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ORIGINAL ARTICLE
Ahead of print publication  

Determination of the factors contributing to depression and anxiety in advanced stage lung cancer patients


1 Department of Pulmonology, University of Health Sciences Dr. Abdurrahman Yurtaslan Oncology Education and Research Hospital, Ankara, Turkey
2 Department of Pulmonology, Sincan Dr. Nafiz Körez State Hospital, Ankara, Turkey
3 Department of Pulmonology, University of Health Sciences Dr. Abdurrahman Yurtaslan Oncology Education and Research Hospital, Ankara, Turkey
4 Department of Radiation Oncology, University of Health Sciences Dr. Abdurrahman Yurtaslan Oncology Education and Research Hospital, Ankara, Turkey
5 Department of Department of Biostatistics, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey

Date of Submission14-Jul-2020
Date of Acceptance29-Jul-2022
Date of Web Publication14-Oct-2022

Correspondence Address:
Cigdem Ozdilekcan,
Ozdilekcan, Ankara Onkoloji Hastanesi, Demetevler Mahallesi, 06200, Yenimahalle, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_967_20

 > Abstract 


Background: The diagnosis of cancer and initiation of treatment disrupt physical, emotional, and socio-economical stability of the patients by reducing the quality of lives and ultimately leading to depression and anxiety. We aimed to observe the indicators for anxiety and depression among lung cancer (LC) patients by comparing with other cancer (OC) patients.
Methods: This study has been conducted between 2017 and 2019. Questionnaires were provided for both LC and OC patients.
Results: Two hundred and thirty patients with the ages varied between 18 and 86 (median: 64.0) were included in the study. A total of 115 patients (case group) were diagnosed as LC, and the remaining were with OC diagnosis (control). No difference was determined between the groups in means of median anxiety and depression scores. Patients who required assistance in hospital procedures, daily life activities, and self-care had higher depression and anxiety scores (p < 0.05) compared to those did not require assistance. Anxiety and depression scores in OC groups showed a remarkable difference according to performance status (p < 0.001). The depression score of the patients who stated that they did not know their social rights was remarkably higher than those of the patients who stated that they know their social rights. We found no relationship between depression and anxiety scores because of disease caused income loss and expense increase.
Conclusion: For LC patients, declaration of requirement for assistance and supportive care in daily life can be an important indication for anxiety and depression. Lung cancer patients, especially those informed by health care professionals and provided psychosocial support following the information, require a patient-specific professional management approach.

Keywords: Anxiety, depression, lung cancer, quality of life, supportive care



How to cite this URL:
Ozdilekcan C, Turkkani MH, Ozdemir T, Goksel F, Akyol M. Determination of the factors contributing to depression and anxiety in advanced stage lung cancer patients. J Can Res Ther [Epub ahead of print] [cited 2022 Dec 9]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=358620




 > Background Top


The Greek stoic philosopher Epictetus (born in 50 C.E within borders of Turkey), who has been influenced by Hippocrates, wrote his book The Enchiridion, which means “handbook”. He stated that “man is not worried by real problems so much as by his imagined anxieties.” Since the ancient times, anxiety has been known as an issue for mankind to deal with.[1]

Depression and anxiety are frequently seen among cancer patients. The diagnosis of cancer and initiation of treatment, changes on the physical appearance; disruption on family and social relations; and disturbances such as maladaptation, fear, depression, and anxiety result in an impaired quality of life. There is a concern that psycho-social factors contribute to both incidence and prognosis of cancer.[2],[3]

By having a natural course with severe pain and dyspnea, LC differs from other cancer types by causing quick disruption on general conditions, functional capacity, psychological and physical integrity of the patient, and being more fatal. Feeling of guilt caused by relating the disease with smoking, continuing smoking, failing to give up, having been aware of bad prognosis, and being accused by others are among the factors disrupting psychological integrity. LC is mostly at advanced stages when diagnosed. At these advanced stages of LC, unstable emotional experiences can frequently be observed.[4] Many factors such as long-lasting chemotherapy sessions, requirement of recurrent hospitalizations, side effects of medications, radiotherapy applications, being irresponsive to medical treatment, worrying about the future, socio-economic losses, and progressively losing hope to be cured may negatively affect psychology of the patient. Patients such as having anxiety and depressive mood have a lower life quality.[5],[6] Supportive treatments, aiming to increase the life quality of the patient, including psycho-social care and assistance, have to be applied to the LC patients from diagnosis to death as well. Such psycho-social care and assistances must have applications such as to be executed during the entire course of the disease.[7],[8]

