Introduction

Following curative resection of cancer, patients must manage a wide range of physical and psychological symptoms prior to undertaking adjuvant chemotherapy [1]. These symptoms can compromise tolerance to treatment and compliance. Thus, the overall 5-year survival rate is three to four times higher among those who complete complementary chemotherapy [2, 3]. Treatment toxicity, and physical and psychological symptoms during this period upset these individuals, as they are associated with a decline in health-related quality of life (HRQoL), decreased psychological well-being, and interference with their activities and the plans they have for their lives [4, 5].

The most usual symptoms among subjects with resected cancer include malnutrition, depression, anxiety, and somatization, which have been evaluated separately in various studies [4, 6, 7]. Malnutrition, present in 39% of cancer patients [8], is a critical predictor of toxicity and negatively related to clinical outcomes and to increased mortality [6]. Psychological distress affects 8–50% of all patients [4, 5, 7, 9, 10].

This study seeks to examine the concurrent prevalence of risk of malnutrition, depression, anxiety, and somatization in individuals with resected cancer and determine which of these factors exerts a major effect on HRQoL in people with non-metastatic, resected cancer. This could aid oncologists in designing effective interventions to improve patients’ expectations for survival.

Methods

Participants and procedure

A cross-sectional, multicentre study was conducted in 15 Spanish hospitals. Candidates were ≥ 18 years of age who had undergone cancer surgery in the previous month and who initiated adjuvant chemotherapy between June 2015 and July 2018 at 15 Spanish hospitals. The Spanish Agency of Medicines and Medical Devices (AEMPS) classified it as a prospective, observational study; the centers obtained ethics committee approval, and all participants provided written informed consent in advance. Subjects were asked to complete a set of validated, self-report measures.

Measures

Quality of life (QoL) was evaluated by the Spanish version of the European Organization for Research and Treatment of Cancer QoL Questionnaire (EORTC-QLQ30), which was specifically designed for cancer patients [11]. The questionnaire consists of 30 items divided among functional scales (physical, social, role, cognitive, and emotional), symptom scales (fatigue, nausea/vomiting, pain, dyspnea, sleeping disturbances, appetite loss, constipation, diarrhea, and financial impact), and global QoL. Higher functional scale and overall health status scores and lower symptom scale scores indicate better QoL.

Risk of malnutrition was evaluated by the Malnutrition Screening Tool (MST). This tool is a fast, straightforward nutrition screening tool based on weight loss and appetite changes, yielding a score of 0–5; risk of malnutrition was defined as a score ≥ 2 [12]. It has been validated in cancer patients [12].

We measured psychological distress with the Brief Symptom Inventory (BSI) (Derogatis and Spencer 1982). The BSI-18 is a valid, reliable, widely used screening measure [13]. The 18-item questionnaire contains three subscales: somatization (six items), anxiety (six items), and depression (six items). For the purpose of the current study and according to the cutoff recommended by Derogatis [14], a T-score ≥ 63 was used as indicative of caseness. The Spanish version of the BSI has proven good reliability and validity [15].

Demographic characteristics included: age, gender, marital status, educational level, and employment status. Medical information included: tumor site, disease stage, cancer treatments received, and Charlson comorbidity index. These data were collected from medical records.

Statistical analysis

Descriptive statistics were used to analyze participants’ sociodemographic and clinical characteristics. Cutoffs for risk of malnutrition, depression, anxiety, and somatization were based on appropriate values as per previous studies conducted in a population similar to that of this study [12, 14]. Pearson correlations were performed to identify correlated factors affecting HRQoL. Multiple linear regressions were used to determine if higher functional scores are related to HRQoL. Significance was set at p < 0.05. Statistical analyses were performed with Statistical Package for Social Sciences (SPSS) software, 23.0 version (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp.).

Results

Patient characteristics

The study population comprised 747 patients, 433 (58%) women and median age was 59.6 (range 26–85) years. The most frequent primary tumor sites were colon (43.4%) and breast (31.9%), and the most common stage, III (42.8%). Half of the sample (52%) had a Charlson index score of 0. All underwent adjuvant chemotherapy and 32.8% received associated radiotherapy (see Table 1).

Table 1 Demographic and clinical characteristics of the study population (n = 747)
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Prevalence of malnutrition risk, somatization, depression, and anxiety

Prevalence rates of malnutrition risk (MST score ≥ 2), depression, anxiety, and somatization (all BSI T-score ≥ 63) were 36.4%, 35.5%, 35.2%, 48.8%, respectively.

