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Symptom Distresses and Coping Strategies in Patients With Non-small Cell Lung Cancer

Kuo, Ting-Ting MN, RN; Ma, Fung-Chi PhD, RN


The purpose of this study is to understand the correlation of symptom distresses and coping strategies of patients with lung cancer. Seventy-three patients with non-small cell lung cancer from the cancer center or ward in the two medical centers located in northern Taiwan participated. The instruments used in this study were the Symptom Distress Scale and Coping Strategies Scale. The results of the study showed that the degree of symptom distress during the therapeutic period was mild to moderate. When patients were confronted with symptom distress, they combined problem- and emotion-focused coping strategies. Participants with higher physical symptom distress had higher psychological distress and emotion-focused coping strategy frequency. It was also found that the distress of tension–anxiety and age explained 39.4% of variance in physical symptom distresses. The physical symptom distresses and the frequency of emotion-focused coping strategy frequency explained 48.8% of variance in the psychologic symptom distresses. Finally, it is recommend that a support group be established to enable sharing of experiences and emotional support among patients.

From Tri-Service General Hospital and National Yang Ming University Institute of Clinical Nursing, Taiwan, ROC.

Corresponding author: Ting-Ting Kuo, MN, RN, No. 325 Chang-chung Rd, Ne-hu 114, Taipei, ROC (e-mail:

Accepted for publication April 12, 2002.

Since 1986, cancer has been the leading cause of death in Taiwan, and since 1997, lung cancer has overtaken cancer of the liver as the leading form of death from cancer. In 1998, there were 6,126 patients with cancer of thoracic organs, of which 5,749 had cancer of the trachea, bronchi, or lungs. Non-small cell lung cancer (NSCLC) accounts for a majority of lung cancer. 1 Because of the differing locations of their tumors, patients with cancer experience different physical and emotional symptom distress. With the number of patients with lung cancer in Taiwan increasing each year, the health problems of these patients should receive more attention, particularly in terms symptom distress that patients experience, their adaptation methods, and the effectiveness of these adaptations.

Chemotherapy and radiotherapy are the principal treatments for lung cancer. 1–3 Treatment can be to cure, control, or alleviate symptom distress, but such treatments also increase patients’ symptom distress, affecting them physically, emotionally, and socially. 3,4 Patients often attempt to reduce the severity of symptom distress, thus minimizing its effect. Effective coping methods allow a patient to face the disease and treatment with an active and positive attitude, which can alleviate symptoms. Inappropriate coping strategies can worsen the degree of symptom distress and affect the patient’s physical and emotional health. 5,6 A coping strategy that is effective at one time may not necessarily be effective in another situation or at a different time. 7 To understand patients’ use of coping strategies, it is necessary to distinguish between different times. Our study investigates patient’s symptom distress and coping strategies during the treatment phase.

Symptom distress refers to the level of physical or emotional discomfort experienced by the patient as the result of a particular symptom. Age, socioeconomic position, culture, role in the household, educational level, degree of health knowledge, values, and past experience influence symptom distress. 8 When McCorkle and Young developed their Symptom Distress Scale (SDS), they also indicated that it is impossible to separate symptom distress caused by illness and that caused by treatment. 9 The physical symptom distress of patients with cancer is rooted in the tumor and side effects of the treatment. Patients with lung cancer often seek medical attention for symptom distress, such as difficulty in breathing, increased sputum, or hemoptysis. Consequently, their emotional distress increases. 10 “Difficulty in breathing” is one of the symptoms that most troubles patients with lung cancer. This symptom is inextricably linked with fatigue and often occurs in tandem with coughing, chest pain, wheezing, and insomnia. 11,12 Because their tumors involve the blood vessels to the lungs, patients with lung cancer often experience hemoptysis, metastasis to the brain and pressure on nerves bring about neurogenic symptoms, and metastasis to the bones causes pain. 13

Treatment can alleviate or even eliminate the symptom distress caused by tumors; however, treatment brings with it side effects that are another source of symptom distress for patients. 13 Recently, patients with NSCLC who have undergone chemotherapy have often been given gemcitabin and navelbine, in combination with cisplatin, or ifosfamide, taxotere, and VP-16 (etoposide). Injections of gemcitabin or navelbine alone cause few side effects, but in combination with cisplatin, symptom distress intensifies. In chemotherapy, the type of agent and the dosage are the major factors for determining the severity of symptom distress. Patients receiving radiotherapy are mostly irradiated in the chest and in areas of metastasis in the head, spine, skeleton, and superior vena cava. Table 1 shows common side effects experienced by patients with lung cancer. Whether a patient receives chemotherapy or radiotherapy, lack of appetite, weight loss, insomnia, fatigue, and pain are major symptom distresses experienced by patients during therapy. 14