Considering that humans have biological, psychological, and social components together as an integrity, we in our study focused on a different aspect of LC patients to reveal the care need, social and financial and daily performance statuses, and co-operation with the health care professionals. By using the demographic data and questionnaires, we aimed to find out the effect of several contributing factors as indicators for anxiety and depression in these groups of patients.


 > Material and Methods Top


Participants

This study was conducted prospectively between September 2017 and November 2019. A total of 230 patients who underwent palliative radiation therapy with advanced stages were included in the study protocol. The patient groups were defined as the LC group (the case) and the OC group (control). Both cancer patients were selected from the advanced stages and with similar ECOG (Eastern Cooperative Oncology Group) performance statuses to maintain the proper match between the groups. Following the achievement of written informed consent from the patients, meeting with previously trained interviewers had been held in a room proper for patient privacy.

Study protocol and questionnaires

Questionnaires were administered to the patients including demographic data such as age, sex, education, marital status, residence, and questions related with income level, care requirement, and reach to health personnel and information. Besides, ECOG questionnaires and Hospital Anxiety Depression Scale (HAD) were applied to the same patient group. Patients who have not given consent or having the lack of co-operation were excluded from the study.

Ethical consideration

The Local Ethics Committee approved the protocol, dated December 2018 Number: 2018-12/169. All subjects were provided written informed consent. Data of the patients were treated according to the Declaration of Helsinki Guidelines.

Statistical analysis

Number and percentage were used in the representation of categorical variables (gender, cancer type, residence). The test of normality of continuous variables (such as age, depression, and anxiety score) was analyzed graphically and by the Shapiro–Wilk test. While comparing continuous variables according to cancer types, the Student t-test was used for body mass index (BMI) and the Mann–Whitney test was used for other variables. The Mann–Whitney test was used to compare anxiety and depression scores by gender. The Chi-square test was used to compare the questions in the scale and other categorical variables according to cancer types. Kruskal–Wallis non-parametric analysis of the variance test was applied to compare anxiety and depression scores according to education level, BMI classification, study status, and ECOG grades. When the difference was found, post-hoc comparisons were made with the Mann–Whitney test by Bonferroni corrections to determine the difference group. IBM SPSS Statistics for Windows, Version 22.0. Armonk, and NY: IBM Corp. programs were used. A P value <0.05 was considered as an indicator of significant difference.


 > Results Top


General characteristics of the study group

This present study was conducted with 230 patients with the ages varying between 18 and 86 (median: 64). A total of 115 of the patients (50.0%) were diagnosed as LC (case group), and 115 patients (50.0%) with OC diagnosis were taken as the control. The OC group consisted of 32 prostate cancer, 26 colorectal cancer, 20 breast cancer, eight stomach cancer, seven brain tumor, five bone cancer, four nasopharynx cancer, four cervix cancer, one larynx cancer, one thyroid cancer, one bladder cancer, one pancreas cancer, one endometrium cancer, one esophagus cancer, and one cholangiocarcinoma patients. A total of 49 (21.3%) of the patients were women, and 181 (%78.7) were men. Demographic data of the patients are presented in [Table 1]. There was no difference (p > 0.05) between OC and LC groups in means of median age, marital status, education level, average BMI, BMI types, and residence. The rate of men in the LC group was higher, whereas the rate of women was higher in the OC group (p = 0.016). Similarly, the rate of men in the LC group and the rate of women in the OC group were found to be higher (p = 0.014).
Table 1: Demographic characteristics of the patients

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Economical status of the study group

The median monthly income of the patients in the OC group before diagnosis was 2.000,-TL (415,-$), whereas the median income of the study group was 1.600,-TL (332 $). The monthly income of the OC group before diagnosis was significantly higher than that of the LC group [2.000TL (415$) and 1.500TL (311$), respectively] (p < 0.001). Similarly, the monthly regular median income after disease was defined to be higher in the OC group than in the LC group (p < 0.001). Although 24.3% of the OC group experienced loss of income because of absenteeism or an increase in expenses during the disease course, the rate was 17.4% in the LC group. The loss of income in both groups was found to be statistically similar (p = 0.194).

