ABSTRACT

Background: Cancer can lead to fatigue and the manifestation of psychological symptoms in patients, including depression, anxiety, and stress.

Objectives: The aim of this study was to investigate the relationship between fatigue and psychological symptoms in patients with gastrointestinal cancer.

Materials and Methods: The study had a descriptive, cross-sectional design. We assessed levels of fatigue and the psychological health of 70 patients with gastrointestinal cancer who had been referred to the cancer institute in Tehran, Iran in 2014.We used the Rhoten Fatigue Scale to assess patients’ levels of fatigue and the Depression Anxiety Stress Scale (DASS-21) to assess their psychological symptoms. We performed a correlation analysis and stepwise multiple linear regression to compare the relationship between fatigue and psychological symptoms in the cancer patients.

Results: There was a significant relationship between psychological symptoms, including depression, stress, and anxiety and fatigue in patients with gastrointestinal cancer (p<0.05).

Conclusion: Our study results demonstrate that the severity of fatigue is related to the extent of psychological symptoms (depression, anxiety, and stress) in patients with cancer. A patient’s depression and anxiety predicts the fatigue.

Keywords: Anxiety; Depression; Fatigue

Introduction

Cancer occurs when there is an abnormal proliferation of cells with loss of their differentiation (1). Cancer constitutes an enormous burden on society in developed and underdeveloped countries. The incidence of cancer is increasing because of population growth and general aging of the population. There is also an increasing prevalence of  smoking, obesity, and physical inactivity, and these factors are tied to an increase in the incidence of cancer. According to GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred worldwide in 2012. Over the years, the burden has shifted to poorer nations, which currently account for about 57% of new cancer cases and 65% of cancer deaths worldwide (2). Cancer can threaten one’s independence and limits the ability of people to play an effective role in their family and society. This can lead to a decreasing lack of self confidence in cancer patients. A cancer diagnosis may come with an unpredictable prognosis and the potential for a premature death can contribute to the onset of stress in cancer patients. Cancer is often a debilitating disease that can result in severe physical and psychological ailments (3).Cancer affects each person’s emotions and behaviour differently. Patients cope with cancer in different ways.There is a complex interaction between thoughts, feelings, actions, and physical expressions. Negative thoughts can lead to patient depression and reduces one’s motivation; depressed patients may leave their social activities and experience low moods. Depression often causes infirmity and is associated with torpor. The physical symptoms can exacerbate misinterpretation of disease and increase one’s sense of hopelessness and depression (4).The most common psychological reactions to cancer include denial, anxiety, depression, somatization, and the overall fear of failure, pain, death, and missing out on future opportunities(5). Cancer patients are also often concerned with the loss of social interactions or losing their job and may worry about becoming financially or physically dependent on others (6).

The nervous system and immune system interact in many ways. Evidence increasingly suggests that the immune system affects mental health. Some studies have demonstrated that one’s mental health affects immune system function. Changes in one’s mental health in turn change the trend of serious disorders such as cancer, infection, or autoimmune diseases (7).

One of the most complex and the most common cancer-related symptoms is fatigue. Between 72 and 99 percent of cancer patients suffer from fatigue. Patient fatigue may be caused by the disease and/or cancer treatments such as chemotherapy (8). Fatigue is the most common symptom among patients receiving chemotherapy and is the one symptom that is perceived as being the most annoying among these patients. Patients with cancer experience severe fatigue more often than healthy people and this situation often does not improve with what would otherwise be adequate amounts of rest and sleep (9).

Chemotherapy treatments can also damage a patient’s bone marrow and treatment-related side effects such as nausea, vomiting, diarrhea, and loss of appetite intensify patient fatigue (10). The results of a study conducted in the United States (n=419 cancer patients and 197 oncologists) demonstrated that 80 percent of oncologists feel that fatigue in patients is either ignored or not adequately treated, 50% of patients reported that they spoke about fatigue with their physicians, and only 27% of patients reported that their doctor had considered their fatigue (11).

More understanding is needed in the areas of patient fatigue and psychological health and how the two interact. More research on these subjects could help specialists design appropriate interventions for patients to increase their adaptability and ability to cope with fatigue and psychological distress while undergoing cancer treatment.

The main objective of this study was to obtain more information about the severity of fatigue in cancer patients and how it relates to psychological symptoms in these patients. Our question for this study was as follows: What is the   relationship between patient fatigue and the mental health of patients with cancer?

Materials and Methods

The methods used in this study were descriptive and cross-sectional in nature and correlation-based. We evaluated 70 patients using purposive sampling techniques in 2014. Patient subjects were being treated incancer institute in Tehran, Iran. All patients had received a diagnosis of having gastrointestinal cancer. Patients were between 25 and 40 years of age. Patients were excluded from the study if they had an acute form of the cancer, had another debilitating disease, or had severe cognitive problems to the extent that the patient would not have been able to complete the questionnaire.

Data were collected using the Rhoten Fatigue Scale to assess patient fatigue and the Depression Anxiety Stress Scale to measure levels of patient anxiety, depression, and stress. Patients first completed a demographic questionnaire, which included questions pertaining to the patient’s age, sex, education level, marital status, employment status, duration of disease after diagnosis, and other information. A trained researcher administered the Rhoten Fatigue Scale. A trained psychologist assessed levels of patient anxiety, depression, and stress in the hospital between 16:00 and 20:00 hours. The items of questionnaires were read to patients with low levels of education, and their verbal responses were recorded.

Rhoten Fatigue Scale

The Rhoten Fatigue Scale was used to quantify levels of fatigue in test subjects. The fatigue scale is a visual scale that ranges from 0 to 10 with the total score interpreted as follows: no fatigue (0), minimal fatigue (1 to 3), medium levels of fatigue (4 to 6), high levels of fatigue (7 to 9), and severe fatigue (10). The test-retest method has shown the reliability of this instrument to be 0.93 (12). Aghebati (13) reported the reliability for this scale as 0.89.

Depression Anxiety Stress Scale (DASS-21)

DASS-21 was designed by Lovibond and Lovibond (14) and includes 21 items with 7 questions used to measure levels of anxiety, stress, and depression. Patients assign a number between 0 and 3 for each question with 0 being not applicable to the patient and 3 being very much applicable to the patient (14). Its reliability and validity was evaluated by Samani and Jokar (15). The retest reliability for the scales of depression, anxiety, and stress were0.80, 0.76 and 0.77, respectively and Cronbach's alpha for the scale of depression, anxiety, and stress was 0.81, 0.74 and 0.78, respectively. The results of this study indicate DASS-21 is an effective scale for use in Iran (15). 

In this study, means and standard deviations were used in descriptive statistics. The Pearson correlation coefficient was used to assess the relevance assumptions and stepwise multiple linear regression analysis was used to predict the criterion variable (fatigue) from the predictor variables (depression, anxiety, stress) using software SPSS 20.

Results

A total of 70 patients with gastrointestinal cancer (35 males and 35 females) participated in this study. Among the patients, 9 patients were divorced, 23 were single, and 38 were married. The mean age of the patients was 33.12±8.32. Patients had an average of 12.3±4.3 years of education; this indicates most patients had at least high school education.

Patient subjects had cancer an average of 52.79±43.65 months. Patient fatigue was 7.07±1.64; this indicates these cancer patients were experiencing more than moderate levels of fatigue. Levels of depression and stress were 54.12±4.97 and 65.60±3.65, respectively. Patient anxiety measured 37.27±3.44 and demonstrated the group had high amounts of stress (Table 1).