Selected aspects of biopsychosocial functioning during the pandemic in adult patients diagnosed with cancer

Introduction

Cancer is the second most common cause of death in the European Union, following cardiovascular diseases (EU) [1, 2]. Every year, 2.6 million people are diagnosed with cancer, and another 1.2 million die from it. According to the State of Health in the EU, although Europeans make up less than 10% of the world’s population, approximately one-quarter of all cancer cases occur in Europe, starkly illustrating the significant burden of cancer in Europe [1, 2].
For many years, the biomedical model dominated the treatment of physical diseases. According to its principles, a disease may be explained by identifying abnormalities in the functioning of the body, such as wounds, developmental problems, viruses, or gene mutations. However, this model proved to be insufficient as it failed to explain certain issues, such as: Why do individuals with similar physical conditions cope with illness in completely different ways? Why do some people develop disease more frequently than others? How is it possible that individuals in a good physical condition complain about their health status? The development of the biopsychosocial model of health has allowed for a much better understanding of those issues. According to its principles, the well-being of each individual, health, and illness are influenced by a combination of three types of factors: biological, psychological, and social. The biopsychosocial theory is an approach to understanding health and disease by considering three key aspects of human functioning: biological (bio), psychological (psycho), and social (social). This theory helps to understand how those three spheres affect the development of psychological and emotional problems and how they may be treated.
The diagnosis of cancer and the application of oncological therapies represent a unique type of stressful situation. It is associated with numerous changes not only in the areas of biological and psychological functioning but also in the social sphere, causing disruptions in the fulfilment of the social roles played by the individual [3]. The nature of cancer is primarily characterised by the fact that the symptoms do not quickly subside; on the contrary, they persist over time and tend to progressively worsen. It has an adverse impact in almost every aspect of life. Physical performance and well-being deteriorate, mental well-being worsens, and the rhythm of life changes to accommodate the illness and the necessary actions associated with it, such as taking medications, attending medical appointments, undergoing diagnostic procedures, and undergoing complex therapies. Cancer is associated with the theory of labelling (stigmatisation), particularly in Goffman’s framework that refers to the social reaction based on stereotypes about the lack of chances for effective cure and the belief in the incurability of cancer. Typical stigmatisation regarding cancer patients is based on ‘uncertainty about the future’. Cancer patients experience the stigma of having a ‘terrible disease and impending death’, and people around them often try to avoid contact due to fear of the disease and anxiety, usually stemming from a lack of skills to meet the expectations of cancer patients [4]. Within that context, the level of psychological resilience of patients seems crucial. It refers to the ability to manage emotions during critical moments, which, for many people, may be the diagnosis of cancer.
The aim of the study was to assess selected aspects of the biopsychosocial functioning of adult patients diagnosed with cancer and hospitalized during the pandemic. The specific objectives included assessment of the level of life satisfaction, perceived stress, degree of emotional control, and the patient’s belief in the ability to cope with difficult situations and obstacles among patients diagnosed with cancer. Additionally, the study aimed to determine whether those factors depend on the patient’s gender, the level of stress management across various coping strategies presented by the respondents, whether they feel lonely, and whether that loneliness is dependent on the patient’s gender.
The research hypotheses were formulated as follows:

1. The level of life satisfaction, perceived stress, degree of emotional control, and the belief in one’s ability to cope with difficult situations and obstacles is low among patients diagnosed with cancer, with men exhibiting lower levels than women.
2. Patients diagnosed with cancer generally exhibit low levels of stress management across all of the coping strategies, with men more frequently adopting task-oriented and avoidance-oriented coping strategies compared to women.
3. Patients diagnosed with cancer feel lonely, with women experiencing loneliness more frequently than men.

