, monthly family income, payment method, and radiation dermatitis and proctitis are factors independently influencing SPB.

Key Words: Cervical cancer; Radiotherapy; Self-perceived burden; Influencing factors; Self-perceived burden; Prospective research

Core Tip: Cervical cancer is the fourth commonest malignancy in women around the world. The present study aimed to assess self-perceived burden (SPB) and related influencing factors in cervical cancer patients undergoing radiotherapy. The survey was completed using a self-designed general information questionnaire, the SPB scale for cancer patients, and the self-care self-efficacy scale, Strategies Used by People to Promote Health. The results suggested that patients with cervical cancer undergoing radiotherapy often have SPB. Self-care self-efficacy scale, place of residence, monthly family income, payment method, and radiation dermatitis and proctitis are factors independently influencing SPB.

INTRODUCTION

Cervical cancer is the fourth commonest malignancy in women around the world[1]. Individuals with cervical cancer tend to be younger than previously reported[2,3]. External beam radiation and brachytherapy are often applied for cervical cancer treatment[4]. After diagnosis with cervical cancer, the women have short-term and long-term psychophysical and sexual problems; for example, undergoing brachytherapy could be perceived as a negative, humiliating experience resulting in pain, fear, fatigue, financial issues, among others[5,6].

The psychological pressure of long-term treatment, care, and financial and emotional problems generally results in the negative experience of self-perceived burden (SPB), as demonstrated in other cancers, including breast cancer and hematologic malignancies[7,8]. Currently, studies assessing SPB in cervical cancer patients undergoing radiotherapy are scarce, and the effects of radiotherapy on mental and physical health in such individuals are not completely understood.

Therefore, the present study aimed to assess SPB and related influencing factors in cervical cancer patients undergoing radiotherapy. Our findings will provide a reference for reducing SPB in these patients.

MATERIALS AND METHODS

Patients

Patients were prospectively included by convenient sampling at The Fifth Affiliated Hospital of Sun Yat-Sen University, China between March 2018 and March 2019.

The inclusion criteria were: (1) Pathological diagnosis of cervical cancer[9]; (2) Consciousness; (3) Current radiotherapy; (4) Age ≥ 18 years; (5) Ability to read the questionnaire and answer the questions correctly; and (6) Agreement to voluntarily participate in the survey. The exclusion criteria were: (1) Cognitive impairment and mental disease history; (2) Other organ ailments, including respiratory and cardiovascular system diseases; and (3) No caregiver during radiotherapy. The study was approved by the ethics committee of Sun Yat-Sen University, and signed informed consent was provided by each participant.

Questionnaires

The survey was completed by distributing questionnaire forms to eligible subjects, including a self-designed general information questionnaire, and the SPB and self-care self-efficacy scales.

The general information questionnaire mainly assesses parameters such as age, nationality, place of residence, marital status, religion, occupation, education level, monthly family income, payment method, situation of caregivers, and disease information, obtained from medical records.

The SPB scale for cancer patients (SPBS-CP) was proposed by Ren et al[10] referring to the global SPB assessment tool, which includes care burden (items 1-4), financial/ family burden (items 5-11), emotional burden (items 12-17), and treatment burden (items 18-21). A 5-level Likert scale was used for scoring from "never" to "always" (1-5). After summing the scores obtained for various items, the SPB level of patients was measured as follows: SPB < 30, no obvious burden; 30 ≤ SPB < 50, mild burden; 50 ≤ SPB < 70, moderate burden; SPB ≥ 70 severe burden. Content validity was 0.81, for a Cronbach's coefficient of 0.938.

The strategies used by people to promote health scale was developed by Lev et al[11] in 1996, and further modified by Qian et al[12] from China in 2011. It includes the three dimensions of positive attitudes (15 items), self-decision-making (3 items), and self-decompression (10 items), with a total of 28 items. A 5-level Likert scale was used for scoring, from "no confidence" to "very confident" (1-5), and total scores were 28-140. The higher the score, the greater the confidence in self-care by patients. The Cronbach's α for this scale was 0.970.

Radiation Therapy Oncology Group classification criteria for acute radiation injury were used for radiation complications[13], and the digital scoring method was used for pain assessment.

Survey and quality control

Based on informed consent, unified guidance was applied by the investigators to perform the one-to-one questionnaire survey. The questionnaires were collected on the spot. Then, the filled questionnaires were assessed by two investigators, who immediately input the data into the system.

