Anxiety and Depression Symptoms Among Ovarian Cancer Patients in Western China: A Cross-Sectional Study

Symptoms Among Ovarian Cancer Patients A Cross-Sectional Abstract Background: It is well known that cancer patients tend to have different degrees of

Meantime, the prevalence and mortality of ovarian cancer varies from different countries. It was estimated that, in the United States, 21,200 women are diagnosed with ovarian cancer, and 14,300 die from the disease each year, approximately [4]. In Australia, it was forecasted that near 1480 women would be diagnosed with ovarian cancer, and 1040 cases would die from this disease [5]. And the highest number of deaths (34,575 deaths) [6] caused by ovarian cancer were found in Asian and China, with 110,526 diagnoses. The five-year survival rate is nearly 90% in early stage, but only 30% in advanced stage [7]. However, it's difficult to diagnose ovarian cancer at early-stage(Ⅰ/Ⅱ) due to the nonspecific symptoms, and there is no recommended screening test. So, the majority of ovarian cancer patients are diagnosed at advanced stage. In Poland, as many as 42.5% of patients with adenocarcinoma were diagnosed in stage IV [8].
As the high diagnosis rate of advanced-stage and high mortality of the disease, patients who are suffering ovarian cancer have to tolerate not only physical pain, but also enormous psychological pressure and huge financial burden [9,10]. Some studies have indicated that depression and anxiety are two common types of psychological disorders in cancer patients [11][12][13]. Anxiety is often described as the emotion of fear, involving the feelings of tension, nervousness, worry, apprehension and dread for something perceived as threaten in the further. Depression has been defined as an emotion of sadness, hopelessness, lack of energy and gloom [14]. Among many types of cancer patients, the degree of anxiety in female patients was significantly higher than in male patients, and gynecological cancer patients were regarded to have the highest level of anxiety [15]. In the past, poor mental state is often regarded as a normal phenomenon accompanied by the disease, which led medical workers to ignore these symptoms. But in fact, anxiety, depression and other adverse psychological state will not only affect the patient's subjective feelings, quality of life, but also the disease progression and prognosis [16]. Especially for patients with gynecological oncology, the diseases often cause the loss of function or organism that represents female characteristics, which make the patients feel ashamed. So gynecological cancer patients are more likely to suffer from poor mental state, and interruption treatment than other cancer patients [17]. Several previous studies have shown that a monitoring coping style is related to reduce psychological impact for ovarian cancer [18,19]. So, identifying influencing factors associated with poor psychological status is important to develop appropriate target interventions for ovarian cancer patients [20,21]. Therefore, we conducted this crosssectional study to assess the prevalence of depression and anxiety in ovarian cancer patients in western China and analyze the related influencing factors.

Study Design and Recruitment Criteria
We carried out a cross-sectional study to assess the symptoms of anxiety and depression among ovarian cancer patients and the

Measurements of Anxiety and Depression Symptoms
We adopted Hospital Anxiety and Depression Scale (HADS) [22] to measure the degree of anxiety and depression symptoms. This 14-item questionnaire includes two subscales, anxiety subscales (seven items) and depression subscales (seven items). Responses for each question range from 0 to 3 (0=completely not; 1= a little; 2=somewhat and 3=very much). The total score point ranges from 0 to 21. The higher of the score, the severe of anxiety and depression symptom is. The score "less than 8" is within normal range, "8-10" suggests a possible clinical anxiety or depression and "over 10" indicates a probable anxiety or depression mood disorder. The instrument has been widely used in China with sufficient reliability.
The internal reliability alpha valued for the symptoms of anxiety and depression were 0.828 and 0.901 respectively in the current study.

Measurement of Coping Style
Coping style was measured by the 20-item Simplified Coping Style Questionnaire (SCSQ) [23]. Each item is rated as four-point

Statistical Analysis
According to the epidemiology of sample size estimates, the required sample size is 10 times of the research factors and the number of related factors in our study is 10. Meantime consider about the 20% loss rate; 120 participants are needed to be enrolled.
Pre-survey showed that the prevalence of cancer-related anxiety and depression were about 50%, the actual sample should be more than 240 cases. The survey data were entered into Epidata, and specialized software was used for managing data. This program facilitates interactive entry and data correction and maintains consistent and accurate trial data. SPSS 17.0 software package was used for statistical analyses. Chi-square test or T test was used to analyze the statistical differences of qualitative data. Significance was set at P<0.05. In the multivariate analysis, binary logistic regression analysis was used and odds ratios (OR) with 95% confidence intervals (CI) were calculated.

