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Is the Postsurgical Quality of Life of Patients With Esophageal or Gastric Cancer Influenced by Emotional Competence and Neoadjuvant Treatments?

Baudry, Anne-Sophie PhD; Gehenne, Lucie PhD; Grynberg, Delphine PhD; Lelorain, Sophie PhD; Piessen, Guillaume PhD, Pr; Christophe, Veronique PhD, Pr; the FREGAT Working Group

Author Information

Author Affiliations: Pôle cancérologie et spécialités médicales–Centre Hospitalier de Valenciennes, Valenciennes (Dr Baudry); Univ. Lille, CNRS, UMR 9193 - SCALab -Sciences Cognitives et Sciences Affectives (Dr Baudry, Dr Gehenne, Dr Grynberg, Dr Lelorain, and Pr Christophe), Lille, France; Institut Universitaire de France, Paris (Dr Grynberg); UMR-S 1172-JPARC-Centre de Recherche Jean-Pierre AUBERT Neurosciences et Cancer, University Lille (Pr Piessen), Lille, France; Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille (Pr Piessen), Lille, France; and Human and Social Sciences Department, Centre Léon Bérard, Lyon, France (Pr Christophe).

The authors have no conflicts of interest to disclose.

This work was supported by the SIRIC ONCOLille (Grant INCa-DGOS Inserm 6041).

Correspondence: Anne-Sophie Baudry, PhD, Université de Lille–UMR CNRS 9193 SCALab, Rue du Barreau, BP 60149, F-59653 Villeneuve d’Ascq cedex, France ([email protected]).

Accepted for publication January 4, 2021.

doi: 10.1097/NCC.0000000000000946
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Abstract

The health-related quality of life (HRQoL) of gastric and esophageal cancer patients, an important variable in care, has been an increasing focus of recent literature. Pretreatment HRQoL predicts the survival of esophageal cancer patients in contrast to the clinician-assigned performance status.1 Postsurgical HRQoL can provide clinical information concerning cancer recurrence and can predict the early death of patients.2 However, the postsurgical period represents a risk factor for a significant deterioration in HRQoL3–9 and psychological well-being (ie, 33% of postsurgical patients reporting clinical anxiety or emotional distress).8,10–12

Little is known about the determinants of impaired HRQoL.10 Researchers have not yet succeeded in identifying profiles/clusters that explain reduced HRQoL based on clinical and sociodemographic characteristics (eg, age, gender, employment, location and stage of tumor).3 Emotion-related traits and emotional competence (EC) can influence the HRQoL of esophageal or gastric cancer patients,13,14 with EC being associated with better postdiagnostic and postsurgical HRQoL of esophageal and gastric cancer patients.13

Emotional competence refers to emotional intelligence models and the interindividual differences in the processing of emotional information in daily life. Emotional competence represents the perception of individuals’ tendency to identify, understand, express, and regulate emotions in daily life.15 Emotional competence involves emotional abilities (eg, identification, regulation), which are more related to intelligence, and emotion-related traits of personality (eg, optimism, self-esteem, expressive trait), which are more related to typical performance.16–19 In this way, EC enables better adaptation to the environment and life events by facilitating the analysis and management of emotions and coping strategies. Importantly, the roles of intrapersonal (ie, one’s own emotions) and interpersonal (ie, emotions of others) EC can be systematically distinguished as they have different effects on health outcomes and disease adjustment: intrapersonal EC has the stronger effects.15,20–22

The effect of EC on anxiety and depressive symptoms (ADSs) is central in cancer adjustment (ie, supportive care needs, HRQoL).13,21 For example, the EC of patients with esophageal and gastric cancer influences their postsurgical HRQoL via fewer anxiety and, to a greater extent, fewer depressive symptoms.13 Thus, by their tendency to identify, understand, express, and regulate their emotions, patients with higher EC can report fewer ADSs and better cancer adjustment. Based on theories and empirical findings, we propose a conceptual model presented in Figure 1. Because EC has a greater direct influence on HRQoL after diagnosis than after surgery, care pathway stages need to be taken into account. In addition, neoadjuvant treatments and specifically high-dose chemoradiotherapy contribute to the deterioration of HRQoL after surgery compared with surgery alone,23 which may reduce the significant influence of emotional processes on postsurgical HRQoL. It is important to know whether EC has the same effect on HRQoL after surgery depending on the received treatments (ie, with or without neoadjuvant treatments) and by which mechanisms. In addition, context (eg, based on situational cues, emotions, social interactions), and therefore health and care settings, can have an impact on emotional processes and their influences.22

F1
Figure 1:
The proposed theoretical model of the emotional processes involved in the adjustment of cancer patients.