Performance status and need for assistance

Sixty three percent of the patients stated that they needed assistance of another person during the hospitalization period. This ratio was similar in both groups (p = 0.682). The participant rate regarding required assistance in daily activities was defined as 37.6% (n = 86). Approximately only one out of eight patients who needed assistance for self-care was observed with the rate of 13.0% (n = 30). Care requirement of the patients because of their disease and their statements about their need for care and also the communication with health care professionals are given in [Table 2]. The number of patients in the LC group answering “No” to the questions “ Have you been adequately informed by health care personnel?”, “Do you easily reach to health care professional to learn about the issues you wonder about your disease?”, and “Did you meet a dietitian about nutrition related with your disease?” was higher than that of patients in the OC group (p < 0.05). The rates of “Yes” and “No” answers to the other questions were found to be similar in both groups (p > 0.05).
Table 2: Care need of the patients and information status about their disease

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Scores for anxiety and depression

According to [Table 3], anxiety was present in 24.3% of patients in LC and 29.6% in the OC group without a statistical significant difference (p = 0.373). Also, there was no statistically significant difference in means of depression rates with the values of 54.8% and 53.9% in the OC and LC groups, respectively.
Table 3: Anxiety and depression rates in the study group

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HAD scores obtained from anxiety and depression scales were determined according to the groups. The anxiety scores in the OC group varied between 0 and 21 with the median value of 5.0. In the LC group, the anxiety score varied between 0 and 20 with the median value of 5.0. No difference was determined between the groups for median anxiety scores (p = 0.712). The depression score interval was 0–18 in the control group; the median was defined as 7.0, and it is in the 0–16 interval in the LC group. No statistical difference was found between the LC and OC groups in means of depression scores (p = 0.676).

The comparison between anxiety and depression scale scores according to demographic characteristics and care requirement is shown in [Table 4]. People requiring assistance in hospital procedures, daily life activities, and self-care had higher depression and anxiety median scores (p < 0.05) compared to those who did not require assistance. It was defined in the OC group that women had a higher anxiety score than men. The anxiety and depression scores from the point of view of other demographic characteristics were found to be similar in both groups (p > 0.05) [Table 4].
Table 4: Comparison of anxiety and depression scores according to demographic data and care requirement

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The anxiety and depression scores of the patients experiencing and not experiencing loss of income are shown in [Table 4]. Similarly, the comparison of anxiety and depression scores of the patients taking part in the study in accordance with being informed about their disease is also shown in [Table 5].
Table 5: Comparison of anxiety and depression scores in accordance with social and performance statuses

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The depression score of the LC patients stated that they have been informed enough by health care professional, who were higher than the ones who stated that they have not been informed enough (p = 0.008). The depression score of the LC patients unable to reach easily to health care professional was found to be remarkably higher than that of the patients able to reach health care professionals (p = 0.034). The depression scores of the patients who stated that they did not know their social rights were remarkably higher than those of the patients who stated that they know their social rights (p = 0.031). The ones admitted to psychiatry departments in the LC group had higher anxiety and depression scores (p < 0.05) compared to the ones not admitted [Table 5].

Anxiety and depression scores in OC group showed a remarkable difference according to ECOG performance status (p < 0.001). On one hand, the depression scores were statistically significant in patients with LC according to ECOG values (p < 0.001). The median scores of anxiety and depression of the ones with grade 0 and grade 1 were lower than those of grade 3 (p < 0.05) [Table 5].


