Abstract
Objective:
Patients' anxiety and stress levels are increased after the surgery. High levels of anxiety and stress could increase postoperative complications, as well as to prolong postoperative hospitalization and postoperative morbidity. This prospective, cross-sectional study was to evaluate the preoperative stress levels in patients undergoing breast cancer surgery.
Methods:
In the study participated 165 female patients who underwent breast cancer surgery, in a major oncological hospital in Greece. Demographic and clinical data were collected, and anxiety and stress levels assessed using the State-Trait Anxiety Inventory (STAI) Scale, which was a self-report questionnaire consisting of 40, 4 Likert Scale questions. The first 20 questions, STAI-X-1, were concerned to how the patient felt while answering the questionnaire (anxiety as a condition) and the remaining 20 questions, STAI-X-2, based on how the patient felt overall (stress as a personality trait). Descriptive statistics and nonparametric tests were performed at a significance level alpha = 0.05.
Results:
In the present study, 165 females were enrolled who underwent breast cancer surgery. The mean age of the participants was 55.86 years, whereas the mean body mass index was 26.85. The 60.6% of patients underwent a lumpectomy and 28.5% had mastectomy. The 35.8% experienced moderate levels of anxiety, and the 17.6% experienced high levels. The two scales were positively correlated (rho = 0.643, P < 0.001), at the significance level P = 0.01. Furthermore, the Stai-X-2 Scale was negatively correlated with body height (rho = −0.1188, P = 0.016).
Conclusions:
The present study showed that patients' personality influenced their anxiety levels. Thus, the role of the nurse is a cornerstone in their psychological support preoperatively, to reduce the anxiety and stress levels.
Keywords: Preoperative Stress and State-trait Anxiety Inventory Scale, preoperative stress, Stress Levels and State-Trait Anxiety Inventory Scale
Introduction
Patients, who undergo surgery, have increased anxiety and stress levels.[1] In fact, the effects of this problem can be observed in all aspects of patient's hospitalization, with implications on his recovery after the surgery. This concern, though it may be expected, should be considered harmful as the chances of increased postoperative complications, as well as prolonged postoperative hospitalization and morbidity are possible.[1]
During the preoperative phase, patients are exposed to various stressful situations and this can lead to higher stress levels, both intraoperatively and postoperatively. The impact can be large, with physical and mental consequences.[2] Furthermore, the ability to return to daily activities and their quality of life after the surgery might be influenced.[3] Higher preoperative stress levels have been associated with the high levels of postoperative pain, leading to increased need for analgesics.[4] In general, higher levels of preoperative anxiety are an inhibitory factor in the postoperative recovery of the patient.[5]
Many metaanalyses have shown that the prevalence of anxiety reaches 10% in oncological patients.[6] Similarly, in 2013, these numbers were lower and reached the 7%.[7] It is important to be mentioned that the majority of patients with high-depression levels express anxiety symptoms.[8] While, 9% of patients with breast cancer appears to have high depression levels.[9,10] Studies have explored the postoperative anxiety levels of patients with breast cancer or the anxiety levels of caregivers of these patients.[11]
Breast cancer is the most common cancer among women, with psychological, occupational and social consequences.[12] This prospective, cross-sectional study was to evaluate the preoperative stress levels in patients undergoing breast cancer surgery. Diagnosis and treatment, as well as the consequences on women's everyday life, are often severe. Nurses' ultimate goal is interventions to reduce anxiety levels, preoperatively, and promote postoperative recovery of patient.
Methods
The present study was a prospective, cross-sectional study. It was performed at a major Oncological Hospital in Greece July–September 2019. The research protocol was submitted for the approval to the Scientific Council of the hospital. Patients were signed the informed consent. In the study was participated patients (one arm) with breast cancer, treated with surgery. The questionnaire was filled in 1 day before the surgery.
