Perception of cancer in patients diagnosed with the most common gastrointestinal cancers

Background Gastrointestinal cancers, including colorectal cancer, stomach cancer and pancreatic cancer are among the most common cancers in Poland. Cancer patients usually assess their quality of life much worse than the general population, while negative emotions associated with the illness may affect the results of treatment. Methods The study involved 378 patients with colorectal cancer, stomach cancer and pancreatic cancer, treated as outpatients at the Oncology Center - Maria Skłodowska-Curie Institute in Warsaw in 2013–2018. Standardized tools were used in the study: the Beliefs about Pain Control Questionnaire (BPCQ), the Pain Coping Strategies Questionnaire (CSQ), Approval Illness Scale (AIS), Mental Adjustment to Cancer (MiniMAC). The main goal of the study was to assess pain control, pain management strategies, illness acceptance and adaptation to cancer in patients with the most common gastrointestinal cancers. Results Patients with gastrointestinal cancers ascribe the greatest role in controlling pain to internal factors (M = 16.84, SE = .34), and the highest score in this area was obtained by patients with colorectal cancer (M = 17.33, SE = .35). The most frequently chosen strategy is declaring coping (M = 20.95, SE = .57), although patients with pancreatic cancer obtained a high score also in the area of catastrophizing (M = 17.99, SE = 1.14). The average value of illness acceptance for patients with gastrointestinal cancers was M = 25.00 (SE = .50) and it was the lowest in the group of patients diagnosed with pancreatic cancer (M = 23.41, SE = 1.16), and the highest in a group of people with colorectal cancer (M = 27.76, SE = .51). Patients with gastrointestinal cancers obtained the highest values of the MiniMAC test in the area of the fighting spirit (M = 21.30, SE = .25), characteristic mainly for patients with colorectal cancer. Patients with pancreatic cancer were characterized by high anxiety and helplessness/hopelessness. Conclusions Patients with gastrointestinal cancers use different methods of pain control and pain coping strategies, with active behaviors being preferred by patients with colorectal cancer and destructive - by patients with pancreatic cancer. The majority of socio-economic variables, as well as the treatment method, affect the patients’ behaviors.


Background
Cancer, especially at its advanced stage, affects both the reduction of the physical functioning of the patient (mainly due to the strong pain experienced), but it also affects psychological aspects. Cancer patients usually assess their quality of life much worse than the general population, and this assessment may be related to both the severity of the illness and various sociodemographic features [1].
Gastrointestinal cancers are among the most common in Poland. Colorectal cancer is the second most common cancer in women (after breast cancer) and the third in men (after lung and prostate cancer). In terms of mortality, it is the second most common cause of cancer deaths among men (after lung cancer) and the third most common among women (after lung and breast cancer). Generally, the standardized incidence rate of colorectal cancer in Poland is 23.9/100,000 people, and mortality rate 14.0/100,000 people [2].
Stomach cancer is the fifth most common cancer in men, being the fourth most common cause of death due to cancer among this group of Poles. Currently, the standardized rate for developing stomach cancer in Poland is 7.7/100,000 people, and the mortality rate is 7.4/100,000 people [3].
Pancreatic cancer is the fifth leading cause of death in women and the sixth in men due to cancer. The standardized incidence rate for pancreatic cancer in Poland is 4.8/100,000 people, and the mortality rate -6.4/100, 000 people [4].
Limitations resulting from the treatment of gastrointestinal cancer can significantly affect the quality of life of patients. The acceptance of the diagnosis of cancer and related discomfort of life, pain, and reduced independence is of crucial importance in this respect. Cancer affects many aspects of functioning, both the physical and mental spheres as well as the functioning in society.
In turn, stress or anxiety that patients may feel at any stage of diagnosis or treatment may affect each of these spheres, causing the intensification of many negative emotions associated with the illness in patients. However, studies indicate that a passive or destructive approach to the illness significantly reduces quality of life assessed by patients, and many sources confirm that the approach to cancer significantly affects the results of treatment [5,6].
The main objective of the study was to assess pain control, pain coping strategies, acceptance of illness and psychological adaptation to cancer in patients with the most common gastrointestinal cancers in Poland. The influence of socioeconomic variables on the obtained results as well as the dependence of these results on the diagnosis of metastases and the type of treatment applied were also examined.

