Correlation of anxiety and depression with mindfulness in esophageal cancer patients undergoing esophagectomy and analysis of risk factors

Abstract

BACKGROUND

Anxiety complicates recovery in esophagectomy patients undergoing esophagectomy, while preoperative depressive symptoms may further delay surgery-associated malnutrition resolution, highlighting a critical need for psychological intervention.

AIM

To explore the correlation of anxiety and depression with mindfulness levels in patients undergoing esophagectomy for esophageal cancer and analyze associated risk factors.

METHODS

A total of 120 patients with esophageal cancer, all of whom underwent esophagectomy in The Affiliated Yongchuan Hospital of Chongqing Medical University between September 2022 and September 2024, were enrolled. The hospital anxiety and depression scale (HADS) was utilized to evaluate the anxiety (HADS-anxiety subscale, HADS-A) and depression (HADS-depression subscale, HADS-D) levels of these patients, and the Mindful Attention Awareness Scale (MAAS) was employed to assess their mindfulness levels. The relationships among anxiety, depression, and mindfulness levels were analyzed, and both univariate and multivariate analyses were conducted to identify the risk factors for anxiety and depression in these patients.

RESULTS

Data revealed that the mean HADS-A score of patients undergoing esophagectomy was (10.43 ± 4.24) points, and 40.00%, 35.00%, and 10.83% of the patients had mild, moderate, and severe anxiety, respectively. The mean HADS-D score was (9.20 ± 4.66) points, and 37.50%, 23.33%, and 9.17% of the patients had mild, moderate, and severe depression, respectively. Patients with negative or mild anxiety (or depression) exhibited significantly higher MAAS scores than those with moderate or severe anxiety (or depression). The HADS-A and HADS-D scores showed a strong and negative correlation with the MAAS score. Univariate and multivariate analyses demonstrated that sex (P = 0.006), age (P = 0.017), per capita monthly household income (P = 0.005), and educational level (P = 0.004) were all independently associated with the exacerbation of anxiety in patients undergoing esophagectomy. Age (P = 0.026), living status (P = 0.005), per capita monthly household income (P = 0.024), educational level (P = 0.002), and postoperative complications (P < 0.001) were all independently related to the aggravation of depression in such patients.

CONCLUSION

This study indicated a significant negative correlation among anxiety, depression, and mindfulness levels in patients undergoing esophagectomy. Sex, age, per capita monthly household income, and educational level were risk factors for anxiety in patients undergoing esophagectomy, whereas age, living status, per capita monthly household income, educational level, and postoperative complications were risk factors for depression.

Key Words: Esophagectomy; Anxiety; Depression; Mindfulness level; Risk factors

Core Tip: Studies investigating the associations among anxiety, depression, and mindfulness in patients undergoing esophagectomy remains scarce. In this study of 120 patients who underwent esophagectomy, moderate anxiety and mild depression were prevalent, both inversely correlated with mindfulness. Mindfulness-based interventions may help in alleviating psychological distress. Female sex and higher educational attainment (≥ high school) were found to increase anxiety risk, whereas depression was linked to solitary living, higher education, and postoperative complications. Conversely, older age and high per capita monthly household income conferred protection against anxiety and depression in these patients.

