Stress coping among people undergoing surgical treatment for pancreatic cancer

INTRODUCTION

Stress is an individual’s reaction to stimuli experienced – at various stages of life – that force the need to adapt to a changing situation [1]. Most definitions of the concept are based on the idea that a stressful reaction is a disruption or announcement of an imbalance between an individual’s resources and a disruption between their predispositions and environmental conditions [2]. The prerequisites for a stressful situation are internal or external demands that significantly exceed or limit the individual’s adaptability, related to adequate cognitive evaluation, and causing negative emotional experiences. Consequently, measures must be taken to improve the emotional state and regain the balance be-tween their capabilities and the demands, referred to as “stress coping” [1]. The perception of stressful situations and triggered reactions are individualised, and coping proves the potential problem-solving capabilities and influences the choice of a pro- or anti-health lifestyle [3].
A stressor that has a significant impact on peoples’ lives in the emotional, cognitive, existential, and social spheres and requires them and their loved ones to cope with the difficulties that arise is disease. Because it contributes to a significant burden on the body, it causes the development of a stress reaction and exceeds the adaptive capabilities of the individual [4, 5]. The diagnosis of malignant disease is considered one of the most stressful life events and the cause of the occurrence of negative emotions revealed in the form of anger, disorders of a depressive nature, anxiety disorders, or somatic symptoms resulting from both the disease and the ongoing treatment. Increased feelings of distress among those with the disease can cause feelings of helplessness, fear, and sadness and lead to social isolation or spiritual crisis [6, 7].
Medical activities undertaken for diagnostic, therapeutic, rehabilitative, or nursing purposes are a source of psychological stress. Undergoing surgical treatment is a particularly difficult situation, which verifies the level of stress coping skills in view of the surgical activities undertaken. The surgical procedure requires adaptation or coping to gain control over one’s own emotions. Otherwise, this type of stress can contribute to exceeding individual resources and hinder recovery from surgical treatment [8, 9]. The treatment team’s understanding of the ways in which the patient struggles with oncological disease can significantly condition the treatment process throughout the perioperative period [10, 11].
The ability to cope with stress in the face of oncological disease is affected by, among others, personality and environmental conditions, which are variables that modify the relationship between coping and the occurrence of cancer. Individuals struggling with oncological disease show different reactions in relation to their own subtle configuration of cognitive functions, behavioural stereotypes, and emotional responses. This type of action is relatively constant and is used at different stages of the disease. Emotional and personal determinants based mainly on negative emotions expressed through pessimism, low self-esteem, worry, reduced mood, and lack of predisposition to use support significantly hinder the process of coping with the disease [6, 11, 12].
The aim of this study was to evaluate the stress coping of people undergoing surgical treatment for pancreatic cancer.

MATERIAL AND METHODS

The study included 69 patients undergoing surgical treatment for pancreatic cancer at a Krakow hospital between November 2020 and June 2021. The Inclusion criteria for participation in the study, in addition to the diagnosis, were age between 18 and 80 years, female/male sex, planned hospital admission, surgical treatment applied, at least one day after the surgical procedure performed, and informed consent given to participate in the study. A diagnostic survey was used to conduct the study. Document analysis, interview, and scale were chosen as techniques, and data were collected using the Inventory for the Measurement of Coping with Stress – Mini-COPE [13, 14], electronic medical records, and the author’s interview questionnaire. The questionnaire allowed the collection of information regarding sociodemographic data, disease history, the subjects’ ways of coping with stress, and social support.
Statistical analysis was carried out in the statistical environment of R ver. 3.6.0, the PSPP program, and MS Office 2019. Parametric tests (Student’s t test or ANOVA analysis of variance) or their non-parametric equivalents (Mann-Whitney U test or Kruskal-Wallis test) were used to analyse quantitative variables. The choice of tests was dictated by the distribution of variables, verified by the Shapiro-Wilk test. Pearson’s chi-square test was used to analyse qualitative variables. Correlations between variables were made using Spearman’s rank correlation coefficient. The level of statistical significance was adopted as p < 0.05.

RESULTS

Among the total 69 subjects, women accounted for 52.20% and men for 47.80%. The youngest person was 52 years old, and the oldest was 78 years old (mean age 65.35 ±7.94 years). Married couples accounted for 72.50% of the respondents, and 92.80% were parents. Most of the respondents had a university education (65.20%). The place of residence for more than half of the individuals (59.40%) was a large city. Residence with family made up 82.60% of the total. The majority of the respondents had retired status (59.40%), while the employed group accounted for 23.20%.

