Longitudinal Analysis of Severe Anxiety Symptoms in the Last Year of Life Among Patients With Advanced Cancer: Relationships With Proximity to Death, Burden, and Social Support

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  • a From Chang Gung University, School of Nursing, Tao-Yuan City, Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, and Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou, Tao-Yuan City, Taiwan.
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Background: Temporal changes in the prevalence of anxiety disorders/symptoms for patients with cancer at the end of life (EOL) remain unclear. This study was undertaken to describe changes in the prevalence of severe anxiety symptoms and to identify its correlates in the last year of life for patients with cancer. Methods: A convenience sample of 325 patients with cancer was followed until death. Severe anxiety symptoms were identified as anxiety subscale scores of 11 or greater on the Hospital Anxiety and Depression Scale. Longitudinal changes in and correlates of severe anxiety symptoms were examined from demographics, disease-related characteristics, disease burden, perceived burden to others, and social support using multivariate logistic regression modeling with generalized estimating equations. Results: The prevalence of severe anxiety symptoms increased as death approached (18.6%, 21.9%, 26.7%, and 33.4% at 181–365, 91–180, 31–90, and 1–30 days before death, respectively). However, after controlling for covariates, this temporal increase was not significant. The prevalence of severe anxiety symptoms was not associated with fixed demographics and disease-related characteristics, except for diagnosis and metastatic status, but was significantly higher in patients with cancer with high physical symptom distress, severe depressive symptoms, high perceived burden to others, and strong perceived social support. Conclusions: Severe anxiety symptoms were not associated with time proximity to death per se but were related to factors modifiable by high-quality EOL care. Clinicians may decrease the likelihood of severe anxiety symptoms at EOL by adequately managing physical and depressive symptoms and lightening perceived burden to others for patients strongly connected with their social network to improve their psychological well-being.

Author Contributions: Study concept and design: Tang, Chen, Chou, Chang, Wu, Hsieh, Chiang, and Kuo. Acquisition of data: Tang, Chen, Chou, Chang, Wu, Hsieh, Chiang, and Kuo. Analysis and interpretation of data: Tang. Drafting of manuscript: Tang. Final approval of manuscript: Tang, Chen, Chou, Chang, Wu, Hsieh, Chiang, and Kuo.

Correspondence: Siew Tzuh Tang, DNS, Chang Gung University, School of Nursing, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan, 333. E-mail: sttang@mail.cgu.edu.tw
  • 1.

    Kolva E, Rosenfeld B, Pessin H. Anxiety in terminally ill cancer patients. J Pain Symptom Manage 2011;42:691701.

  • 2.

    Miovic M, Block S. Psychiatric disorders in advanced cancer. Cancer 2007;15:16651676.

  • 3.

    Mitchell AJ, Chan M, Bhatti H. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol 2011;12:160174.

    • Search Google Scholar
    • Export Citation
  • 4.

    Spencer R, Nilsson M, Wright A. Anxiety disorders in advanced cancer patients: correlates and predictors of end-of-life outcomes. Cancer 2010;116:18101819.

    • Search Google Scholar
    • Export Citation
  • 5.

    Wilson KG, Chochinov HM, Skirko MG. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manage 2007;33:118129.

  • 6.

    Cripe LD, Rawl SM, Schmidt KK. Discussions of life expectancy moderate relationships between prognosis and anxiety or depression in men with advanced cancer. J Palliat Med 2012;15:99105.

    • Search Google Scholar
    • Export Citation
  • 7.

    Delgado-Guay M, Parsons HA, Li Z. Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting. Support Care Cancer 2009;17:573579.

    • Search Google Scholar
    • Export Citation
  • 8.

    Mystakidou K, Rosenfeld B, Parpa E. Desire for death near the end of life: the role of depression, anxiety and pain. Gen Hosp Psychiatry 2005;27:258262.

    • Search Google Scholar
    • Export Citation
  • 9.

    O'Connor M, White K, Kristjanson LJ. The prevalence of anxiety and depression in palliative care patients with cancer in Western Australia and New South Wales. Med J Aust 2010;193(5 Suppl):S4447.

    • Search Google Scholar
    • Export Citation
  • 10.

    Salvo N, Zeng L, Zhang L. Frequency of reporting and predictive factors for anxiety and depression in patients with advanced cancer. Clin Oncol 2012;24:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    Seow H, Barbera L, Sutradhar R. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol 2011;29:11511158.

    • Search Google Scholar
    • Export Citation
  • 12.

    Stark D, Kiely M, Smith A. Anxiety disorders in cancer patients: their nature, associations, and relation to quality of life. J Clin Oncol 2002;20:31373148.

    • Search Google Scholar
    • Export Citation
  • 13.

    Teunissen SC, de Graeff A, Voest EE, de Haes JC. Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients. Palliat Med 2007;21:341346.

    • Search Google Scholar
    • Export Citation
  • 14.

    Vodermaier A, Linden W, MacKenzie R. Disease stage predicts post-diagnosis anxiety and depression only in some types of cancer. Br J Cancer 2011;105:18141817.

    • Search Google Scholar
    • Export Citation
  • 15.

    Warmenhoven F, van Weel C, Vissers K, Prins J. Screening instruments for depression in advanced cancer patients: what do we actually measure? Pain Pract 2013;13:467475.

    • Search Google Scholar
    • Export Citation
  • 16.

    McCoubrie RC, Davies AN. Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer 2005;14:379385.

    • Search Google Scholar
    • Export Citation
  • 17.

    Johnson KS, Tulsky JA, Hays JC. Which domains of spirituality are associated with anxiety and depression in patients with advanced illness? J Gen Intern Med 2011;26:751758.

    • Search Google Scholar
    • Export Citation
  • 18.

