Psychosocial factors associated with quality of life in cancer patients undergoing treatment: an umbrella review

Abstract

Background

Cancer treatment greatly impacts physical and psychological functioning of cancer patients, negatively affecting their quality of life (QoL). This Umbrella Review (UR) aims to systematically summarize psychological and social factors positively or negatively associated with QoL in cancer patients undergoing treatment.

Method

Four scientific databases (PubMed, Embase, Scopus, and PsycInfo) were searched to identify systematic reviews between 2012 and 2023 analyzing the relationship between QoL and psychosocial factors in cancer patients in treatment. The UR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Joanna Briggs Institute (JBI) review guidelines. The methodological quality of the included studies was evaluated using Assessment of Multiple Systematic Reviews 2 (AMSTAR2).

Results

Eighteen systematic reviews were included. The major psychological factors influencing QoL are depression, coping strategies, anxiety, and distress. Results also demonstrate the significant impact of social factors on QoL: perceived social support has a positive influence on QoL of cancer patients, while lowered social support, impaired social functioning, interactions, and role limitations worsen their QoL and overall well-being.

Conclusion

This UR provides a comprehensive overview of the psychosocial factors impacting QoL of cancer patients and serves as a prominent base for developing questionnaires and policies aimed at measuring QoL in cancer patients undergoing treatment. Moreover, the findings of the study can guide future research or the development of personalized clinical interventions aimed at improving QoL for this cancer population group.

Introduction

Cancer represents a major threat to global health, with roughly twenty million new cases reported in 2022 [1]. Indeed, cancer is the second biggest cause of death worldwide, with one of the highest rates of mortality [2]. Nonetheless, the number of cancer survivors is still rising due to breakthroughs in early detection and advancements in cancer treatments [3]. Cancer diagnosis is a traumatic experience for individuals facing it since it determines several challenges such as emotional and psychosocial problems, physical dysfunctions, and financial difficulties [4]. Indeed, many psychological and physical factors experienced by cancer patients, such as fatigue, decreased self-esteem, anxiety, emotional distress, and depression have a huge impact on their overall well-being [5]. Furthermore, all the negative consequences of cancer could in turn heighten vulnerability and depression, raising the importance of timely addressing and managing the faced challenges [6]. Thus, cancer disease and treatment symptoms may negatively affect patients’ life lowering their Quality of Life (QoL) [4]. Although QoL represents a self-perceived complex and dynamic construct, several authors define it using objective descriptors such as physical, psychological, and social well-being [7, 8]. The World Health Organization (WHO) defines QoL as “an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” [9]. Hence, QoL is a multidimensional construct involving various domains and representing an individual’s own perceptions and needs. Scientific literature highlights that a lower QoL is associated with patient-perceived unmet needs [10], mostly shared within the cancer community. Indeed, information and communication about the disease, physical symptom management, psychological support, spiritual concerns, family and social challenges, and purpose of life, which are reported as the primary needs of cancer patients, are highlighted in the literature as common necessities to all cancer population groups [11].

On the other hand, QoL perception may vary along the cancer pathway, according to patients’ clinical condition and personal challenges: a recent study found that individuals undergoing cancer treatment report lower QoL than patients in survivorship [12]. At this time cancer patients not only struggle with the physical consequences of their therapy, but also with the psychosocial features, as the severity of the symptoms, the uncertainty, and the unpredictability of the treatment have a significant impact on the mental state of the patients. All these aforementioned side effects and consequences enhance cancer patients' negative experiences, constantly lowering their social and psychological well-being. Patients in treatment report experiencing a lack of emotional and social support, which can negatively impact their QoL considering its correlations with psychological changes and the risk of developing depressive symptoms [13, 14]. This goes in line with findings reporting social support as a recognized protective factor for cancer-related distress, thus enhancing QoL and patient’s ability to develop coping strategies [15].

Consequences of oncological disease may have a negative effect on cancer patients’ well-being, thus strengthening the importance of identifying the essential determinants responsible for increasing or worsening QoL and developing individual interventions. The identification of QoL-related traits may help tailor interventions targeted at improving individuals' overall well-being, allowing people to fulfil their own unmet needs.