COURSE OF DISEASE AND CURRENT TREATMENT

All respondents were admitted to the hospital on a scheduled basis. At the time of hospital admission, 82.60% of the respondents had symptoms indicative of pancreatic cancer – most of them reported pain (77.19%). The first symptoms were noticed between 2 and 6 months before surgery by 60.40% of the respondents, while a small percentage (7.50%) noticed symptoms more than a year before surgery. The presence of risk factors for pancreatic cancer was confirmed by more than half of the respondents (52.20%). Among them, 66.66% indicated smoking and 55.55% obesity. At the time of survey, the respondents had been in the ward an average of 4.81 ±1.45 days, and they were an average of 3.71 ±1.53 days after surgery. Respondents were most likely to have had the procedure performed using the laparotomy technique, at 82.60%, while the remaining patients were subjected to laparoscopic surgery. More than half of the procedures were performed using the Whipple method – 59.40%, while 11.60% were performed using the Traverso method, peripancreatic resection was performed in 17.40% of the patients, and central pancreatic resection in 11.60%.
Most of the respondents (76.80%) indicated the occurrence of special difficulties during the current treatment. As the main source of difficulties, 67.92% of them pointed to perceived pain. The mean value of the intensity of perceived pain assessed on the NRS scale was 4.91 ±1.28. After surgery, more than half of the patients (53.60%) developed a moderate deficit in self-care, as a result of which they required systematic nursing care, assistance, and motivation, while the remaining patients (46.40%) required intensive care and nursing, due to a complete lack of self-care ability.

PERCEPTION OF STRESS AND STRATEGIES OF COPING WITH STRESS PREFERRED BY THE SUBJECTS

Perception of stress was confirmed by more than half of the respondents (58.00%). The patients who admitted to currently feeling stress stated health problems as the cause. The average level of perceived stress in the study group was 3.65 ±3.28 points (marked on a 10-point scale).
Patients presented different groups of strategies of coping with stress – most often problem-focused. The obtained results based on the Inventory for the Measurement of Coping with Stress – Mini-COPE are presented in Table 1.
Respondents most often used active coping, planning, acceptance, and seeking emotional support in the coping process. The strategies used (based on the Inventory for the Measurement of Coping with Stress – Mini-COPE) are presented in Table 2.
Patients took various measures to cope with stress during their hospital stay. The most common were talking to loved ones (70.00%) or medical personnel (60.00%) and reading (50.00%). Support in a stressful situation was expected by 75.40% of the respondents – 76.92% of them expected conversation, 61.54% expected information, and 53.85% expected consolation. Asking for help in a stressful situation was confirmed by 69.60% of patients. All survey participants declared having a source of support and most often pointed to children (94.20%) and spouses (75.36%).

RELATIONSHIPS BETWEEN RESPONDENTS’ COPING STRATEGIES PRESENTED AS WELL AS DEMOGRAPHIC FACTORS, COURSE OF DISEASE AND CURRENT TREATMENT, STRESS-RELATED FACTORS, AND SOCIAL SUPPORT

