Associations Between Distinct State Anxiety Profiles, Exposure to Stressful Life Events, Resilience, and Coping in Patients with Gynecologic Cancers Receiving Chemotherapy

Anxiety is a common symptom in patients with gynecologic cancers, with an estimated 50% and 30% of patients meeting case criteria for subclinical and clinical anxiety, respectively.1, 2, 3 In patients with cancer, anxiety is associated with decrements in quality of life (QOL)4 and decreased survival.5 Timely identification and treatment of anxiety are essential components of high-quality cancer care. However, psychological symptoms are underrecognized and undertreated in outpatient oncology settings.6 The identification of risk factors for anxiety in patients with gynecologic cancers will assist clinicians to diagnose and refer these patients for psychological support and management.

In a 2008 systematic review,7 younger age, more advanced stage of disease, shorter time since diagnosis, worse disability status, and more physical symptoms were associated with worse distress in patients with ovarian cancer. However, the authors of this review did not differentiate between factors associated with anxiety versus depression. Four additional studies have assessed for associations between anxiety and demographic and clinical characteristics,1,2,8,9 symptom burden,9 and social support.1,8,9 Findings from these studies suggest that being younger,1,2 being recently diagnosed,1 having more physical symptoms,9 and having less social support8,9 are associated with greater anxiety.

Another factor that may contribute to higher levels of anxiety in patients with gynecologic cancers is exposure to stressful life events. For example, in a study of 251 patients with breast cancer and 13 patients with gynecologic or hematologic cancers,10 exposure to more lifetime and recent stressful life events was associated with greater anxiety. In a study of patients with head and neck cancers,11 exposure to childhood physical neglect was associated with greater anxiety. In several studies of patients with breast and heterogenous types of cancer,12, 13, 14, 15 exposure to more stressful life events was associated with greater general and cancer-specific psychological distress. In two of these studies,10,15 lower levels of resilience and greater use of disengagement coping strategies were associated with increased stress and worse psychological outcomes. To the best of our knowledge, no study has assessed for associations between anxiety and global, cancer-specific, and cumulative life stress; as well as resilience and the use of various coping strategies, in patients with gynecologic cancers.

While a need exists to identify novel risk factors for anxiety in patients with gynecologic cancers, equally important is the need to determine unique anxiety profiles in these patients. Most studies of anxiety in patients with gynecologic cancers were cross-sectional.3 However, limited research suggests that subgroups of patients with gynecologic cancers have varied experiences with anxiety over time. For example, in a longitudinal study of 85 patients with peritoneal or fallopian tube cancers who were receiving first-line chemotherapy,1 52% of patients occasionally and 22% consistently met criteria for clinical anxiety. Similarly, a 2015 meta-analysis of six studies of patients with ovarian cancer concluded that the prevalence of anxiety was higher during than before treatment.3 The characterization of subgroups of patients with distinct anxiety profiles will assist clinicians to identify patients who are at increased risk for anxiety that persists throughout treatment. Therefore, the purpose of this study, in a sample of patients with gynecologic cancers, was to identify subgroups of patients with distinct anxiety profiles across two cycles of chemotherapy. In addition, differences among the subgroups in demographic and clinical characteristics, use of coping strategies, and levels of global, cancer-specific, and cumulative life stress and resilience were evaluated.

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