Table 1

Table 1

Anxiety and depression follow the disease and the treatment, and there is generally psychologic symptom distress. Moreover, patients with cancer also worry about becoming a burden to family members, or experience feelings of guilt, shame, or anger about having gotten lung cancer after many years of smoking. Severe physical symptom distress is worsened by psychologic symptom distress, and difficulty in breathing makes patients with lung cancer experience even less vitality than patients with other types of cancer. This not only deepens the depression but also can cause panic, anger, feelings of helplessness, powerlessness, fear, and other psychologic symptom distress. 3,4,12,15–19

Coping is an individual’s attempt to manage stress and adapt to the demands of added problems. Use of coping strategies alleviates the effects of stress on an individual’s physical and psychologic symptom distress. Besides management of stress, coping strategies can also alleviate unhappy feelings caused by stress. The extent to which physical and psychologic stress is reduced and social function is restored indicates the effectiveness of the coping strategies used to alleviate the stress. 7 Effective adaptation by patients with cancer to their illness and to the stress of treatment increases the feeling of control, fills the patient with hope, gives the patient goals for the future, and enables him or her to interact in society to seek related information and make positive lifestyle changes, and enables appropriate emotional expression. 5–7,20

Lazarus and Folkman 7 classified coping strategies into two major groups: problem-focused forms of coping relating to actively or directly eliminating or solving problems, analyzing and exploring the causes of stress incidents, changing individual expectations, setting goals, seeking related information, seeking assistance, and becoming familiar with new techniques to increase self-control. Emotion-focused forms of coping are not directed toward solving a problem but rather are subjective changes in a person’s thoughts, such as escape, hopeful thinking, acceptance, transference, repression, denial, projection, reactive behaviors (such as drinking alcohol or letting feelings out), responsibility, and others. Neither of these two coping strategy types is superior to the other. They can only be evaluated for effectiveness in the long- and short-terms. Short-term effects include helping an individual to alleviate the demands of a particularly stressful situation and allowing him or her to adjust his or her own emotional reaction to the stress felt. In the long-term, he or she might maintain and improve his or her personal health and social function.

Patients with lung cancer facing symptom distress often rely on religion, obey treatment regimens, seek social support, and distract their attention from their symptoms. When a patient believes that he or she can do nothing because of the negative feelings brought on by the illness and treatment, he or she may be inclined to use more emotion-focused coping strategies and be less inclined to use problem-focused coping strategies. 5–6,17,21 Acceptance of a patient’s coping strategies by family members, medical professionals, and friends is an important factor influencing the appropriateness of use, the consistency, and the effectiveness of use of a coping strategy. 5 Medical personnel are also important in providing emotional support, and training in coping techniques and can improve the patient’s symptom distress and increase the effectiveness of adaptation to stress. 12

To date, only a few studies have looked at the symptom distress and coping strategies of patients with NSCLC during treatment. Wang 15 examined fatigue in patients with small cell lung cancer (SCLC) and NSCLC receiving radiotherapy. Ni, Yu, and Huang 21 did a case report on symptom distress and coping strategies in patients with NSCLC. Liu 16 looked at symptom distress in patients with SCLC and NSCLC but did not focus particularly on the treatment phase and gave no consideration to the effect of treatment strategies on symptom distress, and the results were more indicative of the general symptom distress experiences of patients with lung cancer.

Based on the dearth of information in the medical literature and motivation for the present study, the types and severity of symptom distress experienced and the coping strategies employed by patients during the treatment phase of lung cancer was investigated. Furthermore, the relationships between patient characteristics, disease-related variables and therapeutic-related variables, and symptom distress and coping strategies we investigated. The factors that influence the degree of severity of symptom distress in patients with NSCLC were explored to provide a reference for clinical research and practical applications in the future.

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The present study uses a descriptive correlation design, with surveys performed using a cross-sectional structured scale.

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Sample and Setting

During May and June 2000, a purposive sampling was done of patients with cancer in the cancer center and thoracic medical departments of two Taipei hospital centers. The requirements for participation in the study were that patients (1) had to be at least 18 years of age, (2) had to be aware of their own diagnosis, (3) had to be currently receiving only chemotherapy or only radiotherapy (patients on chemotherapy had to have completed an entire cycle of therapy [1 month], and patients on radiotherapy must have received a total of at least 2,000 cGy), (4) must have had clear consciousness and cognition (be able to accurately answer questions on persons, place, and time within 30 seconds), (5) have no history of psychiatric problems, and (6) be able to communicate in Mandarin and Taiwanese languages. Before data collection was performed, the researcher first explained the purpose and steps in the study to the subjects. After patient consent was obtained, data related to medical history were collected. Based on a structured questionnaire, the researcher conducted the survey. Initially, 82 subjects began the survey process. Three subjects refused to participate, and 5 suffered from metastasis to the brain, and consequently had serious impairment to consciousness. One subject was eliminated because of many years of a history of bipolar disorder. The final sample size consisted of 73 patients and included 42 who were receiving only chemotherapy and 31 who were receiving radiotherapy, all for NSCLC.

