Anxiety During Cancer Diagnosis - Examining The Influence of Monitoring Coping Style and Treatment Plan
Anxiety During Cancer Diagnosis - Examining The Influence of Monitoring Coping Style and Treatment Plan
Anxiety During Cancer Diagnosis - Examining The Influence of Monitoring Coping Style and Treatment Plan
Madelon B. Bronner1, Minh Hao Nguyen1, Ellen M. A. Smets3, Anthony W. H. van de Ven2,
& Julia C. M. van Weert1
1
Amsterdam School of Communication Research / ASCoR, University of Amsterdam
2
Academic Medical Center, Gastro-Intestinal Oncological Center Amsterdam (GIOCA)
3
Academic Medical Center, Department of Medical Psychology, University of Amsterdam
Author Note. Correspondence concerning this article should be addressed to Minh Hao Nguyen,
Amsterdam School of Communication Research, University of Amsterdam, P.O. Box 15791, 1001
NG Amsterdam, The Netherlands. E-mail: [email protected]
This study was funded by the Dutch Cancer Society (KWF). Grant application
numbers UVA 2014-6700 and UVA 2010-4740. KWF was not involved in the study design,
data collection, analysis and writing.
Acknowledgments. We wish to thank all patients and the GIOCA clinic for facilitating the
data collection. Furthermore, we thank Nadine Bol, Eugène Loos, and Kristien Tytgat for
their contributions.
cancer;coping;stress;oncology;diagnosis;anxiety;chemotherapy;monitoring;communication
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.4560
Methods: Anxiety scores (STAI-6) were collected from 81 colorectal cancer patients before
and after their visit to the outpatient Gastro-Intestinal Oncological Center Amsterdam
(GIOCA). A cutoff score (>44) was used to indicate highly anxious patients.
Results: More than half (59%) of the patients were classified as highly anxious before
consultation. Although anxiety scores significantly decreased after consultation (t = 3.149, p
= .002), 37% of the patients remained highly anxious. Reductions in anxiety were specifically
observed for patients with a higher monitoring coping style and patients for whom a
treatment plan without chemotherapy was proposed. Interestingly, high monitors for whom
treatment without chemotherapy was proposed showed a major decrease in anxiety, whereas
low monitors for whom treatment starting with chemotherapy was proposed showed a great
increase in anxiety.
Conclusions: The diagnostic phase is associated with high levels of anxiety. Distinct patterns
of anxiety were identified, depending on patients’ coping style and the suggested treatment
plan. Remarkably, patients with a lower monitoring coping style became particularly anxious
when they were advised to start treatment with chemotherapy.
Stable individual differences have been found in patients’ tendencies to either seek or
avoid threatening medical information [13]. Patients who actively seek information have a
so-called monitoring coping style [14]. High monitors, who tend to focus on threat, generally
know more about their illness and acquire more detailed and voluminous information than
low monitors [14, 15]. Information seems to help high monitors to understand their situation
and to reduce uncertainty. Medical care frequently involves periods of uncertainty [16].
However, when awaiting a cancer diagnosis, the information needed to resolve uncertainty is
not immediately available, and thus this may be particularly anxiety-provoking [17]. In line
with this finding, high monitors seem to experience more anxiety in anticipation of their
genetic test results than low monitors [18, 19].
Measures
Patient characteristics. Socio-demographic information was collected from the online
questionnaire (T1) and included age, gender, education level, employment status and living
situation. Education level was categorized as low (primary education, lower or middle
general secondary education), middle (higher secondary education, middle vocational
education) and high (higher vocational education, university) education. Employment status
was dichotomized as having paid work (1) vs. no paid work (0). Living situation was
dichotomized as living alone (0) vs. living with other(s) (1).
