Risk factors for depression in patients in perimenopause with cervical cancer

Abstract

BACKGROUND

Cervical cancer is a significant health concern among females in perimenopause, with a high prevalence of depression in this population. The rationale for this study was to explore the risk factors associated with depression in patients in perimenopause with cervical cancer. We hypothesized that socioeconomic status, disease characteristics, and quality of life factors contributed to the development of depression in these patients.

AIM

To investigate the risk factors associated with depression in patients in perimenopause with cervical cancer.

METHODS

A retrospective study was conducted on 254 patients in perimenopause with cervical cancer admitted to a single center. Patients were divided into a non-depression group (n = 152) and a depression group (n = 102) based on whether depression occurred after treatment. Data collection included demographic, clinical, and psychosocial factors. The Hamilton Depression Rating Scale was used to assess depression. Logistic regression analysis was performed to identify risk factors.

RESULTS

Patients with depression more often had low income (< 4000 China yuan: 66.7% vs 6.6%, P < 0.001), initial disease onset (70.6% vs 57.2%, P = 0.001), low social support (70.6% vs 55.3%, P = 0.014), pathological stages III-IV (70.6% vs 41.5%, P < 0.001), high pain level (65.7% vs 34.2%, P < 0.001), and poor sleep quality (67.6% vs 32.2%, P < 0.001). Logistic regression identified low income [odds ratio (OR) = 32.606, P < 0.001], initial disease onset (OR = 4.282, P = 0.001), pathological stages III-IV (OR = 4.123, P = 0.0005), high pain level (OR = 1.181, P = 0.0000434), and poor sleep quality (OR = 3.094, P = 0.0041) as key risk factors.

CONCLUSION

Low income, initial onset, low support, advanced stages, high pain, and poor sleep quality increased depression risk in patients in perimenopause with cervical cancer. Studies investigating interventions for this population are needed.

Key Words: Cervical cancer; Perimenopause; Depression; Social support; Risk factors

Core Tip: This study retrospectively analyzed 254 patients in perimenopause with cervical cancer to identify risk factors associated with depression. Results revealed that low monthly family income, initial disease onset, low social support, advanced pathological stage, high pain level, and poor sleep quality were significant risk factors. These findings highlighted the importance of addressing mental health in this vulnerable population and provided a basis for targeted clinical interventions to prevent depression.

INTRODUCTION

Cervical cancer is one of the most common malignant tumors of the female reproductive system. It is currently believed to be closely related to human papilloma virus infection[1,2]. In recent years, the global incidence and mortality of cervical cancer have generally shown a downward trend, but countless females still die from cervical cancer. According to the 2022 global cancer data statistics released by the International Agency for Research on Cancer, there are approximately 662000 new cases of cervical cancer and approximately 349000 deaths worldwide, accounting for 6.8% and 8.1% of the total number of cancer cases and deaths in females worldwide, and it is still the fourth most common cancer in terms of incidence and mortality in females[3,4]. Studies have shown that the 5-year survival rate of early cervical cancer is 90%, while the 5-year survival rate of late-stage cervical cancer is only 25%. Persistent human papilloma virus infection can easily induce cancer cell invasion and metastasis, which is the main cause of the occurrence and development of cervical cancer[5,6].

The high-risk age group for cervical cancer is 15 to 59 years old, and the incidence rate is on the rise during this period. As age increases, the immune function and physical recovery ability of elderly females decline. If they develop cervical cancer, the disease is more likely to progress to the late stage, making treatment more difficult. The mortality rate of cervical cancer increases with age[7]. Therefore, the incidence and mortality rate of cervical cancer in perimenopausal females are relatively high.

The probability of depression in perimenopausal females is high. The prevalence of perimenopausal depression is as high as 33.9%[8]. Compared with depression in general adult females, their depression, anxiety, and physical symptoms are more prominent[9] and seriously affects their quality of life and social function. On the other hand, cervical cancer and its treatment will cause serious physical and mental burdens on patients[10], leading to an increased probability of depression. First, the diagnosis of cervical cancer often brings great psychological impact. Patients may face uncertain life expectancy and anxiety about the economic burden. Secondly, the treatment process of the disease, such as surgery, radiotherapy, and chemotherapy, is often accompanied by physical pain, physical weakness, and changes in appearance, all of which further damage the patient’s psychological state. These dual physical and psychological pressures can easily lead to emotional problems such as depression and anxiety in patients This affects the patient’s compliance and may affect the smooth progress of treatment in severe cases, leading to a serious effect on the prognosis and causing continuous harm to patients with cervical cancer[11]. Therefore, the risk factors related to depression in patients in perimenopause with cervical cancer deserve in-depth analysis and discussion.

