ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 15

THE DISTRESS OF ADOLESCENTS WITH CANCER IN ROMANIA. PILOT STUDY

Elisabeta NIȚĂ (1) Maria-Magdalena JIANU (2), Cristian CONSTANTIN (3) Mihaela Camelia POPA (4)
Key words: adolescent, cancer, stress, distress, Brain Station, hospital school.

DOI: https://doi.org/10.26758/15.1.26

(1) Fundeni Clinical Institute, Bucharest, Romania, e-mail: beti_iris@yahoo.com

(2) UNATC “I.L.Caragiale” Bucharest, Theater Faculty, Romania, volunteer in the Pediatric Oncology Department, within the P.A.V.E.L. Association; e-mail: magdajianu1@yahoo.com

(3) PhD student, School of Advanced Studies of the Romanian Academy. Institute of Philosophy and Psychology ,,Constantin Rădulescu – Motru”, Romanian Academy, Romania; e-mail: cristianconstantin16@icloud.com

(4) Institute of Philosophy and Psychology “Constantin Rădulescu – Motru”, Romanian Academy, UNATC “I.L.Caragiale” Bucharest; e-mail: popa_zaizon@yahoo.com

Address correspondence to: Elisabeta Niță, Fundeni Clinical Institute, șoseaua Fundeni, 252, București, sector 2, Ph.: + 40-720-100- 692; E-mail: beti_iris@yahoo.com

Abstract

Objective. The objective of this study was to analyze the emotional distress among the adolescents with cancer. This distress negatively affects both the health-related quality of life and the treatment outcomes.

Material and method. 42 adolescents (18 female and 24 male; 15 years +-1.8 SD) were included in the study and we emphasize that to them were applied the followings: a short scale of distress with 6 items and a scale of emotional thermometers, at the start of treatment and 6 months after the start of treatment. All the adolescents participating in the study benefited from the interventions of the non-formal Brain Station program and the formal program of the Hospital School. The study took place between September 2023 and June 2024.

Results. At the beginning of the treatment, stress had a significant influence on distress, explaining approximately 21.49% of its total variance (r2=0.2149, p<0.05). After the interventions of the non-formal Brain Station program and the formal Hospital School program, stress continued to have a considerable influence on the distress, but explained only 9.54% of the variance (r2=0.0954, p<0.05). Also, the results of the study indicated that, 6 months after starting treatment: depression decreased significantly, anger decreased marginally significantly, while stress, anxiety, and need for help did not show statistically significant decreases.

Conclusions. Interventions aimed to reducing stress early in treatment may have a relevant impact on reducing distress relative to interventions applied later. Thus, it was essential to pay a special attention to the stress management in the early stages of the oncology treatment, in order to maximize the reduction of distress in patients.

Key words: adolescent, cancer, stress, distress, Brain Station, hospital school.

Suggested citation (APA)

Niță, E., Jianu, M.M., Constantin, C., & Popa, M. C. (2025). The distress of adolescents with cancer in Romania: Pilot study. Anthropological Researches and Studies, 15, 393-401. https://doi.org/10.26758/15.1.26

Introduction

Pediatric cancer is a major challenge for the patient, not only from the physically point of view, but also from the emotionally one. Adolescents diagnosed with cancer often experience high levels of emotional distress, manifested by symptoms of anxiety, depression, and avoidance behaviors (Kosir, Wiedemann, Wild & Bowes, 2018; Adams et al., 2021). Distress may negatively influence both patients’ quality of life and the effectiveness of oncological treatment (Kazak, Alderfer, Rourke, Simms, Streisand &Grossman, 2004; Patenaude & Kupst, 2005).

It is written, in the specialized literature, that distress in adolescents with cancer is influenced by a number of factors (Weiss, Hahn, Wallace, Biggs, Bruce &Harrison, 2013; Lee, 2024) such as the following:

  • Psychosocial and support – family and social support play a crucial role in managing distress. The adolescents who receive adequate emotional support from family and friends show lower levels of distress;
  • Severity of the disease – the advanced stage of the disease and the negative prognosis were associated with a higher level of emotional distress;
  • Type and intensity of treatment – ​​the intensive treatments such as aggressive chemotherapy and radiotherapy may increase the emotional distress due to the severe side effects and prolonged hospital stays.