Hence, given the importance of ensuring greater levels of QoL, the present work aims to summarize possible factors related to cancer patients’ well-being, providing a deeper overview of the potential variables that may impact on QoL. Moreover, despite the significant number of scientific works focusing on this topic, to our knowledge, this is the first umbrella review (UR) synthetizing the scientific evidence of systematic reviews (SR) analysing current psychosocial variables affecting QoL in patients undergoing cancer treatments. The scientific importance of the study is also determined by its wide population range, i.e., including various cancer types and stages, while most of the studies focus on a specific cancer. Indeed, the broad range of population we explored allowed us to collect an extensive framework of prominent QoL determinants critical for scientific research. Thus, this UR contributes to the scientific literature as a unique work providing a complete overview of the main factors impacting QoL in various cancer patients undergoing treatment.

Material and methods

An UR, defined as a work integrating consolidated findings from various SRs to comprehensively explore research evidences related to a specific topic, was conducted [16]. Specifically, SRs on psychosocial factors affecting the QoL in adult cancer patients with ongoing treatments were systematically synthesized. To provide a more complete overview, some major clinical factors that have been multiply reported in the included systematic reviews were collected.

Data sources and search strategy

Three psychologist researchers developed the search strategy, which was subsequently modified by a research librarian (A. V. A.) to suit the specific requirements of four electronic scientific databases: PubMed, Embase, Scopus, and PsycInfo. Specific search strings were optimized using a combination of various search terms related to “Cancer”, “Quality of Life”, “Factors”, “Psychosocial Impact”, and “Ongoing treatment” (Full search strings and the related themes with the keywords are presented in Supplemental Tables 1 and 2).

The UR was conducted following the guidelines provided by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [17].

The results were reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (see PRISMA flowchart in the results section) [18].

Furthermore, the protocol of the study was registered in the International Prospective Register of Systematic Reviews (PROSPERO, identifier: CRD42023413899) [19]. A narrative synthesis was performed to report the results.

Inclusion and exclusion criteria

For the present UR clear exclusion and inclusion criteria were established to avoid biases that could impact the quality of the research itself. The following eligibility criteria were established according to the research question (PICO questions; Population/Problem: ongoing treatment adult cancer patients; Intervention: not applicable; Comparison: not applicable; Outcome: factors affecting QoL and type of association).

Hence, the research was limited to (a) systematic reviews, (b) without geographical restrictions, (c) conducted from 1st January 2012 to January 2023, (d) including adult cancer patients (> 18 years), (e) undergoing treatments and (f) investigating the relationship between quality of life and psychosocial factors.

Studies investigating (a) non-psychosocial factors associated with QoL (e.g. economic, cultural, interventional outcomes), (b) non-in-treatment adult cancer patients (e.g. survivors, end of life patients, other diseases aside from cancer, caregivers, families of end-of-life cancer patients, children, etc.), and (c) written in other languages than English were excluded.

Literature search and data selection

Starting from the presented search strategy, search results were imported into the online software Rayyan and duplicates were identified and removed. The preliminary screening was independently conducted by two researchers (D. S. and V. V.) using the blinded mode. Data selection was based on the titles, abstracts, and keywords and was organized by labelling each article. Any disagreement concerning the eligibility of studies was resolved involving a third researcher (C. M.), through group discussion and full-text review, until a total consensus was reached. The reference lists of the included articles were also screened to find any other relevant articles that were not identified during the automatic search.

Consequently, an Excel© worksheet designed by the research team with registered included articles was organized as follow: publication data (title, authors, year, study origin), study characteristics (number of studies included in each review, study design, year of publication and country origin of included articles), aim of the review, participants’ details (i.e. total number and sociodemographic characteristics, if included in the reviews), cancer group, and psychological, social, and clinical factors associated with QoL.

Assessment of methodological quality and risks of bias

An assessment of the methodological quality of included studies was independently conducted using A MeaSurement Tool to Assess systematic Reviews (AMSTAR2) Checklist by two reviewers [20]. This instrument includes 16 items evaluating the quality and the risk of bias of the selected studies. Selected articles received a single-item score based on positive/partial positive/negative/not applicable (Yes/Partial Yes/No/N/A) responses, thus identifying high, moderate, low, and critically low ratings.

For this UR, the scoring system of AMSTAR 2 was slightly modified: researchers added “partial yes” to the sixteen questions if the review did not meet one of the criteria for rating “Yes”. The same modification was applied to question N1 following the present criterion: non-interventional reviews with a clear and predefined research question, but only reporting population and outcomes were rated as “Yes”.

Results

Data extraction and analysis

Through the scientific database research, 2872 potentially relevant references were found in four different scientific databases: PubMed, Embase, Scopus, and PsycInfo (See Fig. 1 PRISMA Flowchart); after the detection of duplicates, 1952 reviews remained for the screening of titles and available abstracts. Successively, 1899 articles were excluded and a total number of 53 reviews remained for the full-text screening. Of these, 3 papers were excluded because the full-text was not available, while 32 other studies were excluded due to the pre-established exclusion criteria. The most common reasons for exclusion were: wrong outcome or population and absence of psychological factors related to QoL.