Because the two hospitals where the study was performed were veterans’ and military hospitals, the majority of subjects were men, ranging in age from 39 to 84 years, and the majority were older than 71 years of age. Patients’ educational levels ranged from no formal education to 16 years of schooling, with an average of 8.1 years of formal education. The majority were married, with a small proportion either unmarried or widowed. The majority were retired or not working due to their illness. Of the 13 women subjects, the majority had no profession. Average monthly income was generally less than NT$20,000, with a small minority making more than NT$100,000. Most participants practiced religion.

In terms of disease-related variables, most subjects in the study had stage IV tumors (n = 50, 70%). Tumor metastasis was mostly from lung to lung or to the brain, skeleton, or spine. Most (n = 58) patients had been diagnosed within the last year, were in the early stage after diagnosis, and had no recurrence of tumors. The other 15 subjects had been diagnosed more than 1 year before and all had tumor recurrence. The majority of subjects had quit smoking cigarettes when their diagnoses were confirmed. Some had quit smoking before their diagnoses. A minority still smoked. However, all had reduced their smoking because of the diagnosis or because of symptom distress from coughing or other symptoms. The majority of subjects had no history of chronic disease. Those who did were mostly elderly and complained primarily of hypertension, heart disease, diabetes, stroke, or renal insufficiency. The subjects were all in stable condition.

In terms of therapeutic-related variables, the subjects who received chemotherapy were given gemcitabin, navelbine, and cisplatin, with taxotere and ifosfamide in second place. Participants had from 2 to 21 sessions of chemotherapy, with an average of 7.62 sessions. Subjects receiving radiotherapy received doses ranging from 2,000 to 5,400 cGy, with an average of 3,002.26 cGy. Participants received radiation primarily in the chest, with some receiving radiation in the spine or skeleton. A portion of those with metastasis to the brain exhibited loss of mental function and could not be included in the study. This caused a reduction in the number of subjects in the survey who received radiation to the brain. Patients had been in treatment from 1 to 84 months, with an average of 10.12 months. The majority of patients had been in treatment since their diagnoses or soon thereafter, and the majority had not received treatment past. Those who had received treatment had surgery, chemotherapy, radiotherapy, or a combination of these treatments. Patients generally lived with their families during treatment. Most data for patients undergoing chemotherapy were collected in the hospital rooms, and for patients undergoing radiotherapy, in the clinic.

A Chi-square analysis or t tests showed significantly higher values on educational level, status of tumor recurrence, and past surgeries for patients undergoing chemotherapy; other basic data showed no significant differences between groups.

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The SDS included two sections, one for physical and one for psychologic symptoms. The physical symptoms section was based on Liu’s 16 revised patient with lung cancer “physical symptom distress scale,” with reference to the literature and to the opinions of 5 specialists, some 18 physical symptoms experienced by patients with lung cancer in treatment were included. These were pain, difficulty breathing, increased sputum, nausea, vomiting, loss of appetite, difficulty swallowing, constipation, diarrhea, fatigue, alopecia, insomnia, difficulty concentrating, sore throat, itchy or red skin, weight loss, and numbness. Patients could also write in any other symptoms. The psychologic symptoms section was modeled after Yang’s translation and adaptation of five negative emotions on the Profile of the Mood State (POMS) 26: tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia, and confusion-bewilderment. Similar items were eliminated, leaving 29 items for negative emotions to evaluate patient’s psychological symptom distress.

Effectiveness ratings on content by 5 specialists gave average values of 4.8 and 4.6 (out of a possible 5 points). For pretest and formal research content consistency, Cronbach’s alpha for the physical symptom section was 0.75 and 0.77, respectively; for the psychological symptom section, both pretest and formal research content consistency were 0.94.

The Coping Strategies Scale is an adaptation of the translation by Chiu, 27 who translated Jalowiec and Power’s 1981 Jalowiec Coping Scale (JCS). It included 15 problem-focused and 25 emotion-focused coping behaviors. The original scale was developed for nursing and has been broadly used in studies both in Taiwan and abroad. The Chinese version of the scale 27 was given effectiveness ratings on content by 5 specialists, which in pretest and formal research in use on hemodialysis patients yielded Cronbach’s alpha values of 0.78 for both pretest and formal research. To accommodate patient characteristics and the special needs of this study, the wording was slightly altered, as appropriate. Effectiveness ratings on content by 5 specialists yielded average scores of 4.6 and predicted formal research Cronbach’s alpha values of 0.70 and 0.67, respectively.

