Latent Profiles of Illness Cognition and Their Associations with Postoperative Symptom Burden Among Patients with Esophageal Cancer After Minimally Invasive Esophagectomy: A Multicentre Cross-Sectional Study

Abstract

Purpose

To identify latent profiles of illness cognition among esophageal cancer patients during the early postoperative period following minimally invasive esophagectomy, and to examine differences in postoperative symptom experiences across these profiles.

Patients and Methods

A total of 405 patients were recruited from the thoracic surgery departments of three hospitals in Anhui Province. A general information questionnaire, the Illness Cognition Questionnaire, and the Convalescent Symptom Assessment Scale for Esophagectomy Patients were used. Latent profile analysis was used to identify distinct profiles and to compare symptoms across profiles.

Results

Four distinct illness cognition profiles were identified: helplessness-dominant group (13.1%), high helplessness-adaptive cognition group (43.7%), moderate cognition group (24.2%) and adaptive cognition-dominant group (19.0%). The influencing factors of four latent profiles of illness cognition included residential status, education status, work status, tumor location, and anastomotic site. The adaptive cognition-dominant group reported lower late recovery symptom scores than the high helplessness-adaptive cognition group and moderate cognition group, and lower psychosocial symptom scores than all other groups. However, no significant differences were observed among the groups in terms of early recovery symptoms and persistent present symptoms.

Conclusion

Illness cognition among esophageal cancer patients in the early postoperative period following MIE is heterogeneous and differentially associated with symptom experiences. Notably, one profile was characterized by high acceptance and perceived benefits together with high helplessness, indicating that these cognitive responses may coexist. Considering illness cognition profiles together with concurrent symptom burden may provide a basis for more tailored supportive care during the early postoperative period.

Introduction

Esophageal cancer is a common malignant tumor of the digestive tract worldwide. Global cancer statistics indicate that there were 511,000 new cases of esophageal cancer and 445,000 related deaths worldwide.¹ Approximately 44% of new cases and 42% of deaths occurred in China.² Although advances in surgical techniques, chemoradiotherapy, and targeted therapy have improved survival for some patients, the overall prognosis remains poor. The five-year survival rate for patients with esophageal cancer in China is only 27.9%.³ Surgical resection remains the primary curative treatment for patients with resectable esophageal cancer. With advances in minimally invasive surgical techniques and perioperative care, minimally invasive esophagectomy (MIE) has been increasingly adopted and is associated with reduced surgical trauma and faster postoperative recovery.⁴ Nevertheless, patients undergoing MIE commonly experience symptoms such as fatigue, productive cough, and anxiety, which may interfere with recovery.⁵ The early postoperative period after MIE represents a clinically distinct and unstable phase of recovery. During this period, patients are recovering from anesthesia, experiencing acute postoperative pain, and adapting to multiple indwelling devices, including nasogastric and chest drainage tubes.^6,7 Oral intake has generally not resumed, swallowing function remains impaired, and enteral or parenteral nutritional support is often required. Mobility may also be restricted, while physical symptoms can change rapidly during recovery. Previous studies suggest that this period is associated with particularly high symptom burden and pronounced physical and psychological vulnerability among patients with esophageal cancer.^8,9 Patients must not only cope with persistent physical discomfort but also process and interpret their illness experiences and the immediate consequences of surgery.¹⁰ Therefore, the early postoperative period provides a clinically relevant window for assessing illness cognition during the initial stage of recovery.

Illness cognition refers to patients’ cognitive appraisal and reappraisal of illness-related stress, reflecting how individuals interpret the aversive meaning of illness and incorporate it into psychological adjustment.¹¹ In this study, illness cognition was assessed using the Illness Cognition Questionnaire (ICQ). Although initially developed in chronic illness populations, the ICQ assesses general cognitive appraisals of stress associated with illness rather than symptoms specific to any particular disease. The Chinese version of the ICQ has shown good reliability and validity among Chinese patients with cancer.¹² The ICQ has also been applied during major changes in illness and treatment, including liver transplantation and adaptation following rectal cancer treatment with a stoma.^13–15 These studies support its relevance when patients are adapting to substantial changes in illness and treatment. Illness cognition assessed during the early postoperative period may be context dependent and may evolve as recovery progresses, but it can still reflect patients’ initial appraisal of illness and postoperative challenges. Postoperative symptoms provide immediate bodily information that may be incorporated into this appraisal. However, it remains unclear whether illness cognition is associated with symptom burden among patients after MIE. Examining this association may contribute to a more complete understanding of patients’ early postoperative experiences and inform supportive care that considers both cognitive characteristics and symptom burden.

