A Comparative Study of Symptoms, Social Support, and Quality of Life at Different Survival Stages of Lung Cancer Patients
Article information
Abstract
Purpose
This study aimed to compare symptoms, social support, and quality of life across different stages of survival in patients with lung cancer.
Methods
The study included 145 participants: 49 in the acute survival phase (less than 2 years), 50 in the extended survival phase (2∼5 years), and 46 in the lasting survival phase (> 5 years). A structured questionnaire was utilized to assess symptoms, social support, and quality of life. Analysis of covariance was used to control for demographic and disease-related variables.
Results
Quality of life was significantly higher in the lasting survival stage (F=5.05, p=.008). The severity of symptoms was highest in the acute survival stage, followed by the extended survival stage, and lowest in the lasting survival stage (F=15.79, p<.001). Symptom interference with life was greater in the extended survival stage than in the lasting survival stage (F=11.11, p<.001). Social support was the lowest in the extended survival stage (F=10.03, p<.001). Notably, the extended survival stage had the highest scores for symptoms affecting daily activities, relationships, walking, and work (p<.001).
Conclusion
This study highlights the differences in symptoms, social support, and quality of life in patients with lung cancer across their survival stages. Tailored interventions are essential for each survival stage to improve the quality of life, with emotional and social support being critical in the extended survival phase, whereas symptom management is key in the acute phase.
INTRODUCTION
Cancer has remained the leading cause of death in South Korea over the past decade, with lung cancer being the second most common cause of death in terms of in-cidence and the most fatal cancer in terms of mortality rate [1]. However, the 5-year survival rate of patients with lung cancer, which was only 16.6% in 2005, increased significantly to 38.5% by 2021, showing the highest growth rate among all cancer types [2]. This increase suggests that many patients with lung cancer are overcoming the disease and achieving long-term survival, highlighting the growing importance of improving the quality of life and providing long-term management.
Mullan classified the survival stages of patients with cancer into acute, extended, and lasting stages based on changes and conditions during the cancer treatment proc-ess [13]. The acute survival stage refers to the period im-mediately following cancer diagnosis, during which patients undergo various types of treatment, typically occurring within two years of diagnosis. The extended survival stage is when the disease and treatment are nearly complete, usually between two and five years after diagnosis. The lasting survival stage is characterized by a substantial reduction in the recurrence rate and cancer cell activity, occurring five or more years after diagnosis [13]. As the types and severity of symptoms can vary depending on the survival stage of patients with lung cancer, examining the symptoms and quality of life experienced by patients at each survival stage and exploring potential interventions to address them would be meaningful.
Patients with lung cancer typically experience a higher symptom burden than those with other malignancies [8]. The severe physical and psychological distress associated with lung cancer significantly increases the risk of suicidal ideation [9]. The severity of symptoms often increases during chemotherapy and radiation therapy [5]. A notable characteristic of lung cancer is the frequent occurrence of symptom clusters in which two or more related symptoms manifest concurrently [6,7]. This complex symptomatol-ogy contributes to the overall disease burden, and may have implications for patient management and quality of life. In the early stages of lung cancer treatment, symptoms related to decreased lung function such as extreme fatigue, dyspnea, and shortness of breath are particularly notice-able. In later stages, symptoms related to treatment complications are more commonly observed [10,11]. Additionally, even after treatment is completed, long-term survi-vors often continue to experience respiratory-related symptoms that can interfere with daily activities [12].
Social support enhances the ability of patients with cancer to adapt to their illness [14] and positively affects their overall physical and mental quality of life [15]. During the acute survival phase, patients with cancer experience varying levels of shock and anxiety, whereas during the extended survival phase, they experience fear of recurrence and limitations caused by physical weakness. In the lasting survival phase, they experience pain due to the stigma and prejudice associated with the disease. Conse-quently, the type and intensity of social support required by patients with cancer differ depending on their survival stage [13]. Therefore, appropriate social support tailored to each stage of survival is crucial. Examining the differences in social support needs at each survival stage is crucial for patients with lung cancer.
Quality of life is not only a factor in evaluating the effectiveness of cancer treatment, but also a powerful predictor of survival and is as important as a patient's lifespan [3]. However, the quality of life of patients with lung cancer is substantially lower than that of patients with other types of cancer, and the number and severity of symptoms have been found to have a particularly large impact on the quality of life [4].