Material and methods

The main study was preceded by pilot studies involving a group of 20 oncology patients and 20 members of their families to verify the clarity of the questions included in the survey. It was not necessary to revise the questionnaire.
The main study, conducted in 2020–2022, involved a group of 185 patients diagnosed with cancer who were hospitalised at the Bia³ystok Oncology Centre.
The inclusion criteria for patients included a diagnosis of cancer and expressing consent to participate in the study. Respondents were given questionnaires to complete after having given verbal consent to participate, and those were distributed by a single interviewer. Participants were informed that the study was completely anonymous; participation was voluntary; it complied with the Personal Data Protection Act; the collected information would be used solely for scientific purposes; results would be presented only in aggregate form; they could withdraw from the study at any time without consequences while filling out the questionnaires; and starting the survey was considered consent to complete it. After completion, participants deposited the questionnaires into a specially prepared container located in the Surgical Oncology Department of the Bia³ystok Oncology Centre.
For the purpose of the study, a diagnostic survey method was applied, using the following questionnaires:

• a proprietary questionnaire consisting of four parts;
• the family affluence scale [5];
• the satisfaction with life scale (SWLS) by Diener, adapted in Poland by Juczyñski; the reliability coefficient of the scale (Cronbach’s) is 0.81, and the stability coefficient of the scale is 0.86 [6];
• social readjustment rating scale by Holmes and Rahe [7];
• perceived stress scale (PSS-10). The reliability coefficient of the scale (Cronbach’s ) is 0.86. Reliability established based on a two-day test-retest is 0.90 whereas a four-week test retest is 0.72 [6];
• coping inventory for stressful situations (CISS). High internal consistency of individual scales (coefficients in the range 0.78–0.90) and satisfactory stability (correlation coefficients in the range 0.73–0.80) [8, 9];
• courtauld emotional control scale (CECS). Cronbach’s  values: 0.80 for anger control; 0.77 for depression; 0.78 for anxiety; 0.87 for total emotional control [6];
• generalised self-efficacy scale (GSES) reliability – Cronbach’s  is 0.85 [6];
• de Jong Gierveld loneliness scale (DJGLS). The internal consistency coefficient Cronbach’s  is high ( = 0.89), similarly to the value of the average inter-item correlation (r = 0.42) and Loevinger’s homogeneity coefficient (H = 0.47) [10].

Statistical calculations were performed by means of Statistica 13.3 software. The analysed variables were elaborated upon in terms of basic statistics including mean, median, standard deviation, minimum and maximum values, and lower and upper quartiles. For the purpose of the statistical analysis (in order to determine relationships between variables), Pearson’s parametric correlation analysis was applied to normally distributed variables, and Spearman’s non-parametric correlation analysis was used when at least one variable in the pair had a distribution deviating from normality. A significance level of  = 0.05 was adopted for all the statistical analyses.

