Navigating Cancer: Mental Adjustment as Predictor of Somatic Symptoms in Romanian PatientsA Cross-Sectional Study

INTRODUCTION

The prevalence of cancer is increasing worldwide, with almost 18.1 million cases in 2020 and a rise of 28 million cases in 2040 [1]. Romania has a lower incidence of cancer related to EU mean value, but the mortality of this disease is higher, which reflects the overall weakness in the cancer approach in our country, Romania having among the highest oncological mortality rates in Europe [2,3]. Approximately 100,000 people are diagnosed with cancer in Romania every year, a number that could be even higher. In response, Romania approved a National Plan for Beating Cancer in 2022 to be implemented during 2023-2026. Addressing the cancer burden will require sustained efforts to improve cancer prevention, early diagnosis, treatment access, and cancer surveillance systems [4,5,6]. Key measures included in the country`s National Plan for Beating Cancer are integrated and present a multidisciplinary approach, health innovation fund, cancer registry, and data collection, clinical guidelines and protocols, and oncological experts’ boards. Among these last ones, a special place will be highlighted by the Psycho-oncological approach. Psycho-oncology is facing significant challenges, including major gaps in services and a critical shortage of specialized professionals, resulting in a nationwide deficit in Psycho-oncology care. However, the concepts of mental adjustment, psychological distress, and quality of life are very scarcely mentioned in local literature. Broader searches for Eastern Europe yielded limited similar results, indicating a general lack of research [7].

Patients with cancer may present more frequent anxiety, depressive symptoms, somatic symptoms, and overall psychological imbalance due to the perceived poor outcome and recurrence of the disease. Recent research has reinforced the link between psychological distress and an increased likelihood of mortality and worse survival outcomes [8]. Psychological distress in patients with cancer is defined as the psychological damage that impairs an individual’s ability to operate. This illness comprises a range of emotional and behavioral features arising from the diagnosis and prognosis uncertainty [9]. Prior studies have emphasized the importance of depressive disorders and extreme emotional response patterns as crucial elements in diminishing the quality of life of these patients. It is important to acknowledge the

interconnection between anxiety, sadness, and somatic symptoms in the context of cancer experience [10].

The cancer adjustment frame was developed by Watson and includes five adjustment mechanisms: fighting spirit, avoidance–denial, fatalism–stoic acceptance, helplessness–hopelessness, and anxiety [11]. Mental adjustment to cancer refers to the process of coping with emotional distress and restoring mental balance after a cancer diagnosis. It involves specific attitudes and strategies that patients use to adapt to the challenges of cancer and its treatment. Patients with a fighting spirit tend to have better quality of life and lower anxiety/depression compared to those with a helpless/hopeless attitude [12,13]. Maladaptive coping styles like helplessness/hopelessness are associated with a higher risk of mortality in some studies, although the evidence is not yet conclusive [12]. Factors like age, performance status, social support, and satisfaction with support can influence mental adjustment. Mental adjustment, economic status, perceived disease severity, and symptom severity directly affect the comprehensive quality of life outcome (CoQoLO) in terminally ill patients [12,13].

Somatic symptoms constitute about 50% of all general medical consultations, remaining prone to further investigations and bringing frustration to both patients and doctors in approximately one-third to one-half of cases. Both physiological and psychological variables seem to contribute to the reporting of somatic symptoms, especially in individuals with long-term medical conditions [14]. These symptoms are linked to significant limitations in functioning, disability, and utilization of healthcare services, even when considering other medical and mental conditions [14,15,16]. Research on the frequency of somatic symptoms in cancer has frequently concentrated on individuals with advanced stages of the disease or specific forms of cancer observed at specialized medical facilities [12,13,17,18]. Research revealed that a minimum of 30% of patients with cancer experience the following symptoms: fatigue and low energy, unspecified pain, loss of appetite, constipation, sleep disorders, and dizziness. The connection between psychological distress and reporting of somatic symptoms, also known as somatization, has only been examined in a limited number of small-scale research on cancer [15, 16,19,20]. This gap is significant since several studies in non-cancer medical populations have shown a high occurrence of somatic symptoms, even among symptoms that are regarded to be more specific to a particular disease. Moreover, the somatization concept refers to the expression of psychological distress through physical symptoms. Somatic symptoms, the term we chose to use throughout this paper, conversely denotes the way emotional stress can materialize as physical symptoms. A thorough comprehension of this matter is crucial to effectively address the psychological requirements of individuals with cancer, thereby enhancing their quality of life and their capacity to manage the illness [13,16,21]. Despite the recognized importance of mental adjustment on QoL and prognosis in cancer care [12], there is limited research focusing on the interplay between mental adjustment and somatic symptoms specifically.