Patients at similar stages of illness and receiving comparable treatment may nevertheless differ in their cognitive responses.¹⁶ Such variation may be reflected in distinct overall response patterns across illness cognition dimensions rather than only in higher or lower scores on a single dimension. Previous research has also reported heterogeneity in psychological responses among patients with esophageal cancer.¹⁷ This suggests that latent subgroups with distinct illness cognition characteristics may exist within this population. The distribution of these profiles may also vary according to patients’ demographic and clinical characteristics.^18–20 Examining these associations may help characterize the patients represented by each profile and clarify how illness cognition patterns are distributed across different patient groups. Such differences may be particularly relevant during the early postoperative period, when patients are adapting to substantial changes associated with their illness and treatment. Therefore, the present study requires an analytical approach capable of identifying latent subgroups based on patients’ overall response patterns across illness cognition indicators.

The exclusive use of traditional analytical methods for assessing illness cognition limits our ability to discern individual-specific patterns across various dimensions and to delineate distinct psychological subgroups. Latent Profile Analysis (LPA), a statistical method that classifies latent subgroups from individual characteristics, can be applied to patients’ response patterns on multidimensional illness cognition scales to identify those with similar cognitive characteristics.²¹ The core advantage of LPA lies in its ability to uncover the latent heterogeneous structure within a population, rather than treating all patients as a homogeneous entity. In recent years, LPA has been extensively applied in psychological and behavioral research among patients with chronic diseases and cancer. By applying LPA, this study identified distinct subtypes of patients’ illness cognition, thereby informing targeted interventions.

Therefore, this study aimed to: (1) identify latent profiles of illness cognition among patients with esophageal cancer during the early postoperative period following MIE; (2) explore the demographic and clinical characteristics of patients with different illness cognition profiles; (3) compare differences in postoperative symptoms reported by patients with varying illness cognition profiles. By characterizing illness cognition profiles and their concurrent associations with symptom experiences, this study may provide evidence for supportive care that considers both cognitive characteristics and symptom burden.

Methods

Aim

The aim of this study was to identify latent profiles of illness cognition among patients with esophageal cancer during the early postoperative period following minimally invasive esophagectomy and to explore the associations between these profiles and concurrent postoperative symptoms.

Study Design and Participants

A multicentre cross-sectional study was designed. We recruited a convenience sample of esophageal cancer patients from the thoracic surgery departments of three Grade A Tertiary hospitals in Anhui Province from August 2022 to August 2023. The inclusion criteria were as follows: (1) pathologically confirmed diagnosis of esophageal cancer; (2) age ≥ 18 years; and (3) were informed about the study and agreed to participate voluntarily. The exclusion criteria were as follows: (1) did not undergo minimally invasive esophagectomy; (2) history of psychiatric disorders; (3) presence of severe cognitive or hearing impairments; and (4) inability to complete the questionnaires independently. Based on the sample size requirements for Latent Profile Analysis,²² each profile should comprise at least 50 participants. Given the anticipated 2 to 5 latent classes, a sample size between 100 and 250 is required. Accounting for an anticipated 20% nonresponse or incomplete questionnaire rate, a minimum of 125 to 313 participants was required. Consequently, a total of 405 patients were included in the final analysis.

Data Collection

Researchers recruited eligible patients from the wards by sending them study invitations. After the study aims were explained and written informed consent was obtained, participants completed a paper questionnaire during postoperative days 1–3. Following uniform training, data were collected by two researchers. Researchers immediately checked all items upon participant completion to verify questionnaire completeness. The questionnaires took approximately 15–20 minutes to complete. A total of 469 patients were assessed for eligibility. Of these, 64 were excluded, leaving 405 patients for the final analysis. The participant selection process is shown in Figure 1.

Figure 1.

Flow diagram of participant selection.

Measures

General Information Questionnaire

The study utilized a self-designed general information questionnaire, encompassing both demographic variables and disease-related variables. Demographic variables encompassed age, sex, residential status, educational status, and work status. Disease-related variables included disease stages, tumor location, anastomotic site, comorbidity and complications.

Illness Cognition Questionnaire (ICQ)

This questionnaire was originally developed by Evers¹¹ and was subsequently translated into Chinese by Han.¹² This questionnaire is designed to assess cancer patients’ illness cognition across various psychological dimensions. The ICQ comprises 18 items across three distinct subscales: Helplessness, Acceptance, and Perceived Benefits. Each subscale consists of 6 items and is scored independently. Responses are recorded on a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). The total score for each subscale ranges from 6 to 24. The helplessness dimension assesses patients’ negative feelings about the adverse changes caused by their illness. In contrast, acceptance and perceived benefits reflect adaptive cognition by reducing the aversive meaning of illness or attributing positive meaning to the illness experience. A higher score reflects a stronger presence of the perception measured by each dimension. The Cronbach’s α coefficients for the three subscales ranged from 0.855 to 0.878.