This study enrolled 254 patients in perimenopause with cervical cancer as the research subjects and analyzed the risk factors related to depression in this population to provide a certain theoretical basis for their treatment.

MATERIALS AND METHODS

Patients

Research subjects with cervical cancer admitted to the hospital were selected as the research subjects for retrospective analysis. There were 152 cases in the non-depressed group with an average age of 52.68 ± 6.02 years old. There were 102 cases in the depressed group with an average age of 50.89 ± 4.34 years old. This study was approved by the hospital’s Medical Ethics Committee, and all patients signed informed consent.

Inclusion and exclusion criteria

Inclusion criteria: Diagnosed with cervical cancer according to relevant clinical diagnostic criteria; in perimenopause; with irregular vaginal bleeding or contact bleeding during sexual intercourse as the main symptoms; and the shape, boundary, and size of the lesion were examined by ultrasound.

Exclusion criteria: Patients with other malignant tumors; patients who were pregnant or breastfeeding; patients with cognitive behavioral and speech communication disorders; patients with mental disorders; patients with low compliance or unable to cooperate with the intervention due to physical reasons; and patients with intolerance or allergy to chemotherapy drugs.

Research methods

Depression assessment: The Hamilton Depression Rating Scale (HAMD)[12] was used to assess whether the patients had depression, with a cutoff value of 7. A score < 7 indicated normal, and a score ≥ 7 indicated the presence of depression. The higher the score, the more severe the depression.

Data collection: Perimenopause, depression, cervical cancer and their corresponding English keywords were used to search domestic and foreign databases such as CNKI, Wanfang, VIP, and PubMed. Then we sorted the relevant literature, screened literature with a high credibility within the past 5 years, analyzed relevant content in the literature, summarized the relevant factors and high-risk factors that may affect patients in perimenopause with depression and cervical cancer, and formulated a survey plan for factors that may affect this population combined with clinical data collected in this hospital.

The nurses who have received unified training conducted the questionnaire survey using standard guided language. If the patient had poor vision, the investigator assisted in completing the questionnaire. The questionnaire was distributed, completed, and collected at the same time to ensure the accuracy and authenticity of the questionnaire survey. According to whether depression occurred after surgery, the patients were divided into a depression group and a non-depression group.

The relevant risk factors for depression in patients in perimenopause with cervical cancer were analyzed. The collected data included age, body mass index (BMI), household registration, occupational status, educational level, monthly family income, medical payment method, marital status, fertility status, social support, self-management effectiveness, smoking history, drinking history, basic medical history, family history of cervical cancer, incidence, pathological classification, pathological stage, pain level, and sleep quality.

Social support was assessed using the Social Support Rating Scale[13], which consists of ten items and three dimensions, including three items of objective support, four items of subjective support, and three items of utilization of social support. The total score ranges from 12 to 72 points. The higher the score, the better the patient’s social support. In this study, a score of < 36 was considered low social support, and a score of ≥ 36 was considered high social support.

Self-management efficacy was assessed using the Strategies Used by People to Promote Health scale[14], which consists of four dimensions, namely behavioral complexity, behavioral change, time management, and stress control. The total score ranged from 1 to 5 points. The higher the score, the better the patient’s self-management efficacy. In this study, a score of < 70 was considered low self-management efficacy, and a score of ≥ 70 was considered high self-management efficacy.

The pain level was assessed using the numerical rating scale[15], which consists of a total score of 0 to 10 points. The higher the score, the higher the patient’s pain level. In this study, a score of < 5 was considered low pain, and a score of ≥ 5 points indicated a high pain level.

Sleep quality was assessed using the Pittsburgh Sleep Quality Index[16], which has seven dimensions, with each dimension ranging from 0 to 3 points and a total score ranging from 0 to 21 points. The lower the score, the better the sleep quality. In this study, a score of < 10 was considered high sleep quality, and a score of ≥ 10 was considered low sleep quality.

To ensure the consistency of the data collection process, all nurses involved in the questionnaire survey received unified training on the usage of the questionnaire and the interpretation of the assessment scales. The training included a detailed explanation of each question, the assessment criteria for the Hamilton Depression Rating Scale, the Social Support Rating Scale, the Strategies Used by People to Promote Health scale, the numerical rating scale, and the Pittsburgh Sleep Quality Index. Additionally, mock surveys were conducted to practice the data collection procedure, and feedback sessions were held to address any inconsistencies or confusion among the nurses. This process ensured that data collection was consistent across different nurses, thereby improving the accuracy and reliability of the collected data.

