ORIGINAL ARTICLE
Preoperative psychological distress, coping and quality of life in Chinese patients with newly diagnosed gastric cancer Jingfang Hong, Zengzeng Wei and Weili Wang
Aims and objectives. The purpose of this study was to investigate the prevalence of preoperative psychological distress and its relationship with coping style and quality of life in Chinese patients with newly diagnosed gastric cancer. Background. Being newly diagnosed with cancer can be a source of psychological distress. Understanding the preoperative psychological distress may contribute to the development of appropriate interventions. Design. This is a descriptive correlational survey study. Methods. The study was conducted in two teaching hospitals in Anhui province, China. A total of 165 patients with gastric cancer completed a battery of self-report questionnaires including the Distress Thermometer, the revised Chinese version of the Quality of Life Questionnaire-Stomach 22 and the Cancer Coping Modes Questionnaire. Results. The prevalence of clinically significant preoperative psychological distress was 7697% in this group. Statistically significant correlations were identified between the distress score and stomach pain, eating restrictions and anxiety subscale. Positive associations were found between the distress scores and four subdimensions of coping (avoidance and suppression, resignation, fantasy and catharsis), whereas a negative association was found between the distress scores and one subdimension of coping (Confrontation). There were also significant differences in the quality of life and coping style of patients who had different psychological distress statuses. Conclusion. These findings indicate a relatively high prevalence of preoperative psychological distress among Chinese patients with gastric cancer. Patients with clinically psychological distress were more likely to have poor quality of life and to demonstrate negative coping styles. Relevance to clinical practice. Nursing professionals need to carefully assess the psychological status of patients with gastric cancer. Tailored interventions can be administered to help these patients appropriately cope with the disease and to enhance their quality of life.
What does this paper contribute to the wider global clinical community?
• The findings of current study
•
indicate a relatively high prevalence of preoperative psychological distress in Chinese patients with gastric cancer. Positive coping styles are negatively correlated with psychological distress, whereas poor quality of life is positively correlated with psychological distress. Tailored and culturally appropriate interventions need to be developed and implemented for preoperative patients with gastric cancer to reduce their psychological distress, improve their coping strategies and enhance their quality of life.
Key words: cancer, coping, oncology nursing, psychological distress, quality of life Accepted for publication: 1 February 2015 Authors: Jingfang Hong, PhD, Associate Professor, School of Nursing, Anhui Medical University, Hefei, Anhui; Zengzeng Wei, MSN, RN, Nurse Practitioner (NP), The Second Affiliated Hospital of Anhui Medical University; Weili Wang, MD, Professor, School of Nursing, Anhui Medical University and Anhui Provincial Nursing International Research Center, Hefei, Anhui Province, China Correspondence: Weili Wang, Professor, School of Nursing, MD, Professor, Anhui Medical University, No. 69 Mei Shan Road, Shu
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447, doi: 10.1111/jocn.12816
Shan District, Hefei 230032, Anhui Province, China. Telephone: +86 551 63869167. E-mail: [email protected] Dr Hong and Ms Wei are co-first authors and contributed equally to this work.
2439
J Hong et al.
Introduction Gastric cancer is the fourth most common malignancy and remains the second leading cause of cancer-related mortality worldwide (Qiu et al. 2005, NCCN 2010). Despite considerable geographical variation in its incidence, nearly 414% of male gastric cancer patients and 192% of female gastric cancer patients live in China (Yang 2006). In 2008, around one million new cases were detected in the world, but half of them occurred in East Asian countries, especially in China (Shin et al. 2011). The latest data show that China has the highest annual incidence of gastric cancer (NCCN 2010). Given the high incidence of gastric cancer in China, the diagnosis of cancer is a life stress that may result in subsequent psychological distress. The psychological distress among cancer patients has been addressed consistently in an international context. The notable feature is that the findings of prevalence of psychological distress varied from one sample to another. For instance, studies have reported that the prevalence of depression in cancer patients was 71% among Australian cancer patients (Pascoe et al. 2000), and 519% with a heterogeneous sample of cancer patients in Jordan (Mhaidat et al. 2009). The variation in prevalence may result from the heterogeneity of cancer types, different criteria for identification of cases, and the treatment of disease. Currently, surgical resection is the most widespread treatment for gastric cancer patients. Therefore, a careful examination of the psychological distress of patients who are awaiting surgical treatment may have practical clinical implications.
