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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 112-124

Perceived stress in cancer patients: An integrative review

1 Department of nursing, NIMS Nursing College, NIMS University Rajasthan, Jaipur, India
2 Sher-i-Kashmir Institute of Medica Sciences, Soura Srinagar, Jammu and Kashmir, India

Date of Submission06-Jan-2021
Date of Decision10-Mar-2021
Date of Acceptance19-Apr-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Firdousa Jan
Bagi Mehtab, Government Housing Colony, House No. 34 Near Ahlihadees Masjid Railway Bridge
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iopn.iopn_4_21

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Cancer is disease that many people fear and despise. Cancer is associated with significant psychological and social morbidity. As a result of the disease, cancer patients can experience physical, emotional, and social stress. One of the key factors linked to cancer initiation, development, and metastasis is perceived stress. The aim of this integrative analysis is to assess the literature on cancer patients' perceptions of stress, its relationship to cancer, and health problems associated with perceived stress in cancer patients. A search of Pub Med, CINAHL, Psycho Data, Springer science direct, and the descriptors level of perceived stress and cancer patients between 2000 and 2020 yielded 24 studies that met the review criteria. The following were the examination questions: (1) What is the relationship between perceived stress and cancer? (2) What health issues are associated with perceived stress in cancer patients? Findings support the prevalence of perceived stress in many cancer patients, as well as its connection to other health concerns. Patients' perceptions of stress are linked to cancer, and their general health is affected. It is critical for nurses to measure perceived stress, recognize stressors, and their effect on cancer patients' health and quality of life. Not only oncology nurses, but also all nurses, will benefit from a better understanding of how patients with various forms of cancer experience stress.

Keywords: Cancer, health, oncology, patient, perceived, stress

How to cite this article:
Jan F, Singh M, Nisar S. Perceived stress in cancer patients: An integrative review. Indian J Psy Nsg 2021;18:112-24

How to cite this URL:
Jan F, Singh M, Nisar S. Perceived stress in cancer patients: An integrative review. Indian J Psy Nsg [serial online] 2021 [cited 2022 Aug 15];18:112-24. Available from: https://www.ijpn.in/text.asp?2021/18/2/112/332799

  Introduction and Background Top

The human body is made up of millions of cells that divide, develop, and die in the usual manner. As the system malfunctions, an uncontrolled number of cells develops, resulting in cancer. Cancer cells combine and form extra mass tissue known as tumor that invades and destroys normal adjacent tissues.[1]

There are over 200 different forms of cancers, some of which are much more prevalent than others around the world, such as lung and breast cancer (12.3% of total cases each), colorectal cancer (10.6%), (prostate cancer 7.5%), and stomach cancer (6.1%)[2] (International Statistics Fund for World Cancer Research).

Cancer is the world's leading cause of disease. In 2012, there were an estimated 14.1 million new cancer cases worldwide, with 7.4 million (53%) males and 6.7 million (47%) females, resulting in a male-to-female ratio of 10:9. 1 According to the World Age-Standardised (AS) incidence rate, there are 205 new cancer cases for every 100,000 men and 165 for every 100,000 women in the world.[3]

India has around 2.25 million cases, with more than one lack of new cases recorded every year. In 2018, the disease caused nearly seven deaths. As depicted in [Figure 1], In India among combined sexes most commonly observed cancer is breast cancer (14.1%) followed by cancer of lip and oral cavity(10.40%),cervix uteri (8.4%), lung (5.9%), and stomach (5%).[40] It has been estimated that more than 1.7 million new cases are likely to be recorded and more than 0.8 million deaths reported by 2020 (ICMR).[2]
Figure 1: New cases in 2018 both sexes of all ages

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Kashmir is a landlocked geographical entity located at a very high altitude, with a multiethnic Muslim majority population with unique cultural practices. It has traditionally been considered an endemic cancer zone with a peculiar cancer profile. One study found that CA esophagus (14.11%) was the most common cancer in Kashmir in both sexes.[4]

Since there is a scarcity of statistical data on cancers in Jammu and Kashmir, the researcher was only able to include a few research studies in this study. Among males in Kashmir, stomach cancer is the most frequently identified cancer (25.2%), followed by colorectal cancer (16.4%) and lung cancer (13.2%). Colorectal cancer (16.8%), breast cancer (16.1%), and stomach cancer (10.4%) were the most commonly identified cancers among females in order of incidence. Tobacco-related cancers have contributed to more than three-fourths of male cancers and more than half of female cancers.[5]

