CERTIFICATION

This is to certify that this research entitled “PREVALENCE AND CORRELATES OF

ANXIETY AND DEPRESSION AND THE LEVEL OF SATISFACTION DERIVED
FROM THE QUALITY OF NURSING CARE RENDERED TO CANCER PATIENTS
AT THE DOUALA GENERAL HOSPITAL” is an original work of CHELSEA KUNBID-
GAMVAH PASIAH (HS18A018). Under the supervision of Prof Tendongfor Nicholas and Dr
Esoh Bassah and lecturers in the department of Nursing of the University of Buea in partial
fulfillment of a masters degree in Medico-Surgical Nursing.

PROF. TENDONGFOR NICHOLAS (Supervisor)

Signature __________ Date__________

Dr. ESOH BASSAH (Co- Supervisor)

Signature __________ Date __________

Dr .PALLE JOHN (HOD)

Signature __________ Date ___________

i
 DEDICATION

This work is dedicated to my father Mr Pasiah Kenneth Bobvah and to the entire Pasiah

family for their love and support and most especially to God almighty for the strength to

complete this paper.

ii
 ACKNOWLEGDEMENT

My sincere appreciation goes to my supervisors Prof Tendongfor Nicholas and

Dr Esoh Bassah for accepting and taking out time from their busy schedule to
supervise my work with relentless efforts toward the realisation of this research.

Special thanks go to the Head of the Nursing Department Assoc Prof Palle John
and to all my lecturers especially; Prof Achidi Eric, Dr Eta Vivian, Dr Nkemayim
Florence, and Dr Chichom Mefire for their supports, direction and expertise.

My immense thanks go Mr kinge lifafa who dedicated his time and went through
sleepless nights to analyse my data, providing mentorship and research education.
I will also like to thank the administrators of the Douala General Hospital who
granted me authorisation to carry out this research at the Oncology unit and to all
the cancer patients who gave their consent to participate in this study.

I am highly indebted to my family especially my father Mr. Pasiah Kenneth

Bobvah for his moral and financial support, friends and well-wisher in various
ways to see me succeed in this work.

I sincerely appreciate all my classmates for their encouragement and motivation

during this project.

Above all, glory, honour and praise go to the Almighty GOD who made it
possible for this work to be realised through this constant renewal of my strength,
knowledge, hope, love, and health to overcome any obstacle. .

iii
 ABSTRACT
Background: Cancer has remained a disease equated to hopelessness pain, fear and death despite
recent advances in cancer treatment. Clinical physicians and nurses in Cameroon have always put
much attention on some aspects of cancer treatments, such as surgical and
chemotherapy/radiotherapy, but the role of psychological factors such as anxiety and depression in
cancer treatment was neglected. This study aim is to determine the prevalence and correlates of
anxiety and depression and the level of satisfaction derived from the quality of nursing care rendered
to cancer patients at the DGH.

Methods: The study used a descriptive cross-sectional study designed with purposive sampling to select
the hospital and recruiting patients at the Douala General Hospital. All eligible patients informed
consent was obtained and a face to face interview was conducted. Anxiety, depression and their
correlates information was gathered using a well-structured questionnaire made of the basic socio-
demographic features, clinical and medical history of the participants and the 14 item Hospital Anxiety
and Depression scale (HADS). An additional questionnaire was administered to find out the level of
satisfaction derived from the quality of nursing care rendered to cancer patients at the DGH. The data
will be collected for 2 months and sample size of 196 participants was computed. Data was entered in
Microsoft Excel and analysed in SPSS version 23 where descriptive (frequency, percentage, mean, SD)
and inferential statistics (linear regression, CI, Chi square, odd ratio and p values) was computed and
results will be presented on tables and figures (pie chart and bar chart).

Results: From the study, the prevalence of anxiety was 77% and depression was 85%. Most of the
cancer patients were females (74.4%), above the age of 40 (64.4%), married (50%) and unemployed
(57.2%). More than half of the patients ended school at the secondary level (53.3%) and 17.2% of them
had 4 children. The patients were mostly Christians (92.2%) who lived mostly in urban areas (67.8%).
Anxiety was associated with educational level (P=0.011), employment status (P=0.015), marital status
(P=0.64), religion (P=0.48) and address (P=0.001). Depression was associated with sex (P=0.063), age
(P=0.043), employment status (P= 0.060), marital status (P= 0.015), religion (P=0.093) and area of
location (0.040). Carcinoma had the highest category of cancer (75.56%) with breast cancer being the
most common site of cancer (33.3%). Half of the cancer patients (50%) were diagnosed in 2020 with
stage 2 being dominant (38.3%). 64.4% of the cancer patients had family members who equally suffered
from cancer and 31.1% died. 32 (17.8) people said the cancer had spread to other sites of their body and
5 people claimed it was their hand (2.8%). Most of the cancer patients were undergoing chemotherapy
(83.3%). The study revealed a high level of satisfaction of nursing quality care with a mode of 5
(excellent) for majority of the questions (17), though coordination of care after discharge was poor.

Conclusion: It can be concluded that cancer patients have a high prevalence of anxiety and
depression which is not supposed to go unrecognised. Health care providers especially nurses are at
the fore front in identifying and preventing anxiety and depression especially in the old, unemployed,
low levels of education and those who are married and are at risk of developing anxiety and
depression. Therefore, nurses are supposed to have technical and scientific knowledge and skills in
interpersonal relationships. Although an excellent level of satisfaction with the quality of nursing
care rendered to cancer patients undergoing treatment at the DGH was achieved, respondents gave
one or more responses which showed that they were not satisfied with the quality of nursing care.

Key words: Cancer, Prevalence, anxiety, depression, nursing care, patient satisfaction, correlates

iv
 TABLE OF CONTENTS

CERTIFICATION ................................................................................................................. i

ABSTRACT ........................................................................................................................ iii

TABLE OF CONTENTS ...................................................................................................... v

LIST OF TABLES AND FIGURES ..................................................................................... ix

CHAPTER ONE

INTRODUCTION

1.1Background ...................................................................................................................... 1

1.2 Problem statement ........................................................................................................... 4

1.3 Research Questions ......................................................................................................... 5

1.4 Research Hypotheses ....................................................................................................... 5

1.5 Research Objectives ........................................................................................................ 5

1.5.1 General Objectives ....................................................................................................... 5

1.5.2 Specific Objectives ....................................................................................................... 6

1.6 Significance of study ....................................................................................................... 6

1.7 Scope of study ................................................................................................................. 6

1.8 Operational Definition of Terms: ..................................................................................... 7

CHAPTER TWO

REVIEW OF LITERATURE

2.1 Conceptual Review ......................................................................................................... 7

2.1.1 Definition of Cancer ..................................................................................................... 7

2.1.2 Clinical manifestations ................................................................................................. 8

2.1.2.1 Local Symptoms ........................................................................................................ 8

2.1.2.2 Systemic symptoms ................................................................................................... 9

2.1.2.3 Metastasis .................................................................. Error! Bookmark not defined.

2.1.3 Causes .......................................................................... Error! Bookmark not defined.

v
2.1.3.1 Chemicals ................................................................................................................ 10

2.1.3.2 Diet and exercise ..................................................................................................... 11

2.1.3.3 Infection .................................................................... Error! Bookmark not defined.

2.1.3.4 Radiation ................................................................................................................. 12

2.1.3.5 Heredity .................................................................................................................. 13

2.1.3.6 Physical agents ........................................................................................................ 14

2.1.3.7 Hormones ................................................................................................................ 15

2.1.3.8 Autoimmune diseases .............................................................................................. 16

2.1.4 Pathophysiology ........................................................... Error! Bookmark not defined.

2.1.5 Metastasis................................................................................................................... 18

2.1.6 Diagnosis ................................................................................................................... 19

2.1.7 Classification .............................................................................................................. 19

2.1.8 Prevention .................................................................................................................. 21

2.1.8.1 Dietary .................................................................................................................... 21

2.1.8.2 Medication .............................................................................................................. 22

2.1.8.3 Vaccination ............................................................................................................. 23

2.1.8.4 Screening................................................................................................................. 23

2.1.9. Management .............................................................................................................. 24

2.1.9.1 Chemotherapy ......................................................................................................... 24

2.1.9.2 Radiation ................................................................... Error! Bookmark not defined.

2.1.9.3 Surgery .................................................................................................................... 26

2.1.9.4 Palliative care .......................................................................................................... 26

2.1.9. 5 Immunotherapy ...................................................................................................... 27

2.1.9.6 Laser therapy ........................................................................................................... 27

2.1.9.7 Alternative medicine................................................................................................ 28

2.1.9.8 Society and culture .................................................................................................. 28

2.2 Anxiety in Cancer patients............................................................................................. 30

vi
2.2.1 Clinical presentation of Anxiety Disorder [140].......................................................... 31

2.2 .1.1 Acute anxiety symptoms [140] ............................................................................... 31

2.2.1.2 Chronic pre-existing anxiety disorder [140] ............................................................. 32

2.2.2 Psychometric Instruments used to measure anxiety in cancer patients ......................... 32

2.2.3 Management of anxiety in the cancer setting [145] ..................................................... 32

2.2.3.1 Psychological interventions ..................................................................................... 32

2.2.3.2 Pharmacological Interventions [145]........................................................................ 33

2.2.3.3 Nurse- patient communication [40] .......................................................................... 33

2.3 Depression in cancer patients......................................................................................... 34

2.3.1 Diagnosis of depression in cancer patients .................................................................. 34

2.3.1.1 Major depressive episode: Diagnostic criteria (147) ................................................. 35

2.3.1.2 Approaches used to diagnose depression in cancer patients ...................................... 36

2.3.2 Medical Conditions Associated with Depression in Cancer Patients [149] .................. 37

2.3.3 Psychometric instruments in the measurement of depression ...................................... 37

2.3.4 Consequences of Depression in cancer patients........................................................... 38

2.3.5 Cancer and Suicide ..................................................................................................... 38

2.3.6 Psychiatric history of suicide attempts and what can be done [157]............................. 39

2.3.6.1 Suicide risk factors in cancer patients [158] ............................................................. 40

2.3.7 Management of depression in cancer patients ............................................................. 40

2.3.7.1 Psychosocial management of depression in cancer patients ...................................... 40

2.3.7.2 Pharmacotherapy for depression in the cancer setting: general rules......................... 41

2.4 Theoretical Review ....................................................................................................... 44

2.4.1 The Cognitive Theory of Psychological Stress and coping or the Transaction Model of
Stress and Coping. It is a useful theory to guide health care providers in identifying individual
traits in depression with cancer survivors [164]. .................................................................. 44

2.4.2 Social supportive theory ............................................................................................. 48

2.5 Empirical Review .......................................................................................................... 48

2.5.1 Estimating the prevalence of anxiety and depression in cancer patients ....................... 48
vii
2.5.1.1 Prevalence of Anxiety in cancer patients .................................................................. 48

2.5.1.2 Prevalence of Depression in cancer patients ............................................................. 49

2.5.2 Risk factors associated with Anxiety and Depression .................................................. 50

2.5.2.1 Risk factors associated with Anxiety in cancer patient ............................................. 50

2.5.2.2 Risk factors of Depression in cancer patients [147] .................................................. 50

2.5.3 Nursing interventions in the prevention and management of anxiety and depression
[147] ..................................................................................... Error! Bookmark not defined.

CHAPTER THREE

METHODOLOGY

3.1 Study design .................................................................................................................. 54

3.2 Study area ..................................................................................................................... 54

3.2.1 Study setting ............................................................................................................... 54

3.3 Sampling technique ....................................................................................................... 55

3.3.1 Inclusion criteria ......................................................................................................... 56

3.3.2 Exclusion criteria ........................................................................................................ 56

3.4 Sample size ................................................................................................................... 56

3.5 Research procedure ....................................................................................................... 57

3.5.1 Data collection ........................................................................................................... 57

3.5.2 Data collection tools ................................................................................................... 57

3.6 Ethical considerations .................................................................................................... 59

3.7 Data Management and Analysis .................................................................................... 59

3.8 Study Time Table ............................................................ Error! Bookmark not defined.

3.9 BUDGET ....................................................................... Error! Bookmark not defined.

REFERENCES ................................................................................................................... 62

APENDIX 1 ........................................................................................................................ 71

viii
 LIST OF TABLES AND FIGURES

Table 1: Medical Conditions Associated with Depression in Cancer Patients [149] ............. 37

Table 2: Prevalence of depression by cancer site [176] ........................................................ 50

Figure 1: Folkman Model, taken from the stress and coping model of lazarus and folkman

updated Holand (2002) ........................................................................................................ 47

ix
 Chapter one

Introduction

1.1Background

Cancer has become the second leading cause of mortality worldwide. It is responsible for an

estimated 9.6 million deaths in 2018 and globally, about 1 in 6 deaths is due to cancer [1].