Background An increasing number of international studies have indicated that psychological distress is common in patients who are affected by cancer; the prevalence of psychological distress in these patients ranges from one-third to one-half (Carlson & Bultz 2003, Gao et al. 2010). From the limited knowledge available concerning this issue in China, the prevalence of psychological distress seemed much higher, ranging from 527% (Zhang 2012) to 81% in cancer patients (Han et al. 2008). The National Comprehensive Cancer Network (NCCN) in the United States has issued specific guidelines for distress management in oncology. According to the definition of the NCCN, distress is ‘a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioural, emotional), social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment’ (NCCN 2010). Moreover, distress is not conducive
2440
to treatment compliance and self-care (Murray et al. 2007). Distress may result in poor quality of life, inappropriate health behaviour, excessive consumption of medical resources, and high mortality (Hamer et al. 2009). Additionally, previous studies also revealed that psychological distress was related to the use of less adaptive coping methods (Walker et al. 2006) and the negative coping style was one of the predictors of distress among cancer patients (Esplen et al. 2007). However, the research on univariate relationship between quality of life, coping style and psychological distress specifically among gastric cancer patients has been very limited. Additionally, studies that explored quality of life, coping and psychological distress simultaneously in this certain population are scarce. Despite its high prevalence and negative consequences, distress has been ignored and undetected in real clinical settings. Fewer than 10% of patients are identified and treated appropriately (Vanderwerker et al. 2005). The main reasons for this problem are insufficient health personnel resources and a lack of simple and effective measurements (Clover et al. 2009). The majority of the medical staff’s time is occupied with substantial routine care to meet physiological needs, whereas mental health needs are underrecognised. Furthermore, many tools have difficulty selecting and comparing diagnostic validity. For instance, more than 40 short screening tools were reported in the most recent meta-analysis (Mitchell 2010). The NCCN advocates that clinicians use the Distress Thermometer (DT) as a screening tool for all cancer patients. The American Psychosocial Oncology Society (APOS) also stresses that substantial attention should be paid to identifying psychological distress in cancer diagnosis and continuing to screen cancer patients. Fortunately, because of its simplicity and ability to quantify the distress level and identify causes concurrently, the DT has been adopted in many Western countries, which have pooled invaluable information in this area (Carlson & Bultz 2003, Gao et al. 2010). However, there is an apparent knowledge gap in this area in China. First, the DT is still not widely used in China, which is most likely due to insufficient attention to the psychosocial needs of cancer patients. Second, to the best of our knowledge, no previous studies have addressed the specific prevalence of psychological distress in Chinese patients with gastric cancer. Considering the above issues, the present study aims to (1) investigate the prevalence of preoperative psychological distress and its specific manifestations in Chinese patients with gastric cancer; (2) examine the relationship between psychological distress and patients’ coping style and quality of life; and (3) explore the differences in the quality of life © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447
Original article
and coping styles of patients with different psychological distress statuses.
Methods Design and sample procedure A cross-sectional, descriptive correlational study design was adopted. A consecutive sample of patients was recruited from six surgical wards at two university teaching hospitals in Anhui province, China. The inclusion criteria were the following: being newly diagnosed with gastric cancer within three months and not undergoing any forms of treatment prior to the survey; being aware of their own diagnosis; and no current evidence of relapse or metastasis from any other types of cancer. Individuals who were mentally or physically unable to participate in this study (such as those who could not understand the informed consent or comply with the required study procedures, or the patients whose Karnofsky performance status scores were under 40) were excluded. During the recruitment period of 12 months, all potential patients who were eligible for inclusion were provided with oral and written information about the study after diagnosis but before surgery. Signed consent was obtained before the patients completed a questionnaire on the second day of admission. The study was approved by the Ethics Committee of the two study hospitals. Aspects including the qualification of researchers, sampling methods, instruments for measurement and fully informed consents were submitted to the Ethics Committee. Nearly 2000 patients with gastric cancer were awaiting surgical treatment during the period of data collection, and 236 of them met the inclusion criteria. The main reason for such low proportion of eligible patients is protective nature in of Chinese family members, which means patients are not always informed of diagnoses. Hence, some patients are not aware of their own cancer diagnosis and have been excluded. A total of 186 patients agreed to participate in the study, which represented the 79% of the eligible patients. Nine of them could not be included because they were transferred to other wards or decided to not seek treatment for their cancer. Thus, the study consisted of 177 participants. Of the 177 returned questionnaires, 165 were valid, and 12 questionnaires were excluded because more than one-third of the items were not completed.