This study aims to fill this gap by exploring the relationship between mental adjustment to cancer and somatic symptoms in patients with cancer. The findings could provide valuable insights for Psycho-oncology professionals enhancing supportive care strategies, ultimately improving patient outcomes and quality of life. The primary objectives of this study are to assess the levels of mental adjustment to cancer among Romanian patients, to measure the prevalence and severity of somatic symptoms, and to investigate their relationship with mental adjustment as being predicted by certain types of adaptive and maladaptive mechanisms. We hypothesize that maladaptive coping styles will predict somatic symptoms and their burden, while adaptive coping styles may represent protective factors in the onset and maintenance of somatic symptoms. This cross-sectional study involved a sample of Romanian patients, implementing validated psychological assessment tools to evaluate mental adjustment and somatic symptoms. Statistical analyses were conducted to explore correlations and identify significant predictors.

MATERIALS AND METHODS

Study design

This study employed a cross-sectional design to investigate the relationship between mental adjustment to cancer and somatic symptoms and their burden in Romanian cancer survivor outpatients.

Participants

A total of 88 patients with cancer were recruited from the cancer department of Elias University and Emergency Hospital in Bucharest, Romania, for one month, between May and June 2023. Inclusion criteria were: a confirmed diagnosis of cancer in the last three years, age 18 years or older, out-patients regularly monitored during their cancer treatment follow-up, and ability to understand and provide informed consent. Exclusion criteria included: severe cognitive impairment, DSM-5-TR diagnosis of a severe psychiatric disorder such as schizophrenia, depression or bipolar disorder currently or in the past based on information obtained from behavioral scales, a clinical psychiatric evaluation, and the Structured Clinical Interview for DSM Disorders [22]; diagnosis of neurological conditions (e.g., Parkinson’s disease, multiple sclerosis) that could affect cognitive or emotional processing, other genetic diseases or syndromes that might affect mental adjustment mechanisms or cognitive function.

Ethical approval

The study was approved by the Ethics Committee of the Elias University and Emergency Hospital of Bucharest, Romania (nr. 9286/2023). All participants provided written informed consent before participation.

Data Collection

Data were collected through structured interviews and self-administered questionnaires. The following tools were used:

Socio-demographic data- this section included information such as age, gender, education level, employment status, marital status, residence, income level, number of children, cancer stage, cancer location, chemotherapy, hormonal, surgery, and radiotherapy history.

Mini-Mental Adjustment to Cancer (Mini-MAC) – The questionnaire, designed by Watson[11], used the Romanian-translated version [23]. The mini-MAC questionnaire consists of 29 items, assessing different ways of coping with cancer: Anxiety- refers to fear concerning the disease without prior control which is anxiety-causing; Fighting spirit- refers to framing cancer as a challenge that may prone the patient to take action and fight it; Helplessness–hopelessness- refers to feelings of passivity and fatalism towards cancer leading to submission; Positive revaluation- refers to framing the life already lived in the light of satisfaction. Coping with cancer can be made within a constructive framing including fighting spirit and positive revaluation while anxiety and helplessness may represent a destructive pattern of coping. The items are rated on a scale of 1 to 4 representing variations of responses from „definitely not” to „definitely yes” which may offer results for each of the coping strategies from 7 to 28 points. The higher the score the more frequent and intense each mental adjustment mechanism is represented.

Somatic Symptoms Scale-8 (SSS-8)- The 8-item was developed after a version of the Patient Health Questionnaire-15 (PHQ-15) [24] and validated in the general population and Romanian population [25] as well as inpatient and outpatient settings, with SSS-8 not yet validated in Romanian language [26] to detect somatic symptoms burden. The level of the experienced somatic symptoms is scored from 0 meaning „not at all” until 4 which represents „very strongly”. The results are grouped into different categories with minimum, low, medium, and high groups containing symptoms such as pain in the arms, legs, or joints, gastric problems, insomnia, unspecified thoracal pain or trouble breathing, fatigue, or different ranges of headaches.

Somatic Symptom Disorder-12 (SSD-12)- this tool was first developed by Toussaint et al. [27] and focused on criterion B of the Somatic Symptom Disorder (SSD) diagnosis including subscales on cognition, affect, and behavior. 12 items are scored from 0 meaning „never” to 4 meaning „very often”. The scale was already validated in outpatient settings [28], and the Romanian version used, was previously translated and validated [19,29]. 18 score was chosen to screen for potential cases by the creators of the scale with studies still being concerned with the validity of cut-off points [30].