A review of the domestic literature on quality of life at different cancer survival stages revealed studies comparing posttraumatic growth and quality of life across survival stages in patients with gynecological [16,17] and breast cancers [16,18]. International studies have compared differences in quality of life at various survival stages in patients with breast cancer [19,20], and some studies have compared symptom burden and quality of life in patients with cancer [21]. Domestic research in Korea spe-cifically focusing on patients with lung cancer has compared the differences in the quality of life Within two years after diagnosis and more than two years after diagnosis. Aside from some differences in symptoms such as numbness, dullness, and difficulty walking, that study found no substantial differences in the quality of life after two years [10]. However, it included approximately 64% of patients in the acute survival stage, 27% in the extended survival stage, and only 9% in the lasting survival stage. Therefore, it does not adequately reflect the characteristics of each survival stage, thereby limiting its ability to reveal the specific characteristics of patients at different survival stages.
International literature includes studies comparing the quality of life before and after chemotherapy in patients with acute-stage lung cancer [5]. However, there is a lack of domestic and international literature addressing the quality of life at each survival stage, as proposed by Mullan (1985). Many patients suffer from cancer, but those with lung cancer often experience more intense symptoms than those of other types of cancer, making disease pro-gression particularly agonizing [8,9]. This typically does not occur in isolation but appears alongside a variety of other symptoms, leading to even greater challenges [6,7]. The severity and nature of these symptoms vary depending on the patient's survival stage, making it crucial to un-derstand how symptoms differ across stages and how they impact quality of life [10,11]. Furthermore, these symptoms tend to be influenced by the patient's perceived level of social support [22]. Therefore, it is essential to explore the differences in symptoms and social support at various survival stages of lung cancer as well as how social support may affect these factors.
Therefore, the present study aimed to investigate the differences in symptoms, social support, and quality of life across survival stages in patients with lung cancer. The goal was to provide foundational data for offering tailored interventions based on differences in symptoms, social support, and quality of life at each survival stage as well as the specific needs associated with each stage.
METHODS
1. Study Design
This descriptive comparative study investigated the differences in symptoms, social support, and quality of life across the survival stages of patients with lung cancer.
2. Participants
The study included patients diagnosed with lung cancer who joined an online lung cancer support group and voluntarily agreed to participate after understanding the purpose and methods of the study and reviewing the recruitment announcement posted on the group forum.
A recruitment notice was posted in an online commun-ity for lung cancer patients and clearly outlined the inclusion and exclusion criteria. It also specified that only individuals who met these criteria would be eligible to participate in the survey. According to Mullan's (1985) classi-fication of survival stages [13], 50 participants were recruited for each stage, and data were collected using Google Forms. The inclusion criteria were adults aged 18 years or older who were diagnosed with lung cancer, un-derstood the purpose of the study, and voluntarily agreed to participate. Exclusion criteria were individuals with communication difficulties, cognitive impairments, or mental disorders; those in the end stages of lung cancer; or those who had been diagnosed but had not yet begun treatment. The sample size for this study was calculated using the G*Power 3.1.9.2 program, with a significance level of .05, an effect size of .40, a power of .80, six co-variates, and a 3-group analysis of covariance (ANCOVA), resulting in a total of 111 participants [33]. Anticipating an attrition rate of approximately 25%, 150 participants (50 in each survival stage) were recruited. Data collection was limited to 50 participants per survival stage through an online survey conducted on a first-come-first-served basis. Five participants were excluded because they did not agree to one or more items in the informed consent section, leaving 145 participants. There were no dropouts owing to in-sufficient responses. The final sample comprised 49 in the acute survival stage, 50 in the extended survival stage, and 46 in the lasting survival stage.
3. Measures
The data used in this study were collected online using a self-reported Google questionnaire. Before using the tool, permission was obtained from the authors through email. The specific tools used in this study were as follows:
1) General and clinical characteristics
The participants’ general characteristics were assessed using the following six questions: gender, age, marital status, occupational status, religious status, and average monthly household income. Clinical characteristics were assessed using the following five questions: duration since lung cancer diagnosis, cancer stage, treatment modality, perceived severity of illness, and perceived health status.
2) Symptoms
The symptoms of patients with lung cancer were measured using the Korean version of the M.D. Anderson Symptom Inventory-Lung Cancer (MDASI-LC) [23], with permission obtained from the Symptom Research Team at the M.D. Anderson Cancer Center (Mdanderson.org). The MDASI-LC consists of 16 symptoms severity and 6 items evaluating the extent to which these symptoms interfere with daily life. Each symptom was rated on an 11-point scale from 0 (none) to 10 (as bad as imaginable), indicating the severity of symptoms over the past 24 h. Items regarding interference with daily life were also measured on an 11-point Numerical Rating Scale ranging from 0 (no interference) to 10 (complete interference), reflecting the extent to which the symptoms interfered with daily activities during the past 24 h. At the time that the tool was developed, the symptom items had a Cronbach's ⍺ of .91 and the daily life interference items had a Cronbach's ⍺ of .93. In this study, the overall Cronbach's ⍺ was .92.
