Journal of the Academy of Consultation-Liaison Psychiatry 2021:62:595–605

ª 2021 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.

Original Research Article

Correlates of Psychological Distress in Patients

With Cancer at a Psycho-oncology Clinic

Harin Kim, M.D., C. Hyung Keun Park, M.D., Ph.D., Yangsik Kim, M.D., Ph.D.,
Yeonho Joo, M.D., Ph.D.

Background: Patients with cancer experience significant
psychological distress. Most studies investigated indi-
vidual risk factors for distress in their respective treat-
ment setting, which limit generalizability of results or
comparison of relative importance. Objective: To inves-
tigate the relation between psychological distress in pa-
tients referred to a psycho-oncology clinic and its
correlates in a comprehensive manner. Method: Medical
charts of patients who visited the psycho-oncology clinic
at a tertiary hospital from May 2019 to May 2020 were
reviewed. Demographic, cancer-related, and psychiatric
factors; health-related quality of life; and somatic pain
were investigated. The Hospital Anxiety and Depression
Scale, item 9 on the Patient Health Questionnaire-9,
Functional Assessment of Cancer Therapy-General,
Present Pain Intensity, and Distress Thermometer were
measured at the index visit. Simple and multiple linear
regression analyses were performed with the Distress
Thermometer score as a dependent variable. Results: A
total of 454 patients were included. The univariate
analyses showed age and physical, emotional, and func-
tional well-being scores on the Functional Assessment of
Cancer Therapy-General were negatively associated with
the Distress Thermometer scores, while female genital
cancer, advanced disease, recent radiotherapy, the Hos-
pital Anxiety and Depression Scale score, and the Pre-
sent Pain Intensity score showed a positive relation.
After adjusting for all other variables, female genital
cancer (P = 0.027), anxiety subscale of the Hospital
Anxiety and Depression Scale (P , 0.001), the Present
Pain Intensity (P = 0.002), and physical (P , 0.001)
and functional (P = 0.019) well-being subscales of the
Functional Assessment of Cancer Therapy-General
remained significant. Conclusions: Patients with cancer
who visited a psycho-oncology clinic experienced more
distress if they had female genital cancer, low health-related
quality of life score, severe anxiety, or somatic pain.
(Journal of the Academy of Consultation-Liaison Psy-
chiatry 2021; 62:595–605)

Key words: anxiety, cancer, pain, psychological distress, psycho-oncology, quality of life.

INTRODUCTION
Cancer is a leading cause of death, accounting for 158.2
deaths per 100,000 of the general population in South
Korea.1 Although the incidence and mortality rates
have been decreasing in recent years, the improvement
in survival inevitably leaves a long-term disease
burden2 and psychological distress from cancer, which
is accepted as a field that requires clinical attention.3
Received February 24, 2021; revised May 4, 2021; accepted May 26,
2021. From the Department of Psychiatry (H.K., C.H.K.P., Y.J.), Asan
Medical Center, Seoul, Korea; Department of neuropsychiatry (Y.K.),
National Center for Mental Health, Seoul, Korea; College of Medicine
(H.K., Y.J.), University of Ulsan, Seoul, Korea. Send correspondence
and reprint requests to Yeonho Joo, MD, PhD, Department of Psychi-
atry, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul,
Korea; e-mail: jooyeonho@gmail.com
ª 2021 Academy of Consultation-Liaison Psychiatry. Published
by Elsevier Inc. All rights reserved.

Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021 595

Correlates for Distress in Cancer Patients
Patients with cancer experience significant psy-
chological distress, which is usually interpreted as psy-
chiatric comorbidities. It is commonly manifested as
anxiety or depression, followed by adjustment prob-
lems, and posttraumatic stress.4,5 Distress from cancer
is highly common; more than half of patients with
cancer experience psychological distress.6 Overall
prevalence does not change regardless of the disease
continuum, whereas the rate is affected by the prog-
nosis, type of cancer, and terminal stage of the dis-
ease.7,8 Psychological distress might be associated with
patients’ resistance to cancer, which could have an
impact on longer recurrence-free periods and overall
survival.9
The clinical importance of distress in patients with
cancer has grown significantly in recent decades. The
Distress Thermometer (DT) was developed by the
National Comprehensive Cancer Network to quickly
identify patients with significant distress. As the Visual
Analogue Scale was routinely used in clinical practice
and resulted in the improvement of pain management
in the United States, the DT was developed to enable
patients with cancer to rate their distress level, thus
facilitating communication between medical staff and
patients. As a result, emotional distress was also
approved as the sixth vital sign in Canada.3,10 The DT
is an efficient measure because it consists of a single
item that assesses subjective distress of patients with
cancer in the past week. The Problem List with the DT
enables patients to indicate their psychosocial
stressors including practical, familial, emotional,
spiritual/religious, and physical domains. Previous
studies have validated the DT as a screening tool in
many clinical settings. Subsequently, the DT has
become one of the most widely used screening tools
for detecting psychological distress.11 When high
scores on the DT are detected, patients could be
referred to mental health professionals to further
evaluate and manage their distress. Therefore, the DT
score could represent clinically relevant impression of
overall severity of mental health problems in patients
with cancer.
Research on psychological distress in patients with
cancer suggested that demographic,12,13 disease-spe-
cific,14,15 treatment-related,16 health-related quality of
life (HRQOL),17 and psychological factors18,19 are
associated with a higher level of distress. Most studies
were performed during routine oncological care or
psychosocial screening programs,7 and a few studies
596 Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021
confirmed psychiatric diagnosis with structured in-
terviews by trained personnel.20,21 Moreover, they
investigated individual risk factors for distress in their
respective treatment settings, which could limit gener-
alizability of results or comparison of relative
importance.
In this study, we aimed to investigate which
clinical characteristics should be considered most
significant in patients with cancer who visited a
psycho-oncology clinic. We included a wide range
of demographic, cancer-related, and psychiatric
characteristics, as well as perceived HRQOL in the
analysis.
METHODS
Subjects
Medical charts of patients aged 18 years or older who
visited the Asan Stress Clinic for Cancer Patients, a
psycho-oncology outpatient clinic in Asan Medical
Center, Seoul, Korea, were reviewed. A person with
any kind of cancer could visit this psycho-oncology
clinic. Patients with psychiatric symptoms were typi-
cally referred by other clinicians involved in cancer
treatment, among whom oncologists accounted for the
majority. They could also visit the clinic if they were in
need of psycho-oncology care. A self-report question-
naire was provided as a routine procedure to evaluate
psychiatric symptoms and other clinically relevant
characteristics. We thoroughly investigated demographic
and other clinical factors at the first visit from May 2019
to May 2020.
Index visit was defined as the first visit during the
observation period. Cases were not included if the pa-
tient refused to complete the survey, was medically
unstable such that psychiatric interview could not be
proceeded, was 80 years old or older, or was not fluent
in Korean language. The Institutional Review Board at
Asan Medical Center approved our work (IRB no.
2020-1721). Informed consent was waived, as our
research was conducted retrospectively.
Measures
Demographic and Cancer-Related Factors
Age and sex data at the time of the index visit were
collected. Cancer-related factors included index cancer
sites, multiple cancer diagnoses (either single cancer

