The supportive care needs and its influencing factors among thyroid cancer patients after surgery: A cross-sectional study

Objective To study the supportive care needs (SCNS) of thyroid cancer (TC) patients after surgery, and to identity its influencing factors. Methods By convenience sampling method, total of 115 patients undergoing thyroid surgery who met the inclusion criteria from May 2021 to July 2021 were selected as the research objects. The general information questionnaire, Supportive Care Need Survey Short-Form (SCNS-SF34), functional subscale of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) were used to investigate these patients. Results The average score for the items of SCNS-SF34 in 102 TC patients was 2.15 ± 0.71. The domain with the highest item average score was “health system information needs” (2.48 ± 1.17). The domain with the highest unsatisfied rate was “psychological needs” (69.6%). The item with the highest average score was “fear of cancer spreading” in the psychological needs domain (2.80 ± 1.48). The scores of physical function (r = −0.431, P < 0.001), role function (r = −0.428, P < 0.001), cognitive function (r = −0.531, P < 0.001), emotional function (r = −0.388, P < 0.001), social function (r = −0.464, P < 0.001) were correlated with the total score of SCNS-SF34. The univariate analysis of SCNS-SF34 scores showed that TC patients who were women (t = 2.013, P = 0.047), older (F = 1.353, P = 0.013), and with longer hospital stays (F = 3.705, P = 0.028) had higher demand of SCNS. The results of multiple linear regression analysis showed that the significant variables that entered the regression equation were gender, age, length of stay in hospital, cognitive function and social function (P < 0.05). Conclusion TC patients after surgery have many SCNS in different domains. It is necessary to focus on women, older patients, patients with long hospital stays and poor functioning. The implementation of a supportive care screening tool is recommended and the individualized interventions need to be developed to provide targeted support and care.


Introduction
In recent years, the number of patients with thyroid cancer (TC) has exploded, making it the solid malignant tumor with the fastest-growing incidence (1). In 2020, TC is the most commonly diagnosed malignancy of the endocrine system and the ninth leading cancer, and accounted for 586,000 new cases worldwide (2). Surgery is the main method of treating TC (3). Postoperative patients will have different needs in many aspects such as physical, psychological, spiritual and social (4)(5)(6). Unmet needs can increase negative emotions such as anxiety and depression, reduce diagnosis and treatment compliance and disease coping ability, thereby seriously affecting physical and mental health and quality of life (7)(8)(9). Supportive Care Needs (SCNS) refers to the general term for all kinds of help that cancer patients and their families may need to prevent, control or alleviate various complications and side effects in addition to medical, surgical and other interventions (10). The essence of Supportive Care is to comprehensively assess the needs of cancer patients, proactively provide targeted support and care, and maximize the satisfaction of patients' needs, thereby improving their quality of life. In order to ensure that health professionals are meeting the holistic care needs of cancer patients and prioritize resource allocation to those aspects of care that need improvement, it is essential to identify what those needs are and evaluate whether care delivery meets those expectations. To the best of our knowledge, there are few studies focused specifically on SCNS in TC patients. The researches on the needs for TC patients were mainly conducted in Europe and the United States (11,12), and there were problems such as inconsistent use of validated instruments and study designs which leaded to different results. The nature and degree of patients' SCNS are influenced by their cultures (13). This cross-sectional study was the first conduced in mainland China to investigate the SCNS and related influencing factors of TC patients after surgery to provide the basis for formulating targeted care and support measures.

Setting and participants
From May 2021 to July 2021, the convenience sampling method was used to select TC patients newly admitted to the Department of Thyroid Surgery, West China Hospital, Sichuan University for surgery as the research subjects. The inclusion criteria were (1) patients aged between 18 and 80 years; (2) patients with TC who had chosen surgical treatment; (3) patients were able to understand the survey content and express their inner feelings clearly; (4) patients had given informed consent to the research content, voluntarily participated and could actively cooperate. The exclusion criteria were: (1) patients accompanied by other malignancies; (2) patients had other serious illness. The eliminative criteria were: (1) patients who did not complete surgery; (2) patients dropped out of the survey. The sample size of this study is based on the sample size estimation method of multiple regression analysis (14). The sample size is at least 10 times the number of main independent variables. Considering the 15% loss rate of the sample, the sample size = 10 × 10 × (1 + 15%) = 115 cases.

