ORIGINAL ARTICLE

Symptoms, psychological distress, and supportivecare needs in lung cancer patients

Yu-Chien Liao & Wei-Yu Liao & Shiow-Ching Shun &Chong-Jen Yu & Pan-Chyr Yang & Yeur-Hur Lai

Received: 15 April 2010 /Accepted: 20 September 2010 /Published online: 15 October 2010# Springer-Verlag 2010

AbstractPurpose The purpose of this study was to examine the levelof symptoms, psychological distress, and supportive careneeds and factors related to five unmet need domains inlung cancer patients.Methods A cross-sectional study of 152 lung cancerpatients at a medical center in Taiwan assessed theirsymptoms, psychological distress, and unmet supportiveneeds in five major care domains. Logistic regression wasapplied to examine the related factors of unmet supportivecare needs.Results In general, patients had mild-to-moderate levels ofsymptoms and high prevalence of psychological distress.Regardless of their treatment status, they reported highlevels of supportive care needs. The top three need domainswere: (1) health system and information, (2) psychological,and (3) patient care and support. Levels of symptoms,anxiety, and depression were the most significant factors inunmet supportive care needs.

Conclusion The effect of symptoms and psychologicaldistress on unmet supportive care needs is substantial.Therefore, a systematic assessment of patients distress andcare needs is important for clinical lung cancer care. Furtherintervention consisting of symptom management, continu-ing counseling, and preparation for transition from activetreatment to the follow-up stages are essential in improvingquality of care.

Keywords Lung cancer . Need . Symptom . Psychologicaldistress

Introduction

Lung cancer is one of the most life-threatening diseases andleading causes of cancer deaths worldwide [1]. Previousreports have shown that most lung cancer patients arediagnosed at an advanced stage [2] and generally undergocomplex treatments (e.g., chemotherapy (CT), radiotherapy(RT), epidermal growth factor receptor tyrosine kinaseinhibitor (EGFR-TKI), or combined modalities) [3]. Theimpact of aggressive treatment may cause different levels ofphysical and psychological distress [4, 5] and lead todifferent care needs [6, 7]. In addition, the transition froman active treatment stage to a follow-up could inducespecial needs for patients [6, 8].

Previous research noted that more than 80% of lungcancer patients have multiple symptoms [5, 9, 10] as wellas more symptoms and psychological distress than dopatients suffering from other cancer types [11, 12]. Studiesshowed that, among various types of psychological distress,depression, and anxiety are especially common with 23% to47% of lung cancer patients experiencing these problems atsome point in their illness [4, 12].

Y.-C. Liao : S.-C. Shun :Y.-H. Lai (*)Department of Nursing, College of Medicine,National Taiwan University,1 Jen-Ai Rd., Sec. 1,Taipei 100, Taiwane-mail: laiyhwk@ntu.edu.tw

Y.-C. LiaoDepartment of Nursing,Yuanpei University,Hsinchu, Taiwan

W.-Y. Liao : C.-J. Yu : P.-C. YangDepartment of Internal Medicine,National Taiwan University Hospital and National TaiwanUniversity College of Medicine,1 Jen-Ai Rd., Sec. 1,Taipei 100, Taiwan

Support Care Cancer (2011) 19:17431751DOI 10.1007/s00520-010-1014-7

According to symptom management theories [13, 14],patients responses to a symptom are multi-dimensional.These responses include physical decline, psychologicaldistress, and other sociocultural and behavioral changes.Furthermore, unsolved symptoms and their resultant emo-tional response (e.g., anxiety and depression) and cognitiveevaluation could cause the patient to transform an unpleas-ant sensation into action. This can increase their need toseek help from health care professionals.

Similarly, empirical studies also show that supportivecancer care needs are related to factors, such as disease/treatment [1519], and important demographic factors [1620]. Patients in a more advanced cancer stage, with ashorter time since their diagnosis, and who are undergoingtreatments may experience more impact from differentsymptoms or side effects and may develop different careneeds [1319]. Varying individual backgrounds (age,gender, and education) may result in different ways ofcoping or responding to symptoms and help-seekingbehavior [13, 14, 16, 18, 19, 21, 22] and cause differentsupportive care needs [15]. However, these factors have notbeen simultaneously examined in a lung cancer population,thus more study is needed to understand how these factorsare related to needs of lung cancer patients.

Numerous studies examined the supportive care needs ofcancer patients [7, 15, 16, 20, 23, 24] and revealed that lungcancer patients had higher unmet supportive care needsthan did other cancer patients [16, 25]. However, fewstudies focused on ways in which to meet those needs [17,25, 26]. Little information exists concerning the distress oflung cancer patients, and their supportive care needs duringactive medical treatment or in the follow-up stage. InTaiwan, it is particularly crucial to explore the distress andsupportive care needs in lung cancer patients because itaccounts for nearly 20% of the annual cancer-related deaths[27]. There is also a trend toward shorter hospital stays andincreased treatment in outpatient settings due to cost-savings and insurance policies, which may create additionalunresolved distress and greater supportive care needsduring the treatment stage. Unfortunately, little informationis available regarding the most efficient ways to meet thesupportive care needs of lung cancer patients.