Although many advances have been made in the treatment, prevention and screening of cancer,

its prevalence, incidence and mortality are still extremely high. With the growing number of

cancer survivors, the need for evidence-based interventions to meet survivor’s psycho-social

needs is also increasing [2].

According to data from the International Agency for Research on Cancer, in 2012, 14.1 million

new cases and an 8.2 million mortality rate were reported worldwide. By 2030, it is projected

that cancer deaths will increase by 45% from 7.9 million recorded in 2010 to 11.5 million [3].

Studies have demonstrated that individuals diagnosed with cancer suffer psychological distress

such as anxiety [29%] and depression (21%) as co-morbid conditions [4]. Research has well

documented that cancer patients face many difficulties starting from the appearance of the first

symptom, time of diagnosis, during treatment and palliative care [5]. Despite recent advances

in securing remission and possible cure, cancer still remains a disease equated with

hopelessness, pain, fear and death. Its diagnosis and treatment often produces psychological

distress resulting from the actual symptoms of the disease, as well as patient’s and family’s

perception of the disease. Patients have common fears, which have been called the six Ds:

Death, Dependency on family, spouse and physician; Disfigurement and change in early

appearance and self-image, sometimes resulting in loss or changes in sexual functioning;

Disability interfering with achievement of age appropriate tasks in work, school or leisure

1
roles; Disruption of interpersonal relationships; and finally, Discomfort or pain in later stages

of illness [5].

The most common risk factors for cancer development in the developing countries are; an

unhealthy lifestyle [including tobacco and alcohol use, poor diet and physical inactivity],

exposure to occupational [e.g asbestos] or environmental carcinogens [indoor air pollution],

exposure to radiation (e.g ultraviolet and ionizing radiation), and infection [e.g hepatitis B and

Human Papilloma Virus in infection] [3].

Depression is a psychological syndrome that has received the most attention in cancer patients

often leading to poor quality of life, resulting in high rates of suicide. The overall prevalence

of depression in oncology patients remains unclear, and according to previous studies the

prevalence is reported to be between 0% and 58%. The wide range of rates may be due to

several factors, including: [i] the use of different instruments to assess depression with different

psychometric properties, [ii] the use of different criteria for defining depression, and [iii]

differences between included cancer populations with respect to cancer type, stage and

treatment modality [6].

Anxiety occurs in many patients with cancer varying from the “normal” worries and fears

associated with a life threatening illness, through syndrome distress, adjustment disorders, and

generalized anxiety disorders and anxiety due to the medical condition [7]. The four common

causes of anxiety in patients with cancer are as follows:

(a) Situational: which includes diagnosis or illness relate crisis, conflict with family or

members of staffs, anticipating a frightening procedure or test results, and fear of recurrence.

(b) Disease related: poorly controlled pain, abnormal metabolic states, hormone secreting

tumour, Para neoplastic syndromes ( remote central nervous system effects).

2
(b) Treatment related: such as anxiety producing drugs (anti-emetic, neuroleptic,

bronchodilators), withdrawal states (opioids, benzodiazepines, and alcohol), conditioned

(anticipatory) anxiety, nausea, and vomiting with cyclic chemotherapy and

(d) Exacerbation of pre-existing anxiety disorder: Phobias (needles, claustrophobia), Panic and

generalized anxiety disorders, Post traumatic stress disorders or as a result of traumatic cancer

treatments (e.g. Bone marrow transplant) [8].

Most of the cancer patients do not discuss their psychological symptoms with health care

providers as well as many of the health care providers do not inquire about it due to their busy

schedule and ignorance. Thus majority of psychological morbidity goes unrecognized and

untreated. If the patient is not adequately counseled for psychological distress, he/she may

discontinue medications, withdraw from family members give up on good health habits and

thus be unable to cope with emotional and financial stress. All cancer patients undergo some

amount of anxiety and depression irrespective of their religious beliefs, culture and financial

background [9].

Although infectious disease are more predominant in the developing world with morbidity

and mortality rate, chronic disease including cancer have recently been recognized as public

health problems in Cameroon [10]. The epidemiology of cancer is relatively unknown.

Though they are reliable data on its incidence and pattern, with an estimated 15,000 new

cases diagnosed annually and a prevalence of about 25,000 cases [11]. Little has been done

on the prevalence and correlates of anxiety and depression with the level of satisfaction

derived from the nurses quality care provided to cancer patients in Cameroon, the purpose of

this research is to determine the prevalence and correlates of anxiety and depression and the

level of satisfaction derived from the quality of nursing care rendered to cancer patients at the

DGH?

3
1.2 Problem statement

Statistics by WHO indicates that cancer is the second leading cause of death worldwide from

non-communicable disease and by 2030, it is projected that cancer deaths will increase by 45%

from 7.9 million recorded in 2010 to 11.5 million. Research has well documented that cancer

patients face many difficulties starting from the onset of the disease and most common

psychological conditions experienced by patients with cancer are anxiety and depression.

Cameroon has a public health concern about cancer that has been neglected and majority of the

cancer patients do not discuss their psychological symptoms with health care providers as well

as many of the health care providers do not inquire about it due to their busy schedule and

ignorance. Thus anxiety and depression goes unrecognized and untreated. If the patient is not

adequately counseled for psychological distress such as anxiety and depression, he/she may

discontinue medications, withdraw from family members, give up on good health habits and

thus be unable to cope with emotional and financial stress. Again, receiving a diagnosis of

having cancer causes various feelings such as anxieties and depression in people, precisely

because the future becomes obscure, often with no prospects, since the threat of life seems to

become closer when the diagnosis is instituted. To provide quality care to cancer patients,

health professionals, at all levels of care, must have technical and scientific knowledge and

skills in interpersonal relationships. In this scenario, nursing, whose essence is the art of care,

is entirely linked to humanization, and it is impossible to deal with a ‘human being’ without

‘being’ human (especially cancer patients). Establishing a relationship of acceptance and trust

between health care professional and patient, this allows patients to express themselves through

dialogue which is critical. This bond contributes to their rehabilitation in all aspects, preventing

anxiety and depression, maintaining their autonomy, self-care ability, family and social life.

4
1.3 Research Questions

1.3.1 Specific Questions

What are determinants of the prevalence and correlates of anxiety and depression and the

level of satisfaction derived from the quality of nursing care rendered to cancer patients at the

DGH?

1.3.2 General Questions

1. What is the prevalence of anxiety and depression in cancer patients at the DGH?

2. What are the correlates of anxiety and depression in cancer patients at the DGH?

3. What is the level of satisfaction derived from the quality of nursing care rendered to cancer

patients at the DGH .

1.4 Research Hypotheses

1. Cancer patients at the DGH have a high prevalence of anxiety and depression.

2. Female cancer patients are more depressed than male cancer patients.

3. The is correlation between anxiety and depression with the socio-demographic factors of

cancer patients

4. Cancer patients are satisfied with the quality of nursing care rendered to them.

1.5 Research Objectives

1.5.1 General Objectives

To determine the prevalence and correlates of anxiety and depression and the level of

satisfaction derived from the quality of nursing care rendered to cancer patients at the Douala

General Hospital.

5
1.5.2 Specific Objectives

1. To estimate the prevalence of anxiety and depression in cancer patients at the DGH

2. To bring out the correlates between the socio-demographic factors with anxiety and

depression in cancer patients at the DGH.

3. To find out the level of satisfaction derived from the quality of nursing care rendered to

cancer patients at the DGH.

1.6 Significance of study

This study aims at determining the prevalence and correlates of anxiety and depression and the

level of satisfaction derived from the quality of nursing care rendered to cancer patients at the

DGH with aim of improving patient outcome and reducing health care expenditure. Again the

findings of this study will serve as a guide for health care workers especially nurses to be able

to quickly identify, understand and prevent anxiety and depression at their early stage in other

to improve cancer patient’s ability cope and adapt to the disease condition.

Also, the findings of this study will promote planning, implementing and evaluation of

interventional programs among cancer patients on how to reduce their anxiety and depression.

Furthermore, create awareness to nurses on the satisfaction derived from their nursing care by

patients in order to improve, adjust or modify the care render to cancer patients. Lastly the

findings of this research will form a base line for further research on cancer in Cameroon.

1.7 Scope of study

In this study, only cancer patients coming for treatment at the Douala General Hospital was

included. The factors accessed include; Socio- demographic data, Clinical and medical

history of participants, the Hospital Anxiety and Depression Scale (HADS) and lastly patient

satisfaction with nursing care quality questionnaire (PSWNCQQ).

6
1.8 Operational Definition of Terms:

Prevalence: The absence and presence of anxiety and depression in cancer patients

Incidence: The proportion of new cases with respect to the population under investigation.

Depression: According to DMS-1V depression is the loss of interest or pleasure in daily

activities consistently for at least two-week period.

Anxiety: It is a natural response and a necessary warning adaptation in humans.

Suicide: Intentional killing of oneself.

Appraisal: How a person evaluates the environment to his or her personal well being. It can

be viewed as harm or loss, threat or a challenge

Threat: Anticipated harms or losses that have not yet taken place and calls for coping efforts

Coping: Is a person’s cognitive and behavioral efforts to manage the internal and external

demands on the person-environment relationship that is appraised and stressful.

Hodgkin’s disease: A malignant lymphoid neoplasm characterized by the formation of large

tumours cells in the lymph nodes.

CHAPTER TWO

REVIEW OF LITERATURE

2.1 Conceptual Review

2.1.1 Definition of Cancer [12]

Cancers are a large family of diseases that involve abnormal cell growth with the potential to

invade or spread to other parts of the body. They form a subset of neoplasm. A neoplasm or

7
tumor is a group of cells that have undergone unregulated growth and will often form a mass

or lump, but may be distributed diffusely. All tumor cells show the six hallmarks of cancer.

These characteristics are required to produce a malignant tumor. They include;

- Cell growth and division absent the proper signals

- Continuous growth and division even given contrary signals

- Avoidance of programmed cell death

- Limitless number of cell divisions

- Promoting blood vessels construction

- Invasion of tissue and formation of metastases

The progression from normal cells that can form a detectable mass to outright cancer involves

multiple steps known as malignant progression.

2.1.2 Clinical manifestations [12]

When cancer begins, it produces no symptoms. Signs and symptoms appear as the mass grows

or ulcerates. The findings that result depend on the cancer's type and location. Few symptoms

are specific. Many frequently occur in individuals who have other conditions. Cancer can be

difficult to diagnose and can be considered a “great imitator”. People may become anxious or

depressed post-diagnosis. The risk of suicide in cancer patients is approximately double [12].

2.1.2.1 Local Symptoms [12 ]

Local symptoms may occur due to the mass of the tumor or its ulceration. For example, mass

effects from lung cancer can block the bronchus resulting in cough or pneumonia; esophageal

cancer can cause narrowing of the esophagus, making it difficult or painful to swallow; and

8
colorectal cancer may lead to narrowing or blockages in the bowel, affecting bowel habits.

Masses in breasts or testicles may produce observable lumps. ulceration can cause bleeding

that can lead to symptoms such as coughing up blood (lung cancer), anemia or rectal bleeding

(colon cancer), blood in the urine (bladder cancer), or abnormal vaginal bleeding (endometrial

or cervical cancer). Although localized pain may occur in advanced cancer, the initial tumor is

usually painless. Some cancers can cause a buildup of fluid within the chest or abdomen [12].

2.1.2.2 Systemic symptoms

Systemic symptoms may occur due to the body's response to the cancer. This may include

fatigue, unintentional weight loss, or skin changes [13]. Some cancers can cause a systemic

inflammatory state that leads to ongoing muscle loss and weakness, known as cachexia.

Some types of cancer such as Hodgkin disease, leukemias and cancers of the liver or kidney

can cause a persistent fever [14].