Convalescent Symptom Assessment Scale for Esophagectomy Patients (CSAS_EC)

This scale was developed by our research team to assess the presence and severity of symptoms in patients recovering from esophagectomy.²³ Patients were asked to rate the symptoms they had experienced during the preceding 24 hours. It comprises four dimensions with a total of 28 items: eight for early recovery symptoms, eight for late recovery symptoms, six for persistent present symptoms, and six for psychosocial symptoms. Each symptom is rated on a scale from 0 to 10, with higher scores indicating greater severity. The severity levels are categorized as follows: 0–3 for mild, 4–6 for moderate, and 7–10 for severe. The scale demonstrated good internal consistency with a Cronbach’s alpha of 0.827.

Data Analysis

Statistical analysis was performed using SPSS software (version 23.0). Categorical variables were summarized as frequencies and percentages, whereas normally distributed continuous variables were presented as means ± standard deviations (SDs). The chi-square test or Fisher’s exact test, multinomial logistic regression, and general linear models were applied as appropriate. General linear models were adjusted for relevant demographic and clinical covariates, with results reported as estimated marginal means ± standard errors and partial η². Bonferroni correction was applied to pairwise comparisons. All tests were two-sided, and P < 0.05 was considered statistically significant.

Latent profile analysis was performed on the 18 ICQ items using Mplus version 8.3. The 18 ICQ items were treated as continuous indicators, and the models were estimated using robust maximum likelihood estimation (MLR) to reduce the potential influence of non-normal item distributions. Only questionnaires with complete ICQ data were included in the LPA; therefore, no missing values were present for the LPA indicators. For each model, 200 random sets of starting values were generated, and the best 10 solutions were retained for final-stage optimization to reduce the risk of convergence on local maxima. Model convergence was confirmed by replication of the best log-likelihood value across random starts, which was achieved for all retained models. The models were specified under the local independence assumption. The model fit was evaluated using the following indices: the Akaike Information Criterion (AIC), the Bayesian Information Criterion (BIC), and the sample-adjusted Bayesian Information Criterion (aBIC). In addition, the Lo-Mendell-Rubin (LMR) likelihood ratio test and the Bootstrapped Likelihood Ratio Test (BLRT) were employed to compare the differences in fit between the competing models.²⁴ The aforementioned evaluation indices serve primarily to inform the selection of the optimal number of latent classes. Once the best-fitting model is identified, the final class solution should be determined by considering whether the classes are substantively distinct and each comprises a sufficient proportion of the sample (typically ≥10%).²⁵

Results

Patient Characteristics in Post-MIE Esophageal Cancer Patients

A total of 469 patients with esophageal cancer were assessed, of whom 405 patients who underwent MIE were included in the final analysis and 64 were not included. Among the included patients, 320 (79.0%) were male and 85 (21.0%) were female, with a mean age of 67.1 years (SD = 8.8). Demographic characteristics revealed that 238 patients (58.8%) resided in rural areas, 288 (71.1%) had an education level of primary school or below, and 287 (70.9%) were unemployed. Regarding disease-related variables, the tumor was located in the mid-section for 226 patients (55.8%), and 269 (66.4%) had a cervical anastomosis. Comorbidities were present in 211 patients (52.1%), and 23 (5.6%) experienced postoperative complications. No statistically significant differences were found in the measured demographic and clinical characteristics between the included and non-included patients (all P > 0.05). Detailed data are presented in Table 1.

Table 1.

Comparison of Baseline Characteristics Between Included and Non-Included Patients

Characteristics	Classifications	Included Patients (n = 405)	Non-Included Patients (n = 64)	χ2	P
Age, n (%)	≤ 60	91 (22.5)	10 (15.6)	1.648	0.439
	60–70	132 (32.6)	24 (37.5)
	≥ 70	182 (44.9)	30 (46.9)
Sex, n (%)	Male	320 (79.0)	56 (87.5)	2.504	0.114
	Female	85 (21.0)	8 (12.5)
Residential status, n (%)	Urban*	167 (41.2)	23 (35.9)	0.643	0.422
	Rural	238 (58.8)	41 (64.1)
Education status, n (%)	Primary or none	288 (71.1)	46 (71.9)	0.016	0.900
	Secondary or above	117 (28.9)	18 (28.1)
Work status, n (%)	Retiree	62 (15.3)	8 (12.5)	0.886	0.642
	Unemployed	287 (70.9)	49 (76.5)
	Worker	56 (13.8)	7 (10.9)
Disease Stages, n (%)	I	92 (22.7)	13 (20.3)	0.319	0.853
	II	125 (30.9)	19 (29.7)
	III or above	188 (46.4)	32 (50.0)
Tumor location, n (%)	Upper	43 (10.6)	6 (9.3)	0.094	0.954
	Middle	226 (55.8)	36 (56.3)
	Lower	136 (33.6)	22 (34.4)
Anastomosis site, n (%)	Cervical anastomosis	269 (66.4)	46 (71.9)	0.746	0.388
	Intrathoracic anastomosis	136 (33.6)	18 (28.1)
Comorbidity, n (%)	No	194 (47.9)	35 (54.7)	1.019	0.313
	Yes	211 (52.1)	29 (45.3)
Complications, n (%)	No	382 (94.4)	59 (92.2)	0.448	0.503
	Yes	23 (5.6)	5 (7.8)

