Sohrab Amiri- Spiritual Health Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
Objective: Cancer can have negative effects on mental health. The aim of this study was to investigate the prevalence of anxiety symptoms/disorders in cancer patients’ worldwide using meta-analysis.
Methods: The study population was cancer patients who had cancer at the time of the study. The outcome studied in this study was anxiety symptoms/disorders. PubMed and Scopus were searched based on the syntax of keywords, this search was limited to articles published in English until September 2021. For this meta-analysis, data on the prevalence of anxiety were first extracted for each of the eligible studies. The random-effects method was used for the pool of all studies. Subgroup analysis was performed based on sex, anxiety disorders, cancer site, and continents. Heterogeneity in the studies was also assessed.
Result: After evaluating and screening the studies, eighty-four studies were included in the meta-analysis. Prevalence of anxiety symptoms/disorders in cancer patients showed that this prevalence is 23% (I2 = 99.59) in the 95% confidence interval between 22-25%. This prevalence was 20% (I2 = 96.06%) in the 95% confidence interval between 15-24% in men and this prevalence is 31% (I2 = 99.72%) in the 95% confidence interval between 28-34% in women. The highest prevalence of anxiety was in patients with ovarian, breast, and lung cancers.
Discussion: It showed a high prevalence of anxiety symptoms/disorders in cancer patients, in addition to therapeutic interventions for cancer, the necessary interventions should be made on the anxiety of these patients. Methodological limitation was the heterogeneity between the studies included in the meta-analysis. Some types of cancer sites could not be studied because the number of studies was small or the site of cancer was not identified.
Introduction
Mental disorders are among the leading causes of disease burden in the world so that a global study in 2019 showed that one of the two debilitating mental disorders was anxiety disorders, which was classified among the top 25 disease burden factors in 2019 (1, 2). Anxiety disorders continue to be one of the most common mental disorders in the world (3). Accordingly, a study by the Global Burden of Disease shows that anxiety disorders are responsible for 26.68 million disability-adjusted life years (DALYs) (4). Studies show that anxiety disorders are more common than other mental disorders such as mood disorders, substance abuse, and impulse control disorders (5, 6). An examination of the prevalence of anxiety disorders shows that the prevalence of these disorders varies in different countries (7). According to the report published by the World Health Organization, anxiety symptoms often begin in childhood and adolescence (8). Currently, studies have reported a prevalence of anxiety disorders of 7.3%, ranging from 4.8% to 10.9% (9, 10).
There are gender differences in the prevalence of anxiety so that women are more likely to be affected by anxiety compared to men (11). Lifetime Generalized anxiety disorder prevalence was 3.7%, 12-month prevalence was 1.8%, and 1-month prevalence was 0.8% (3). The prevalence of generalized anxiety disorder was higher in high income countries (5%) than low income countries (1.6%) (3). Some of factors associated with the risk of developing anxiety disorders, including high body mass index (12–14), diabetic (15–17), stroke (18, 19), and personality and social risk factors (20). Cancer is diseases associated with anxiety (21).
Cancer is one of the leading causes of death in the world (22). A global study published in 2016 shows that cancer is responsible for 213 million DALYs and 8.9 million deaths (23, 24). Between 2006 and 2016, cancer cases increased by 28%, the lowest increase was in countries with high sociodemographic index (23). In general, lung cancer is the most common type of cancer between the sexes (25). The most common type of cancer among men is prostate cancer, while the most common type of cancer among women is breast cancer (23). It is estimated that the number of cancers will increase to 28.4 million by 2040, which shows a 47% increase compared to 2020 (26). A range of factors has been suggested to increase the risk of cancer, including diet (27–29), smoking and alcohol use (30–32), aging (33, 34), psychological factors (35–37). Considering the effect of cancer on the dimensions of mental health (38, 39), studies have investigated the prevalence of mental disorders in cancer patients (40–42).
The 12-month prevalence of mental disorders in cancer patients was reported to be 39.4%, the most common of which were anxiety disorders (15.8%), followed by mood disorders (12.5%) and somatoform disorders (9.5%) (43). Extensive systematic review and meta-analysis studies have examined the prevalence of mental disorders, especially anxiety disorders, in cancer patients (44–50). Although studies examining the prevalence of anxiety disorders in cancer patients have become widespread, and systematic review and meta-analysis studies have been conducted in this area, several points required a new global study. First, fewer studies have been conducted on the prevalence of anxiety disorders, and most studies have studied a combination of mental disorders, and less distinction has been made between types of mental disorders. Second, in previous studies, each study often dealt with some types of cancer, and therefore different cancer sites have been less studied, and therefore a comprehensive view of different types of cancer is needed. Third, it is necessary to differentiate between men and women based on the types of cancer and anxiety disorders because types of cancer and anxiety disorders have different prevalence in men and women. Fourth, in studying the prevalence of anxiety disorders in cancer patients, a distinction should be made between cancer patients and cancer survivors. In this study, the focus was on cancer patients and not cancer survivors.