Methods
The study was conducted between 2013 and 2018 among representative sample of 378 patients with gastrointestinal cancers being outpatients of the Oncology Center -Maria Skłodowska-Curie Institute in Warsaw. Inclusion criteria involve: age over 18 years, diagnosis of gastrointestinal cancer (stomach, colorectal or pancreatic cancer), ongoing cancer treatment (chemotherapy, radiotherapy, targeted therapy).
All patients approached the study met the inclusion criteria and were included in the study.
The exclusive criterion was the diagnosis of another cancer in the patient.

Measures
The following four psychometric tests were used in the study: Patients were also asked about socio-economic data: gender (woman/man), education (basic, vocational, secondary, higher), place of residence (village, a city of up to 20,000 inhabitants, up to 50,000, up to 100,000, up to 500,000 and a city with over 500,000 inhabitants), average monthly income (below PLN 500, PLN 501-1000, PLN 1001-1500, PLN 1501-2000, over PLN 2000), professional status (working person, student, retired, housekeeper, unemployed), marital status (single, married, widow/widower, divorced / divorcee), as well as the presence of metastasis (yes/no) and the type of treatment used (chemotherapy, radiotherapy, targeted therapy).
The study used the PAPI technique (Paper and Pencil Interview).
The obtained results were subjected to statistical analysis using t Student for independent samples, U Mann-Whitney test, H Kruskall-Wallis test, one-way analysis of variance and Pearson and Spearman r correlation (in case of age variable). The assumed level of statistical significance is p < 0.05. Statistical analysis was performed in two steps. Firstly the associations between socio-medical variables and analysed variables were assessed. The statistically significant associations between socio-medical data and analysed variables were used in the subsequent analysis. The socio-medical variables significantly related to analysed variables were used as covariates in computing adjusted estimated marginal means which were then used in the comparisons between the groups of patients diagnosed with three types of cancer.

Results
The study involved 378 patients aged 23 Detailed descriptive results regarding the studied socioeconomic and clinical variables in the three groups are presented in Table 1. The table also presents the values of likelihood ratio which was used to verify statistical significance of the associations between the group membership and other variables. Table 1. Descriptive results of the studied socioeconomic and clinical variables.
There were statistically significant associations between type of cancer and place of residence, being treated with radiotherapy and being treated with targeted treatment. There were more patients living in the cities with over 500,000 inhabitants in the group of patients diagnosed with stomach cancer and in the group of patients diagnosed with large intestine cancer. More patients from the group of patients diagnosed with pancreas were treated with radiotherapy and with targeted treatment.

Pain control
Analyzing the results of the BPCQ, in all patients with gastrointestinal cancers, the influence of some of the studied socio-economic variables on particular areas of pain control can be noticed. Age statistically significantly affects the average patient results obtained in the areas of the influence of doctors (r = 0.132) and random events (r = 0.242). The obtained positive correlations indicate that the older the patient the higher the average score obtained in both these areas.
Education significantly influences locating pain control in random events (p = 0.001). People with primary/vocational education were characterized by the highest scores in this area (M = 16.49, SD = 4.14), and with the increase in education, the average values of this area were decreasing (for patients with secondary education M = 15.4; SD = 4.31, and for patients with higher education M = 14.17, SD = 4.77).
Income also influenced the results obtained by patients in the BPCQ. Patients with lower incomes (up to PLN 1500 net per household member) obtained higher averages in the area of the influence of doctors (p = 0.014) and random events (p = 0.001) than people with higher incomes. In the case of the influence of doctors, the average result of people with lower incomes was M = 16.90 (SD = 4.60), and with higher income -M = 15.63 (SD = 4.65). In the area of random events, the  In the area of the influence of doctors, the differences among patients considering the location of the primary lesion are much smaller. However, due to the significant inequality of the compared groups, the statistical significance of these differences was not calculated (Table 2).

Strategies for coping with pain
Strategies of coping with pain by patients with gastrointestinal cancers were differentiated by gender, age, education, income, professional status, metastasis diagnosis and the fact of chemotherapy, radiotherapy or targeted treatment. Only the place of residence did not influence the pain management strategy adopted by patients (p > 0.05).
The patients' gender conditioned the result obtained in praying/hoping (p = 0.002), in which women obtained significantly higher values than men (respectively M = 22.68, SD = 9.11 for women and M = 19.65; SD = 9.47 for men).
The age of patients differentiated the results obtained in the area of catastrophizing (ρ Spearman = − 0.127), where the higher average was obtained by younger patients.
The    Table 3). Due to the lack of an equal number of patients with pancreatic cancer, stomach cancer and colorectal cancer, statistical tests were not possible to carry out in this respect.