Note: *Urban residence includes both cities and towns.

LPA of Illness Cognition in Post-MIE Esophageal Cancer Patients

A latent profile analysis of the 18 illness cognition items tested models with one to five latent classes, and the fit indices are shown in Table 2. All models converged successfully, and the best log-likelihood values were replicated. As the number of classes increased from 1 to 4, the AIC, BIC, and aBIC decreased, with all entropy values above 0.8. The four-class model had the highest entropy, and both the LMR and BLRT indicated a better fit than the three-class model. Although the five-class model had lower AIC and aBIC values, its BIC was higher, the LMR test was not significant, and the smallest class accounted for only 4.0% of the sample. In addition, the fifth class did not yield a new clinically meaningful group and appeared mainly to split an existing class into a small subgroup. Therefore, the model with four latent classes was identified as the optimal latent profile model.

Table 2.

Model Fit Indices of Different Classes of Illness Cognition

Model	AIC	BIC	aBIC	Entropy	LMR(P)	BLRT(P)	Class Probability
1	17,598.406	17,742.546	17,628.313	–	–	–	–
2	16,991.070	17,211.284	17,036.762	0.826	0.0000	0.0000	0.343/0.657
3	16,652.720	16,949.008	16,714.196	0.841	0.0003	0.0000	0.338/0.222/0.440
4	16,417.336	16,789.697	16,494.597	0.875	0.0001	0.0000	0.242/0.131/0.437/0.190
5	16,361.925	16,810.360	16,454.970	0.872	0.3574	0.0000	0.040/0.180/0.227/0.415/0.138

Latent Class Characteristics and Designation of Illness Cognition in Post-MIE Esophageal Cancer Patients

The illness cognition of esophageal cancer patients after MIE could be categorized into four distinct classes. The mean scores of the items for each class are presented in Figure 2. The four groups were designated as follows: (1) helplessness-dominant group (Class 1, n = 53, 13.1%): This group was characterized by high helplessness (3.19 ± 0.29) and low acceptance (2.08 ± 0.19) and perceived benefits (2.44 ± 0.71). (2) high helplessness-adaptive cognition group (Class 2, n = 177, 43.7%): This group showed high scores across helplessness, acceptance, and perceived benefits, with an overall mean item score of 3.04 ± 0.09, indicating the coexistence of high helplessness and adaptive cognition. (3) moderate cognition group (Class 3, n = 98, 24.2%): This group showed moderate scores across all three dimensions, with an overall mean item score of 2.45 ± 0.09. (4) adaptive cognition-dominant group (Class 4, n = 77, 19.0%): This group was characterized by low helplessness (1.95 ± 0.12) and high acceptance (3.06 ± 0.07) and perceived benefits (3.27 ± 0.19), indicating that adaptive cognition was more prominent than helplessness.

Figure 2.

LPA model of illness cognition among esophageal cancer patients following MIE.

Univariate Analysis of Latent Classes in Illness Cognition in Post-MIE Esophageal Cancer Patients

Univariate analysis revealed that patients with different latent profiles of illness cognition differed significantly in five aspects: residential status, education status, work status, tumor location, and anastomotic site (P < 0.05). The results are presented in Table 3.

Table 3.