In a recent retrospective review study of Jammu and Kashmir, the overall incidence of cancer has increased, stomach-related cancers are 24.4%, lung 23.6%, esophagus and GE 13.7%, colorectal 8.9%, lymphoma 26.5%, ovarian 4.1%, breast 3.7%, and gallbladder 2.1%.[6]

Stress can be described as a person's reaction to any change that necessitates a response or adjustment, whether physical, mental, or emotional.[7] Perceived stress is the feelings or thoughts that an individual has about how much stress they are under at a given point in time or over a given period of time. Feelings about the unpredictability and uncontrollability of one's life, how much one has to deal with frustrating hassles, how much change is happening in one's life, and faith in one's ability to deal with problems or difficulties are all part of perceived stress. It is not measuring the types or frequencies of stressful events which have happened to a person, but rather how an individual feels about the general stressfulness of their life and their ability to handle such stress.[8]

  Methods Top

Review questions

The aim of this study is to assess the clinical literature on cancer patients' perceptions of stress. The following are the review questions:

  1. What is the relationship between perceived stress and cancer?
  2. What health issues are associated with perceived stress in cancer patients?

Search criteria

Patients (18 years and older) who have been diagnosed with some form of cancer and are seeking some treatment are the target demographic. Full-text articles published in the last 20 years (2000–2020) and in English are also needed. Perceived stress is the primary outcome measure of interest. This analysis considers randomized controlled trials, nonrandomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case–control studies, and analytical cross-sectional studies, as well as experimental and epidemiological research designs.

Search strategy

A systematic review quest was conducted using PubMed, CINAHL, PsycINFO, Science Direct, and Springer. The papers' titles, abstracts, and keywords were reviewed for relevance to the inclusion criteria. The following keyword combinations were used in the quest. Stress perception, stress assessment, and the connection between stress and cancer. An instrument was used to collect data on the publication (main authors and year of publication), study intent, methodological characteristics (design, sample, and instruments), and findings with conclusions on perceived stress and related health issues.

  Results Top

We chose 24 studies for analysis after a preliminary search yielded 210 papers, as shown in [Figure 2]. We retrieved 24 articles that met the inclusion requirements as illustrated in [Table 1] from the 210 articles contained in the databases searched.
Figure 2: PRISMA flow diagram showing the Study selection process and results Perceived stress and cancer

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Table 1: Summary of research on perceived stress and associated health issues in cancer patients

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Characteristics of articles

Six of the 24 articles included in the study were cross sectional, 4 were observational, 3 were descriptive comparative, 2 were correlational, 2 were longitudinal, 1 was a randomized control trial, 2 were prospective, 1 was retrospective, 1 was a cohort, 1 was an experiment, and 1 was a survey. Over the past few years, a number of journals have published papers on cancer patients' perceived stress. The largest number of articles was found in the Psycho-Oncology Journal and the Support Care Cancer, each with three articles. Several international oncology journals including the European Journal of oncology nursing and Journal of Geriatric Oncology, as well as more general publications in the Indian Journal of Palliative Psychology, published papers. Two papers were published in 2002, one in 2005, two in 2012, one in 2013, one in 2015, two in 2016, five in 2017, three in 2018, five in 2019, and two in 2020. Perceived stress scale (PSS) was the most popular data collection instrument.

What is the relationship between perceived stress and cancer?

In all 24 studies included in this study, cancer patients reported high levels of perceived stress at different stages of their treatment. [Table 1] presents a summary of the results.

The PSS revealed that 60%–70% of patients had a high degree of stress. As compared to the general population, cancer patients had a 70% higher prevalence of perceived stress. 75.7% recorded moderate to high perceived stress, with depression at 49.2% and anxiety at 26.5% as possible causes for concern.[22]

The correlation between stress and carcinogenesis is evident because stress has been suggested to be able to alter the DNA repair mechanism. In one study, the levels of an essential DNA repair enzyme methyl transferase were significantly reduced in stressed animals after exposure to the carcinogen dimethylnitrosamine.