Results

The study involved a group of 185 patients hospitalised at the Bia³ystok Oncology Centre in the Department of Gastrointestinal Tumour Surgery. Women constituted 62% of the study group, while men accounted for 38%. The average age of the respondents was 59.2 ±1.96 years. The youngest respondent was 23 years old, and the oldest was 88 years old. The modal age of the respondents was 58 years. A significant majority of the respondents (45%) lived in towns with up to 15 000 inhabitants, while only 18% lived in rural areas.
The majority of respondents obtained scores indicating a low level of family affluence resources (50%). Only a small proportion of respondents had high affluence resources (8%).
The average score obtained by the respondents was 4.3 ±1.97 points (min. 1 point, max. 8 points), indicating an average level of affluence resources. The most frequently occurring score was 4 points, obtained by 17.8% of individuals.
In the group of respondents, the diagnosed cancers were distributed as follows: colon cancer – 36%, liver cancer – 16%, small intestine cancer – 11%, stomach or small intestine cancer – 11%, and pancreatic cancer – 9%. Ovarian cancer was diagnosed in 7% of cases.
The largest group of patients (26.5%) received their diagnosis in 2019. In 2020, the disease was diagnosed in 17.8% of the respondents, in 2018 in 17.3%, and in 2021 in 14.6% of individuals.
The average length of hospital stay for the respondents was 7.6 ±0.32 days. The minimum hospitalisation period was one day, while the longest was 18 days. The hospitalisation time varied depending on the type of cancer diagnosis: ovarian cancer had an average of 2.14 ±2.9 days, pancreatic cancer 10.74 ±4.66 days, liver cancer 10.58 ±4.58 days, colorectal cancer 7.21 ±3.67 days, stomach cancer 8.7 ±3.27 days, small intestine cancer 8.85 ±3.01 days, and cancers of uncertain or unclear nature 5.57 ±2.85 days. A statistically significant association was found between the diagnosed cancer type and the length of hospital stay (p = 0.026752).
The majority of respondents at the time of the study were undergoing planned treatment for cancer (57%). About 18% were undergoing medical examination to confirm or rule out cancer. Palliative care was being provided to 9% of patients, 4% were hospitalised for post-treatment monitoring, and 12% were hospitalised due to disease recurrence.
The majority of surveyed patients underwent colonoscopy (76%) and surgical procedures (77%). Over a half of the respondents (53%) underwent chemotherapy, and 34% received radiotherapy. A small percentage of respondents (23%) underwent gastroscopy. A statistically significant association was found between the diagnosed condition and the type of therapy administered (p = 0.000005). The results are presented in Table 1.
The vast majority of respondents believed they independently recognised the initial symptoms of their cancer process (74%). Spouses identified the cancer in 11% of respondents, incidental testing detected cancer in 8% of patients, while doctors were the first to notice disease symptoms in only 5% of patients, and other family members in 2%.
In the vast majority of cases, patients personally conveyed information about their diagnosed cancer to their families. In 35% of cases, it was the doctor who informed the patient’s family about the diagnosis. A small percentage of respondents stated that it was their children who informed the rest of the family about the cancer diagnosis (11%).
Half of the respondents (50%) stated that the information they provided to their families was sufficient. A small percentage of respondents (38%) believed the information was insufficient, while 12% had difficulty providing a clear response.
A similar percentage of respondents stated that they personally conveyed information about the planned therapy to their families (49%), and that it was done by a doctor (46%). Only 5% of patients said that their children conveyed information about the planned treatment to the rest of the family.
Just under a half of the respondents (48%) believed that the information about the planned therapy given to their families was sufficient. The group of patients who had the opposite opinion accounted for 39%, and 13% did not have a clear opinion on that matter. Fifty-one percent of the patients informed their families about the prognosis independently, 44% did so through their doctor, and 5% involved their children in conveying the information.
Just under a half of the respondents (48%) felt that the information they provided to their families about the prognosis was sufficient. On the other hand, 41% expressed the opposite opinion, feeling that the information provided was not comprehensive enough. 11% did not have a clear opinion on that matter.