Univariate Analysis of 4 Classes of Illness Cognition (n=405)

Characteristics	Class 1 (n = 53)	Class 2 (n = 177)	Class 3 (n = 98)	Class 4 (n = 77)	χ2	P
Age					2.803	0.833
≤ 60	8 (15.1)	42 (23.7)	22 (22.4)	19 (24.7)
60–70	17 (32.1)	58 (32.8)	34 (34.7)	23 (29.9)
≥ 70	28 (52.8)	77 (43.5)	42 (42.9)	35 (45.4)
Sex					1.447	0.694
Male	39 (73.6)	141 (79.7)	80 (81.6)	60 (77.9)
Female	14 (26.4)	36 (20.3)	18 (18.4)	17 (22.1)
Residential status					8.568	0.036
Urban	14 (26.4)	69 (39.0)	48 (49.0)	36 (46.8)
Rural	39 (73.6)	108 (61.0)	50 (51.0)	41 (53.2)
Education status					13.021	0.005
Primary or none	44 (83.0)	135 (76.3)	63 (64.3)	46 (59.7)
Secondary or above	9 (17.0)	42 (23.7)	35 (35.7)	31 (40.3)
Work status					22.268*	< 0.001
Retiree	6 (11.3)	18 (10.2)	21 (21.4)	17 (22.1)
Unemployed	42 (79.2)	121 (68.4)	68 (69.4)	56 (72.7)
Worker	5 (9.4)	38 (21.5)	9 (9.2)	4 (5.2)
Disease Stages					9.086	0.169
I	18 (34.0)	29 (16.4)	25 (25.5)	20 (26.0)
II	15 (28.3)	58 (32.8)	28 (28.6)	24 (31.2)
III or above	20 (37.7)	90 (50.8)	45 (45.9)	33 (42.8)
Tumor location					17.216	0.009
Upper	6 (11.3)	23 (13.0)	8 (8.2)	6 (7.8)
Middle	36 (67.9)	101 (57.1)	42 (42.9)	47 (61.0)
Lower	11 (20.8)	53 (29.9)	48 (49.0)	24 (31.2)
Anastomosis site					44.876*	< 0.001
Cervical anastomosis	50 (94.3)	122 (68.9)	43 (43.9)	54 (70.1)
Intrathoracic anastomosis	3 (5.7)	55 (31.1)	55 (56.1)	23 (29.9)
Comorbidity					2.890	0.409
No	28 (52.8)	89 (50.3)	40 (40.8)	37 (48.1)
Yes	25 (47.2)	88 (49.7)	58 (59.2)	40 (51.9)
Complications					1.564*	0.693
No	52 (98.1)	166 (93.8)	92 (93.9)	72 (93.5)
Yes	1 (1.9)	11 (6.2)	6 (6.1)	5 (6.5)

Notes: Class 1: helplessness-dominant group; Class 2: high helplessness-adaptive cognition group; Class 3: moderate cognition group; Class 4: adaptive cognition-dominant group; *Fisher exact test; The units in parentheses are %.

Multivariate Analysis of Latent Classes in Illness Cognition in Post-MIE Esophageal Cancer Patients

We performed a multinomial logistic regression analysis to assess the associations between the independent variables and the illness cognition categories. The model included the four illness cognition categories as dependent variables and the five significant variables from univariate analysis (residential status, education status, work status, tumor location, and anastomotic site) as independent variables, using the “helplessness-dominant group” as the reference. Results are shown in Table 4.

Table 4.

Logistic Regression Analysis of Factors Influencing 4 Groups of Illness Cognition

Group	Characteristics	Classifications	B	P	OR	95% CI
						Lower Limit	Upper Limit
Class2	Residential status	Urban	0.453	0.259	1.573	0.716	3.453
		Rural
	Education status	Primary or none	−0.215	0.633	0.806	0.334	1.949
		Secondary or above
	Work status	Retiree	−1.219	0.078	0.295	0.076	1.146
		Unemployed	−0.827	0.132	0.437	0.149	1.282
		Worker
	Tumor location	Upper	0.500	0.411	1.649	0.500	5.441
		Middle	0.183	0.665	1.201	0.524	2.754
		Lower
	Anastomosis site	Cervical anastomosis	−2.147	0.001*	0.117	0.033	0.420
		Intrathoracic anastomosis
Class3	Residential status	Urban	0.768	0.085	2.155	0.899	5.169
		Rural
	Education status	Primary or none	−0.762	0.118	0.467	0.179	1.214
		Secondary or above
	Work status	Retiree	−0.018	0.981	0.982	0.215	4.490
		Unemployed	0.226	0.731	1.253	0.346	4.536
		Worker
	Tumor location	Upper	0.151	0.829	1.163	0.295	4.582
		Middle	−0.263	0.568	0.769	0.312	1.896
		Lower
	Anastomosis site	Cervical anastomosis	−2.827	< 0.001*	0.059	0.016	0.221
		Intrathoracic anastomosis
Class4	Residential status	Urban	0.726	0.111	2.067	0.847	5.047
		Rural
	Education status	Primary or none	−1.140	0.019*	0.320	0.123	0.830
		Secondary or above
	Work status	Retiree	0.582	0.496	1.789	0.335	9.566
		Unemployed	0.944	0.211	2.570	0.585	11.292
		Worker
	Tumor location	Upper	−0.089	0.904	0.914	0.214	3.911
		Middle	0.070	0.883	1.073	0.421	2.737
		Lower
	Anastomosis site	Cervical anastomosis	−1.717	0.013*	0.180	0.046	0.695
		Intrathoracic anastomosis

Notes: The helplessness-dominant group serves as the reference group; Class 2: high helplessness-adaptive cognition group; Class 3: moderate cognition group; Class 4: adaptive cognition-dominant group; *P<0.05.

