Correlation of postoperative anxiety and depression with fear of cancer recurrence and sleep disorders in oral cancer patients

Abstract

BACKGROUND

Patients with oral cancer face a higher risk of postoperative anxiety and depression, often accompanied by varying degrees of fear of cancer recurrence (FCR) and sleep disorders, which may hinder postoperative recovery.

AIM

To analyze the correlation of postoperative anxiety and depression with FCR and sleep disorders in patients with oral cancer.

METHODS

A total of 147 patients with oral cancer admitted to Chongqing University Cancer Hospital between December 2021 and December 2024 were recruited as research subjects. Clinical data, including postoperative Hospital Anxiety and Depression Scale (HADS), Fear of Progression Questionnaire-Short Form (FoP-Q-SF), and Pittsburgh Sleep Quality Index (PSQI) scores, were collected. Patients scoring ≥ 8 on either the HADS-Anxiety subscale (HADS-A) (anxiety subscale) or HADS-Depression subscale (HADS-D) (depression subscale) were classified into the anxiety or depression group; the remainder were assigned to the control group. FoP-Q-SF and PSQI scores were compared between groups. Pearson/Spearman correlation analysis was used evaluate the associations between postoperative HADS-A/HADS-D scores and FoP-Q-SF and PSQI scores. Univariate and binary logistic regression analyses were used for the identification of factors influencing postoperative anxiety and depression in patients with oral cancer.

RESULTS

Among the 147 patients, the rates of anxiety, depression, anxiety or depression, and combined anxiety and depression were 34.01%, 46.26%, 60.54%, and 39.46%, respectively. The total FoP-Q-SF and PSQI scores were 40.61 ± 6.43 and 9.00 (8.00, 10.00), respectively. The anxiety or depression group (n = 89) showed significantly higher FoP-Q-SF and PSQI scores. Anxiety and depression correlated positively with both FCR and poor sleep quality. Educational level, recurrence, and FoP-Q-SF score were identified as independent predictors of anxiety or depression in patients with oral cancer.

CONCLUSION

These findings suggested that postoperative anxiety and depression in patients with oral cancer were closely associated with higher FCR and poorer sleep quality; educational level, disease recurrence, and fear intensity were considered important independent predictors.

Key Words: Oral cancer; Anxiety; Depression; Fear of cancer recurrence; Sleep disorders

Core Tip: This study analyzed the correlation of postoperative anxiety and depression with fear of cancer recurrence (FCR) and sleep disorders in patients with oral cancer. Anxiety or depression was common after surgery and was accompanied by moderate-to-high levels of FCR and sleep disorders. There was a significant positive correlation of anxiety and depression levels with FCR and sleep disorders. Lower educational level, disease recurrence, and higher FCR increased the risk of postoperative anxiety or depression in patients with oral cancer.

INTRODUCTION

Oral cancer is a global health concern, with approximately 400000 new cases reported in 2022, of which up to 77% occurred in men[1]. It is primarily classified as an epithelial carcinoma, with risk factors including epigenetics, tobacco/betel nut/cigarette/alcohol consumption, and microbial factors[2].

Patients with oral cancer commonly present with intolerable persistent throat pain, impaired chewing, swallowing, and speech functions, and jaw swelling; treatment-related side effects such as postoperative facial deformities may also occur[3,4]. These impairments limit the patients’ ability to perform daily activities and give rise to psychological distress. Consequently, compared with the general population, such patients face an increased risk of postoperative anxiety and depression[5].

At present, increased attention has been paid to the biological relationship between psychological factors and tumor progression. Cancer development and progression may be influenced by psychoneuroimmunological factors[6]. Tumor progression may be promoted by anxiety and depression via inducing neurohormonal imbalance, activating the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, and abnormally increasing the secretion of stress-related neurohormonal mediators such as catecholamines and cortisol[7].