To bridge the gap between the supportive care given bythe clinical service and the unmet needs perceived by thepatients during the treatment and follow-up stages, thisstudy aimed to: (1) examine the level of symptoms,psychological distress, and supportive care needs acrossgroups with different treatment status, and (2) examine therelationship between various supportive care needs andsymptom levels, psychological distress, selected demo-graphic factors, and treatment variables. According tosymptom management theories [13, 14] and past research,we hypothesized that the unmet supportive care needs of

lung cancer patients would relate to their levels ofsymptoms, their psychological distress, and their treatmentstatus. We also hypothesized that demographic and disease-related factors would affect their need for supportive care.The findings could provide the basis of an improvedsupportive care model to serve the specific needs of lungcancer patients.

Methods

Participants and procedure

After obtaining Institutional Review Board approval, weconducted a cross-sectional survey of adult lung cancerpatients that were either actively undergoing cancertreatment or in the follow-up stages following treatment.For the purpose of this study, we excluded very ill patientsand those with terminal lung cancer receiving palliativecare. The research team identified and enrolled eligiblepatients when they visited either the Outpatient Clinic orthe Chest/Oncology Inpatient Unit at a medical center innorthern Taiwan. After understanding the purpose andprocedures of the study, patients who agreed to participatesigned a written consent form. Face-to-face interviews withthe patients provided data for the study.

Measures

Symptom Severity Scale

We used the 21-item Symptom Severity Scale (SSS)developed by the corresponding author [28] to assess thepatients symptom severity. The scale contains the 21 mostcommon symptoms, such as fatigue, pain, and poorappetite, which occur during treatment of lung cancer. TheSSS is a 0 to 10 numerical rating scale listing specificsymptoms in cancer patients within the past 7 days, with 0indicating no symptoms at all and 10 indicating assevere as I can imagine. The higher the score, the moresevere the symptoms. Cronbachs alpha in the present studywas 0.87.

Hospital Anxiety and Depression Scale

To assess depression and anxiety in patients, we used theChinese version of Hospital Anxiety and Depression Scale(HADS) [29]. The widely used 2-subscale, 14-item HADS,Chinese version, has been a valid assessment for depressionand anxiety in Taiwanese cancer patients [30]. Each item isscored from 0 (not at all) to 3 (always) with a subscalescore from 0 to 21. The higher the score, the greater thelevel of anxiety and depression. The ranges of score for

1744 Support Care Cancer (2011) 19:17431751

non-cases, borderline cases, and clinical cases were 07, 810, and 1121, respectively [29]. Cronbachs alpha valuesin this study were 0.73 and 0.83 for the anxiety anddepression subscales, respectively.

Cancer Needs QuestionnaireShort Form 32

We used the Chinese version of the Cancer NeedsQuestionnaire (CNQ)Short Form 32 developed by Foot(1996) [31, 32] to assess patient needs. The questionnaire iscomposed of five needs domains (subscales), including: (1)health system/information (e.g., to be fully informed aboutcancer remission, to be fully informed about the odds oftreatment success); (2) psychological (e.g., dealing withfeeling down or depressed, coping with fears about the painand suffering you might experience); (3) physical and dailyliving care (e.g., dealing with lack of energy and tiredness,coping with keeping up with work around the home); (4)patient care and support (e.g., for cancer specialist, showsensitivity to your feelings and emotional needs; for nurses,to attend promptly to patients physical needs in hospital);and (5) interpersonal communication (e.g., coping withchanges in other peoples attitudes and behavior towardsyou, coping with awkwardness in talking with others aboutthe cancer). The CNQ is a 5-point scale instrument. Thesummated scores of each subscale are further converted intostandardized scores, ranging from 0 to 100 with higherscores representing greater unmet needs [31]. The CNQspsychometric properties have been established [16, 19, 31,32]. In the current study, Cronbachs alpha values werebetween 0.83 and 0.95 in the five subscales.

Background information

This included demographic characteristics, such as age,gender, education, marital status, employment status,religious affiliation, and caregivers. It also containeddisease and treatment related factors, such as cancer stage,cancer type, treatment status, and Karnofskys PerformanceStatus (KPS) [33].

