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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 257-263

Psychological impact of lung cancer: A cross-sectional study


1 Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Submission18-Mar-2020
Date of Decision07-Oct-2020
Date of Acceptance18-Nov-2020
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Kashish Dutta
Senior Resident, Department of Pulmonary Medicine, GMCH, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_49_20

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  Abstract 


Background: Lung cancer patients and caregivers suffer psychological side effects that encompass poorer treatment outcomes, and are associated with negative quality of life outcomes. Therefore, psychological screening and appropriate intervention of both patients and caregiver is an essential part of advanced cancer care. Aims and Objectives: To assess for psychological distress and its correlates in newly diagnosed lung cancer patients and their caregivers. Materials and Methods: It was a cross-sectional study conducted among 40 lung cancer patients and their caregivers. The patients and caregivers were administered psychological questionnaire, and their psychological attributes were thus studied. Normality of quantitative data was checked by measures of Kolmogorov Smirnov tests. Comparisons for two groups were made by t-test. Proportions were compared using Chi-square or Fisher's exact test whichever applicable. Results: Twenty nine patients (72.5%) and twenty five caregivers (62.5%) had GHQ>=3 (P value=0.34). Nineteen patients (47.5%) and twenty one caregivers (52.5%) were diagnosed as having psychiatric diagnosis (P value=0.65). Sex, educational level, residence, and monthly income did not have any significant association with the psychological comorbidities. The other psychiatric scales used had a significant correlation with the results of GHQ and psychiatric morbidity (P value=0.00). Conclusions: Psychological comorbidities are found in lung cancer patients and their caregivers to a significant extent. The treating physicians should screen lung cancer patients and their caregivers for psychological comorbidities and manage them adequately.

Keywords: Caregivers, lung cancer patients, psychological morbidity


How to cite this article:
Dutta K, Saini V, Gupta N, Garg K. Psychological impact of lung cancer: A cross-sectional study. Indian J Soc Psychiatry 2022;38:257-63

How to cite this URL:
Dutta K, Saini V, Gupta N, Garg K. Psychological impact of lung cancer: A cross-sectional study. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Dec 5];38:257-63. Available from: https://www.indjsp.org/text.asp?2022/38/3/257/327748




  Introduction Top


The diagnosis of cancer in family scares not only the patients but also their families as a whole because of the shock and uncertainty associated with the diagnosis. The survival rates are very less as the disease is usually diagnosed in advanced stages with little or no hope of treatment, and this leads to imbalanced emotional capabilities.[1],[2] Lung cancer patients have significantly more unmet supportive care needs than any other cancer patients and suffer from various psychological disorders because of the fear of death, disruption of life plans, treatment-related fears, and financial concerns.[2],[3] Majority of these psychological disorders include adjustment disorders with anxiety or depression, major depression, and even delirium.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Many studies have shown significant psychological comorbidities in the caregivers of these patients as well.[14],[15],[16],[17],[18],[19],[20] This is because, not only do they have to cope with their unmet emotional needs due to fear of losing a loved one, but also deal with the emotional reactions of the patients and manage the medical care expenses. However, Indian studies in this regard are lacking, and also, the disparities in methodology are a significant barrier to producing comparable results.[7],[8],[9],[19],[20]

A structured interview is the gold standard for the diagnosis of psychological disorders but is time-consuming and cumbersome for our busy oncology clinics.[21] However, many psychological tools can screen psychological comorbidities within minutes and can be used for screening lung cancer patients. Different studies have used different screening tools leading to the substantial heterogeneity in the results; however, the superiority of one over another is not proven. In a developing country such as India, psychological counseling is rare and the cancer care lacks quality care, the use of generic and advanced instruments to measure the psychological morbidity is much needed.[22] Thus, this study was done to study the psychological morbidity in patients with lung cancer and their caregivers by using questionnaires and screening tools and to examine the correlates that predict this psychosocial burden.


  Materials and Methods Top


This cross-sectional study was conducted in the Department of Pulmonary Medicine in collaboration with the Department of Psychiatry at Government Medical College and Hospital, Chandigarh, India, after approval from the Institutional Ethical Committee. Based on the age, standardized incidence of lung cancer in 2008 in India which is 10.9 and 2.2 cases per lakh population for men and women, respectively, it was estimated that forty participants are required as cases and forty as caregivers to give a power of 90%.[23] Hence, forty newly diagnosed lung cancer patients from the pulmonary medicine outdoor department between November 2017 and September 2018 and their caregivers were enrolled after taking informed consent.