Fig. 1

PRISMA Flowchart of the study selection process

Finally, 18 SRs were included in the present UR.

Study characteristics

The articles included in each SR spanned from 2015 to 2022 in terms of their publication years. The number of studies included in each review ranged from 11 to 59. The included SRs cover different study designs: most frequent types are cross-sectional studies (n = 277), longitudinal studies (n = 88), clinical trials (n = 59), cohort studies (n = 34), and retrospective cross-sectional studies (n = 31). The psychosocial factors have been mostly investigated in breast (9 SRs), prostate (2 SRs), and gastric (1 SR with a large number of participants) cancer types. The total number of subjects is 275.855, of which 75.733 included gastric cancer, followed by 71.865 breast cancer patients, 54.571 DTC (i.e. differentiated thyroid carcinoma) patients, 27.849 hepatocellular cancer patients, and 22.769 all cancer types. The summarized articles focused on specific cancer populations (e.g. gastric cancer, breast cancer, DTC, etc.), except for two articles that included different cancer populations without specific distinctions. The details of the study characteristics are presented in Table 1. Furthermore, the population also varies in number of patients included in the summarized articles (with a total sample range between 10–3294), sex, age (ranging from 18–90 years old), and country. Eleven studies were published by European institutions, 3 were conducted in America, 2 in Asia, and the remaining 2 were conducted in Africa.

Table 1 Characteristics of the included studies

QoL and associated psychosocial factors

The results of the present UR reported that the main psychological factors associated with QoL are depression, coping strategies, anxiety and distress (See Table 2). Depression was significantly associated with lower QoL in all the studies in which it was analyzed [22, 24,25,26, 29,30,31,32, 34, 36]. Another prominent factor significantly associated with QoL is coping strategies: both positive and negative impacts on QoL were identified [24,25,26, 29, 35, 36]. Specifically, active coping strategies (such as problem-solving, emotion-focused strategies, and adaptation) were associated with better QoL, while maladaptive behaviors (e.g. avoidance and isolation) correlated with lower QoL.

Table 2 Results of the included studies

Anxiety was reported as a factor negatively impacting QoL[22, 23, 26, 29, 30, 36]. Symptoms of distress were always related to lower QoL in all the four SRs where distress was analyzed[22, 31, 35, 37].

Our results also demonstrate the significant impact of optimism, resilience, and unmet needs on QoL of cancer patients in treatment [23, 25, 28,29,30, 35, 36]. Also, one study reported an association between locus of control and QoL: internal locus of control was associated with better QoL, while external one had a negative impact on QoL [35].

Other factors negatively associated with QoL in cancer patients undergoing treatment were: negative change in body image, neuroticism, fear of cancer recurrence, mental fatigue, post-traumatic stress disorder and impaired mental health [21, 22, 24, 32, 34, 36, 37].

Besides negative factors, this UR also identify factors that had a positive impact on QoL of cancer patients undergoing treatment: self-efficacy, tolerant personality type, self-regulation, sense of coherence, faith, spiritual well-being, and hope [23, 27, 30, 33, 35, 36, 38].

Regarding the social factors identified in this UR, our finding report that perceived social support had a positive impact on QoL of cancer patients [29, 30, 36]. Lower social support, impaired social functioning, interactions and role limitations worsened QoL as well as the overall well-being of cancer patients in treatment [22, 31, 35].

Clinical factors

Though this UR was aimed at the identification of psychosocial factors associated with QoL, clinical factors mentioned in the included reviews were also extracted. Indeed, clinical factors play a significant role in the development of psychosocial factors impacting the QoL of cancer patients undergoing treatment. The severity of symptoms and their impact on the mental state of patients were discussed in the introduction.

Our findings report that the main clinical factors that have a great impact on QoL of patients undergoing treatment are cancer stage, cancer severity, time since diagnosis, type of surgery, cancer-specific symptoms (e.g. fatigue, pain), chemotherapy, comorbidities with other diseases (e.g. hypertension, arthritis, diabetes), hormone and immune therapy, radiotherapy and higher symptom score [24, 25, 30,31,32, 34,35,36]. Advanced cancer stages were associated with lower QoL, while early cancer stage and early treatment were associated with better QoL [30, 35, 36]. Strong negative associations were also found between chemotherapy, comorbidities, and QoL [30, 31, 34, 35]. Comorbidities with other diseases such as hypertension, arthritis, and diabetes significantly decreased QoL and the overall well-being of cancer patients [32, 35]. The type of treatment has also been found to influence QoL. More specifically, immune therapy, hormone therapy and radiotherapy are reported to positively influence QoL of cancer patients [30, 35]. Results also show that breast reconstruction surgery, timing of reconstruction, complementary alternative medicine, and nanomedicine played an important role in increasing QoL of cancer patients [27, 30, 34].