The vast majority of respondents stated that they primarily took care of themselves (58%). Children were most often caregivers for 49% of the respondents, while spouses cared for 43%, sisters for 34%, and brothers for 21%. A small percentage of respondents identified friends as those who provided them with the most care (18%). The question allowed more than one correct answer to be selected; hence the values did not sum up to 100%. Analysis of the results led to the following conclusions regarding life satisfaction: 4.6% of individuals were strongly dissatisfied with their lives (including 4.3% of women and 17.4% of men); 14.1% were very dissatisfied with their lives (including 15.8% of women and 11.6% of men), 34.6% were rather dissatisfied with their lives (including 33% of women and 37.7% of men), 8.7% were neither satisfied nor dissatisfied with their lives (including 9.6% of women and 7.2% of men), 18.4% were rather satisfied with their lives (including 19% of women and 17.4% of men), 5.4% were very satisfied with their lives (including 5.2% of women and 5.8% of men), 4.3% were extremely satisfied with their lives (including 5.2% of women and 2.9% of men). The average score obtained by the respondents was 17.54 ±7.5 points (range 5– 35 points), indicating that the respondents were generally dissatisfied with their lives. The most frequently occurring score was 19 points (indicating ‘rather dissatisfied’ with life), obtained by 9.2% of individuals. Upon converting the point scores into ranges, it became evident that a majority of the respondents scored in the range indicating low life satisfaction (52%). A small group of respondents reported a high level of life satisfaction (6%).
The level of life satisfaction was lower among men (average score 16.8 ±6.9 points) compared to women (average score 18 ±7.12 points) (not significant, p = 0.788683). Upon converting the point scores into ranges, the distribution of life satisfaction among the respondents was as follows: at a low level – 47.8% of men and 43.5% of women; at an average level – 39% of men and 37% of women; and at a high level – 13.5% of men and 19.5% of women.
The distribution of life satisfaction across different age groups shows statistically significant relationships: Among respondents aged 23–40 years, 2.7% reported low life satisfaction, 3.8% reported average life satisfaction, and 1.6% reported high life satisfaction. For those aged 41–61 years, 26.5% reported low life satisfaction, 16.2% reported average life satisfaction, and 9.2% reported high life satisfaction. Among respondents aged 61–88 years, 18.4% reported low life satisfaction, 15.1% reported average life satisfaction, and 6.5% reported high life satisfaction. Those results indicate a statistically significant relationship between the age of the respondents and their level of life satisfaction. Specifically, older individuals (aged 41–61 years and 61–88 years) tend to report lower levels of life satisfaction as compared to younger individuals (aged 23–40 years), among whom a higher proportion report average to high levels of satisfaction.
The results of the survey conducted amongst respondents in terms of the scale by Holmes and Rahe are presented in Table 2. Respondents were most often impacted by bodily injury or disease (17.35%), family member’s illness (7.56%) and affluence variations (6.94%).
The relationships between stressors included in the scale and the likelihood of developing a serious illness were as follows: a 79% risk of developing a disease within the next two years was reported by 2% of respondents (4 individuals); a 37% risk was reported by 28% of respondents (52 individuals); and a risk below 37% was reported by 61% of respondents (113 individuals). The average score obtained by respondents was 56.6 ± 7.2 points.
The results obtained by the surveyed respondents in terms of the PSS-10 are presented in Table 3. During the last month, the most frequently experienced events among respondents were as follows: feeling annoyed and tense quite often (43.8%), and sometimes feeling annoyed and tense (50.3%); a sense that important matters were slipping out of control (49.7%); belief in one’s ability to cope with personal problems (47%); belief that things were going well (45.4%); managing to control irritation (45.4%); feeling that everything was turning out well (45.4%); feeling angry without having any influence on what happened (45.4%); and belief that one couldn’t cope with all responsibilities (43.2%). Analysing the responses “quite often” and “often”, the most frequently classified experience in the last month was feeling annoyed and tense (53.4%), followed by the feeling that one cannot overcome mounting difficulties (35.1%), that important matters in life were slipping out of control (31.2%), and feeling irritated because something unexpected happened (30.2%). The results are presented in Table 3.
The average score obtained by the respondents was 21.78 ±7.1 points (on a scale of 0–40 points). The most frequently occurring score was 26 points, achieved by 32 individuals, indicating a level of stress above average. The overall index, transformed into standardised units according to the properties characterising the sten scale, was interpreted as follows (Table 4): a low score (1–4 sten) was observed in 9 individuals (4.9%); an average score (5–6 sten) in 79 individuals (42.7%); and a high score (7–10 sten) in 97 individuals (52.4%). The average level of perceived stress among the respondents was higher for women (average of 22.1 ±5.62 points on a scale 0–40 points) compared to men (who scored 21.4 ±9.0 points) (not significant, p = 0.634636).
For a level of worry rated 1 (on a scale of 1–5), the average level of perceived stress was 21.2 ±6.7 points. At level 2, it was 21.7 ±5.4 points, at level 3 it was 22.1 ±5.3 points, at level 4 it was 21.9 ±4.4 points, and at level 5 it was 23.5 ±7.8 points. It indicates that the higher the level of worry reported by the respondents, the higher their perceived level of stress tended to be.
In terms of coping with stressful situations, the majority of respondents (73%) obtained a low score in the task-oriented coping strategy (TOC), while 7% scored average and 20% scored high. The average score for the respondents was 45.32 ±17.64 (on a scale of 16 to 80 points).