Acceptance of illness
The average value of acceptance of illness in the group of women was 25.18 (SD = 8.25) and it was significantly lower than the average value obtained in the group of men M = 27.12 (SD = 8.32) (p < 0.05).
The acceptance of illness did not correlate with the age of patients (r (376) = 0.04, p > 0.05).  Table 4).

Mental adaptation to the illness
Among the variables studied, the patients' gender, age, education, professional status, diagnosis of metastasis, chemotherapeutic treatment and targeted treatment influence mental adaptation to cancer. Place of residence, income, and treatment with radiotherapy did not affect the mental adjustment of patients to the illness (p > 0.05).

Discussion
At each stage of cancer, patients experience different emotions, which may depend on both the type of cancer, its advancement, the prognosis associated with the treatment, as well as personality factors of the patient.  Negative emotions, including anxiety and depression are typical for cancer patients [11]. Cancer can thus deteriorate the quality of life of patients in all areas. Although some studies indicate that a decrease in the quality of life is noticed in patients treated with chemotherapy, studies comparing the quality of life of patients with cancer treated with chemotherapy and patients not treated with chemotherapy do not indicate significant differences among the two groups, which may suggest that the deterioration of the quality of life can be caused by the very fact of making a diagnosis, which causes fear and a feeling of powerlessness, especially in young people [12][13][14]. Studies show that experiencing symptoms of depression, anger, and anxiety may be affected by experiencing pain [15,16]. Pain can be felt at any stage of cancer. It occurs in about 50% of patients, and in the advanced period of the disease -in over 75%. Pain may be caused by the neoplastic process, cancer cachexia, and may also be the result of anticancer treatment [17]. Pain can be felt by patients in a variety of ways, and the patients' response to the pain sensation often depends on personality factors.
Patients with gastrointestinal cancers assign the greatest role in controlling pain to internal factors, similar to patients with lung cancer [18], patients with breast cancer in the study conducted by Czerw A. et al. [19] and patients with prostate cancer [20]. What is interesting, the main socio-economic variables, differentiating the attribution of the impact of individual areas on the degree of pain control were education and net income per household member. People with higher education and higher income attributed less influence to these areas [21].
Patients with gastrointestinal cancers usually cope with pain by declaring coping and praying/hoping. Patients with lung cancer [18] and patients with breast cancer [19], similarly to patients with gastrointestinal cancer in the author's study, usually choose the strategy of declaring coping, and the results in both patients with breast and lung cancer are differentiated by education and income [22].
The selection of strategies for coping with pain by patients with gastrointestinal cancers in the author's study is affected by all socio-economic variables studied (gender, age, education, professional status, income) apart from the place of residence. The results are also differentiated by the diagnosis of metastases, chemotherapy, radiotherapeutic and targeted therapy. A significant difference was observed between the patients analyzed due to the location of cancer in the area of catastrophizing. The author's own study indicates that the catastrophizing strategy is most often chosen by patients with pancreatic cancer, and much less frequently by patients with colorectal cancer.
The catastrophizing strategy significantly reduces the quality of life assessed by patients. Studies indicate that patients who require surgery are often using the catastrophizing strategy [23]. A strong relationship of anxiety with the use of the catastrophizing strategy is also emphasized, which also translates into a reduction in the sense of self-efficacy as to the impact on health or not following pharmacological recommendations [24][25][26]. Among patients with gastrointestinal cancers in the author's study, the catastrophizing strategy was selected more often by younger patients, patients with lower income, with metastases, as well as patients treated with chemotherapy and receiving targeted therapy.
The quality of life with the illness (in this case cancer) assessed by patients is strongly influenced by the acceptance of this illness. Chronic diseases, associated with numerous limitations of many activities, may determine the difficulty in accepting the illness [27]. B.J. Felton et al. indicate that low acceptance of the illness is strongly associated with negative attitudes towards the perceived illness, which in turn affects the deepening of symptoms and faster progression of the illness [28]. In addition to the acceptance of the illness and the strength of the symptoms, the impact of the level of acceptance of the illness on the daily activity of patients can be noticed [29,30]. The more the patient accepts their illness, the more often he or she takes active actions, aimed at minimizing the feeling of pain or changing his or her behavior for