Based on this data, the questionnaire included demographic data on subjects (gender, age, educational level, marital status, profession, economic status, religion), disease-related variables (tumor stage, tumor recurrence, time from diagnosis, smoking status, history of chronic disease), and therapeutic-related variables (therapeutic strategy, time receiving therapy, therapies received past, whether patient was living with family members during treatment time, and location of treatment).

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Symptom Distresses During Therapeutic Periods

On average, patients experienced 7.32 physical symptom distresses of a slight to moderate severity. Patients receiving chemotherapy and those receiving radiotherapy experienced different types of physical symptom distress (Figure 1). Fatigue, loss of appetite, and weight loss were the principal physical symptom distresses reported by subjects during the therapeutic period (Table 2). Psychological symptom distresses were slight to moderate and were, in order, fatigue-inertia, confusion-bewilderment, and depression-dejection. The relationships between subjects’ demographic data and disease and therapeutic variables and degrees of physical and psychological symptom distress did not reach statistical significance.

Table 2

Table 2

Figure 1

Figure 1

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Coping Strategies During Therapeutic Periods

Patients facing symptom distress during the therapeutic period all used a combination of problem-focused and emotional-focused coping strategies. Problem-oriented coping strategies that were used “always” or “often” included “coordinating with the doctor in hopes of controlling the illness,” “allowing others to solve symptom distress (for example, family members, nursing staff),” “doing one’s best to grasp the symptom distress problem,” “preparing for the thing one most wishes to do after therapy,” and “exchanging opinions with others in the same situation.” Emotion-focused coping strategies used included “seeking comfort and support from family members or friends,” “hoping that the severity of symptom distress will decrease,” “accepting reality,” “preparing mentally for the worst-case scenario,” “believing in fate,” and “carrying on normally and hoping that the symptom distress problem would resolve itself.”

Research has shown that women patients with higher levels of educational attainment, who were not working or who were retired, had no tumor recurrence, who were nonsmokers, had a long history of treatment to date, who lived with family members during treatment, and who were inpatients receiving chemotherapy showed significantly higher use of problem-focused coping strategies. Women aged 41 to 50 years with a monthly household income of less than NT$20,000, with religious faith, with tumor recurrence, and who were nonsmokers show significantly higher use of emotion-focused coping strategies. Employed nonsmoking women aged 41 to 50 years who were undergoing chemotherapy showed a significantly higher incidence of adaptive behaviors.

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Correlation Between Symptom Distresses and Coping Strategies

Clear correlations were seen between some physical and emotional symptom distresses (P < .05). Apart from diarrhea, hair loss, and difficulty concentrating, other physical symptom distresses were positively correlated with overall physical symptom distress (P = .000-.016). In particular, fatigue, lack of appetite, insomnia, increased sputum, and difficulty breathing were highly correlated (r = .502-.735). These frequently experienced symptom distresses were also correlated with other physical and psychological symptom distresses (Table 2).

There exists correlation between the physical and psychological symptom distresses experienced by patients during the therapeutic period and the frequency of use of coping strategies. Frequency of use of emotion-focused coping strategies was positively correlated with the severity of physical symptom distress for fatigue, insomnia, coughing, sore throat, overall physical symptom distress score, number of times physical symptom distress was experienced, and overall and individual psychological symptom distress scores (P < .05). Number of coping behaviors was positively correlated with degree of symptom distress for the overall score for patient psychological symptom distress during therapy, tension-anxiety, depression-dejection, and fatigue-inertia (P < .05).

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Predictors of Symptom Distress

Independent t tests, one-way analysis of variance (ANOVA), and Pearson correlations showed that the degree of physical and psychological symptom distress was not only influenced by individual physical or psychological symptom distress variables but also was related to frequency of use of coping strategies and the number of times adaptive behavior was used. Although demographic data, disease-related variables, and therapeutic-related variables did not show a statistically significant relationship to the degree of physical and psychological symptom distress, these variables are all potential confronting factors to the degree of physical and psychological symptom distress. For this reason, the SPSS statistical package was used for analysis of those variables for which the F value on the ANOVA tables was P < .05, and these variables were entered into a stepwise multiple regression analysis with variables for which P > .10 had eliminated from the analysis.