Quality assessment

Although all eighteen included articles featured an explicit search strategy, study selection methodology, and PRISMA flowchart, only eight studies explicitly declare having followed a protocol previously registered on PROSPERO, whereas seven declared not having registered their protocol on PROSPERO. Results of the quality assessment demonstrate that most of the SRs included in this UR show low scores mostly for the following questions: “N3. Did the review authors explain their selection of the study designs for inclusion in the review?”, “N7. Did the review authors provide a list of excluded studies and justify the exclusions?”, and “N10. Did the review authors report on the sources of funding for the studies included in the review?”. The details of the quality assessment results are shown in Table 3.

Table 3 AMSTAR quality assessment

Discussion

This UR investigated the association between psychosocial factors and QoL in cancer patients undergoing treatment in order to highlight the impact of these determinants on increasing or worsening QoL.

Analyzing the findings from 18 systematic reviews included in this UR, our results identified various psychosocial factors that are responsible for higher or lower levels of QoL and the overall well-being of cancer patients undergoing treatments. The major factors that have a profound impact on the QoL of cancer patients are depression, coping strategies, social support/functioning/interaction, anxiety, distress, faith/religiosity, optimism, resilience, and unmet needs [22,23,24,25,26, 28,29,30,31,32, 34,35,36,37,38], showing a great diversity of the psychosocial factors associated with the QoL in this cancer phase. The specific treatment that cancer patients are going through may lead to a great variety of factors impacting QoL, according to the high vulnerability these patients may face in this period of the cancer trajectory. Indeed, research highlights that more than 70% of cancer patients in treatment experience treatment side effects, which leave a trace on their QoL: treatment symptoms impact not only the physical but also the mental state of patients, who in addition to physiological issues (e.g. pain, appetite loss, nausea), are facing psychological challenges like depression, anxiety or distress [39, 40].

The significance of the correlation between physical and psychological symptoms has also been confirmed in the scientific literature by a number of studies that demonstrate the association between treatment-related side effects and mental issues experienced by cancer patients. Niedzwiedz et al. and Smith et al. highlighted that treatment symptoms could impact the development and even the level of depression [41, 42]. This is also confirmed by our results mentioning depression as the main factor negatively impacting QoL of cancer patients [22, 24,25,26, 29,30,31,32, 34, 36]. However, the correlation between physical and psychological symptoms is even more profound: not only may side effects lead to depression, but also depression may in turn influence the intensity of treatment symptoms and outcomes, thus worsening the overall physical state of cancer patients [43]. Along with depression, our findings show that QoL in cancer patients undergoing treatment has been impacted by a complex interplay of various factors. Evidence here summarized demonstrate a great negative impact of anxiety, distress, and unmet needs on QoL in cancer patients [22, 23, 26, 29,30,31, 35,36,37]. These factors significantly influence cancer patients’ recovery outcomes, as the literature highlights a great association between anxiety and distress and treatment outcomes [44, 45]. Research shows that high levels of distress may influence treatment adherence and increase the possibility of hospitalization [46]. Moreover, it may worsen cancer patients’ emotional health, eventually leading to hopelessness and an even increased suicide risk, which is almost four times higher for certain cancer types (e.g., head and neck cancer) compared with people without cancer [47]. Unmet needs, in health and information domains, as well as physical, psychological, and daily life needs, are reported to contribute to reduced QoL, to increase psychological distress and significantly impact on high symptom burden [48,49,50].