Statistical analysis

SPSS 21.0 software (SPSS, United States) was used for data analyses. Measurement data are expressed as the mean ± SD. Enumeration data are expressed as frequencies or percentages. Total SPB score was considered a continuous variable, and analyzed by the Kolmogorov–Smirnov test for normality of distribution. The t-test and analysis of variance were used to evaluate measurement data. Spearman correlation analysis was carried out to analyze the correlation between SPB and self-care self-efficacy scale score. Multivariate linear regression analysis of influencing factors of SPB in cervical cancer patients undergoing radiotherapy was performed. Using the SPB score as the dependent variable, parameters in general patient information with P < 0.05 in univariate analysis and self-care self-efficacy scale score as independent variables were assessed by stepwise multivariate linear regression. Two-sided P < 0.05 was considered statistically significant.

RESULTS

Patient general data

A total of 115 questionnaires were released, and five patients were excluded for too long evaluation time (n = 2) and the inability to confirm the questionnaire contents (n = 3). Finally, a total of 110 questionnaires were collected. They were aged 31-79 years, with the 40-59 age group being most represented (65.4% of all cases). Most patients were married (91.8%) and an overwhelming number had no religion (92.7%). Caregivers were the spouse, offspring, and other in 46.4, 40.9 and 12.7%, respectively, and the majority were male (59.1%). As for pathological type, 90 and 20 cases had squamous and adenocarcinoma/adenosquamous carcinomas, respectively. Stage IV disease was found in 12 (10.9%) patients. Table 1 shows the characteristics of cervical cancer patients undergoing radiotherapy.

Table 1 General information of cervical cancer patients undergoing radiotherapy (n = 110).

Item	Cases (n)	%	Variable	Cases (n)	%
Age (yr)			Times of current radiotherapy
31-39	10	9.1	1-10	25	22.7
40-59	72	65.4	11-20	51	46.4
60-79	28	25.5	> 20	34	30.9
Residence			Pathological type
Rural area	59	53.6	Squamous carcinoma	90	81.8
City	51	46.4	Adenocarcinoma or adenosquamous carcinoma	20	18.2
Marital status			Tumor stage
Single or widowed	9	8.2	Stage I	27	24.6
Married	101	91.8	Stage II	34	30.9
Religion			Stage III	37	33.6
No	102	92.7	Stage IV	12	10.9
Yes	8	7.3	Radiation way
Education level			In vitro	71	64.5
Primary school or below	54	49.1	In vitro + intracavity	39	35.5
Junior high school	36	32.7	Recurrence
Senior high school	8	7.3	No	104	94.5
College degree or above	12	10.9	Yes	6	5.5
Monthly family income per capita			Metastasis
< 3000	31	28.1	No	85	77.3
3000-5000	50	45.5	Yes	25	22.7
> 5000	29	26.4	Radiation dermatitis
Payment method			0	36	32.7
Self-paying	26	23.6	1	68	61.8
Networking inside and outside province	17	15.5	> 2	6	5.5
Health care in the city	67	60.9	Radiation proctitis
Caregiver			0	27	24.5
Spouse	51	46.4	1	53	48.2
Offspring	45	40.9	> 2	30	27.3
Other	14	12.7	Radiation cystitis
Caregiver Age (yr)			0	87	79.1
18-39	48	43.6	1	15	13.6
40-59	37	33.7	> 2	8	7.3
60-	25	22.7	Pain
Gender of caregiver			No	78	70.9
Female	45	40.9	Yes	32	29.1
Male	65	59.1

SPB subscores and self-care self-efficacy scale scores and correlations with total SPB score in cervical cancer patients undergoing radiotherapy

The SPB scale was used to evaluate SPB levels in cervical cancer patients undergoing radiotherapy. The total SPB score was 43.13 ± 16.65. The financial/family burden score was the highest (16.89 ± 6.44), while treatment burden had the lowest score (7.31 ± 3.48). Meanwhile, total self-care self-efficacy scale score was 99.52 ± 25.34. Correlation analysis indicated that SPB and self-care self-efficacy scale scores were negatively correlated, with statistical significance (r = -0.701, P < 0.01). Detailed data are provided in Table 2.

Table 2 Self-perceived burden subscores and self-care self-efficacy scale scores and correlations with total self-perceived burden score in cervical cancer patients undergoing radiotherapy (n = 110).