Results showed that the degree of tension-anxiety and patient age account for 39.4% of the variance in predicting the degree of physical symptom distress; the single variable “degree of tension-anxiety” accounted for 34.1% of total variance. Degree of physical symptom distress = 7.981 × degree of tension-anxiety + 0.148 × patient age − 2.307. For each unit increase in degree of tension-anxiety (for example, from slight to moderate), physical symptom distress increased 7.981 points. For each additional year of age, physical symptom distress increased 0.148 points; overall score for physical symptom distress and frequency of use of emotional-focus coping strategies predicts severity of psychological symptom distress, accounting for 48.8% of total variance. The single variable “overall physical symptom distress score” accounts for 31.1% of total variance. Degree of psychological symptom distress = 1.227 × overall physical symptom distress score + + 31.999 × frequency of use of emotion-focused coping strategies − 61.704. Each time overall physical symptom distress scores increased 1 point, psychological symptom distress increased 1.227 points; when frequency of use of emotion-focused coping strategies increased by one unit (for example, from “never this way” to “seldom this way”), psychological symptom distress increased 31.999 points.

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Symptom Distresses During Therapeutic Periods

Apart from demonstrating that cancer-related symptom distresses and side effects from therapies are sources of physical symptom distress in patients with lung cancer, the present study shows that difficulty in breathing and coughing are common cancer-related symptom distresses among patients with NSCLC. Cancer-related symptoms can be alleviated by reduction in tumor size through therapy. In the present study, radiotherapy reduced the size of tumors such that 67.7% of patients experienced a slight degree or less of difficulty breathing and 51.6% of patients experienced a slight degree or less of coughing.

Medication dosage and type directly affect the severity of symptom distress experienced by chemotherapy patients. The results of the current study and the literature reviewed show that approximately 60% of chemotherapy patients are given gemcitabin, navelbine, and cisplatin and, consequently, nausea and vomiting are the most common typical physical symptom distresses encountered in patients undergoing chemotherapy. These symptom distresses are caused by side effects of therapy. Because it is expected that patients undergoing chemotherapy will experience these side effects during the therapeutic period, most are given antiemetics or sedatives before chemotherapy. Some 88.1% of patients receiving chemotherapy experienced a slight degree of nausea or vomiting.

The major psychological symptom distresses experienced by subjects in the present study were fatigue-inertia, confusion-bewilderment, and depression-dejection. There were positive correlations among all of the psychological symptom distresses, and there was a high correlation between anxiety and depression (r = .855, P = .000). This demonstrates that psychological symptom distresses are major symptom distresses in patients with cancer, and that anxiety and depression often coexist. 4,10,13,17,18,20 Moreover, 50.7% of the patients sampled had been diagnosed with lung cancer within the past 3 months. The threat of death and uncertainty about the future are major sources of stress for patients with cancer in the early stage. These lead to confusion-bewilderment becoming a major psychological symptom distress among the sample. 10

McCorkle and Young 9 discovered that the later the phase of the tumor, the more severe the physical symptom distress. In this study, only 17 out of 45 patients were in the late tumor stages (38%); given the small number of patients, the results did not reach the level of statistical significance. Our study and Liu’s 16 study of patients with primarily late-stage cancer share highly similar subject characteristics. Although both found that tumor stage and degree of physical symptom distress were clearly correlated, further research is required to increase the number of subjects at different tumor stages to reach a conclusion. The present study also supports the results in the literature that, regardless of the tumor stage or type of therapy received (chemotherapy or radiotherapy), depression of appetite, weight loss, problems sleeping, and fatigue are major symptom distresses experienced by patients with NSCLC during therapy. 14,16

After considering the effect of treatment strategies on symptom distress and discussing separately the symptom distress experiences of patients with NSCLC on chemotherapy and radiotherapy, respectively, the present study supports the findings of Liu 16 that patients with lung cancer experience slight to moderate physical and psychological symptom distress. Furthermore, there is no significant difference between the two types of therapy. Apart from the small number of patients participating in the present study, the sampling opportunity is another factor that might have influenced results. Patients undergoing chemotherapy were all selected while undergoing chemotherapy, and clinically all had been given antiemetic and sedatives before treatment to reduce side effects. The data collection process showed that, just as reported in Lia, 29 when Chinese people receive chemotherapy, the greatest severity of symptom distress occurs the first few days after they return home rather than during the actual period of dosing. Even though there was no significant difference in symptom distress for patients receiving radiotherapy in terms of the dosage or irradiation location, patients who had accumulated dosages of more than 3,000 cGy showed significantly higher degrees of physical symptom distress than those who had received lower accumulated radiation doses. This was particularly true in terms of sore throat and weakness of the lower limbs. Therapeutic strategy influences the degree of symptom distress experienced by a patient during therapy. Sampling opportunity and the small sample size also led to results different from the hypotheses. The results of the present study show that for patients with NSCLC receiving chemotherapy under current practices during the therapeutic period, and patients with NSCLC receiving radiation therapy of low accumulated dosage, severity of symptom distress was slight to moderate.