INTRODUCTION

Esophageal cancer (EC) is one of the malignant tumors in the digestive tract with a suboptimal prognosis, with a 5-year survival rate of merely approximately 20%[1]. Statistically, it ranks as the eighth most prevalent tumor and the sixth most lethal tumor globally[2]. Esophagectomy serves as the principal radical treatment approach for patients with EC, which can effectively ameliorate the clinical outcomes of those in the early and intermediate stages[3,4]. However, this surgical procedure imposes significant surgical stress on patients, leading to adverse psychological conditions such as anxiety and depression, and brings a relatively high risk of postoperative morbidity and mortality, which is detrimental to the health-related quality of life of the patients[5,6]. The effect of anxiety and depression, as common psychological disorders among patients with EC, on patients’ physical and mental well-being may be underestimated[7]. These two negative emotions can exert a detrimental effect on multiple facets, including the treatment efficacy, treatment compliance, prognosis, and quality of life of patients with EC[8]. For instance, Coffey et al[9] elucidated that anxiety in patients undergoing esophagectomy was unfavorable for their smooth convalescence and would markedly prolong their postoperative hospital stay. Nakamura et al[10] also reported that preoperative depressive mood in patients undergoing esophagectomy might impede recovery from surgery-related malnutrition. Additionally, a study revealed that female patients with EC exhibited a higher risk of anxiety than their male counterparts, and patients with restricted activity status had a greater propensity for depression, suggesting that female patients and those with activity limitations were in greater need of psychological support[11]. Conversely, mindfulness, as a positive psychological state, empowers individuals to confront stressful events with a more positive and optimistic attitude, enabling them to divert attention from stressors, reinterpret given events, and ascribe positive connotations thereto[12,13]. Previous studies have consistently demonstrated that mindfulness intervention is efficacious in enhancing the psychological well-being and sleep quality of patients with lung cancer. Moreover, for patients with early-stage breast cancer, it mitigates anxiety and depression, thereby facilitating the cultivation of a positive mindset[14,15]. Considering the limited research on the correlation between anxiety, depression, and mindfulness levels among patients with EC undergoing esophagectomy, as well as the dearth of comprehensive analyses of the associated risk factors, this study undertook a pertinent exploration. The overarching objective was to discover the relationships among anxiety, depression, and mindfulness in patients undergoing esophagectomy for EC. Additionally, it endeavors to determine the factors that influence anxiety and depression in this patient cohort to contribute as much as possible to the psychological guidance and improvement of the clinical outcomes of such patients.

MATERIALS AND METHODS

General information

This study was conducted with formal approval from the hospital ethics committee. Complete data anonymization procedures were implemented, maintaining full compliance with the ethical standards of the Declaration of Helsinki. Patients who underwent esophagectomy for EC in the Affiliated Yongchuan Hospital of Chongqing Medical University between September 2022 and September 2024 were selected. The inclusion criteria were as follows: All patients were definitively diagnosed with EC via gastroscopic biopsy and pathological examination. Preoperative evaluation by computed tomography of the chest demonstrated the feasibility of radical resection for EC. Moreover, all patients were receiving treatment for the first instance, with clear consciousness and cognitive abilities, and could fully comprehend the content of the relevant scales. Exclusion criteria were as follows: (1) Those with a severe allergic history to anesthetic agents; (2) Individuals whose prothrombin time > 15 seconds; (3) Patients who had recently participated in psychological research studies; (4) Persons afflicted with severe cardiovascular, pulmonary, cerebral, or renal insufficiency; (5) Participants with drug or alcohol addiction; (6) Those with poor compliance and uncooperative with the research team; and (7) Women in the gestational or lactational period.

Outcome measures

Anxiety and depression assessment: The hospital anxiety and depression scale (HADS) was adopted, and its anxiety subscale score (HADS-A) and depression subscale score (HADS-D) were respectively employed to quantitatively evaluate patients’ anxiety and depressive emotional states. This scale is composed of 14 items and employs the Likert 4-point scoring regime, wherein scores range from 0 to 3 points. Among these items, seven are specifically designed for anxiety evaluation, whereas the remaining seven are dedicated to depression assessment. For the anxiety and depression subscales, the score classification is as follows: Score ranges of 0-7, 8-10, 11-14, and 15-21 points are designated as negative, mild, moderate, and severe, respectively. The excellent reliability indices (Cronbach’s α = 0.943; test-retest r = 0.867) confirm the scale’s measurement stability.

Mindfulness level evaluation: The Mindful Attention Awareness Scale (MAAS) was utilized to gauge the extent of an individual’s attentiveness to current events. It includes 15 items and adopts a 6-point scoring system. Each item has a score range of 1-6 points, and the overall total score spans from 15 to 90 points. Notably, a higher total score reflects a superior level of the patient’s mindfulness awareness. MAAS achieved high-reliability coefficients, including a Cronbach’s α coefficient of 0.890 and test-retest reliability of 0.870.

Statistical analysis

IBM SPSS Statistics version 22.0 was adopted for comprehensive data analysis. The mean ± SEM was utilized as the means of statistical summarization. The independent-samples t-test was implemented when comparing two sets of measurement data, whereas the paired-samples t-test was employed when comparing data before and after a particular treatment regimen. The frequency (expressed as a percentage) served as the descriptive statistic for count data. The χ² test was conducted to assess the differences between two sets of count data. The Pearson correlation coefficient was strategically employed to determine the relationships among depressive symptomatology, anxiety manifestations, and level of mindfulness. Through binary logistic regression analysis, a comprehensive multifactor analysis was conducted to identify the potential risk factors that could lead to the exacerbation of anxiety or depression in patients. Statistically, a difference was significant when the P value was < 0.05.

