The Relationship of Health Locus of Control and Psychological Distress in Lung Cancer Patients during the COVID-19 Pandemic ()
1. Introduction
During the past decade, lung cancer mortality has moderately but steadily declined across Europe due to access to novel treatments ( Bosetti et al., 2013 ; De Angelis et al, 2014 ; Sung et al., 2021 ). However, lung cancer remains the second most common cancer and the leading cause of cancer-related deaths worldwide ( Huang et al., 2022 ) with a total of 1.8 million annual deaths, accounting for 18% of all cancer mortality ( Sung et al., 2021 ). Lung cancer is a debilitating disease with many life changing persisting symptoms that impact on quality of life despite novel treatments leading to a prolonged progression free survival ( Chen et al., 2018 ; Deer et al., 2011 ; Caraceni et al., 2012 ; Paice & Ferrell, 2011 ). Aside from clinical symptoms, psychological distress stemming from lung cancer plays a pivotal role in disease perception and management. Psychological distress is an emotional state characterized by mental health problems, including depression and anxiety, and it is associated with poor treatment compliance and low quality of life ( Plank & Nemesure, 2016 ; Chad-Friedman et al., 2017 ; Wang et al., 2017 ).
Psychological distress affects up to 65% of lung cancer patients ( Plank & Nemesure, 2016 ) which accounts for one of the highest rates among patients with solid organ cancers ( Liu et al., 2018 ; Occhipinti et al., 2019 ). Females are more affected than men (58.2% vs 28.7% respectively) as they are more emotional, sensitive, and tend to express their feelings while males tend to try to rationalize them and do not express them ( Passarelli et al., 2021 ). The increased frequency of psychological distress among lung cancer patients is mainly attributed to the severity and dismal clinical course of the disease and poor prognosis ( Wang et al., 2017 ).
Psychological distress among lung cancer patients has increased further during the COVID-19 pandemic mainly due to the patients’ fear of diagnostic and treatment delays ( Albano et al., 2021 ). Τhe entire lung cancer pathway, from diagnosis to treatment and palliative care, has been significantly challenged by the COVID-19 pandemic, mainly due to changes in the delivery of care and re-organization of healthcare services to meet the increased demands posed by the pandemic. These changes resulted in delays in clinic appointments, investigations and treatments ( Indini et al., 2020 ) and most importantly impacted on the timeliness and completion of shared decision-making as healthcare professionals were re-allocated to other services to meet the new unprecedented needs ( Di Giacomo et al., 2020 ; Zhang, Xie, & Huang, 2020 ). To address these new needs, scientific societies have issued new guidelines for the diagnosis and management of lung cancer including palliative care amidst the COVID-19 pandemic ( European Society for Medical Oncology, 2022 ).
Furthermore, psychological distress further increased among lung cancer patients during the pandemic due to the possibility of contracting COVID-19 and suffered potential respiratory complications leading to intensive care unit (ICU) admission ( Indini et al., 2020 ; Tian et al., 2020 ; Wang & Zhang, 2020 ; Liang et al., 2020 ). This perception combined with the emotional distress caused by lung cancer symptoms, treatments and side-effects pose a great challenge in lung cancer patients’ management ( Tian et al., 2020 ).
The emotional distress experienced by lung cancer patients is closely linked with internal and external Health Locus of Control (iHLOC, eHLOC) . Internal HLOC patients believe they have control over their cancer which results in an improved psychological adjustment to this life-changing condition. As a result, they are actively involved in the decision making process, which leads to improved health outcomes ( Hashimoto & Fukuhara, 2004 ; Wallston, 2005 ; Marton et al., 2021 ; Dopelt et al., 2022 ).
External HLOC patients believe their physicians, families and fate are in control of their disease ( Wallston et al., 1994 ) and subsequently they have adopted a passive approach with low adjustment levels. eHLOC patients are not involved in the decision making process regarding their diagnosis and treatment and this has been correlated with poor health outcomes ( Gibek & Sacka, 2019 ; Arraras et al., 2002 ). This behavior impacts negatively on their prognosis and quality of life and has an additive effect on the preexisting emotional distress ( Henselmans et al., 2015 ; Bailo et al., 2019 ; Albano et al., 2021 ). However, a recent meta-analyses investigating the psychosocial and emotional impact of the COVID-10 pandemic on cancer patients, reported that the majority of the reviewed studies used tools that did not provide deeper and improved understanding of how and why patients’ emotional states were affected (https://www.sciencedirect.com/science/article/pii/S0093775422000604, accessed on 21.12.2022). Therefore, the relationship between HLOC and emotional distress among cancer patients and in particular those with lung cancer has not been extensively investigated especially amidst health care crises, such as the COVID-19 pandemic.
