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

Restricted access

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.

    KolvaERosenfeldBPessinH. Anxiety in terminally ill cancer patients. J Pain Symptom Manage2011;42:691701.

  • 2.

    MiovicMBlockS. Psychiatric disorders in advanced cancer. Cancer2007;15:16651676.

  • 3.

    MitchellAJChanMBhattiH. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol2011;12:160174.

    • Search Google Scholar
    • Export Citation
  • 4.

    SpencerRNilssonMWrightA. Anxiety disorders in advanced cancer patients: correlates and predictors of end-of-life outcomes. Cancer2010;116:18101819.

    • Search Google Scholar
    • Export Citation
  • 5.

    WilsonKGChochinovHMSkirkoMG. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manage2007;33:118129.

  • 6.

    CripeLDRawlSMSchmidtKK. Discussions of life expectancy moderate relationships between prognosis and anxiety or depression in men with advanced cancer. J Palliat Med2012;15:99105.

    • Search Google Scholar
    • Export Citation
  • 7.

    Delgado-GuayMParsonsHALiZ. Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting. Support Care Cancer2009;17:573579.

    • Search Google Scholar
    • Export Citation
  • 8.

    MystakidouKRosenfeldBParpaE. Desire for death near the end of life: the role of depression, anxiety and pain. Gen Hosp Psychiatry2005;27:258262.

    • Search Google Scholar
    • Export Citation
  • 9.

    O'ConnorMWhiteKKristjansonLJ. The prevalence of anxiety and depression in palliative care patients with cancer in Western Australia and New South Wales. Med J Aust2010;193(5 Suppl):S4447.

    • Search Google Scholar
    • Export Citation
  • 10.

    SalvoNZengLZhangL. Frequency of reporting and predictive factors for anxiety and depression in patients with advanced cancer. Clin Oncol2012;24:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    SeowHBarberaLSutradharR. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol2011;29:11511158.

    • Search Google Scholar
    • Export Citation
  • 12.

    StarkDKielyMSmithA. Anxiety disorders in cancer patients: their nature, associations, and relation to quality of life. J Clin Oncol2002;20:31373148.

    • Search Google Scholar
    • Export Citation
  • 13.

    TeunissenSCde GraeffAVoestEEde HaesJC. Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients. Palliat Med2007;21:341346.

    • Search Google Scholar
    • Export Citation
  • 14.

    VodermaierALindenWMacKenzieR. Disease stage predicts post-diagnosis anxiety and depression only in some types of cancer. Br J Cancer2011;105:18141817.

    • Search Google Scholar
    • Export Citation
  • 15.

    WarmenhovenFvan WeelCVissersKPrinsJ. Screening instruments for depression in advanced cancer patients: what do we actually measure?Pain Pract2013;13:467475.

    • Search Google Scholar
    • Export Citation
  • 16.

    McCoubrieRCDaviesAN. Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer?Support Care Cancer2005;14:379385.

    • Search Google Scholar
    • Export Citation
  • 17.

    JohnsonKSTulskyJAHaysJC. Which domains of spirituality are associated with anxiety and depression in patients with advanced illness?J Gen Intern Med2011;26:751758.

    • Search Google Scholar
    • Export Citation
  • 18.

    Suarez-AlmazorMENewmanCHansonJBrueraE. 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 Oncol2002;20:21342141.

    • Search Google Scholar
    • Export Citation
  • 19.

    LichtenthalWGNilssonMZhangB. Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches?Psychooncology2009;18:5061.

    • Search Google Scholar
    • Export Citation
  • 20.

    NortonSCoscoTDoyleF. The Hospital Anxiety and Depression Scale: a meta confirmatory factor analysis. J Psychosom Res2013;74:7481.

  • 21.

    TraegerLGreerJAFernandez-RoblesC. Evidence-based treatment of anxiety in patients with cancer. J Clin Oncol2012;30:11971205.

  • 22.

    TangSTChangWCChenJS. Trajectory and predictors of quality of life during the dying process: roles of perceived sense of burden to others and posttraumatic growth. Support Care Cancer2014;22:29572964.

    • Search Google Scholar
    • Export Citation
  • 23.

    ZigmondASSnaithRP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scan1983;67:361370.