Fear of cancer recurrence (FCR), defined as worry about cancer recurrence or progression, is a common psychological condition coexisting with anxiety and depression in cancer patients. In patients with oral cancer, it affects medical decision-making, treatment adherence, and clinical outcomes[8,9]. To alleviate FCR-related anxiety and depression, excessive worry should be reduced and perceived control should be enhanced[10]. In patients with head and neck cancer, elevated anxiety and depression levels are predictive indicators of FCR[11], suggesting a potential close correlation of anxiety and depression with FCR in patients with oral cancer.

Additionally, patients with oral cancer may suffer from sleep disorders, which affects about 44% of newly diagnosed cases[12]. Generally, the sleep quality of patients with oral cancer is seriously impaired by existing symptoms and negative emotions; by stimulating chronic inflammation and hypoxia, the resulting sleep disorders may, in turn, exacerbate cancer progression and emotional distress[13]. In a case-control clinical study, sleep and emotional disorders are commonly observed in oral cancer survivors, and their quality of life can be improved through timely intervention and alleviation[14].

However, few studies have comprehensively examined the relationships among postoperative anxiety, depression, FCR, and sleep disorders in patients with oral cancer. In order to assess the current status of these factors postoperatively and to explore their interrelationships, this study was conducted to help identify high-risk patients in the early stage and provide reliable clinical evidence for targeted interventions.

MATERIALS AND METHODS

Case selection

Inclusion criteria were as follows: Patients diagnosed with oral cancer via pathological examination[15]; patients aged 18-80 years; patients who underwent radical resection; treatment-naïve patients who received first-time treatment; patients with normal vision, hearing, communication, and cognitive abilities; and patients with complete clinical records. Exclusion criteria were as follows: Presence of other malignancies; patients with recent major traumatic events (e.g., loss of a family member or friend, severe physical or functional impairment, and divorce); patients who were using anxiolytics, antidepressants, analgesics, or sedatives; patients with severe acute or systemic infection; patients with severe cardiopulmonary dysfunction or coagulation disorders; and patients with psychiatric illness or severe cognitive impairment. Based on these criteria, 147 patients with oral cancer admitted to Chongqing University Cancer Hospital between December 2021 and December 2024 were included as study subjects. The patient screening process is shown in Figure 1.

Figure 1 Flowchart of patient screening process. PSQI: Pittsburgh Sleep Quality Index; FoP-Q-SF: Fear of Progression Questionnaire-Short Form; HADS: Hospital Anxiety and Depression Scale; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale.

Data collection and outcome measurement

Negative emotions: Anxiety and depression were assessed using the validated Chinese version of the Hospital Anxiety and Depression Scale (HADS)[16], which comprises an HADS-Anxiety subscale (HADS-A) and a HADS-Depression subscale (HADS-D), each containing seven items (score range: 0-21; total score: 42 points). A score ≥ 8 on either subscale indicated anxiety or depression, and ≥ 8 on both indicated comorbid anxiety and depression. In subsequent analyses, patients scoring ≥ 8 on either HADS-A or HADS-D were classified into the anxiety or depression group (n = 89); the remainder into the control group (n = 58).

Fear of cancer progression: FCR was assessed using the Fear of Progression Questionnaire-Short Form (FoP-Q-SF)[17], which includes two dimensions (social/family and physical health), each containing six items scored on a 5-point Likert scale (total score: 12-60). A score ≥ 34 indicated FCR, with higher scores reflecting greater FCR.

Sleep quality: Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI)[18], comprising seven dimensions: Subjective sleep quality, latency, duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. Each dimension is scored from 0 to 3. Scores of ≤ 3 indicate excellent sleep quality; 4-8 indicate good sleep quality; 9-16 indicate poor sleep quality; and ≥ 7 indicate extremely poor sleep quality. Scores are inversely proportional to sleep quality.

Statistical analysis

Data were analyzed using SPSS 20.0. Categorical data are presented as n (%), whereas continuous data are expressed as mean ± SD. The χ² test was used for the comparison of categorical data between the two groups. Pearson/Spearman correlation coefficients were used to evaluate associations between postoperative HADS-A/HADS-D scores and FoP-Q-SF/PSQI scores. Factors influencing postoperative anxiety and depression in patients with oral cancer were identified using univariate and binary logistic regression analyses. P < 0.05 was considered statistically significant.