Malnutrition risk and psychological factors related with HRQoL

The results of the correlation analysis revealed associations between the risk of malnutrition, somatization, depression, and anxiety with functional, symptom, and global HRQoL scales (see Table 2). The results of the hierarchical multiple regression analysis indicated that the risk of malnutrition, somatization, depression, and anxiety concurrently described 50.8% of the variance in the functional scale (F = 189.47, p < 0.001), 45.3% in the symptom scale (F = 153.77, p < 0.001), and 52.2% in the global HRQoL (F = 202.22, p < 0.001) (see Table 3).

Table 2 Pearson product–moment correlations between malnutrition risk (MST), psychological factors (BSI-18), and EORTC scales
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Table 3 Linear regression analysis of factors correlated with functional, symptom, and global quality of life (QoL) scale
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Discussion

This study analyzed the prevalence of malnutrition, depression, anxiety, and somatization to determine which of these factors had the greatest impact on HRQoL in people surgically treated for non-metastatic cancer prior to undertaking adjuvant chemotherapy. The presence of malnutrition, together with psychological symptoms were seen to have strong explanatory power in all HRQoL scales (functional, symptom, and global).

Our findings of 36.4% malnutrition risk and 48.8% somatization are similar to figures previously reported in oncology patients, 29–56% [16,17,18] and 40–50% [19, 20], respectively. Somatization and depression are the two most common symptoms in oncological populations [20]. The rate of depression in our series (35.5%) is relatively higher than in earlier research (9–33%) [21,22,23]. This discrepancy might be explained by the differences in types of tumors and treatments and by psychosocial variables, such as age or marital status [24]. In general, people with cancer undergoing adjuvant chemotherapy report higher rates of physical problems and psychological distress, including anxiety and somatization, than patients only treated with surgery [25]. Subjects, generally younger ones, who receive higher dosages of chemotherapy communicate more depression and somatization [26, 27]. Another possible explanation for this disparity could be the cutoffs used on the questionnaire scoring; for instance, the BSI cutoff in this study was T-score ≥ 63, as in most clinical trials [13, 28, 29], albeit higher than the one used by another study (T-score ≥ 50) [28]. The higher rates of depression may also be due to the timing of administration; 1 month following resection in our series. Thus, the prevalence of depression appears to be strikingly lower (7.5%) 6 months post-diagnosis among individuals with colorectal cancer [30]. As for somatization, it is worth investigating if the higher scores on this scale might be due to patients’ tendency to hide and avoid expressing their negative emotions, such as anger, when they find themselves in adverse situations, such as having cancer [31]. It would, therefore, be compelling for future research to analyze the relationship between somatization–depression and emotional repression in people of this type.

The results also reveal that physical factors, such as the risk of malnutrition, and psychological factors, such as depression, anxiety, and somatization, account for a large proportion of variance in HRQoL rating tools. These outcomes are consistent with earlier studies that point to the management of depression as being decisive to cancer patients’ emotional well-being, in addition to having a long-term impact on QoL [32, 33]. This is cardinal in our study, since the presence of depression and somatization in people preparing to receive chemotherapy may increase withdrawal rates and/or dose reductions due to the adverse effects of treatment.

This study has several limitations. First of all, the study is cross-sectional; hence, we cannot infer causality in the relationships between HRQoL and nutritional status, depression, anxiety, and somatization. Second, the use of self-report subjective measures cannot accurately reflect patients’ experiences, expectations, and behavior and incur such limitations as response bias (social desirability, inaccurate memory, etc.). Finally, factors other than those investigated in this study can affect HRQoL.

To the best of our knowledge, this study is the first to examine nutritional risk, depression, anxiety, and somatization concurrently to determine which account best for the proportion of variance in HRQoL in subjects with resected cancer who are getting ready to receive adjuvant chemotherapy. The results can be used to develop effective interventions that contribute to improving quality of life in this population, which should be our prime objective.

In conclusion, these results have interesting implications, such as ensuring that individuals with cancer who are initiating adjuvant chemotherapy are at their best both physically and psychologically. The risk of malnutrition and the presence of depression, anxiety, and somatic symptoms can influence tolerance and compliance with adjuvant treatment, with the risk of compromising long-term survival.