Item	(Score, mean ± SD)	Total score of SPB
		r	P
Financial/family burden	16.89 ± 6.44	0.914	< 0.05
Care burden	8.90 ± 4.22	0.835	< 0.05
Treatment burden	7.31 ± 3.48	0.770	< 0.05
Emotional burden	10.10 ± 5.03	0.872	< 0.05
Total score of SPB	43.13 ± 16.65
Total score of self-care self-efficacy scale	99.52 ± 25.34	-0.701	< 0.05

SPB: Self-perceived burden.

Univariate analysis of SPB scores based on general parameters of cervical cancer patients undergoing radiotherapy

A univariate analysis was performed to assess the correlations of various patient parameters with SPB score. As shown in Table 3, place of residence, monthly family income per capita, payment method, metastasis, pain, and radiation-associated complications (dermatitis, proctitis, and cystitis) were correlated with SPB score (P < 0.05).

Table 3 Univariate analysis of self-perceived burden scores based on general data in cervical cancer patients undergoing radiotherapy (n = 110).

Item	Case (n)	mean ± SD	t/F	P	Pairwise comparison
Age (yr)			0.620	0.540
(1) 31-39	10	48.60 ± 24.075
(2) 40-49	72	42.83 ± 15.959
(3) 60-79	28	41.93 ± 15.604
Residence			4.667	< 0.05	(1) > (2)
(1) Rural area	59	49.44 ± 16.406
(2) City	51	35.82 ± 13.811
Marital status			0.143	0.887
(1) Single or widowed	9	43.89 ± 19.637
(2) Married	101	43.06 ± 16.471
Religion			1.015	0.312
(1) No	102	43.58 ± 16.766
(2) Yes	8	37.38 ± 14.851
Education level			0.044	0.987
Primary school or below	54	43.17 ± 15.779
Junior high school	36	43.04 ± 17.064
Senior high school	8	44.88 ± 27.205
College degree or above	12	42.08 ± 12.117
Family per capita monthly income			24.572	< 0.05	(1) > (2)
< 3000	31	56.77 ± 18.353			(2) > (3)
3000-5000	50	41.06 ± 12.904			(1) > (3)
> 5000	29	32.10 ± 9.344
Payment method			13.051	< 0.05	(1) > (2)
Self-paying	26	56.27 ± 16.185			(1) > (3)
Networking inside and outside province	17	40.53 ± 13.172
Health care in the city	67	38.69 ± 15.060
Caregiver			1.418	0.247
Spouse	51	40.31 ± 17.136
Offspring	45	45.18 ± 13.890
Other	14	46.79 ± 21.959
Caregiver age (yr)			1.183	0.310
(1) 18-39	48	45.85 ± 16.720
(2) 40-59	37	41.49 ± 15.073
(3) 60-	25	40.32 ± 18.538
Gender of caregiver			1.538	0.127
(1) Female	45	46.04 ± 16.628
(2) Male	65	44.01 ± 16.605
Times of current radiotherapy			0.096	0.909
(1) 1-10	25	42.16 ± 16.570
(2) 11-20	51	42.98 ± 16.861
(3) > 20	34	44.06 ± 16.843
Pathological type			-1.807	0.074
(1) Squamous carcinoma	90	41.79 ± 15.489
(2) Adenocarcinoma or adenosquamous carcinoma	20	49.15 ± 20.497
Clinical tumor stage			1.272	0.288
(1) Stage I	27	39.41 ± 14.550
(2) Stage II	34	41.24 ± 16.672
(3) Stage III	37	46.43 ± 17.868
(4) Stage IV	12	46.67 ± 16.516
Radiation way			0.035	0.972
(1) In vitro	71	43.17 ± 16.902
(2) In vitro + intracavity	39	43.05 ± 16.401
Recurrence			-0.660	0.511
(1) No	104	42.88 ± 15.826
(2) Yes	6	47.50 ± 29.331
Metastasis			-5.333	< 0.05	(2) > (1)
(1) No	85	39.02 ± 13.885
(2) Yes	25	57.08 ± 17.944
Radiation dermatitis			20.183	< 0.05	(2) > (1)
(1) 0	36	31.92 ± 07.951			(3) > (1)
(2) 1	68	47.22 ± 16.977			(3) > (2)
(3) > 2	6	64.00 ± 09.143
Radiation proctitis			8.199	< 0.05	(2) > (1)
(1) 0	27	33.74 ± 11.772			(3) > (1)
(2) 1	53	43.75 ± 15.859
(3) > 2	30	50.47 ± 18.122
Radiation cystitis			3.926	< 0.05	(3) > (1)
(1) 0	87	41.03 ± 16.340
(2) 1	15	48.67 ± 15.351
(3) > 2	8	55.50 ± 16.440
Pain			-3.132	< 0.05	(2) > (1)
(1) No	78	40.06 ± 14.848
(2) Yes	32	50.59 ± 18.604

Factors independently affecting SPB

Multivariate regression analysis showed that self-care self-efficacy scale score, place of residence, monthly family income, payment method, and radiation and radiation proctitis in cervical cancer patients undergoing radiotherapy independently affected SPB, with statistical significance. The combined total variance was 75.1%, as shown in Table 4.