RESULTS

Anxiety and depression levels in patients with EC undergoing esophagectomy

According to the HADS-A scores, among the 120 patients who underwent esophagectomy for EC, 40.00%, 35.00%, and 10.83% of the patients had mild, moderate, and severe anxiety, respectively. The mean score was documented as 10.43 ± 4.24. As regards the HADS-D results, 37.50%, 23.33%, and 9.17% of among identical 120 patients had mild, moderate, and severe depression, respectively, with an average score of 9.20 ± 4.66 (Table 1).

Table 1 Anxiety and depression levels of patients undergoing esophagectomy for esophageal cancer, mean ± SEM/n (%).

Indicators	Negative	Mild	Moderate	Severe
HADS-A	17 (14.17)	48 (40.00)	42 (35.00)	13 (10.83)
	10.43 ± 4.24
HADS-D	36 (30.00)	45 (37.50)	28 (23.33)	11 (9.17)
	9.20 ± 4.66

HADS-A: Hospital anxiety and depression scale-anxiety; HADS-D: Hospital anxiety and depression scale-depression.

Relationship among depression, anxiety, and mindfulness in patients with EC undergoing esophagectomy

The correlation between depression, anxiety, and mindfulness levels in patients undergoing esophagectomy for EC was analyzed. Specifically, 65 patients had negative or mild anxiety, whereas 55 had moderate to severe anxiety. Notably, the MAAS scores of those with negative or mild anxiety were significantly higher than the scores of their counterparts with moderate to severe anxiety (P < 0.05). In addition, 81 patients had negative or mild depression, whereas 39 had moderate to severe depression. Additionally, the MAAS scores of patients with negative or mild depression surpassed those of patients with moderate to severe depression, also with a significant difference (P < 0.05; Table 2).

Table 2 Relationship between depression, anxiety, and mindfulness levels in patients undergoing esophagectomy for esophageal cancer, mean ± SEM.

Indicators	MAAS	t	P value
Negative or mild anxiety (n = 65)	55.43 ± 5.61	3.084	0.003
Moderate to severe anxiety (n = 55)	52.47 ± 4.76
Negative or mild depression (n = 81)	55.99 ± 5.43	2.599	0.011
Moderate to severe depression (n = 39)	53.33 ± 4.85

MAAS: Mindful Attention Awareness Scale.

Correlation between anxiety, depression, and mindfulness in patients with EC undergoing esophagectomy

The Pearson correlation coefficient was employed to explore the associations of anxiety and depression with mindfulness in patients who had undergone esophagectomy for EC. The obtained data clearly indicated a highly significant inverse correlation between the HADS-A and MAAS scores of these patients (r = -0.360, P < 0.001). Likewise, when examining the connection between the HADS-D and MAAS scores, an equally remarkable negative correlation was unveiled (r = -0.404, P < 0.001). A visual illustration is provided in Figure 1.

Figure 1 Correlation between anxiety, depression, and mindfulness in patients undergoing esophagectomy for esophageal cancer. A: Correlation between anxiety and mindfulness in patients undergoing esophagectomy for esophageal cancer; B: Correlation between depression and mindfulness in patients undergoing esophagectomy for esophageal cancer. HADS-A: Hospital anxiety and depression scale-anxiety; HADS-D: Hospital anxiety and depression scale-depression; MAAS: Mindful Attention Awareness Scale.

Univariate and multivariate analyses of factors influencing anxiety in patients with EC undergoing esophagectomy

Univariate analysis was initially conducted to comprehensively understand the determinants underlying anxiety in patients undergoing esophagectomy for EC. The findings demonstrated that sex, age, employment status, monthly per capita household income, educational level, and postoperative complications exhibited a close correlation with the exacerbation of anxiety among these patients (P < 0.05). Subsequently, a more in-depth multivariate analysis was implemented to further identify the factors that manifested significant differences. The results revealed that sex (P = 0.006), age (P = 0.017), monthly per capita family income (P = 0.005), and educational level (P = 0.004) were all independent and significant factors that correlated with the intensification of anxiety in patients with EC undergoing esophagectomy (Tables 3 and 4).

