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Journal of Clinical Oncology, Vol 22, No 5 (March 1), 2004: pp. 919-926 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.07.028 Prevalence and Predictors of Psychological Distress Among Women With Ovarian CancerFrom the Fox Chase Cancer Center, Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, Temple University Hospital, Albert Einstein Medical Center, Philadelphia, PA; and Cooper Hospital, Camden, NJ Address reprint requests to Tina R. Norton, PhD, Fox Chase Cancer Center, Division of Population Science, 510 Township Line Rd, 1st Floor, Cheltenham, PA 19012; e-mail: tr_norton@fccc.edu
PURPOSE: To identify the prevalence of psychological distress among women with ovarian cancer and to examine the association between these symptoms of distress and demographic and medical variables. PATIENTS AND METHODS: Participants were 143 women with ovarian cancer. Forty-eight percent of participants had been diagnosed with advanced-stage disease (stage III or IV) and most (80%) were currently receiving treatment. Psychological distress was assessed with the following measures: the Beck Depression Inventory, the Mental Health Inventory, the Impact of Events Scale, and a questionnaire regarding mental health service use. RESULTS: Approximately one fifth of women reported moderate to severe levels of distress, and more than half reported high stress responses to their cancer and its treatment. Most participants (60%) were not using any mental health services or psychotropic medications. There was also evidence to suggest that younger patients, patients with more advanced or recurrent disease, and patients who had more recently been diagnosed with ovarian cancer experienced greater psychological distress. CONCLUSION: These findings indicate that psychological distress and high stress responses to cancer are prevalent among women with ovarian cancer, suggesting they should be carefully evaluated to determine whether treatment for these symptoms is warranted.
The diagnosis and subsequent treatment of ovarian cancer can be emotionally distressing. Indeed, women with ovarian cancer may be at increased risk for psychological distress relative to patients diagnosed with other cancers [1]. However, few studies have focused on the prevalence of distress among women with ovarian cancer. Across empirical studies, approximately 30% to 50% of ovarian cancer patients report moderate to severe levels of anxiety [2-4], and up to one third of women with this disease report levels of depressive symptoms suggestive of clinical depression [1,2]. Given the paucity of studies that have examined the psychological distress of women with ovarian cancer, more research is needed to identify the prevalence of distress reactions in this population and to examine indicators of psychological distress beyond anxiety and depressive symptoms. It is also unclear what factors place women with ovarian cancer at increased risk for distress. One reason it is difficult to draw conclusions is that only three studies have examined predictors of distress among these women, focusing primarily on demographic and medical factors [1,2,4]. Although these studies indicated that more physical symptoms and worse physical functioning were associated with greater psychological distress [1,2,4], other results have been less consistent. For instance, one study found younger ovarian cancer patients more likely to be distressed than older patients [1], but another study failed to find a significant relationship between age and distress [2]. Similarly, advanced-stage disease was associated with greater distress in one study [2], yet no such relationship was found in another study [1]. Further research is needed to clarify the existing findings regarding demographic and medical risk factors for psychological distress among women with ovarian cancer. The identification of these factors could potentially assist in developing interventions for women at greatest risk for distress reactions. Although it is well accepted that cancer diagnosis and treatment is distressing, little is known of the extent to which individuals with cancer make use of mental health services to deal with this distress [5]. Research suggests that individuals who have been diagnosed with cancer are significantly more likely to have used mental health services in the past year than individuals without a cancer history (7.2% v 5.7%, respectively) [5]. Other findings indicate that among women who had recently completed treatment for breast cancer, 20% had used mental health services, and 52% had used support services in the past [6]. Additional research is needed to assess the use of mental health services among individuals with cancer, including ovarian cancer. The purpose of the present study was to examine psychological distress among women with ovarian cancer. The first objective was to identify the prevalence of several indicators of psychological distress: Symptoms of anxiety, depression, and loss of behavioral and emotional control, cancer-specific distress (intrusive and avoidant thoughts), and mental health service use. The second objective was to examine the association between demographic and medical variables and psychological distress.
Participants Participants in the present study were 143 women diagnosed with ovarian cancer. Patients were approached for study participation in outpatient oncology clinics. Participants were age 18 years or older; had a primary diagnosis of stage I to stage IV ovarian cancer; were undergoing treatment (chemotherapy or radiation) or less than three-months postsurgery; had a physician-rated score of  80 on the Karnofsky performance scale [7] or an Eastern Cooperative Oncology Group score [8] of 0 or 1, indicating they were able to carry out their normal activities; and were English speaking. The study participation rate was 51% (171 of 335 patients). The most frequent reasons for study refusal were that the patient was not interested (26%), was too busy (16%), or felt too ill (10%). Comparisons were made between refusers and participants on available demographic and medical data. Participants were significantly younger and more likely to have recurrent disease than refusers (P < .05). Participants did not differ significantly from refusers in terms of marital status, ethnicity, or performance status. Of the 171 participants, 28 women were excluded from the present analyses because of incomplete data.