Measures
The general information questionnaire included basic demographics: gender, age, occupation, marital status, length of hospital staying, surgical method. The Supportive Care Need Survey Short-Form (SCNS-SF34) (15) was used to assess the SCNS of patients. This questionnaire can comprehensively assess the needs of all aspects of cancer patients. Au et al. (16) translated SCNS-SF34 into Chinese and Cronbach alpha reliability coefficients exceeded 0.7 for all domains. Five domains of the SCNS-SF34 include physical and daily living, psychological, sexual, care and support, and health system information. Each item adopts Likert 5-level scoring method, 1 point for no demand, 2 points for there is demand and the current demand has been met, 3, 4, and 5 points indicate that the degree of demand is low, medium, and high, respectively. The higher the score, the higher the level of demand. Domain average score = d total score/number of patients; item average score = domain total score/patient number/number of items in this domain; unmet need rate = number of patients with unmet needs (score ≥3 points)/patient case number. The functional subscale of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) (17, 18) was used to assess the functioning of patients. This questionnaire has been widely used to measure the quality of life of Chinese cancer patients, with a Cronbach alpha reliability coefficient of 0.810. In this study, the functional subscale was selected for evaluation. The functional subscale has a total of 15 items and 5 functional domains (physical, role, cognitive, emotional and social). All items have 4 response categories (not at all, a little, quite a bit and very much), directly score 1-4 points. Add the scores of the items included in each domain and divide by the number of included items to get the score in the field. After linear transformation, all subscales range from 0 to 100. A higher score means better functioning. Participants were asked to to fill out two questionnaires based on their current situation. The overall Cronbach's alpha SCNS-SF34 and EORTC QLQ-C30 were 0.943 and 0.853, which indicates a reliable instrument in the study.

Data collection
The whole process of the investigation was completed by the investigator himself, and the patients were included on the day of admission. The purpose, method and significance of the study were introduced to the patients, and all patients signed an informed consent form before the investigation. The general data of the patients were investigated and collected before discharge. SCNS-SF34 and EORTC QLQ-C30 functional subscale questionnaires were conducted on the second day after the Frontiers in Surgery operation face-to-face. Each survey included an information letter and instructions to complete the questionnaires. The investigator was available to answer further questions if requested. Questionnaires were distributed and collected on the spot. All data were entered after double-checking.

Statistical analysis
Statistical analysis was performed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA). Internal consistency of the modified tool was assessed using Cronbach's alpha. K-S test was used to verify whether the data conformed to normal distribution. The qualitative data with a normal distribution were expressed as mean ± standard deviation. The quantitative data were expressed as frequency and percentage. The qualitative data with a normal distribution and homogeneity of variance were compared using the independent-sample t test between two groups, and ANOVA test between multiple groups. Pearson correlation analysis was used to analysis the correlation between the scores of SCNS-SF34 and EORTC QLQ-C30. Multiple linear regression analysis was carried out with the factors affecting the SCNS-SF34 score as independent variables. P < 0.05 was considered statistically significant.

Ethical considerations
Ethical approval to conduct the study was granted from the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University [Ethics Approval Number 2020(947)].

Results
A total of 115 cases were included in this study, of which 9 were discharged without surgery and 4 were excluded from the survey, resulting in a final sample of 102 cases. All patients completed the questionnaires. Among the 102 patients, the pathological type of 100 patients were papillary thyroid carcinoma, the pathological type of 1 was poorly differentiated thyroid carcinoma and the pathological type of 1 was medullary thyroid carcinoma, and there were no patients who had undergone reoperation. In this study, most of the participants were female (73.5%), under the age of 40 (67.7%), married (79.4%) and employee (59.8%). Demographic and disease characteristics are presented in Table 3.
The average score for the items of SCNS-SF34 was 2.15 ± 0.71. The scores of each domain of SCNS-SF34 are shown in Tables 1, 2.
The domain with the highest average score was "health system information needs", the domain with the highest unmet rate was "psychological needs". The results of the average score of items were ranked to determine the ten most prevalent SCNS requiring help across all domains ( Table 2). The item with the highest score was "fears about the cancer spreading" in the psychological needs domain.
Univariate analysis of SCNS-SF34 is shown in Table 3. There was significant difference in score of patients with different gender, age and length of hospital stay (P < 0.05). The scores of the physical function, role function, cognitive function, emotional function, and social function were negatively correlated with the score of SCNS-SF34 (P < 0.05), as shown in Table 4. Taking the SCNS-SF34 total score as the dependent variable, the variables with statistically significant differences in the univariate analysis and correlation analysis in this study were used as independent variables for multiple linear regression analysis. The variable assignments were as follows: gender (male = 0, female = 1), age (≤40 = 0, 41-50 = 1, ≥51 = 2), length of hospital stay (≤5 = 0, 6-7 = 1, ≥8 = 2). The results showed that the significant variables entering the regression equation were gender, age, length of hospital stay, cognitive function and social function (P < 0.05), which together explained 43.3% of the variance in the equation, as shown in Table 5.