Some systemic symptoms of cancer are caused by hormones or other molecules produced by

the tumor, known as paraneoplastic syndromes. Common paraneoplastic syndromes include

hypercalcemia which can cause altered mental state, constipation and dehydration, or

hyponatremia that can also cause altered mental status, vomiting, headache or seizures [12].

2.1.2.3 Metastasis

Cancer can spread from its original site by local spread, lymphatic spread to regional lymph

nodes or by hematogenous spread via the blood to distant sites, known as metastasis. When

cancer spreads through the blood, it may spread through the body but is more likely to travel

to certain areas depending on the cancer type. The symptoms of metastatic cancers depend on

the tumor location and can include enlarged lymph nodes (which can be felt or sometimes seen

9
under the skin and are typically hard), enlarged liver or enlarge spleen, which can be felt in the

abdomen, pain or fracture of affected bones and neurological symptoms [12]

2.1.3 Causes

The majority of cancers, some 90–95% of cases, are due to genetic mutations from

environmental and lifestyle factors. The remaining 5–10% is due to inherited genetics.

Environmental refers to any cause that is not inherited genetically, such as lifestyle, economic,

and behavioral factors and not merely pollution. Common environmental factors that contribute

to cancer death include tobacco (25–30%), diet and obesity (30–35%), infections (15–20%),

ration (both ionizing and non-ionizing, up to 10%), lack of physical activity, and pollution.

Psychological stress does not appear to be a risk factor the onset of cancer, though it may

worsen outcomes in those who already have cancer.

It is not generally possible to prove what caused a particular cancer because the various causes

do not have specific fingerprints. For example, if a person who uses tobacco heavily develops

lung cancer, then it was probably caused by the tobacco use, but since everyone has a small

chance of developing lung cancer as a result of air pollution or radiation, the cancer may have

developed for one of those reasons. Excepting the rare transmissions that occur with

pregnancies and occasional organ donors, cancer is generally not a transmissible disease.

2.1.3.1 Chemicals [12]

Exposure to particular substances has been linked to specific types of cancer. These substances

are called carcinogens. Tobacco smoking, for example, causes 90% of lung cancer. It also

causes cancer in the larynx, head, neck, stomach, bladder, kidney, oesophagus and pancreas.

Tobacco smoke contains over fifty known carcinogens, including nitrosamines and polycyclic

aromatic hydrocarbons.

10
Tobacco is responsible for about one in five cancer deaths worldwide and about one in three in

the developed world. Lung cancer death rates in the United States have mirrored smoking

patterns, with increases in smoking followed by dramatic increases in lung cancer death rates

and, more recently, decreases in smoking rates since the 1950s followed by decreases in lung

cancer death rates in men since 1990.

In Western Europe, 10% of cancers in males and 3% of cancers in females are attributed to

alcohol exposure, especially liver and digestive tract cancers. Cancer from work-related

substance exposures may cause between 2 and 20% of cases, causing at least 200,000 deaths.

[12] Cancers such as lung cancer and mesothelioma can come from inhaling tobacco smoke or

asbestos fibers, or leukemia from exposure to benzene.

2.1.3.2 Diet and exercise [12]

Diet, physical activity and obesity are related to up to 30–35% of cancer deaths. In the United

States, excess body weight is associated with the development of many types of cancer and is

a factor in 14–20% of cancer deaths. A UK study including data on over 5 million people

showed higher body mass index to be related to at least 10 types of cancer and responsible for

around 12,000 cases each year in that country. Physical inactivity is believed to contribute to

cancer risk, not only through its effect on body weight but also through negative effects on the

immune system and. More than half of the effect from diet is due to over-nutrition (eating too

much), rather than from eating too few vegetables or other healthful foods.

Some specific foods are linked to specific cancers. A high-salt diet is linked to gastric cancer.

Aflatoxin B1, a frequent food contaminant, causes liver cancer. Betel nut chewing can cause

oral cancer. National differences in dietary practices may partly explain differences in cancer

incidence. For example, gastric cancer is more common in Japan due to its high-salt diet while

11
colon cancer is more common in the United States. Immigrant cancer profiles mirror those of

their new country, often within one generation.

2.1.3.3 Infection

Worldwide approximately 18% of cancer deaths are related to infectious disease. This

proportion ranges from a high of 25% in Africa to less than 10% in the developed world.

Viruses are the usual infectious agents that cause cancer but cancer bacteria and parasites may

also play a role.

Oncoviruses (viruses that can cause cancer) include human papillomavirus (cervical cancer),

Epstein-Barr virus (B-cell lymphoproliferative disease and nasopharyngeal carcinoma),

Kaposi’s sarcoma herpes virus (Kaposi’s sarcoma and primary effusion lymphomas), hepatitis

B and hepatitis C viruses (hepatocellular carcinoma) and human T-cell leukemia virus-1 (T-

cell leukemias). Bacterial infection may also increase the risk of cancer, as seen in Helicobacter

pyloric-induced gastric carcinoma. Parasitic infections associated with cancer include

Schistosoma haematobium (squamous cell carcinoma of the bladder) and the lives fluke,,

opisthorchis viverrini and Clonorchis sinensis (cholangiocarcinoma). [12]

2.1.3.4 Radiation [12]

Radiation exposure such as ultraviolet radiation and radioactive material is a risk factor for

cancer. Many non-melanoma skin cancers are due to ultraviolet radiation, mostly from sunlight.

Sources of ionizing radiation include medical imagine and radon gas.

Ionizing radiation is not a particularly strong mutagen. Residential exposure to radon gas, for

example, has similar cancer risks as passive smoking. Radiation is a more potent source of

cancer when combined with other cancer-causing agents, such as radon plus tobacco smoke.

12
Radiation can cause cancer in most parts of the body, in all animals and at any age. Children

are twice as likely to develop radiation-induced leukemia as adults; radiation exposure before

birth has ten times the effect.

Medical use of ionizing radiation is a small but growing source of radiation-induced cancers.

Ionizing radiation may be used to treat other cancers, but this may, in some cases, induce a

second form of cancer. It is also used in some kinds of medical imaging.

Prolonged exposure to ultraviolet radiation from the sun can lead to melanoma and other skin

malignancies. Clear evidence establishes ultraviolet radiation, especially the non-ionizing

medium wave UVB, as the cause of most non-melanoma skin cancers, which are the most

common forms of cancer in the world.

Non-ionizing radio frequency radiation from mobile phones, electric power transmission and

other similar sources has been described as a possible carcinogen by the World Health

Organization's International Agency for Research on Cancer.

2.1.3.5 Heredity [12]

The vast majority of cancers are non-hereditary (sporadic). Hereditary cancers are primarily

caused by an inherited genetic defect. Less than 0.3% of the populations are carriers of a genetic

mutation that has a large effect on cancer risk and these causes less than 3–10% of cancer.

Some of these syndromes include: certain inherited mutations in the genes and BRCA1 and

BRCA2 with a more than 75% risk of breast cancer and ovarian cancer and hereditary non-

polyposis colorectal cancer (HNPCC or Lynch syndrome), which is present in about 3% of

people with colorectal cancer, among others.

13
Taller people have an increased risk of cancer because they have more cells than shorter people.

Since height is genetically determined to a large extent, taller people have a heritable increase

of cancer risk.

2.1.3.6 Physical agents [12]

Some substances cause cancer primarily through their physical, rather than chemical, effects.

A prominent example of this is prolonged exposure to asbestos, naturally occurring mineral

fibers that are a major cause of mesothelioma (cancer of the serous membrane) usually the

serous membrane surrounding the lungs. Non-fibrous particulate materials that cause cancer

include powdered metallic cobalt and nickel and crystalline silica (quartz, cristobalite and

tridymite). Usually, physical carcinogens must get inside the body (such as through inhalation)

and require years of exposure to produce cancer.

Physical trauma resulting in cancer is relatively rare. Claims that breaking bones resulted in

bone cancer, for example, have not been proven. Similarly, physical trauma is not accepted as

a cause for cervical cancer, breast cancer or brain cancer. One accepted source is frequent,

long-term application of hot objects to the body. It is possible that repeated burns on the same

part of the body, such as those produced by kanger and kairo heaters (charcoal hand warmers),

may produce skin cancer, especially if carcinogenic chemicals are also present. Frequent

consumption of scalding hot tea may produce esophageal cancer. Generally, it is believed that

cancer arises, or a pre-existing cancer is encouraged, during the process of healing, rather than

directly by the trauma. However, repeated injuries to the same tissues might promote excessive

cell proliferation, which could then increase the odds of a cancerous mutation.

Chronic inflammation has been hypothesized to directly cause mutation. Inflammation can

contribute to proliferation, survival, angiogenesis and migration of cancer cells by influencing

14
the tumors microenvironment. Oncogenes build up an inflammatory pro-tumourigenic

microenvironment.

2.1.3.7 Hormones [12]

Some hormones play a role in the development of cancer by promoting cell proliferation.

Insulin like growth factor and their binding proteins play a key role in cancer cell proliferation,

differentiation and apoptosis, suggesting possible involvement in carcinogenesis.

Hormones are important agents in sex-related cancers, such as cancer of the breast,

endometrium, prostate, ovary and testis and also of thyroid cancer and bone cancer. For

example, the daughters of women who have breast cancer have significantly higher levels of

estrogen and progesterone than the daughters of women without breast cancer. These higher

hormone levels may explain their higher risk of breast cancer, even in the absence of a breast-

cancer gene. Similarly, men of African ancestry have significantly higher levels of testosterone

than men of European ancestry and have a correspondingly higher level of prostate cancer.

Men of Asian ancestry, with the lowest levels of testosterone-activating androstanediol

glucuronide, have the lowest levels of prostate cancer.

Other factors are relevant: obese people have higher levels of some hormones associated with

cancer and a higher rate of those cancers. Women who take hormone replacement therapy have

a higher risk of developing cancers associated with those hormones. On the other hand, people

who exercise far more than average have lower levels of these hormones and lower risk of

cancer. Osteosarcoma may be promoted by growth hormones. Some treatments and prevention

approaches leverage this cause by artificially reducing hormone levels and thus discouraging

hormone-sensitive cancers.

15
2.1.3.8 Autoimmune diseases [12]

There is an association between celiac disease and an increased risk of all cancers. People with

untreated celiac disease have a higher risk, but this risk decreases with time after diagnosis and

strict treatment, probably due to the adoption of a gluten-free diet, which seems to have a

protective role against development of malignancy in people with celiac disease. However, the

delay in diagnosis and initiation of a gluten-free diet seems to increase the risk of malignancies.

Rates of gastrointestinal cancers are increased in people with Crohn’s disease and ulcerative

colitis, due to chronic inflammation. Also, immune-modulators and biological agents used to

treat these diseases may promote developing extra-intestinal malignancies.

2.1.4 Pathophysiology [12]

Cancer is fundamentally a disease of tissue growth regulation. In order for a normal cell to

transform into a cancer cell, the genes that regulate cell growth and differentiation must be

altered.

The affected genes are divided into two broad categories. Oncogenes are genes that promote

cell growth and reproduction. Tumor suppressor genes are genes that inhibit cell division and

survival. Malignant transformation can occur through the formation of novel oncogenes, the

inappropriate over-expression of normal oncogenes, or by the under-expression or disabling of

tumor suppressor genes. Typically, changes in multiple genes are required to transform a

normal cell into a cancer cell.

Genetic changes can occur at different levels and by different mechanisms. The gain or loss of

an entire chromosome can occur through errors in mitosis. More common are mutations, which

are changes in the nucleotide sequence of genomic DNA.

16
Large-scale mutations involve the deletion or gain of a portion of a chromosome. Genomic

amplification occurs when a cell gains copies (often 20 or more) of a small chromosomal locus,

usually containing one or more oncogenes and adjacent genetic material. Translocation occurs

when two separate chromosomal regions become abnormally fused, often at a characteristic

location. A well-known example of this is the Philadelphia chromosome, or translocation of

chromosomes 9 and 22, which occurs in chronic myelogenous leukemia and results in

production of the BCR-abl fusion protein, an oncogenic tyrosine kinase.

Small-scale mutations include point mutations, deletions, and insertions, which may occur in

the promoter region of a gene and affect its expression, or may occur in the gene's coding

sequence and alter the function or stability of its protein product. Disruption of a single gene

may also result from integration of genomic material from a DNA virus or retrovirus, leading

to the expression of viral oncogenes in the affected cell and its descendants.