Procedures
Measures Medical variables. Participants' disease stage (I-IV or recurrent), treatment status (chemotherapy or radiation v no current treatment), time since original diagnosis, and symptom ratings were obtained from the medical chart. Each symptom (nausea, vomiting, diarrhea, constipation, neurosensory disturbance, fatigue, pain, hair loss, or mucositis) was rated as 0 (not experienced) or 1 (experienced) based on a symptom checklist completed by the physician or nurse at each patient's most recent outpatient visit. A composite score was created to reflect the number of symptoms, ranging from 0 to 9. Beck Depression Inventory (BDI). Psychological distress was assessed with the 21-item BDI [9]. The following cutoff scores have been used for the BDI: No or minimal depression is less than 10; mild to moderate depression is 10-18; moderate to severe depression is 19 to 29; and severe depression is 30 to 63 [9]. Internal reliability was good (alpha = 0.85). Mental Health Inventory (MHI). Three subscales of the 18-item version MHI [10] were used to measure psychological distress: anxiety (alpha = 0.88), depression (alpha = 0.89), and loss of behavioral and emotional control (alpha = 0.85). Items across these subscales were summed to create a total distress scale (alpha = 0.94), with higher scores indicating greater distress. There is no clinical cutoff score for the MHI, but normative data are available for comparison. Impact of Events Scale (IES). Cancer-specific distress was measured with the IES [11]. This 15-item scale comprises two subscales that assess avoidance (alpha = 0.87) and intrusive thoughts (alpha = 0.83) related to cancer and its treatment. Subscales were summed to create a total IES scale (alpha = 0.90). Thresholds have been identified for low (< 8.5), medium (9-19), and high (> 19) stress responses [12]. Mental health service use. Participants were asked whether they were currently (1) seeing a counselor or therapist, (2) seeing a religious counselor, (3) participating in a support or therapy group, or (4) taking any mediations to help with mood, nerves, or sleep. A composite score was created to reflect the number of services being used, ranging from 0 to 4.
Analysis Plan
To examine the relationship between demographic and medical variables and psychological distress, a structural equation model was tested using EQS 5.7 software [13]. Structural equation modeling (SEM) has several advantages over other statistical techniques used to test predictive ordering: (1) it allows multiple indicators of a construct to be considered, (2) it simultaneously tests all variables (and their relationships) in the model, and (3) it acknowledges measurement error when estimating the model, which is a source of variability not accounted for by other techniques. Thus, SEM is well suited for testing the more complex model of psychological distress conceptualized in the present study. The maximum likelihood estimation method was used to generate the standardized parameter estimates because it is robust to violations of multivariate normality [14]. The Satorra-Bentler scaled The latent variable of psychological distress was created by using each of the four measures of distress as an indicator. For these analyses, the two somatic items of the BDI (appetite and weight loss) were excluded because these symptoms might be side effects of the participants' cancer or treatment. A measurement model of the construct of psychological distress was tested and measures of fit indicated that it fit the data well (Fig 1), suggesting that the construct is reasonably well measured.
Demographic and medical variables were tested as predictors of psychological distress in a structural model. A measured variable was used for each of the demographic and medical variables. Household income was not included in the model because of the number of participants (n = 27) with missing data on this variable. In SEM, a parameter/sample size ratio of 1:5 is commonly recommended [18] because estimates are not stable below this ratio. Given that 17 parameters are estimated in the model, the current sample size provides more than adequate power to conduct this analysis.
Demographic and Medical Data Participants' demographic and medical data are in Table 1. Participants in this study were primarily white and well-educated. On average, participants were 55 years of age. Most participants were married and had been married for an average of 29 years.
The majority of participants (n = 87) had been diagnosed with a first occurrence of cancer and approximately half (49%; n = 70) were diagnosed within the past 6 months. Forty-eight percent were diagnosed with advanced-stage disease (stage III or IV). Most participants (n = 114) were currently receiving either chemotherapy or radiation treatment. On average, participants' symptom ratings were in the low range.