Compared with patients with secondary or higher education, those with primary or no education had lower odds of being classified into Class 4 rather than Class 1 (OR = 0.320, 95% CI: 0.123–0.830, p = 0.019), indicating that lower educational attainment was associated with a greater relative likelihood of membership in Class 1. In addition, compared with patients with an intrathoracic anastomosis, those with a cervical anastomosis had lower odds of being classified into Class 2 (OR = 0.117, 95% CI: 0.033–0.420, p = 0.001), Class 3 (OR = 0.059, 95% CI: 0.016–0.221, p < 0.001), or Class 4 (OR = 0.180, 95% CI: 0.046–0.695, p = 0.013) rather than Class 1. These findings suggest that cervical anastomosis was associated with a higher relative likelihood of belonging to Class 1 than to the other three groups.

The Association Between Illness Cognition and Symptoms Reported by Post-MIE Esophageal Cancer Patients

After adjustment for demographic and clinical covariates, significant differences across profiles were observed for late recovery symptoms (F = 7.262, p < 0.001), psychosocial symptoms (F = 6.922, p < 0.001), and total symptom burden (F = 4.709, p = 0.003). Bonferroni-adjusted comparisons showed that Class 4 had lower late recovery and total symptom scores than Class 2 and Class 3, and lower psychosocial symptom scores than Class 1, Class 2, and Class 3. No significant differences were found for early recovery symptoms (F = 1.827, p = 0.142) or persistent present symptoms (F = 1.675, p = 0.172). The differences across the four symptom dimensions for each group are detailed in Table 5, and the variations for each specific symptom are shown in Figure 3.

Table 5.

Adjusted Symptom Burden Across Four Illness Cognition Profiles

Symptom Dimension	Class 1 Mean ± SE	Class 2 Mean ± SE	Class 3 Mean ± SE	Class 4 Mean ± SE	F	P	Partial η2	Pairwise
Early recovery symptoms	29.376±2.027	32.452±1.486	32.224±1.631	30.057±1.740	1.827	0.142	0.014	NS
Late recovery symptoms	7.230±0.902	8.139±0.661	8.418±0.726	5.492±0.775	7.262	< 0.001	0.053	C4 < C2, C3
Persistent present symptoms	17.024±1.386	16.922±1.016	16.900±1.115	14.927±1.190	1.675	0.172	0.013	NS
Psychosocial symptoms	21.738±1.882	20.394±1.379	19.926±1.513	15.095±1.615	6.922	< 0.001	0.051	C4 < C1, C2, C3
Total symptoms	75.368±4.914	77.908±3.602	77.467±3.952	65.570±4.217	4.709	0.003	0.035	C4 < C2, C3

Notes: Values are estimated marginal means ± SE. Models were adjusted for age, sex, residential status, education status, work status, disease stages, tumor location, anastomotic site, comorbidities, and complications. Pairwise comparisons were performed using Bonferroni correction. Class 1: helplessness-dominant group; Class 2: high helplessness-adaptive cognition group; Class 3: moderate cognition group; Class 4: adaptive cognition-dominant group; C1–C4 correspond to Class 1–Class 4.

Abbreviation: NS, not significant.

Figure 3.

Mean scores of individual symptoms across four dimensions by illness cognition group. Class 1: helplessness-dominant group; Class 2: high helplessness-adaptive cognition group; Class 3: moderate cognition group; Class 4: adaptive cognition-dominant group. (A–D) correspond to the four symptom dimensions, respectively: (A) early recovery symptoms; (B) late recovery symptoms; (C) persistent present symptoms; and (D) psychosocial symptoms. Difficulty swallowing and choked on drinking water were not displayed in the figure because no participants reported these symptoms during postoperative days 1–3. These two items were retained in the CSAS_EC scoring as zero and were not removed from the validated scale structure.

Discussion

This study evaluated patients’ illness cognition based on three dimensions: helplessness, acceptance, and perceived benefits. The study identified heterogeneity in illness cognition among esophageal cancer patients during the early postoperative period following MIE, which was categorized into four types: helplessness-dominant group (13.1%), high helplessness-adaptive cognition group (43.7%), moderate cognition group (24.2%) and adaptive cognition-dominant group (19.0%).