Data analysis

Descriptive statistics were used to analyze the demographicdata, levels of distress, and patient needs. Analysis ofvariance (ANOVA) with post hoc comparison and Chi-square with Fishers exact test were conducted to comparethe differences in symptom severity, psychological distress,and needs among treatment subgroups. To identify thefactors associated with each care domain, we developedfive logistic regression models representing the five needsdomains. Patient data were categorized as no need andsome needs for each item [7, 34, 35]. No need included

1 (no need) and 2 (needs already satisfied), whilesome need indicated scores higher than 2 (low needs,moderate needs, or high needs). The independent variablesincluded gender, age, recruitment site (outpatient orinpatient), types of treatments (CT, CT+RT, EGFR-TKI,or follow-up), cancer stage (early and advanced stage),months since diagnosis, educational level, performancestatus (KPS), overall symptom level (mean of 21 symptomlevels), and depression and anxiety scores.

Results

Subject characteristics

Of 188 eligible patients, 152 subjects agreed to participatein the study (response rate: 81.3%). Thirty-two patientsrefused to take part in the study, and four failed to completethe interview due to feeling unwell. Two thirds of thesubjects (69.1%) came from the outpatient clinics (Table 1).There were slightly more male patients (52.6%) than therewere female patients with the mean age of all subjects 60.2(SD=11.0). Two thirds of the subjects had an educationallevel of high school or higher.

The majority diagnosis of the subjects was non-smallcell lung cancer (NSCLC) (87.5%). Close to half of thesubjects were receiving CT (45.4%) and 21.7% had EGFR-TKI while they were involved in the study. Sixteen percentof the subjects completed their treatment and were infollow-up care. Patients had a wide range of performancestatus with a KPS of 68.8 (SD=10.1). The patientsreceiving CT+RT had lower KPS scores (M=63.2, SD=9.5) than the patients in EGFR-TKI (M=70.9, SD=9.5) orthe follow-up groups (M=75.2, SD=8.2). The patientsreceiving CT (M=67.4, SD=9.9) had poorer KPS scorethan the follow-up patients (F=7.72, p=0.000).

Symptom experience

Patients averaged 10.4 (SD=5.0) different kinds of symp-toms with a relatively wide range (7.8 to 13.2) across thefour treatment subgroups. Most patients experienced mild-to-moderate levels of symptom severity (M=2.0, SD=1.4).The five symptoms reported as most severe were, in order,fatigue, weakness, insomnia, cough, and alopecia. Regard-ing the differences among treatment subgroups, patientsreceiving CT perceived more symptoms and higher level ofsymptom severity than did the follow-up group, while theCT+RT group had higher symptom severity and moresymptoms than the EGFR-TKI and follow-up groups.Twelve of the 21 symptoms had significantly differentmean levels among treatment subgroups. As Table 2 shows,the major differences occurred between the follow-up group

Support Care Cancer (2011) 19:17431751 1745

and the CT or CT+RT groups. For instance, patientsreceiving CT had higher levels of fatigue, weakness, andnausea than did the follow-up patients. Patients in CT+RTgroup had greater levels of weakness, dry mouth, poorappetite, drowsy, distraction, and vomiting compared to thefollow-up patients.

Psychological distress

The mean scores for depression and anxiety of all subjectswere 7.4 (SD=4.2) and 5.6 (SD=4.0), respectively.According to the HADS classification, 25.7% and 14.5%of the participants were classified as clinical depression oranxiety cases, and 15.1% and 21.1% were identified asborderline depression or anxiety cases, respectively. TheANOVA and Chi-square with Fishers exact test showed nosignificant difference in the mean scores of depression andanxiety nor in the percentage of clinically depressed casesamong treatment subgroups (see Table 3).

Correlation between symptom severity and psychologicaldistress

Significant relationships existed between overall symptomlevels and depression (r=0.55, p

ings and emotional needs (39.5%), and dealing with lackof energy and tiredness (28.3%) ranked highest asmoderate-to-high unmet needs of psychological, patientcare and support, and physical and daily living domains,respectively.

Factors related to unmet supportive care needs

Five logistic regressions were performed to identify thesignificant predictors of the reported unmet care need in thefive domains. Overall, higher anxiety was found to be

Table 2 Symptom number and severity by different treatment subgroups in last week (N=152)

Overall (N=152) F test Post hocCT (n=69) CT+RT (n=25) EGFR-TKI (n=33) Follow-up (n=25)

M (SD) M (SD) M (SD) M (SD) M (SD)

Symptom number 10.4 (5.0) 11.0 (4.8) 13.2 (4.6) 8.9 (4.5) 7.8 (5.2) 7.91* >; >,

Overall symptom level 2.0 (1.4) 2.1 (1.4) 2.7 (1.4) 1.6 (1.2) 1.1 (0.9) 7.30* >; >,