  • 24.

    WastesonEBrenneEHigginsonIJ. Depression assessment and classification in palliative cancer patients: a systematic literature review. Palliat Med2009;23:739753.

    • Search Google Scholar
    • Export Citation
  • 25.

    MitchellAJMeaderNSymondsP. Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis. J Affect Disord2010;126:335348.

    • Search Google Scholar
    • Export Citation
  • 26.

    CareyMNobleNSanson-FisherRMacKenzieL. Identifying psychological morbidity among people with cancer using the Hospital Anxiety and Depression Scale: time to revisit first principles?Psycho-Oncol2012;21:229238.

    • Search Google Scholar
    • Export Citation
  • 27.

    McCorkleRYoungK. Development of a symptom distress scale. Cancer Nurs1978;1:373378.

  • 28.

    BenolielJQMcCorkleRYoungK. Development of a social dependency scale. Res Nurs Health1980;3:310.

  • 29.

    StapletonSJHoldenJEpsteinJWilkieDJ. A systematic review of the symptom distress scale in advanced cancer studies[published online ahead of print August 6 2015]. Cancer Nursin press.

    • Search Google Scholar
    • Export Citation
  • 30.

    TangSTMcCorkleR. 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.

    TangSTChenJSChouWC. 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 Cancer2016;24:8391.

    • Search Google Scholar
    • Export Citation
  • 32.

    CousineauNMcDowellIHotzSHebertP. Measuring chronic patient's feelings of being a burden to their caregivers: development and preliminary validation of a scale. Med Care2003;41:110118.

    • Search Google Scholar
    • Export Citation
  • 33.

    McPhersonCJWilsonKGChyurliaLLeclercC. 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 Psychol2010;55:194203.

    • Search Google Scholar
    • Export Citation
  • 34.

    McPhersonCJWilsonKGLobchukMMBrajtmanS. Self-perceived burden to others: patient and family caregiver correlates. J Palliat Care2007;23:135142.

    • Search Google Scholar
    • Export Citation
  • 35.

    McPhersonCJWilsonKGLobchukMMBrajtmanS. Family caregivers' assessment of symptoms in patients with advanced cancer: concordance with patients and factors affecting accuracy. J Pain Symptom Manage2008;35:7082.

    • Search Google Scholar
    • Export Citation
  • 36.

    SherbourneCDStewartAL. The MOS Social Support Survey. Soc Sci Med1991;32:705714.

  • 37.

    ShyuYILTangWRLiangJ. Psychometric testing of the Social Support Survey on a Taiwanese sample. Nurs Res200655:411417.

  • 38.

    ChristakisNAEscarceJJ. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med1996;335:172178.

  • 39.

    LiangKYZegerS. Longitudinal data analysis using generalized linear models. Biometrika1986;73:1322.

  • 40.

    Kadan-LottickNSVanderwerkerLCBlockSD. Psychiatric disorders and mental health service use in patients with advanced cancer. Cancer2005;104:28722881.

    • Search Google Scholar
    • Export Citation
  • 41.

    TangSTLiuTWChowJM. 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-Oncol2014;23:780787.

    • Search Google Scholar
    • Export Citation
  • 42.

    KimHSShermanDKTaylorSE. Culture and social support. Am Psychol2008;63:518526.

  • 43.

    CohenSEWillsTA. Stress, social support, and the buffering hypothesis. Psychol Bull1985;98:310357.

  • 44.

    ChochinovHMHackTMcClementS. Dignity in the terminally ill: a developing empirical model. Soc Sci Med2002;54:433443.

  • 45.

    FirestoneRW. Individual defenses against death anxiety. Death Studies1993;17:497515.

  • 46.

    BathDM. Separation from loved ones in the fear of death. Death Studies2010;34:404425.

  • 47.

    ThompsonGNChochinovHMWilsonKG. Prognostic acceptance and the well-being of patients receiving palliative care for cancer. J Clin Oncol2009;27:57575762.

    • Search Google Scholar
    • Export Citation
  • 48.

    TemelJSGreerJAMuzikanskyA. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med2010;363:733742.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 129 129 12
PDF Downloads 35 35 1
EPUB Downloads 0 0 0