Procedures

Participants were approached during their routine medical visits and invited to participate in the study. Those who consented were given the questionnaires to complete on-site, with instructions for returning them. Structured interviews were conducted on-site by trained researchers and clinical psychologists to ensure consistency and accuracy in data collection and that the data collection processes did not interfere with the regular cancer follow-up procedure.

Statistical Analysis

Data were analyzed using JASP software [31]. In line with the explorative nature of our study, we first described the demographics of the study participants. The internal consistency of psychometric scales was assessed using Cronbach’s alpha coefficient, and all instruments had coefficients above 0.7, which is the minimum acceptable value for proper reliability. Descriptive statistics (means, standard deviations, frequencies) were used to summarize the demographic and clinical characteristics of the sample. Pearson correlation coefficients were calculated to examine the relationship between mental adjustment and somatization scores. Multiple regression analyses were conducted to identify significant predictors of somatic symptoms, controlling for potential confounders and considering standard p-value < 0.05

RESULTS

Psychometric scales reliability

All the psychometric tools used proved to be reliable. As confirmed in our analysis, a tool needs to have a Cronbach Alpha of at least 0.7 to be used. Moreover, SSS-8 presented values of 0.815, SSD-12 of 0.910, and Mini-MAC of 0.879, with all subscales also confirmed to be reliable.

Descriptive analysis

Socio-demographic data

Table 1 presents the socio-demographic characteristics of the participants. The most frequent age interval of the participants was 4150 years with over 70% being in the age interval of 41-60 years. The sample included 86 females (97.7%). 69,3% were married, over 68% graduated from at least one university, and 75% declared a good financial status. Concerning cancer, 82,5% had local cancer, and 71% presented breast cancer with various periods since surgery, from less than one year (20,4%) to over three years (36.6%). 79% declared chemotherapy intervention, while 64% declared radiotherapy, with over 90% presenting surgery history .

Psychometric scales scores

The scores for SSS-8 indicated moderate somatic symptoms burden (mean= 10.214, SD=5.903), while SSD-12 presented a mean of 16.753, close to the cut-off point of 18, considered for SSD screening [30]. Also, the behavioral aspect of SSD-12 presented a mean of

6.110 (SD=3.256). Concerning Mini-MAC subscales, we identified anxious preoccupation (mean=17.352; SD=4.857) and helplessness (mean=14.082; SD=4.198) among the highest-scoring mechanisms checked.

The missing data pertains specifically to the behavioral aspects subscale of the SSD-12, with approximately 17% of participants not completing this part of the scale. This indicates that the missing data is not spread across the entire SSD-12 scale but is confined to a particular subset. To address this, analyses related to the behavioral component were conducted on available data. This approach

minimizes data loss but may introduce bias if the missing data is systematic (e.g., patients with more severe symptoms avoiding completion). No imputation was used for the missing data, and as such, the findings should be interpreted with caution. Sensitivity analyses showed that the inclusion or exclusion of these cases did not substantially alter the overall findings of the study.

Correlation between all psychometric scales analysis

We found significant correlations between SSS-8 scores and overall SSD-12 score including affective and behavioral aspects subscales (r=0,63; r=0,57; p<.001), anxious preoccupation (r=0.328; p<.01), helplessness (r=0.354, p<.01) and significant negative correlations with fighting spirit (r=-0.299; p<.001). SSD-12 scores were significantly correlated with helplessness and anxious preoccupation (r=0.558, p<.001; r=0.578, p<.001) as seen in Table 3.

p < 0.05, p < 0.01, p < 0.001

Tables 3 and 4 show the contribution and significance of each predictor of MAC mechanisms to somatization as follows. Helplessness and anxious avoidance negatively predict somatization (t=2.520, p<.01; t=2.462, p<.01) while fighting spirit is moderator of the relationship between somatization (SSS-8) and its burden (SSD-12) (t= 0.157, p<.01) with low and medium values having a positive correlation which disappears at highest levels.

DISCUSSION

Our study showed that mental adjustment to cancer and somatic symptoms are significantly interrelated in patients with cancer. Specifically, only negative mechanisms such as anxious preoccupation and helplessness predicted somatic symptoms burden and not the positive ones, while fighting spirit moderated the relationship between somatic symptoms burden and their overall impact on a cognitive, affective and behavioral level, suggesting a potential protective factor in the relationship between SSS-8 and SSD-12.