Study Purpose

The first objective of this study was to compare the HRQoL and ADSs after diagnosis (T1) and after surgery (T2) of esophageal and gastric cancer patients without neoadjuvant treatment (group 1) and with neoadjuvant treatment (group 2). The second objective was to assess the direct effect of intrapersonal and interpersonal EC on ADSs and HRQoL at T1 and T2 in the 2 groups separately. The third objective was to assess the indirect effect of intrapersonal and interpersonal EC on HRQoL after surgery (T2) via 3 mediators: (1) anxiety symptoms (T2), (2) depressive symptoms (T2), and (3) HRQoL (T1), in the 2 groups separately. Overall, patients in group 2 might report a greater deterioration of their HRQoL and emotional state at T2 (hypothesis 1). Emotional competence, especially intrapersonal EC, could have (1) a direct beneficial influence but a weaker influence at T2 (after surgery) and in group 2 (hypothesis 2) and (2) a significant indirect effect on HRQoL at T2, especially via fewer depressive symptoms, and for group 1 (hypothesis 3).

Methods

Patients and Procedure

This study was a descriptive, by self-report questionnaires, and longitudinal survey with repeated measures. Data were collected via a clinico-biological database, FREGAT (French EsoGastric Tumors; https://www.fregat-database.org/en), from 30 French centers.24 All participants were patients older than 18 years, newly diagnosed with carcinoma of the esophagus, esophagogastric junction, or stomach and had not received any treatment related to these cancers. They provided written informed consent, and the study was conducted in accordance with the Declaration of Helsinki, French regulations on clinical trials, and authorizations from the Nord Ouest IV Ethics Committee (project number 13/67).

The study was based on 271 patients recruited from 2014 to 2018. Inclusion criteria were having undergone surgery and completed and sent the self-reported questionnaire twice: after diagnosis (T1, before starting any treatment) and after surgery (T2, within 4 months of surgery and before undergoing any adjuvant treatments). Participants were categorized into 2 groups according to their received treatments: patients who had only surgery without neoadjuvant treatments (group 1) and patients who had received neoadjuvant treatments (ie, chemotherapy or chemoradiation) in addition to surgery (group 2).

Measures

Clinical data (eg, type of cancer, stage of cancer pathway, surgery and medical complications) were retrieved from the patients’ medical charts with their consent. Participants completed self-reported questionnaires twice to assess (1) their intrapersonal and interpersonal EC (Profile of Emotional Competence [PEC]), (2) their HRQoL (Quality of Life Questionnaire–Core 30), and (3) their ADSs (Hospital Anxiety and Depressive Scale [HADS]).

The intrapersonal and interpersonal EC of patients was assessed using the PEC.15 This scale is composed of 50 items with a 5-point response (1 “strongly disagree” to 5 “strongly agree”) and provides an assessment of the patients’ perception of their intrapersonal (25 items, eg, “When I am touched by something, I immediately know what I feel”) and interpersonal (25 items, eg, “I am good at sensing what others are feeling”) EC used in daily life. Higher scores, based on the mean of the responses to corresponding items, indicate a higher use of EC.

The HRQoL was assessed using the global score of HRQoL (ie, based on 2 items, assessing the perception of participants about their health and quality of life, with a 7-point response) of the Quality of Life Questionnaire-Core 30.25 Only this global score of perceived HRQoL was used to investigate the patients’ perception of their global HRQoL, which reduced the risk of type 1 error. A higher global HRQoL score, based on the mean of the responses to the 2 items, indicates a better perceived HRQoL.

The ADSs of patients were assessed using the HADS.26 This scale is composed of 14 items with a 4-point response and provides an assessment of the patients’ perception of the severity of their anxiety (7 items) and depressive (7 items) symptoms. Higher scores, based on the sum of the responses to corresponding items, indicate higher anxiety or depressive symptoms.