Anxiety levels were assessed with State-Trait Anxiety Inventory (STAI) Scale.[13] This is a self-report questionnaire consisting of 40 questions. The first 20 questions, STAI-X-1, referred to how the patient felt while answering the questionnaire (anxiety as a condition), whereas the remaining 20 questions, STAI-X-2, referred to how the patient felt overall (anxiety as a personality trait). The scale is a 4-point Likert scale. The scale has been validated in Greek by Liakos and Giannitsi[14] and the Cronbach's a scale reliability and validity index are:
STAI-X1 scale a = 0.938
STAI-X2 scale a = 0.8 With Cronbach's values a >0.7 to be considered satisfactory.
The demographic data were included age, family status, education level, and profession. As well, clinical data were collected, such as body mass index (BMI), body height, and body weight. Statistical analysis was performed using the SPSS version 22.0 Statistical Software package (IMSS SPSS software, Chicago, Illinois, USA). Significant level was P < 0.05. The variables were tested for their distribution and nonparametric tests were used rho (Mann–Whitney test, and Spearman rho), whereas parametric tests (t-test) were used if normal distribution was followed. The results are expressed as mean (Standard deviation). To avoid Type I error, Bonferroni correction was used for multiple comparisons according to the significant level 0.05/k (k = number of comparisons). The demographic data were analyzed as nominal variables, except the age that it was analyzed as scale variable.
Results
The final sample of the study consisted of 165 consecutive female patients who had undergone breast surgery. Patient demographic and clinical data are presented in Table 1. The mean age of the patients was 55.86 years, whereas the mean BMI was 26.85. Whereas, Table 2 presents patients' daily habits, preoperatively, and Table 3 shows the results of the STAI-X1 and STAI-X2 scale.
Table 1.
Patients’ demographic and clinical data (n=165)
| Anthropometric data | Mean (SD) |
|---|---|
| Age (years) | 55.86 (12.88) |
| Body weight (kg) | 71.37 (12.69) |
| Body height (cm) | 163.41 (5.89) |
| BMI (kg/m2) | 26.85 (5.36) |
| Demographic data | n (%) |
| Family status | |
| Single | 27 (16.4) |
| Married | 102 (61.8) |
| Divorced | 19 (11.5) |
| Widow | 17 (10.3) |
| Education level | |
| Preliminary | 47 (28.5) |
| High school | 67 (40.6) |
| University degree | 51 (30.9) |
| Profession | |
| Unemployed | 64 (38.8) |
| Free lancer | 20 (12.1) |
| Private employee | 53 (32.1) |
| Public employee | 28 (17) |
| Smoking | |
| No | 102 (61.8) |
| Yes | 63 (38.2) |
| Heredity | |
| No | 57 (34.5) |
| Yes | 108 (65.5) |
| Kind of surgery | |
| Biopsy | 4 (2.4) |
| Lumpectomy | 100 (60.6) |
| Partial mastectomy | 7 (4.2) |
| Mastectomy | 47 (28.5) |
| Double mastectomy | 1 (0.6) |
| Mastectomy + breast reconstruction | 6 (3.6) |
Table 2.
Patients’ daily habits (n=165)
| Daily habits | n (%) |
|---|---|
| How many times do you eat fast food, the week? | |
| Once | 105 (63.6) |
| Twice | 34 (20.6) |
| Three times | 18 (10.9) |
| >3 | 8 (4.8) |
| How often do you go to the gym, the week? | |
| No | 115 (69.7) |
| Little | 39 (23.6) |
| A lot | 11 (6.7) |
| Do you receive contraceptives? | |
| No | 142 (86.1) |
| Yes | 23 (13.9) |
Table 3.
State-Trait Anxiety Inventory-X1 and State-Trait Anxiety Inventory-X2 scores (n=165)
| STAI’ s Total Score | n (%) |
|---|---|
| STAI-X1 scale | |
| Somewhat | 77 (46.7) |
| Moderately so | 59 (35.8) |
| Very much so | 29 (17.6) |
| STAI-X2 scale | |
| Sometimes | 85 (51.5) |
| Often | 76 (46.1) |
| Almost always | 4 (2.4) |
STAI: State-Trait Anxiety Inventory
The two scales correlated positively with rho = 0.643, P < 0.001, at significant level P = 0.01, as well both scales were positively correlated with age, meaning that older patients showed higher levels of anxiety, more specifically STAI-X1 rho = 0.153, P = 0.049. Moreover, STAI-X2 rho = 0.319, P < 0.001, respectively. The STAI-X2 scale was negatively correlated with body height, rho = –0.1188, P = 0.016. Whereas, it was positively correlated with body weight and BMI, rho = 0.215, P = 0.006 and rho = 0.2271, P < 0.001, respectively.