diagnosis or double primary cancers), time interval
between index visit and index cancer diagnosis, disease
status (defined as active disease or disease-free status),
advanced disease (covering both metastatic and
recurred cancer), and brain metastasis. Treatment mo-
dalities including surgery, chemotherapy, radiotherapy,
and other therapy in the past 2 months were reviewed.
“Other therapy” included a combination of hormone
therapy, immunotherapy, and targeted therapy. More
details of the cancer-related variables are provided in
the Supplemental Material.
Psychiatric Diagnosis and Symptom Scales
Patients were evaluated for comorbid psychiatric dis-
orders by 3 different board-certified consultation-
liaison psychiatrists. The diagnoses were established
according to the Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition, during routine psychi-
atric interviews.22 Primary psychiatric diagnosis was
selected in case of multiple psychiatric diagnoses. The
Hospital Anxiety and Depression Scale (HADS) was
applied to assess the degree of anxiety (HADS-A) and
depressive (HADS-D) symptoms. Item 9 of the Patient
Health Questionnaire-9 was used to evaluate the fre-
quency of suicidal ideation in the past 2 weeks.
Health-Related Quality of Life
We used the Functional Assessment of Cancer
Therapy-General (FACT-G), a 5-point Likert scale, for
evaluating HRQOL. The FACT-G represents physical
well-being (PWB), social/family well-being, emotional
well-being, and functional well-being (FWB).
Somatic Pain
The Present Pain Intensity (PPI), a one-item self-report
measure, was used to evaluate the severity of somatic
pain. The score ranges from 0 (none) to 5 (excruciating).
Psychological Distress (Primary Outcome)
The DT ranges from 0 (no distress) to 10 (extreme
distress) and is used as primary outcome as previously
suggested.23 We compared the DT score before and after
the first case of coronavirus disease 2019 (COVID-19) in
South Korea, which was officially announced on 20
January 2020 because the study spanned the COVID-19
pandemic. Details of scales discussed previously are
further provided in the Supplemental Material.
Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021
Kim et al.
Statistical Analyses
We used Student’s t-test for continuous variables and
Pearson’s c2 test for categorical variables. We excluded
patients from further analysis if the DT score was
missing. The representativeness of the sample was
evaluated via direct comparison of the characteristics of
subjects with complete and missing patient data.
We conducted univariate linear regression using
the DT score as a dependent variable. The independent
variables were as follows: age, sex, cancer-related fac-
tors, psychiatric diagnosis, scores on the HADS, item 9
of the Patient Health Questionnaire-9, 4 subscales of
the FACT-G, and the PPI. A P value , 0.1 was
considered clinically significant and adopted for multi-
variate analysis. Other clinical variables that were
considered clinically relevant were also included as in-
dependent variables in multivariate regression, using
the DT score as a dependent variable. A P value , 0.05
was considered statistically significant. All statistical
analyses were performed using IBM SPSS Statistics for
Windows, version 24.0 (IBM Corp., Armonk, NY).
RESULTS
Comparison of Subjects with Complete and Missing
Patient Data
A total of 740 patients visited the psycho-oncology
clinic during the observation period. Those who did
not complete self-report questionnaires including the
DT for any kind of reasons were categorized as patients
with missing data. Patients with complete patient data
(n = 454) and those with missing patient data (n = 286)
were directly compared (Table 1). A female predomi-
nance was observed in both groups while patients with
complete data consisted of younger patients
(mean = 55.0 y, standard deviation [SD] = 11.9 vs.
mean = 58.0 y, SD = 12.0; P = 0.001).
In patients with complete data, breast cancer
(43.0%) and cancer in the digestive system (31.7%)
accounted for the majority, followed by cancers in the
thorax (9.0%), hematolymphoid (5.9%), urinary and
male genitalia (4.0%), female genitalia (2.6%), and
others (3.7%). “Others” included cancers in the head
and neck (1.5%), soft tissue and bone (0.9%), endocrine
system (0.7%), central nervous system (0.4%), and skin
(0.2%). The time interval between the index cancer
diagnosis and index visit was shorter (mean = 30.5
597
Correlates for Distress in Cancer Patients