Measurements Psychological distress The DT was used to assess psychological distress. The DT is a single item with an 11-point scale (0 = no dis© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447
Distress, coping, and quality of life in cancer
tress to 10 = extreme distress) in a thermometer format (NCCN 2007). In addition to the distress rating, a problem list was included on the same page as the Distress Thermometer to identify specific problems, such as physical (21 items), practical (five items), emotional (six items), family (two items) and spiritual issues (one item). The answer to each question is ‘yes’ or ‘no’, indicating ‘have the experience of the specific problem’ or ‘no experience of the specific problem’. The psychometric properties of the DT have been well documented in many studies (Kornblith et al. 2001, Kennard et al. 2004, Bui et al. 2005). The internal consistency Cronbach’s a for the problem list part was 075 in the present study. A DT score of 4 or above is considered an internationally accepted indicator of clinically significant distress for patients who need support (Tang et al. 2011, Donovan et al. 2014). In one of our previous studies, the optimal cut-off point on the DT with reference to the hospital anxiety and depression scale was four with an area under the Receiver Operating Characteristic (ROC) curve of 0885 (p < 001) in Chinese cancer patients (Zhang 2012). Quality of life Considering the research population, the researchers chose a revised Chinese version of the Quality of Life Questionnaire-Stomach 22 (QLQ-STO22) to measure quality of life. The translated Chinese version was validated by Jiang with acceptable validity and reliability. It was originally a 22-item, self-administered questionnaire with ratings on a four-point Likert scale (1 = not at all and 4 = extremely). This scale contains five multi-item sub-domains (dysphasia, stomach pain, reflux, eating restriction and anxiety) and four single item domains (dry mouth, tasting, body image and hair loss) that cover disease and treatmentrelated symptoms as well as the emotional consequences of stomach cancer (Blazeby et al. 2004). In our study, preoperative patients seldom lost their hair; therefore, two items related to hair loss were removed. Therefore, 20 items covering eight sub-domains were included as the indexes of quality of life. Based on linear conversion, the final score was between 0–100 for each domain [converted score = (real crude score/total maximum score) *100]. A high score represents poor quality of life in gastric cancer patients. Generally, the boundary level of Cronbach’s a is 065, which suggests an acceptable reliability, while the number of 070 or above suggests a good reliability (Devellis 2003). The internal consistency Cronbach’s a for the revised Chinese version of the QLQSTO22 in our pretest with 20 cancer patients in another
2441
J Hong et al.
surgical ward was 074, which suggested the internal consistency is good. Coping The Cancer Coping Modes Questionnaire (CCMQ) was used to measure the participants’ coping. The CCMQ was originally developed for a Chinese cancerous population by Huang and her colleagues (Huang et al. 2007). This selfreport questionnaire includes a 26-item, four-point Likert scale (1 = never, 4 = always) and contains five dimensions: confrontation, avoidance & suppression, resignation, fantasy, and catharsis. The criterion validity for the Medical Coping Modes Questionnaire (MCMQ) was 072, and the split-half reliability was 092. We tested the CCMQ in 20 cancer patients in another surgical ward. The results demonstrated acceptable internal consistency, with Cronbach’s a of 067, 081, 072, 074 and 086 for the five dimensions, respectively, which suggested an acceptable reliability. Sociodemographic and clinical data The participants’ sociodemographic data, including age, gender, educational level, marital status and monthly income, were collected. Clinical information, such as the Karnofsky performance status score, disease duration and pathological differentiation, was extracted from the participants’ medical charts.