 > Discussion Top


The study was conducted in a comprehensive cancer center where the patients from all over Turkey were referred. The number of the studies that comparatively exhibited a socio-economical status and anxiety-depression relation in lung cancer is limited. According to our study results, no similarity was found between two groups from the anxiety and depression point of view when median values were compared and also compared with intersection values. The pre-disease income and post-disease income in the LC group was lower than those in the OC group. However, there was no difference between post-disease income losses. The rate of patients in the LC group having not been informed about their disease by health care professionals, not having the ease to reach health care professionals to learn the issues about their disease they wonder about, and not being able to meet a dietitian about nutrition related with their disease was remarkably higher than that of the OC group. In both groups, we defined a higher rate of anxiety and depression among the patients requiring assistance for hospital procedure, daily works, and self-care than the patients not requiring assistance. The depression scores of the LC patients who stated that they have been informed enough about their disease were higher than those of the LC patients who stated that they have not been informed enough. We found that the depression score among the LC patients who did not easily reach health care professionals was remarkably higher than those of the LC patients who were able to reach health care professionals. The depression score of the LC patients stated that they did not know that their social rights were remarkably higher than those of the LC patients who stated that they knew their social rights.

LC, all around the world, is a serious health problem that concerns patients, their families, and public health in all aspects.[9] Following his/her diagnose, the patient faces up with many questions and problems related with his/her course of disease. LC, because of short life expectation, treatment options, and courses, affects both the psycho-social status and life quality of the patients.[10] Psycho-therapeutic, psycho-social, and education-related interventions may have a role in ameliorating the life quality of the patients.[11] The LC patients may require assistance in self-care, daily works, and hospital procedures. The patients may experience difficulty as they are forced to manage their requirements, and many of them ask for assistance to overcome difficulties they are experiencing.[12] According to a previous study, among almost half of the patients with lung cancer, requirement for professional therapy during the diagnostic period covering mostly personal care field was defined.[13] In another study, it was reported that 40% of the LC patients received as much assistance from public services as they required.[14] Steele R et al.,[15] in their previous study, reported that the patients might have had several supportive care concerns and such concerns should quickly and effectively be determined and proper interventions should be proposed. In order to provide the best support for psycho-social requirements of the LC patients during treatment and follow-up, the age, gender, stage, and social status of the patients have to be taken into consideration.[16] Self-care support to cancer patients in our country is mostly provided by the relatives of the patients and generally by their spouses. More depression and anxiety than the general public were defined among the couples affected by LC.[17] Lower anxiety and depression were experienced among LC patients with high social support.[18] In both groups, we defined higher anxiety and depression among the ones requiring assistance in hospital procedures, daily works, and self-care according to the ones not requiring so.

Getting bad news is an important event both for the patients and for their relatives.[19] Unawareness of the patients about being informed, cultural effects, insufficient medical sources and education, financial worries of the families, and necessity to protect doctors from violation were shown as reasons for hiding cancer diagnosis from the patients.[20] We consider that such a situation is also valid for our country. A valid tendency in our country is to hide the diagnosis from the patient.[21] It is generally preferred to disclose diagnosis to the family members rather than the patient.[22] We found in our study that LC patients, compared with the OC group, were not informed enough by health care professionals about their disease and were not easily reaching to health care professionals to learn about the issues they wonder about their disease. Besides, we observed that the depression scores among these patients who were not easily reaching health care professionals was higher. However, the depression scores of the LC patients stating that they have been informed about their disease enough by health care professionals were higher than the ones stating that they have not.

Anxiety and depression have to be examined properly while evaluating cancer-related symptoms and findings. Anxiety and depression are one of the problems frequently observed among LC patients but are not given enough importance. Psychologic problems are related with bad progression and a low quality of life among advanced cancer patients and may have unfavorable effects on treatment decisions.[23] Depression among advanced cancer patients is related with high symptom load.[24] Therefore, psychological screening and proper intervention are important parts of advanced cancer care.[25],[26] According to our results, the LC patients who were evaluated by a psychiatrist had higher anxiety and depression score than the ones who did not. We therefore think that only the patients who require psychiatric support because of anxiety and depression have to be referred to psychiatric evaluations.

Financial distress is one of less studied cancer-related symptoms, and there are a limited number of studies explaining the impact on the quality of life of cancer patients.[27],[28] We found no relationship between depression and anxiety scores because of disease-caused income loss and expense increase.

A lower basic performance status in ECOG and availability of depression and anxiety were found to be remarkably irrelevant with worse pain and life quality results.[29],[30] In our study, we also observed that depression and anxiety rates were higher in the poor performance status.