Data collation: The data collection and collation personnel were trained to unify the judgment criteria of various indicators, organize the data of patients who met the inclusion criteria, group and count the various indicators of the survey plan, and make statistical tables for the project leader to conduct unified data analysis and discussion. Based on the data analysis results, they summarized the depression prevention and health care strategies for patients in perimenopause with cervical cancer.

Assignment of relevant indicators: Of related factors for depression in patients in perimenopause with cervical cancer are shown in Table 1.

Table 1 Risk level assignment table for related factors of depression in patients in perimenopause with cervical cancer.

Variable	Serial number	Assignment
Age (years)	1	0 ≤ 50, 1 ≥ 50
BMI (kg/m²)	2	0 ≤ 24, 1 ≥ 24
Household registration	3	0 = urban, 1 = rural
Occupational status	4	0 = employed, 1 = retired or unemployed
Education	5	0 = junior high school and below, 1 = high school and above
Monthly household income	6	0 ≤ 4000, 1 ≥ 4000
Medical payment method	7	0 = medical insurance, 1 = self-funded
Marital status	8	0 = single, divorced, or widowed, 1 = married
Fertility status	9	0 = no children, 1 = children
Social support	10	0 = low, 1 = high
Self-management effectiveness	11	0 = low, 1 = high
Smoking history	12	0 = yes, 1 = no
Drinking history	13	0 = yes, 1 = no
Basic medical history	14	0 = yes, 1 = no
Family history of cervical cancer	15	0 = yes, 1 = no
Disease	16	0 = first onset, 1 = recurrence
Pathological classification	17	0 = squamous cell carcinoma, 1 = non-squamous cell carcinoma
Pathological staging	18	0 = Stage I, Stage II, 1 = Stage III, Stage IV
Pain level	19	0 = low, 1 = high
Sleep quality	20	0 = low, 1 = high

BMI: Body mass index.

Statistical analysis

SPSS 22.0 statistical software was used to process the data. Enumeration data were expressed as n (%), and the χ² test was used. Measurement data were expressed as mean ± SD. Intergroup comparisons were performed using independent sample t-tests. Statistically significant indicators were included in the multivariate logistic system for multivariate regression analysis. P < 0.05 was considered statistically significant.

RESULTS

Baseline information

The baseline data of the depression group and the non-depression group were subjected to univariate analysis.

During data collection, some variables had missing values. For continuous variables (e.g., age, BMI), missing values were imputed using the mean of the non-missing data. For categorical variables (e.g., social support, pain level), missing values were imputed with the mode of the non-missing data. This imputation strategy was chosen to minimize the impact of missing data on the statistical analysis. Compared with the non-depressed group, the depressed group had a significantly higher proportion of family monthly income < 4000 China yuan (CNY), initial onset of disease, low social support, pathological stage III and IV, high pain level, and low sleep quality. The differences were statistically significant (P > 0.05). There was no statistically significant difference in basic medical history, family history of cervical cancer, incidence, and pathological classification (P > 0.05; Table 2).

Table 2 Comparison of baseline data between the two groups of patients.