3) Social support
In this study, the social support of lung cancer patients was measured using the Multidimensional Scale of Perceived Social Support (MSPSS) developed by Zimet et al. [24] and adapted and modified by Shin and Lee [25]. Permission to use the scale was obtained from the original authors and those who adapted and modified the scale. The MSPSS includes 12 items divided into three subscales: family support, friend support, and significant others. A significant other refers to support from considerable others, and was defined in this study as support from healthcare professionals. Responses were measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a total score ranging from 12 to 60. Higher scores indicated higher levels of social support. The reliability of the tool at the time of its development was Cronbach's ⍺=.83. In this study, the overall reliability was Cronbach's ⍺=.92.
4) Quality of life
In this study, the quality of life of patients with lung cancer was measured using the Functional Assessment of Cancer Therapy-Lung (FACT-L) [26], with permission obtained from the Functional Assessment of Chronic Illness Therapy (FACIT) to use the tool. The Korean version of FACIT-L was used in this study [27]. The tool consists of 34 items: seven on physical condition, six on social/family condition, six on emotional condition, seven on functional status, and eight on lung cancer symptoms. The FACIT-L uses a 5-point Likert scale ranging from 0 (not at all) to 4(very much), with a total score ranging from 0 to 136. Higher scores indicate a higher quality of life. The reliability of the tool at the time of its development was Cronbach's ⍺=.89. You et al.[27], using the Korean version of FACIT-L, calculated Cronbach's ⍺=.86. In this study, the overall reliability was Cronbach's ⍺=.95.
4. Statistical Analysis
The collected data were analyzed using IBM SPSS Statistics 22.0 for Windows as follows: General and clinical characteristics were analyzed using frequencies, percen-tages, means, and standard deviations. Differences in symptoms, social support, and quality of life across survival stages were analyzed using ANCOVA and the Bonferroni test while controlling for general and clinical characteristics.
5. Ethical Considerations
This study was approved by the Institutional Review Board (IRB) of K University (KUIRB 2024-0025). The survey was conducted online, and the first page included an online consent form where participants could select “Yes” or “No” to indicate their consent. The purpose, methods, confidentiality, and anonymity of the study were dis-closed through an internet cafe, and it was clearly stated that participation was voluntary. The data used in the study will be permanently deleted three years after com-pletion of the study. The participants were provided with a small mobile coupon as a token of appreciation.
RESULTS
1. General and Clinical Characteristics by Survival Stage of the Participants
The general and disease-related characteristics, as well as the differences in the survival stages of the participants, are presented in Table 1.
Baseline Characteristics of Patients with Lung Cancer Across Survival Stages (N=145)
The study sample comprised 49 participants (33.8%) in the acute survival stage, 50 (34.5%) in the extended survival stage, and 46 (31.7%) in the lasting survival stage. Of the participants, 94 (64.8%) were male and 51 (35.2%) were female. The mean age was 50.88±9.99 years. The majority were married (79.3%, n=115), and 75.9%(n=110) of the participants were employed. The most common religious status was nonreligious, with 54.5%(n=79) reporting being unaffiliated. In terms of monthly income, the largest group (45.5%, n=66) earned 4-6 million KRW. Most participants had stage 2 cancer (66.9%, n=97), and the most common treatment modality was combination therapy (84.8%, n=123). In terms of the perceived severity of illness, 70.3% (n=102) considered it moderately severe. Finally, when as-sessing self-perceived health status, 61.4% (n=89) of participants rated their health as “good.”
The differences in general and clinical characteristics according to survival stage were as follows: Regarding general characteristics, significant differences were found in occupation status (x2=15.98, p<. 001) and religious status (x2=22.78, p=.001) across the survival stages. No substantial differences were observed in the other general characteristics. Regarding clinical characteristics, significant differences were found in cancer stage (x2=28.38, p<.001) and treatment modality (x2=11.41, p=.003). Additionally, significant differences were found in the perceived illness severity (F=13.64, p=.009) and perceived health status (F=33.42, p<.001).
2. Differences in Symptoms, Social Support, and Quality of Life Across Survival Stages of Participants
The results of comparing the differences in symptoms, social support, and quality of life across survival stages after adjusting for general and clinical characteristics as co-variates are presented in Table 2.