Based on what was stated, the aim of the present study was to investigate the global prevalence of anxiety symptoms/disorders in cancer patients and also to investigate the prevalence of anxiety based on sex, cancer site, type of anxiety disorder, and continents by conducting a meta-analysis.
Method
Protocol
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (51) guide was used for this study.
Information sources
Two databases, including PubMed and Scopus, were searched. This search was limited to articles published in English until September 2021. This search examined articles that were available online.
Search strategy
This search based on the syntax of keywords in Appendix 1; For example: The search strategy included terms such as ‘cancer’, ‘anxiety disorders’, ‘anxiety symptoms’, combined with Boolean operators.
Selection criteria
In the present study, a set of inclusion and exclusion criteria was considered. The study population was cancer patients who had cancer at the time of the study. The outcome studied in this study was anxiety disorders or anxiety symptoms (Anxiety measurement included anxiety scales or anxiety diagnostic interviews). For the present study, cross-sectional, prospective and longitudinal studies (at baseline) were selected as the eligible study design. The following studies were not eligible: 1) Studies that have studied incidence rate. 2) Studies that have studied anxiety and depression together. 3) Studies on cancer survivors. 4) Studies with a sample size of fewer than 100 participants. 5) Review studies, studies with insufficient information to calculate the prevalence, and studies with the same database.
Data extraction
The extracted information included the characteristics of the authors, the year of the study, the demographic characteristics of the study population, as well as the methodological characteristics and results of each study. One researcher was responsible to data extraction.
Qualitative assessment
For quality evaluation, EPHPP tool (52, 53) was used, which in this study, three adjusted dimensions were used. These dimensions included selection bias, data collection method bias, and withdrawals/dropouts, and missing bias.
Meta-analysis
For this meta-analysis, data on the prevalence of anxiety symptoms/disorders were first extracted for each of the eligible studies. After extracting the data for each study, some of the studies had several effect sizes, in which the average effect size was calculated. In some studies that used several anxiety measurement tools, one tool was selected. The random effects method was used for the pool of all studies in the form of meta-analysis. Subgroup analysis was performed based on sex, anxiety disorders, cancer site, and continents. Also, in the end, the degree of heterogeneity in the studies was examined using I2 and χ2 (54, 55). Data analysis in this study was using Stata-14 (Stata Corp., College Station, TX).
Results
Selected studies
Figure 1 shows the selection and screening steps for articles. After screening, 84 eligible articles (43, 56–139) were included in the current meta-analysis (Table 1).
Figure 1. Flowchart of included studies. From: Moher et al. (150). For more information, visit www.prisma-statement.org.
Table 1. Studies included in the meta-analysis.
Quality of studies
Examination of the results in selective bias showed that except for 2 studies that had a high bias, the rest of the studies had a low and moderate bias. All studies had a low bias in the data collection method. Except for 1 study that had a high bias, the rest of the studies had a low and moderate bias in withdrawals/dropouts and missing.
Prevalence of anxiety
Prevalence of anxiety symptoms/disorders in cancer patients showed that this prevalence is 23% in the confidence interval between 22-25% (I2 = 99.59%). This finding shows that approximately one in four cancer patients was anxious.
Prevalence of anxiety symptoms/disorders in cancer patients showed that this prevalence was 20% in the confidence interval between 15-24% (I2 = 96.06%) in men. Prevalence of anxiety symptoms/disorders in cancer patients showed that this prevalence was 31% in the confidence interval between 28-34% (I2 = 99.72%) in women (Figure 2).
Figure 2. Prevalence of pooled anxiety symptoms/disorders in cancer patients based on sex.
Prevalence of generalized anxiety disorder in cancer patients showed that this prevalence was 7% in the confidence interval between 5-8% (I2 = 95.27%). Prevalence of panic disorder in cancer patients showed that this prevalence was 3% in the confidence interval between 2-4% (I2 = 90.43%). Prevalence of PTSD in cancer patients showed that this prevalence was 12% in the confidence interval between 8-16% (I2 = 98.91%). Prevalence of specific phobia in cancer patients showed that this prevalence was 4% in the confidence interval between 0-7% (I2 = 0%). The prevalence of social phobia in cancer patients showed that this prevalence was 2% in the confidence interval between 0-4% (I2 = 90.92%). Prevalence of OCD in cancer patients showed that this prevalence was 0% in the confidence interval between 0-1% (I2 = 0%). The prevalence of agoraphobia in cancer patients showed that this prevalence was 2% in the confidence interval between 0-3% (I2 = 0%) (Table 2).
Table 2. Prevalence of different anxiety symptoms/disorders in cancer patients.
Highest prevalence of anxiety symptoms/disorders was in ovarian cancer patients showed that this prevalence was 43% in the confidence interval between 31-56% (I2 = 93.30%). Lowest prevalence of anxiety symptoms/disorders was in colorectal cancer patients showed that this prevalence was 1% in the confidence interval between 1-1% (I2 = 0%) (Table 3).
Table 3. Prevalence of anxiety symptoms/disorders in cancer patients based on cancer site.