The STAI-X2 scale was correlated with the number of times the patient was exercised, occupation, marital status, and education. Specifically, patients who did not exercise (16.97%) showed higher levels of anxiety (P = 0.001), whereas patients who were unemployed (23%) showed the moderate levels of anxiety (P = 0.009). At the same time, patients who were primary school graduates (17.58%) and secondary education graduates (19.39%) had moderate levels of anxiety (P = 0.016). Finally, patients who were married (27.27%) had the moderate levels of anxiety (P = 0.022).
Discussion
The present study observes and evaluates the preoperative levels of anxiety in patients undergoing breast cancer surgery. It was a prospective study with cross-sectional comparisons. It focuses on assessing the preoperative anxiety levels. The benefit of the present study remarks the use of more objective tools for better evaluation of preoperative stress levels. Anxiety assessment and the immediate response by health professionals will help to reduce it.
Initially, the study showed that patients' personality influenced their anxiety levels. Patients with high preoperative anxiety levels also reported as personalities with high levels of anxiety. Data are consistent with international bibliography. A study by İzci et al. found that patients with breast cancer and those with extroversion personality features had lower levels of anxiety and depression, maintaining a better quality of life, whereas patients with higher scores on anxiety levels may have lower levels of anxiety and quality of life. Therefore, the psychological support of breast cancer patients during and after the treatment cannot be excluded (P < 0.05).[15]
At the same time, the present study showed that older patients had higher levels of preoperative anxiety. However, a study by Hinz et al., in cancer patients in Germany, showed that all patients, regardless of age and gender, had high levels of anxiety, whereas the anxiety levels were assessed using the Hospital Anxiety and Depression Scale.[16]
Our study found that patients with high BMI and body weight exhibited the higher levels of preoperative anxiety. The findings are in contrast to an international study, which showed that patients had higher levels of anxiety when BMI was low because of eating disorders.[17]
It is also important to note that socioeconomic factors influenced stress levels. Patients married and graduating from the primary and secondary education level reported higher levels of preoperative anxiety. Thus, data are in line with international studies. In the study of González-Mesa et al., pregnant women who were unemployed with low educational background were found to have higher levels of anxiety.[18]
Even though, there are not studies for patients undergoing breast surgery, whose preoperatively anxiety levels have evaluated and compared with demographic data, there are studies evaluating the stress levels of patients' spouses[11] or perioperatively interventions with complementary care, such as music therapy to reduce patients' anxiety levels.[19]
Conclusion
The present study showed that patients' personality related with their anxiety levels, whereas nurses' interventions are the cornerstone for their psychological support preoperatively, reducing stress and anxiety levels. Marital status and education caused moderate increased anxiety levels, whereas younger patients had decreased anxiety ones. This is important because physiological support, as well other treatments such as music and aroma therapy could help patients undergoing surgery for breast cancer to decrease their anxiety.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Pritchard MJ. Identifying and assessing anxiety in pre-operative patients. Nurs Stand. 2009;23:35–40. doi: 10.7748/ns.23.51.35.s46. [DOI] [PubMed] [Google Scholar]
- 2.Wong EM, Chan SW, Chair SY. Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma. J Adv Nurs. 2010;66:1120–31. doi: 10.1111/j.1365-2648.2010.05273.x. [DOI] [PubMed] [Google Scholar]