Statistical Analyses

The scores of ADSs and HRQoL were compared according to time (T1 and T2) and group using the Mann-Whitney or Wilcoxon tests appropriately, in the absence of a normal distribution of data (objective 1). Hierarchical regression analyses were used to test the direct effect of intrapersonal and interpersonal EC at baseline on the ADSs and HRQoL at T1 and T2 for the 2 groups separately (objective 2). The effects of intrapersonal and interpersonal EC on issues and between the 2 groups were described and compared using standardized β and adjusted R2.

The PROCESS Macro27 in SPSS v. 22 was used to test the indirect effect of intrapersonal and interpersonal EC at T1 on HRQoL at T2 via ADSs (T2) and HRQoL (T1) for the 2 groups separately (objective 3). PROCESS enables indirect effects, that is, the effects of variable X (ie, EC) on variable Y (ie, HRQoL at T2) via several variables M (ie, ADSs and HRQoL) to be quantified. This approach tests whether variable X influences variables M that, in turn, influence variable Y, without necessarily having a direct effect of X on Y.28,29 A bootstrapping nonparametric resampling procedure was applied for sampling distributions of the indirect effects. It provided estimates with a 95% confidence interval and maximized the statistical power. In each group, 2 models were tested: 1 with intrapersonal EC as the predictor and 1 with interpersonal EC as the predictor (Figure 2). The indirect effects of intrapersonal and interpersonal EC on issues and between the 2 groups were described and compared using the standardized estimates.

F2
Figure 2:
Models testing the indirect effect of intrapersonal and interpersonal EC used in daily life after diagnosis (T1) on HRQoL after surgery (T2) via ADSs (T2) and HRQoL (T1) in groups 1 and 2 separately. c’ = total indirect effect of intrapersonal or interpersonal EC on HRQoL through anxiety and depression symptoms and HRQoL; c1’ = specific indirect effect of intrapersonal or interpersonal EC on HRQoL (T2) through anxiety; c2’ = specific indirect effect of intrapersonal or interpersonal EC on HRQoL (T2) through depression; c3’ = specific indirect effect of intrapersonal or interpersonal EC on HRQoL (T2) through HRQoL (T1). The models were adjusted for age, gender, tumor location, surgery, and medical complications.

Results

Sample Description

The total sample was composed of 271 participants, mostly men (n = 209, 77%), with an esophageal cancer (n = 130, 48%) and having received a neoadjuvant treatment (group 2: n = 167, 62%). A detailed description of the participants in the 2 groups is provided in Table 1. The results revealed no significant difference between the 2 groups, except for gender and cancer site.

Table 1 - Sample Characteristics and Comparisons of Characteristics Groups (N = 271)
Variable Group 1 (n = 104) Group 2 (n = 167) Diff.
N % N % P
Mean age (SD), range 64.30 (12.20) 19-93 62.98 (9.11) 33-83 .342
Gender .015
 Female 32 31 30 18
 Male 72 69 137 82
Living .539
 In a couple 65 62 118 71
 Alone 28 27 31 19
 Other 7 7 12 7
 Missing data 4 4 6 3
Employment status .723
 Employed—active 10 9 17 10
 Inactive 26 25 43 26
 Retired 62 60 98 59
 Missing data 6 6 9 5
Cancer site .000
 Esophageal 48 46 82 49
 Gastric 42 40 21 13
 Esophagogastric junction 14 14 64 38
Neoadjuvant treatments (before surgical treatment) –
 Chemotherapy only – – 87 52
 Chemoradiation – – 80 48
Surgery type .000
 Esophagectomy 46 44 109 65
 Gastrectomy 44 42 26 16
 Esophagectomy and Gastrectomy 12 12 30 18
 Missing data 2 2 2 1
Duration of postsurgery hospitalization, mean (SD), range, y 17.81 (14.22) 5-99 15.43 (9.84) 0–74 .139
Duration between surgery and questionnaire completion at T2, mean (SD), range, y 33.59 (23.25) 0-120 30.31 (17.41) 5–101 .217
Surgery complications T2 .252
 Yes 35 34 45 27
 No 69 66 121 72
 Missing data – – 1 1
Medical complications T2 .859
 Yes 45 43 70 42
 No 59 57 96 57
 Missing data – – 1 1

Score Comparisons (Objective 1)

In the 2 groups, participants reported an increase in their depressive symptoms and a decrease in their anxiety symptoms and HRQoL between T1 and T2 (Table 2). The results revealed no significant difference between the 2 groups, except for anxiety at T2 (P < .007). Participants in group 1 (ie, surgery alone) reported stronger anxiety symptoms at T2 than did participants in group 2 (ie, neoadjuvant treatment and surgery).