Low concentrations of carcinogenic agents12-0-tetradeconoyl-phorbol-13-acetate, according to Tomei LD et al., explicitly block apoptosis in peripheral blood lymphocytes in response to ionizing radiation. As a result, stress can cause changes in apoptosis in the body, resulting in abnormal DNA levels in the cells that survive, increasing the risk of cancer growth.[31] Stress has been linked to the development of tumors. Chronic stress has been linked to tumor growth in a variety of cancers in both clinical and laboratory studies. The main hypothalamic mediator of stress is corticotrophin release factor.[32] Cancer patients showed higher perceived stress and psycho neuroimmune (PNI) symptoms such as memory issues and fatigue, according to Gilbertson et al. As a clinical indicator of PNI symptoms, perceived stress outperformed cytokine genotypes.[25] For decades, researchers have studied the connection between stress and the immune system. Psychosocial factors have been linked to changes in the cellular immune response, not only in the peripheral blood but also in tumors. The existence of stress factors in the tumor microenvironment is supported by these findings.[33] By suppressing the immune system, severe stress can lead to cancer. Stress may also reduce the function of cytotoxic T lymphocytes and natural killer cells, which can contribute to malignant cell formation, genetic instability, and tumor expansion.[34]

What health issues are associated with perceived stress in cancer patients?

All 24 studies found that a moderate-to-serious level of anxiety is linked to a variety of health problems, including severe fatigue, fear, depression, anxiety, pain, and a lower overall quality of life. One research found a significant connection between fatigue and stress. Kang et al. found that a high level of stress was associated with high level of mood disturbance, which was linked to a high level of symptom perception, a poor quality of life, and an immune profile of high neutrophils and low lymphocytes.[12] High perceived stress 1.65; 95% <1000 kcal of physical activity per week 2.17; and high consumption of fried and stir-fried food 1.86 were all found to be positively correlated with breast cancer in one study. Breast cancer was associated with the combination of high perceived stress and daily alcohol consumption of 11.0 g or more per day 3.18.[13] Mazor et al. discovered a connection between severity and stress and 32 symptoms, with an average of symptoms of 9.1 (5.2). Stress was found to be higher and related to a higher symptom burden, accounting for 45.6% of symptom burden variation. A large number of cooccurring symptoms of moderate severity and distress have been reported.[27] In comparison to cancer survivors, patients with cancer experienced maladaptive coping and psychological distress, resulting in a lower quality of life.[24] In another randomized placebo clinical trial, psychological tension was found to worsen the incidence of skin reactions in breast cancer patients. Twenty patients (26%) of the 78 patients in the study were considered depressed. Stressed patients had twice the severity of skin reactions as nonstressed patients (P = 0.001), and they were five times more likely to experience moist desquamation. According to a study done by Sutherland et al., psychological stress worsens the incidence of skin reactions during radiation therapy.[17] Social constraints were linked to higher perceived stress (r = 0.32, P =0.002) and lower sleep quality (r = 0.33, P = 0.001) in one observational study. Sleep quality was correlated with perceived tension (r = 0.47, P = 0.001). Social constraints had a major indirect impact on poor sleep quality (as measured by the Pittsburgh Sleep Quality Index [PSQI]) through perceived stress (=0.20; 95% confidence intervals [CIs)] = 0.06, 0.40). After accounting for perceived stress as a mediator, the path coefficient for the direct impact of social constraints on PSQI fell from = 0.32 (95% CI = 0.11, 0.51) to = 0.13 (95% CI = −0.12, 0.35), indicating a mediation effect.[18] In a Cox regression study with possible confounders, Kikuchi et al. found an important connection between perceived stress and rectal cancer incidence.[19] Psychosocial factors linked to stress play a role in cancer incidence and survival. In a study of 165 studies, Chida et al. found that stress-related psychosocial factors are linked to a higher cancer incidence in initially healthy populations (P = 0.005), as well as lower survival in patients with diagnosed cancer in 330 studies (P = 0.001) and higher cancer mortality in 53 studies (P = 0.001).[35] Chronic stress not only exacerbates the progression of illness, but also it also causes psychological issues in cancer patients. The Depression Scale, Zung Self-Rating Anxiety Scale, Resilience Scale-14, and PSS-10 were used in a study of Chinese bladder and renal cancer patients to look into the links between psychological stress and depressive and anxiety symptoms. Depressive and anxiety symptoms were found to be present in 78.0% and 71.3% of bladder cancer patients, respectively, and 77.6% and 68.3% of renal cancer patients, according to the report. Psychological stress was discovered to be associated with depressive and anxiety symptoms.[16]

  Discussion Top

The findings of the analysis revealed the unappreciated stress disorders in cancer, as well as the connection between stress and other symptoms such as depression, anxiety, hopelessness, and poor sleep quality. Furthermore, the high prevalence of perceived stress and low quality of life is reliably reported in these 24 studies. We suggest using tools like the PSS for assessing perceived stress in cancer patients to start addressing this critical patient care problem. 3.4% of patients in one longitudinal study had mild-to-moderate cancer-related posttraumatic stress disorder (PTSD). At the first assessment, 18.5% of people had PTSD, and 16.3% had it at the second. According to the findings, cancer patients experience more stress, which has an affects their quality of life.[9] The most commonly used psychological tool for assessing stress experience is the PSS.[36] This scale has been widely used in cancer studies. The PSS was factored in 111 women who had breast cancer surgery in a first study using exploratory factor analysis. This model was provided along with some observations on the use of the measure in cancer research.