Fatigue 3.7 (2.7) 4.3 (2.8) 4.0 (2.9) 3.2 (2.2) 2.4 (2.3) 3.39** >

Weakness 3.0 (2.7) 3.4 (2.8) 3.7 (2.7) 2.2 (2.5) 1.8 (2.0) 3.93*** ,>

Insomnia 2.8 (3.0) 3.0 (3.3) 2.4 (2.6) 2.3 (2.6) 3.1 (3.1) 0.67

Cough 2.6 (2.6) 2.5 (2.7) 3.2 (2.8) 1.9 (2.1) 1.8 (1.9) 2.46

Alopecia 2.5 (3.4) 2.6 (2.4) 5.4 (3.9) 1.4 (2.7) 0.7 (1.5) 11.35* >,,

Dry mouth 2.4 (2.5) 2.5 (2.9) 3.4 (3.0) 2.2 (2.2) 1.2 (2.5) 3.33** >

Pain 2.3 (2.9) 2.9 (3.0) 3.1 (2.7) 2.3 (2.5) 1.2 (2.0) 2.22

Dyspnea 2.3 (2.9) 2.8 (3.0) 2.3 (2.3) 1.9 (2.7) 1.8 (2.3) 1.18

Poor appetite 2.3 (2.7) 2.6 (3.0) 4.5 (3.2) 1.4 (2.4) 0.8 (1.5) 9.33* >,

Drowsy 2.0 (2.5) 2.1 (2.5) 3.2 (2.7) 1.7 (2.6) 1.2 (1.7) 2.95** >

Appearance alteration 2.0 (2.7) 2.1 (2.8) 3.2 (3.5) 1.8 (2.5) 0.7 (1.4) 3.60** >

Distraction 1.9 (2.4) 2.2 (2.6) 2.6 (2.8) 1.0 (1.8) 1.6 (2.0) 2.91** >

Chest tightness 1.7 (2.6) 2.0 (2.3) 2.0 (2.3) 1.3 (2.0) 1.1 (1.7) 1.70

Weight lose 1.6 (2.5) 1.7 (2.8) 2.4 (2.6) 1.2 (2.1) 0.9 (1.4) 1.76

Numbness 1.6 (2.6) 1.4 (2.5) 1.9 (2.4) 1.9 (3.1) 1.8 (2.4) 0.46

Nausea 1.4 (2.5) 1.9 (2.7) 2.3 (3.1) 0.5 (1.8) 0.3 (1.0) 5.66*** ,>

Skin darkness 1.2 (2.2) 1.0 (1.9) 2.2 (3.1) 1.5 (2.3) 0.5 (1.2) 3.20** >

Constipation 1.2 (2.3) 1.4 (2.5) 1.9 (2.4) 0.8 (1.9) 0.3 (1.2) 2.56

Diarrhea 1.0 (2.0) 0.9 (2.0) 0.4 (0.8) 1.9 (2.5) 0.4 (1.5) 3.64*** >

Vomiting 0.9 (2.2) 1.3 (2.5) 1.6 (2.8) 0.3 (1.4) 0.1 (0.6) 3.73*** >

Muconitis 0.9 (2.2) 0.8 (2.0) 1.1 (2.3) 0.3 (2.7) 0.3 (1.0) 1.10

Ranking order as mean scores* p

significantly related to each of the five domains of unmetneed. Higher level of overall symptoms was found to berelated to three domains of unmet needs in health system/information, psychological, physical, and daily care. Agewas related to psychological needs with younger patientsreporting higher psychological needs. More depressedpatients had fewer unmet health system/information needsbut reported more unmet psychological needs. Patients withhigher levels of education were more likely to expressunmet needs in physical and daily care (Table 5). Gender,treatment, time since diagnosis, recruitment site, anddisease stage had no significant relationship to any domainsof unmet needs.

Discussion

This study simultaneously explored the symptoms, psycho-logical distress, supportive care needs, and the factorsrelated to those needs of lung cancer patients. The resultssupported the hypothesis that the levels of physicalsymptoms and psychological distress were significantlyrelated to unmet supportive care needs. However, there wasno significant difference in needs across treatment sub-groups in this study. The results have important clinicalimplications for understanding the distress of lung cancerpatients and their supportive care needs during activetreatment and follow-up stages.

Table 4 Supportive care needs across subgroup by treatment (N=152)

Supportive care needs domains Overall CT CT+RT EGFR-TKI Follow-up F (p)(n=69) (n=25) (n=33) (n=25)

M (SD) M (SD) M (SD) M (SD) M (SD)

Health system/Information 67.9 (27.5) 68.1 (28.1) 61.6 (28.3) 70.2 (27.4) 69.6 (24.9) 0.55 (0.12)

Psychological 41.9 (24.4) 43.8 (23.3) 40.9 (25.8) 40.0 (25.3) 40.5 (23.5) 0.24 (0.87)

Patient care support 41.1 (23.1) 41.5 (21.2) 39.5 (26.9) 42.7 (23.9) 39.8 (22.5) 0.12 (0.94)

Daily living care 28.3 (22.6) 29.7 (22.5) 30.0 (25.3) 25.0 (23.3) 27.2 (19.5) 2.56 (0.06)