TABLE 1. Comparison of the Characteristics of Eligible Subjects With Complete Patient Data and Those With Missing Patient Data
Variables Patient data Statistics (c2 or t) P
Missing (n = 286) Complete (n = 454)
Demographic factors
Sex, n (%) 2.116 0.146
Female 187 (65.4) 320 (70.5)
Male 99 (34.6) 134 (29.5)
Age, M (SD), y 58.0 (12.0) 55.0 (11.9) 3.354 0.001†
Cancer-related factors
Index cancer site, n (%) 13.704 0.033*
Breast 101 (35.3) 195 (43.0)
Digestive system 84 (29.4) 144 (31.7)
Thorax 23 (8.0) 41 (9.0)
Hematolymphoid 29 (10.1) 27 (5.9)
Urinary and male genitalia 18 (6.3) 18 (4.0)
Female genitalia 15 (5.2) 12 (2.6)
Other 16 (5.6) 17 (3.7)
Multiple cancer diagnosis, n (%) 0.948 0.623
No 253 (88.5) 411 (90.5)
Yes 33 (11.5) 43 (9.5)
Time interval between index visit and 38.9 (47.3) 30.5 (37.4) 2.556 0.011*
index diagnosis, M (SD), months
Disease status, n (%) 0.186 0.666
Disease free 164 (57.3) 253 (55.7)
Active disease 122 (42.7) 201 (44.3)
Advanced disease, n (%) 0.096 0.757
No 179 (62.6) 279 (61.5)
Yes 107 (37.4) 175 (38.5)
Brain metastasis 4.240 0.039*
No 263 (92.0) 434 (95.6)
Yes 23 (8.0) 20 (4.4)
Surgery (past # 2 months), n (%) 2.411 0.121
No 259 (90.6) 394 (86.8)
Yes 27 (9.4) 60 (13.2)
Chemotherapy (past # 2 months), n (%) 13.83 ,0.001‡
No 214 (74.8) 279 (61.6)
Yes 72 (25.2) 174 (38.4)
Radiotherapy (past # 2 months), n (%) 1.302 0.254
No 268 (93.7) 415 (91.4)
Yes 18 (6.3) 39 (8.6)
Other therapy (past # 2 months), n (%) 0.040 0.841
No 178 (62.2) 284 (63.0)
Yes 108 (37.8) 167 (37.0)
Psychiatric factors
Diagnosis, n (%) 21.838 0.003†
Depressive disorder 100 (35.0) 134 (29.5)
Sleep-wake disorder 63 (22.0) 121 (26.7)
Adjustment disorder 38 (13.3) 98 (21.6)
Anxiety disorder 24 (8.4) 37 (8.1)
Delirium 22 (7.7) 11 (2.4)
Bipolar disorder 14 (4.9) 18 (4.0)
Other 20 (7.0) 25 (5.5)
None 5 (1.7) 10 (2.2)
HADS-D, M (SD) 9.8 (4.2) 9.9 (4.4) 20.239 0.812
HADS-A, M (SD) 9.2 (4.9) 9.7 (4.9) 20.826 0.409
PHQ-9 Item 9 ($1), n (%) 115 (40.2) 430 (94.7) 268.6 ,0.001‡
Health-related quality of life
FACT-G PWB, M (SD) 17.6 (6.6) 17.4 (6.4) 0.434 0.664
FACT-G SWB, M (SD) 13.2 (6.1) 15.0 (6.4) 22.889 0.004†
FACT-G EWB, M (SD) 11.9 (6.1) 13.3 (6.3) 22.103 0.036*