Previous research has proved that psychological distress can exacerbate somatic symptoms in patients with cancer [32]. Also, somatic symptoms were highlighted to have mediating effects between psychological distress and quality of life in patients with cancer, while screened-positive SSD patients represented a significant predictor of lower quality of life (QOL) (B = −0.476, p < 0.00) [33]. Also, previous studies reported somatic symptoms as being risk factors for cancer patients’ prognosis using the same psychometric tool of SSD-12 but without an emphasis on mental adjustment mechanisms [34]. Moreover, research reported greater psychological adaptation and maturity in coping mechanisms are associated with lower levels of somatic symptoms and depression in patients with cancer [35]. Also, maladaptive emotional responses to cancer, characterized by strong associations between emotional and somatic symptoms, can lead to higher levels of somatization and poorer quality of life in patients with cancer [36]. To our knowledge, until now, no other study explored mental adjustment to cancer mechanisms in relationship with somatic symptoms and their burden.

Concerning specific mental adjustment to cancer mechanisms, previous research linked positive and negative affect to fatalism and fighting spirit with fighting spirit being negatively correlated to fatalism and negative affect [12,37], while another study highlighted anxious preoccupation as a predictor for significant decreases in all the domains of quality of life, with helplessness-hopelessness predictor for significant decreases in emotional and functional wellbeing domains [38].

We showed the strong association between helplessness and somatic symptoms suggesting that patients who feel more overwhelmed and powerless by their illness are more likely to report physical symptoms. Similarly, anxious preoccupation, characterized by excessive worry about the disease, may lead to heightened awareness and reporting of somatic symptoms. An interesting finding of our study relies on fighting spirit as an adaptive mechanism that moderates the relationship between somatic symptoms and overall impact on patients with low and medium values, having a positive correlation that disappears at the highest levels. This may explain fighting spirit as a protective factor in the relationship, an aspect worth considering in modern psycho-oncological approaches and in accordance with previous research on its link to positive affect [39]. The absence of significant effects for adaptive mechanisms in our sample may be attributed to the homogeneity of the sample, particularly regarding cancer type and stage, as well as potential measurement limitations of the Mini-MAC scale in capturing nuanced coping responses. These findings align with literature suggesting that adaptive mechanisms may exert more influence during acute or early-stage illness phases and less during chronic or long-term survivorship. However, our results contrast with studies reporting sustained benefits of fighting spirit over time. This discrepancy highlights the need for future research to explore these mechanisms in more diverse and heterogeneous patient populations and consider longitudinal designs to capture temporal changes in coping efficacy. Tailored interventions that account for individual patient contexts and preferences may be more beneficial than a one-size-fits-all approach focusing solely on adaptive mechanisms like fighting spirit [40].

Concerning somatic symptoms assessment, although the SSD-12 and SSS-8 have good reliability and validity, they cannot replace the diagnostic accuracy of a psychiatric interview. Our descriptive results obtained from this study for both SSD-8 and SSD-12 need to be interpreted appropriately. For many diagnoses, the DSM-5 requires that symptoms from SSD should not be the results of an underlying organic cause [41]. For patients with a medical condition such as cancer, this criterion is not realistic as symptoms may indeed be associated with both the underlying medical condition [42].

Somatic symptom identification in patients with cancer needs more attention to be paid to the psychological care of patients with physical symptoms. However, the observed relationship between mental adjustment mechanisms, such as fighting spirit, and somatic symptoms could be influenced by several confounding variables not fully controlled in our study. For instance, time since diagnosis may alter the effectiveness of coping strategies, with recently diagnosed individuals potentially exhibiting more distress and somatic symptomatology compared to long-term survivors who have developed adaptive coping mechanisms. Additionally, the type and intensity of treatment—particularly chemotherapy and radiotherapy—can exacerbate physical symptoms like fatigue and cognitive impairment complicating the assessment of psychological coping. Furthermore, the disease stage significantly impacts psychological well-being and symptom burden, with advanced stages often associated with higher levels of distress and lower fighting spirit. These

confounders could attenuate or amplify the observed relationships between mental adjustment and somatic symptoms, suggesting the need for future studies to incorporate these variables more comprehensively into their analytical models in order to disentangle their effects.