Interpersonal communication 18.7 (26.6) 20.0 (26.3) 27.5 (27.7) 17.4 (27.4) 8.0 (16.5) 0.39 (0.76)

Overall supportive care 43.7 (20.0) 45.1 (20.0) 42.3 (22.4) 42.9 (20.7) 42.2 (17.0) 0.22 (0.89)

Needs domains and related factors Beta SE (Wald test/p) Odds ratio (95%CI)

Health system/Information (Chi-square=25.21, p=0.022, Nagelkerke R square=0.31)

Anxiety 0.24 0.12 3.90/0.048 1.27 (1.021.59)

Depression 0.40 0.14 7.78/0.005 0.67 (0.510.89)Overall symptom level 0.85 0.29 8.50/0.003 2.39 (1.344.29)

Psychological needs (Chi-square=65.98, p=0.000, Nagelkerke R square=0.52)

Age 0.07 0.02 6.40/0.011 0.93 (0.890.99)Anxiety 0.20 0.09 4.95/0.026 1.22 (1.021.44)

Depression 0.22 0.09 5.76/0.020 1.26 (1.151.57)

Overall symptom level 0.63 0.22 8.08/0.004 1.89 (1.222.90)

Patient care and support needs (Chi-square=24.79, p=0.025, Nagelkerke R square=0.21)

Anxiety 0.20 0.07 9.79/0.002 1.22 (1.081.39)

Physical and daily living care needs (Chi-square=58.36, p=0.000, Nagelkerke R square=0.43)

Overall symptom level 0.58 0.22 6.65/0.010 1.78 (1.152.76)

Anxiety 0.17 0.07 6.52/0.011 1.19 (1.041.35)

Performance status 0.07 0.03 4.95/0.026 0.94 (0.890.98)Education (year) 0.10 0.05 5.34/0.021 1.14 (1.021.26)

Interpersonal communication needs (Chi-square=20.09, p=0.044, Nagelkerke R square=0.19)

Anxiety 0.15 0.06 5.50/0.019 1.16 (1.031.32)

Table 5 Significant factorsrelated to needs in each domainby logistic regression (N=152)

Input independent variable: age,gender, education (year), monthsince diagnosed, recruitment site(inpatient or outpatient), perfor-mance status (KPS), Overallsymptoms level, depression,anxiety (numbered scores), stage(early or advanced), treatment(CT, CT+RT, EGFR-TKI,follow-up)

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Similar to previous studies [5, 9, 10], patients in thisstudy reported multiple symptoms. Although the overallsymptom level was mild-to-moderate, there were signifi-cant differences across treatment subgroups. Patients thatreceived CT only or CT+RT concurrently experiencedsignificantly higher levels of symptom severity and numb-ers of symptoms than the EGFR-TKI and follow-up groups.Attribution of the differences might be to the side effects ofthe chemotherapy and poor performance. Dodd et al. (2001)asserted that symptoms could cause declines in physicalfunctioning and, in turn, functioning declines mightaccentuate the symptoms [13]. Fatigue remained thesymptom causing the greatest distress, as reported inprevious research [5, 9, 10]. This suggests that helpinglung cancer patients effectively manage fatigue should be apriority in clinical care, particularly for those undergoingtreatment.

Our patients reported high depression and anxietymorbidity with 40.8% and 35.6% of them categorized asclinical or borderline cases, respectively. Furthermore, thelevels of depression and anxiety correlated with the levelsof most severe symptoms. Compared to previous studies[12, 36], the psychological distress morbidity in the currentstudy was slightly higher than in studies focused on patientsin pre-treatment or initial treatment stage. The possiblereason might be that our patients had a longer length oftime since diagnosis (M=15.1 months, SD=13.3 months)than the subjects in the prior studies [12, 36, 37]. Previousresearch indicated that psychological distress in lung cancerpatient often persists and intensifies over time due to theincrease of symptoms and more advanced disease con-ditions [12, 38]. Thus, medical professionals should assessand manage psychological distress concurrently withphysical symptoms when delivering lung cancer interven-tions in the disease continuum.

Our participants reported very high information careneeds, psychological needs, and patient care and supportneeds. These needs were higher than those measured inother cancer types, such as prostate cancer [34, 39], oralcavity cancer, [15] breast cancer [7], and colorectal cancer[40]. Moreover, over 60% of patients reported moderate-to-high unmet needs, including things helping self getwell, cancer remission, benefits and side effects oftreatment, and dealing with fears about disease spread-ing and return. It might reflect the extreme distress,threat, and uncertainty brought on by multiple symptoms[14] and the low 5-year survival rate of less than 15% oflung cancer patients [41]. Although the primary physicianexplained the disease- and treatment-related information tothe patients before and during the treatment process in theclinical setting, our results strongly suggested that patientcare needs exceeded those provided in the current medicalsystem. The results also suggested improvement of

symptom management in controlling physical distresswas not enough to meet the needs of lung cancer patients.Heath care professionals should critically identify thepatients needs and provide comprehensive supportivecare.

