Interactive Cardiovascular and Thoracic Surgery 2 (2003) 206–209

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Institutional review - Thoracic general

Preoperative attitudes, fears and expectations of non-small cell lung

cancer patients
Peter H. Hollaus, Ingeborg Pucher*, Gerold Wilfing, Peter N. Wurnig, Nestor S. Pridun

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Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Sanatoriumstrasse 2, A-1140 Vienna, Austria
Received 15 November 2002; received in revised form 20 February 2003; accepted 26 February 2003

Abstract
Knowing preoperative fears in cancer patients should help us to overcome perioperative psychological problems. One hundred and three
patients underwent a semistructured interview addressing the effect of preoperative information on disease and forthcoming operation,
attitude towards operation, expectations for the postoperative time and family support. Evaluation was performed by three psychologists by
qualitative structured content analysis according to Mayring. Interrater reliability was 85%. Only 42 patients (40.8%) were informed in detail
about their diagnosis. Eighty-three patients (80.6%) considered the information given on their disease and the forthcoming operation as
understandable, 57 patient (55.3%) experienced reduction of fear. Eighty-three patients (80.6%) showed a positive attitude to the operation,
21 (20.4%) expected an impairment of later life after operation although becoming healthy again. Diffuse fears were named in 47 cases
(45.6%), 19 (18.4%) patients were afraid of metastases, 11 (10.7%) of postoperative death, 19 (18.4%) of pain, 11 (10.7%) of mutilation and
17 (16.5%) of surgical complications. Seventy-three patients (70.9%) had good family support, seven (6.8%) not. Of the support group 32
patients (31%) considered their relatives’ empathy as onerous. Problems, that are self-evident to the attending staff may be insurmountable
for the patients. If we succeed to overcome their most simple fears they can focus their energy on mastering the postoperative course.
q 2003 Elsevier Science B.V. All rights reserved.
Keywords: Preoperative fears; Preoperative expectations; Family problems; Non small cell lung cancer

1. Introduction 2. Patients and methods

The preoperative situation is a unique setting for every
patient and represents an extreme emotional stress. The time
until operation is inspired with numerous fears and concerns
related to the underlying disease and the imminent
operation. It is aggravated in cancer patients who face the
risk of inoperability, and, if operable, have to await the final
pathology report before the success of the intervention can
be judged – another period of several days of uncertainty,
hope and new fears.
The knowledge of these sorrows should help us to
alleviate them when preoperative instruction is given and to
improve the relationship between surgeon and patient.
* possibility of exploratory thoracotomy in case of question-
Corresponding author. Institute of Medical Psychology, University of
Vienna, Severingasse 9, A-1090 Vienna, Austria. Tel.: þ43-1-4277-65624;
fax: þ 43-1-4277-9656.
E-mail address: ingeborg.pucher@akh-wien.ac.at (I. Pucher).
1569-9293/03/$ - see front matter q 2003 Elsevier Science B.V. All rights reserved.
doi:10.1016/S1569-9293(03)00048-3
A total of 103 patients scheduled for lung surgery for
NSCLC between March 1997 and August 1998 were
recruited for participation. No patient had undergone
thoracic surgery before. Exclusion criteria comprised
major psychiatric illness, emergency cases, preoperative
mediastinoscopy, neoadjuvant chemotherapy, neuroendo-
crine carcinoma grade I and grade III and pulmonary
metastasis originating from an extrapulmonary primum and
if the patient was not German-speaking. Additionally,
patients living more than 150 km from the hospital were
excluded to allow optimal follow-up.
Routine preoperative instruction included: position and
length of surgical incision, extent of resected lung volume
including the possibility of pneumonectomy (this point was
discussed in relation to the preoperative spirometry), the
able anatomical or functional resectability. Concerning the
postoperative period the importance of physiotherapy,
cooperation with the medical staff, adequate pain therapy
 P.H. Hollaus et al. / Interactive Cardiovascular and Thoracic Surgery 2 (2003) 206–209 207

and the danger of postoperative pneumonia were stressed. Table 1

As possible complications bleeding with rethoracotomy, Demographic data and education
infection of skin, empyema, bronchopleural fistula, and Age (years) 39–82 (mean 61.2 ^ 9.03)
recurrent laryngeal nerve damage in case of left sided Sex
resections were discussed. Patients were informed that the Male 66 (64%)
final evaluation of their tumor stage was only possible after Female 37 (36%)
Living alone 32 (31%)
the arrival of the final pathology report.
Marital status
A semi-structured interview was conducted one to six Single 11 (10.7%)
days before operation. In all cases the patients had been Married 61 (59.2%)
informed about their disease and the forthcoming operation. Divorced 13 (12.6%)
The interview is shown in Appendix A. It was conducted by Widowed 18 (17.5%)
Education
an experienced psychologist in a separated room to provide Grade I: professional (e.g. doctor) 6 (5.8%)
an optimal atmosphere for a free and unconstrained

