In this study, we evaluated the association between stress coping strategy and psychological distress with esophageal cancer from the time of the outpatient consultation (time 1) through to 3 months after esophagectomy (time 5). Our results showed that the relationship between psychological distress and psychological factors, such as Coping strategy, was stronger than that between psychological distress and individual patient characteristics. The C-index for these analyses showed high predictive performance at times 1–5. This is the first study to use prospective clinical data for the relation between the psychological distress and Coping strategy on each points of the treatment of esophageal cancer and may serve as a baseline for future research.
In the past report, Hellstadius et al.  reported that the proportion of patients with anxiety was 33% prior to surgery, 28% at 6 months, and 37% at 12 months and depression was 20% prior to surgery, 27% at 6 months, and 32% at 12-month. He concluded that anxiety symptoms remained stable over time whereas depression symptoms appeared to increase from pre-surgery to 6 months, levelling off between 6 and 12 months. On the other hand, this report showed that the proportion of patients with psychological distress was 36.2% in outpatients clinic, 40.2% prior to surgery, 47.1% at 14 days after surgery, 43.1% at 1 month, and 34.3% at 3 months (Table 1). In our study, the results were a little different that psychological distress appeared to increase from outpatient clinic to about 14 days after surgery, and gradually decreases from one month to 3 months after surgery. This study is the first report that examined the risk factors and psychological reactions or conditions in each point of treatment in more detail from outpatient clinic to 3 months after surgery.
In the past report, there were significant associations between the Coping strategies and psychological distress [13,14,15]. Therefore, there is a possibility that the Coping strategy improves the psychological distress. In another report, how patients cope with and adjust to threats is reportedly associated with depression . However, it is still unclear whether the Coping strategies act on the psychological distress effectively in the various situations of the episode of the esophageal cancer treatment. Therefore, we investigated in more details the association between stress coping strategy and psychological distress on each points of the treatment of esophageal cancer.
Patients with a helpless/hopeless response and anxious preoccupation were at increased risk of psychological distress during the course of treatment for esophageal cancer, whereas those with a fighting spirit response were better able to adjust to their situations [13, 14]. Previous studies of the association between psychological distress and Coping strategy have suggested that the most beneficial response is fighting spirit and the most deleterious response may be helpless/ hopeless [11, 15, 25]. On the other hand, Petticrew et al. reported that the association between fighting spirit and psychological distress was not confirmed by larger study . In esophageal cancer patients, maintaining a positive focus Coping strategies appears to minimize psychological harm in the past report [17, 30, 31]. However these reports didn’t describe such advantage on each points of the treatment of esophageal cancer. Therefore, it is yet unclear if such advantage can be observed on every point of the treatment or only on some limited phase. In the present study, helpless/ hopeless response was at increased risk of psychological distress at almost all the situations (times 2 to time 5). Anxious preoccupation was risk factor focusing on Coping strategy only at time 1. On the other hand, patients with a fighting spirit had fewer symptoms of anxiety and depression at the time of diagnosis in the outpatient clinic (time 1), at the determination of clinical stage (time 2), and at the determination of final staging (time 4). Recent advances in surgical techniques and perioperative intensive care have reduced the mortality and complications associated with esophagectomy, but it continues to be a challenging procedure with a reported mortality rate of 2.9–3.0% and a postoperative complication rate of 42.8–50.0% [2, 6, 8]. These esophageal cancer patients felt depressed and expressed fear of metastases and death during the course of treatment for esophageal cancer. In this study, we described that the deleterious Coping strategy such as helpless/ hopeless and anxious preoccupation had affected the psychological response all the situation of the treatments. On the other hand, the beneficial Coping strategy such as fighting spirit affected the psychological distress at the important situations for patients including of first outpatients clinic, determination of clinical stage, and determination of final stage after esophagectomy. On the other hand, although fighting spirit and anxious preoccupation were strongly related to psychological distress before treatment, as time of treatment passes, helpless/ hopeless was strongly related to psychological distress after esophagectomy. Therefore, we do not have to force patients to fighting spirit after esophagectomy, and also it is important to recognize and understand that feeling of helpless/hopeless may appear in these patients. In brief, we have to be responsible for continuous support so that patients do not give up a fight against esophageal cancer until the last. The two other adjustments styles such as fatalism and avoidance were not significant risk factors of psychological distress in this study.
We found that pathological staging was a significant risk factor of psychological distress at the determination of final staging after esophagectomy (time 4). It was reported that there is an association between psychological distress and tumor staging in the past report . This is considered to be caused by the patient’s regret at allowing cancer to progress to an advanced stage, which interferes with the coping process. Previous research on emotional outcomes after resection for esophageal cancer found that a substantial proportion of patients who were alive at 1 year expressed fear of metastasis and death (80%) . Therefore, we strongly recommend the development of a supportive care method for reducing anxiety and stress coping with esophageal cancer that as progressed to an advanced stage.
We expected before this study that the patients with history of surgery might be hard to feel depressed than the patients without history of surgery. However, we found that history of surgery was a significant risk factor of psychological distress but only at 1 month postoperatively before final staging (time 3). One possible explanation to this is that these patients may have felt postoperative agony from the gap with the former operation and the esophagectomy which is one of the most invasive in gastrointestinal surgery. Another explanation can be made that the esophagectomy in patients with previous abdominal or thoracic surgery tend to be more complex and time-consuming.
We already have a system in which various kinds of medical professionals such as gastroenterologists, surgeons, nurses, nutrients, dentists, otolaryngologists, and physical therapists, support esophageal cancer patients. However, psychiatrists and clinical psychologist have not been included in this team. For the patients having the predictive factors of the psychological distress, it would be very important to provide the mental intervention by psychiatrists before treatment. Therefore, we have to include psychiatrists and clinical psychologists in this esophageal team in our hosptal. And also, we hope that these medical teams are organized in other hospitals of Japan. More specific and personalized mental intervention will be needed in the near future.
Esophageal cancer is associated with substance dependence such as alcohol as reviewers comments. In this report, there were no relationships between psychological distress and drunker/ smoker. However, factors related to substance dependence influence coping style. In considering psychological support, it is important for medical professionals to prevent subsequent re-smoking and polydipsia in order to prevent recurrence, in addition to support related to cancer treatment.
This study has some limitations, in particular its single-center design, restricted nationality to Japanese, and small sample size. An external validation study or an international multicenter trial with a larger number of cases is needed to confirm our observations. There were also several factors potentially associated with psychological distress related to treatment for esophageal cancer that could not be controlled for this study. Nevertheless, our results confirm that the risk of psychological distress can be estimated reasonably accurately using the clinical factors investigated in this study. Our preliminary risk analysis could therefore be useful for risk stratification in actual clinical settings. Prospective accumulation of clinical data using this analysis could provide important information for better psychological management of patients undergoing treatment for esophageal cancer.