    Suarez-Almazor ME, Newman C, Hanson J, Bruera E. Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. J Clin Oncol 2002;20:21342141.

    • Search Google Scholar
    • Export Citation
  • 19.

    Lichtenthal WG, Nilsson M, Zhang B. Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches? Psychooncology 2009;18:5061.

    • Search Google Scholar
    • Export Citation
  • 20.

    Norton S, Cosco T, Doyle F. The Hospital Anxiety and Depression Scale: a meta confirmatory factor analysis. J Psychosom Res 2013;74:7481.

  • 21.

    Traeger L, Greer JA, Fernandez-Robles C. Evidence-based treatment of anxiety in patients with cancer. J Clin Oncol 2012;30:11971205.

  • 22.

    Tang ST, Chang WC, Chen JS. Trajectory and predictors of quality of life during the dying process: roles of perceived sense of burden to others and posttraumatic growth. Support Care Cancer 2014;22:29572964.

    • Search Google Scholar
    • Export Citation
  • 23.

    Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scan 1983;67:361370.

  • 24.

    Wasteson E, Brenne E, Higginson IJ. Depression assessment and classification in palliative cancer patients: a systematic literature review. Palliat Med 2009;23:739753.

    • Search Google Scholar
    • Export Citation
  • 25.

    Mitchell AJ, Meader N, Symonds P. Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis. J Affect Disord 2010;126:335348.

    • Search Google Scholar
    • Export Citation
  • 26.

    Carey M, Noble N, Sanson-Fisher R, MacKenzie L. Identifying psychological morbidity among people with cancer using the Hospital Anxiety and Depression Scale: time to revisit first principles? Psycho-Oncol 2012;21:229238.

    • Search Google Scholar
    • Export Citation
  • 27.

    McCorkle R, Young K. Development of a symptom distress scale. Cancer Nurs 1978;1:373378.

  • 28.

    Benoliel JQ, McCorkle R, Young K. Development of a social dependency scale. Res Nurs Health 1980;3:310.

  • 29.

    Stapleton SJ, Holden J, Epstein J, Wilkie DJ. A systematic review of the symptom distress scale in advanced cancer studies [published online ahead of print August 6, 2015]. Cancer Nurs, in press.

    • Search Google Scholar
    • Export Citation
  • 30.

    Tang ST, McCorkle R. A user's manual for the Enforced Social Dependency Scale. Available at: http://fhsson.mcmaster.ca/apn/images/stories/pdfs/Social_Dependency_Scale_User's_Manual.pdf. Accessed February 14, 2016.

    • Search Google Scholar
    • Export Citation
  • 31.

    Tang ST, Chen JS, Chou WC. Prevalence of severe depressive symptoms increases as death approaches and is associated with disease burden, tangible social support, and high self-perceived burden to others. Support Care Cancer 2016;24:8391.

    • Search Google Scholar
    • Export Citation
  • 32.

    Cousineau N, McDowell I, Hotz S, Hebert P. Measuring chronic patient's feelings of being a burden to their caregivers: development and preliminary validation of a scale. Med Care 2003;41:110118.

    • Search Google Scholar
    • Export Citation
  • 33.

    McPherson CJ, Wilson KG, Chyurlia L, Leclerc C. The balance of give and take in caregiver-partner relationships: an examination of self-perceived burden, relationship equity, and QOL from the perspective of care recipients following stroke. Rehabil Psychol 2010;55:194203.

    • Search Google Scholar
    • Export Citation
  • 34.

    McPherson CJ, Wilson KG, Lobchuk MM, Brajtman S. Self-perceived burden to others: patient and family caregiver correlates. J Palliat Care 2007;23:135142.

    • Search Google Scholar
    • Export Citation
  • 35.

    McPherson CJ, Wilson KG, Lobchuk MM, Brajtman S. Family caregivers' assessment of symptoms in patients with advanced cancer: concordance with patients and factors affecting accuracy. J Pain Symptom Manage 2008;35:7082.

    • Search Google Scholar
    • Export Citation
  • 36.

    Sherbourne CD, Stewart AL. The MOS Social Support Survey. Soc Sci Med 1991;32:705714.

  • 37.

    Shyu YIL, Tang WR, Liang J. Psychometric testing of the Social Support Survey on a Taiwanese sample. Nurs Res 2006,55:411417.

  • 38.

    Christakis NA, Escarce JJ. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med 1996;335:172178.

  • 39.

    Liang KY, Zeger S. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:1322.

  • 40.

    Kadan-Lottick NS, Vanderwerker LC, Block SD. Psychiatric disorders and mental health service use in patients with advanced cancer. Cancer 2005;104:28722881.

    • Search Google Scholar
    • Export Citation
  • 41.

    Tang ST, Liu TW, Chow JM. Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012. Psycho-Oncol 2014;23:780787.

    • Search Google Scholar
    • Export Citation
  • 42.

    Kim HS, Sherman DK, Taylor SE. Culture and social support. Am Psychol 2008;63:518526.

  • 43.

    Cohen SE, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull 1985;98:310357.

  • 44.

    Chochinov HM, Hack T, McClement S. Dignity in the terminally ill: a developing empirical model. Soc Sci Med 2002;54:433443.

  • 45.

    Firestone RW. Individual defenses against death anxiety. Death Studies 1993;17:497515.

  • 46.

    Bath DM. Separation from loved ones in the fear of death. Death Studies 2010;34:404425.

  • 47.

    Thompson GN, Chochinov HM, Wilson KG. Prognostic acceptance and the well-being of patients receiving palliative care for cancer. J Clin Oncol 2009;27:57575762.

    • Search Google Scholar
    • Export Citation
  • 48.

    Temel JS, Greer JA, Muzikansky A. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733742.

    • Search Google Scholar
    • Export Citation
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