Distress may have significant negative consequences on: quality of life of adolescents with cancer, treatment compliance and overall psychological development. Thus, the high levels of distress were associated with a low quality of life, affecting domains such as physical, emotional, and social well-being (Barakat, Marmer & Schwartz, 2010). Regarding the therapeutic compliance, patients with high levels of distress may have difficulties in adhering to the treatment regimen, which negatively influenced the therapeutic outcomes (Butow et al., 2010). In addition, experiences of severe distress may affect the normal psychological development, generating some long-term mental health problems (Abrams, Hazen & Penson, 2007; Wu, Chin, Haase &Chen , 2009).

The psychosocial interventions were essential in order to reduce the distress and improve quality of life in young cancer patients; in this sense, we exemplify with:

  • Cognitive-behavioral therapy (CBT), which has been shown to be effective in reducing symptoms of anxiety and depression, thus improving the emotional well-being (Melesse, Chun Chau, & Nan, 2022);
  • Mindfulness techniques, represented by practices such as meditation and controlled breathing, which may help reduce stress and improve the emotional state (Murphy et al., 2022);
  • Psychoeducation and emotional support from the behalf of the family, which may create a more stable and meaningful-sustainable environment for the adolescent (Park, Kyoung Choi, Joo Lyu, Woo Han, & Min Hahn, 2022);
  • Ongoing psychological support programs, such as the long-term psychological counseling, which may provide the ongoing support, helping patients cope with the emotional challenges throughout treatment and recovery (Neylon, Condren, Guerin & Looney, 2023).
  • The educational passport, a tool specially designed in order to ensure the continuity and the adaptation of education, both during treatment and during the reintegration period (Tresman, Brown, Fraser, Skinner & Bailey, 2016; van den Oever et al. 2024).

Material and methods

42 adolescents (18 female and 24 male; 15 years +-1.8 SD) were included in the longitudinal study, to whom were applied: a short scale of distress with 6 items developed by Niță& Popa (2023) and a scale of emotional thermometers (Mitchell, Baker-Glenn, Granger & Symonds, 2010) at the start of the treatment and 6 months after the start of the treatment.

The adolescents participated in the study with informed parental consent.

All participants benefited from the interventions of the non-formal Brain Station program and the formal program of the Hospital School. The parents of the study participants signed the informed consent.

The study was conducted between September 2023 and June 2024. The items that make up the short distress assessment scale (Niță&Popa, 2023, p.295) were :

  • I have a poorer school performance compared to last year
  • I have to force myself to do school activities
  • When I get close to starting to work on homework, I think that I need more time to have the necessary mood
  • I worry about my medical treatments
  • I worry about the side effects of my medical treatments
  • I worry about needle stick pain (injections, tests, infusions, etc.).

The six items were evaluated by the patient using a Likert scale with the following response options: 1. Totally disagree 2. Disagree 3. Neither agree nor disagree 4. Agree 5. Strongly agree.

A visual scale of the emotional thermometers (ET – Emotion Thermometers; Mitchell et al., 2010) was also used to measure the oncological distress, which measures stress, anxiety, depression, anger and the need for help. The five domains were rated by patients using a 10-point Likert scale (0-10).

Research Questions and Objectives

The primary research questions were:

  1. What is the impact of stress, anxiety, depression, anger, and the need for help on distress among adolescents with cancer at the start of treatment?
  2. How do these emotional parameters change after a 6-months intervention period?
  3. What effect does the Brain Station and Hospital School interventions have on reducing the emotional distress over time?

The objectives were to:

  • Assess the baseline levels of the emotional distress, including stress, anxiety, depression, anger, and the need for help.
  • Evaluate changes in these emotional domains after a 6-months intervention period.
  • Determine whether the psychoeducational interventions reduce distress in adolescents.

All participants underwent interventions from the two programs:

  • Brain Station Program: A non-formal intervention program involving cognitive, emotional, and social development activities tailored to adolescents with cancer.
  • Hospital School Program: A formal educational program that continued the academic development of participants while accommodating their medical needs.