The vast majority of respondents (66%) achieved a high score in the emotion-oriented coping strategy (EOC). A low score was obtained by 32% of respondents, and 2% scored average. The average score obtained by the respondents was 50.1 ±18.84 points (on a scale 16–80 points). The majority of respondents (45%) exhibited a low degree of substitution-oriented coping strategy and engaged in substitute activities. The second group of respondents, however, highly preferred substitute activities (43%), while 12% exhibited an average level. The average score obtained by the respondents was 12 ±8.89 points (on a scale 8–17 points).
The largest percentage share of respondents achieved a low score in the avoidance-oriented coping strategy related to seeking social contacts (44%), while 30% scored high, and 26% scored average. The average score obtained was 18 ±4.9 points (on a scale 5–25 points).
The results obtained by the surveyed respondents in terms of the CISS questionnaire are presented in Table 5.
It was found that patients aged 25–54 showed low engagement in substitute activities in 35.3% of cases, high engagement in 51.9%, and average engagement in 13%. On the other hand, patients aged 55–79 exhibited low engagement in 44.3% of cases, high engagement in 47.9%, and average engagement in 7.6%. There was a statistically significant association between the age of the respondents and their level of engagement in substitute activities (p = 0.044791).
Male respondents more frequently than females exhibited a stress-coping strategy focused on avoidance and engagement in substitute activities. The distribution was as follows: low – 52% of males vs. 69% of females; average – 39% of males vs. 22% of females; and high – 9% of males vs. 9% of females. The average score obtained by males was 41 ± 11 points, while females scored 38 ± 10.1 points (on a scale ranging 16–80 points). However, no significant difference was observed (p = 0.118).
Tendencies towards exhibiting a TOC were as follows: low level – 3% of males and 2% of females; average level – 84% of males and 74% of females; high level – 13% of males and 24% of females. The average score obtained by females was 43.5 ±18.5 points whereas for males it was 39.7 ±15.6 points. Again, no significant difference was observed (p = 0.096085).
The results for EOC were as follows: low level – applied to 27.5% of males and 38.3% of females; average level – applied to 24.6% of males and 21.7% of females; high level – applied to 47.8% of males and 40% of females. The average score obtained by females was 44.7 ±18.9 points, whereas for males it was 50.4 ±18.6 points. No significant difference was observed (p = 0.060835) between males and females in the emotion-oriented coping strategy. The overall average score of the CECS obtained by respondents was 51 ±15.4 points (on a scale 21–80 points), indicating a fairly high ability to suppress negative emotions. Males suppressed negative emotions to a greater extent (average score 51.3 ±14.1 points) than females (average score 50.9 ±16.1 points), but the difference was not significant (p = 0.883307). The highest degree of emotional control was exhibited by individuals who indicated a worry level of  1 on a scale 0–5 (average score 57.5 ±2.12 points) and those with a worry level of 3 (average score 52.5 ±18.4 points). Individuals with a worry level of 2 obtained an average score of 50.19 ±14.6 points, those with a worry level of 4 obtained 50.9 ±14.3 points, and those with a worry level of 5 obtained 50.0 ±15.2 points.
Regarding the DJGLS, respondents obtained an average score of 13.23 ±4.4 points on a scale 11– 55 points (with a minimum score of 6 and a maximum of 26), indicating a relatively low level of loneliness among the participants. The feeling of loneliness among female respondents was generally lower as compared to male respondents (average scores were 12.6 ±4.2 points for females vs. 14.2 ±4.5 points for males). Within the range of 11–15 points on the loneliness scale, 71.3% of females and 62.3% of males fell within this category, while in the range of 16–30 points, 28.7% of females and 37.7% of males scored within this range. A significant difference (p = 0.016909) was found between females and males in terms of loneliness levels based on the DJGLS.
The respondents, according to the GSES scale, most frequently obtained scores indicating a low level of perceived self-efficacy (58.3%). A small group, only 7.1% of the respondents, showed a high level of perceived self-efficacy. The results are presented in Table 6. The average score obtained by the respondents was 22.04 ±5.11 points on a scale 10–40 points, which is an average result. The lowest score obtained by a respondent was 11 points, while the highest was 40 points.
Women obtained a lower score on average, 21.7 ±5.0 points, compared to men, who scored on average 22.6 ±5.4 points (on a scale 10–40 points), but the difference was not significant (p = 0.2072222).
It was found that the higher the degree of worry among respondents, the higher was their level of coping with difficult situations. Individuals with a worry level rated at 1 point scored an average of 18.5 ±4.9 points on the GSES scale, those with a worry level of 2 points scored 21.8 ±4.6 points, those with 3 points scored 22.0 ±4.8 points, those with 4 points scored 22.2 ±5.8 points, and those with 5 points scored 22.3 ±5.0 points.