Anxiety. Anxiety was measured with the short Dutch version of the Spielberger State-Trait
Anxiety Inventory (STAI-6) [26, 27]. Patients were asked to rate the degree to which they
Monitoring coping style. Monitoring coping style was measured with a 3-item, 5-point scale
[30-31] adapted from the shortened Threatening Medical Situation Inventory (TMSI) as
validated by Ong and colleagues [32]. Patients’ own medical situation (“Please indicate to
which extent the following statements apply to you since you have been told that you might
be ill”) was followed by three of the original items in the monitoring subscale of the
shortened TMSI, i.e. (a) looking for information within the threatening situation (‘I planned
to ask my health care provider as many questions as possible’); (b) going deeply into the
situation by reading about it (‘I planned to read about my disease’); and (c) getting
information about the situation from other doctors, patients or organisations (‘I decided to
deepen my understanding of the treatment as much as possible’) [32,33]. Statements could be
rated from 1 (not at all applicable to me) to 5 (strongly applicable to me). A total sum score
was calculated and could range from 3 to 15 (M = 10.75, SD = 2.59). A higher score indicates
a higher monitoring coping style. Patients were classified as either high or low monitors on
the basis of the median split (Mdn = 11, IQR = 9-12). Cronbach’s α for the monitoring scale
was .78.
Treatment plan. Medical data were obtained from the electronic medical records of the
patients. Treatment plans involving chemotherapy as the primary treatment were dummy
coded as 1. Any treatment plan without chemotherapy and involving surgery as the primary
treatment was dummy coded as 0.
Statistical Analyses
All analyses were conducted using the Statistical Package for Social Sciences for Windows
22.0 (SPSS, Inc., Chicago, IL, USA). Chi-square and independent samples t-tests were used
to examine differences in gender and age between participants and non-participants. A paired
sample t-test was conducted to evaluate the course of anxiety scores over time. To further
explore the course of anxiety, three mixed (between-within-subjects) ANOVA repeated
Results
Sample characteristics
In total, 91 patients participated in this study. No significant differences were found between
patients who participated and patients who did not (n = 89) regarding gender (χ2 (1) = 1.779,
p = 0.182) and age (t = 1.444, df = 165.108, p = 0.152). Ten patients were excluded from the
data analysis because of dropouts or incomplete data. This resulted in a final study sample of
81 patients (Table 1). No significant differences were found between patients for whom a
treatment plan was proposed with chemotherapy (n = 24) or without chemotherapy (n = 57)
regarding gender (χ2 (1) = 0.130, p = 0.719), age (t = 0.205, df = 79, p = 0.838), monitoring
coping style (t = 1.245, df = 79, p = 0.217), and anxiety before consultation (t = -1.249, df =
79, p = 0.215).
The average anxiety score before consultation (T1) was 46.30 (SDT1 = 11.29). In total, 59.3%
of the patients (n = 48) met the criteria for clinically high levels of anxiety before
consultation (>44). There was a statistically significant decrease in anxiety scores from T1 to
T2 (MT2 = 41.69, SDT2 = 12.05), t = 3.149, p = 0.002. The mean decrease was 4.61 (95% CI
[1.70, 7.52]). Cohen’s d was 0.40, indicating a small to moderate effect size [35]. After
consultation at GIOCA 37.0% of patients (n = 30) still experienced clinically high levels of
anxiety. The detailed anxiety scores are presented in Table 2.
Subsequently, we examined the course of anxiety within the four subgroups. The repeated
measures analysis showed a significant interaction effect between group and time, F (3, 77) =
10.92, p = 0.000, η2 = .30. Post hoc tests demonstrated a significant decrease in anxiety scores
in both high (Mdif = -12.04, p = 0.000) and low (Mdif = -5.79, p = 0.004) monitors for whom a
treatment plan without chemotherapy was suggested. Anxiety scores did not change
significantly in high monitors for whom starting with chemotherapy was suggested.
However, a significant increase in anxiety (Mdif = -10.56, p = 0.002) was found for low
monitors for whom starting with chemotherapy was suggested (Figure 2).
Discussion
This study showed that anxiety during the diagnostic and treatment planning phase is
extremely high. Six out of ten patients reported scores that indicate clinical levels of anxiety
before the initial treatment consultation for colorectal cancer. In general, anxiety decreased
after consultation. However, 37% of patients remained highly anxious. Reductions in anxiety
were specifically observed for patients with a higher monitoring coping style and patients for
whom a treatment plan without chemotherapy was proposed. Moreover, the subgroup of high
monitors who were advised to follow a treatment plan without chemotherapy showed the
greatest decrease in anxiety. Anxiety scores did not change for low monitors or for patients
for whom starting with chemotherapy was proposed. More interestingly, in the subgroup of
low monitors for whom starting with chemotherapy was proposed, anxiety scores increased
significantly.