However, unexpectedly, there was no significant differ-ence in needs across treatment subgroups in this study. Thismay be due to the multi-facets of the factors related tounmet needs. For example, the physical and psychologicaleffects of the treatment affect the patient rather than thetreatment itself. It is worth noting that the follow-uppatients reported similar levels of psychological distressand care needs even though they had lower levels ofsymptoms than the patients in active treatment. Previousresearch suggested that cancer patients in the post-treatmentfollow-up phase had complex concerns including symptomdistress, psychological distress, and fears of relapse anduncertain future [6]. The results emphasized the importanceof routinely assessing distress and needs and of offeringsupportive care to all lung cancer patients, including thosewho have completed treatment. Moreover, preparation forthe transition from the treatment to follow-up phase shouldbe a component of intervention.

Similar to previous studies on patients with breast cancer[42] and oral cancer [15], anxiety was the only factorsignificantly related to all domains of care needs. Accord-ing to the symptom management theories [13, 14], whichstate that the emotional response might raise the need forhelp-seeking, patients with higher anxiety can have highercare needs. This suggests the importance of being aware ofpatients anxiety levels as well as their care needs in orderto offer comfort.

Patients with higher depression had greater psychologicalneeds but fewer information care needs. This was inconsis-tent with previous research [17, 18, 34] showing that patientswith higher depression had increased information care needs.Our patients had a higher prevalence of clinical depression(25.7%) than those in other studies. Fewer needs for seekinginformation might reflect withdrawal and lack of interest inmedical participation in depressed cancer patients [43]. Theother explanation might be that depressed patients did notregister needs for information to avoid receiving bad newsand to preserve hope [44, 45].

Consistent with previous research [16, 18, 20], youngerpatients reported more unmet psychological care needs thandid the seniors, and patients with higher educational levelsreported more physical and daily care needs. The resultsindicated that younger people had greater impacts fromcancer [20]. The other plausible reason might be thatyounger patients and those with more education were morelikely to express their needs and seek help than were theirolder and lower education counterparts [16, 21, 22]. Wesuggest that different care strategies should support lung

Support Care Cancer (2011) 19:17431751 1749

cancer patients according to specific subgroups. Forexample, clinicians should actively provide psychologicalcounseling to younger patients and carefully inquire ofsenior and lower education patients in case they do notexpress their needs.

Although our results provide important information forthe care of lung cancer patients, this study had limitationsdue to its cross-sectional nature in detecting the change ofcare needs during the cancer progression and treatmenttrajectory. In addition, for the purposes of this study, werecruited only lung cancer patients who were receivingactive treatments or were in the survival period. Thus, ourconclusions do not apply to terminally ill patients. Finally,though some patients who might have higher distress orcare needs refused to take part, the high response rate(81.3%) in this study still provides valuable data about thedistress and care needs of lung cancer patients undergoingactive treatment or during their follow-up period.

Conclusion

Lung cancer patients in this study had mild-to-moderatephysical distress but very high psychological distress andunmet supportive care needs, regardless of their treatmentstatus. The effect of symptoms and psychological distresson unmet supportive care needs is substantial. The findingsprovide guidance for health care professionals in improvinglung cancer supportive care. First, health care professionalsshould strengthen their awareness and expertise in identi-fying the needs of and providing supportive care to lungcancer patients. Second, we strongly suggest a systematicassessment of the patients physical and psychologicaldistress and care needs as the basis for providing improvedoverall care. Moreover, a comprehensive intervention,tailored to meet the care needs of lung cancer patients inthe illness continuum, is essential. The intervention com-ponents should include symptom management, psycholog-ical distress reduced intervention, continuing counseling,information provision, and preparation for transition fromthe active treatment stage to the follow-up. Additionalresearch examining longitudinal changes of care needs aswell as testing possible interventions to meet lung cancercare needs are strongly recommended for future study.

Acknowledgement This study was supported by a grant from theNational Health Research Institute, Taiwan, R.O.C. (NHRIEX989807PI). We would like to thank Dr. Girgis and the Centre for HealthResearch & Psycho-oncology for their permission to use the CancerNeeds Questionnaire short form. We gratefully acknowledge all thestudy participants for sharing their experiences. The authors also thankMarc Anthony and Marc D. Baldwin for their English editing.

Conflict of interest No conflict of interest declared.