Therefore, it is necessary to conduct a comprehensive assessment of the patient`s psychological dimensions of the clinical presentation. Hence, we hope to present the phenomenon of somatic symptom prevalence as a consequence of poor mental adjustment mechanisms in patients with cancer, thus highlighting the need to consider this issue by both oncologists and psychiatrists [43,44].

Clinical Implications

Somatic symptoms can be as easily confusing as physical symptoms in this specific type of population, which results in both overmedication and insufficient psychosocial care. In our study, we demonstrated a significant correlation between somatic symptoms and maladaptive mental adjustment mechanisms, a finding that should warrant greater attention to this unique issue among patients with cancer. Identifying patients with high levels of helplessness and anxious preoccupation can help Psychooncologists target interventions to reduce it. Psycho-oncology programs focusing on enhancing coping skills and reducing anxiety may be beneficial in this regard for Romania and other countries as costs for invasive and time and financially resources consuming investigations may overwhelm an already limited and insufficiently developed multidisciplinary approach, which may lead to confusion and medical shopping among patients [3].

Limitations

Several limitations should be acknowledged. This was a cross-sectional study, which was unable to determine the causal relationship between mental adjustment mechanisms and somatic symptoms. We selected a single cancer department, including only one hospital from one area in the country, which may limit the generalizability of the findings considering the relatively small sample size. The patient population from this hospital may not be representative of the broader population of patients with cancer in other regions or countries considering factors such as regional healthcare practices, socioeconomic status, higher in Bucharest region, and cultural differences [2,45,46]. Also, the gender imbalance significantly limits the generalizability of the findings, especially for male cancer patients. Studies incorporating larger and more diverse cancer samples, as well as longitudinal studies, are recommended to further understand the relationship between previously described variables. In this study, a formal power analysis was not conducted prior to data collection. Given the complexity of the moderation analyses, particularly in examining the role of ‘fighting spirit,’ the current sample size of 88 participants may not provide sufficient power to detect small to medium interaction effects reliably. This limitation should be considered when interpreting the findings, as true moderating effects may not have been detected due to insufficient statistical power. Future research should aim to recruit larger samples and conduct a priori power analyses to ensure adequate power for detecting moderation effects. Many patients have more than one concomitant disease, especially advanced patients with cancer and those who have received or are undergoing conventional anticancer treatments. However, we collected information on all somatic symptoms but did not distinguish between symptoms derived from cancer, those derived from treatments and those that resulted from other illnesses. We would like to consider this issue in our future studies on somatic symptoms in cancer populations.

Future directions

Research on patients with cancer focusing on somatic symptoms is still scarce. Most of the studies remain in the stage of presenting descriptive outcomes. More research on the mechanism of somatic symptoms in cancer, whether it has a profound impact on quality of life or survivorship, how to identify it properly and in a timely manner, and which kind of psychosocial interventions would be more effective are necessary in the future. This is the first study to explore how mental adjustment to cancer may predict and moderate somatic symptoms and its burden in Romania and beyond. Future research should consider longitudinal designs to establish causal relationships between the described variables. Studies involving diverse cultural groups are also needed to explore the generalizability of these findings, considering the cultural aspect of somatic symptoms an important point to consider. Furthermore, investigating the effectiveness of psychological interventions in reducing maladaptive adjustment mechanisms would be a valuable contribution to the field of Psycho-Oncology .

CONCLUSION

In conclusion, this study highlights the significant relationship between mental adjustment mechanisms as predictors of somatic symptoms in patients with cancer. Considering the intricate nature of somatic symptoms and targeting through Psycho-oncologic interventions, helplessness, anxious avoidance, and fatalism while also exploring fighting spirit may help mitigate somatic symptoms and improve overall well-being in this population, leading to high-quality care for patients.

Conflicts of interest and sources of funding

The authors declare no conflict of interest.

Authors’ contribution

Conceptualization, M.L., C.G.I. and L.S.; methodology, L.S.; software, D.M.P.; validation, M.L.., O.V., and A.C.; formal analysis, D.M.P.; investigation, L.S.; resources, M.L.; data curation, C.G.I.; writing—original draft preparation, C.G.I.; writing—review and editing, M.L. and A.C.; visualization, O.V.; supervision, M.L.; project administration, L.S.; funding acquisition, M.L. All authors have read and agreed to the published version of the manuscript.

Acknowledgment

The current manuscript does not contain previously published materials or self-generated AI text.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Elias Emergency and University Hospital, Bucharest, Romania (nr. 9286/2023).

Patient consent for publication

Informed consent was obtained from all subjects involved in the study.

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