• Coping strategies vs. sociodemographic variables Statistical analysis showed no statistically significant relationship between coping strategies and respondents’ age and education, living alone or with family, having children, and gender (p > 0.05). Those in a relationship were significantly more likely to use the strategy of emotional relief (p = 0.021). Residents of rural areas or small towns were significantly more likely than residents of large cities to use an acceptance strategy (p = 0.035). Surveyed retirees and pensioners were statistically significantly more likely to choose the acceptance strategy (p = 0.001). Table 3 presents the data.
The results obtained showed no statistically significant correlation between the subjects’ age, gender, marital status, level of education, occupational activity, having children, place of residence and living alone or with family, and the individual groups of strategies in coping with stress (p > 0.05).
• Coping strategies vs. course of disease and current treatment It was shown that patients who observed the first symptoms of pancreatic cancer were significantly more likely to use a self-blame strategy (p = 0.039), and significantly less likely to use a distraction strategy (p = 0.023). Respondents who observed their first symptoms up to 6 months prior to the surgical procedure were significantly less likely to use an emotional relief strategy compared to those who observed their first symptoms more than 6 months prior to the surgical procedure (p = 0.046). Subjects with pancreatic cancer risk factors were statistically significantly more likely to use a strategy of turning to religion (p = 0.021), as well as seeking emotional support (p = 0.004) and seeking instrumental support (p = 0.042), compared to subjects with no risk factors. The results of this study showed no statistically significant correlations in the stress coping strategies used and the technique of surgery (laparotomy, laparoscopy), the day of hospitalisation, and the presence of cancer symptoms during hospital admission (p > 0.05). It was shown that the longer the respondents were after surgery, the more often they used a strategy of cessation (R = 0.276, p = 0.021), and that among the subjects, as the severity of their current pain treatment increased, the frequency of using humour strategies decreased (R = –0.255, p = 0.034). Patients with a moderate deficit in self-care were statistically significantly more likely to use distraction strategies (p = 0.001) compared to subjects with a complete lack of self-care.
Respondents with cancer risk factors were significantly more likely to present an emotion-focused strategy group compared to those without these factors (p = 0.014). No statistically significant differences were obtained between the presented groups of coping strategies and noticing or not noticing the first symptoms of pancreatic cancer, the period of noticing the first symptoms of cancer, the presence of cancer symptoms during admission to the hospital, and the technique of surgery, the day of hospitalisation, the day after surgery, and the severity of pain complaints. Subjects with a moderate deficit in self-care were statistically significantly more likely to use avoidance strategies (p = 0.037) compared to subjects with a complete lack of self-care.
• Coping strategies vs. stress-related factors Statistical analysis showed that the frequency of cessation strategies decreased with the severity of stress in the subjects (R = –0.303, p = 0.011). There was no statistically significant correlation between the level of perceived stress and the use of other strategies (p > 0.05). The results of the study confirmed that the frequency of avoidance-focused strategy groups decreased with the severity of stress in the subjects (R = –0.252, p = 0.037).
However, there were no statistically significant correlations between the presented groups of coping strategies and the the belief in the ability to cope with a stressful situation, perceived emotions, the occurrence of a difficult recent life event, and the perception of disease (p > 0.05).
• Coping strategies vs. social support There were no statistically significant differences in coping strategies used and strategy groups presented between those who expected support in a stressful situation and those who did not, and those who sought help in a stressful situation and those who did not (p > 0.05).