Table 3 Univariate analysis of factors influencing anxiety in patients undergoing esophagectomy for esophageal cancer, n (%).

Indicators	n	Negative or mild anxiety (n = 65)	Moderate to severe anxiety (n = 55)	χ2	P value
Sex				4.062	0.044
Male	60	38 (58.46)	22 (40.00)
Female	60	27 (41.54)	33 (60.00)
Age, years				5.582	0.018
< 60	69	31 (47.69)	38 (69.09)
≥ 60	51	34 (52.31)	17 (30.91)
Living arrangement				0.123	0.725
Cohabitation	59	31 (47.69)	28 (50.91)
Solitude	61	34 (52.31)	27 (49.09)
Employment status				4.435	0.035
Unemployed	67	42 (64.62)	25 (45.45)
Employed	53	23 (35.38)	30 (54.55)
Medical conditions				2.719	0.099
Convenient	60	37 (56.92)	23 (41.82)
Inconvenient	60	28 (43.08)	32 (58.18)
Per capita monthly household income				7.633	0.022
< 3000	76	34 (52.31)	42 (76.36)
3000-5000	28	19 (29.23)	9 (16.36)
> 5000	16	12 (18.46)	4 (7.27)
Educational level				5.245	0.022
Below senior high school	96	57 (87.69)	39 (70.91)
Senior high school or above	24	8 (12.31)	16 (29.09)
Smoking history				0.012	0.911
Without	43	23 (35.38)	20 (36.36)
With	77	42 (64.62)	35 (63.64)
Alcohol consumption history				2.937	0.087
Without	56	35 (53.85)	21 (38.18)
With	64	30 (46.15)	34 (61.82)
Postoperative complications				5.009	0.025
Without	92	55 (84.62)	37 (67.27)
With	28	10 (15.38)	18 (32.73)

Table 4 Multivariate analysis of factors influencing anxiety in patients undergoing esophagectomy for esophageal cancer.

Variable	β	SE	Wald	P value	Exp (β)	95%CI
Sex	1.279	0.466	7.526	0.006	3.595	1.441-8.966
Age, years	-1.097	0.460	5.697	0.017	0.334	0.136-0.822
Employment status	0.867	0.452	3.676	0.055	2.380	0.981-5.775
Per capita monthly household income	-0.917	0.327	7.859	0.005	0.400	0.211-0.759
Educational level	1.779	0.610	8.506	0.004	5.926	1.792-19.595
Postoperative complications	1.006	0.519	3.762	0.052	2.735	0.989-7.561

SE: Standard error; CI: Confidence interval.

Univariate and multivariate analyses of factors affecting depression in patients with EC undergoing esophagectomy

The univariate analysis of factors influencing depression among patients who underwent esophagectomy for EC indicated that age, living arrangement, per capita monthly household income, educational level, history of alcohol consumption, and postoperative complications exhibited a close and significant relationship with the exacerbation of depression in these patients (P < 0.05). To gain a more profound understanding of the functional mechanisms underlying each factor, a multivariate analysis was subsequently conducted on factors that had shown significant differences. The results further elucidated that age (P = 0.026), living arrangement (P = 0.005), per capita monthly household income (P = 0.024), educational level (P = 0.002), and postoperative complications (P < 0.001) were all pivotal factors independently contributing to the aggravation of depression in patients with EC following esophagectomy (Tables 5 and 6).

Table 5 Univariate analysis of factors affecting depression in patients undergoing esophagectomy for esophageal cancer, n (%).