Limitations

Having the questionnaire data based on statements of the patients can be considered as a limitation of our study. The heterogeneity of the control group that included various cancer types can be another limitation.


 > Conclusions and implementations Top


This study suggested that for a cancer patient, declaration of requirement for assistance and care in daily life can be an important indication for anxiety and depression. Patients in the lung cancer group have been informed less and reaching health care professionals less when compared with other cancers. However, having higher depression both among the patients not reaching to health care professional and among the ones being informed enough was seen as a dilemma within itself. However, this situation is evaluated as an important finding from the point of reflecting chaotic psychology that lung cancer patients were into and difficulties to manage such a course. There was no relationship between depression and anxiety scores because of disease-caused income loss and expense increase. Lung cancer patients frequently face up with anxiety and depression by an impaired performance status other than financial restrictions. Lung cancer patients, especially those informed by health care professionals and provided psychosocial support following the information, require a patient-specific professional management approach.

Acknowledgements

The authors would like to thank Ankara Oncology Hospital Radiotherapy department healthcare workers for their providing the support during the preparation of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
White N. Handbook of Epictetus. Indianapolis: Hackett; 1983.  Back to cited text no. 1
    
2.
Wang YH, Li JQ, Shi JF, Que JY, Liu JJ, Lappin JM, et al. Depression and anxiety in relation to cancer incidence and mortality: A systematic review and meta-analysis of cohort studies. Mol Psychiatry 2020;25:1487-99.  Back to cited text no. 2
    
3.
Yan X, Chen X, Li M, Zhang P. Prevalence and risk factors of anxiety and depression in Chinese patients with lung cancer: A cross-sectional study. Cancer Manag Res 2019;11:4347-56.  Back to cited text no. 3
    
4.
He Y, Jian H, Yan M, Zhu J, Li G, Lou VWQ, et al. Coping, mood and health-related quality of life: A cross-sectional study in Chinese patients with advanced lung cancer. BMJ Open 2019;9:e023672.  Back to cited text no. 4
    
5.
Janssens A, Derijcke S, Galdermans D, Daenen M, Surmont V, Droogh ED, et al. Prognostic understanding and quality of life in patients with advanced lung cancer: A multicenter study. Clin Lung Cancer 2019;20:e369-75.  Back to cited text no. 5
    
6.
Polański J, Chabowski M, Chudiak A, Uchmanowicz B, Janczak D, Rosińczuk J, et al. Intensity of anxiety and depression in patients with lung cancer in relation to quality of life. Adv Exp Med Biol 2018;1023:29-36.  Back to cited text no. 6
    
7.
Turkish Thoracic Society: The Guideline of Diagnosis and treatment in Lung Cancer. 2006.  Back to cited text no. 7
    
8.
Gu W, Xu YM, Zhong BL. Health-related quality of life in Chinese inpatients with lung cancer treated in large general hospitals: Across-sectional study. BMJ Open 2018;8:e019873.  Back to cited text no. 8
    
9.
Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JW, Comber H, et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. Eur J Cancer 2013;49:1374-403.  Back to cited text no. 9
    
10.
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108.  Back to cited text no. 10
    
11.
Rueda JR, Solà I, Pascual A, Subirana Casacuberta M. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev 2011;2011:CD004282.  Back to cited text no. 11
    
12.
Fitch MI, Steele R. Supportive care needs of individuals with lung cancer. Can Oncol Nurs J 2010;20:15-22.  Back to cited text no. 12
    
13.
Bentley R, Hussain A, Maddocks M, Wilcock A. Occupational therapy needs of patients with thoracic cancer at the time of diagnosis: Findings of a dedicated rehabilitation service. Support Care Cancer 2013;21:1519-24.  Back to cited text no. 13
    
14.
Krishnasamy M, Wilkie E, Haviland J. Lung cancer health care needs assessment: patients' and informal carers' responses to a national mail questionnaire survey. Palliat Med 2001;15:213-27.  Back to cited text no. 14
    
15.
Steele R, Fitch MI. Why patients with lung cancer do not want help with some needs. Support Care Cancer 2008;16:251-9.  Back to cited text no. 15
    