Patients in the helplessness-dominant group (Class 1) demonstrated lower levels of illness cognition in both acceptance and perceived benefits, accompanied by significant helplessness. A high proportion of patients in this group had a lower level of education (83.0%) and were from rural areas (73.6%). Previous studies have shown that patients with lower educational attainment tend to exhibit poorer coping abilities when confronted with illness.²⁶ In the early postoperative period, this group may have greater difficulty grasping key points in the recovery process due to more limited educational exposure. They may experience greater difficulty coping with postoperative changes, making them prone to feelings of helplessness. Additionally, compared to the other three groups, patients with cervical anastomoses were more likely to be classified into the helplessness-dominant group. Previous studies have shown that patients who undergo cervical anastomosis often experience severe pharyngeal pain in the early postoperative period and face a high risk of anastomotic fistula and recurrent laryngeal nerve injury.^27,28 These early discomforts and the risk of potential complications may cause patients to worry about their recovery process and feel a strong sense of helplessness, which can hinder the development of adaptive illness cognition in the early postoperative period. However, the decision to perform a cervical anastomosis is primarily determined by tumor location and surgical complexity. In clinical practice, healthcare providers could offer patients undergoing cervical anastomosis more detailed information about expected postoperative symptoms and targeted guidance on the prevention of potential complications.^29,30 Although this group reported high helplessness, elevated scores on Item 8 (“My illness has made me cherish life more”, 3.18) and Item 16 (“My illness has made me realize what is most important in life”, 2.94) suggested early signs of perceiving positive changes. In the early postoperative period, healthcare providers should proactively provide accurate, concise, and easily understandable information about the disease and recovery process, while encouraging patients to report physical discomfort and ask questions. Timely clarification and responses to these concerns may help patients develop a clearer and more adaptive understanding of their condition and support their adjustment to postoperative life.³¹

The high helplessness-adaptive cognition group (Class 2) constituted the largest proportion of patients (43.7%). Patients in this group scored high on acceptance and perceived benefits while also reporting high helplessness, indicating the coexistence of adaptive cognition and helplessness. Because the relatively positive features of their illness cognition may make the accompanying helplessness less readily recognized in routine clinical assessments, this group may be easily overlooked and therefore warrants closer attention. In terms of symptom presentation, the high helplessness-adaptive cognition group showed higher mean scores for throat pain, hoarseness, and reduced social interaction than the other three groups. Throat discomfort and hoarseness during the early postoperative period may increase the effort required to speak and interfere with normal communication. Even when symptoms are pronounced, some patients may be less likely to speak up because of the effort involved in speaking or changes in their voice.^27,32 Such reduced expression does not necessarily indicate successful adaptation and instead it may conceal the patients’ actual symptom burden and psychological distress. Thus, although patients in this group may appear to understand their condition and recognize the importance of treatment, physical discomfort and reduced social engagement may still leave them feeling isolated and helpless. In clinical practice, care for this group should extend beyond routine health education and information provision to include assessment of helplessness alongside symptom burden. Patients should be encouraged to report their symptoms and emotional concerns with timely tailored symptom management and psychological support provided when needed.³³

The moderate cognition group (Class 3) exhibited moderate levels across the three dimensions of illness cognition, without a clearly dominant illness cognition pattern. Compared with the helplessness-dominant group, patients in this group did not exhibit a pronounced sense of helplessness. However, relative to the adaptive cognition-dominant group, their understanding of the disease and postoperative condition appeared to be less well developed. Therefore, patients should not be considered low priority during the early postoperative period simply because they show no obvious negative reactions. For patients in this group, nursing care should focus on linking their existing acceptance of the illness with specific postoperative recovery tasks. Healthcare professionals can provide explanations tailored to the patient’s daily recovery status, covering fasting and dietary progression, throat discomfort, effective coughing and sputum clearance, early mobilization, and the reporting of abnormal symptoms, while offering timely feedback.^34,35 Such individualized support may help patients gradually develop a clearer understanding of their own recovery, rather than remaining at the level of general illness acceptance.