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conversation, took between 10 and 20 min and was tape
recorded.
The interview was written down and underwent quali-
tative content analysis according to Mayring [1], which we
describe briefly: the object of qualitative content analysis
can be all sort of recorded communication (transcripts of
interviews, discourses, protocols of observations, video
tapes, documents, etc.). Content analysis analyzes not only
the manifest content of the material, as its name may
suggest, but additionally intends to identify contents at its
differentiated levels: themes and main ideas of the text as
primary content, context information as latent content.
Contents were identified and coded according to the
following criteria:
Positive verbalization: a subject-matter is expressed
directly or mentioned indirectly. In the latter case it
can be definitely identified in the context, although not
being mentioned literally.
Negative verbalization: the content is strictly neglected.
Conflicting verbalization: a subject-matter is positively
expressed but immediately rejected in the following
sentence.
The identification of different subject matters and their
expressions was performed independently by three psychol-
ogists and their results compared. In case of contradictory
ratings the interview passages were reevaluated and
discussed in the panel in order to achieve a consensus.
Either the researchers finally agreed or the content had to be
newly evaluated.
Interrater reliability was established by having all
investigators independently evaluate participants’
responses. The investigators agreed on 85% of the initial
coding categories. Subsequent discussion led to agreement
by the researchers regarding the final data coding.
3. Results
Age, sex, demographic data and educational status are
Grade II: intermediate (e.g. teacher) 5 (4.8%)
Grade III: skilled (e.g. secretary) 17 (16.6%)
Grade IV: partly skilled (e.g. agricultural 53 (51.5%)
worker)
Grade V: unskilled (laborer) 16 (15.5%)
Missing 6 (5.8%)
shown in Table 1 [2,3]. Five patients (4.8%) underwent
exploratory thoracotomy. They were not interviewed again.
3.1. Preoperative information on disease and forthcoming
operation
Ninety-two patients (89.3%) had been informed by their
physician, eight (7.8%) by non-doctors; three (2.9%)
patients did not know by whom they had been informed.
Forty- four patients (42.7%) simply knew the name of
their illness, 42 patients (40.8%) were informed in detail
about their diagnosis, five patients (4.8%) thought that the
definitive diagnosis could only be obtained after surgery; in
12 patients (11.7%) their answers could not be classified.
Eighty-three patients (80.6%) considered the information
given on their disease and the forthcoming operation as
understandable. Nine patients (8.7%) were rather confused
and in 11 patients (10.7%) no information could be obtained
on how they had experienced the given information.
However, only 57 patients (55.3%) experienced reduction
of fear. Fourteen (13.6%) felt disquieted, one (1%)
ambivalent, and 31 (30%) felt indifferent after the
information.
3.2. Attitude towards operation
Eighty-three patients (80.6%) showed a positive attitude
to the operation; of these 35 (34%) spontaneously negated
preoperative fears. Ten (9.7%) had had positive experiences
after previous other operations, eight (7.8%) were encour-
aged by their roommates. However, nine patients (8.7%)
who had had negative experiences with doctors before were
rather skeptical and even showed a negative attitude towards
the medical staff. Twenty-two men (21.3%), but only 15
women (14.5%), spontaneously mentioned preoperative
fear. Twenty men (19.4%) and 13 women (12.6%) negated
208 P.H. Hollaus et al. / Interactive Cardiovascular and Thoracic Surgery 2 (2003) 206–209
Table 2
Directly and indirectly verbalized preoperative fears (multiple statements
by a single patient were possible)
Fears Direct Indirect
Diffuse 37 10
Metastases 8 11
Postoperative death 4 7
Pain 14 5 19 (18.4%)
Mutilation 3 8
Acceleration of tumor growth 3 0
Surgical complication 5 12
Total 84 53
preoperative fears. The fears identified are shown in Table
2.
3.3. Expectations for the postoperative time
Thirty-five patients (34%) expected to become healthy
again, while 21 (20.4%) expected an impairment of later life
after operation although becoming healthy again. Seven
(6.8%) patients expected to die from cancer. The rest could
not be classified.
Most patients considered several factors important for a
favorable course of their disease. Optimism and trust for the
future was mentioned 57 times (55.3%), changing of life
habits in 60 cases (58.3%) (e.g. cessation of smoking,
sports, healthy nutrition). Forty-three patients (41.7%)
intended to profit from their relatives’ empathy and support,
37 (35.9%) relied on good medical compliance, and 26
(25.2%) on positive thinking and a strong will to survive.
3.4. Family support
Seventeen patients (16.5%) gave no classifiable answers.
Six patients (5.8%) had no families or friends. Seventy-three
patients (70.9%) stressed that they received good support
and empathy by their family, seven (6.8%) did not.
Nevertheless, 32 patients (31%) stated that they considered
their relatives’ empathy as onerous, because they reacted
with more shock and fear than the patients themselves.
Those patients receiving support by their family (n ¼ 73)
could be divided into two groups. Forty-six patients (44.7%)
gratefully accepted the support of their family (support
group). The non-support group consisted of 27 patients
(26.2%), who rejected their relatives’ support due to several
reasons: 16 (15.5%) considered themselves as loners, 11
(10.7%) wanted to spare their relatives due to different
reasons.
4. Discussion
The communication of cancer diagnosis is one of the
most difficult tasks in medicine. Much of cancer patients’
dissatisfaction with the exchange of information stems from
a lack of concordance between the perceptions of patients
and doctors [4]. Even if the physician might think that the