Studies show that women and younger patients with cancer have significantly higher degrees of psychological symptom distress. 4,16,17,28 Patients with religious faith and those who receive support from family and friends and who maintain hope can reduce their psychological symptom distress. 5,6,17 In this study, the small number of women in the sample (n = 13, 17.8%) is quite different from the ratio of men to women among Taiwanese patients with lung cancer (2.37:1). 1 It is possible that because of the small number of women in the sample, the results did not reach the level of statistical significance, even though the women patients had higher scores for individual items and overall psychological symptom distress. Differences between groups reached the level of statistical significance only for the “tension-anxiety” factor (P = .53).

Physical symptom distresses interact with psychological symptom distresses, and the most important influence on psychological symptom distresses is physical symptom distresses. 4 The present study supports the findings in Liu 16 that lack of religious belief or lack of family support for patients has no clear correlation to the severity of psychological symptom distress. This may be because with relatively slight degrees of physical symptom distress, the effect of religious belief or familial support in alleviating psychological symptom distress was not as marked.

It is possible that one reason for which later tumor stages result in greater degrees of psychological symptom distress is a reduction in therapeutic success. 28 In this study, the majority of patients sampled had been diagnosed within the past 6 months and the patients were largely still independent in their daily lives. Their feelings of success had not yet been seriously damaged, meaning that although those in later tumor stages showed higher scores for single factors and for overall psychological symptom distress than early stage patients, the results did not reach the level of statistical significance.

Patients with cancer whose therapy regimen is about to end may fear recurrence of the tumor as well as the physical symptom distress caused by cancer, which adds to their anxiety and depression. 5,21 In this study, only a very small proportion of patients sampled were nearing the end of their treatment regimen, and there was no statistically significant relationship between duration of treatment to date and the degree of psychological symptom distress. However, one patient was receiving the final chemotherapy treatment and expressed uncertainty toward the future and toward the effectiveness of this treatment phase; he was concerned about the recurrence or metastasis of the tumor after the conclusion of treatment.

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Coping Strategies During Therapeutic Periods

When patients with cancer face fear of pain, disfigurement, death and the future, fear of loss of their role functions, reliance, social isolation, and side effects and if they believe that they are powerless to do anything in the face of the uncertainty of the disease and treatment, they tend to use emotional coping strategies. 5 Negative emotions are not helpful in solving the problem. These may also lead to an increase in psychological distress. 21 Feelings of fatigue-inertia were the most common psychological distress reported by subjects in this study. When the patients in this study faced their illnesses and the physical symptom distress, although they used a combination of problem-focused and emotional-focused coping strategies, problem-focused coping strategies were used more frequently. It is obvious that although patients are filled with hope and uncertainty about the effectiveness of their treatments and the possibilities of a cure, they still do not surrender to fate or give up the chance of a cure but tend toward problem-focused coping strategies. Thus, they grasp the situation and reduce the severity of their psychological symptom distresses.

Patients who were newly diagnosed were generally concerned about how to accept their diseases. 10 Of the patients sampled, 50.7% had been diagnosed with lung cancer within the past 3 months. Confusion-bewilderment was one of their major psychological symptom distresses. This reflects the patient’s uncertainty toward the future and the results of the treatment during the diagnosis and early stages of treatment. To cope with the physical symptom distress brought on by the therapy, patients resorted to the professional support of their doctor, the psychological support of their family and friends, or the sharing of experiences with other patients to obtain more information and support of their treatment and illness. They also tried to accept the illness or believed that it was all mandated by fate, adapting to the pressure with a hopeful way of thinking.

The results of the current study support the literature in terms of frequency of “praying or seeking spiritual help”; women sought spiritual help significantly more frequently than men. 5,6,17 Moreover, the majority of the women patients were nonsmokers, and their age (60.38 ± 12.52 years) was significantly lower than that of the men’s group (70.6 ± 9.21 years). The men’s use of coping behaviors, both in number used and frequency of use, were significantly higher. The research process also showed that most elderly people said that they had already lived long lives and did not fear death. It is possible that the women patients, because of their younger age, held more hope for the future and were not willing to be defeated by the disease. Thus, they increased their trials of various coping strategies and turn to religion for comfort and to reduce the additional psychological distress of having developed lung cancer without, in most cases, having been a smoker. The results of the current study support the literature in that when patients with higher educational attainment faced symptom distress, frequency of use of problem-focused coping strategies increased. With lower educational level, the frequency of use of the emotion-focused coping strategies of avoidance and repression increased. 17

Support and assistance from family members is helpful in helping the patient cope with stress resulting from the disease and treatment. 3,6,12 Moreover, doctors are also an important source of emotional support and information 10,12 and serve to reduce the degree of physical and psychological symptom distress, reducing the impact of whether there are family members around the patient to a point where it is unclear. Nonetheless, the patients sampled used support and assistance from family members and reliance on the doctors’ professional skills as their major coping behaviors. Thus, family and doctors play an important role in patients’ strategies for coping with stress.