Indicators	n	Negative or mild depression (n = 81)	Moderate and severe depression (n = 39)	χ2	P value
Sex				0.342	0.559
Male	60	42 (51.85)	18 (46.15)
Female	60	39 (48.15)	21 (53.85)
Age, years				4.831	0.028
< 60	69	41 (50.62)	28 (71.79)
≥ 60	51	40 (49.38)	11 (28.21)
Living arrangement				5.795	0.017
Cohabitation	59	46 (56.79)	13 (33.33)
Solitude	61	35 (43.21)	26 (66.67)
Employment status				0.093	0.761
Unemployed	67	46 (56.79)	21 (53.85)
Employed	53	35 (43.21)	18 (46.15)
Medical conditions				0.950	0.330
Convenient	60	43 (53.09)	17 (43.59)
Inconvenient	60	38 (46.91)	22 (56.41)
Per capita monthly household income				6.862	0.032
< 3000	76	45 (55.56)	31 (79.49)
3000-5000	28	22 (27.16)	6 (15.38)
> 5000	16	14 (17.28)	2 (5.13)
Educational level				9.126	0.003
Below senior high school	96	71 (87.65)	25 (64.10)
Senior high school or above	24	10 (12.35)	14 (35.90)
Smoking history				0.644	0.422
Without	43	31 (38.27)	12 (30.77)
With	77	50 (61.73)	27 (69.23)
Alcohol consumption history				4.127	0.042
Without	56	43 (53.09)	13 (33.33)
With	64	38 (46.91)	26 (66.67)
Postoperative complications				25.229	< 0.001
Without	92	73 (90.12)	19 (48.72)
With	28	8 (9.88)	20 (51.28)

Table 6 Multivariate analysis of factors affecting depression in patients undergoing esophagectomy for esophageal cancer.

Variable	β	SE	Wald	P value	Exp (β)	95%CI
Age, years	-1.224	0.549	4.966	0.026	0.294	0.100-0.863
Living arrangement	1.575	0.563	7.828	0.005	4.831	1.603-14.560
Per capita monthly household income	-0.955	0.424	5.087	0.024	0.385	0.168-0.882
Educational level	2.136	0.696	9.425	0.002	8.469	2.165-33.127
Alcohol consumption history	0.793	0.527	2.262	0.133	2.210	0.786-6.210
Postoperative complications	2.529	0.631	16.048	< 0.001	12.544	3.639-43.236

SE: Standard error; CI: Confidence interval.

DISCUSSION

In this study, a total of 120 patients with EC who underwent esophagectomy were included. Among them, patients exhibiting negative or mild anxiety constituted 54.17%, whereas those with moderate to severe anxiety accounted for 45.83%; overall, the anxiety level was categorized as moderate. Regarding depression, patients with negative or mild symptoms accounted for 67.50%, and those with moderate to severe depression made up 32.50%; overall, the study participants exhibited mild depression. Cancer-related anxiety and depression are typically influenced by factors such as patients’ psychological responses to cancer diagnosis and treatment and alterations in body image, sexual function, employment circumstances, and social interactions[16,17]. A study pointed out that in addition to the aforementioned negative consequences, anxiety and depression in adult patients with metastatic cancer can also augment the likelihood of requiring palliative treatment, highlighting the crucial necessity of implementing appropriate mental health care measures for patients with cancer[18]. Notably, the MAAS scores were markedly high among patients with negative or mild anxiety and those with negative or mild depression. This phenomenon suggests a close and intrinsic connection between patients experiencing aggravated anxiety or depression and a diminished level of hope. Oberoi et al[19] elucidated that mindfulness-based interventions bear a significant association with the reduction of anxiety and depression among patients with adult cancer. This result indicates that the level of mindfulness may be an efficacious ameliorative factor in alleviating negative affective states such as anxiety and depression in the patient cohort. Other investigations have corroborated that mindfulness interventions can facilitate patients undergoing surgery in cultivating healthy behavioral patterns, alleviating pain perception, and enhancing mental well-being and the overall quality of life[20]. The correlation analysis revealed that both anxiety and depression manifestations in patients with EC undergoing esophagectomy exhibited a remarkably negative correlation with the level of hope. In the meta-analysis conducted by Xu et al[21], the correlation coefficients of the public’s mindfulness level with anxiety and depression during the coronavirus disease 2019 pandemic were -0.330 and -0.353, respectively (P < 0.05), a result that was highly congruent with our findings. Pérez-Aranda et al[22] postulated that resilience might, to a certain extent, mediate the effect of mindfulness on depression in patients who underwent esophagectomy for EC, partially explaining the potential relationship between mindfulness and depression in such patients. Through univariate and multivariate analyses, the potential factors underlying the exacerbation of anxiety or depression in patients with EC receiving esophagectomy were identified. Being female and completing high school or above emerged as risk factors for the exacerbation of anxiety among these patients. Meanwhile, living alone, attaining high school or a higher educational level, and suffering from postoperative complications are factors aggravating depression in patients EC who underwent esophagectomy. Conversely, advanced age and a high per capita monthly household income exhibited protective effects against anxiety and depression in such patients. The root causes can be elucidated as follows. The independent correlation between female sex and aggravation of anxiety in patients with EC who underwent esophagectomy may stem from the social, family, and economic circumstances of this group, thus experiencing greater psychological pressure. For patients with high educational attainment, the inability to pursue their psychological ambitions before and after illness onset creates a substantial psychological gap, making them susceptible to anxiety and depression. Patients living alone, due to limited family support and social engagement, are more inclined to feel helpless and succumb to depression following disease onset. Those with postoperative complications, enduring both physical and mental distress, are comparatively more likely to have diminished willpower, making them more susceptible to depression[23-26]. Conversely, older patients, who have broader cognition and richer life experiences, may find it easier to accept the concept of death and often adopt a calmer attitude toward diseases and death. Such a mindset potentially renders a protective factor in reducing anxiety or depression. For patients with a high per capita monthly household income, their relatively affluent economic circumstances typically translate into diminished financial stress. This provides them access to relatively superior medical resources and stronger social support, facilitating their recovery from psychological troubles, such as anxiety and depression[27,28]. Wu et al[29] elucidated that elements such as age, sex, educational attainment, and tumor size, which is similar to our observations influenced the emotional states of patients with early-stage EC after endoscopic submucosal dissection.