Inclusion criteria in patients

  • Diagnosed primary lung cancer
  • Age >18 years
  • Willing to participate
  • First contact with the department of pulmonary medicine
  • Not on any treatment for lung cancer.


Exclusion criteria in patients

  • Patients <18 years of age
  • Those with organic disease or having evident memory deficits on clinical assessment
  • Critically ill
  • Uncooperative or who were already knowing the diagnosis of malignancy, whether from the primary site or because of histological confirmation from a distant site.


Inclusion criteria in caregivers

  • Those individuals who were to provide care to the patient for a major part of their illness, i.e., more than 50% of the duration of illness
  • Staying with the patient since the onset of disease
  • Age >18 years
  • Willing to participate.


Exclusion criteria in caregivers

  • Age <18 years of age
  • Those having the presence of any organicity (delirium, dementia) or with a lack of capacity.


Those fulfilling the above inclusion criteria were enrolled, and their baseline demographic data were recorded. On their first contact, they were sensitized about the possibility of lung cancer. Then, clinical examination and investigations were done, and staging of lung cancer was done as per the American Joint Committee on Cancer-Tumor Node Metastasis guidelines. The patient and his/her primary caregivers were contacted to come for the breaking of the news, and then psychological tests were administered. We used General Health Questionnaire 12 Hindi version (GHQ 12),[24] Patient's Distress Thermometer (PDT),[25] Thakur's Death Anxiety Scale Hindi version,[26] Rotterdam symptom checklist (RSCL),[27] Coping strategy checklist Hindi version (CSCL),[28] WHO Quality of Life Bref Hindi version (WHOQOL Bref 26),[29] Depression Anxiety Stress Scales (DASS)[4] for anxiety and depressive symptoms scales for the patients and GHQ 12, Thakur's Death anxiety scale, CSCL, WHOQOL Bref 26, and DASS for the caregivers. If the score on GHQ was >3, they were additionally referred to the psychiatrist for assessment based on the International Classification of Diseases-10 and further management as per their clinical need. Psychological distress and its correlates were assessed and compared in newly diagnosed lung cancer patients and their caregivers. Further, the management of lung cancer was done as per the National Comprehensive Cancer Network guidelines.[30]

Statistical analysis

The statistical analysis was conducted with the Statistical Package IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, N.Y., USA). Discrete categorical data were presented as n (%). The normality of quantitative data (age) was checked by the measures of Kolmogorov–Smirnov tests of normality. As age was normally distributed, it was represented as mean ± standard deviation or median (range). Comparisons for two groups were made by the t-test. Proportions were compared using the Chi-square or Fisher's exact test whichever applicable. The data were represented as mean ± standard deviation and range/median and interquartile range. Continuous variables between the two groups were compared using the Mann–Whitney test. All statistical tests were two-sided and the level of statistical significance was set at 5% (P < 0.05). Spearman correlation coefficients were calculated to see the relationship of different variables.


  Results Top


The sociodemographic profile, the GHQ-2 results and the presence of psychiatric illness in patients and caregivers are compared in [Table 1]. Our groups were gender-matched but not age-matched. Ten patients and 12 caregivers were diagnosed to have depression, whereas six patients and four caregivers were diagnosed to have an adjustment disorder. Rest suffered from miscellaneous disorders, including anxiety, mood disorders, personality disorder, and even psychosis.
Table 1: Sociodemographic characteristics of lung cancer patients and caregivers

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GHQ proved accurate in 65.5% of patients and 84.0% in caregivers for screening the presence or absence of psychiatric illness. The sensitivity and specificity of GHQ were found to be 82.50% and 90.00%, respectively. The relationship of GHQ and psychiatric morbidity with sociodemographic profile such as age groups, gender, marital status, education, employment, and presence of comorbidities is depicted in [Table 2] and [Table 3]. As shown in [Table 2], employment had significant correlation with GHQ in patients. No other sociodemographic factor had any correlation with GHQ or psychiatric illness Only seven patients were in Stage III of lung cancer, rest 33 were in Stage IV so the correlation of stage of lung cancer with GHQ or psychiatric illness was not possible. Similarly, as six patients refused for chemotherapy, so the correlation in reference to treatment with GHQ or psychiatric illness could not be done.
Table 2: Sociodemographic characteristics of general health questionnaire-12 Hindi version positive and general health questionnaire-12-Hindi version negative patients of lung cancer patients and caregivers