Replication of the data contained within the DNA of living cells will probabilistically result in

some errors (mutations). Complex error correction and prevention is built into the process and

safeguards the cell against cancer. If a significant error occurs, the damaged cell can self-

destruct through programmed cell death, termed apoptosis. If the error control processes fail,

then the mutations will survive and be passed along to daughter cells.

Some environments make errors more likely to arise and propagate. Such environments can

include the presence of disruptive substances called carcinogens, repeated physical injury, heat,

ionising radiation or hypoxia.

The errors that cause cancer are self-amplifying and compounding, for example:

- A mutation in the error-correcting machinery of a cell might cause that cell and its children

to accumulate errors more rapidly.

17
- A further mutation in an oncogene might cause the cell to reproduce more rapidly and more

frequently than its normal counterparts.

- A further mutation may cause loss of a tumor suppressor gene, disrupting the apoptosis

signaling pathway and immortalizing the cell.

- A further mutation in the signaling machinery of the cell might send error-causing signals to

nearby cells.

The transformation of a normal cell into cancer is akin to a chain reaction caused by initial

errors, which compound into more severe errors, each progressively allowing the cell to escape

more controls that limit normal tissue growth. This rebellion-like scenario is an undesirable

survival of the fittest, where the driving forces of evolution work against the body's design and

enforcement of order. Once cancer has begun to develop, this ongoing process, termed clonal

evolution, drives progression towards more invasive stages. Clonal evolution leads to intra-

tumor heterogeneity (cancer cells with heterogeneous mutations) that complicates designing

effective treatment strategies.

Characteristic abilities developed by cancers are divided into categories, specifically evasion

of apoptosis, self-sufficiency in growth signals, insensitivity to anti-growth signals, sustained

angiogenesis, limitless replicative potential, metastasis, reprogramming of energy metabolism

and evasion of immune destruction.

2.1.5 Metastasis [12]

Metastasis is the spread of cancer to other locations in the body. The dispersed tumors are

called metastatic tumors, while the original is called the primary tumor. Almost all cancers can

metastasize. Most cancer deaths are due to cancer that has metastasized.

18
Metastasis is common in the late stages of cancer and it can occur via the blood or the lymphatic

system or both. The typical steps in metastasis are local invasion, intravasation into the blood

or lymph, circulation through the body, extravasations into the new tissue, proliferation and

angiogenesis. Different types of cancers tend to metastasize to particular organs, but overall

the most common places for metastases to occur are the lungs, liver, brain and the bones.

2.1.6 Diagnosis [12]

Most cancers are initially recognized either because of the appearance of signs or symptoms or

through screening. Neither of these leads to a definitive diagnosis, which requires the

examination of a tissue sample by a pathologist. People with suspected cancer are investigated

with medical tests. These commonly include blood tests, X-rays, (contrast) CT scans and

endoscopy.

The tissue diagnosis from the biopsy indicates the type of cell that is proliferating, its

histological grade, genetic abnormalities and other features. Together, this information is useful

to evaluate the prognosis and to choose the best treatment.

Cytogenetics and immune-histochemistry are other types of tissue tests. These tests provide

information about molecular changes (such as mutations, fusion genes and numerical

chromosome changes) and may thus also indicate the prognosis and best treatment.

Cancer diagnosis can cause psychological distress and psychosocial interventions, such as

talking therapy, may help people with this.

2.1.7 Classification [12]

Cancers are classified by the type of cell that the tumor cells resemble and are therefore

presumed to be the origin of the tumor. These types include:

19
 -Carcinoma: Cancers derived from epithelial cells. These groups include many of the most

common cancers and include nearly all those in the breast, prostate, lung, pancreas and

colon.

- Sarcoma: Cancers arising from connective tissue (i.e. bone, cartilage, fat, nerve), each of

which develops from cells originating in mesenchymal cells outside the bone marrow.

- Lymphoma and leukemia: These two classes arise from hematopoietic (blood-forming)

cells that leave the marrow and tend to mature in the lymph nodes and blood, respectively.

- Germ cell tumor: Cancers derived from pluripotent cells, most often presenting in the

testicle or the ovary (seminoma and dysgerminoma, respectively).

- Blastoma: Cancers derived from immature "precursor" cells or embryonic tissue.

Cancers are usually named using -carcinoma, -sarcoma or -blastoma as a suffix, with the Latin

or Greek word for the organ or tissue of origin as the root. For example, cancers of the liver

parenchyma arising from malignant epithelial cells is called hepatocarcinoma, while a

malignancy arising from primitive liver precursor cells is called a hepatoblastoma and a cancer

arising from fat cells is called a liposarcoma. For some common cancers, the English organ

name is used. For example, the most common type of breast cancer is called ductal carcinoma

of the breast. Here, the adjective ductal refers to the appearance of cancer under the microscope,

which suggests that it has originated in the milk ducts.

Benign tumors (which are not cancers) are named using -oma as a suffix with the organ name

as the root. For example, a benign tumor of smooth muscle cells is called a leiomyoma (the

common name of this frequently occurring benign tumor in the uterus is fibroid). Confusingly,

some types of cancer use the -noma suffix, examples including melanoma and seminoma.

20
Some types of cancer are named for the size and shape of the cells under a microscope, such

as giant cell carcinoma, spindle cell carcinoma and small-cell carcinoma.

2.1.8 Prevention [12]

Cancer prevention is defined as active measures to decrease cancer risk. The vast majority of

cancer cases are due to environmental risk factors. Many of these environmental factors are

controllable lifestyle choices. Thus, cancer is generally preventable. Between 70% and 90% of

common cancers are due to environmental factors and therefore potentially preventable.

Greater than 30% of cancer deaths could be prevented by avoiding risk factors including:

tobacco, excess weight/obesity, poor diet, physical inactivity, alcohol, sexually transmitted

infections and air pollution. Not all environmental causes are controllable, such as naturally

occurring background radiation and cancers caused through hereditary genetic disorders and

thus are not preventable via personal behavior.

2.1.8.1 Dietary [12]

The primary dietary factors that increase risk of cancer are obesity and alcohol consumption.

Diets low in fruits and vegetables and high in red meat have been implicated but reviews and

meta-analyses do not come to a consistent conclusion. A 2014 meta-analysis found no

relationship between fruits and vegetables and cancer. Coffee is associated with a reduced risk

of liver cancer. Studies have linked excess consumption of red or processed meat to an

increased risk of breast cancer, colon cancer and pancreatic cancer, a phenomenon that could

be due to the presence of carcinogens in meats cooked at high temperatures.

21
Dietary recommendations for cancer prevention typically include an emphasis on vegetables,

fruit, whole grains and fish and an avoidance of processed and red meat (beef, pork, lamb),

animal fats, pickled foods and refined carbohydrates.

2.1.8.2 Medication [12]

Medications can be used to prevent cancer in a few circumstances. In the general population,

NSAIDs reduce the risk of colorectal cancer; however, due to cardiovascular and

gastrointestinal side effects, they cause overall harm when used for prevention. Aspirin has

been found to reduce the risk of death from cancer by about 7%. COX-2 inhibitors may

decrease the rate of polyp formation in people with familial adenomatous polyposis; however,

it is associated with the same adverse effects as NSAIDs. Daily use of tamoxifen or raloxifen

reduces the risk of breast cancer in high-risk women. The benefit versus harm for 5-alpha-

reductase inhibitor such as finasteride is not clear.

Vitamin supplementation does not appear to be effective at preventing cancer. While low blood

levels of vitamin D are correlated with increased cancer risk, whether this relationship is causal

and vitamin D supplementation is protective is not determined. One 2014 review found that

supplements had no significant effect on cancer risk. Another 2014 review concluded that

vitamin D3 may decrease the risk of death from cancer (one fewer death in 150 people treated

over 5 years), but concerns with the quality of the data were noted.

Beta-carotene supplementation increases lung cancer rates in those who are high risk. Folic

acid supplementation is not effective in preventing colon cancer and may increase colon polyps.

Selenium supplementation has not been shown to reduce the risk of cancer.

22
2.1.8.3 Vaccination [12]

Vaccines have been developed that prevent infection by some carcinogenic viruses. Human

papilloma virus vaccine (Gardasil and Cervarix) decrease the risk of developing cervical cancer.

The hepatitis B vaccine prevents infection with hepatitis B virus and thus decreases the risk of

liver cancer. The administration of human papilloma virus and hepatitis B vaccinations is

recommended where resources allow.

2.1.8.4 Screening [12]

Unlike diagnostic efforts prompted by symptoms and medical signs, cancer screening involves

efforts to detect cancer after it has formed, but before any noticeable symptoms appear. This

may involve physical examination, blood or urine tests or medical imaging.

Cancer screening is not available for many types of cancers. Even when tests are available,

they may not be recommended for everyone. Universal screening or mass screening involves

screening everyone. Selective screening identifies people who are at higher risk, such as people

with a family history. Several factors are considered to determine whether the benefits of

screening outweigh the risks and the costs of screening. These factors include:

- Possible harms from the screening test: for example, X-ray images involve exposure to

potentially harmful ionizing radiation

- The likelihood of the test correctly identifying cancer

- The likelihood that cancer is present: Screening is not normally useful for rare cancers.

- Possible harms from follow-up procedures

- Whether suitable treatment is available

23
- Whether early detection improves treatment outcomes

- Whether the cancer will ever need treatment

- Whether the test is acceptable to the people: If a screening test is too burdensome (for

example, extremely painful), then people will refuse to participate.

- Cost

2.1.9. Management [12]

Many treatment options for cancer exist. The primary ones include surgery, chemotherapy,

radiation therapy, hormonal therapy, targeted therapy and palliative care. Which treatments are

used depends on the type, location and grade of the cancer as well as the patient's health and

preferences. The treatment intent may or may not be curative.

2.1.9.1 Chemotherapy [12]

Chemotherapy is the treatment of cancer with one or more cytotoxic anti-neoplastic drugs

(chemotherapeutic agents) as part of a standardized regimen. The term encompasses a variety

of drugs, which are divided into broad categories such as alkylating agents and anti metabolites.

Traditional chemotherapeutic agents act by killing cells that divide rapidly, a critical property

of most cancer cells.

It was found that providing combined cytotoxic drugs is better than a single drug; a process

called the combination therapy; which has an advantage in the statistics of survival and

response to the tumor and in the progress of the disease. A Cochrane review concluded that

combined therapy was more effective to treat metastasized breast cancer. However, generally

24
it is not certain whether combination chemotherapy leads to better health outcomes, when both

survival and toxicity are considered.

Targeted therapy is a form of chemotherapy that targets specific molecular differences between

cancer and normal cells. The first targeted therapies blocked the estrogen receptor molecule,

inhibiting the growth of breast cancer. Another common example is the class of Bcr-Abl

inhibitors, which are used to treat chronic myelogenous leukemia (CML). Currently, targeted

therapies exist for many of the most common cancer types, including bladder cancer, breast

cancer, colorectal cancer, kidney cancer, leukemia, liver cancer, lung cancer, lymphoma,

pancreatic cancer, prostate cancer, skin cancer, and thyroid cancer as well as other cancer types.

The efficacy of chemotherapy depends on the type of cancer and the stage. In combination with

surgery, chemotherapy has proven useful in cancer types including breast cancer, colorectal

cancer, pancreatic cancer, osteogenic sarcoma, testicular cancer, ovarian cancer and certain

lung cancers. Chemotherapy is curative for some cancers, such as some leukemias, ineffective

in some brain tumors, and needless in others, such as most non-melanoma skin cancers. The

effectiveness of chemotherapy is often limited by its toxicity to other tissues in the body. Even

when chemotherapy does not provide a permanent cure, it may be useful to reduce symptoms

such as pain or to reduce the size of an inoperable tumor in the hope that surgery will become

possible in the future.

2.1.9.2 Radiation [12]

Radiation therapy involves the use of ionizing radiation in an attempt to either cure or improve

symptoms. It works by damaging the DNA of cancerous tissue, killing it. To spare normal

tissues (such as skin or organs, which radiation must pass through to treat the tumor), shaped

radiation beams are aimed from multiple exposure angles to intersect at the tumor, providing a

25
much larger dose there than in the surrounding, healthy tissue. As with chemotherapy, cancers

vary in their response to radiation therapy.