RESULTS

Postoperative anxiety and depression

As shown in Figure 2, the HADS-A and HADS-D scores of the 147 patients with oral cancer were 6.00 (5.00, 9.00) and 7.35 ± 3.24, respectively. Using a cutoff of ≥ 8, the anxiety rate and depression rate were calculated as 34.01% and 46.26%, respectively. The proportions of anxiety or depression and comorbid anxiety and depression were 60.54% and 39.46%, respectively.

Figure 2 Postoperative anxiety and depression. A: Hospital Anxiety and Depression Scale (HADS)-Anxiety subscale and HADS-Depression subscale scores of 147 oral cancer patients; B: Proportion of anxiety, depression, anxiety or depression, and anxiety combined with depression among 147 oral cancer patients. HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale.

Postoperative FoP-Q-SF and PSQI scores

As shown in Figure 3, the total FoP-Q-SF and PSQI scores were 40.61 ± 6.43 and 9.00 (8.00, 10.00), respectively. FoP-Q-SF subscale scores for physical health and social/family were 18.39 ± 4.71 and 22.00 (19.00, 25.00), respectively. The PSQI subscale scores, ranked from highest to lowest, were: Sleep duration, subjective sleep quality, habitual sleep efficiency, sleep latency, sleep disturbances, daytime dysfunction, and use of sleeping medications.

Figure 3 Postoperative Fear of Progression Questionnaire-Short Form and Pittsburgh Sleep Quality Index. A: Postoperative Fear of Progression Questionnaire-Short Form in oral cancer patients; B: Postoperative Pittsburgh Sleep Quality Index in oral cancer patients. PSQI: Pittsburgh Sleep Quality Index; FoP-Q-SF: Fear of Progression Questionnaire-Short Form.

Effects of anxiety or depression on FoP-Q-SF and PSQI scores

As shown in Figure 4, patients scoring ≥ 8 on either HADS-A or HADS-D were assigned to the anxiety or depression group (n = 89), and the remaining in the control group (n = 58). The anxiety or depression group had significantly higher FoP-Q-SF and PSQI scores (all P < 0.01).

Figure 4 Effects of anxiety or depression on patients’ Fear of Progression Questionnaire-Short Form and Pittsburgh Sleep Quality Index scores. A: Fear of Progression Questionnaire-Short Form scores in the anxiety or depression group (n = 89) and the control group (n = 58); B: Pittsburgh Sleep Quality Index scores in the anxiety or depression group (n = 89) and the control group (n = 58). FoP-Q-SF: Fear of Progression Questionnaire-Short Form; PSQI: Pittsburgh Sleep Quality Index.

Correlation of HADS with FoP-Q-SF and PSQI

As shown in Figure 5 and Table 1, Pearson/Spearman correlation analysis revealed significant positive correlations between HADS-A and both FoP-Q-SF (r = 0.359, P < 0.001) and PSQI (r = 0.369, P < 0.001). Similarly, HADS-D was significantly positively correlated with FoP-Q-SF (r = 0.322, P < 0.001) and PSQI (r = 0.484, P < 0.001).

Figure 5 Correlation of Hospital Anxiety and Depression Scale with Fear of Progression Questionnaire-Short Form and Pittsburgh Sleep Quality Index. A: Correlation between Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A) and Fear of Progression Questionnaire-Short Form (FoP-Q-SF); B: Correlation between Hospital Anxiety and Depression Scale-Depression subscale (HADS-D) and Pittsburgh Sleep Quality Index (PSQI); C: Correlation between HADS-A and FoP-Q-SF; D: Correlation between HADS-D and PSQI. FoP-Q-SF: Fear of Progression Questionnaire-Short Form; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; PSQI: Pittsburgh Sleep Quality Index.

Table 1 Correlation analysis results.

Indicator	r	P value
HADS-A and FoP-Q-SF	0.359	< 0.001
HADS-A and PSQI	0.369	< 0.001
HADS-D and FoP-Q-SF	0.322	< 0.001
HADS-D and PSQI	0.484	< 0.001

FoP-Q-SF: Fear of Progression Questionnaire-Short Form; PSQI: Pittsburgh Sleep Quality Index; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale.