Highest prevalence of anxiety symptoms/disorders in cancer patients was 38% in the confidence interval between 24-52% (I2 = 99.69%) in Asia. Lowest prevalence of anxiety in cancer patients was 12% in the confidence interval between 8-15% (I2 = 99.55%) in America (Figure 3).
Figure 3. Prevalence of anxiety symptoms/disorders in cancer patients based on continents.
Heterogeneity
To check the heterogeneity of the studies, the I2 was used, which showed that it was equal to 99.59 and was high (54). Also, this index was studied at the level of subgroups, but no significant difference was found. χ2 as the second test to check heterogeneity was also equal to 20230.12 (d.f 83; p <0.001).
Discussion
The aim of this study was to investigate the global prevalence of anxiety symptoms/disorders in cancer patients who had cancer at the time of the study. The prevalence of anxiety symptoms/disorders in cancer patients showed that 23% of patients had anxiety, in other words, it can be said that about one in four cancer patients had anxiety symptoms/disorders. This finding indicates a high prevalence of anxiety symptoms/disorders in cancer patients. However, studies in the general population show that the prevalence of anxiety is lower (140). Studies in other countries have also shown that the prevalence of anxiety in the general population is lower (10, 141). Therefore, the findings of the present study highlight the fact that patients with cancer have a higher prevalence of anxiety symptoms/disorders, just as similar studies in cancer patients show a high prevalence of anxiety symptoms/disorders in this population (142, 143). Experiencing anxiety symptoms/disorders after being diagnosed with cancer can be a common process and reaction that a person experiences (144). Cancer, on the other hand, can be considered a traumatic event, and as stated in the etiology of anxiety symptoms/disorders, stressful events can lead to anxiety (145).
Another finding from the current study was that the prevalence of anxiety symptoms/disorders in men with cancer was 20%, while the prevalence was 31% for women. This finding clearly shows that the prevalence of anxiety symptoms/disorders in women with cancer is almost one-third higher than men with cancer. In this regard, studies have shown that in the general population, the prevalence of anxiety in women is higher than men, accordingly (146), the lifetime prevalence of anxiety was 30.5% for women and 19.2% for men (147). The same finding has been shown in various types of anxiety disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, GAD, PTSD, OCD), ie higher prevalence of various types of anxiety disorders in women than men (147–149). Another finding from the current study showed that the highest prevalence of anxiety symptoms/disorders among cancers is in ovarian cancer (43%), followed by breast cancer (27%) and lung cancer (26%). Previous studies have shown that the prevalence of anxiety symptoms/disorders varies according to the cancer site (48, 143, 150). The most common type of anxiety disorder in cancer patients was post-traumatic stress disorder (12%), followed by generalized anxiety disorder (7%).
Limitations
One strength of this study was that it provided a comprehensive meta-analysis of the prevalence of anxiety based on different types of cancer sites. The second strength was that analyzes were based on a variety of anxiety symptoms/disorders and sex. One methodological limitation was the heterogeneity between the studies included in the meta-analysis, and this could be due to different sources, especially since different tools were used to measure anxiety. Some types of cancer sites could not be studied because the number of studies was small or the site of cancer was not identified. The study of prevalence points (4-weeks, 6-months, 12-months, and lifetime) was not possible in the present study and future studies could be performed in this area. Because the studies did not present these distinctions in the results.
Clinical implications
Considering the role that physical diseases play in mental symptoms and disorders, it is necessary to pay more attention to the appropriateness of psychological interventions for different groups of physical patients in the protocols related to the promotion of mental health as well as therapeutic interventions. After facing a physical disease, one person can suffer from a range of symptoms or mental disorders. Therefore, it is necessary to pay more attention to treatment based on each person. Therefore, it is necessary to develop diagnostic, therapeutic and educational protocols based on cancer and symptoms/anxiety disorders.
Conclusion
The present study showed that the prevalence of anxiety symptoms/disorders in cancer patients is very high and this issue can impair their level of health and also affect the effectiveness of therapeutic interventions. Therefore, in addition to conventional interventions for cancer treatment, it is necessary to make psychological interventions to improve the mental health of cancer patients. It is also necessary to note that each person has unique characteristics that can affect health, healthy and unhealthy behaviors. Therefore, in interventions related to prevention and treatment, it is always necessary to pay special attention to the issue of personal characteristics.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.
Author contributions
SA: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1422540/full#supplementary-material
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Keywords: anxiety, cancer patients, meta-analysis, systematic review, anxiety symptoms
Citation: Amiri S (2024) The prevalence of anxiety symptoms/disorders in cancer patients: a meta-analysis. Front. Psychiatry 15:1422540. doi: 10.3389/fpsyt.2024.1422540
Received: 30 April 2024; Accepted: 15 October 2024;
Published: 15 November 2024.
Edited by:
Valeria Sebri, European Institute of Oncology (IEO), ItalyReviewed by:
Mohsen Khosravi, Zahedan University of Medical Sciences, IranJerry Lorren Dominic, Jackson Memorial Hospital, United States
Copyright © 2024 Amiri. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Sohrab Amiri, YW1pcnlzb2hyYWJAeWFob28uY29t