Table 2 - Comparison of the Anxiety, Depression, and HRQoL Scores in Groups 1 and 2 at Baseline (T1) and After Surgery (T2) (N = 271)
Scores Group 1 (n = 104) Group 2 (n = 167)
Mean (SD) Range Mean (SD) Range
Anxiety
 T1 9.26 (4.39) 0.00–20.00 8.52 (3.91) 0.00–18.00
 T2a 8.08 (4.10) 0.00–20.00 6.74 (3.37) 0.00–20.00
 Comparisons between T1 and T2 P < .002 P < .000
Depression
 T1 4.71 (4.06) 0.00–21.00 4.83 (3.39) 0.00–17.00
 T2 6.03 (4.49) 0.00–21.00 5.85 (3.77) 0.00–19.00
 Comparisons between T1 and T2 P < .006 P < .000
HRQoL
 T1 4.53 (1.39) 1.00–7.00 4.42 (1.27) 1.00–7.00
 T2 4.11 (1.32) 1.00–7.00 4.04 (1.09) 1.00–7.00
 Comparisons between T1 and T2 P < .005 P < .001
Intra-EC
 T1 3.25 (.54) 1.44–4.64 3.31 (.47) 1.88–4.52
 T2 3.20 (.50) 2.04–4.48 3.25 (.44) 1.96–4.68
 Comparisons between T1 and T2 P < .356 P < .182
Inter-EC
 T1 3.01 (.50) 1.72–4.36 3.03 (.56) 1.65–4.60
 T2 3.00 (.43) 2.16–4.12 2.99 (.46) 1.96–4.96
 Comparisons between T1 and T2 P < .810 P < .287
Abbreviations: EC, emotional competence; HRQoL, health-related quality of life.
aSignificant difference between the 2 groups (P < .007).

Direct effects (Objective 2)

Overall, confirming Hypothesis 2, intrapersonal EC, and to a lesser extent interpersonal EC, predicted fewer ADSs and higher HRQoL at T1 and T2 (Tables 3 and 4). Intrapersonal EC showed a stronger effect than interpersonal EC (eg, for anxiety in group 1: βStand = −.29, P = .003, and βStand = −.08, P = .408, respectively). Overall, EC in group 2 showed a weaker effect on depressive symptoms and no effect on HRQoL at T1 and T2 compared with group 1.

Table 3 - Regression Analysis Predicting Scores of Anxiety, Depression, and HRQoL at Baseline (T1) and After Surgery (T2) From Intrapersonal or Interpersonal EC at Baseline (T1) for Group 1 (n = 104)
Variable R 2 adj ΔR 2 adj F β Stand P
Criterion: anxiety (T1)
 Intra-EC 0.08 0.09 3.04a −.29 .003
 Inter-EC −0.01 0.01 0.88 −.08 .408
Criterion: anxiety (T2)
 Intra-EC 0.06 0.03 2.57a −.18 .078
 Inter-EC 0.04 0.01 1.87 −.08 .443
Criterion: depression (T1)
 Intra-EC 0.28 0.31 10.81b −.56 .000
 Inter-EC 0.17 0.20 6.12b −.45 .000
Criterion: depression (T2)
 Intra-EC 0.09 0.11 3.48a −.33 .001
 Inter-EC 0.06 0.08 2.62a −.28 .005
Criterion: HRQoL (T1)
 Intra-EC 0.13 0.13 4.50c .36 .000
 Inter-EC 0.10 0.10 3.69c .32 .001
Criterion: HRQoL (T2)
 Intra-EC 0.04 0.05 2.00 .23 .025
 Inter-EC 0.03 0.04 1.77 .21 .040
Results show the effect of intrapersonal or interpersonal EC on issues (step 2). Each model was adjusted for age, gender, and tumor location in step 1.
Abbreviations: EC, emotional competence; HRQoL, health-related quality of life.
aSignificant model at P < .05, Bonferroni adjustment: P < .004.
bSignificant model at P < .001, Bonferroni adjustment: P < .004.
cSignificant model at P < .01, Bonferroni adjustment: P < .004.