The PSS will provide clinical information on the extent to which cancer patients view their lives as stressful in general. The measure has the ability to recognize the role of perceived stress in important cancer outcomes such as patient quality of life and adherence to care when used in the form of a stress model.[37] Latest studies also emphasized the importance of cancer-related symptoms as a focus for nursing research. In caring for people who have been diagnosed with cancer, knowledge of symptoms, their associations, and their effect on patient prognosis is essential. According to the findings of this study, nurses should actively assess for the occurrence of multiple symptoms, with the expectation that treatment of these symptoms can have an effect on overall health outcomes. In addition, the emphasis of treatment should be on symptom interactions and their relationship to quality of life. Oncology nurses must abandon the obsolete method of treating stress, pain, exhaustion, depression, or poor sleep quality as separate symptoms by identifying and treating these associated health issues simultaneously. Nurses may use tools such as PSS to measure cancer patients' perceived tension. Perceived stress is faced by cancer patients, according to the studies in this study. Nurses must assess their current stress in order to choose and execute strategies that will enhance their quality of life. Chronic stress has been shown to hasten the development of cancer. Intervention trials are widely recommended, and the authors concluded that cognitive therapies such as cognitive behavioral therapy and directed visualization can be an effective therapy for stress relief. In one study, directed visualization was found to be an effective treatment for thyroid cancer patients who were stressed and tired. In the experimental group, there were substantial reductions in stress (F = 28.45, P = 0.001) and exhaustion (F = 26.17, P = 0.001) over time as compared to the control group.[38] In another study, as compared to controls, the intervention group showed a substantial reduction in depression (4.57 2.94 vs. 7.25 4.25), anxiety (5.83 3.07 vs. 8.66 4.92), and stress (7.51 4.33 vs. 11.17 4.25) scores (P. 05 for all).[39] It is important to remember, however, that patients frequently pay little attention to perceived stress, dismissing it as a "natural" side effect of treatment. Despite having the most up-to-date information on the subject, many nurses fail to recognize and treat their patients' illnesses. In cancer patients, untreated stress can lead to chronic health conditions that last long after the disease has been treated.


There was a chance that this overview missed any important articles. Future research is needed to learn more about the links between stress-related disorders and cancer.

Practical implications

Any type of cancer patient requires nurses to determine their level of perceived stress. This evaluation can take place at many main points in the cancer treatment process, including the initial consultation before diagnosis, the diagnosis, treatment, treatment completion, and follow-up. We recommend the use of validated screening tools such as the PSS. Furthermore, we recommend that nurses increase their knowledge of normal and chronic stress to identify stress-related issues, counsel their patients, and refer for further evaluation and management. Through regular assessment of stress, they can improve the quality of life of cancer patients.

  Conclusions Top

The increased occurrence of various types of cancers, as well as the high prevalence of perceived stress, necessitates this study. In today's society, psychological stress has become a chronic and pervasive disorder. When we are emotionally challenged by perceived challenges, we experience stress. Perceived stress is a significant contributor to a wide range of mental and physical disorders including cancer. According to this study, there is a clear connection between stress and carcinogenesis. Stress appears to play a role in cancer development rather than cancer initiation, according to the data. There is a correlation between stress and various biological mechanisms, according to experimental studies. Through psychosocial influences on immune functions, psychological factors can affect the incidence or progression of cancer. The authors of this study concluded that the level of stress experienced by cancer patients should be measured before, during, and after diagnosis. Since the mind and body are connected, when a patient's physical well-being is given priority, his mental health should not be neglected. Early warning signs of psychological issues must be handled. Many studies have shown that combining medical and psychological therapies (psychoeducation, calming technique-guided visualization, and cognitive therapy) decreased stress and increased cancer patients' quality of life, as a result of patients Psychological treatments such as stress management through relaxation strategies and social support should be prepared for these patients because they can improve survival among cancer patients and deserve further investigation, especially in the treatment of cancers linked to stress and depression.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]


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