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Correlations Between Symptom Distresses and Coping Strategies

All psychological symptom distress experienced by patients during the therapeutic phase correlated positively with the number of uses and frequency of use of emotion-focus coping strategies. This shows that patients who tended toward using negative emotion-focus coping strategies also experience a rise in their psychological symptom distresses. 5,21 Moreover, in the present study, patients with a greater number of coping behaviors may reflect a situation where the ineffectiveness of those coping strategies increases the number of strategies employed as patients’ psychological symptom distress increases. This is a topic that requires further research.

The more severe a patient’s physical symptom distress, the less exchange of opinions there is with other patients. This could be because the physical problems lead to emotional stress, increased inertia, and reduced social activities.

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Nursing Implications

Integrating the results of this study will provide some suggestions in terms of practical nursing, education, and administration. In the area of clinical nursing, early stage assessment of the degree of symptom distress and early intervention measures to alleviate the problems of symptom distress can achieve good results in caring for the whole patient. 18 Using regression analysis, based on the degree of tension-anxiety and age of the patient, the degree of physical symptom distress in the dosing stage of chemotherapy with low to moderate levels of radiation in radiotherapy can be predicted. Based on the overall score for physical symptom distress and frequency of use of emotional-focus coping strategies, the degree of psychological symptom distress can be extrapolated. Therapeutic strategies can be altered in the case of patients with anticipated severe physical symptom distress. In the case of patients with anticipated severe psychological symptom distress, the introduction of a therapist, religious figure, or patient support group could be considered. The clinical nursing staff must also improve its management of normal symptom distress, which is often overlooked or seen as natural. This includes insomnia, weight loss, lack of appetite, fatigue, and others. A systemic assessment can help a nurse to thoroughly understand the possible causes of symptom distress to provide individualized management. There is an opportunity when the patient enters the hospital for treatment for a functional assessment of the patient across various body systems and to discover and manage any problems at an early stage.

The support and assistance of family members and friends and the emotional support and information provided by doctors are important coping behaviors for patients coping with symptom distress. The implementation of patient discharge plan gives patients or major caregivers simple information, including possible symptom distresses that the patient may experience upon returning home, as well as means to combat them. Increasing the ability of the patient to care for him or herself at home reduces added physical symptom distress after returning home, which triggers increased psychological symptom distress. Promotion of community-centered tumor care makes use of periodic home visits that provide appropriate nursing guidance and training in stress management techniques, increasing the ability to manage symptom distress successfully.

In the area of education and training, it is necessary to enable the clinical nursing staff to recognize that the degree of physical and psychological symptom distress can be predicted and to guide the nursing staff in learning to use the assessment tools to benefit their clinical practice. In terms of administration, as the number of people developing lung cancer continues to increase year by year, public health professionals should put their energies behind reducing carcinogenic factors and strengthening early detection and early treatment concepts among the population. The hospital can be used as a unit where a patient with cancer’s group can be established, with systematic information and technical training provided by a professional staff. The patient with cancer’s group would also enable sharing of experiences and emotional support among patients, enabling the patients and their families to effectively adapt to the pressure brought on by the illness and therapy, further relieving patients physical and psychological symptom distress.

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The authors thank Associate Professor Ma Fung-Chi of the Yang-Ming University Institute of Clinical Nursing; Director Hsiao Tzu-Yi of the Department of Oncology, Tri-Services General Hospital; Director Tsai Chun-Ming of Taipei Veterans’ General Hospital; and Assistant Professor Ku Chi-Hong of the National Defense Medical Center Institute of Public Health for their guidance and assistance and the 73 patients who graciously participated in the study.