Univariate and binary logistic regression analyses

As shown in Table 2, univariate analysis revealed that age, sex, marital status, monthly income, smoking, and alcohol use were not significantly associated with anxiety or depression (P > 0.05), whereas educational level, pathological stage, recurrence, and FoP-Q-SF and PSQI scores were significantly associated (P < 0.05).

Table 2 Univariate analysis of factors influencing anxiety or depression in oral cancer patients, n (%).

Indicator	Anxiety or depression group (n = 89)	Control group (n = 58)	χ2 value	P value
Age (years)			0.384	0.536
< 60 (n = 79)	46 (51.69)	33 (56.90)
≥ 60 (n = 68)	43 (48.31)	25 (43.10)
Gender			1.008	0.315
Male (n = 81)	52 (58.43)	29 (50.00)
Female (n = 66)	37 (41.57)	29 (50.00)
Married			0.566	0.452
No (n = 51)	33 (37.08)	18 (31.03)
Yes (n = 96)	56 (62.92)	40 (68.97)
Educational level			4.990	0.026
Below high school (n = 85)	58 (65.17)	27 (46.55)
High school or above (n = 62)	31 (34.83)	31 (53.45)
Monthly income (RMB)			1.804	0.179
< 4000 (n = 81)	53 (59.55)	28 (48.28)
≥ 4000 (n = 66)	36 (40.45)	30 (51.72)
Smoking			0.783	0.376
Absent (n = 77)	44 (49.44)	33 (56.90)
Present (n = 70)	45 (50.56)	25 (43.10)
Alcohol abuse			0.025	0.874
Absent (n = 85)	51 (57.30)	34 (58.62)
Present (n = 62)	38 (42.70)	24 (41.38)
Pathological stage			4.673	0.031
T1-2 (n = 88)	47 (52.81)	41 (70.69)
T3-4 (n = 59)	42 (47.19)	17 (29.31)
Recurrence			9.636	0.002
Absent (n = 73)	35 (39.33)	38 (65.52)
Present (n = 74)	54 (60.67)	20 (34.48)
FoP-Q-SF (points)			11.963	< 0.001
< 40 (n = 63)	28 (31.46)	35 (60.34)
≥ 40 (n = 84)	61 (68.54)	23 (39.66)
PSQI (points)			5.010	0.025
< 9 (n = 43)	20 (22.47)	23 (39.66)
≥ 9 (n = 104)	69 (77.53)	35 (60.34)

FoP-Q-SF: Fear of Progression Questionnaire-Short Form; PSQI: Pittsburgh Sleep Quality Index.

As shown in Table 3, binary logistic regression analysis including significant variables from univariate analysis identified disease recurrence [odds ratio (OR): 3.272, 95% confidence interval (CI): 1.500-7.137, P = 0.003] and FoP-Q-SF ≥ 40 (OR: 4.917, 95%CI: 2.248-10.752, P < 0.001) as independent risk factors for anxiety or depression in patients with oral cancer, increasing the risk by 3.27-fold and 4.92-fold, respectively. Additionally, a high school education or above (OR: 0.446, 95%CI: 0.206-0.969, P = 0.041) was a protective factor against anxiety or depression. Pathological stage and sleep quality were not independent predictors (P > 0.05).

Table 3 Multivariate analysis of factors influencing anxiety or depression in oral cancer patients.

Indicator	β	SE	Wald	P value	OR	95%CI
Educational level	-0.807	0.396	4.156	0.041	0.446	0.206-0.969
Pathological stage	0.705	0.409	2.971	0.085	2.023	0.908-4.508
Recurrence	1.185	0.398	8.873	0.003	3.272	1.500-7.137
FoP-Q-SF (points)	1.593	0.399	15.916	< 0.001	4.917	2.248-10.752
PSQI (points)	0.818	0.426	3.686	0.055	2.267	0.983-5.228

FoP-Q-SF: Fear of Progression Questionnaire-Short Form; PSQI: Pittsburgh Sleep Quality Index; OR: Odds ratio; CI: Confidence interval.