DISCUSSION

Hospitalisation and the interventions taken significantly reduce the mental and physical functioning of the patient. Malignant disease management includes various forms of treatment. It is often aggressive in nature, and surgical treatment is an additional source of perceived stress for patients [15]. Current medical procedures for surgical intervention are aimed at either radical excision of the cancer or alleviation of the symptoms present [16].
The level of perceived stress and the coping strategies undertaken by people who experience malignant disease and undergo various medical procedures have been the subject of many studies. Szadowska-Szlachetka et al. conducting a study on perceived stress among hospice patients experiencing various types of cancer showed that the severity of stress on a 0-10 point scale was at an average level (4.08 ±2.09) [17]. In comparison, in a study conducted by Car et al. the mean level of perceived stress among patients with lung cancer or after mastectomy was 4.53 ±2.98, while among women after mastectomy it was 5.74 ±2.86, and among those with lung cancer it was 3.27 ±2.37 points [18]. The intensity of perceived stress among patients after orthopaedic surgery in the study by Sobieralska-Michalak et al. was at 2.65 ±1.67 points on the day of surgery and had a decreasing trend [19]. In our study, the average level of perceived stress among patients was 3.65 ±3.38 points, which can be interpreted as a moderate intensity of perceived stress.
Baczewska et al. showed that patients treated with chemotherapeutic agents most often used the strategies of fighting spirit and positive reevaluation in coping with stress. These strategies were particularly notable among individuals with current glioma or breast cancer, while patients diagnosed with bladder, reproductive organ, breast, and pancreatic tumours most often used the strategies of anxiety preoccupation and helplessness [20]. Patients after mastectomy or bowel stoma removal participating in the study by Glińska et al. most frequently used the strategies of positive reevaluation and fighting spirit, and least frequently used the strategy of helplessness. Presentation of a constructive style was predominant among the subjects [21]. Our own study showed that patients with pancreatic cancer, in the course of surgical treatment, mainly presented a problem-focused strategy group, considered constructive, most often using the strategies of active coping, planning, acceptance, and seeking emotional support. The indicated strategies can be categorised as active forms of coping, influencing reduced feelings of stress.
In Baczewska’s study, the use of anxiety preoccupation and hopelessness/helplessness strategies increased with the subjects’ age, while the use of fighting spirit strategies decreased [20]. Similarly, in a study conducted by Kulpa et al. the attitude of helplessness positively correlated with the age of the subjects treated with various methods in cancer clinics [22]. On the other hand, Mziray et al. indicated that individuals over the age of 60 years were significantly more likely to present an emotion-focused style compared to younger individuals [7]. In our study, there was no correlation be-tween the strategies used and coping group strategies presented and the subjects’ age. This may be due to the fact that there was little variation by age among the subjects – the majority were patients of advanced age.
A study by Humeniuk et al. among laryngectomy patients confirmed the more frequent use of constructive strategies among women compared to men, more often indicating destructive strategies [23]. A study by Baczewska et al. also found that women were more likely to present a constructive coping style, while showing significantly higher levels of anxiety preoccupation [20]. Gender differences in the use of stress coping strategies were not confirmed in Mziray’s study [7]. The results of our own study also did not confirm significant relationships in this area. Rogala et al. found that women with cervical cancer who were in relationships were more likely to use the strategy of hopeless-ness/helplessness, as well as positive reevaluation, compared to single women [24]. A study by Pasek and Jackowska among post-mastectomy women indicated that individuals who were divorced or not in a relationship most often showed use of anxiety preoccupation and helplessness and hopelessness strategies [25]. Humeniuk et al. showed that singles were less likely to use the fighting spirit strategy and positive reevaluation [23]. Our own study showed that persons in a relationship were more likely to use the strategy of emotional relief compared to single persons. In a study conducted by Mziray et al. subjects with higher education were significantly more likely to show a solution-focused style [7], and a fighting spirit or positive reevaluation dominated in patients with higher education in studies by Humeniuk et al. [23] as well as Pasek and Jackowska [25]. Rogala et al. found no differences between education and the coping strategies used [24]. Our own study also did not confirm significant relationships between the coping strategies used and the education of the subjects.
A long period of treatment and development of the disease can lead to the depletion of protective resources of the mental state. Łosiak, studying the emotional processes and coping capacities of patients during a period of increased stress due to illness, hospitalisation, and surgical treatment, proved that the use of coping forms decreases after surgery, and that longer hospitalisation promotes the use of problem-focused and emotion-directed strategies to a lesser extent [15]. Similarly, the results of our own study showed that, in general, the longer the patients were after surgery, the more often they used the strategy of cessation. Experiencing a difficult health situation and deciding to undergo surgery triggers a variety of coping mechanisms, especially active ones, that are focused on the problem. On the other hand, the post-operative period, due to its nature, is a time of waiting for the positive effects of treatment undertaken, and there-fore periodic cessation of activities can be observed in patients.
Pain in the course of malignant disease is a difficult experience, and surgical treatment intensifies the perceived dis-comfort. The stress and strong emotions experienced can reduce the level of tolerable pain [19]. A study conducted by Szadowska-Szlachetka et al. confirmed that the higher the intensity of pain among the subjects, the more often they used the strategies of reevaluating the pain experience and distraction, while the strategies of hoping and praying were used less often [17]. In our study, patients were less likely to use the strategy of humour as their pain complaints in-creased.
Social support in a stressful situation in the course of malignant disease has an important protective function. Due to its multidimensional nature, it enables the expression of negative feelings, release of tensions, and influences remedial action and understanding of the current situation [26]. Michałowska-Wieczorek’s research on the role of support in struggling with malignant disease showed that the lower the index for perceived support, the higher the presentation of helplessness and hopelessness [26]. Wyszomirska et al. showed that in a group of patients undergoing palliative treatment, perceived support and its seeking were important for the use of constructive coping strategies, while subjects undergoing radical treatment who had higher support needs were more likely to use the fighting spirit strategy [27]. In our study, there was no correlation between the applied strategies and presented strategy groups of coping with stress and factors related to social support.
Research on the issue of coping with stress in the course of malignant disease is extremely important, especially in view of the epidemiological data confirming the steady increase in the incidence of oncological diseases. Evaluation of the occurrence and severity of perceived stress by a patient undergoing surgical treatment for cancer, as well as the methods of coping with stress used, should be carried out by all members of the therapeutic team. Knowledge of the above allows the implementation of adequate interventions to facilitate the healing process after surgery.
The presented results of our study expand the database in the area of coping with difficult surgical treatment among patients, in this case for pancreatic cancer. However, due to the limited number of respondents (69 subjects) and the conduct of this study in only one facility, the results cannot be considered fully representative. It should be remembered that the study was conducted during the pandemic period. It was a time of social isolation and growing fear for one’s own health or life, which influenced the respondents’ decisions regarding the coping strategies used to deal with stress.

CONCLUSIONS

Most of the respondents admitted to experiencing stress, and the level of stress was moderate.
The most frequently presented strategy groups of coping with stress in disease was problem-focused. In the coping process, respondents used various strategies – most often active coping, planning, acceptance, and seeking emotional support.
Treatment plans and care provided to oncological patients by members of the interdisciplinary treatment team should take into account the coping strategies shown by post-operative patients, and appropriate interventions should be implemented aimed at shaping patients’ constructive coping skills.
Patients’ coping strategies in the course of malignant diseases should continue to be the subject of research aimed at sensitising professionals to their importance in the treatment process of oncological patients.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References