Table 4 - Regression Analysis Predicting Scores of Anxiety, Depression, and HRQoL at Baseline (T1) and After Surgery (T2) from Intrapersonal or Interpersonal EC at Baseline (T1) for Group 2 (n = 167)
Variable R 2 adj ΔR 2 adj F β Stand P
Criterion: anxiety (T1)
 Intra-EC 0.13 0.08 6.40a −.29 .000
 Inter-EC 0.07 0.03 3.93b −.18 .031
Criterion: anxiety (T2)
 Intra-EC 0.09 0.03 4.45b −.20 .014
 Inter-EC 0.07 0.02 3.67b −.15 .073
Criterion: depression (T1)
 Intra-EC 0.13 0.09 6.40a −.31 .000
 Inter-EC 0.10 0.07 5.21a −.28 .001
Criterion: depression (T2)
 Intra-EC 0.09 0.05 4.63b −.23 .006
 Inter-EC 0.10 0.06 5.07a −.25 .002
Criterion: HRQoL (T1)
 Intra-EC 0.02 0.03 1.91 .12 .130
 Inter-EC 0.04 0.03 2.54c .18 .031
Criterion: HRQoL (T2)
 Intra-EC 0.01 0.00 1.40 .05 .538
 Inter-EC 0.01 0.01 1.52 .08 .925
Results show the effect of intrapersonal or interpersonal EC on issues (step 2). Each model was adjusted for age, gender, and tumor localization in step 1.
Abbreviations: EC, emotional competence; HRQoL, health-related quality of life.
aSignificant model at P < .001, Bonferroni adjustment: P < .004.
bSignificant model at P < .01, Bonferroni adjustment: P < .004.
cSignificant model at P < .05, Bonferroni adjustment: P < .004.

Indirect Effects (Objective 3)

Supporting hypothesis 3, the results showed a significant indirect effect of intrapersonal and interpersonal EC on HRQoL at T2, especially via depressive symptoms at T2 (Table 5). The specific indirect effect of EC on HRQoL at T2 via HRQoL at T1 was significant only in group 1. Lastly, the indirect effects of EC were higher in group 1 (ie, 0.14 and 0.15) than in group 2 (ie, 0.10 and 0.11). Thus, patients who reported a stronger use of their EC in daily life at baseline reported fewer depressive symptoms after surgery and, consequently, a less impaired postsurgical HRQoL in the 2 groups.

Table 5 - Indirect Effects of Intrapersonal and Interpersonal EC After Diagnosis (T1) on HRQoL After Surgery (T2) Via Anxiety and Depression Symptoms (T2) and HRQoL (T1) for Group 1 (n = 93) and Group 2 (n = 143)
Unstandardized Indirect Effects Standardized Indirect Effects
BCa 95% CI BCa 95% CI
Estimate SE Lower Upper Estimate SE Lower Upper
Group 1 (n = 93)
 Intra-EC
  Via anxiety (T2) 0.07 0.07 −0.01 0.28 0.03 0.03 −0.00 0.10
  Via depression (T2) 0.38a 0.16 0.11 0.74 0.15a 0.06 0.05 0.29
  Via HRQoL (T1) 0.19a 0.09 0.06 0.41 0.08a 0.03 0.03 0.17
  Total indirect effect 0.64a 0.20 0.28 1.07 0.26a 0.07 0.12 0.41
 Inter-EC
  Via anxiety (T2) 0.04 0.05 −0.03 0.22 0.01 0.02 −0.01 0.08
  Via depression (T2) 0.38a 0.15 0.14 0.78 0.14a 0.05 0.06 0.27
  Via HRQoL (T1) 0.20a 0.08 0.07 0.41 0.07a 0.03 0.03 0.16
  Total indirect effect 0.62a 0.20 0.28 1.07 0.23a 0.07 0.11 0.37
Group 2 (n = 143)
 Intra-EC
  Via anxiety (T2) −0.05 0.05 −0.19 0.02 −0.02 0.02 −0.08 0.01
  Via depression (T2) 0.22a 0.10 0.04 0.45 0.10a 0.05 0.02 0.20
  Via HRQoL (T1) 0.00 0.03 −0.04 0.07 0.00 0.01 −0.02 0.03
  Total indirect effect 0.18 0.10 −0.01 0.39 0.08 0.05 −0.00 0.18
 Inter-EC
  Via anxiety (T2) −0.03 0.03 −0.13 0.01 −0.02 0.02 −0.07 0.01
  Via depression (T2) 0.22a 0.08 0.09 0.41 0.11a 0.04 0.05 0.21
  Via HRQoL (T1) 0.00 0.03 −0.05 0.07 0.00 0.02 −.03 0.04
  Total indirect effect 0.19a 0.08 0.06 0.37 0.10a 0.04 0.03 0.19
Specific and total indirect effects; 5000 bootstrap samples as recommended.28
Age, gender, tumor location, surgery, and medical complications were controlled in all models.
Abbreviations: BCa, bias corrected and accelerated; CI, confidence interval; EC, emotional competence; HRQoL, health-related quality of life.
aSignificant indirect effects (ie, zero is not included in the confidence intervals).