On the other hand, our results also found some major psychosocial factors positively associated with QoL, such as appropriate coping strategies, social support, and resilience [25, 26, 28,29,30, 35, 36]. Obviously, to overcome all the above-mentioned cancer-related issues, patients need to adopt appropriate coping strategies, develop a sense of resilience, and receive support from close people or their community. Social support either from close people or cancer support associations, reduces levels of distress and contributes to patients’ resilience, which has a positive impact on QoL in cancer patients [51]. Family harmony improves the cognitive and emotional QoL by reducing levels of rumination, mental fatigue, anxiety, and depression: patients with good social support may experience lower loneliness, less social isolation, and helplessness [52,53,54]. Social interactions also provide practical assistance and cultivate a fighting spirit, helping develop appropriate coping strategies [55]. In this regard, problem-solving and proactive approaches have a significant role in managing emotional challenges experienced by cancer patients and improving their mental state. Indeed, a positive mindset may be developed by patients feeling a greater support from family and/or friends. This would help them to focus on positive aspects rather than concentrate on some negative outcomes of the disease journey. Moreover, such mindset may generate positive mood and optimism, which have a great impact on cancer patients’ well-being. Our findings confirm a positive association between positive thinking and optimism and higher QoL [23, 26, 55], increasing patients’ hope and contributing to their confidence in remaining cancer-free [33, 36].

Our findings also reported the spiritual dimension plays a major role in patients undergoing treatments, stressing the importance of faith and spiritual well-being in this phase [30, 35, 38]. These factors may help enhance patients’ overall health and provide a sense of meaning during their cancer journey. Indeed, a recent study on the impact of spirituality and religiosity on QoL of cancer patients found a positive association between these factors and physical, emotional, and social functioning [56]. This also goes in line with Brady et al.’s findings reporting that a higher level of spirituality contributes to patients’ ability to enjoy life and tolerate levels of some symptoms such as fatigue and pain [57].

Our findings can shape public health policies and be integrated into the development of QoL questionnaires or m-Health technologies. Based on our results, it can be concluded that the first steps to be taken to stabilize and improve QoL of cancer patients in treatment are to manage depression, help patients develop appropriate coping strategies, and provide social support. This knowledge represents key areas to pay attention to while developing QoL questionnaires, interventions, and policies aimed at improving QoL. Moreover, due to current advances in technology, great attention is given to technological solutions aimed at improving cancer care. Our results can be beneficial for designing and developing interactive services for personalized medicine or m-Health technologies, the benefits of which are highlighted in the scientific literature [58, 59]. A mobile or web-based user-friendly application for cancer patients that provides them social and psychological support (eg. cancer community/discussion forum, articles on management of psychological challenges, etc.) could address cancer patients’ unmet informational and psychological needs, and significantly increase their QoL and life satisfaction. Scientific literature highlights the importance of understanding the role of cancer diagnosis and its association with life satisfaction, and developing strategies aimed at improving QoL outcomes [60]. Considering public health dimension, understanding widespread psychosocial needs in cancer patients can help driving resources allocation towards the managements of these crucial factors. This could in turn, raise public awareness potentially shaping the social environment and enhancing the knowledge of the oncological world.

Limitations and future directions

Despite the great evidence achieved by this UR, some limitations have to be mentioned. Firstly, our inclusion criteria implied the selection of SRs published only in English, which contributes to the possibility of missing some relevant studies written in other languages. This limitation might have contributed to missing some cultural variables influencing cancer experience. Secondly, this UR included studies on patients of any cancer type and treatment stage, but the diversity of cancer- and treatment-specific symptoms may be not fully addressed, leading to some heterogeneity of the results. For example, nausea and vomiting caused by chemotherapy may impact the development of some psychosocial factors negatively influencing the QoL of patients undergoing this specific treatment, while persistent coughing (often with blood) and shortness of breath specific for lung cancer patients may create specific psychological issues for this cancer population group.

Despite these possible limitations, this UR provides a first attempt to comprehensively summarize the existing scientific findings on psychosocial factors affecting QoL in cancer patients undergoing treatment. Moreover, it provides a detailed overview of the psychosocial variables responsible for worsening and increasing QoL during treatment. However, it has to be considered that the great advancements in treatments options and their impact on the physical well-being may also contribute to the variation of psychological issues faced in this cancer phase. Thus, this UR highlights the importance of further research on this topic in order always to have an up-to-date overview of QoL and the factors impacting it. Furthermore, we encourage considering multilingual SRs to gather a more complete overview of cultural insights that can influence QoL and promote high-value oncological care.

Conclusion

Treatment is one of the most vulnerable time in the cancer journey. Aggressive treatments and unpredictable results may leave a negative trace on cancer patients’ physical and psychological states, worsening their QoL and overall well-being. This UR, at the extent of our knowledge, is the first attempt to provide a comprehensive overview of psychosocial factors impacting QoL of cancer patients and underline the negative or positive impact of these factors on it.

These findings are essential to better address the challenges patients are facing, and develop personalized interventions aimed at managing factors negatively affecting QoL, thus improving the overall QoL of cancer patients undergoing treatment.