delivered information is sufficient this may not be the case
Total for the patient himself. Although all our patients had been
informed about their disease, only a small part of them had
47 (45.6%) received sufficient information, a fact which is supported by
19 (18.4%) the literature [5].
11 (10.7%)
The same applies to routine preoperative instruction.
11 (10.7%) Only 50% of our patients experienced a reduction of fear
3 (2.9%) after preoperative instruction. The presence of preoperative
17 (16.5%) anxiety is almost universal in the preoperative patient, no
127 matter which diagnosis is present. It is influenced by
uncertainty about the impending procedure, by past
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experiences of anesthesia and surgery and by suggestions
of family, friends and fellow-patients and can be reliably
measured by the release of catecholamines [6]. Patients,
only recently having been informed about their diagnosis of
lung cancer, usually are overwhelmed by the bad news and
enter different phases of coping, which may not be
completed when routine preoperative instruction is given.
Therefore they may retain very little of the preoperative
information, which serves to heighten anxiety and uncer-
tainty [5].
Our results suggest that our communication techniques
need to be refined: The optimal scenario would be if the
patient himself repeats the previously given information and
the doctor completes missing details. This prevents
misunderstandings due to medical terminology which the
patient is not familiar with. Further patients should be
encouraged to discuss their main concerns without inter-
ruption [7].
Nearly half of all preoperative fears identified during the
interview were diffuse. Thus the majority of patients are not
able to specify their worries. The content analysis according
to Mayring proved to be very useful to identify uncon-
sciously expressed fears.
We did not expect to be confronted with this rather high
rate of fear of mutilation, pain or death due to operation and
surgical complications. Addressing these fears helped to
alleviate them during routine preoperative instruction.
However, detailed explanations do not seem to reduce
anxiety more than a relatively brief explanation [8].
Therefore it is not important how much is said but what is
said. We must address the features of the disease and the
forthcoming operation worrying the patient [9] without
introducing new concerns.
The fact that only 35% of our patients expected cure from
their disease is worrisome, and it is to be asked why the
remaining 65% are accepting an operation that does not cure
them. The goal of surgery is taken for granted by the
surgeon but obviously not by the patient, and therefore was
not explained sufficiently either. Why patients only expect
to be cured in 35%, but to die from cancer only in 7.5%, is a
contradiction for which we have no explanation.
The change of lifestyle should be accepted as an
individual way of coping. In fact only cessation of smoking
 P.H. Hollaus et al. / Interactive Cardiovascular and Thoracic Surgery 2 (2003) 206–209
should be advised. All other possibilities are an expression
of adapting one’s life to completely new circumstances.
Our number of one third of our patients belonging to the
non-support group is confirmed by the literature [10]. The
problem is a rather complex one and only some features can
be addressed in this discussion: Partners have a more
negative view of the cancer diagnosis and experience
greater anxiety and depression [11]. The fear of recurrence
and general health worries continue for patients and spouses
well after diagnosis [12]. Spouses often do not know how to
help to alleviate the suffering that they observe in their
partners [13,14]. Patients have greater difficulty in adjusting
in terms of family relationships [15] and have concerns how
their families, especially their spouses, would handle the
new situation [10].
We must accept that the diagnosis of lung cancer initiates
different coping mechanisms in spouses and patients which
are not yet completed when surgery takes place. It is
obvious that partners are less frequently accessible and their
needs may be less apparent. However, the family is a
system. A crisis affects each family member and the family
as a whole. This should be considered if information is
given to spouses and family members and if tensions
between patients and their family are observed.
5. Conclusion
Even if the diagnosis of cancer has already been
communicated by another physician, the patient should be
asked whether he had received appropriate information. It is
advisable to explore the patients’ family situation preopera-
tively and to distinguish between support and non-support
patients to avoid intrafamilial tensions caused by inadequate
information given to family members. During preoperative
instruction the most simple fears should be addressed if the
patient remains anxious. People who had bad experiences
during previous operations will react more distrustfully and
less cooperatively unless their fears are addressed.
Acknowledgements
We are very grateful for the financial support of the
Wiener Krebshilfe during this study.
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Appendix A
† Who communicated the diagnosis of cancer to you?
† Have you received sufficient information about your
disease? Were there any questions left unanswered?
† How did you experience the given information?
† What are your feelings when you think of the forth-
coming operation?
† Do you think that surgery will help you?
† What are your expectations for the time after surgery?
† What do you consider important for becoming healthy
again?
† How did your relatives and friends react when you told
them about your disease?
† Did their behavior change?
† Do you feel that your family understand and support
you?
† Being together with your family can you express your
emotions ?
† How do you experience your relatives’ and friends’
empathy? Do you need it or do you reject it?