Discussion

Cancer represents a life hazardous situation for individuals. The diagnosis alone is highly traumatic, triggering stress. On the other hand, crises arise during the course of the disease, starting from the treatment process, through changes in the course of the disease (recurrences, progression, metastases, other issues), and emotional crises (difficulty in controlling emotions, depression, anxiety, suicidal thoughts). There are also social support crises (marital and/or family problems, divorces, lack of empathy from other people) [11–13].
According to the theory by Lazarus and Folkman [14] stress is ‘a specific relationship between a person and the environment, which is perceived by the individual as burdensome or exceeding the resources, and threatening one’s well-being’. The authors [14] argue that ‘psychological stress is not located in the situation itself or in the individual, although it is conditioned by environmental factors and by the characteristics of the person in a given situation’. In a stressful situation, there is a confrontation between the skills, values, and beliefs possessed by the individual and the demands, constraints, and resources imposed by the situation. Such a relationship is termed a transaction, assuming that not only does the environment influence the person, but the person may also influence the environment [14]. The results published by Dryhinicz et al. [15] focused on verifying the relationship between the level of anxiety, acceptance of illness, and coping with stress among non-oncological and oncological patients. The study was conducted on a group of  50 oncological patients and 50 patients without any cancer diagnosis. Oncological patients obtained an average score of 54.35 points in the TOC (score range 16–80 points). The average score for the emotion-oriented coping strategy was 49.6 points among the respondents. The average score for the style describing engagement in substitute activities was 22.64 points among female oncological patients. In the stress coping strategy through seeking social contacts, the respondents scored 16.53 points [15]. In our own study, respondents scored fewer points in the TOC, specifically 45.32 points, and similarly in the engagement in substitute activities style, where they scored 22 points. They scored higher in the emotion-oriented coping strategy, with 50.1 points, and in the stress coping style through seeking social contacts, where they scored 18 points. Quality of life is described as ‘the individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns’ [16]. Assessing the quality of life in cancer patients is a significant component of holistic care. On the one hand, it allows for evaluation of the effects of treatment beyond biological and objective indicators, encompassing the patient’s subjective experience and opinion [17]. It is important to remember that patients may react differently to diagnosis and treatment, and their quality of life may depend on many factors. The study was conducted among 80 patients diagnosed with small cell lung cancer undergoing chemotherapy (cycles I and IV). It was found that regardless of the chemotherapy cycle, patients’ functioning was reduced by an average of 40–50% in physical, emotional, cognitive, and social/work-related roles. The highest scores were reported for fatigue, insomnia, and financial problems. A negative correlation was observed between the severity of fatigue and the quality of life of patients [17]. According to Zieliñska-Wiêczkowska et al. [18], in patients who started chemotherapy, lower parameters of quality of life and health status were noted, along with increased intensity of disease symptoms, especially in terms of experiencing nausea. However, Leppert [19] reported that more than a half of the patients experienced difficulties in their daily functioning. In this study, the satisfaction with life among the patients was assessed on a scoring scale, with an average score of 17.54 points, indicating that the participants were generally dissatisfied with their lives. It was confirmed after having converted the scores into stens, as the majority of respondents obtained a score indicating a low level of life satisfaction (52%). Similar results were obtained by Gliñska et al. [20], who, when assessing life satisfaction by means of the SWLS among 50 individuals with a stoma, found that there was a very low level of life satisfaction, with only slightly higher satisfaction observed among men. Conversely, Zieliñska-Wiêczkowska et al. [21] obtained a higher average score on the SWLS (20.10 ±5.57 points) for a group of 90 patients of the Clinical Gastroenterology Department and Intestinal Diseases Clinic. Kapela et al. [22] also found that their life satisfaction reached values slightly above average (55.8%) in a study of 92 patients with colorectal cancer undergoing chemotherapy in hospital settings [23]. In this study, it was found that the life satisfaction of patients impacts their perception of various family-related issues, such as a spouse/partner indifference upon learning about the diagnosis, feeling of guilt from spouses/partners regarding the illness, family members not feeling the need to utilise support services outside hospital, patients crying in the presence of their children, spouses/partners not feeling the need to quit their jobs, children limiting social contacts, and increased interest from family members directed towards the patients.