Quality of Life, Social Support, and Symptoms of Patients with Lung Cancer Across Survival Stages (N=145)
Regarding symptom severity, the acute survival stage exhibited the highest severity, followed by the extended survival stage, while the lasting survival stage exhibited the lowest severity (F=15.79, p<.001). Regarding the subdomains of symptom severity, patients in the acute survival stage reported the most severe symptoms including pain, fatigue, shortness of breath, drowsiness, and throat irritation. Patients in the extended survival stage reported symptoms at the next-highest level, whereas those in the lasting survival stage reported the lowest levels (p<.001). Nausea, distress, difficulty remembering, lack of appetite, vomiting, numbness/tingling, coughing, and constipation were more severe in the acute and extended survival stages than in the lasting survival stage (p<.001). However, disturbed sleep (F=1.23, p=.296, overall mean=5.63± 9.40) and sadness (F=1.31, p=.275, overall mean=5.38±7.22) did not show significant differences across the three groups. In terms of the level of symptom interference with life, patients in the extended survival stage experienced significantly higher levels of interference in daily life than those in the lasting survival stage (F=11.11, p<.001). Within the subdomains, patients in the acute and extended survival stages reported significantly higher interference with activities (F=7.84, p=.001) and mood (F=6.98, p=.001) than those in the lasting survival stage. Interestingly, in most areas such as work (including housework) (F=5.90, p= .003), relationships with other people (F=12.32, p<.001), walking (F=11.75, p<.001), and enjoyment of life (F=3.89, p=.023), patients in the extended survival stage scored higher than those in acute or lasting survival stages. These results indicated that the lasting survival stage had a significantly higher quality of life than both the acute and extended survival stages (F=5.05, p=.008). In terms of subdomains, physical (F=8.69, p<.001) and emotional status (F=7.83, p=.001) were significantly higher in the lasting survival stage than in the acute and extended survival stages. Social status was significantly higher in the acute than in the extended survival stage (F=6.27, p=.002). However, there were no statistically significant differences in functional or lung cancer status. Regarding social support, the extended survival stage had significantly lower support than the acute and lasting survival stages (F=10.03, p <.001). In the subdomains, family (F=9.72, p <.001), healthcare professionals (F=7.44, p=.001), and friend support (F=6.44, p=.002) were significantly lower in the extended survival stage than in the acute and lasting survival stages.
DISCUSSION
This study aimed to establish a foundation for stage-specific interventions by examining differences in symptoms, social support, and quality of life among patients with lung cancer at various survival stages. The results of this study show that quality of life was highest in the lasting survival stage, while symptom severity and interference were greatest in the acute and extended survival stages. Social support was lowest in the extended survival stage. The findings regarding the differences in symptoms, social support, and quality of life across these stages are discussed in the following sections.
First, a comparison of symptoms across different survival stages revealed that the severity of symptoms was highest in the acute survival stage, with a mean score of 5.44. This finding indicated that patients in the acute survival stage experienced the most intense symptoms. This finding aligns with previous research, which reported that symptoms tend to worsen and patients with lung cancer experience substantial distress during the active treatment phase [5-7,11]. However, Chae and Park [10] found no substantial differences in symptoms across survival stages, except for more severe late chemotherapy-related symptoms, such as numbness and tingling, in patients who had been diagnosed more than two years. This contrasts with the findings of the current study and can be explained by the differences in the study population. Specifically, Chae and Park [10] categorized survival stages based on a two- year cutoff, with most participants in the acute survival stage and very few in the lasting survival stage. Moreover, regarding the interference of symptoms with daily activities, the patients in the extended survival stage reported the highest levels of distress. This finding suggests that the burden of symptoms persists over time, similar to that observed during the acute survival stage. Although many patients in the extended survival stage return to daily life and work after treatment, they still experience various symptoms, including late complications, that substantially affect their quality of life [10,11]. These findings empha-size the importance of symptom management in patients with lung cancer, with considerable improvements in survival rates owing to advances in medical technology [2,28]. Patients in the acute and extended survival stages require ongoing care and support. These results suggest that interventions focused on improving the quality of life and facilitating better adaptation to daily living are essential for patients with lung cancer as they navigate life beyond survival.
Second, analysis of social support revealed that patients in the extended survival stage reported the lowest levels of social support in all areas. This finding suggests that after receiving intensive attention during the acute survival stage and active treatment, both medical and social support decline once the treatment ends, leaving patients with inadequate support [29]. This result is particularly substantial considering that the extended survival stage marks a critical period when patients transition from addressing immediate survival concerns in the acute stage to reinteg-rating into daily life after completing challenging treatment [30]. Many patients with lung cancer face difficulties in returning to their daily lives after treatment, as they continue to struggle with symptoms such as fatigue, shortness of breath, and weakness [11]. Moreover, the lasting fear of recurrence further threatens quality of life [29]. Social support plays a crucial role in alleviating fear and providing emotional stability [31]. Therefore, social support required for patients in the extended survival stage should extend beyond basic physical assistance. Emotional support from family and friends, as well as more comprehensive support, including peer support programs where cancer survivors can share experiences and emotions, and mental health programs focused on stress management and anxiety reduction, is vital. Such multifaceted support is essential to promote psychological and emotional well-being during this crucial stage.