Radiation therapy is used in about half of cases. The radiation can be either from internal

sources (brachytherapy) or external sources. The radiation is most commonly low energy X-

rays for treating skin cancers, while higher energy X-rays are used for cancers within the

body. Radiation is typically used in addition to surgery and or chemotherapy. For certain

types of cancer, such as early head and neck cancer, it may be used alone. For painful bone

metastasis, it has been found to be effective in about 70% of patients.

2.1.9.3 Surgery [12]

Surgery is the primary method of treatment for most isolated, solid cancers and may play a role

in palliation and prolongation of survival. It is typically an important part of definitive

diagnosis and staging of tumors, as biopsies are usually required. In localized cancer, surgery

typically attempts to remove the entire mass along with, in certain cases, the lymph nodes in

the area. For some types of cancer this is sufficient to eliminate the cancer.

2.1.9.4 Palliative care [12]

Palliative care is treatment that attempts to help the patient feel better and may be combined

with an attempt to treat the cancer. Palliative care includes action to reduce physical, emotional,

spiritual and psycho-social distress. Unlike treatment that is aimed at directly killing cancer

cells, the primary goal of palliative care is to improve quality of life.

People at all stages of cancer treatment typically receive some kind of palliative care. In some

cases, medical specialty professional organizations recommend that patients and physicians

respond to cancer only with palliative care. This applies to patients who:

26
- Display low performance status, implying limited ability to care for themselves

- Received no benefit from prior evidence-based treatments

- Are not eligible to participate in any appropriate clinical trial

- No strong evidence implies that treatment would be effective

Palliative care may be confused with hospice and therefore only indicated when people

approach end of life. Like hospice care, palliative care attempts to help the patient cope with

their immediate needs and to increase comfort. Unlike hospice care, palliative care does not

require people to stop treatment aimed at the cancer.

Multiple national medical guidelines recommend early palliative care for patients whose cancer

has produced distressing symptoms or who need help coping with their illness. In patients first

diagnosed with metastatic disease, palliative care may be immediately indicated. Palliative care

is indicated for patients with a prognosis of less than 12 months of life even given aggressive

treatment.

2.1.9. 5 Immunotherapy [12]

A variety of therapies using immunotherapy, stimulating or helping the immune system to fight

cancer, have come into use since 1997. Approaches include antibodies, checkpoint therapy,

and adoptive cell transfer.

2.1.9.6 Laser therapy [12]

Laser therapy uses high-intensity light to treat cancer by shrinking or destroying tumors or pre-

cancerous growths. Lasers are most commonly used to treat superficial cancers that are on the

surface of the body or the lining of internal organs. It is used to treat basal cell skin cancer and

27
the very early stages of others like cervical, penile, vaginal, vulvar, and non-small cell lung

cancer. It is often combined with other treatments, such as surgery, chemotherapy, or radiation

therapy. Laser-induced interstitial thermotherapy (LITT), or interstitial laser photocoagulation,

uses lasers to treat some cancers using hyperthermia, which uses heat to shrink tumors by

damaging or killing cancer cells. Lasers are more precise than surgery and cause less damage,

pain, bleeding, swelling, and scarring. A disadvantage is surgeons must have specialized

training. It may be more expensive than other treatments.

2.1.9.7 Alternative medicine [12]

Complementary and alternative cancer treatments are a diverse group of therapies, practices

and products that are not part of conventional medicine. "Complementary medicine" refers to

methods and substances used along with conventional medicine, while "alternative medicine"

refers to compounds used instead of conventional medicine. Most complementary and

alternative medicines for cancer have not been studied or tested using conventional techniques

such as clinical trials. Some alternative treatments have been investigated and shown to be

ineffective but still continue to be marketed and promoted. Cancer researcher Andrew J.

Vickers stated, "The label 'unproven' is inappropriate for such therapies; it is time to assert that

many alternative cancer therapies have been 'disproven'.

2.1.9.8 Society and culture [12]

Although many diseases (such as heart failure) may have a worse prognosis than most cases of

cancer, cancer is the subject of widespread fear and taboos. The euphemism of "a long illness"

to describe cancers leading to death is still commonly used in obituaries, rather than naming

the disease explicitly, reflecting an apparent stigma. Cancer is also euphemized as "the C-word";

Macmillan Cancer Support uses the term to try to lessen the fear around the disease. In Nigeria,

one local name for cancer translates into English as "the disease that cannot be cured". This

28
deep belief that cancer is necessarily a difficult and usually deadly disease is reflected in the

systems chosen by society to compile cancer statistics: the most common form of cancer non-

melanoma skin cancers, accounting for about one-third of cancer cases worldwide, but very

few deaths are excluded from cancer statistics specifically because they are easily treated and

almost always cured, often in a single, short, outpatient procedure.

Western conceptions of patients' rights for people with cancer include a duty to fully disclose

the medical situation to the person, and the right to engage in shared decision-making in a way

that respects the person's own values. In other cultures, other rights and values are preferred.

For example, most African cultures value whole families rather than individualism. In parts of

Africa, a diagnosis is commonly made so late that cure is not possible, and treatment, if

available at all, would quickly bankrupt the family. As a result of these factors, African

healthcare providers tend to let family members decide whether, when and how to disclose the

diagnosis and they tend to do so slowly and circuitously, as the person shows interest and an

ability to cope with the grim news. People from Asian and South American countries also tend

to prefer a slower, less candid approach to disclosure than is idealized in the United States and

Western Europe, and they believe that sometimes it would be preferable not to be told about a

cancer diagnosis. In general, disclosure of the diagnosis is more common than it was in the

20th century, but full disclosure of the prognosis is not offered to many patients around the

world.

In the United States and some other cultures, cancer is regarded as a disease that must be

"fought" to end the "civil insurrection"; a War on Cancer was declared in the US. Military

metaphors are particularly common in descriptions of cancer's human effects, and they

emphasize both the state of the patient's health and the need to take immediate, decisive actions

29
himself rather than to delay, to ignore or to rely entirely on others. The military metaphors also

help rationalize radical, destructive treatments.

In the 1970s, a relatively popular alternative cancer treatment in the US was a specialized form

of talk therapy, based on the idea that cancer was caused by a bad attitude. People with a "cancer

personality" depressed, repressed, self-loathing and afraid to express their emotions were

believed to have manifested cancer through subconscious desire. Some psychotherapists said

that treatment to change the patient's outlook on life would cure the cancer. Among other

effects, this belief allowed society to blame the victim for having caused the cancer (by

"wanting" it) or having prevented its cure (by not becoming a sufficiently happy, fearless and

loving person). It also increased patients' anxiety, as they incorrectly believed that natural

emotions of sadness, anger or fear shorten their lives. The idea was ridiculed by Susan Sontag,

who published Illness as Metaphor while recovering from treatment for breast cancer in 1978.

Although the original idea is now generally regarded as nonsense, the idea partly persists in a

reduced form with a widespread, but incorrect, belief that deliberately cultivating a habit of

positive thinking will increase survival. This notion is particularly strong in breast cancer

culture.

One idea about why people with cancer are blamed or stigmatized, called the just-world

hypothesis, is that blaming cancer on the patient's actions or attitudes allows the blamers to

regain a sense of control. This is based upon the blamers' belief that the world is fundamentally

just and so any dangerous illness, like cancer, must be a type of punishment for bad choices,

because in a just world, bad things would not happen to good people.

2.2 Anxiety in Cancer patients

Anxiety is a natural response and a necessary warning adaptation in humans. Anxiety consists

of cognitions (e.g “I will go mad” or “I am going to die”), behaviours ( e.g irritability,

30
restlessness) and physical reactions (e.g chest tightness, breathing difficulties and sleeping

difficulties). Anxiety can become a pathological disorder when it is excessive and

uncontrollable, requires no specific external stimulus and manifests with a wide range of

physical and affective symptoms and changes in behaviour and cognition. As outlined in DSM

IV (Diagnostic and Statistical Manual of Mental Disorders), anxiety disorders include

Generalized Anxiety Disorder (GAD), social anxiety disorder, specific phobia, panic disorder

with and without agoraphobia, Obsessive-Compulsive Disorder (OCD), posttraumatic stress

disorder (PTSD), anxiety secondary to medical condition and Acute Stress Disorder (ASD) and

substance-induced anxiety disorder [15]. Anxiety tends to appear or worsen at critical points

during the course of cancer; at diagnosis, at the beginning and end of treatment, at recurrence

and at advanced or terminal stages

2.2.1 Clinical presentation of Anxiety Disorder [16]

2.2 .1.1 Acute anxiety symptoms [16]

-Uneasiness unpleasant feeling of arousal, restlessness

- Irritability

-Inability to relax; tendency to startle

- Difficulty falling asleep (leads to fatigue and low tolerance to frustration)

- Occasionally, sense of impending doom

- Distraction

- Helplessness and sense of loss of control over feelings

- Symptoms of autonomic arousal; rapid or forceful heartbeat, sweating, unpleasant “tightness”

in the stomach, shortness of breath, dizziness

31
- Vegetative disturbances: loss of appetite decreased sexual interest

- Para sympathetically-medicated symptoms: abdominal distress, nausea, diarrhoea

2.2.1.2 Chronic pre-existing anxiety disorder [16]

- Pre-existing anxiety disorder tend to exacerbate with cancer diagnosis

- Panic attacks (sudden, extreme anxiety accompanied by sympathetic nervous system arousal

and an overwhelming urge to escape) may be re-experienced when exposed to medical

procedures, treatment toxicity e.t.c

- Post-traumatic stress disorder and generalized anxiety disorder may be reactivated by stress

of cancer

- Specific phobias (extreme anxiety on exposure to the feared objects and avoidance of them)

may interfere with administration of cancer treatment (Claustrophobia, phobia to needles) and

may lead to anticipatory anxiety.

2.2.2 Psychometric Instruments used to measure anxiety in cancer patients

- Hospital anxiety and depression scale [17]

- Profile of mood states [18]

- Brief symptom inventory [19]

- State-trait anxiety inventory [20]

2.2.3 Management of anxiety in the cancer setting [21]

2.2.3.1 Psychological interventions

- Individual supportive psychotherapy

32
- Progressive muscle relaxation

- Hypnosis

- Training in deed breathing techniques

- Meditation

- Biofeedback

- Guided imagery

- Systematic Desensitization

- Cognitive techniques (Aim is to change anxiety – provoking beliefs and preoccupations)

- Group Psychotherapy

2.2.3.2 Pharmacological Interventions [22]

- Beta- blockers

- Tricyclic antidepressants (i.e., imipramine)

- Selective serotonin re-uptake inhibitors (1.e., paroxetine)

- Short- acting benzodiazepines (i.e., alprazolam)

- Neuroleptics (i.e., haloperidol)

2.2.3.3 Nurse- patient communication [22]

- Information tailored to patient’s needs

- Effective communication skills are imperative

33
2.3 Depression in cancer patients

Symptoms of depression occur even if the criteria for major depressive episodes are not

fulfilled. For mild to moderate depression the symptoms are the same as for major depressive

episodes but less severe. It may be difficult to estimate the proportion of symptoms as they

vary from natural emotions to severe symptoms with disability in daily activities. According

to the DMS-IV, a person who suffers from major depressive episode has either a depressed

mood or a loss of interest or pleasure in daily activities consistently for at least two-week

period. This mood must represent a change from the person’s normal mood. Social,

occupational, educational or other important functioning must also be negatively impaired by

the change in mood. This episode is characterized by the presence of at least five of the

following symptoms during the same two-week period; depressed mood, diminished interest

or pleasure in almost all activities, significant weight loss/gain, insomnia/hyper insomnia,

feeling of restlessness or being slowed down, fatigue or loss of energy, feelings of

worthlessness or excessive inappropriate guilt, diminished ability to think or concentrate,

recurrent thoughts of death suicidal ideations without a specific plan or suicide attempt or a

specific suicidal plan. The symptoms cause clinical significant distress or functioning

impairment and are not due to general medication condition, substance abuse or bereavement

[22]

2.3.1 Diagnosis of depression in cancer patients

Depressive symptoms occur along a spectrum that ranges from sadness to major affective

disorder. Mode change may be difficult to assess in a patient who feels his life threatened by

disease. Diagnosis of depression in physically healthy individuals depends heavily on the

presence of somatic symptoms (anorexia, fatigue and insomnia and weight loss). Somatic

symptoms are indicators of little value in cancer patients: they are common to cancer and

depression [22].