16.
Leung B, Laskin J, Wu J, Bates A, Ho C. Assessing the psychosocial needs of newly diagnosed patients with nonsmall cell lung cancer: Identifying factors associated with distress. Psychooncology 2019;28:815-21.  Back to cited text no. 16
    
17.
Haun MW, Sklenarova H, Villalobos M, Thomas M, Brechtel A, Löwe B, et al. Depression, anxiety and disease-related distress in couples affected by advanced lung cancer. Lung Cancer 2014;86:274-80.  Back to cited text no. 17
    
18.
Hu T, Xiao J, Peng J, Kuang X, He B. Relationship between resilience, social support as well as anxiety/depression of lung cancer patients: A cross-sectional observation study. J Cancer Res Ther 2018;14:72-7.  Back to cited text no. 18
    
19.
Matthews T, Baken D, Ross K, Ogilvie E, Kent L. The experiences of patients and their family members when receiving bad news about cancer: A qualitative meta-synthesis. Psychooncology 2019;28:2286-94.  Back to cited text no. 19
    
20.
Gan Y, Zheng L, Yu NX, Zhou G, Miao M, Lu Q. Why do oncologists hide the truth? Disclosure of cancer diagnoses to patients in China: A multisource assessment using mixed methods. Psychooncology 2018;27:1457-63.  Back to cited text no. 20
    
21.
Ozdogan M, Samur M, Bozcuk HS, Coban E, Artac M, Savas B, et al. “Do not tell”: What factors affect relatives' attitudes to honest disclosure of diagnosis to cancer patients? Support Care Cancer 2004;12:497-502.  Back to cited text no. 21
    
22.
Oksüzoğlu B, Abali H, Bakar M, Yildirim N, Zengin N. Disclosure of cancer diagnosis to patients and their relatives in Turkey: Views of accompanying persons and influential factors in reaching those views. Tumori 2006;92:62-6.  Back to cited text no. 22
    
23.
Fischer IC, Cripe LD, Rand KL. Predicting symptoms of anxiety and depression in patients living with advanced cancer: The differential roles of hope and optimism. Support Care Cancer 2018;26:3471-7.  Back to cited text no. 23
    
24.
Grotmol KS, Lie HC, Loge JH, Aass N, Haugen DF, Stone PC, et al. Patients with advanced cancer and depression report a significantly higher symptom burden than non-depressed patients. Palliat Support Care 2018;10:1-7.  Back to cited text no. 24
    
25.
Choi S, Ryu E. Effects of symptom clusters and depression on the quality of life in patients with advanced lung cancer. Eur J Cancer Care (Engl) 2018;27. doi: 10.1111/ecc.12508.  Back to cited text no. 25
    
26.
Kang HL, Chen VC, Hung WL, Hsiao HP, Wang WH. Preliminary comparison of neuropsychological performance in patients with non-small-cell lung cancer treated with chemotherapy or targeted therapy. Neuropsychiatr Dis Treat 2019;15:753-61.  Back to cited text no. 26
    
27.
Barbaret C, Delgado-Guay MO, Sanchez S, Brosse C, Ruer M, Rhondali W, et al. Inequalities in financial distress, symptoms, and quality of life among patients with advanced cancer in France and the U.S. Oncologist 2019;24:1121-7.  Back to cited text no. 27
    
28.
Barbaret C, Brosse C, Rhondali W, Ruer M, Monsarrat L, Michaud P, et al. Financial distress in patients with advanced cancer. PLoS One 2017;12:e0176470.  Back to cited text no. 28
    
29.
Jeon HJ, Shim EJ, Shin YW, Oh DY, Im SA, Heo DS, et al. Discrepancies in performance status scores as determined by cancer patients and oncologists: Are they influenced by depression? Gen Hosp Psychiatry 2007;29:555-61.  Back to cited text no. 29
    
30.
Maximiano C, López I, Martín C, Zugazabeitia L, Martí-Ciriquián JL, Núñez MA, et al. An exploratory, large-scale study of pain and quality of life outcomes in cancer patients with moderate or severe pain, and variables predicting improvement. PLoS One 2018;13:e0193233.  Back to cited text no. 30
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

 
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