The high levels of anxiety in the acute phase demonstrated in this study are not
unusual. In the scarce literature on pre-diagnostics, 33-60% of patients were classified as
highly anxious [6]. These anxiety levels are higher than those reported during the course of
the illness [2-5], underlining the enormous psychological impact of the phase of diagnostics
and treatment planning. Furthermore, anxiety levels before consultation were higher for
patients with a monitoring coping style. This confirms the findings from the earlier literature
showing that high monitors report higher levels of anxiety than low monitors in anticipation
of their genetic test results [18, 19]. In the period of waiting, when information is not
immediately available, high monitors seem particularly anxious.
Different patterns of anxiety were found in this study. Patients receiving a treatment
plan without chemotherapy (often primary surgery only) showed a greater decline in anxiety
compared to patients for whom starting with chemotherapy was proposed. The current
findings are in line with those of earlier studies demonstrating that anxiety levels differ for
The most striking finding of the current study was the interplay between the content of
the provided information (‘what was told to the patient’) and the patients’ coping style on
anxiety. High monitors for whom treatment without chemotherapy was proposed showed a
major decrease in anxiety, whereas low monitors for whom starting with chemotherapy was
proposed showed a great increase in anxiety. In contrast to these findings, earlier research
[20-22] suggests that high monitors become particularly anxious after receiving highly
threatening medical information. These earlier studies, however, were conducted immediately
after cancer screening, when most people do not expect to receive bad news. The current
study is based on patients from a tertiary referral clinic meaning the patients had already an
initial cancer diagnosis or were already highly suspected to have malignancies. In other
words, they had had time to adjust to the idea of having cancer and to anticipate forthcoming
challenges. In high monitors, this had probably led to prior information seeking on treatment
possibilities along with worry about treatment outcomes, as high monitors amplify threat [14,
15]. Given the substantial decrease in anxiety after they received the final diagnosis and
treatment plan, it is likely that high monitors were more relieved upon hearing that surgery
seemed possible. In contrast, low monitors probably avoided searching for stressful medical
information beforehand and preferred to cope with the potential threat by not addressing it
initially. Learning that they had to start with chemotherapy made low monitors feel highly
upset and shocked afterward, probably because they were less likely to anticipate bad news.
Clinical implications
This research points to some fruitful directions for clinical practice. First, many patients are
highly distressed when they enter the consultation room. Physicians should be aware that,
Study limitations
One of the limitations of this study is the relatively small and heterogeneous sample size.
Although all patients were referred for colorectal malignancy, some came for an early form
of colon cancer, while others were referred for more advanced cancer. In addition, some
patients (n = 18) indicated that their initial diagnosis was not yet discussed by their referring
physician. Post hoc analysis without those patients showed similar patterns of anxiety. Next
to this, the suggested treatment plan also differed widely. For example, within the
chemotherapy group, some patients were suggested neoadjuvant chemotherapy, others
adjuvant chemotherapy, and others palliative chemotherapy. Post hoc analysis without those
patients whose treatment had no curative intent (n = 7), showed similar results, though the
effect sizes were slightly smaller. This finding is consistent with previous research
demonstrating no difference in anxiety between palliative and non-palliative settings [40].
Future research should continue to address the effect of medically relevant variables (e.g.,
stage of cancer diagnosis or type of treatment) on anxiety in a larger group of patients.
Another limitation of this study was the cut-off score (>44) of the STAI-6 for clinical anxiety
[27]. Adequate normative data for cancer patients are lacking on the STAI-6.
Nevertheless, the current study extends the existing literature by providing
information on anxiety in colorectal cancer patients at a unique point in time, underlining the
enormous psychological impact of the diagnostic and treatment planning phase. As this study
is only a first step towards a better understanding of cancer patients’ anxiety patterns during
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Education level
Treatment plan
n T1 T2 Δ
Treatment plan
Approached
(n = 180)
Not eligible (n = 32)
- No e-mail address or computer (n = 26)
- Insufficient command of Dutch
language (n = 6)
Eligible
(n = 148)
Non-response (n = 57)
- Felt too sick (n = 7)
- Had no time (n = 13)
- Too burdensome (n = 27)
- No specific reason given (n = 10)
Informed consent
(n = 91)
Excluded (n = 10)
- Incomplete data (n = 4)
- Dropped out (n = 6)
Analysis
(n = 81)
Figure 2 Anxiety scores (STAI-6) before (1) and after (2) consultation.