The Understanding and Emotional State of Patients About to Undergo Visceral Surgery for Cancer

Many patients feel anxious prior to visceral surgery for cancer. Patients need to have an adequate understanding of what is involved before they can decide to undergo such a procedure. Adequate patient understanding, also known as health literacy, is defined as the ability of a patient to understand information about health, treatment options, and medical instructions and to participate in informed decision-making. There is evidence to suggest that psychological stress can impair the understanding of information (1). In this context, a negative relationship between health literacy and emotional stress and a positive relationship between level of education, health literacy and subjective awareness are assumed to exist (2).

Methods

Altogether 114 adult patients were surveyed about their emotional state and understanding prior to undergoing visceral surgery for cancer at the University Hospital Halle and after their surgical informed consent discussion. The questionnaire covered health literacy (Health Literacy Survey – HLS), symptoms of anxiety and depression anxiety and depression (Hospital Anxiety and Depression Scale – HADS) and include German translations regarding the subjective feeling of being well informed (Informed Decision Making – IDM), as well as anxiety related to the surgical procedure (Surgical Anxiety Questionnaire—SAQ). In addition, the patients rated on a visual analog scale how likely they thought they were to experience surgical complications. Examples of the complications were provided and classified according to their severity using the Clavien-Dindo classification (CD1: deviation from the normal postoperative course, without invasive treatment; CD2: pharmacological treatment with drugs, parenteral nutrition, blood transfusion; CD3: surgical, endoscopic or radiological intervention; CD4: life-threatening complication, intensive care unit (ICU) management; CD5: death of patient) and subsequently compared with the complication rates published in the scientific literature (3).

The study was approved by the local ethics committee (MLU 2021–223). Statistical analysis was performed using the SPSS software package and Pearson correlations between the variables health literacy, psychological stress, age, and informed decision-making were determined. One-factorial ANCOVA and the Bonferroni-corrected post hoc test were used to analyze potential disparities in psychological stress and health literacy in the context of various educational attainment levels.

Results

Altogether 114 patients (median age 67; 42.1% female) were included in the study. Of these, 17.5% had no formal school-leaving qualifications and 65.8% had an intermediate school-leaving qualification (general secondary school, intermediate secondary school, university preparatory high school, A-levels, vocational baccalaureate). Fourteen percent of the patients held high-level educational qualifications (university degree) (3 patients with no response). The patients underwent elective surgery of the gastrointestinal tract or the hepatopancreatobiliary system for cancer.

There was a moderate negative correlation between health literacy and psychological stress, with lower health literacy correlating with higher psychological stress (HADS:r = −0.425, 95% confidence interval [−0.57; −0.25] and SAQ:r = −0.369, [−0.52; −0.19]). A moderate positive correlation was found between HLS and IDM. The greater the health literacy of the patients, the more informed they perceived themselves to be (r = 0.495 [0.33; 0.63]).

The psychological stress (HADS) differed across the various educational attainments after adjusting for sex and age (F[2.98] = 3.42, p = 0.04, partial η² = 0.07)). There was a difference between no school-leaving qualifications and intermediate qualifications (p = 0.035, M_Diff = 6.38 [0.34; 12.42]). No difference was found between the remaining groups (Figure 1).

Figure 1

Mean values with standard deviation of psychological stress (HADS) and of health literacy (HLS) of patients with different educational qualifications.*1 p = 0.035, *2 p = 0.009

After adjustment for sex and age, health literacy differed by the various educational attainments (F[2.98] = 4.79, p = 0.01, partial η² = 0.09), with a difference between a high qualification and no qualification (p = 0.009, M_Diff = 8.06, [1.63; 14.49]) (Figure 1).

A weak negative correlation was found between age and the subjective feeling of being well informed (r = −0.233 [−0.41; −0.04]) and health literacy (r = −0.210, [−0.39; −0.02]). The available data did not reveal any sex-specific differences with regard to psychological stress.

Less than 60% of patients were able to realistically assess complications, with the exception of CD5 (death). With increasing severity of the complications, patients assessed these more realistically, with patients with higher levels of psychological stress showing a tendency to overestimate complications (Figure 2).

Figure 2

Mean values with standard deviation of the Hospital Anxiety and Depression Scale (HADS) scores of patients who underestimated, realistically estimated and overestimated complications.

Discussion

The results of our survey reveal potential correlations between psychological stress and the understanding of patients prior to undergoing visceral surgery for cancer. Interventions to optimize patient understanding could be particularly beneficial for older patients and those with a lower educational qualification, as they had a more limited patient understanding.

A positive correlation was found between health literacy and informed decision-making. Results published in the literature show that patients with lower health literacy are poorer at understanding information and therefore less likely to be involved in informed decision-making (2).

Patients find it very difficult to assess the likelihood at which complications may occur and patients with higher levels of psychological stress tend to overestimate complications. For this reason, surgeons should critically assess their patients’ level of understanding and encourage active involvement in the informed consent process. Using this approach, a reduction in preoperative anxiety could ultimately lead to better postoperative outcomes (4).

The findings imply a need to take into account the individual emotional states of the patients in the legal assessment of the informed consent discussion to ensure that an adequate informed consent discussion was held and the patients are capable of making an informed decision.

Consequently, the recommendation was made to use self-description questionnaires (HADS grade of recommendation: A) to identify any psychological stress so that, for example, a specific psycho-oncological assessment can be initiated and informed decision-making can be promoted (5).

A limiting factor is the small number of patients in the individual groups classified according to educational qualification. In addition, patients can develop biased expectations due to psychological stress, which only become apparent later in the clinical course.

Tina Gürlich, Peter Szatmary, Ulrich Ronellenfitsch, Heike Schmidt, Jörg Kleeff

Conflict of interest statement
The authors declare no conflict of interest.

Manuscript received on 18 February 2024, revised version accepted on 27 May 2024

Translated from the original German by Ralf Thoene, M.D.

Cite this as:
Gürlich T, Szatmary P, Ronellenfitsch U, Schmidt H, Kleeff J: The understanding and emotional state of patients about to undergo visceral surgery for cancer. Dtsch Arztebl Int 2024; 121: 750–1. DOI: 10.3238/arztebl.m2024.0119

References

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2. Mancuso CA, Rincon M: Asthma patients‘ assessments of health care and medical decision making: the role of health literacy. J Asthma 2006; 43: 41–4

3. Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205–13

4. Ali A, Altun D, Oguz BH, Ilhan M, Demircan F, Koltka K: The effect of preoperative anxiety on postoperative analgesia and anesthesia recovery in patients undergoing laparascopic cholecystectomy. J Anesth 2014; 28: 222–7

5. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Psychoonkologische Diagnostik, Beratung und Behandlung von erwachsenen Krebspatient*innen, Langversion 2.1, 2023, AWMF-Registernummer: 032–051OL. www.leitlinienprogramm-onkologie.de/leitlinien/psychoonkologie/ (last accessed on 28 April 2024).