The results were processed with the help of the free statistical program JASP 0.17 (https://jasp-stats.org/), using statistical methods of linear regression and the t-test for paired samples, with the aim to evaluate the evolution of the emotional distress, between September 2023 and June 2024 among the adolescents with cancer.

Results

At the beginning of the treatment, the stress had a significant influence on distress, explaining approximately 21.49% of the total variance. The regression coefficient of 0.61 indicated a moderate increase in distress with increasing stress (Table 1).

Table 1

Linear regression – distress (to see Table 1, please click here)

After going through the Brain Station program (Jianu, Niță, Benchea, Petrescu & Vicovan, 2023, pp.23-26) and during the interventions within the Hospital School, at 6 months after the start of treatment, the stress continued to  have a relevant influence on distress,
but this explained only 9.54% of the variance. The regression coefficient of 0.42 suggested a lower influence of this, compared to the start of the treatment period (Table 2).

Table 2
Linear regression – distress after interventions (to see Table 2, please click here)

Paired sample t-test analysis revealed that there was no statistically significant difference between stress level, anxiety level, and need for help at baseline but also at 6 months post-treatment. However, there was a statistically significant difference between the baseline and the 6-month levels of depression, as well as a marginally statistically significant reduction in anger levels between baseline and that period of 6 months also taken into consideration (Table 3).

Tabel 3

Paired sample t-test (to see Table 3, please click here)

The results of this study show that, after 6 months of treatment, adolescents with cancer showed a significant reduction in levels of depression and anger, while levels of stress, anxiety and need for help remained relatively constant. 

Discussions

The results suggest that a multidisciplinary approach is essential for managing distress in adolescents with cancer. The involvement of hospital school teachers showed by Jianu et al. (2023) and the involvement of psychologists, social workers and the medical teams in an integrated treatment plan may significantly reduce distress levels (Osmani, Hörner, Klug &Tanaka, 2023; Niță, Bradu & Popa, 2021). Also, the early and tailored interventions were crucial in order to prevent the development of the severe long-term emotional problems.

Distress among adolescents with cancer is a significant problem that requires a special attention, given its impact on the quality of life and especially on the therapeutic adherence and treatment outcomes.

Multidisciplinary approaches, family support, and tailored psychosocial interventions were essential with the aim to reduce distress and improve quality of life for these patients (Elledge, Leavitt, Hoeft&Albritton, 2024). In this context, the continued collaboration between the health and the education professionals appeared crucial to the development and the implementation of the effective strategies for managing the emotional distress (Hughes et al., 2024).

In the present study, the depression of the studied group was reduced due to the involvement of adolescents in the didactic activities which took into account the valorization and the personal recognition and the understanding of the disease not as a permanent condition, but as a temporary obstacle that may be overcome.

Anxiety in cancer patients was often related to specific fears and concerns that could be more difficult to address through general activities (Ozturk & Toruner, 2022), and their anger may have multiple causes, such as frustrations, trauma or communication difficulties (Miers et al., 2007). Consistent with these findings, the present study identified that psychoeducational interventions had little impact on anger and no significant effect on stress, anxiety, and need for help, thus suggesting that these complex emotions required more specific and more targeted approaches.

The findings of this study aligned with the previous research that emphasized the necessity of addressing psychological distress earlier in cancer treatment. Adolescents with cancer are were particularly vulnerable to developing emotional problems due to the disruption cancer causes in their physical, social, and educational development (Zebrack & Isaacson, 2012). This vulnerability underscored the importance of the early, tailored interventions that focused on mitigating stress and emotional turmoil from the onset of treatment (Sansom-Daly & Wakefield, 2013).

In our study, stress was a significant predictor of distress early on, supporting the idea that interventions focused on stress management, such as mindfulness or cognitive-behavioral strategies, this manner of approaching might be particularly effective during the initial stages of treatment (Kazak et al., 2004). Future research should explore the long-term efficacy of such interventions to better understand their potential in improving their health outcomes and their emotional well-being.