Statistical analysis Data were entered into separate files and were audited and verified using EPI statistical software, version 3.1 (EPI3.1, The EpiData Association, Odense, Denmark). The data were then analysed using Statistical Package for Social Sciences, version 20.0 (SPSS-20.0, IBM, New York, USA.). (1) The sociodemographic data and clinical characteristics of the participants were described using descriptive statistics, such as the frequency and percentage of gender, education level, and marital status and the mean and standard deviation for age. (2) After checking the normality of scores from the DT, CCMQ, and revised Chinese version of the QLQ-STO22, Spearman’s correlation coefficient was applied to examine the relationship between psychological distress and patients’ coping style and QOL. (3) Student’s t-test or a Mann–Whitney U-test were conducted to compare the differences in the quality of life between subgroups of patients with clinically significant distress (DT score ≥4) and those without clinically significant distress (DT score
Preoperative psychological distress, coping and quality of life in Chinese patients with newly diagnosed gastric cancer Jingfang Hong, Zengzeng Wei and Weili Wang
Aims and objectives. The purpose of this study was to investigate the prevalence of preoperative psychological distress and its relationship with coping style and quality of life in Chinese patients with newly diagnosed gastric cancer. Background. Being newly diagnosed with cancer can be a source of psychological distress. Understanding the preoperative psychological distress may contribute to the development of appropriate interventions. Design. This is a descriptive correlational survey study. Methods. The study was conducted in two teaching hospitals in Anhui province, China. A total of 165 patients with gastric cancer completed a battery of self-report questionnaires including the Distress Thermometer, the revised Chinese version of the Quality of Life Questionnaire-Stomach 22 and the Cancer Coping Modes Questionnaire. Results. The prevalence of clinically significant preoperative psychological distress was 7697% in this group. Statistically significant correlations were identified between the distress score and stomach pain, eating restrictions and anxiety subscale. Positive associations were found between the distress scores and four subdimensions of coping (avoidance and suppression, resignation, fantasy and catharsis), whereas a negative association was found between the distress scores and one subdimension of coping (Confrontation). There were also significant differences in the quality of life and coping style of patients who had different psychological distress statuses. Conclusion. These findings indicate a relatively high prevalence of preoperative psychological distress among Chinese patients with gastric cancer. Patients with clinically psychological distress were more likely to have poor quality of life and to demonstrate negative coping styles. Relevance to clinical practice. Nursing professionals need to carefully assess the psychological status of patients with gastric cancer. Tailored interventions can be administered to help these patients appropriately cope with the disease and to enhance their quality of life.
What does this paper contribute to the wider global clinical community?
• The findings of current study
•
indicate a relatively high prevalence of preoperative psychological distress in Chinese patients with gastric cancer. Positive coping styles are negatively correlated with psychological distress, whereas poor quality of life is positively correlated with psychological distress. Tailored and culturally appropriate interventions need to be developed and implemented for preoperative patients with gastric cancer to reduce their psychological distress, improve their coping strategies and enhance their quality of life.
Key words: cancer, coping, oncology nursing, psychological distress, quality of life Accepted for publication: 1 February 2015 Authors: Jingfang Hong, PhD, Associate Professor, School of Nursing, Anhui Medical University, Hefei, Anhui; Zengzeng Wei, MSN, RN, Nurse Practitioner (NP), The Second Affiliated Hospital of Anhui Medical University; Weili Wang, MD, Professor, School of Nursing, Anhui Medical University and Anhui Provincial Nursing International Research Center, Hefei, Anhui Province, China Correspondence: Weili Wang, Professor, School of Nursing, MD, Professor, Anhui Medical University, No. 69 Mei Shan Road, Shu
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447, doi: 10.1111/jocn.12816
Shan District, Hefei 230032, Anhui Province, China. Telephone: +86 551 63869167. E-mail: [email protected] Dr Hong and Ms Wei are co-first authors and contributed equally to this work.
2439
J Hong et al.
Introduction Gastric cancer is the fourth most common malignancy and remains the second leading cause of cancer-related mortality worldwide (Qiu et al. 2005, NCCN 2010). Despite considerable geographical variation in its incidence, nearly 414% of male gastric cancer patients and 192% of female gastric cancer patients live in China (Yang 2006). In 2008, around one million new cases were detected in the world, but half of them occurred in East Asian countries, especially in China (Shin et al. 2011). The latest data show that China has the highest annual incidence of gastric cancer (NCCN 2010). Given the high incidence of gastric cancer in China, the diagnosis of cancer is a life stress that may result in subsequent psychological distress. The psychological distress among cancer patients has been addressed consistently in an international context. The notable feature is that the findings of prevalence of psychological distress varied from one sample to another. For instance, studies have reported that the prevalence of depression in cancer patients was 71% among Australian cancer patients (Pascoe et al. 2000), and 519% with a heterogeneous sample of cancer patients in Jordan (Mhaidat et al. 2009). The variation in prevalence may result from the heterogeneity of cancer types, different criteria for identification of cases, and the treatment of disease. Currently, surgical resection is the most widespread treatment for gastric cancer patients. Therefore, a careful examination of the psychological distress of patients who are awaiting surgical treatment may have practical clinical implications.