In this study we aim to investigate this relationship and identify the factors associated with the presence of psychological distress.
2. Materials and Methods
2.1. Sample
We prospectively reviewed 160 lung cancer patients (stage III-IV) at the Oncology Outpatients’ Clinic, “Sotiria” Athens’ Chest Diseases Hospital, Greece. The study was approved by the Hospital’s Science and Medical Ethics Board (registration number 7488/12-3-2021) and met the General Data Protection Regulation (GDPR) requirements. Patients were enrolled in the study following their informed consent.
2.2. Data Collection
Data collection was conducted during 2021-2022. Patients completed general and specific forms as follows:
1) General form: demographics (gender, age), educational and marital status, financial situation, place of residence and occupation which was based on Ginieri-Coccossis’ et al., form (2008) .
2) Focused forms
a) The Health Locus of Control Scale (HLΟC) form which was developed to predict health-related behaviors ( Wallston et al., 1994 ) and has been used in the Greek population, with Cronbach’s alpha ranging from .50 to .85 ( Ginieri-Coccossis et al., 2008 ). It consists of eighteen 6-point Likert scale questions, ranging from “strongly disagree” to “strongly agree”. These questions are allocated to 4 subscales which are: the Internal subscale, Chance, Doctors, Other people. The HLΟC form with interpretation is attached in the supplements’ section. The internal consistency of the HLC was α = .77.
b) The Distress Thermometer (DT) form applied by the National Comprehensive Cancer Network (NCCN) to screen cancer patients for the presence of psychological distress, with sensitivity .80 and specificity .70 ( Tang et al., 2011 ). It consists of 40 “yes” or “no” items which are grouped into five categories: practical problems, family problems, emotional problems, religious/spiritual problems, and physical problems. Furthermore, the form includes a question requiring from patients to choose a score which represents their distress levels the previous week, ranging from 0 to 10, with 0 indicating absence of distress and 10 presence of severe distress. The DT form is available in the supplements’ section. The internal consistency of DT in this study was α = .85.
3. Results
We prospectively reviewed 160 patients, Mean patient age was 66.2 years (±8.2), 70% (n = 112) were male and the majority were married (n = 110, 68.8%). 38.1% (n = 61) had received only basic education, 53.8% (n = 86) described their financial situation as sufficient and half of them (n = 80) were retired (Table 1.)
Μost patients (45.0%) were diagnosed with lung cancer in 2020. Treatment options included chemotherapy, immunotherapy and radiotherapy as stand alone treatments or combined. Table 2 summarizes clinical information including treatment options and comorbidities. 45.6% (73/160) patients had chronic comorbidities while 6.9% contracted COVID-19 prior, during or after oncological treatment.
Regarding DT results, insurance and financial situation were the most frequently reported concerns (n = 46, 28.7%), followed by family-health problems (n = 26, 16.3%), anxiety (n = 75, 46.9%) and fatigue (n = 10, 63.7%). The less frequent problems concerned childcare (n = 150, 93.8%), fertility (n = 158, 98.8%), depression (n = 142, 88.8%), spiritual/religious worries (n = 145, 90.6%) and substance use (n = 157, 98.1%) (Table 3).
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Table 1. Demographics characteristics patients with lung cancer (N = 160).
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Table 2. Medical characteristics of lung cancer patients during COVID-19 pandemic.
Regarding DT results, fatigue (63.7%%), anxiety (46.9%), insurance and financial situation (28.7%) and family health problems (16.3%) were the most frequently reported outcomes and fertility (1.3%), substance use (1.9%), childcare (6.3%), spiritual/religious worries (9.4%) and depression (11.3%) were the least reported (Table 3).
DT was positively correlated with HLOC “chance” subscale (p < .001) and HLOC “doctors” subscale (p < .001). Also, regarding the subscales of DT, Family problems were correlated with practical problems (p < .001), emotional problems with practical and family problems (p < .001), physical problems with all the rest of DT subscales (p < .001) (Table 4).
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Table 3. Problems identified by DT (DT).