References

1. American Cancer Society (2009) Global cancer fact and fig-ure 2009.

2. Little AG, Gay EG, Gaspar LE, Stewart AK (2007) Nationalsurvey of non-small cell lung cancer in the United States:epidemiology, pathology and patterns of care. Lung Cancer 57(3):253260

3. National Comprehensive Cancer Network (2009) NCCN clinicalpractice guidelines in oncology. V1. 2009. Non-small-cell-lungcancer. http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf. Accessed 16 Sep 2008

4. Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B (2002)Predictors of depressive symptomatology of geriatric patients withlung cancer-a longitudial analysis. Psychooncology 11:1221

5. Cooley ME, Short TH, Moriarty HJ (2003) Symptom prevalence,distress, and change over time in adult receiving treatment forlung cancer. Psychooncology 12:694708

6. Harrison JD, Young JM, Price MA, Butow PN, Solomon MJ(2009) What are the unmet supportive care needs of people withcancer? A systematic review. Support Care Cancer 25:25

7. Girgis A (2000) Perceived needs of women diagnosed with breastcancer: rural versus urban location. Aust NZ J Public Health 24(2):166

8. Surbone A, Baider L, WT S, Brames MJ, Ritternberg CN,Johnson J (2010) Psychosocial care for patients and their familiesis integral to supportive care in cancer: MASCC positionstatement. Support Care Cancer 18:255263. doi:10.1007/s00520-009-0693-4

9. Tishelman C, Petersson LM, Degner LF, Sprangers MA (2007)Symptom prevalence, intensity, and distress in patients withinoperable lung cancer in relation to time of death. J Clin Oncol25(34):53815389

10. Wang XS, Fairclough DL, Liao Z, Komaki R, Chang JY, MobleyGM, Cleeland CS (2006) Longitudinal study of the relaitonshipbetween chemoradiation therapy for non-small-cell lung cancerand patient symptoms. J Clin Oncol 24(27):44854491

11. Whelan TJ, Mohide EA, Willan AR, Arnold A, Tew M, Sellick S,Gafni A, Levine MN (1997) The supportive care needs of newlydiagnosed cancer patients attending a regional cancer center.Cancer 80(8):15181524

12. Hopwood P, Stephens RJ (2000) Depression in patients with lungcancer: prevalence and risk factors derived from quality-of-lifedata. J Clin Oncol 18(4):893903

13. Dodd M, Janson S, Facione N, Faucett J, Froelicher ES,Humphreys J, Lee K, Miaskowski C, Puntillo K, Rankin S,Taylor D (2001) Advancing the science of symptom management.J Adv Nurs 33(5):668676

14. Henly S, Kallas KD, Klatt CM, Swenson KK (2003) The notionof time in symptom experiences. Nurs Res 52(6):410417

15. Chen SC, Liao CT, Lin CC, Chang JTC, Lai YH (2009) Distressand care needs in newly diagnosed oral cavity cancer patientsreceiving surgery. Oral Oncol 45(9):815820

16. Sanson-Fisher R, Girgis A, Boyes A, Bonevski B, Burton L, CookP (2000) The unmet supportive care needs of patients with cancer.Supportive care review group. Cancer 88(1):226237

17. Sanders SL, Bantum EO, Owen JE, Thornton AA, Stanton AL(2009) Supportive care needs in patients with lung cancer.Psychooncology 19(5):480489

18. Ream E, Quennell A, Fincham L, Faithfull S, Khoo V, Wilson-Barnet J, Richardson A (2008) Supportive care needs of men livingwith prostate cancer in England: a survey. Br J Cancer 98:19031909

19. Cossich T, Schofield P, McLachlan SA (2004) Validation of thecancer needs questionnaire (CNQ) short-form version in anambulatory cancer setting. Qual Life Res 13:12251233

1750 Support Care Cancer (2011) 19:17431751

http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/nscl.pdfhttp://dx.doi.org/10.1007/s00520-009-0693-4http://dx.doi.org/10.1007/s00520-009-0693-4

20. Smith DP, Supramaniam R, King MT, Ward J, Berry M,Armstrong BK (2007) Age, health, and education determinesupportive care needs of men younger than 70 years with prostatecancer. J Clin Oncol 25(18):25602566

21. Steginga SK, Campbell A, Ferguson M, Beeden A, Walls M,Cairns W, Dunn J (2008) Socio-demographic, psychosocial andattitudinal predictors of help seeking after cancer diagnosis.Psychooncology 17(10):9971005

22. Ramanadhan S, Viswanath K (2006) Health and the informationnonseeker: a profile. Health Commun 20(2):131139

23. Beesley V, Eakin E, Steginga S, Aitken J, Dunn J, Battistutta D(2008) Unmet needs of gynaecological cancer survivors: implica-tions for developing community support services. Psychooncol-ogy 17(4):392400

24. Rainbird K, Perkins J, Sanson-Fisher R, Rolfe I, Anseline P(2009) The needs of patients with advanced, incurable cancer. Br JCancer 101(5):759764

25. Li J, Girgis A (2006) Supportive care needs: are patients with lungcancer a neglected population? Psychooncology 15(6):509516