Background An increasing number of international studies have indicated that psychological distress is common in patients who are affected by cancer; the prevalence of psychological distress in these patients ranges from one-third to one-half (Carlson & Bultz 2003, Gao et al. 2010). From the limited knowledge available concerning this issue in China, the prevalence of psychological distress seemed much higher, ranging from 527% (Zhang 2012) to 81% in cancer patients (Han et al. 2008). The National Comprehensive Cancer Network (NCCN) in the United States has issued specific guidelines for distress management in oncology. According to the definition of the NCCN, distress is ‘a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioural, emotional), social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment’ (NCCN 2010). Moreover, distress is not conducive
2440
to treatment compliance and self-care (Murray et al. 2007). Distress may result in poor quality of life, inappropriate health behaviour, excessive consumption of medical resources, and high mortality (Hamer et al. 2009). Additionally, previous studies also revealed that psychological distress was related to the use of less adaptive coping methods (Walker et al. 2006) and the negative coping style was one of the predictors of distress among cancer patients (Esplen et al. 2007). However, the research on univariate relationship between quality of life, coping style and psychological distress specifically among gastric cancer patients has been very limited. Additionally, studies that explored quality of life, coping and psychological distress simultaneously in this certain population are scarce. Despite its high prevalence and negative consequences, distress has been ignored and undetected in real clinical settings. Fewer than 10% of patients are identified and treated appropriately (Vanderwerker et al. 2005). The main reasons for this problem are insufficient health personnel resources and a lack of simple and effective measurements (Clover et al. 2009). The majority of the medical staff’s time is occupied with substantial routine care to meet physiological needs, whereas mental health needs are underrecognised. Furthermore, many tools have difficulty selecting and comparing diagnostic validity. For instance, more than 40 short screening tools were reported in the most recent meta-analysis (Mitchell 2010). The NCCN advocates that clinicians use the Distress Thermometer (DT) as a screening tool for all cancer patients. The American Psychosocial Oncology Society (APOS) also stresses that substantial attention should be paid to identifying psychological distress in cancer diagnosis and continuing to screen cancer patients. Fortunately, because of its simplicity and ability to quantify the distress level and identify causes concurrently, the DT has been adopted in many Western countries, which have pooled invaluable information in this area (Carlson & Bultz 2003, Gao et al. 2010). However, there is an apparent knowledge gap in this area in China. First, the DT is still not widely used in China, which is most likely due to insufficient attention to the psychosocial needs of cancer patients. Second, to the best of our knowledge, no previous studies have addressed the specific prevalence of psychological distress in Chinese patients with gastric cancer. Considering the above issues, the present study aims to (1) investigate the prevalence of preoperative psychological distress and its specific manifestations in Chinese patients with gastric cancer; (2) examine the relationship between psychological distress and patients’ coping style and quality of life; and (3) explore the differences in the quality of life © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447
Original article
and coping styles of patients with different psychological distress statuses.
Methods Design and sample procedure A cross-sectional, descriptive correlational study design was adopted. A consecutive sample of patients was recruited from six surgical wards at two university teaching hospitals in Anhui province, China. The inclusion criteria were the following: being newly diagnosed with gastric cancer within three months and not undergoing any forms of treatment prior to the survey; being aware of their own diagnosis; and no current evidence of relapse or metastasis from any other types of cancer. Individuals who were mentally or physically unable to participate in this study (such as those who could not understand the informed consent or comply with the required study procedures, or the patients whose Karnofsky performance status scores were under 40) were excluded. During the recruitment period of 12 months, all potential patients who were eligible for inclusion were provided with oral and written information about the study after diagnosis but before surgery. Signed consent was obtained before the patients completed a questionnaire on the second day of admission. The study was approved by the Ethics Committee of the two study hospitals. Aspects including the qualification of researchers, sampling methods, instruments for measurement and fully informed consents were submitted to the Ethics Committee. Nearly 2000 patients with gastric cancer were awaiting surgical treatment during the period of data collection, and 236 of them met the inclusion criteria. The main reason for such low proportion of eligible patients is protective nature in of Chinese family members, which means patients are not always informed of diagnoses. Hence, some patients are not aware of their own cancer diagnosis and have been excluded. A total of 186 patients agreed to participate in the study, which represented the 79% of the eligible patients. Nine of them could not be included because they were transferred to other wards or decided to not seek treatment for their cancer. Thus, the study consisted of 177 participants. Of the 177 returned questionnaires, 165 were valid, and 12 questionnaires were excluded because more than one-third of the items were not completed.