Discussion

The main objective of this study was to examine the involvement of emotional processes in the postoperative HRQoL of esophageal and gastric cancer patients according to the presence or absence of neoadjuvant treatments. Different results were found between the 2 treatment groups, confirming the importance of taking into account neoadjuvant treatments. Overall, EC predicted fewer ADSs at T1 (ie, after diagnosis) and T2 (ie, after surgery) but a less impaired and higher HRQoL at T1 and T2 only in group 1 (ie, without neoadjuvant treatment). Lastly, EC, particularly intrapersonal EC, showed a significant indirect effect on HRQoL after surgery, especially via fewer depressive symptoms and in both groups with higher effects in group 1 than in group 2.

The results showed an increase in depressive symptoms and a decrease in both anxiety symptoms and HRQoL of esophageal and gastric cancer patients between diagnosis and surgery, in accordance with previous findings.3–8,11 Consequently, depressive symptoms and HRQoL could follow the same processes contrary to anxiety symptoms. Neoadjuvant treatments did not aggravate the postsurgical HRQoL of esophageal and gastric cancer patients, in accordance with other studies revealing that neoadjuvant treatments in addition to surgery improve the survival of patients compared with surgery alone without further reducing HRQoL.30,31

Overall, EC, and especially intrapersonal EC, predicted fewer ADSs and a better HRQoL after diagnosis and after surgery, confirming previous findings in esophageal and gastric cancer patients13 and in other cancer settings.21,32–34 Thus, EC protects patients from the negative impact of diagnosis and surgery on their emotional state, regardless of the neoadjuvant treatment received, and their perception of HRQoL. However, neoadjuvant treatments in addition to surgery seem to reduce the beneficial impact of EC on depressive symptoms and HRQoL after surgery but not on anxiety symptoms. The results also confirm the importance of distinguishing the effect of intrapersonal and interpersonal EC separately and of further analyzing these intrapersonal and interpersonal dynamics in future studies.22

Two patterns of results appeared: (1) a reduction in anxiety across the care pathway, reinforced by the presence of neoadjuvant treatments (ie, group 2) and (2) a more limited effect of EC on anxiety than on depressive symptoms, not dependent on treatment group. Anxiety symptoms may be more related to the psychological impact of cancer diagnosis and to the time required to adjust and assimilate to the diagnosis. The decrease in anxiety symptoms could reveal the use of social and medical support from relatives and healthcare professionals. Neoadjuvant treatments could provide more opportunities to mobilize personal (eg, coping, EC), social (eg, social support), or medical and care (eg, supportive care, information) resources and a stronger feeling of being well integrated in a care pathway. Outcomes could be a greater sense of control and reassurance in the medical management of the disease, with a better knowledge of the healthcare system, and better adapted coping strategies,35 which may help to reduce anxiety symptoms. Importantly, EC seems to have the same effect on anxiety at each step of the cancer pathway. Emotional competence may promote the emotional and cognitive processes needed for adjustment, resulting in a reduction in anxiety symptoms.