From a biological perspective, stress is defined as a reaction to stimuli that disrupt the normal homeostasis of the body, and cancer is a unique type of stressful situation acting as a biological stressor. Stress associated with cancer originates from somatic symptoms, life-threatening conditions, uncertain prognosis, and changes in both professional and personal situations. The literature [24–26] related the consequences of stress during illness refers to distinguishable effects such as mood changes and/or excessive emotional arousal; somatic changes (e.g., increased cortisol levels, elevated blood pressure); and cognitive disturbances (e.g., difficulty concentrating, obsessive thoughts inducing anxiety, disorganised thinking). Soria-Reyes et al. [25] in their study included 215 Spanish breast cancer patients who completed the PSS-10 questionnaire found that the surveyed patients obtained an average score of 21.58 points on a scale 0–40 points. That result aligns closely with the findings from our research, where the patients obtained an average score of 21.78 points.
Pilleron et al. [26] analysed 8 720 literature entries, encompassing 19 studies (11 quantitative, 6 qualitative, 2 mixed methods), primarily from the United States, Netherlands, and Belgium, with most publications dating from 2010 onwards. In those works, loneliness was assessed by means of the DJGLS and the UCLA loneliness scale. It was found that 50% of individuals reported feeling lonely, often correlated with depression and anxiety. The authors [26] emphasise that loneliness may intensify during the first 6–12 months of treatment. None of the studies have investigated the impact of loneliness on the care of cancer patients and health outcomes. Rêbia³kowska-Stankiewicz [27] emphasised that ‘loneliness, alongside love, freedom, and growth, can be counted among the fundamental values describing the character of human life. It is a common, universal, timeless phenomenon. It affects people in every phase of their development. It appears particularly challenging in chronic illnesses.’ Hejwosz [28] on the other hand, pointed out that in illness, factors contributing to loneliness include lack of full information about the disease, haste, paternalism, and lack of support or inadequate support, while acknowledging that having a large family does not preclude loneliness. Within the framework of the study conducted by Kornaszewska-Polak et al. [29] as many as 53% of patients reported to have experienced loneliness in various types of interpersonal relationships but most acutely in close relationships (romantic and sexual relationships).
The specific course of cancer and its invasive treatment methods categorise it as a severe chronic illness. That type of illness is always accompanied by anxiety, fear of pain, and a disruption of basic life values and goals. Social myths about cancer, suffering, and the likely prospect of death exacerbate this anxiety. The accumulation of all those factors may lead to a distorted perception of one’s own health situation and the emergence of feelings of loneliness in the battle against cancer. In this study, the level of loneliness has also been assessed by means of the DJGLS. Patients obtained an average score of 13.23, indicating a relatively low sense of loneliness among the respondents. Among female patients, the sense of loneliness was lower compared to male patients. This study also found the sense of loneliness among patients to influence their perception of various family-related issues, such as spouses/partners’ indifference to the news of the cancer diagnosis, emotional support from spouses/partners in the face of illness, and the determination of surveyed children to strive for a better future.
Kopczyñska-Tyszko [30] emphasised that loneliness is most commonly experienced negatively (as social isolation) and limits individual development, disrupting normal functioning. Its opposite is positively experienced loneliness (good solitude) that may be seen as an opportunity for personal growth, motivating the patient to seek the meaning and integrate the illness into her or his life story. Unfortunately, negative loneliness combined with the experience of a chronic and poorly prognosed disease does not promote effective coping strategy with the consequences of cancer [30]. Kurowska et al. [31] examined 78 patients undergoing oncological therapy at the Oncology Center in Bydgoszcz and based on the analysis of stress coping strategies. They found that the most commonly used strategy by the respondents was the task-oriented one (a correct response to stress). At the same time, there was a higher level of emotional reactions as compared to avoidance reactions. Dryhinicz et al. [15], in their study involving 50 women with oncological and non-oncological diseases, found that statistically significant differences occurred only in the case of the EOC, which was more frequently indicated by oncological than non-oncological patients [15]. Mazurkiewicz [32] analysed coping strategies in a stress situation among a group of 40 women undergoing radiation therapy due to malignant tumour at the Oncology Center of the Lublin Region. A significant positive correlation was