DISCUSSION

This study’s findings indicate that postoperative anxiety and depression are prevalent among patients with oral cancer, with a high overall incidence of negative emotions (60.54%), and depression being more prominent than anxiety. These results are consistent with reports of substantial emotional burden in this population. For instance, in a study by Zhang et al[19], high rates of distress (89.56%) and sadness (63.95%) were observed in preoperative oral cancer patients, which fell within the same spectrum as anxiety and depression. This indirectly suggests that negative emotions are already present before surgery and may persist after surgery. In comparison with an anxiety rate of 36.96% and a depression rate of 65.21% among patients with oral cancer in China reported by Yuan et al[20], the anxiety rate was similar while the depression rate was lower, which may be attributed to the earlier tumor stages among the included patients. Hence, screening for anxiety and depression as well as timely and effective psychological interventions, including health education, individualized psychological support, and behavioral strategies, should be provided to alleviate psychological distress, promote cognitive adjustment, and improve quality of life and social functioning[21].

Moderate-to-high levels of sleep disorders and FCR were observed in patients with oral cancer. Specifically, fear related to social and family domains outweighed concerns about physical health, and primary sleep disorders mainly included insufficient sleep duration and poor sleep quality. These findings confirm the importance of addressing psychosocial adaptation challenges associated with the disease and corresponding treatments. According to Gao et al[22], patients with head and neck cancer undergoing radiotherapy generally experience moderate levels of social alienation, confirming the role of fear of disease progression (FoP) in exacerbating social isolation. Taken together, internal psychological distress (anxiety and depression), sleep disorders, and social withdrawal can be directly triggered by FoP, thereby negatively affecting overall well-being and quality of life.

Remarkably higher levels of FoP and more severe sleep disorders were noted in oral cancer patients with anxiety or depression, suggesting a close clinical comorbidity among these factors. As indicated by correlation analyses, anxiety and depression were positively correlated with both FoP and poorer sleep quality, indicating complex interactions among these factors. Podina et al[23] reported that FoP in cancer survivors was bound up with depression and anxiety. Additionally, Yin et al[24] also demonstrated similar results, that postoperative sleep disorders are commonly observed in Chinese esophageal cancer patients and may be indirectly affected by anxiety and depression. Overall recovery may be hindered by perioperative sleep disorders via increasing postoperative pain sensitivity and exacerbating anxiety or depression; therefore, the application of appropriate interventions (e.g., mindfulness-based stress reduction) before or during treatment may help alleviate these effects[25,26].

Disease recurrence and high levels of FoP were identified as independent risk factors for postoperative anxiety or depression by univariate and multivariate analyses, whereas higher educational level was a protective factor. Disease recurrence lead to increased physical and psychological burden, reduced confidence in treatment, and even intensified negative emotions. Elevated FoP reflect maladaptive cognition, featured by heightened vigilance and excessive emotional resource consumption, so that patients are prone to anxiety or depression. However, higher educational level is associated with more accurate understanding and better acceptance of disease-related information, negative emotions are therefore reduced to some extent. These findings are in line with those of Zhang et al[27]. Furthermore, FoP may notably hinder post-traumatic growth by weakening positive coping strategies, as evidenced by the observed impact on psychological outcomes. Thus, FoP is considered a key negative factor in psychological adjustment, which directly contributes to anxiety and depression and hinders positive personal growth. Li et al[28] indicated in an intervention study that in patients with head and neck cancer, group-guided management reduced FoP and improved hope and quality of life. This supports the potential utility of structured group-based interventions in patients with oral cancer in reducing disease-related fear and improving psychological outcomes.

CONCLUSION

To sum up, patients with oral cancer generally suffer from postoperative anxiety and depression as well as moderate-to-high levels of FoP and sleep disorders. There are significant positive correlations among these factors. Lower educational level, disease recurrence, and higher FoP are important factors related to increased risk of postoperative anxiety or depression in this population.