The adaptive cognition-dominant group (Class 4) demonstrated a positive illness cognition pattern, characterized by low helplessness alongside high acceptance and perceived benefits. Based on the results of the symptom assessment, the overall symptom burden in this group of patients was relatively mild. This finding may be related to the patients’ subjective evaluations of their postoperative physical changes. The burden of multiple symptoms commonly experienced by patients with esophageal cancer during the early postoperative period is often accompanied by significant declines in physical, role, and social functioning.^36–38 When multiple physiological and psychological burdens occur simultaneously, patients who perceive these physical changes as less overwhelming may experience less subjective distress from postoperative symptoms and consequently report lower symptom severity. Meanwhile the possibility that postoperative symptom experiences may in turn shape illness cognition cannot be ruled out. Patients who experience milder postoperative discomfort and a relatively smooth recovery may find it easier to accept their current condition and may be less likely to develop pronounced feelings of helplessness. Thus, this group represents an early postoperative profile characterized by the coexistence of a relatively low symptom burden and adaptive illness cognitions. Healthcare providers may offer targeted positive reinforcement to help these patients consolidate their existing positive perceptions of illness. Nevertheless, patients’ symptom fluctuations and changes in psychological status should continue to be monitored to ensure that potential discomfort and support needs are not overlooked simply because they report low levels of helplessness or appear to be adapting well overall.

This study also found differences in several postoperative symptom domains among patients with esophageal cancer across illness cognition profiles. Patients in Class 4 had lower scores for late recovery symptoms and overall symptom burden than those in Classes 2 and 3, and lower psychosocial symptom scores than patients in the other three classes. Most patients remained fasting at the time of assessment and had not yet resumed oral intake. Therefore, the items “difficulty swallowing” and “choked on drinking water” in the late recovery symptoms domain both received scores of 0. Consequently, the observed intergroup differences in this domain were primarily attributable to the remaining items. It is worth noting that patients in Class 2 also reported relatively high levels of acceptance and perceived benefits, while simultaneously showing a high level of helplessness. This suggests that positive illness cognitions and feelings of helplessness may coexist during the early postoperative period rather than being mutually exclusive. Therefore, a simple distinction between positive and negative illness cognitions may not fully explain differences in patients’ symptom experiences. This finding also adds to previous research on the relationship between distinct cognitive patterns and postoperative symptoms.^39–41 In addition, no significant differences were observed among the four groups in early recovery symptoms or persistent present symptoms. Early recovery symptoms may primarily reflect surgical trauma and postoperative physiological stress.⁴² As these symptoms are common during the early postoperative period, the influence of different illness cognition profiles on patients’ symptom experiences may not yet be fully apparent. Persistent present symptoms may more accurately reflect symptoms that were present prior to surgery or those that are more common during the perioperative course.⁴³ Similarly, their severity does not show significant differences across different types of illness cognition. Given the cross-sectional design of this study, the temporal relationship between illness cognition and symptoms cannot be established. These findings may reflect differences in symptom reporting across illness cognition profiles, but they may also indicate that patients with milder symptoms during the early postoperative period are more likely to report lower helplessness and greater acceptance and perceived benefits. Future longitudinal studies should track changes in illness cognition and symptoms over time to clarify their relationship and examine the clinical value of stratified support tailored to patients’ cognitive profiles and symptom burden.

Limitations

This study has several limitations. First, the cross-sectional design and single assessment during the early postoperative period precluded causal inference and did not allow us to determine whether the identified illness cognition profiles were stable or changed throughout recovery. Moreover, the exact postoperative day was not recorded, so potential differences within postoperative days 1–3 could not be examined. Future longitudinal studies should record the exact assessment time and conduct repeated assessments across different stages of postoperative recovery. Second, convenience sampling and the incomplete collection of potentially relevant clinical factors may have introduced selection bias and residual confounding. Future studies should use more representative sampling methods and include a broader range of perioperative variables. Third, because most patients had not resumed oral intake, the items assessing “difficulty swallowing” and “choked on drinking water” received scores of zero. Future studies should reassess these symptoms after oral intake has resumed to provide a more complete evaluation of swallowing-related recovery. Finally, although participants were recruited from three hospitals, all hospitals were located in Anhui Province. Future multicentre studies involving different regions and clinical settings are needed to verify the generalizability of the findings.

Conclusion

Illness cognition among patients with esophageal cancer during the early postoperative period following MIE showed four distinct profiles and was associated with concurrent symptom burden. Differences across profiles were observed in late recovery symptoms, psychosocial symptoms, and total symptom burden, but not in early recovery or persistent present symptoms. Notably, high acceptance and perceived benefits coexisted with high helplessness in one profile. Considering illness cognition profiles together with concurrent symptom burden may help healthcare professionals provide more appropriate supportive care during the early postoperative period.

Funding Statement

The authors did not receive support from any organization for the submitted work.

Data Sharing Statement

The datasets are not publicly available due to participant privacy considerations but are available from the corresponding author on reasonable request.

Ethics Approval and Informed Consent

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Anhui Medical University (Approval No. 84230035). Written informed consent was obtained from all participants.

Consent for Publication

All participants who took part in this study gave informed consent.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.