34
2.3.1.1 Major depressive episode: Diagnostic criteria (23)

A) At least 5 of the 9 symptoms below for the same 2 weeks or more, most of the time almost

every day, and this is a change from his prior level of functioning. One of the symptoms must

be either; depressed mood or loss of interest.

- Depressed mood

- Loss of interest or pleasure in most or all activities

-Weight loss gain

- Insomnia or hypersomnia

- Agitated or slowed down behaviour

- Feeling fatigue or reduced energy

- Thoughts of worthlessness or extreme guilt (not about being ill)

- Reduces ability to think, concentrate or make decisions

- Frequent thoughts of death or suicide

B) Symptoms don’t indicate a mixed episode

C) Symptoms cause great distress or difficulty in functioning at home, work or other

D) Symptoms are not caused by substance use (alcohol, drugs) or a medical condition

E) Symptoms are not due to normal grief for the loss of a loved one; they persist for more than

2 weeks, or they include great difficulty in functioning, frequent thoughts of worthlessness,

thoughts of suicide, psychotic symptoms, or psychomotor retardation.

35
2.3.1.2 Approaches used to diagnose depression in cancer patients

Four approaches have been described in the assessment of depression in the medically ill: [24]

1) Inclusive Approach: Counts a depressive symptom only if it presumed not secondary to

physical illness. High sensitivity, low specificity; does not focus on aetiology.

2) Etiologic Approach: Count a depressive symptom only if it is presumed not secondary to

physical illness.

3) Substitutive Approach: Eliminates symptoms such as anorexia and fatigue, which can be

secondary to cancer and employs other depression criteria. Increases specificity, lowers

sensitivity which may result in lower prevalence and under diagnosis.

4) Substitution Approach: Replaces indeterminate symptoms such as fatigue (frequently

secondary to physical illness) with cognitive symptoms such as indecisiveness, brooding and

hopelessness.

The diagnosis of depression in the oncology setting should depend on psychological not

somatic symptoms, in cancer patients: [24]

- Dysphoric mood

- Feeling of helplessness and hopelessness

- Loss of self-esteem

- Feeling of worthlessness or guilt

- Anhedonia

- Thoughts of wishing death or suicide

36
2.3.2 Medical Conditions Associated with Depression in Cancer Patients [25]

Table 1: Medical Conditions Associated with Depression in Cancer Patients [25]

Endocrine Abnormalities Infections
- Cushing’s Disease - Epstein-Barr virus
- Addison’s Disease - Encephalitis
- Diabetes Mellitus - HIV
- Hypopituitarism - Influenza
- Thyroid dysfunction ( hypo or hyperthyroidism) - Pneumonia
- Syphilis
- Hepatitis

Medications Oncological Disease

- Steroids -Reserpine - Tumours of the SNC
- Interferon - Methyldopa - Lung cancer
- Barbiturates - LAsperginase - Lymphoma
- Some antibiotics - Vincristine - leukaemia

Neurological Disorders Metabolic Disorders

- Cerebrovascular Diseases - Hyponatremia
- Huntington’s Disease - Hypokalaemia
- Alzheimer’s Disease and other forms of - Hyperkalaemia
Dementia - Folic Acid Deficiency
- Parkinson’s Disease - Pellagra
- Multiple sclerosis - Uremia
- Subaracnoid Haemorrhage - Wilson’s Disease

Other medical conditions

- Systemic Lupus Erithematosus - Anaemia
- Rheumatoid Arthritis -Hypertension
- Alcoholism - Uncontrolled Pain

2.3.3 Psychometric instruments in the measurement of depression

- Beck Depression Inventory [26]

- The Hospital Anxiety and Depression Scale [17]

37
- The Brief Symptom Inventory- 18 (BSI-18)

- Depression Subscale [19]

- Profile of Moods State (POMS) [18]

- The Distress Thermometer (DT) [26]

2.3.4 Consequences of Depression in cancer patients

- Increase length of stay in hospital [27]

- Maladaptive coping and abnormal illness behaviour [28]

- Reduced adherence to treatment [27]

- Reduced efficacy of chemotherapy in breast cancer patients [29]

- Reduced quality of life

- Increased psychosocial morbidity within the family

- Complicated family relations and patterns of communication within the family

- Increased risk of suicide [30]

2.3.5 Cancer and Suicide

Suicide has been reported to be 1.5-2 times higher in cancer patients than in the general

population [31] among terminally ill patients with cancer the request for euthanasia is about 4

times higher in patients with depression than in those without depression [32]. Desire for death

in terminally ill cancer patients is frequent and has been shown to be associated to depression

and it’s transitory.

38
2.3.6 Psychiatric history of suicide attempts and what can be done [32]

- Previous depressive episodes? Suicide attempts? Has anyone in the family

attempted/committed suicide before?

- Is there a defined PLAN, INTENTION and what is the VIABILITY of such plan?

(24 hours companion if needed)

- What has kept the patient from committing suicide?

- What are the patient’s support systems? What type of family, social relationships does she

maintain?

- What are the patient’s belief systems?

- What is her sense of meaning in life?

- What meaning do death and pain have for the patient?

- What are the patient’s interests in life? Help maximize values

- Convey that things can be done to improve the quality of life even in the context of a poor

prognosis

- Involve and evaluate patient’s family

- Empathize with patient

- Validate patient’s feelings: many cancer patients have transient

- Maintain a supportive therapeutic relationship

- Adequate pain control (and other physical symptoms)

39
- Assessment of current emotional state: is the patient depressed? Is there a wish to have

ultimate control over intolerable symptoms? Is suicide an alternative to suffering?

2.3.6.1 Suicide risk factors in cancer patients [33]

-Family /personal history of suicide or suicide attempts

- Psychiatric history: Delirium, depression with hopelessness, psychotic features, irrational

thinking, loss of control and impulsivity.

- Uncontrolled pain or other symptoms, advanced disease

- Cancer site (head & neck, lung, gastrointestinal)

- Poor social support

- Older age

- Gender: Males

2.3.7 Management of depression in cancer patients

The treatment of depression in cancer patients involves the combination o f the following:

2.3.7.1 Psychosocial management of depression in cancer patients

- Adjust psycho-therapeutic modality to patient’s needs and disease stage.

- Crisis-intervention models involving an active therapeutic role.

- Educational interventions: clarifying information, explaining emotional reactions to patient

and family.

- Cognitive techniques to help correct misconceptions and exacerbated fears.

- Interventions directed to enhance the spiritual aspects in advanced disease and dying [34]

40
- Interventions designed to maintain patients’ dignity [35]

- Cognitive-Behavioural Interventions [36]

- Group therapies: Supportive-Expressive Group Psychotherapy; Cognitive-Existential

Group Therapy; Multidimensional structured group psychotherapy [37].

2.3.7.2 Pharmacotherapy for depression in the cancer setting: general rules

Choose the drug depending on: [38]

- Which is the safest drug or which has the fewest side-effects for the cancer patients?

- What are the characteristics of the depressive episode?

- What is the best way of administration for a particular patient (oral or parenteral route)

- The most recent scientific advances in the treatment of depression

- Start dose according to patient’s condition (usually half dose for a few days and then titrate)

- It would be important to wait for effects of the drugs (latency is usually 4 weeks)

- Provide continued treatment 6-9 months (more if depression or depressive episodes are

recurrent)

- Discontinue gradually by tapering the dose and follow- up

- Monitor on a continued basis to watch for potential drug interactions that may occur between

antidepressants and certain chemotherapeutic agents.

41
2.3.7.3 Health care provider interventions to reduce depressive symptoms in cancer

patients [62]

A) Training in communication skills: Adequate nurse-patient communication will;

- Reduce patient’s fears

- Help patient understand and elaborate relevant medical information

- Increase patient’s perception of control (which is considerably reduced with the disease)

- Allow the patient to discuss worries that may interfere with treatment administration, with

oncologist

- Enhance treatment adherence

- Facilitate patient’s global psychological adjustment

Baile et al in 2004 described a six-step protocol (SPIKES) to deliver bad news and improve

nurse- patient communication:

S Setting: Prepare an adequate environment; privacy, involve significant others, establish

rapport with patient e.t.c.

P Perception: How does the patient perceive this medical situation? “What do you suspect

your symptoms are due to”?

I Invitation: Obtain patient’s invitation to deliver medical information. “How would YOU

like me to give your test results?

K Knowledge: Deliver medical information. “I am sorry to tell you that your test results have

revealed...”

E Empathising and Exploring: Assess the patient’s emotions using empathetic responses

42
S Strategy and Summary: Describe strategy/follow- up and summarize interview

B) Use of simple screening instruments to detect depressive symptoms

-It is recommended that all patients be screen for depression in the clinic upon their first visit

and on a regular basis thereafter by their oncologist, especially when changes occur in their

disease status (remission, recurrence, progression of disease, etc,).

- Explain to patient and family that depressive symptoms can be treated.

- Provide continuity in patient care.

- Monitor patient’s sense of wellbeing and needs in a continued manner along the disease

continuum.

- Work with the family: Provide basic caretaking guidelines and support for family members.

- Explore one’s own attitude towards illness, suffering, death and dying.

C) Increase patient’s perception of control

- Provide options

- Inform adequately

- Anticipate patient’s needs

- Facilitate adaptive copying mechanisms

- Respect defence mechanism as long as they don’t interfere with treatment administration

- Normalize patient’s feelings

- Help maintain realistic hope

43
- Remain available to listen to patient’s worries and fears

2.4 Theoretical Review

2.4.1 The Cognitive Theory of Psychological Stress and coping or the Transaction

Model of Stress and Coping.

It is a useful theory to guide health care providers in identifying individual traits in

depression with cancer survivors [39].

The National Cancer Institute [40] guidelines, defines “adjustment” or “psychosocial

adaptation” to cancer as a continuing process in which the individual patient attempts to

manage emotional suffering, solves specific cancer related problems, and obtains command or

control of life events related to this disease. Adaptation to cancer is not an isolated and unique

event, but rather a series of constant responses that permit the subject to carry out the multiple

tasks associated to living with cancer. Normal or successful adaptation occurs in patients

capable of reducing the changes in the different functioning areas to a minimum, regulating

emotional stress and remaining involved in the life aspects that still have meaning and

importance for them.

According to Holland [41], psycho-oncology is focused on “suffering of the mind” that occurs

with cancer and that incorporates psychological, social, spiritual and existential dimensions. Its

goal is to help the patient finding a tolerable meaning to the presence of an intrusive and

unwelcome disease that is a threat for the future and life itself. However, presently there is no

unifying model that incorporates all the factors that influence in this suffering associated to

cancer. . Recently, the «paradigm of stress and coping» originally applied to AIDS patients and

their care givers has gained acceptance [42][43]. This has been adapted to cancer, providing a

44
conceptual framework that makes it possible to understand the coping processing of a fatal

disease, «suffering of the mind» accompanying it, and the losses it entails.

According to Folkman and Greer [44] the milestones of this model are two processes:

“appraisal” and “coping”. Appraisal is related with the individual evaluation of personal

meaning of a given event and adaptation of the individual’s resources to cope with it. The

appraisal process is based on the hypothesis that individuals are constantly evaluating their

relationship with the environment. Appraisal of a certain event influences subsequent emotions

and coping.

The stress process begins when the person realizes that suffering with cancer is a highly

probable fact, or that it is already a certainty. At this time, the individual becomes aware of a

change, or threat of change, in his/her goals and concerns conceived up to the that moment.

Appraisal of this present or possible change due to the cancer includes an evaluation of its

personal meaning (it may have a meaning of harm or real loss, of actual or potential harm or

loss, or it will mean a personal challenge), which is called “primary appraisal”, and

evaluation of the coping options, which is called “secondary appraisal”. The primary appraisal

is influenced by the patient’s personal beliefs and values. Secondary appraisals are related with

the degree that the individual can control or change the situation generated by the cancer. For

example, recurrence of breast cancer will lead to an appraisal of a combination of harm (to

his/her mood, hope, trust, family), threat (to short term health, to short or middle term life, to

independence, to economic well-being of his/her family) and losses (of control, physical health,

future projects, etc.).

On one hand, coping refers to the specific thoughts and behaviours that a person uses in his/her

efforts to adapt to the cancer. Patients can recur to three main coping strategies: emotion

focused strategies; strategies focused on the problem, and strategies focused on meaning [44].