The Prevalence of Cancer-Related Depression and Anxiety
The prevalence of cancer-related depression was 47.03% and cancer-related anxiety was 57.77% among the 270 ovarian cancer patients. Approximately 90.38% of cancer-related anxiety and 91.33% of cancer-related depression were both mild ( Table 2).

Associations of Demographic and Clinical Variables with Symptoms of Depression and Anxiety
As shown in

Discussion
The main findings of this population-based cross-sectional study were that a) The prevalence of ovarian cancer-related depression was 47.03% while the prevalence of cancer-related anxiety was 57.77% in western Chinese patients with ovarian cancer.
Approximately 91.33% of ovarian cancer-related depression was slight and 90.38% of cancer-related anxiety was mild.
b) There were statistically significant differences in education level, income and coping style on ovarian cancerrelated depression and anxiety. c) The multivariate analysis showed that education and coping style were the independent influencing factors of cancer-related depression and anxiety.
Chun Li Liu [12] found that the prevalence of ovarian cancerrelated depression was 47% and the anxiety was 51.5%, which was similar to the present study. But Price M A [24] performed a prospective cohort study which enrolled 798 Australian ovarian cancer patients and reported that the clinical anxiety was 15% and depression was only 5.9%. And a meta-analysis indicated that the prevalence of symptoms of depression and anxiety in Chinese cancer patients was 54.90% and 49.69% [25], respectively, which was not limited to ovarian cancer. Moreover, a systematic review has shown that the prevalence of depression and anxiety in women with ovarian cancer is significantly greater than healthy female [26]. Therefore, it suggests that the Chinese ovarian cancer patients have relatively higher levels of anxiety and depression. Besides, in our study, ovarian cancer-related anxiety level was slightly higher than depression level. It is consistent with the results of Mielcarek P [27] in 2016, which also found that the level of anxiety was higher than depression in patiens from Poland with advanced ovarian cancer, and the prevalence of pathological anxiety was the highest(74%) prior to surgery. All the patients participated in our study were advanced stage of ovarian cancer, too. Another study [28] showed that the prevalence of depression in Chinese patients In the study, we found that ovarian cancer-related depression and anxiety are associated with education level, income and coping style. Education and coping style were the independent influencing factors. Binary logistic regression analysis showed that the factors associated with ovarian cancer-related depression were education level, active style and negative style. And cancer-related anxiety was also associated with education level, active style and negative style.
Liu CL [12] found ovarian cancer patients with the higher education levels were tended to have a lower prevalence of cancer-related depression. But another study [30] reported the opposite result which were consistent with the findings of our study. The reason may be that the patients with higher educational levels often took the initiative to get knowledges of cancer relevant information, but the poor prognosis of ovarian cancer gave rise to the symptoms of depression and anxiety. Patients with lower educational levels were tended to dependent on medical institutions and medical staff more and cooperate with the diagnosis and treatment actively. Wang hong-qiao [31] found that the symptoms of depression and anxiety in ovarian cancer patients were positively correlated with negative coping and negatively correlated with positive coping which were consistent with the findings of our study. The reason may be that coping style has played a regulatory and mediating role between stress and psychological response. Previous studies [32] have shown that patients who actively coping with problems are prone to optimism emotion. Several studies have provided evidence for the influence of positive psychological factors in cancer patients [33][34][35], and a meta-analysis [36] have shown that psychological intervention can significantly reduce the anxiety and depression of ovarian cancer patients. This means that clinical staffs should make more efforts to provide health education on coping style and psychological intervention to ovarian cancer patients.

Limitations
Our study has several limitations. Firstly, we didn't compare the differences of anxiety and depression levels in patients with early and advanced ovarian cancer and explore the associations between the psychological and stage of ovarian cancer. Secondly, we only focused on the symptoms of depression and anxiety, other psychological disorders, such as post-traumatic stress disorders, obsession and inferiority, have not been investigated. Thirdly, the study adopted convenient sampling method and conducted in only one hospital, the extrapolation of research results was limited. So, additional well-designed studies with multi-center and rigorous methodologies are required.

Conclusion
Our findings highlight that about half of ovarian cancer patients suffered from cancer-related depression and anxiety, more than 90% of depression, anxiety was mild. Among them education level, coping style were significant and independent determinants. It is essential to ensure that the health care system provides efficient health education, psychological intervention and support. In particular, clinical staff should pay more attention to the mood of ovarian cancer patients, early detection of cancer-related depression and anxiety, to promote the mental health of ovarian cancer patients.