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Table 3: Sociodemographic characteristics of patients of lung cancer patients and their caregivers who were diagnosed to be normal or had psychiatric illness after psychiatric evaluation

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There was a significant positive correlation of PDT, RSCL, CSCL, DASS, and Thakur's death anxiety scale with GHQ-12 and presence of psychiatric illness in patients as depicted in [Table 4], whereas a negative correlation was seen with WHO-QOL-Bref. Similarly, there was a positive correlation of CSCL, DASS, and Thakur's Death Anxiety Scale in caregivers, as shown in [Table 4]; however, a negative correlation was seen with WHO QOL Bref. The correlation of scales with each other in patients and caregivers with or without psychiatric illness is depicted in [Table 5] and [Table 6].
Table 4: Other scales and their relation with general health questionnaire-12 Hindi version and psychiatric illness in patients and caregivers

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Table 5: Correlation of various psychological scales with each other in patients of lung cancer who were diagnosed to be normal (n=19) or had psychiatric illness (n=21) after psychiatric evaluation

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Table 6: Correlation of various psychological scales with each other in caregivers of lung cancer patients who were diagnosed to be normal (n=21) or had psychiatric illness (n=19) after psychiatric evaluation

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  Discussion Top


In this study, 47.5% of patients and 52.5% caregivers, that is, approximately half of our patients and their caregivers suffer from a psychiatric illness. Our results were no different from other studies done, although the scales used were different.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] We also used DASS besides other scales, and the scores came out to be 14, 8, and 12 in patients and 10, 5, and 8 in caregivers. This means that approximately 50% of patients and more than 25% of caregivers had moderate-to-severe levels of depression and stress. However, mild-to-moderate levels of anxiety were seen in half of the patients and one-fourth of the caregivers. This result was in coherence with a study by Margari et al. and Singh et al.[7] On psychiatric evaluation, this was confirmed as most of the patients and caregivers suffered from depression, followed by adjustment disorder and other psychiatric illnesses. Other studies done elsewhere have shown similar results.[4],[5],[6],[7],[8],[10],[14]

In our study, the mean age of patients was 61.50 years ± 10.29, and of the caregivers was 39.10 years ± 11.11. Unlike studies by Braun et al. and Sklenarova et al., who compared patients with advanced gastrointestinal or lung cancer and their spouse caregivers, our groups were not age-matched.[16],[31] This may be because of the fact that lung cancer most commonly occurs in old age but the caregivers, usually being their children, were younger in age. Our groups were gender-matched. However, in the study by Braun et al., females were more in the number in the caregiver group, because of the reason that the patients were males predominantly, and caregivers were mostly their spouses.[31]

GHQ-12 is a validated instrument to screen for common mental disorders and measures a global psychological dimension.[32],[33] We also used GHQ as a screening tool and found that it was an excellent predictor of psychological morbidity with 82.50% sensitivity and 90.00% specificity. Boini et al. had earlier used GHQ-12 along with other scales to measure the impact of cancer occurrence on health-related QOL. They found GHQ-12 has a comparable psychometric performance to that of the mental dimension of 36 Short Form, although their objectives are complementary. GHQ-12 has also been used in a study by Grande et al. in their study on family caregivers caring for the patient in the end of life care and was found to be substantially higher than in the normal population. Such a simple tool as GHQ-12 can be administered in a very short period of time and can give a basic idea about the psychological status and can help in planning suitable psychological interventions.[32],[33]

In our study, we did not find any correlation of psychiatric morbidity with age, gender, education, marital status, and presence of comorbidities in patients or caregivers as in coherence with some previous studies.[18],[19],[34] This may be explained by the fact that the effects of these factors on psychiatric adjustment become less significant when a life-threatening illness like lung cancer approaches. However, it was found in our study that employment had an association with psychiatric morbidity in patients, but not in caregivers. This may be due to their poor health leading to a reduction in work productivity, absenteeism from work, and increased distress. However, other studies have shown different results due to heterogeneity in methods employed and the population studied.[8],[19],[20],[34],[35] However, larger studies are needed to reach a definitive conclusion.