those that will help maintain a relatively good health [31,32]. However, studies suggests that some patients who accept their health status may not undertake pro-health activities. These patients try to accept pain and limitations resulting from the illness, and agree with the fact that their health will deteriorate [33]. Among patients suffering from gastrointestinal cancer, the average value of illness acceptance was the lowest in the group of patients with pancreatic cancer, and the highest in the group of people with colorectal cancer. The study of patients with various types of cancer indicates that the highest level of acceptance of the illness, i.e. the best ability to adapt to cancer, is characteristic for women with cancer of reproductive organs in comparison to patients with gastrointestinal cancers, including colorectal cancer, stomach cancer and pancreatic cancer [34]. In turn, B.J. Felton et al., examining chronically ill persons, indicated that the average value of the AIS test for these patients was M = 28.08 [35].
Among patients with various cancers (breast, lung, prostate, large intestine) the main socioeconomic factor differentiating the results obtained in the AIS test was income. In all groups, there was a linear relationship between the increase in net income per household member and the result of the AIS test [36], and this correlation was also obtained in the author's study. In addition, among patients with gastrointestinal cancers in the author's study, the relationship between the level of acceptance of the illness with gender, professional status and the diagnosis of metastasis was noted. Men, working persons and patients who were not diagnosed with metastases obtained a higher average result in the AIS test.
Analyzing adaptation to the illness, patients with gastrointestinal cancers obtained the highest values in the MiniMAC test in the area of fighting spirit, and the lowest in the area of helplessness/hopelessness. The average value of the area of fighting spirit was the highest in patients with colorectal cancer. Anxiety and helplessness/hopelessness are characteristic for patients with pancreatic cancer. In the study comparing various neoplastic changes, in the areas of anxiety and hopelessness/ hopelessness, the highest scores were obtained successively by the respondents with lung cancer, colorectal cancer, breast cancer and prostate cancer. In the area of fighting spirit there was no reversal of results. Higher results in this area were obtained by respondents who had breast cancer and patients with colorectal cancer, and lower -by responders with prostate cancer and lung cancer [37].
Among the variables studied, mental adaptation to cancer in patients with gastrointestinal cancers is influenced by patients' gender, age, education, professional status, diagnosis of metastasis, chemotherapeutic treatment and targeted treatment.
A study of 572 patients of the Oncology Center in Warsaw diagnosed with cancer of the reproductive system, cancer of the head and neck, gastrointestinal cancer, breast cancer, urological cancer, cancer of the tissues and nervous system, lung cancer indicated a strong relationship of negative emotions felt in connection with the disease with gender. Women are more often characterized by catastrophizing, higher levels of depression and anxiety compared to men, they show greater intensification of anxiety, helplessness/hopelessness, but also fighting spirit and positive reevaluation [11,38,39].
A study of 220 patients with various cancers (stomach cancer, genital cancer, pancreatic cancer, colorectal cancer, prostate cancer) covered by palliative care indicates that mental adaptation to cancer is strongly influenced by the degree of its acceptance. With the increase in acceptance of the illness, the intensity of fighting spirit decreases and the sense of helplessness/hopelessness intensifies [34].
Intensification of the strategy of helplessness/hopelessness is caused by feelings of anxiety and symptoms of depression. The smaller the feeling of anxiety and negative emotions associated with the illness, the more often patients adopt the strategy of fighting spirit. Attitudes towards the illness constitute an expression of how patients cope with the negative effects of cancer: pain, malaise, changes in life [11]. The use of active strategies, such as fighting spirit or positive reevaluation, affects the higher quality of life experienced by patients [6,40].

Patients with gastrointestinal cancers control pain
mainly by internal factors, however, the areas of influence of doctors and random events were most often differentiated by socio-economic variables. 2. The strategy of coping with pain most often selected by patients with gastrointestinal cancers is declaring coping, and the choice of strategy was influenced by all socio-economic variables apart from the place of residence, as well as diagnosis of metastasis and the type of therapy used. 3. Among patients with gastrointestinal cancers, patients with colorectal cancer have the highest level of acceptance of illness, while patients with pancreatic cancerthe lowest. 4. In the area of mental adaptation to illness, patients most often declared fighting spirit, however patients with pancreatic cancer were characterized by significant anxiety and helplessness/hopelessness.