Table 4 Multivariate analysis of factors potentially affecting self-perceived burden in cervical cancer patients undergoing radiotherapy.

Variable	Partial regression coefficient	Standard error	Standardized partial regression coefficient	t	P value
Self-management effectiveness	-0.303	0.036	-0.462	-8.431	0.000
Residence	-4.110	1.784	-0.124	-2.304	0.023
Family per capita monthly income	-5.231	1.242	-0.233	-4.211	0.000
Payment method	-3.515	1.027	-0.178	-3.424	0.001
Radiation dermatitis	6.540	1.672	0.219	3.912	0.000
Radiation proctitis	3.814	1.226	0.166	3.110	0.002

R² = 0.751.

DISCUSSION

Studies conducted in many countries revealed salient SPB among cancer patients. However, studies assessing SPB in cervical cancer patients undergoing radiotherapy are scarce.

This study demonstrated that mild to moderate SPB is common in patients with cervical cancer undergoing radiotherapy. In addition, self-management effectiveness, the place of residence, monthly family income, payment method, and some radiation complications independently affected SPB.

In this study, total SPB score in cervical cancer patients undergoing radiotherapy was 43.13 ± 16.65, reflecting a mild to moderate level overall, corroborating the finding of Zheng et al[14]. There were 44 (40%), 28 (25.5%), and 9 (8.2%) patients with mild, moderate, and severe SPB, respectively. The above results suggested that the assessed patients generally had SPB, with some even showing moderate and severe levels, which is worthy of attention from clinical staff. To help patients with mild SPB, the medical staff should provide timely psychological counseling, apply effective psychological nursing, and provide health education, to avoid progression to moderate and severe levels.

Financial/family burden showed the highest subscores (16.89 ± 6.44) among all dimensions, in agreement with previous studies assessing SPB in patients undergoing radiotherapy[15,16]. The item with the highest subscore was "I feel that I am a burden to my family (or caregiver)", followed by "I am worried that the treatment will cost a lot of money". This indicates that financial/family burden is an important factor affecting SPB in these patients. A Japan study also found that nurses should not only support patients' efforts to tackle the situation by themselves, but also help the family as a whole to tackle problems together. By facilitating meaningful dialogue between family members, patients' feelings of SPB can be alleviated[17]. Therefore, in clinics, patients with poor family finances and low income should be paid particular attention to, and their medical needs should be timely met and medical information and assistance should be provided to them to reduce the burden on their families.

This study showed that the lower the self-care self-efficacy scale score in cervical cancer patients undergoing radiotherapy, the higher the SPB. Patients with low self-care self-efficacy scale scores often have less positive attitudes, less enthusiasm to seek self-decompression methods, and lack of self-decision-making ability, leading to an increased psychological burden[18,19]. Therefore, the clinical staff could reduce the SPB by improving self-care self-efficacy in patients.

As shown above, place of residence was another factor independently affecting SPB in patients with cervical cancer undergoing radiotherapy. The patients living in rural areas accounted for 53.6%, and showed higher SPB scores compared with urban residents, in agreement with the findings by Gong et al[20]. The rural patients also had a lower education level and worried about medical costs. Besides, radiotherapy time was long, and the rural patients had reduced access to medical information, resulting in worries, anxiety, and increased psychological burden. Therefore, the medical staff should pay attention to patients from rural areas, providing proper psychological counseling, specific guidance, and help based on their actual situation, which might alleviate their psychological pressure.

Other parameters independently determining SPB included the monthly family income and payment method. The above results showed that the poorer the family, the higher the SPB, consistent with multiple studies[21-24]. The patients with relatively high family income and medical insurance had no overt worries during treatment and nursing, which provided some comfort. Therefore, the medical staff should focus on patients with poor family financial conditions and those paying all medical bills by themselves to subscribe for medical insurance, providing some medical information and assistance to reduce medical expenses, which could decrease the burden and relieve their worries regarding the medical treatment.