Early-stage lung cancer is amenable to surgery, and hence, the stage of lung cancer can affect the patient differently. This has already been shown by Hung et al. in their large data-based study that surgery has an impact on the psychological status of patients and caregivers.[36] However, in our study, 33 patients were in Stage IV, and only 7 in Stage III. This is because ours is a referral center, most of our patients present in the late stages of cancer when surgery is not possible. Hence, differences in GHQ-12 or psychiatric comorbidity in relation to the stage of lung cancer cannot be commented upon.

In our set-up, we found that approximately 50% of the treatment was funded by the government, so only six patients denied treatment. Hence, the correlation of denial to treatment with GHQ-12 and psychiatric morbidity was not relevant. Had it been a uniform source of funding for all the patients, we could have got different results. The study was done at the time of the breaking of diagnosis and not during the treatment period/posttreatment. Hence, results on defaults due to finances/side effects could not be estimated.

There are a large number of screening tools available and various studies have a lot of variabilities owing to different scales used. For this study, questionnaires were chosen carefully. Besides GHQ, we also used PDT, RSCL, Thakur's Death Anxiety Scale, CSCL, and DASS, WHO-QOL Bref to find the psychosocial correlates of psychological morbidity in patients and Thakur's Death Anxiety Scale, WHO-QOL Bref, CSCL, and DASS in caregivers. As per our study, we found their median scores had a strong correlation with GHQ and the presence of psychiatric illness. WHO-QOL which is used as a measure of the QOL showed a negative correlation with GHQ and the presence of psychiatric illness. Thus, our study found all of these scales as strong correlates of GHQ and psychiatric morbidity.

PDT as a screening tool has also been used in a study by Lynch et al. and Grant et al. in lung cancer patients and their caregivers, respectively.[18],[25] RSCL has shown reliable results in other studies, including a study in cervical and breast cancer patients by Sharma et al. and de Haes et al. (Cronbach's alpha 0.88–0.94) in cancer patients.[27],[37] Another scale used in our study was Thakur's Death Anxiety Scale. Our mean scores were found to be higher than those found in a study in breast and cervical cancers by Sharma et al., showing that the lung cancer patients have higher death anxiety.[37] CSCL as a scale was also used, which has been earlier used by Sharma et al. in breast and cervical cancer patients, and the scores were found to be significantly higher in lung cancer patients and their caregivers who were GHQ positive or had a psychiatric illness.[37] Our study also proved WHO-QOL as a highly reliable tool to measure the QOL in lung cancer patients and a significant correlation was found with psychiatric morbidity. On comparing the patients or the caregivers on the basis of GHQ, the WHO-QOL scores were found significantly lower in GHQ positive patients/caregivers. This scale has also been used by Aggarwal et al. in their study to show the correlation of QOL with the awareness of diagnosis in lung cancer patients. Their study showed a lower QOL score than ours.[9] DASS as a scale has also been prevalidated by a study by Singh et al. in cancer patients and Margari et al. in lung cancer patients.[4],[7]

The results of our study thus showed that lung cancer patients and their caregivers have overall poor psychological status and poor QOL, as measured by different psychological assessment tools. These easy and brief scales can thus help us to screen for psychiatric comorbidities even in busy clinics.

Limitations

Our study had a few limitations. First, the majority of our patients presented in Stage III or IV of lung cancer. This may be because of a lack of early diagnosis in lung cancer as most patients present to the outpatient department in advanced stages. Thus, patients of early stages of lung cancer along with their caregivers could not be evaluated. Second, the patients and caregivers were not followed up over time. Third, the patients and caregivers who were GHQ negative were not further sent for any psychiatric evaluation.


  Conclusion Top


The GHQ-12 used by us is an efficient tool for measuring the mental health status in lung cancer patients and their caregivers as corroborated by significant correlations with the other well-known screening instruments. Thus, any of these short psychological instruments can be used to screen psychological morbidity in our day to day practice. Nearly half of the patients and their caregivers suffer from psychiatric morbidity. This entails the requirement of incorporating psychological screening and counselling in palliative care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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