Moreover, while the depression significantly decreased after the six months of treatment, anxiety and anger remained challenging to address, a finding that mirrors the broader literature on the adolescent oncology (Osborn, 2007). The anxiety in this population is often linked to the concerns about the future health, the body image and the social reintegration, all of them requiring more focused psychological interventions like the cognitive-behavioral therapy or the trauma-informed care (Zebrack&Chesler, 2002). Similarly, the anger, often stemming from frustration with the loss of autonomy and control, demands therapeutic approaches that allow to the adolescents to process these emotions constructively (Patenaude&Last, 2001). Our findings highlighted the need for interventions that not only addressed the general emotional needs of adolescents but also specifically targeted the complex feelings like anxiety and anger through a more tailored, individualized support.

Conclusions

This study demonstrated that the psychoeducational interventions had a significant effect in reducing the depressive symptoms among the adolescents with cancer, addressing the objective of assessing whether these interventions may improve patients’ emotional well-being. These interventions provided participants with the necessary tools with the aim to better understand and manage the depressive symptoms, contributing to improved treatment adherence and the quality of life.

Regarding the first research question, which focused on the impact of the stress, anxiety, depression, anger, and need for help on overall distress, the study found that the stress significantly influenced the distress at the start of the treatment, explaining approximately 21.49% of the total variance. This finding confirmed that the early stress management was crucial in reducing the emotional distress, especially in the initial stages of the treatment. While the interventions also contributed to a reduction in anger, the effect was not as strong as it supposed to be, indicating the need for the additional strategies to effectively address anger-related issues.

For the second research question, which examined the emotional changes after six months of intervention, the results showed a significant decrease in depression and a marginal reduction in anger, confirming the positive impact of psychoeducational interventions in the medium term. However, anxiety levels and the need for help remained relatively constant, suggesting that these emotions were more resistant to the general interventions and that they may require more personalized approaches in order to achieve better outcomes.

In relation to the third objective, which aimed to evaluate the impact of the Brain Station and Hospital School programs on reducing distress, the study found that these programs helped improve depression and anger, though the interventions were less effective at reducing anxiety and the need for help. This suggests that while the programs were successful in certain areas, more tailored interventions were needed for complex emotions like anxiety.

This study’s objectives of assessing the emotional distress changes and to identifying the key factors contributing in these circumstances were partially achieved. While the progress was made in reducing depression and anger, the need for more effective strategies targeting anxiety and stress became evident, particularly in the terms of personalizing interventions for the individual patients. Based on these findings, the early multidisciplinary approaches were recommended, incorporating psychoeducational interventions, academic support through the implementation of an educational passport, and more specific therapies to address anxiety and help needs. This integrated support system could optimize both the emotional and the academic outcomes for the adolescent cancer patients.

Competing interests

The authors declare that the research was conducted in the absence of any commercial or financial relation-ships that could be construed as a potential conflict of interest.

Consent to participate/Ethics

The parents of the study participants signed the informed consent.

All information collected were used completely anonymously, exclusively for scientific purposes. This approach strictly complies with Regulation no. 679/2016 of the European Parliament and of the Council of the European Union.