Third, patients in the lasting survival stage had significantly higher quality of life scores than those in the acute and extended survival stages. Specifically, patients in the lasting survival stage exhibited significantly higher physical quality of life and emotional quality of life than those in the acute and extended survival stages. This finding suggests that after treatment, patients in the lasting survival stage experience a relative reduction in symptom burden and gain psychological stability. These results are consistent with those of previous studies indicating that symptom management leads to an improved quality of life [3,4]. In contrast, social quality of life was significantly higher in patients in the acute survival stage than in those in the extended survival stage (F=6.27, p=.002). This dif-ference could be attributed to the intensive treatment and support provided during the acute stages of survival. However, once treatment ends, such support diminishes, leading to difficulties for patients in the extended survival stage in returning to social activities owing to the absence of active medical management and fear of recurrence [29]. Therefore, patients in the extended survival stage require ongoing long-term management and support to improve their quality of life [28]. Psychological support and management of physical symptoms are crucial for improving the physical and emotional quality of life of patients during acute survival. In conclusion, stage-specific inter-ventions and continuous attention play critical roles in en-hancing the quality of life.
The findings of this study revealed that patients in the lasting survival stage exhibited the highest quality of life, whereas those in the extended survival stage experienced the lowest levels of social support and the highest symptom burden. These results highlight the need for tailored interventions based on the survival stages. In the lasting survival stage, continuous management and support are crucial for maintaining a stable post-treatment life and adapting to daily life. To address this need, we propose the development of a web-based program that can be easily accessed in daily life, offering integrated interventions to help enhance and sustain quality of life. However, for patients in the extended survival stage, psychological and emotional support is crucial to alleviate the fear of recurrence and reduce symptom burden. Therefore, the development of intervention programs to address these concerns is urgently required. Furthermore, given the substantial impact of symptoms on daily life, providing emotional stability through social support is important, and implementing appropriate interventions to facilitate this is necessary. We propose a program that utilizes online support groups to provide a platform for patients and their families to share their experiences and receive emotional support, with healthcare professionals participating regularly to offer psychological support. Additionally, the development of a mindfulness program aimed at reducing anxiety and stress in patients with extended survival stages of lung cancer is recommended [32]. Symptom cluster management and strategies to enhance treatment effectiveness are necessary for patients in acute survival stages. Considering the critical nature of the early treatment phase, adequate medical support and care must be provided to optimize outcomes. Therefore, we proposed the development of a web-based program for symptom monitoring and management that provides continuous and indivi-dualized care for patients in the acute survival stage of lung cancer. The program should include features, such as respiratory rehabilitation, pain management, and acute symptom management, which are tailored to each patient's specific needs.
This study provides valuable insights by comparing the symptoms, social support, and quality of life across different survival stages of patients with lung cancer. However, recruiting participants from an online lung cancer support group limits the generalizability of the findings. Additionally, as a cross-sectional study, it could not track changes over time, restricting its ability to identify stage-specific changes or establish causal relationships. Longitudinal studies are needed to overcome these limitations and offer a more comprehensive understanding of the survival stages in lung cancer.
CONCLUSION
This study compared differences in symptoms, social support, and quality of life across the acute, extended, and lasting survival stages of 145 patients with lung cancer. Patients in the acute survival stage experienced the most severe symptoms, whereas those in the extended survival stage faced the greatest challenges in daily life due to symptoms. Patients in the extended survival stage reported the lowest levels of social support and social quality of life. In contrast, the physical and emotional quality of life was lower in both the acute and extended survival stages than in the lasting survival stage. These results highlight the need for stage-specific interventions and management strategies. Based on these findings, interventions and social support programs tailored to each survival stage should be developed. Additionally, future longitudinal studies are essential to track changes over time and explore causal relationships.
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
AUTHORSHIP
Conceptualization - Heo J; Data curation - Heo J; Methodology - Heo J; Project administration - Heo J; Visualization - Heo J and Kim Y; Writing-Original draft - Heo J; Writing -review & editing - Heo J and Kim Y; Investigation - Heo J; Resources - Heo J and Kim Y; Formal analysis - Kim Y; Software - Kim Y; Supervision - Kim Y.
DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding author upon reasonable request.