Depressive symptoms and HRQoL could be more interdependent and influenced by surgery and the related negative side effects contrary to anxiety symptoms. In fact, the occurrence of postsurgical comorbidities or limitations in activity status could have a greater impact on HRQoL and depressive symptoms.9,11,36 Depressive symptoms have been associated with increased postsurgical complications and negative side effects related to chemotherapy,37 as well as with increased healthcare utilization and costs (eg, hospital costs, cost per registration).37,38 Thus, the effect of treatments, and especially neoadjuvant treatments, could reduce the beneficial impact of EC on depressive symptoms and HRQoL after surgery.

These various underlying processes could explain the different effects found in this study of EC on these outcomes and depending on the group. Although the direct effect of EC on HRQoL after surgery was limited, there was an indirect effect of EC, and particularly intrapersonal EC, on HRQoL at T2, via depressive symptoms at T2 and in particular for group 1. Thus, in group 1 (ie, surgery alone), the more patients report using their EC on a daily basis, the better their HRQoL after diagnosis and the less depressive their symptoms after surgery, leading them to report less deterioration of their HRQoL after surgery. These results support the importance of taking into account the involvement of emotional processes in postsurgical HRQoL, especially via depressive symptoms, in the subjective experience of patients as well as their survival and adherence to treatments. Emotional distress, related to depressive symptoms, has a negative impact on the prognosis of patients with gastric cancer, probably because of greater treatment noncompliance,12 and in other cancer contexts (eg, metastatic prostate cancer).39

Our results support a mediational model considering the central effect of EC on emotional distress in cancer adjustment (Figures 1 and 2) and in specific contexts for postsurgery HRQoL of esophageal or gastric cancer patients depending on cancer pathway. In fact, through their tendency to identify, understand, express, and regulate their emotions, patients better regulate their emotional distress related to diagnosis and surgery to ultimately report less impaired postsurgery HRQoL. Patients may be better able to mobilize their resources and thus better recover from difficult stages such as cancer diagnosis and treatment side effects.

Limitations

The present study has some limitations. The results should be confirmed with another sample to verify that the differences observed between the groups do not depend on the characteristics of the participants of this study. Moreover, we have no information about the diagnosis of anxiety or depression before the cancer diagnosis of participants, which could impact the results. Future studies should also take into account other variables such as the type of surgery, postsurgical negative side effects, or time since diagnosis.

Implications for Practice

In the clinical routine, it may be important to take better account of the patient’s emotional experience upon diagnosis and before surgery for esophageal or gastric cancer. Patients with high ADSs should be identified for further attention. The HADS could be administered in a systematic way to prompt more emotional support by nurses and referral to a psychologist if necessary. A nursing consultation could be proposed at different stages of care to inform and assess difficulties and needs. Theses consultations could help to identify underlying concerns, emotional distress, and postoperative complications.40 Psychosocial interventions could then also be implemented, to strengthen EC for instance. Surgical or oncology departments could develop specific programs to provide appropriate supportive care to patients, with the aim, for example, of (1) reducing anxiety-depressive symptoms before surgery and (2) having better prepared patients for the postsurgery period. In the continuity of care, postsurgery support for the most at-risk patients could be maintained.

A way of reducing the ADSs could be to target EC. In fact, some interventions have shown that it is possible to improve EC in different populations (eg, general population, patients facing chronic diseases) with individual or group approaches.41–44

Conclusion

The EC used by esophageal and gastric cancer patients in daily life after diagnosis could reduce the negative effect of surgery on their depressive symptoms and HRQoL, especially in the context of no neoadjuvant treatment, and reinforce the adjustment processes and the reduction in anxiety symptoms over time. Future research should better explore how the experience of esophageal and gastric cancer patients evolves along the care pathway. Completing further postsurgical questionnaires could give important information on the impact of EC at baseline, or emotional processes, on long-term HRQoL according to the care pathway. In this context, to understand the underlying mechanisms better, the effects of EC on other issues such as life satisfaction or posttraumatic growth could also be investigated.45,46

ACKNOWLEDGMENTS

We thank Christine Delaeter, Florence Duflot, and the clinical research associates for their help, and the Data Treatment Center for the administration of the FREGAT database and the provision of data. FREGAT was funded with support from the French National Cancer Institute (INCa), and the University Hospital (CHU) of Lille is the sponsor of the FREGAT study. Finally, we would also like to thank all the patients for their participation.

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Keywords:

Emotional competence; Surgery; Health-related quality of life; Depression; Esophageal neoplasms; Gastric neoplasms; Neoadjuvant therapy

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