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1. Department of Health, the Executive Yuan, ROC. Health and Vital Statistics. ROC: Department of Health, the Executive Yuan; 1999.
2. Pass HI, Mitchell JB, Johnson DH, Turrisi AT. Lung Cancer. New York: Lippincott-Raven; 1996.
3. Ryan LS. Psychosocial issues and lung cancer: a behavioral approach. Sem Oncol Nurs. 1996; 12( 4):318–323.
4. Liang SY. The emotional impact of cancer pain on outpatients and their family caregivers [theses]. Taipei: Taipei Medical University, Department of Nursing; 1999.
5. Ali NS, Khali HZ. Identification of stressors, level of stress, coping strategies and coping effectiveness among Egyptian mastectomy patients. Cancer Nurs. 1991; 14( 3):232–239.
6. Krause K. Contracting cancer and coping with it: patients’ perceptions. Cancer Nurs. 1991; 14( 5):240–245.
7. Lazarus R, Folkman S. Stress, Appraisal and Coping. New York: Springer; 1984.
8. Rhocles VA, McDaniel RW. The symptom experience and its impact on quality of life. In: Groenwald SL, Frogge MH, Goodman M, Yorbro CH, eds. Cancer Symptom Management. Boston: Jones and Bartlett; 552–563.
9. McCorkle R, Young K. Development of symptom distress scale. Cancer Nurs. 1978; 1( 10):373–378.
10. McCorkle R, Quint-Benolie JQ. Symptom distress, current concerns and mood disturbance after diagnosis of life-threatening disease. Soc Sci Med. 1983; 17:431–438.
11. Narsavage G, Weaver TE. Physical status, coping, and hardiness as predictors of outcomes in chronic obstructive pulmonary disease. Nurs Res. 1994; 43( 2):90–94.
12. Ryan LS. Lung cancer: psychological implication. Sem Oncol Nurs. 1987; 3( 3):222–227.
13. Muers MF, Round CE. Palliative symptom of non-small cell lung cancer: a study by Yorkshire regional cancer organization thoracic group. Thorax. 1993; 48( 4):339–343.
14. Kassa S, Mastekassa A. Psychological wellbeing of patients with inoperable non-small cell lung cancer: the importance of treat- and disease-related factors. Acta Oncol. 1988; 27(6b):829–835.
15. Wang SH. A Study on the Self-care and Related Factors of Lung Cancer Patients During Radiotherapy [thesis]. Taipei, ROC: National Defense Medical Center, Department of Nursing; 1995.
16. Liu KF. Correlates of Symptom Distress and Functional Status of Patients With Lung Cancer [thesis]. Taipei, ROC: National Yang Ming University, Institute of Clinical Nursing, 1999.
17. Tasi LY. An Exploratory Study of the Psychological Distress, Pain Coping Strategies and Related Factors Upon Cancer pain Patients [thesis]. Taipei, ROC: National Defense Medical Center, Department of Nursing; 1995.
18. Holmes S. Preliminary investigations of symptom distress in two cancer patient population: Evaluation of a measurement instrument. J Adv Nurs. 1991; 16:439–446.
19. Janson-Bjerkle S, Carrieri VK, Hudes M. The sensations of pulmonary dyspnea. Nurs Res. 1986; 35( 3):154–159.
20. Folkman S, Lazarus RS, Gruen RJ, DeLongis A. Appraisal, coping, health status, and psychological symptoms. J Pers Soc Psychol. 1986; 50( 3):571–579.
21. Ni LC, Yu PJ, Huang HL. The stressors and coping strategies in patient with lung cancer. Nursing (China). 1997; 44( 5):51–59.
Tang SJ, Lin YC, Cheng CC, Chen CH, Chang MC. Nursing Care of Cancer Symptom. Taipei: Fayfar; 1998.
    Irvine DM, Vincent L, Graydon JE, Bubela N. Fatigue in women with breast cancer receiving radiation therapy. Cancer Nurs. 1998; 21( 2):127–135.
    Cava MA. An examination of coping strategies used by long-term cancer survivors. Can Oncol Nurs J. 1992; 2( 3):99–102.
    Irvine D, Vincent L, Graydon JE, Bubela N, Thompsan L. The prevalence and correlates of fatigue in patients receiving experienced by healthy individuals. Cancer Nurs. 1994; 17( 5):267–278.
      26. Yang WC. The Correlates of Physical, Psychological, Social Distresses, Self-care and Social Support in Patients With Hematological Tumor [thesis]. Taipei, ROC: National Yang Ming University, Institute of Clinical Nursing; 1996.
      27. Chiu CP. The Stress Sensation, Social Adaptation and Relative Factors in Hemodialysis Patients [thesis]. Taipei, ROC: National Defense Medical Center, Department of Nursing; 1987.
      28. Cella DF, Orofiama B, Holland JC, et al. The relationship of psychological distress, extent of disease and performance status in patients with lung cancer. Cancer. 1987; 60:1661–1667.
      29. Lia YH. Symptom distresses and home care needs in out-patients with chemotherapy. Nurs Res. 1998; 6( 4):279–289.

      Non-small cell; lung cancer; Symptom distress; Coping strategies

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