Based on the above results, a clinical pathway integrating mindfulness-based stress reduction (MBSR) was proposed for patients with EC undergoing esophagectomy. An 8-week MBSR program will be implemented and conducted by a professionally trained MBSR team with rich clinical experience. The intervention will consist of weekly 40-minute sessions, with weekly intervention topics covering mindful eating, mindful breathing, mindful stretching, 3-minute breathing space, mindful awareness of thoughts, mindful walking, self-aware mindfulness practice, and experience exercises. Before training initiation, patients will receive educational materials (videos and digital/print handouts) explaining MBSR principles, techniques, and benefits. Interactive discussions and question-and-answer sessions will be arranged to reinforce theoretical understanding while emphasizing practical application. Following each course, participants will receive instructional videos for independent practice, ensuring that each patient can review the weekly learned MBSR content. Monitoring psychological distress, particularly among high-risk subgroups (e.g., younger patients, women, those living alone, and individuals with ≥ high school education, postoperative complications, or low household income) will receive special attention. Furthermore, patients will be encouraged to record their daily practice status voluntarily. For patients presenting postoperative complications, they require continuous assessment of their clinical status, with appropriate interventions administered as needed. Patients from economically disadvantaged backgrounds may receive tailored support solutions, including financial aid or referrals to community assistance programs.

This study has several limitations that warrant improvement in future research. First, the relatively small sample size (n = 120) and single-center design may limit the generalizability of the findings. Future larger, multicenter collaborative research may enhance external validity. Second, the retrospective nature of data collection constrained our ability to account for potential confounders such as postoperative pain, tumor staging, treatment modalities, and type/severity of complications that may influence mental state. Future studies should incorporate more comprehensive clinical variables for multivariate analysis. Third, longitudinal assessments of dynamic changes in anxiety, depression, and mindfulness levels before and after surgery were not performed. A prospective longitudinal design would be valuable to elucidate potential causal relationships. Finally, supplementing quantitative findings with qualitative methods (e.g., in-depth interviews) could provide deeper insights into the underlying mechanisms of anxiety and depression-related factors.

CONCLUSION

In this study, a moderate degree of anxiety and a low depression level prevailed among the 120 patients who underwent esophagectomy for EC. Significantly negative correlations were detected between both anxiety and depression and the mindfulness level. Therefore, providing mindfulness interventions for patients to help them achieve a high level of mindfulness may alleviate anxiety and depression. Furthermore, regarding risk factors, being female and attaining high school or above contribute to the exacerbation of anxiety in patients who underwent esophagectomy for EC. Moreover, living alone, attaining high school or higher, and suffering from postoperative complications were confirmed as pertinent risk factors that aggravate depression in these patients. In contrast, advanced age and a high per capita monthly household income were identified as protective factors against both anxiety and depression in such patients.