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Table 4. Correlation of health locus of control and distress thermometer (N = 160).
*Correlation is significant at .05 level (2-tailed) **Correlation is significant at .01 level (2-tailed).
As per multiple linear regression analyses, HLOC Doctors has a significant statistically positive influence on lung cancer patients’ distress (p = .008). More specifically in the presence of eHLOC patients rely more on their doctors about their lung cancer but they do not rely on others (p = .653) (Table 5).
4. Discussion
The aim of the present study was to investigate the association of HLOC with psychological distress among lung cancer patients during the COVID-19 pandemic. All patients were in advanced stage of their disease and were diagnosed
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Table 5. Influence of locus of control on lung cancer patients’ distress.
Dependent variable: Distress Thermometer, R2 = .06.
during the first two waves of the pandemic when a lot of restrictive measures were put in place to prevent COVID19 transmission and healthcare services were re-organized to meet the rising needs secondary to the pandemic ( Albano et al., 2021 ; Indini et al., 2020 ; Di Giacomo et al., 2020 ).
Regarding COVID-19 infection a small percentage (6.9%) contracted the virus prior, during or after their treatment, which may be due to their shielding and raised self awareness for self-protective measures knowing COVID-19 is an airborne disease ( Wang & Zhang, 2020 ; Tian et al., 2020 ; Liang et al., 2020 ). Family members presented low COVID-19 infection rates amidst the pandemic, alluding to increased cautiousness and protective measures by the entire family to protect their relative with lung cancer. To the best of our knowledge, this study is the first to provide evidence that lung cancer patients’ behaviour is strongly associated with psychological distress and physicians should take this into consideration in order to promote better mental health and quality of life to this population.
Ιn this study, the most prevalent problems concerned insurance and finances, family-health problems, anxiety and fatigue. The less frequent problems concerned childcare, fertility, depression, spiritual/religious worries and substance use. However, emotional and physical problems were found to be the main cause for emotional distress. This could be attributed to the fact that negative feelings derive from the therapy related side-effects, since the participants in this study were already being treated for their lung cancer. This is in agreement with other published papers where it has been shown that physical problems, could enhance psychological distress, and poor quality of life ( Plank & Nemesure 2016 ; Chad-Friedman et al., 2017 ; Wang et al., 2017 ; Liu et al., 2018 ; Occhipinti et al., 2019 ).
In the present study, it was also found that HLOC is strongly associated with psychological distress and it increases proportionally. Increased eLOC is associated with higher psychological distress in lung cancer patients due to the patients’ perception they are not in control of their disease and adopt behaviors negatively impacting their psychological status. This finding is consistent with previously published papers, supporting the opinion that when patients believe their health is controlled by chance or others, such as their doctors, they experience more mental health issues ( Hashimoto & Fukuhar, 2004 ; Marton et al, 2021 ; Dopelt et al, 2022 ).
Moreover, the subscale of HLOC “doctors” was positively correlated with psychological distress. This means that during the COVID-19 pandemic, patients followed their doctor’s advice regarding which treatment they should have. According to Dopelt et al. (2022) many cancer patients rely on their doctors to make a decision for them because they face difficulties regarding treatment decisions, as was also found in the present study.
Psychological distress is increased when cancer patients rely on their doctors about cancer treatment decisions. These patients are retracted and they do not participate actively on the decision-making process. This leads to unhealthy behaviors, such as unhealthy diet and inactive lifestyle, which have been associated with deterioration of their health, poor prognosis, non-adherence to treatment and poor quality of life ( Henselmans et al., 2015 ; Bailo et al., 2019 ).
This study has proven that iLOC is associated with psychological distress among lung cancer patients amidst COVID-19 pandemic, a finding which should be considered when treating cancer patients in highly unpredictable situations so as to screen patients for psychological distress and recognize whether they are characterized by external or internal LOC. However, there are some limitations which should be noted. Our study is limited by the non recording of lung cancer stage and the fact is it a single centre study. Despite these limitations, this study is the first to provide evidence that lung cancer patients’ behavior is strongly associated with psychological distress and physicians should take this into consideration in order to promote better mental health and quality of life to this population.
5. Conclusion
HLOC is strongly associated with psychological distress and in the case of iLOC, the emotional state of lung cancer patients is compromised. Such patients should be screened for the existence of distress and referred to specialists to mitigate its effects on their quality of life and disease management.