26. Steele R, Fitch MI (2008) Why patients with lung cancer do notwant help with some needs. Support Care Cancer 16(3):251259

27. Cancer registry annual report, 2006 (2009) http://crs.cph.ntu.edu.tw/uploadimages/Y95-ALL.pdf. Accessed 16 Jan 2009

28. Lai YH (1998) Symptom distress and home care needs in patientsreceiving chemotherapy in an outpatient setting. Journal ofNursing Research (Chinese) 6:279289

29. Zigmond AS, Snaith RP (1983) The hospital anxiety anddepression scale. Acta Psychiatry Scand 67(6):361370

30. Chen ML, Chang HK, Yeh CH (2000) Anxiety and depression inTaiwanese cancer patients with and without pain. J Adv Nurs 32(4):944951

31. Foot G (1996) Needs assessment in tertiary and secondaryoncologypractice: a conceptual and methodological exposition.University of Newcastle, Newcastle

32. Foot G, Sanson-Fisher R (1995) Measuring the unmet needs ofpeople living with cancer. Cancer Forum 19(2):131135

33. Karnofsky DA, Abelmann WH, Craver LF, Burchenal JH (1948)The use of nitrogen mustards in the palliative treatment of cancer.Cancer 1(4):634656

34. Steginga SK (2001) The supportive care needs of men withprostate cancer (2000). Psychooncology 10(1):6675

35. Bonevski B, Sanson-Fisher R, Girgis A, Burton L, Cook P, BoyesA (2000) Evaluation of an instrument to assess the needs ofpatients with cancer. Cancer 88(1):217225

36. Neron S, Correa JA, Dajczman E, Kasymjanova G, Kreisman H,Small D (2007) Screening for depressive symptoms in patientswith unresectable lung cancer. Support Care Cancer 15(10):12071212

37. Akechi T, Okuyama T, Akizuki N, Azuma H, Sagawa R,Furukawa TA, Uchitomi Y (2006) Course of psychologicaldistress and its predictors in advanced non-small cell lung cancerpatients. Psychooncology 15(6):463473

38. Henoch I, Bergman B, Gustafsson M, Gaston-Johansson F,Danielson E (2007) The impact of symptoms, coping capacity,and social support on quality of life experience over time in patientswith lung cancer. J Pain Symptom Manage 34(4):370379

39. Lintz K, Moynihan C, Steginga S, Norman A, Eeles R, HuddartR, Dearnaley D, Watson M (2003) Prostate cancer patientssupport and psychological care needs: survey from a non-surgicaloncology clinic. Psychooncology 12(8):769783

40. Macvean ML, White VM, Pratt S, Grogan S, Sanson-Fisher R(2007) Reducing the unmet needs of patients with colorectalcancer: a feasibility study of the pathfinder volunteer program.Support Care Cancer 15(3):293299

41. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ(2008) Cancer statistics, 2008. CA Cancer J Clin 58(2):7196.doi:10.3322/ca.2007.0010

42. Hodgkinson K, Butow P, Hunt GE, Pendlebury S, Hobbs KM,Wain G (2007) Breast cancer survivors supportive care needs 210 years after diagnosis. Support Care Cancer 15(5):515523

43. Akechi T, Ietsugu T, Sukigara M, Okamura H, Nakano T, AkizukiN, Okamura M, Shimizu K, Okuyama T, Furukawa TA, UchitomiY (2009) Symptom indicator of severity of depression in cancerpatients: A comparison of the dsm-iv criteria with alternativediagnostic criteria. General Hospital Psychiatry 31(3):225232

44. Leydon GM, Boulton M, Moynihan C, Jones A, Mossman J,Boudioni M, McPherson K (2000) Cancer patients informationneeds and information seeking behaviour: in depth interviewstudy. BMJ 320(7239):909913. doi:10.1136/bmj.320.7239.909

45. Fallowfield L, Ford S, Lewis S (1995) No news is not good news:information preferences of patients with cancer. Psychooncology 4(3):197202

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http://crs.cph.ntu.edu.tw/uploadimages/Y95-ALL.pdfhttp://crs.cph.ntu.edu.tw/uploadimages/Y95-ALL.pdfhttp://dx.doi.org/10.3322/ca.2007.0010http://dx.doi.org/10.1136/bmj.320.7239.909

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c.520_2010_Article_1014.pdfSymptoms, psychological distress, and supportive care needs in lung cancer patientsAbstractAbstractAbstractAbstractAbstractIntroductionMethodsParticipants and procedureMeasuresSymptom Severity ScaleHospital Anxiety and Depression ScaleCancer Needs QuestionnaireShort Form 32Background informationData analysisResultsSubject characteristicsSymptom experiencePsychological distressCorrelation between symptom severity and psychological distressSupportive care needsFactors related to unmet supportive care needsDiscussionConclusionReferences