Variable	Total (n = 254)	No depression group (n = 152)	Depression group (n = 102)	t/χ2	P value
Age (years)				0.011	0.918
< 50	128	77 (50.66)	51 (50.00)
≥ 50	126	75 (49.34)	51 (50.00)
BMI (kg/m²)				3.107	0.078
< 26	37	27 (17.76)	10 (9.80)
≥ 26	217	125 (82.24)	92 (90.20)
Household registration				0.010	0.920
City	123	74 (48.68)	49 (48.04)
Rural	131	78 (51.32)	53 (51.96)
Occupational status				2.380	0.123
Working	76	51 (33.55)	25 (24.51)
Retired or unemployed	178	101 (66.45)	77 (75.49)
Education				0.016	0.900
Junior high school and below	168	101 (66.45)	67 (65.69)
High school and above	86	51 (33.55)	35 (34.31)
Monthly household income, CNY				103.572	0.000
< 4000	78	10 (6.58)	68 (66.67)
≥ 4000	176	142 (93.42)	34 (33.33)
Medical payment method				0.005	0.942
Health insurance	170	102 (67.11)	68 (66.67)
Self-funded	84	50 (32.89)	34 (33.33)
Marital status				3.235	0.072
Single, divorced, or widowed	112	74 (48.68)	38 (37.25)
Married	142	78 (51.32)	64 (62.75)
Fertility status				0.006	0.940
No children	22	13 (8.55)	9 (8.82)
Children	232	139 (91.45)	93 (91.18)
Social support				6.050	0.014
Low	156	84 (55.26)	72 (70.59)
High	98	68 (44.74)	30 (29.41)
Self-management effectiveness				0.000	0.992
Low	152	91 (59.87)	61 (59.80)
High	102	61 (40.13)	41 (40.20)
Smoking history				0.097	0.756
Have	135	82 (53.95)	53 (51.96)
None	119	70 (46.05)	49 (48.04)
Drinking history				0.071	0.789
Have	147	89 (58.55)	58 (56.86)
None	107	63 (41.45)	44 (43.14)
Basic medical history				0.165	0.684
Have	138	81 (53.29)	57 (55.88)
None	116	71 (46.71)	45 (44.12)
Family history of cervical cancer				0.319	0.572
Have	154	90 (59.21)	64 (62.75)
None	100	62 (40.79)	38 (37.25)
Disease				4.647	0.031
Initial	159	87 (57.24)	72 (70.59)
Relapse	95	65 (42.76)	30 (29.41)
Pathological classification				0.021	0.885
Squamous cell carcinoma	188	113 (74.34)	75 (73.53)
Non-squamous cell carcinoma	66	39 (25.66)	27 (26.47)
Pathological staging				20.816	0.000
Phase I, Phase II	119	89 (58.55)	30 (29.41)
Stage III, Stage IV	135	63 (41.45)	72 (70.59)
Pain level				24.286	0.000
Low	135	100 (65.79)	35 (34.31)
High	119	52 (34.21)	67 (65.69)
Sleep quality				30.769	0.000
Low	118	49 (32.24)	69 (67.65)
high	136	103 (67.76)	33 (32.35)

Data are presented as mean ± SD or n (%). BMI: Body mass index; CNY: China yuan.

Logistic regression analysis of risk factors associated with concurrent depression

The following factors were risk factors for depression in patients in perimenopause with cervical cancer: Monthly family income < 4000 CNY; initial onset; low social support; pathological stage III and IV; high pain level; and low sleep quality (Table 3).

Table 3 Results of multivariate logistic regression analysis of depression in perimenopausal patients with cervical cancer.

Variable	Multifactorial
	Beta	OR	95%CI	P value
Monthly household income	3.484	32.606	12.742-83.436	3.63e-13
Disease	1.454	4.282	1.760-10.420	0.0013
Social support	0.525	1.691	0.763-3.745	0.1955
Pathological staging	1.454	4.123	1.849-9.193	0.0005
Pain level	0.166	1.181	0.080-1.411	4.34e-05
Sleep quality	1.129	3.094	1.431-6.689	0.0041

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

Cervical cancer is one of the most common gynecological malignant tumors. The incidence of cervical cancer has generally declined in most developed countries around the world. However, the incidence and mortality of cervical cancer in China are on the rise, and the disease burden is still heavy[17-19]. The lesion of the disease is located in the patient’s cervix. Most lesions are caused by human papillomavirus infection. There may be no obvious symptoms in the early stage, but the disease progresses rapidly. In the late stage, vaginal bleeding, discharge, anemia, infection, and other symptoms may occur[20,21].

In clinical treatment, cervical cancer is relatively sensitive to radiotherapy and chemotherapy. Surgery is still the main treatment method and is supplemented by radiotherapy and chemotherapy, which can control the proliferation of tumor cells and effectively reduce the recurrence rate of the disease[22]. Surgery is effective and can prolong the patient’s survival time, but it will cause changes in the patient’s physical, psychological, and social functions. It can easily lead to negative emotions such as depression[23,24]. Adverse reactions such as immune system disorders, gastrointestinal reactions, and hair loss may occur after radiotherapy and chemotherapy, which may lead to unsatisfactory patient compliance with radiotherapy and chemotherapy. It may also aggravate the patient’s psychological stress and affect the clinical treatment effect[25,26].

Clinical studies[27] have shown that perimenopause is a period of high incidence of malignant tumors of the female reproductive system. Perimenopause is a period of great changes in females’ physiological and psychological states. Due to a decline in ovarian function and lack of sex hormones, the dysfunction of the thalamus-pituitary-ovary endocrine axis leads to autonomic nervous disorder, which leads to psychological problems, such as tension, anxiety, depression, and other symptoms.

Cervical cancer and its treatment often aggravate depression in patients in perimenopause and seriously affect their quality of life. Huang et al[28] confirmed that there is a correlation between the level of psychological flexibility of middle-aged patients with cancer and their level of hope and coping style. Clinical intervention measures can improve the level of hope of cancer patients, help them maintain good mentality and beliefs, and thus change the patient’s coping style and improve their level of psychological resilience. Currently, the attention and research level in China on females in perimenopause with malignant tumors and other related diseases are lagging behind. In particular, there are few studies on females in perimenopause with malignant tumors complicated by depression[29].