Discussion
The main purpose of our study is to investigate the SCNS of TC patients after surgery, so we choose SCNS-SF34 questionnaires which can comprehensively assess the needs of all aspects of cancer patients. Previous studies have shown that patients' needs are closely related to their functional level. EORTC QLQ-C30 questionnaires can fully evaluate the function of patients. To identity the influencing factors of SCNS, we choose to apply this function scale to explore whether the functions will affect the needs.
As shown in Table 1, except for the domain of sexual needs, the unmet needs of the other four domains were all over 45%. This means that TC patients have many SCNS in different domains. This study shows that TC patients after surgery had the strongest demand in the domain of "health system information needs" and echoed the results of a previous studie (12). One previous study (19) have shown that have shown that patients need to be informed about postoperative complications, followup treatment and rehabilitation guidance after surgery. They also expect to be informed that the cancer has been relieved, and they also want to receive relevant guidance on how to deal with uncomfortable symptoms and return to society. Therefore, in the postoperative stage, health care professionals should identify the types of information needs of patients in a timely manner, take the needs of patients as the starting point, and formulate personalized health education programs that combines offline and online to meet their needs for health information. The highest unmet rate was "psychological needs", which was the same as the research results of Sakamoto et al. (20). Psychological stress is a common experience of cancer patients. After diagnosis, patients will have various psychological problems such as worrying about the effect of treatment, fear of cancer spread, and guilt towards their loved ones (21). This suggests that health care professionals should pay attention to the psychological care of patients during the perioperative period, understand their psychological state and give corresponding guidance. We should help patients reduce negative emotions through various ways, such as mindfulness-based stress reduction, incentive nursing. The item of the highest score was "fear of cancer spread" and the same results were also found in patients with gynaecological cancer (22), indicating that the psychological burden of patients is further increased due to lack of disease-related knowledge. Therefore, it is necessary to organically combine health education and psychological care in clinical work to improve the psychological state of patients. The lower scores in the three domains of "physiological and daily life needs", "sexual needs" and "care and support needs" may be related to the fact that most of the patients in this study were papillary thyroid carcinomas, which resulted in a good prognosis (23).
This study showed that the SCNS of women was higher than that of men, the same result was found in other studies (13, 24). Compared with men, women are characterized by rich emotions, sharp minds, and strong family values. They are more susceptible to factors such as disease and surgery, and have higher levels of negative emotions and psychological experiences (25). Therefore,  Frontiers in Surgery gender need to be considered when formulating care plans for patients, and the multiple needs of female patients need to be fully evaluated and met. The SCNS increased by age. The physiological function of the patients gradually declines as the age increases, and the physical and mental discomfort caused by the operation is more prominent. Therefore, the older patients have more needs in health education, basic nursing and psychological counseling. Health care professionals should pay more attention to the needs of older patients, improve their disease awareness, improve their physical discomfort and reduce their emotional fluctuations through effective interventions. The longer the hospitalization time, the higher the SCNS. The patients with longer hospitalization time are often related to factors such as older age, complicated surgery and poor postoperative recovery (26) and the patients themselves have higher needs in terms of physiology and daily life. At the same time, prolonged hospitalization will increase the psychological and economic burden of patients, which will further increase their needs. Therefore, health care professionals should adjust caring strategies in a timely manner and provide targeted support with the prolongation of hospitalization time. The functional status of patients is negatively correlated with SCNS, especially cognitive function and social function are closely related to SCNS. Similar correlations have been shown in other cancer patients (27,28). Therefore, in clinical practice, health care professionals need to provide appropriate psychological, physical, and social support to help patients relieve physical symptoms, reduce negative emotions, improve cognitive and social support levels, and achieve the purpose of improving physical and mental functions. It is worth noting that this study showed that the surgical approach is not related to the degree of need, indicating that any type of TC patients should receive the same attention. This notion of individually assessing patients for their SCNS is supported by a research investigating the patterns and predictors of unmet SCNS in cancer patients (29). They suggest that addressing these deficits is essential to achieving optimal cancer care and satisfaction but in order to do that, there is a need to develop a consistent process to identify the needs of patients using a standardized instrument in clinical practice.
This study had certain limitations. First, it was a single-center study with limited sample representativeness. Second, the study used a cross-sectional survey, and the content of the study was limited. It is expected that more empirical studies will be conducted in the future to further explore the SCNS of TC patients.

Conclusion
Our study shows that TC patients after surgery have many SCNS in different domains, and it is necessary to focus on female patients, older patients, patients with longer hospital stays and poor functional. The implementation of a comprehensive but succinct supportive care screening tool is recommended for ensuring that SCNS are identified. Health care professionals should formulate personalized caring interventions and provide targeted support according to the different needs of patients. Early identification and management of needs may help to reduce the burden on health system resources.

Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement
The studies involving human participants were reviewed and approved by Ethical approval to conduct the study was granted from the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University [Ethics Approval Number 2020 (947)]. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Author contributions
All authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; gave final approval for the version for publication; and agree to be accountable for all aspects of the work. JG is the guarantor and are directly responsible for the manuscript. All authors contributed to the article and approved the submitted version.

Funding
The work was supported by the West China Nursing Discipline Development Special Fund Project (grant no. HXHL21007). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.