Prevalence of Psychological Distress
Unlike the BDI, the Mental Health Inventory-18 does not have an established clinical cutoff score. Therefore, women's scores on the MHI-18 distress scale were compared with normative data provided by the authors of the scale [21]. The mean of the present sample was significantly higher than the normative mean (t (3202) = 2.27; P < .05; M = 23.0; SD = 19.2) but did not differ significantly from the mean of a mixed sample of female cancer patients (t (362) = 1.54; P > .05; M = 28.23, SD = 8.98; Manne SL, unpublished data). In addition, distress scores were categorized as low (< 0.5 SD above the normative mean), moderate (0.5 to 1.49 SD above the normative mean), and high ( 1.5 SD above the normative mean). This categorization was based on prior studies suggesting that scores greater than 1.5 SD above the normative mean can be used as a clinical cutoff for distress [2,22]. Seventy-six percent of women (n = 109) had scores indicating low distress. Twenty-two percent of women (n = 32) had scores suggesting moderate distress and 1% (n = 2) had scores indicating high levels of distress. It is interesting to note that women reported significantly higher mean levels of anxiety than depressive symptoms (t (142) = 6.15; P < .001) or loss of behavioral and emotional control (t (142) = 8.12; P < .001). In terms of cancer-specific distress, 55% of women (n = 79) scored above 19 on the IES total, indicating a high stress response to their cancer and its treatment [12]. The mean of the present sample was significantly higher than the mean for the general population, (t (639) = 6.03; P < .001; M = 14.3; SD = 17.0), [23] and a sample of breast cancer survivors (t (196) = 2.86; P < .01; M = 16.4; SD = 18.0) [24]. Women in the present sample also reported significantly higher levels of avoidance than intrusive thoughts (t (142) = 6.31; P < .001). In terms of mental health services, the majority of women were not using any counseling services or psychotropic medications. Psychotropic medications were the most commonly used, with 34% of women (n = 48) reporting that they took medication to help with mood, nerves, or sleep. Women reported participating in individual counseling (7%), religious counseling (4%), or group counseling (8%) much less frequently.
Demographic and Medical Variables Related to Distress
This study was conducted to identify the prevalence of psychological distress among women with ovarian cancer and to examine the relationship of this distress to demographic and medical variables. Findings indicated that levels of psychological distress were generally higher among women with ovarian cancer than levels found in the general population or among women with other types of cancer. Approximately one fifth of women reported moderate to severe levels of distress, and more than half reported high stress responses to their cancer and treatment. Despite the prevalence of psychological distress among these women, the majority was not using any mental health services. Findings also suggested that younger patients, patients with more advanced or recurrent disease, and patients more recently diagnosed with ovarian cancer experienced greater psychological distress. Our findings are consistent with prior studies indicating that cancer patients experience elevated levels of psychological distress [25,26]. However, relatively few studies have examined the prevalence of distress among women with ovarian cancer. These studies [1,2] reported that roughly one third of ovarian cancer patients experienced high levels of psychological distress. The higher prevalence of severe distress in these studies as compared with the present study may be due in part to differences in participants' physical functioning across studies. Although all participants in the present study were outpatients when they completed the study questionnaire, the majority of participants (94%) in the study by Kornblith et al [2] were hospitalized. In addition, unlike our study, these studies included women with a score below 80 on the Karnofsky performance scale (19%) [2] or an Eastern Cooperative Oncology Group score greater than 1 (21%) [1], which indicates greater impairment in functioning. It has been well established in the literature that worse physical functioning is associated with greater psychological distress among cancer patients [27,28], and these two studies demonstrate this relationship among women with ovarian cancer [1,2]. Thus, women in the present study may have been less distressed because they were experiencing better physical functioning.