- 3.Kil HK, Kim WO, Chung WY, Kim GH, Seo H, Hong JY. Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Br J Anaesth. 2012;108:119–25. doi: 10.1093/bja/aer305. [DOI] [PubMed] [Google Scholar]
- 4.Hobson JA, Slade P, Wrench IJ, Power L. Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section. Int J Obstet Anesth. 2006;15:18–23. doi: 10.1016/j.ijoa.2005.05.008. [DOI] [PubMed] [Google Scholar]
- 5.Alanazi AA. Reducing anxiety in preoperative patients: A systematic review. Br J Nurs. 2014;23:387–93. doi: 10.12968/bjon.2014.23.7.387. [DOI] [PubMed] [Google Scholar]
- 6.Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. Lancet Oncol. 2011;12:160–74. doi: 10.1016/S1470-2045(11)70002-X. [DOI] [PubMed] [Google Scholar]
- 7.Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, et al. The global prevalence of common mental disorders: A systematic review and meta-analysis 1980-2013. Int J Epidemiol. 2014;43:476–93. doi: 10.1093/ije/dyu038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Smith HR. Depression in cancer patients: Pathogenesis, implications and treatment (review) Oncol Lett. 2015;9:1509–14. doi: 10.3892/ol.2015.2944. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Walker J, Hansen CH, Martin P, Symeonides S, Ramessur R, Murray G, et al. Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: A cross-sectional analysis of routinely collected clinical data. Lancet Psychiatry. 2014;1:343–50. doi: 10.1016/S2215-0366(14)70313-X. [DOI] [PubMed] [Google Scholar]
- 10.Pitman A, Suleman S, Hyde N, Hodgkiss A. Depression and anxiety in patients with cancer. BMJ. 2018;361:1–6. doi: 10.1136/bmj.k1415. [DOI] [PubMed] [Google Scholar]
- 11.Hoellen F, Wagner JF, Lüdders DW, Rody A, Banz-Jansen C. Anxiety in caregiving partners of breast cancer patients. Arch Gynecol Obstet. 2019;300:993–1005. doi: 10.1007/s00404-019-05253-2. [DOI] [PubMed] [Google Scholar]
- 12.De Mil R, Guillaume E, Launay L, Guittet L, Dejardin O, Bouvier V, et al. Cost-effectiveness analysis of a mobile mammography unit for breast cancer screening to reduce geographic and social health inequalities. Value Heal. 2019;22:1111–8. doi: 10.1016/j.jval.2019.06.001. [DOI] [PubMed] [Google Scholar]
- 13.Spielberg CD. Manual for the Stale-Trait Anger Expression Inventory (STAXI) Odessa: FL Psychol Assess Resour; 1988. [Google Scholar]
- 14.Liakos A, Giannitsi S. Reliability and validity of modified spielberger greek anxiety scale. Brain. 1984;21:71–6. [Google Scholar]
- 15.İzci F, Sarsanov D, Erdogan Zİ, İlgün AS, Çelebi E, Alço G, et al. Impact of personality traits, anxiety, depression and hopelessness levels on quality of life in the patients with breast cancer. Eur J Breast Heal. 2018;14:105–11. doi: 10.5152/ejbh.2018.3724. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hinz A, Yorck P, Florian H, Joachim L, Faller H, Brähler E, et al. Age and gender differences in anxiety and depression in cancer patients compared with the general population. Eur J Cancer Care (Engl) 2019;28:1–11. doi: 10.1111/ecc.13129. [DOI] [PubMed] [Google Scholar]
- 17.Levinson CA, Sala M, Murray S, Ma J, Rodebaugh TL, Lenze EJ. Diagnostic, clinical, and personality correlates of food anxiety during a food exposure in patients diagnosed with an eating disorder. Eat Weight Disord. 2019;24:1079–88. doi: 10.1007/s40519-019-00669-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.González-Mesa E, Kabukcuoglu K, Körükcü O, Blasco M, Ibrahim N, Cazorla-Granados O, et al. Correlates for state and trait anxiety in a multicultural sample of Turkish and Spanish women at first trimester of pregnancy. J Affect Disord. 2019;249:1–7. doi: 10.1016/j.jad.2019.01.036. [DOI] [PubMed] [Google Scholar]
- 19.Palmer JB, Lane D, Mayo D, Schluchter M, Leeming R. Effects of music therapy on anesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancer diagnosis and treatment: A randomized controlled trial. J Clin Oncol. 2015;33:3162–8. doi: 10.1200/JCO.2014.59.6049. [DOI] [PMC free article] [PubMed] [Google Scholar]