Measurements Psychological distress The DT was used to assess psychological distress. The DT is a single item with an 11-point scale (0 = no dis© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2439–2447
Distress, coping, and quality of life in cancer
tress to 10 = extreme distress) in a thermometer format (NCCN 2007). In addition to the distress rating, a problem list was included on the same page as the Distress Thermometer to identify specific problems, such as physical (21 items), practical (five items), emotional (six items), family (two items) and spiritual issues (one item). The answer to each question is ‘yes’ or ‘no’, indicating ‘have the experience of the specific problem’ or ‘no experience of the specific problem’. The psychometric properties of the DT have been well documented in many studies (Kornblith et al. 2001, Kennard et al. 2004, Bui et al. 2005). The internal consistency Cronbach’s a for the problem list part was 075 in the present study. A DT score of 4 or above is considered an internationally accepted indicator of clinically significant distress for patients who need support (Tang et al. 2011, Donovan et al. 2014). In one of our previous studies, the optimal cut-off point on the DT with reference to the hospital anxiety and depression scale was four with an area under the Receiver Operating Characteristic (ROC) curve of 0885 (p < 001) in Chinese cancer patients (Zhang 2012). Quality of life Considering the research population, the researchers chose a revised Chinese version of the Quality of Life Questionnaire-Stomach 22 (QLQ-STO22) to measure quality of life. The translated Chinese version was validated by Jiang with acceptable validity and reliability. It was originally a 22-item, self-administered questionnaire with ratings on a four-point Likert scale (1 = not at all and 4 = extremely). This scale contains five multi-item sub-domains (dysphasia, stomach pain, reflux, eating restriction and anxiety) and four single item domains (dry mouth, tasting, body image and hair loss) that cover disease and treatmentrelated symptoms as well as the emotional consequences of stomach cancer (Blazeby et al. 2004). In our study, preoperative patients seldom lost their hair; therefore, two items related to hair loss were removed. Therefore, 20 items covering eight sub-domains were included as the indexes of quality of life. Based on linear conversion, the final score was between 0–100 for each domain [converted score = (real crude score/total maximum score) *100]. A high score represents poor quality of life in gastric cancer patients. Generally, the boundary level of Cronbach’s a is 065, which suggests an acceptable reliability, while the number of 070 or above suggests a good reliability (Devellis 2003). The internal consistency Cronbach’s a for the revised Chinese version of the QLQSTO22 in our pretest with 20 cancer patients in another
2441
J Hong et al.
surgical ward was 074, which suggested the internal consistency is good. Coping The Cancer Coping Modes Questionnaire (CCMQ) was used to measure the participants’ coping. The CCMQ was originally developed for a Chinese cancerous population by Huang and her colleagues (Huang et al. 2007). This selfreport questionnaire includes a 26-item, four-point Likert scale (1 = never, 4 = always) and contains five dimensions: confrontation, avoidance & suppression, resignation, fantasy, and catharsis. The criterion validity for the Medical Coping Modes Questionnaire (MCMQ) was 072, and the split-half reliability was 092. We tested the CCMQ in 20 cancer patients in another surgical ward. The results demonstrated acceptable internal consistency, with Cronbach’s a of 067, 081, 072, 074 and 086 for the five dimensions, respectively, which suggested an acceptable reliability. Sociodemographic and clinical data The participants’ sociodemographic data, including age, gender, educational level, marital status and monthly income, were collected. Clinical information, such as the Karnofsky performance status score, disease duration and pathological differentiation, was extracted from the participants’ medical charts.
Statistical analysis Data were entered into separate files and were audited and verified using EPI statistical software, version 3.1 (EPI3.1, The EpiData Association, Odense, Denmark). The data were then analysed using Statistical Package for Social Sciences, version 20.0 (SPSS-20.0, IBM, New York, USA.). (1) The sociodemographic data and clinical characteristics of the participants were described using descriptive statistics, such as the frequency and percentage of gender, education level, and marital status and the mean and standard deviation for age. (2) After checking the normality of scores from the DT, CCMQ, and revised Chinese version of the QLQ-STO22, Spearman’s correlation coefficient was applied to examine the relationship between psychological distress and patients’ coping style and QOL. (3) Student’s t-test or a Mann–Whitney U-test were conducted to compare the differences in the quality of life between subgroups of patients with clinically significant distress (DT score ≥4) and those without clinically significant distress (DT score