45
The first ones help oncology patients to regulate their degree of emotional suffering (e.g.,

avoidance, escape, seeking of social support, distancing); the second ones help them to manage

specific problems, trying to directly modify the problematic situations that cause this suffering

(e.g., through search for information, resolution of pending problems); and the last one helps

to understand the reason for the disease and the impact it will have on their lives. People vary

their coping strategies, depending on the intensity of their emotional response and skill to

regulate it, on the problem solving abilities for each situation, and on the changes in personal

relationship as the situation unfolds.

Folkman’s model [43] updated by Holland [42] is shown in the figure below.

46
Figure 1: Folkman Model, taken from the stress and coping model of lazarus and
folkman updated Holand (2002)

47
2.4.2 Social supportive theory

This theory was proposed by Berkman and Glass on the how social networks influence health

outcomes. The theory says that “When and individual is faced with an extreme stressful event,

having individuals who can provide that person with support can help reduce the intensity of

the stress response and facilitate coping for over the long term” [45]

2.5 Empirical Review

2.5.1 Estimating the prevalence of anxiety and depression in cancer patients

2.5.1.1 Prevalence of Anxiety in cancer patients

Among patients with cancer, anxiety is a natural and common response to threats of

uncertainty, and to fear of suffering and mortality. Prevalence is uncertain due to limitations in

research methodology: Differing study populations (single versus mixed cancer diagnosis;

differing tumour sites; early versus late stage disease; outpatient versus inpatient; etc.); varying

diagnostic criteria and assessment instruments; studies failing to separate anxiety from

depression, etc. Estimated current prevalence of anxiety disorders in oncology is within a range

of 15% -28%. Numerous studies show anxiety disorders are more common in cancer patients

than in the general population. These responses may however also motivate the patient to

adhere to the medical treatment [46]. The prevalence of anxiety in cancer patient varies. Strong

et al. reported 23% with anxiety in a large sample of 3071 cancer patients with varied diagnoses

[47]. In other studies of heterogeneous groups of cancer patients the prevalence varies between

12-34% [48][49]. Stark et al. reported almost half (48%) of the patients in their study with

sufficient anxiety for further assessment. As a second step, a semi-structured diagnostic

interview was used where 30% of the earlier identified patients fulfilled the ICD-10 criteria for

48
anxiety disorder [50]. The prevalence for anxiety of 10% in a recent meta-analysis was unusual

low compared to previous studies [51].

2.5.1.2 Prevalence of Depression in cancer patients

- Reported prevalence rates of depression among cancer patients can be as high as 38% for

major depression and 58% for depression spectrum syndromes [23].

A study carried out by kumar et al in 2016 revealed a prevalence of 56.7% and 64.2% anxiety

and depression respectively [70]. In china, a study involving 203 Taiwanese cancer patients

has reported that the prevalence of anxiety and depression was 11.8 and 20% respectively [71].

- Differences in reported prevalence rates are due to differences in assessment methods as well

as difference in stage and tumour site, among others.

49
Table 1: Prevalence of depression by cancer site [51]

Cancer site Prevalence of depression

Pancreas 33%-50%

Oropharynx 22%-57%

Breast 13%-46%

Lung 11%-44%

Colon 13%-25%

Gynaecological 12%-23%

Lymphomas 8%-19%

Gastric 11%

2.5.2 Correlates of Anxiety and Depression

2.5.2.1 Correlates of Anxiety in cancer patient

- Pre-morbid anxious tendencies (elevated trait anxiety) and obsessional personality traits [16]

- Stage of the disease: Anxiety appears to increase as cancer progresses [52]

- Disease symptoms such as pain are associated to increased anxiety

- Cancer treatments are anxiety-provoking

- Type of treatment and tumour response to it have been associated with anxiety [53]

- Treatment side-effects are associated with anxiety (e.g anticipatory nausea and vomiting) [54]

2.5.2.2 Correlates of Depression in cancer patients [23]

- Young age

50
- Personality factors (pessimism, tendency to repress feelings such as anger)

- Social isolation and lack of support

- Previous negative experience with cancer in the family or personal experiences of physical

illness

- Advance disease (metastatic or terminal illness)

- Physical deterioration

- Tumour location (Lung, pancreatic, head and neck)

- Presence of physical symptoms from cancer, especially if not well controlled

- History of multiple losses

- Previous psychiatric disorders especially episodes of major depression or suicidal attempt

- History of substance abuse (European Society for medical oncology).

2.5.3 Cancer patient’s level of satisfaction with Nursing Care

Patient satisfaction is a concrete criterion for evaluation of health care and therefore quality of

nursing care [54]. In international survey of 183 patients, which aimed to determine the level

of satisfaction of public hospitals users in relation to the care provided by nurses? In this case

there was an overall index of satisfaction with the quality of care of 92.9% [98]. It provides

crucial information for healthcare managers by providing important resources for processes

such as those involved in measuring patients’ expectations and satisfaction with nursing care

quality, improving nursing service quality through identification of areas of failure and

planning and implementing necessary training [55] Evaluation of health care involves defining

the objectives of care, monitoring healthcare inputs, measuring the extent to which the expected

51
outcomes have been achieved and assessing the extent of any unintended or harmful

consequences of the intervention[56] Receiving a diagnosis causes various feelings, anxieties

and concerns in people, precisely because the future becomes obscure, often with no prospects,

since the threat of life seems to become closer when the diagnosis is instituted [57].

Establishing a relationship of acceptance and trust between professional and patient, which

allows patients to express themselves through dialogue is critical. This bond contributes to their

rehabilitation in all aspects, enhancing their quality of life, maintaining their autonomy, self-

care ability, family and social life [58].

To provide quality care to cancer patients, health professionals, at all levels of care, must have

technical and scientific knowledge and skills in interpersonal relationships. In this scenario,

nursing, whose essence is the art of care, is entirely linked to humanization, and it is impossible

to deal with a ‘human being’ without ‘being’ human (especially cancer patients). Humanization

of health services involves changing the very way the service user is understood. The way to

humanize care is characterized by nursing professionals as a practice based in a

professional/patient relationship, which includes personal characteristics by looking at the

needs, through dialogue, attentive listening, holistic vision, empathy, moral and ethical values,

and by including subjective issues such as love, thinking, appreciation of the being, link

establishment, attention, willingness, understanding and caring [59].It is important to

remember that care for patients with cancer also covers all care provided to the patient and

family in their time of anxiety, insecurity, uncertainty, doubts, before their clinical condition

and the imminence of death. The nurse’s role is critical to the control of fear, weakness, anguish

and difficulties encountered by nursing care, promoting psychosocial support, comfort and care

needed to this context [60].In this light, the nurse must have characteristics and skills so that

there is commitment to the patient in order to meet the care requirements necessary for

oncology care, thus impacting the quality of care. The professional experience and specialized

52
skills are aspects that should be rethought in the current context of hiring nurses to work in

oncology [61]. From another angle, it is essential to evaluate the service by patients, putting on

display their perceptions. In this sense, listening to what patients have to report on the quality

of care provided and about their satisfaction can be a chance to build an outcome

indicator[62][63]with which it is acquired information that benefit the organization of these

services as they allow the implementation of changes through valuation and appreciation of

their needs and expectations[64].Accordingly, there is the need to build a study from the view

point of cancer patients with the aim of analyzing their satisfaction on the nursing staff

assistance.

53
 CHAPTER THREE

METHODOLOGY

3.1 Study design

This study was carried out using a descriptive cross-sectional design. The design was

descriptive because data was collected to answer questions concerning the prevalence and

correlates of depression and anxiety and to provide factual descriptive picture of the research

at the time of study. Also the study was cross-sectional because data was collected at one point

in time, i.e. phenomena under study are captured as they are. Data collection was conducted

from June to August 2020.

3.2 Study area

This study was conducted at oncology unit in the ‘’Douala General Hospital” found in Douala.

Douala is the economic capital of Cameroon. It is found in the Littoral Region and it sits on

the estuary of River Wouri. In Douala, Cameroon’s larges sea port and international airport are

found. Douala has an estimated population of about 5000,000 people [66] and a surface area

of about 210km2. It has a tropical monsoon climate and it sees plentiful rainfall during the year,

especially in August, experiencing an average of 3,600mm precipitation of rainfall per year

(67). Douala is situated 19m elevation above sea level and harbour about 80% of Cameroon’s

industries. Due to the centralized nature of economic activities in Douala by the state, Urban

development is more noticeable here than any other city in Cameroon

3.2.1 Study setting

The Douala General Hospital is one of the reference hospitals in Cameroon and it is based in

the biggest metropolis. It is a referral hospital situated in the North East of the City, precisely

in Makepe and was founded in 1987 by a presidential decree. It has about 310 beds and a total

of about 630 personnel (300 nurses). The oncology unit of the Douala General Hospital is a

54
day clinic (not functional during the day) made up of two sections the chemotherapy unit also

known as “medicine B3” located beside the Anapathy unit and the Radiotherapy unit also

known as “colbato-therapy” which is found on the underground floor. The chemotherapy unit

has 3 sections/rooms made of comfortable chairs and beds where patients can sit/lie

comfortably while chemotherapy treatment is being administered. Patients whose

chemotherapy treatments last for more than a day are transferred to the medical unit (also

known as C4) since the chemotherapy unit are not functional by night. It also has a nursing

station made of about 10 nurses who work from Monday to Friday 7am-7pm excluding

weekends and public holidays. Also there’s another room where chemotherapy drugs are

prepared under a bio safety cabinet to prevent hazard from the chemotherapy medications.

Then there is a rest room/ toilet for both patients’ and health care providers. The second unit

which is the radiotherapy unit is has about 5 main oncologist, a psychologist, a radiologist,

general practitioners and 2 nurses who are in charge of clerking the cancer patients both from

in and out of the country (Cameroon), scheduling them for appointment with the oncologist

and providing assistance to patients when need be. The radiotherapy unit also has 2 sections

where radiotherapy treatment is being administered, four dressing rooms for patients to

undress, a comfortable space for patients to wait, 4 doctors’ offices, consultation room and two

rest rooms/toilets. Work starts at 7am and ends at 7pm from Monday to Friday and doctors do

not consult on Fridays.

3.3 Sampling technique

The study will adopt a purposeful sample technique. The purposive sampling method was used

to recruit cancer patients who are under follow up in the oncology unit because they possess

the characteristics relevant for the study.

55
3.3.1 Inclusion criteria
- Patients who were diagnosed of any type of cancer and who come for follow up at the

oncology unit in the DGH.

-Cancer patients who did not have any history of mental disorders.

-Cancer patients >18 who gave their consent to participate in the study.

3.3.2 Exclusion criteria

-Cancer patient who had a history of mental disorder.

-Cancer patients who were critically ill and not able to communicate.

-Cancer patient who did not give their consent to participate in the study.

-Cancer patient aged < 18 years

3.4 Sample size

The sample size was calculated using the following formula (68).

𝜂𝑜 = Ζ2 𝜌(1 − 𝜌)

𝑑2

Where 𝜂𝜊 = The sample size for a very large population > 10000

Ζ = 95% of confidence level and equals 1.96

𝑑 = Degree of sample error 5% (0.05%)

𝑝 = Estimated prevalence of estimated proportion 50% = 0.5

𝜂𝑜 = 1.962 ∗ 0.5 (1 − 0.5)

(0.052 )

𝜂𝜊 = 384.16 ≈ 385participants

The study was adjusted for finite population using the formula stipulated

56
 (fishers’ et al, 1998).
𝜂𝜊
𝑛= 𝜂
1+( 𝑜 )
𝑁

Where 𝑛 = desired sample for population < 10,000

𝜂𝜊= Desired sample size pop > 10000

𝑁 = Estimation of the population size: 1000

n = 385/[1+ (385/400)

n = 196.3 ≈ 196 Participants

3.5 Research procedure

3.5.1 Data collection

A face to face interview was done using a pre-test questionnaire with close and opened ended

question which was adapted for this study. Patient’s records will first be checked to see those

who meet the inclusion criteria. The purpose of the study will be explained to participants and

their informed consent given before they will be interviewed. The data capturing sheets will

be checked on daily basis to ensure correct entry of information.

3.5.2 Data collection tools

Data collection tool was a well structured questionnaire with closed and opened ended

questions in both English and French. The questionnaire will be divided in to the following

sections;

A)The basics socio-demographic;(age, gender, place of residence, marital status,

number of children, educational level, religion, employment status of the study participants.