Refecrences

  1. Abrams, A.N., Hazen, E.P. & Penson, R.T. (2007). Psychosocial issues in adolescents with cancer. Cancer Treatment Reviews, 33(7), 622-630. https://doi.org/10.1016/j.ctrv.2006.12.006.
  2. Adams, S.C., Herman, J., Lega, I.C., Mitchell, L., Hodgson, D., Edelstein, K.,…Gupta, A.A. (2021). Young Adult Cancer Survivorship: Recommendations for Patient Follow-up, Exercise Therapy, and Research. JNCI Cancer Spectrum, 5(1).  https://doi.org/10.1093/jncics/pkaa099
  3. Barakat, L.P., Marmer, P.L. & Schwartz, L.A. (2010). Quality of life of adolescents with cancer: family risks and resources. Health Qual Life Outcome,8(63). https://doi.org/10.1186/1477-7525-8-63
  4. Butow, P., Palmer, S., Pai, A., Goodenough, B., Luckett, T., & King, M. (2010). Review of Adherence-Related Issues in Adolescents and Young Adults With Cancer. JCO, 28, 4800-4809.DOI:1200/JCO.2009.22.2802
  5. Elledge, D., Leavitt, A., Hoeft, A. & Albritton, K. (2024). Utilization of the Adolescent and Young Adult Psycho-Oncology Screening Tool in a Pediatric Hospital Adolescent/Young Adult Program. Journal of Adolescent and Young Adult Oncology, doi: 10.1089/jayao.2023.0170
  6. Hughes, L., Taylor, R.M., Beckett, A.E., Lindner, O.C., Martin, A., McCulloch, J.,…& Stark, D.P. (2024). The Emotional Impact of a Cancer Diagnosis: A Qualitative Study of Adolescent and Young Adult Experience. Cancers, 16(7), 1332. https://doi.org/10.3390/cancers16071332
  7. Jianu , M.-M., Niță , E., Benchea , M., & Ghența , M. (2023). Analysis of The Reintegration into the Schools of Origin of Teenagers With Cancer In Romania. British Journal of Multidisciplinary and Advanced Studies, 4(5), 9–18. https://doi.org/10.37745/bjmas.2022.0318
  8. Jianu , M.-M., Niță , E., Benchea , M., Petrescu, G. &Vicovan, A. (2023). Auxiliar pentru activitati nonformale destinat elevilor pacienți. Christiana. pp.23-56
  9. Kazak, A. E., Alderfer, M., Rourke, M. T., Simms, S., Streisand, R.&Grossman, J.R. (2004). Posttraumatic Stress Disorder (PTSD) and Posttraumatic Stress Symptoms (PTSS) in Families of Adolescent Childhood Cancer Survivors. Journal of Pediatric Psychology, 29(3), 211–219. https://doi.org/10.1093/jpepsy/jsh022
  10. Kazak, A. E., Alderfer, M. A., Streisand, R., Simms, S., Rourke, M. T., Barakat, L. P., Gallagher, P., & Cnaan, A. (2004). Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43), 18(3), 493–504. https://doi.org/10.1037/0893-3200.18.3.493
  11. Kosir, U., Wiedemann, M., Wild, J. & Bowes, L. (2018). Psychiatric disorders among adolescent cancer survivors: A systematic review.  European Journal of Public Health, 28(4). https://doi.org/10.1093/eurpub/cky213.698
  12. Lee, O. N. (2024). Psychosocial challenges in adolescents and young adults affected by cancer : a systematic review of qualitative research (T). University of British Columbia. retrieved from https://open.library.ubc.ca/collections/ubctheses/24/items/1.0442079
  13. Melesse, T.G., Chun Chau, J. P. & Nan, M.A. (2022). Effects of cognitive-behavioural therapy on psychological, physical and social outcomes of children with cancer: A systematic review and meta-analysis. Journal of Psychosomatic Research, 157, 110805. https://doi.org/10.1016/j.jpsychores.2022.110805.
  14. Miers, A.C., Rieffe, C., Meerum Terwogt, M. et al.(2007). The Relation Between Anger Coping Strategies, Anger Mood and Somatic Complaints in Children and Adolescents. J Abnorm Child Psychol, 35, 653–664. https://doi.org/10.1007/s10802-007-9120-9
  15. Mitchell, A. J., Baker-Glenn, E. A., Granger, L., & Symonds, P. (2010). Emotion Thermometers Tool (ET)[Database record]. APA PsycTests. https://doi.org/10.1037/t29937-000
  16. Murphy, S., Donma, A.J., Kohut, S.A., et al. (2022). Mindfulness Practices for Children and Adolescents Receiving Cancer Therapies. Journal of Pediatric Hematology/Oncology Nursing, 39(1), 40-48. doi:1177/27527530211056514