found between post-traumatic growth and the TOC and avoidance-oriented coping strategy. Women with low levels of post-traumatic growth showed a low level of the TOC, an average level of the emotion-oriented coping strategy, and an average level of the avoidance-oriented coping strategy. The participants exhibited an average level of engagement in substitute activities and a low level of seeking social contacts. Women with average levels of post-traumatic growth demonstrated an average level in each coping strategy in stressful situations and in both forms of avoidance-oriented coping strategy. Women with high levels of post-traumatic growth achieved an average score in the TOC, a low level in the emotion-oriented coping strategy, and a high level in the avoidance-oriented coping strategy. They exhibited a high level of engagement in substitute activities and an average level of seeking social contacts [32]. Basiñska [33] studied strategies applied by women with gynaecological cancer and found that they more frequently used emotion- and avoidance-oriented strategies as compared to healthy women, and less frequently used task-oriented strategies. In this study, respondents unfortunately scored low (73%) in the TOC but scored high in the emotion-oriented coping strategy, and low in the avoidance-oriented coping strategy and engagement in substitute activities. They also scored low in the avoidance-oriented coping strategy in terms of seeking social contacts. It was also noted that patients’ coping strategies influenced their perception of selected family-related issues, such as spouses/partners experiencing anxiety and sadness, partners becoming accustomed to the cancer diagnosis, spouses/partners finding it difficult to care for children, and children feeling indifferent about the future of their parent.
The process of cancer, as it has already been mentioned, brings about a series of adverse effects and changes in many aspects of life. Patients are clearly exposed to psychological trauma associated with the treatment process, which often causes changes in the patient’s physical appearance. Strong emotional reactions, as a response to the health and life hazard, constitute a natural phenomenon in cancer. Intensely experienced unwanted emotions, such as anxiety, fear, anger, resentment, and sadness, are sources of psychological and physical discomfort. Each person has his or her own way of coping with difficult emotions. Some need to talk to loved ones, some seek activities to distract themselves from the source of distress, while others cry. In this study, the majority of patients (42%) admitted to frequently crying in the presence of their spouses/partners (42%) or children (45%). Each coping mechanism is valid. Suppressing emotions is also a defence mechanism of the body, but it has an adverse effect on the patient’s mental health. Gliñska et al. [34] conducted a study among 100 patients with breast gland cancer. The majority of the respondents exhibited a fairly high overall emotional control index, which intensified with age. The authors [34] observed an intensification of emotional suppression in the anger scale throughout each stage of the illness. Similarly, in this study, the average overall score on the CECS obtained by the respondents was 51 points, indicating a fairly high ability to suppress negative emotions. At the same time, it was found that men tended to suppress negative emotions to a greater extent than women. It was also noted that the degree of emotional suppression among patients influenced their perception of selected family-related issues. Those issues included denial by spouses/partners in response to the diagnosis, lack of need for assistance outside the hospital for the surveyed children, denial of crying in the presence of spouses/partners, concern by spouses/partners about financial security, perception of worsened financial standing by spouses/partners, necessity for children to limit social contacts, and children’s desire to compensate for the ill parent’s disease.
Following hypothesis testing, Hypotheses 1 and 2 were found to be partially supported, while Hypothesis 3 was strongly supported.

Conclusions

In the group of patients with cancer, a low level of life satisfaction, high levels of perceived stress, a fairly high ability to suppress negative emotions, low effectiveness in coping with difficult situations and obstacles, and a relatively low level of loneliness were observed.
Respondents with cancer presented low levels of the TOC and the avoidance-oriented coping strategy in both aspects, and a high level of the emotion-oriented coping strategy.

Limitations of the study

The research was conducted January 2020 and December 2022, i.e. during the COVID-19 pandemic, which made data collection more difficult due to the reduced number of hospitalized patients. Therefore, it is worth increasing the group of examined cancer patients in the future. It is also worth comparing the research results from the pandemic period with the group of patients after the pandemic.

Disclosures

1. Institutional review board statement: The study has been approved by the Bioethics Commission of the Medical University of Bia³ystok (APK.002.175.2020) and the Directorate of the  Bia³ystok Oncology Centre.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References