Finally, the severity of radiotherapy complications in this study independently affected SPB, which is consistent with multiple studies of cancer patients[16,25,26] in China. Studies from other countries also found that cancer patients' high SPB was precipitated by suffering from severe symptom distress and heavy functional[7,27]. The incidence of radiation dermatitis in radiotherapy of cervical cancer reaches 93.8%[28]. Patients with radiation dermatitis show symptoms such as pruritus, dehumidification, and skin damage in the radiation field, or even bleeding, exudation, and pain in serious cases. Meanwhile, radiation proctitis often occurs at 1-2 wk after radiotherapy, with an incidence of 53%-100%[29]. In this study, 75.5% of patients had radiation proctitis, with grade 1 showing a relatively high incidence and accounting for 48.2%. The most common symptoms of radiation enteritis include diarrhea and increased frequency of defecation, accompanied by anal pain and fall-swell feeling. The affected patients may experience dizziness, gastrointestinal dysfunction, electrolyte imbalance, and even intestinal fistula, and need to discontinue radiotherapy in severe cases. Such symptoms could prolong treatment time, and increase hospitalization duration and cost, pain, and anxiety, subsequently increasing SPB. While paying attention to treatment effects, the medical staff should also dynamically evaluate psychological changes and needs, to reduce the psychological burden. In addition, effective symptom management and comfortable care are also important measures to reduce SPB.

The limitations of this study should be mentioned. First, this was a single-center study, with a relatively small sample size. In addition, there was no follow-up of the patients after the survey. Therefore, further large multi-center studies are required to confirm these findings and better assist cervical cancer patients undergoing radiotherapy.

CONCLUSION

Studies by domestic and foreign scholars have shown that SPB is closely related to the quality of life, including a good death[30], dignity[31], etc. In addition, the burden of self-perception is also related to the patient's end-of-life decision on euthanasia and suicidal behavior[32]. Other studies have shown that cancer patients and patients with severe chronic diseases worry about being a burden on their families, which is a "community test", leading to negative emotional reactions such as guilt, depression, and sense of burden in patients, which seriously affects the mental health of cancer patients[32-34].

Overall, patients with cervical cancer undergoing radiotherapy often have moderate to severe SPB. Self-care self-efficacy scale score, place of residence, monthly family income, payment method, and radiation dermatitis and proctitis are factors independently influencing SPB. In clinics, the medical staff should pay attention to improving the patients' self-care self-efficacy, focus on rural and low-income patients, and provide effective symptom management to cervical cancer patients undergoing radiotherapy, which could reduce SPB and improve prognosis and the quality of life.

ARTICLE HIGHLIGHTS

Research background

Cervical cancer is the fourth commonest malignancy in women around the world. Individuals with cervical cancer tend to be younger than previously reported. The psychological pressure of long-term treatment, care, and financial and emotional problems generally results in the negative experience of self-perceived burden (SPB), Studies by domestic and foreign scholars have shown that SPB is closely related to the quality of life, including a good death, dignity, etc.

Research motivation

Studies conducted in many countries revealed salient SPB among cancer patients. However, studies assessing SPB in cervical cancer patients undergoing radiotherapy are scarce.

Research objectives

This study aimed to assess SPB and related influencing factors in cervical cancer patients undergoing radiotherapy.

Research methods

One-hundred and ten patients with cervical cancer undergoing radiotherapy were selected for questionnaire survey. Research data of these patients were summarized and analyzed.

Research results

Total SPB score was 43.13 ± 16.65. SPB was associated with the place of residence, monthly family income, payment method, transfer status, the presence of radiotherapy complications, and the presence of pain (P < 0.05). The SPB and self-care self-efficacy were negatively correlated (P < 0.01). In multivariate analysis, self-care self-efficacy, place of residence, monthly family income, payment method, and degree of radiation dermatitis and radiation proctitis were influencing factors of SPB (P < 0.05).

Research conclusions

Patients with cervical cancer undergoing radiotherapy often have SPB. Self-care self-efficacy scale score, place of residence, monthly family income, payment method, and radiation dermatitis and proctitis are factors independently influencing SPB.

Research perspectives

In clinics, the medical staff should pay attention to improving the patients' self-care self-efficacy, focus on rural and low-income patients, and provide effective symptom management to cervical cancer patients undergoing radiotherapy, which could reduce SPB and improve prognosis and the quality of life.