  17. Neylon, K., Condren, C., Guerin, S. &Looney, K. (2023). What Are the Psychosocial Needs of Adolescents and Young Adults with Cancer? A Systematic Review of the Literature. Journal of Adolescent and Young Adult Oncology, 12(60), 799-820. doi: 10.1089/jayao.2022.0130
  18. Niță, E., Bradu, D. & Popa, M.C. (2021).The role of psychological support for adolescents with cancer. Anthropological Researches and studies, 11 (1), 15-23. doi: 10.27658/11.1.2, https://www.journalstudiesanthropology.ro/en/the-role-of-psychological-support-for-adolescents-with-cancer/a160/
  19. Niță, E. &Popa, C. (2023). Psihologia oncologică-pediatrică, Academia Română, p.295
  20. Osborn, T. (2007). The psychosocial impact of parental cancer on children and adolescents: a systematic review. Psycho-Oncology, 16, 101-126. https://doi.org/10.1002/pon.1113
  21. Osmani, V., Hörner, L., Klug, S.J.&Tanaka, L.F. (2023). Prevalence and risk of psychological distress, anxiety and depression in adolescent and young adult (AYA) cancer survivors: A systematic review and meta-analysis. Cancer Med, 12, 18354-18367. doi: 1002/cam4.6435
  22. Ozturk, C. S., & Toruner, E. K.(2022). Effectiveness of technology-based psychosocial interventions for child, adolescents and young adults undergoing cancer treatment: A meta-analysis of randomised controlled trials. European Journal of Cancer Care, 31(1), e13515. https://doi.org/10.1111/ecc.13515
  23. Park, M., Kyoung Choi, E., Joo Lyu, C., Woo Han, J.& Min Hahn, S. (2022). Family resilience factors affecting family adaptation of children with cancer: A cross-sectional study. European Journal of Oncology Nursing, 56, 102078. https://doi.org/10.1016/j.ejon.2021.102078.
  24. Patenaude, A.F. & Kupst, M. J. (2005). Psychosocial Functioning in Pediatric Cancer. Journal of Pediatric Psychology, 30(1), 9–27. https://doi.org/10.1093/jpepsy/jsi012
  25. Patenaude, A. F. & Last, B. F. (2001). Cancer and children: Where are we coming from? Where are we going?. Psycho-Oncology, 10(4), 281-283. https://doi.org/10.1002/pon.523
  26. Sansom-Daly, U. M. & Wakefield, C. E. (2013). Distress and adjustment among adolescents and young adults with cancer: An empirical and conceptual review. Translational Pediatrics, 2(4), 167-177. https://doi.org/10.3978/j.issn.2224-4336.2013.10.06
  27. Tresman, R., Brown, M., Fraser, F., Skinner, R. & Bailey, S. (2016). A School Passport as Part of a Protocol to Assist Educational Reintegration After Medulloblastoma Treatment in Childhood. Pediatr Blood Cancer, 63, 1636-1642. https://doi.org/10.1002/pbc.26071
  28. van den Oever, S.R., de Beijer, I.A.E., Kremer, L.C.M. et al.(2024). Barriers and facilitators to implementation of the interoperable Survivorship Passport (SurPass) v2.0 in 6 European countries: a PanCareSurPass online survey study. J Cancer Surviv, 18, 928–940. https://doi.org/10.1007/s11764-023-01335-y
  29. Weiss, K.E., Hahn, A., Wallace, D.P., Biggs, B., Bruce, B.K. &Harrison, T.E. (2013). Acceptance of Pain: Associations With Depression, Catastrophizing, and Functional Disability Among Children and Adolescents in an Interdisciplinary Chronic Pain Rehabilitation Program. Journal of Pediatric Psychology, 38(7), 756-765. https://doi.org/10.1093/jpepsy/jst028
  30. Wu, L.-M., Chin, C.-C., Haase, J.E.&Chen, C.-H. (2009), Coping experiences of adolescents with cancer: a qualitative study. Journal of Advanced Nursing, 65, 2358-2366. https://doi.org/10.1111/j.1365-2648.2009.05097.x
  31. Zebrack, B. & Chesler, M. (2002). Quality of life in childhood cancer survivors. Psycho-Oncology, 11(2), 132-141. https://doi.org/10.1002/pon.569
  32. Zebrack, B. J. & Isaacson, S. (2012). Psychosocial care of adolescent and young adult patients with cancer and survivors. Journal of Clinical Oncology, 30(11), 1221-1226. https://doi.org/10.1200/JCO.2011.39.5467
  33. *** JASP Team. (2023). JASP (Version 0.17) [Computer software]. https://jasp-stats.org
PDF
HTML
Scroll to Top