This section will be made up of 8 questions.

57
 B) Clinical and medical history of the participants including stage of the disease,

type of current treatment, time of diagnosis and type of cancer asked from participants. This

section has 8 questions.

C) The Hospital Anxiety Depression Scale (HAD)

The Hospital Anxiety and Depression Scale (HADS) standardized tool was used to determine

for the presence and absence of anxiety and depression. The HADS standardized tool is a valid

tool with reliability of α=0.8525 for anxiety subscale and α= 0.7784 for depression subscale.

The HADS standardized tool comprises of 14 questions that are used to measure anxiety and

depression. The questions relating to anxiety are marked ‘A’ to depression ‘D’. Questions

categorized into level of depression (D) have scores of 0, 1, 2, 3 in ascending order where 0=

severe depression, 2= moderate depression and 3= no depression. Level of anxiety (A) has

scores ranging from 3, 2, 1, 0 in descending order in which 3= severe form of anxiety, 2=

moderate anxiety and 0= no anxiety. Identification of anxiety and depression in an individual

is calculated by adding up all the scores of seven items for anxiety and depression subscales

respectively. 0-7 total scores indicates normal levels of anxiety and depression, while 8-10 total

scores indicate that someone has borderline abnormal levels of anxiety and depression and 11-

21 total indicates abnormal (Case) levels of depression and anxiety [17].

The HADS was modified to suit the study. A total score of 0-7 on the anxiety and depression

subscale indicates that anxiety and depression is absent while a total score of 8-21 indicates the

presence of anxiety and depression.

D) Patient Satisfaction With Nursing Care Quality Questionnaire (PSNCQQ), which

measures health related properties considered to affect patient satisfaction was used to collect

data. The questionnaire consist of 15 questions, plus 3 additional questions designed to measure

satisfaction with the overall quality of care during the hospital stay, the status of the patient’s

health and overall quality of nursing care. The questions were presented in five options;

58
Excellent, Very Good, Fair and Poor. And 1 additional question was asked about the intention

to recommend the hospital to family and friends present in five options; Strongly Agree,

Somewhat Agree, Agree, Somewhat Disagree and Strongly Disagree, making a total of 19

questions. [69]

3.6 Ethical considerations

-Ethical approval to conduct the study was obtained from the Head of the Nurses Department

of the University of Buea and the Douala General Hospital.

-Consent was obtained from cancer patients who agreed to participate in the study, after

explanation of the study and the voluntary nature of participation.

-Confidentiality was guaranteed as; names and phone numbers of participants did not appear

on the questionnaire.

3.7 Data Management and Analysis

Data was checked for, entered in to Microsoft excel 2010 and analysed using Statistical

Package for Social Sciences (SPSS) version 23. Descriptive statistics such as the mean, mode,

median, standard deviation, minimum and maximum values, and frequency and percentage

distributions were computed. Cancer patients’ information which include; Socio-demographic

data, clinical and medical history of the participants and two questions pertaining to the

PSWNCQQ were used as the independent variables. The absence and presence (prevalence) of

depression and anxiety was used as the outcomes (dependent variables) of the research

correlations. Comparisons between proportions will be made using the chi squared test. The

Pearson’s Chi-Square was used to test for the correlates or association between the independent

and the dependent variables and to determine the P values which was statistically significant at

P < 0.05. The bivariate analysis was performed using logistic regression and odd rations (OR)

at 95% confidence interval. The results were displayed in tables, pie and bar charts

59
 CHAPTER FOUR
RESULTS

4.0 Introduction

60
This chapter presents the results of the study in 3 sections. The first section will have the results

presented generally without taking in to consideration the prevalence (absence and presence)

of anxiety and depression. The second section is going to be done considering the prevalence

of anxiety and depression which will be associated with certain variables of the socio-

demographic data, medical history and two questions from the patient satisfaction with nursing

care quality tool. The third section will be about the bivariate analysis.

196 participants were interviewed with the help of a questionnaire but only 180 questionnaires

were consider valid for the analysis, thus given a total response rate of 91.8%. The remaining

16 questionnaires were considered invalid because the participants did not answer up to 50%

of the questions that target the main objectives of the study.

61
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 APENDIX 1
PARTICIPANTS INFORMATION SHEET

Introduction

My name is Chelsea Kunbid-Gamvah Pasiah. I am carrying out a research titled

“Prevalence and correlates of anxiety and depression and the quality of

nursing care rendered to cancer patients at the DGH”. This study seeks to
determine the prevalence and correlates of depression and anxiety in cancer
patients and the level of satisfaction derived from the quality of nursing care
rendered to cancer patients at the Douala General Hospital.

Invitation to participate: As a cancer patient, I wish to invite you to take part in

this study.

Voluntary participation: Participating in this study is not compulsory and there

are no consequences if you choose not to participate.

Procedure: This research will involve the use of questionnaires, which will
require about 15 minutes providing answers to the questions.

APPENDIX II

Questionnaire
Dear Respondent,

71
I am CHELSEA KUNBID-GAMVAH PASIAH (HSI8P018) a Post graduate student of the
department of Medico-Surgical Nursing, faculty of health sciences of the university of Buea. I
am currently researching on “Prevalence and Correlates of anxiety and depression and the
level of satisfaction derived from the quality of nursing care rendered to Cancer Patients
at the DGH”. Under the approval of the Head of Nurses Department and Director of the Douala
General Hospital. The purpose of this research is to determine the prevalence and correlates of
depression and anxiety in cancer patients and the quality of nursing care rendered to cancer
patients at the Douala General Hospital with the aim of improving patient outcome and
reducing health care expenditure. The findings of this study will also promote planning,
implementing and evaluation of interventional programs among cancer patients on how to
reduce their anxiety and depression. Furthermore, create awareness to nurses on the satisfaction
derived from their nursing care by patients in order to improve, adjust or modify the care render
to cancer patients. ,.

Instruction: answer all questions; place a tick (√) on the later that correspond to
the BEST response of your choice. Some questions may have more than one
answer.

Risk: The only risk involve in this study is your time spent to fill the
questionnaire

Benefits: Each participant shall benefit directly on more knowledge on how to

prevent anxiety and depression and from the recommendations of the study.

Confidentiality: Your names will not be needed and any information you provide
will be kept confidential.

Approval: This research has been authorized by the Head of Department of the
Department of Nursing Sciences, Faculty of Health Sciences of the University
of Buea, by my supervisor and by the administrative head of this health facility.
SECTION A: Socio-demographic Data

1) Patient’s sex: A) Male B) Female

2) Patient’s age in years: _______

3) Patient’s Educational level A) Primary B) Secondary C) University D) Never

4) Patient’s Employment Status A) Employed B) Unemployed C) Retired

5) Patient’s Marital Status A) Single B) Married C) Others (please specify) ___

72
6) Number of children: _________

7) Patient’s Religion A) Christian B) Muslim C) Others ____________

8) Patient’s area of location A) Urban B) Rural

Section B: Clinical and Medical History of the participants

1) What is the Category of cancer? A) Sarcoma B) Carcinoma

C) Leukaemia and Lymphomas D) Others (please specify) _________________

2) When was the Cancer diagnosed? ____________

3) What is site of cancer? A) Breast B) Cervix C) Endometrium/ Uterus D) Lung E)

Bone F) Head and Neck G) Oesophagus H) Lymph nodes H) Others (Please
specify)________

4) What is the stage of Cancer?

A) Stage 1 B) Stage II C) Stage III D) Stage IV

5a) Do you have anyone in your family with cancer? A) Yes B) No

5b) If present, is person alive or death? A) Alive B) Death

6a) Has the cancer spread to other site/parts of the body other than the original site?

A) Yes B) No

6b) If Yes, name the site/part of the body ___________________

7) What is the mode of treatment?

A) Radiotherapy B) Chemotherapy C) Surgery D) others (Please Specify) _____

8a) Do you have any other health condition apart from cancer?

A) Yes B) NO

8b) if Yes please specify __________

Section C) Hospital Anxiety and Depression Scale (HADS)

A D A

73
 I feel tense or ‘wound up’: I feel as if I am slowed down:

3 Most of the time. 3 Nearly all the time

2 A lot of the time 2 Very often

1 From time to time, occasionally 1 Sometimes

0 Not at all 0 Not at all

I still enjoy the things I used to I get a sort of frightened feeling

enjoy: like ‘butterflies in the stomach’:

0 Definitely as much 0 Not at all

1 Not quite so much 1 Occasionally

2 Only a little 2 Quite often

3 Hardly at all 3 Very often

I get a sort of frightened feeling I have lost interest in my

as if something awful is about to appearance:
happen:

3 Very definitely and quite badly 3 Definitely

2 Yes but not too badly 2 I don’t take as much care as I should

1 a little, but it doesn’t worry me 1 I may not take quite as much care

0 Not at all 0 I take just as much care as ever

I can laugh and see the future I feel restless as I have to be on the
side of things: move:

0 As much as I always could 3 Very much indeed

1 Not quite so much now 2 Quite a lot

2 Definitely not so much now 1 Not very much

3 Not at all 0 Not at all

74
 Worrying thoughts go through I look forward with enjoyment to
my mind: things:

3 A great deal of the time 0 As much as I ever did

2 A lot of the time 1 Rather less than I used to

1 From time to time, but not too often 2 Definitely less than I used to

0 Only occasionally 3 Hardly at all

I feel cheerful: I get sudden feelings of panic:

3 Not at all 3 Very often indeed

2 Not often 2 Quite often

1 sometimes 1 Not very often

0 Most of the time 0 Not at all

I can sit at ease and feel relaxed: I can enjoy a good book or radio
or TV Program:

0 Definitely 0 often

1 usually 1 sometimes

2 Not often 2 Not often

3 Not at all 3 Very seldom

Scoring:

Total Score: Depression (D) ______ Anxiety (A) ______

0-7 = Absent

8-21 = Present

SECTION: D

PATIENT SATISFACTION WITH NURSING CARE QUALITY QUESTIONNAIRE

(Laschinger, McGillis Hall, Pedersen & Almost, 2005)

75
Please rate some things about the nursing care during your hospital stay in terms of whether they were
Excellent, Very Good, Good, Fair or Poor. Please check only one rating for each statement.

Very
Excellent Good Good Fair Poor

INFORMATION YOU WERE GIVEN:

How clear and complete the nurses’
explanations were about tests, treatments, and
what to expect.     
EASE OF GETTING INFORMATION:
Willingness of nurses to answer your
questions.     

INFORMATION GIVEN BY NURSES:

How well nurses communicated with patients,
families, and doctors.     

INFORMING FAMILY OR FRIENDS:

How well the nurses kept them informed
about your condition and needs.     

INVOLVING FAMILY OR FRIENDS IN

YOUR CARE: How much they were allowed
to help in your care.     

CONCERN AND CARING BY NURSES:

Courtesy and respect you were given;
friendliness and kindness.     

ATTENTION OF NURSES TO YOUR

CONDITION: How often nurses checked on
you and how well they kept track of how you
were doing.     

CONSIDERATION OF YOUR NEEDS:

Willingness of the nurses to be flexible in
meeting your needs.     
HELPFULNESS: Ability of the nurses to
make you comfortable and reassure you.     
NURSING STAFF RESPONSE TO YOUR
CALLS: How quick they were to help.     

76
SKILL AND COMPETENCE OF
NURSES: How well things were done, like
giving medicine and handling IVs.     

COORDINATION OF CARE: The

teamwork between nurses and other hospital
staff who took care of you.     
RESTFUL ATMOSPHERE PROVIDED
BY NURSES: Amount of peace and quiet.     

DISCHARGE INSTRUCTIONS: how

clearly and completely the nurses told you
what to do and what to expect when you left
the hospital.     

COORDINATION OF CARE AFTER

DISCHARGE: Nurses’ efforts to provide for
your needs after you left the hospital.     
OVERALL PERCEPTIONS
Very
Excellent Good Good Fair Poor
Overall quality of care and services you
received during your hospital stay     

Overall quality of nursing care you received

during your hospital stay.     

In general, would you say your health is:     

Strongly Somewhat Somewhat Strongly
Based on the nursing care I received, I would agree agree Agree disagree disagree
recommend this hospital to my family and
friends     

THANK YOU FOR TAKING THE TIME TO FILL OUT THIS SURVEY.

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78