The results of this study showed that compared with the non-depressed group, the depressed group of patients in perimenopause had a monthly family income of < 4000 CNY, early onset of the disease, low social support, pathological stages III and IV, high pain level, and low sleep quality. The proportion was large, and the difference was significant (P < 0.05). Therefore, the above factors are related risk factors for depression in patients with perimenopause with cervical cancer. The reasons may be as follows.

A monthly family income of less than 4000 CNY means that patients and their families lack sufficient financial support to cope with the cost of cancer treatment, resulting in patients facing a greater financial burden. This financial pressure makes patients prone to anxiety and helplessness. Cancer treatment not only includes drug treatment but also needs to consider other expenses such as transportation, nursing, and nutritional support. When financial capabilities are limited, the patient’s psychological burden will increase, and mood will deteriorate.

The first onset of cervical cancer often has a huge psychological impact on patients. For many patients, cancer means uncertainty and the threat of death, especially during perimenopause, a stage of great physical and psychological changes. Patients’ fear and confusion about cancer may be more obvious. Patients diagnosed with cancer for the first time often experience greater psychological stress reactions. This impact can lead to severe mood swings and further increase the risk of depression.

Social support is important when dealing with major illnesses. Patients with low social support often lack emotional support and help from relatives, friends, family, or society. This makes patients feel lonely and helpless and cannot get timely emotional relief. Patients in perimenopause with cervical cancer are often in the transition period of social roles, and they may face multiple pressures from family and work at the same time and lack an effective support network. This sense of isolation will aggravate their depressive symptoms.

Pathological stages III and IV represent the middle and late stages of cancer. Patients in these stages face more complex treatment options, more side effects, and a more uncertain prognosis. As the disease progresses, the patient’s physical functions are affected and their quality-of-life decreases. Side effects during treatment, such as nausea and vomiting, loss of appetite, weight loss, etc., may cause the patient’s physical condition to become increasingly weak. For these advanced patients, the accumulation of physical and psychological stress caused by the disease will aggravate their risk of depression.

Cancer patients often experience more severe pain. Pain not only affects patients’ physical health but also significantly affects their emotional and psychological state. High-intensity pain makes it difficult for patients to concentrate, rest, or perform daily activities, leading to anxiety, depression, and feelings of helplessness. For patients, persistent pain is a mental burden that cannot be ignored. It may lead to the patient’s perception that “life is hopeless” and further aggravate depression.

Poor sleep quality is a common symptom of depression. At the same time, long-term sleep disorders can also affect mental health. Patients in perimenopause with cervical cancer often have difficulty getting enough sleep due to physical discomfort, treatment side effects, and psychological stress. Insufficient or poor sleep quality can lead to mood swings, inattention, and decreased physical strength, etc., thus forming a vicious cycle and further aggravating the symptoms of depression.

Therefore, for patients in perimenopause with cervical cancer special attention should be paid to their mental health. Timely psychological intervention should be provided in addition to conventional cancer treatment. Social support and pain relief should be provided to help patients improve their quality of life and reduce the probability of depression.

In comparing our findings with those of other similar studies, several similarities and differences emerged. Jia et al[30] conducted a systematic review and meta-analysis on the global prevalence of depression in females in menopause and found that the prevalence of depression in this population was high, which is consistent with our study results. Similarly, Huang et al[28] analyzed the psychological pain level in patients with middle and late-stage cervical cancer and noted the impact of disease progression on depression, which aligns with our finding that patients in pathological stages III and IV are at higher risk of depression.

This study offered valuable insights into depression risk factors in patients in perimenopause with cervical cancer but had limitations. As a retrospective study, it is prone to recall bias, with patients possibly inaccurately recalling illness and treatment details. Conducted at a single center, its findings may not be generalized to other populations. Future research should use prospective designs and multicenter collaborations to enhance external validity. Further investigation is also needed to explore other potential risk factors, such as genetic and environmental influences.

CONCLUSION

Our study identified several risk factors for depression in patients in perimenopause with cervical cancer, including low monthly family income, initial onset of disease, low social support, advanced pathological stages, high pain levels, and poor sleep quality. These findings underscored the importance of addressing not only the physical but also the psychological needs of these patients. Clinicians should develop targeted intervention measures to address each of these risk factors, aiming to prevent the occurrence of depression and improve the overall quality of life of patients in perimenopause with cervical cancer.