The present study extends the literature on psychological distress among women with ovarian cancer by examining stress responses related specifically to their cancer and its treatment. A life-threatening illness such as cancer can be a traumatic experience that evokes intrusive and avoidant thoughts among patients [24]. Using the IES to assess cancer-specific stress is meaningful as these stress responses may not be adequately captured by measures of general distress, such as the MHI or BDI. The present findings indicate that women are more likely to experience intrusive and avoidant thoughts specifically related to their cancer than symptoms of general distress, suggesting that cancer-specific stress is a construct that is distinct from other psychological symptoms. Although prior research has demonstrated elevated stress responses among women with breast cancer [29,30] and a mixed sample of cancer patients [31], only one study to date has examined these intrusive and avoidant thoughts among women who have been diagnosed with ovarian cancer [32]. In contrast to the current findings, Wenzel et al [32] reported that cancer-specific intrusive and avoidant thoughts were not present in their sample of early-stage (I or II), long-term ( This study also extends the literature by examining the extent to which women with ovarian cancer used mental health services. Despite the prevalence of psychological distress among these women, most were not using mental health or support services. However, 34% of these women reported using psychotropic medications. Many patients may rely solely on psychotropic medications to alleviate feelings of distress without considering mental health or support services that may be just as helpful. There is evidence to suggest that psychological interventions are effective in helping cancer patients adjust to their illness [33] and subsequently reducing costs through decreased health care usage [34,35]. Prior research indicates that individuals who have been diagnosed with cancer are more likely to have used mental health services than individuals without a cancer history [5]. However, cancer survivors were also more likely than those without a cancer history to report needing mental health services but not getting them because of the cost, particularly among younger, less educated individuals [5]. Given the apparent (and often unmet) need for mental health services among individuals with cancer, it is important to ascertain whether patients are participating in services and whether failure to do so reflects a choice by the patient or a lack of opportunity or awareness that needs to be addressed. Younger age was associated with greater psychological distress in our study. This result is consistent with other studies of psychological distress among cancer patients, [25,36-38] including women with ovarian cancer [1]. It has been argued that younger cancer patients have fewer expectations of disease or disability being normative than older patients, which may cause a greater sense of emotional distress in response to their cancer [39]. The current results also suggest that a shorter time since diagnosis and advanced or recurrent disease are risk factors for psychological distress. Women who have more recently been diagnosed with ovarian cancer may experience greater distress because they have not had time to adjust to their cancer diagnosis. Furthermore, women with advanced or recurrent disease may view their cancer as a greater threat to their lives, thus increasing their distress. In contrast to previous findings [2,4], number of symptoms was not significantly related to psychological distress. It is possible that our measure underestimated the number of symptoms that women were experiencing. Physicians or nurses may have failed to ask about a particular symptom or women may have minimized their discomfort in an effort to please the medical professional with whom they were interacting. Thus, future work is needed before we conclude that this variable is not predictive of psychological distress among women with ovarian cancer. The present study has several limitations. Because psychological distress was assessed using patient self-report rather than criteria from the Diagnostic Statistical Manual-IV (DSM-IV), [40] we could not determine the number of diagnosable disorders. However, given prior research indicating that the prevalence of major psychiatric disorders (eg, major affective disorders, anxiety disorders) is generally low in cancer populations [26,41], this may not be a serious limitation. Given that the sample was largely white, well educated, and middle-class, it is not known to what extent the present findings would apply to women of different ethnic backgrounds or socioeconomic status. The representativeness of the sample may also be limited due to selection bias. Our participation rate (51%) was lower than that of similar studies of women with ovarian cancer [1,2]. Our analyses indicated that participants in this study were younger and more likely to have recurrent disease than women who refused to participate. In addition, our high refusal rate may have affected the results regarding prevalence of psychological distress. Given that data reported in the present study were derived from a 1-year study of psychological interventions for ovarian cancer patients, it could be argued that women in this study were more distressed than study refusers and chose to participate in order to obtain access to therapy. Conversely, it could also be argued that women in this study were less distressed and therefore more willing and/or able to participate in this research. These findings indicate that psychological distress and high stress responses to cancer are prevalent among women with ovarian cancer, suggesting they should be carefully assessed to determine whether treatment for these symptoms is warranted. Feelings of anxiety were especially common. Medical professionals may help allay this anxiety by addressing patients' individual concerns regarding their diagnosis and treatment in addition to the general information already provided. Furthermore, younger patients, patients with a greater number of disease recurrences, and patients recently diagnosed with ovarian cancer appear to be at greater risk for psychological distress. Awareness of these risk factors among oncologists could facilitate early detection of serious distress reactions.
The authors indicated no potential conflicts of interest.
We thank Sandra Corbett, Rebecca Tendler, Chris Conklin, Camille Thompson, Kelly Gabos, and Sara O'Neal for their assistance with recruitment and data collection; Miah Jung for her editorial assistance; the oncologists at Fox Chase Cancer Center (Drs Boente, Bookman, Ozols, and Schilder), Temple University Medical Center (Dr Houck), Cooper Hospital (Dr Rocetero), Paoli Hospital (Drs Fox and Hoessly) and the Hospital of the University of Pennsylvania (Drs Bandera and Morgan) and the nurses at Temple, Cooper, and Paoli for their cooperation in soliciting participants; and the patients who generously gave of their time.
Authors' disclosures of potential conflicts of interest are found at the end of this article. Supported by grant R01 CA85566 from the National Institutes of Health (S.L.M.) and by a training grant from the National Cancer Institute (R25 CA57708-10).
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 statistic [