598 Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021


TABLE 1. (Continued)
Variables Patient data
Missing (n = 286)
FACT-G FWB, M (SD) 12.2 (5.9)
Somatic pain
PPI, M (SD) 1.4 (1.0)
EWB = emotional well-being; FACT-G = Functional Assessment of Cancer Therapy-General; FWB = functional well-being; HADS =
Hospital Anxiety and Depression Scale, A = anxiety symptoms, D = depressive symptoms; M = mean; PHQ-9 = Patient Health
Questionnaire-9; PPI = Present Pain Intensity; PWB = physical well-being; SD = standard deviation; SWB = social/family well-being.
* Significant findings at P , 0.05.
†
Significant findings at P , 0.01.
‡
Significant findings at P , 0.001.
months, SD = 37.4 vs. mean = 38.9 months, SD = 47.3;
P = 0.011). They were also less likely to have metastatic
brain tumors (4.4% vs. 8.0%, P = 0.039) and more
likely to have had chemotherapy within the past 2
months (38.4% vs. 25.2%, P , 0.001).
Psychiatric diagnosis differed between the 2 groups
(P = 0.003). In the complete patient data group, more
patients were diagnosed with sleep-wake disorder
(26.7% vs. 22.0%) and adjustment disorder (21.6% vs.
13.3%), but fewer patients were diagnosed with
depressive disorder (29.5% vs. 35.0%). They were more
likely to score one or higher on item 9 of the Patient
Health Questionnaire-9 (94.7% vs. 40.2%, P , 0.001),
higher on the social/family well-being (mean = 15.0,
SD = 6.4 vs. mean = 13.2, SD = 6.1; P = 0.004), and
emotional well-being (mean = 13.3, SD = 6.3 vs.
mean = 11.9, SD = 6.1; P = 0.036).
Relation Between Baseline Characteristics and DT
Scores
A total of 454 patients with complete patient data were
included in the analysis. The mean DT score did not
differ significantly before and after the first COVID-19
case in South Korea (P = 0.336); 351 (77.3%) patients
were assessed before (mean = 4.4, SD = 2.8), and 103
(22.7%) patients were assessed after the first COVID-19
case (mean = 4.7, SD = 2.8). Univariate analysis
showed that several variables were significantly associ-
ated with the DT score (Table 2). We found a negative
association between age and the DT score (P = 0.013).
Patients who had a female genital cancer (P = 0.003) as
opposed to breast cancer, an advanced disease
(P = 0.065), and recent radiotherapy (P = 0.048) had
higher DT scores. A diagnosis of sleep-wake disorder,
Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021
Kim et al.
Statistics (c2 or t) P
Complete (n = 454)
11.9 (5.6) 0.447 0.655
1.5 (1.1) 20.615 0.539
adjustment disorder, or no psychiatric diagnosis
showed a negative association with the DT score
(P , 0.001) when compared with a diagnosis of
depressive disorder. In addition, the HADS and PPI
scores were positively related to the DT scores, whereas
scores on PWB, emotional well-being, and FWB
showed a negative relation (P , 0.001).
In the multivariate analysis, the positive relation
between female genital cancer and the DT scores
remained significant (P = 0.027), when breast cancer
was used as a reference. Similarly, the HADS-A
(P , 0.001) and PPI (P = 0.002) scores had a positive
association with the DT score, whereas a negative
relation with scores on PWB (P , 0.001) and FWB
(P = 0.019) domains of the FACT-G remained signif-
icant (Table 3). The model showed an adjusted R2 of
56.8%.
DISCUSSION
We analyzed the data of 454 patients with an average age
of 55 years, of whom more than two-third were female.
Breast cancer and cancer in the digestive system accoun-
ted for the majority of index cancer sites. More than half
of the patients reported a disease-free status at the time of
the index visit, although 61.5% had been diagnosed with
advanced disease initially. Depressive, sleep-wake, and
adjustment disorders were the most prevalent psychiatric
diagnoses. The average HADS-D and HADS-A scores
were 9.9 and 9.7, respectively, exceeding the cutoff score
of 8. The patients were experiencing mild to discomfort-
ing pain on average, and a large proportion of them re-
ported having thought they would be better off dead or
hurting themselves for at least several days in the past 2
599
Correlates for Distress in Cancer Patients

TABLE 2. Simple Linear Regression Analysis Using the Distress Thermometer Scores of 454 Patients With Cancer as a Dependent Variable
Variables Unstandardized Standardized coefficients t P
coefficients
Coefficient (B) SE Beta
Demographic factors
Age 20.028 0.011 20.116 22.483 0.013†
Male 20.469 0.290 20.076 21.616 0.107
Cancer-related factors
Index cancer site
Breast Reference
Digestive system 0.033 0.308 0.005 0.108 0.914
Thorax 20.101 0.481 20.010 20.209 0.834
Hematolymphoid 20.393 0.575 20.033 20.682 0.495
Urinary and male genitalia 20.967 0.690 20.067 21.400 0.162
Female genitalia 2.533 0.833 0.144 3.040 0.003†
Other 0.769 0.709 0.052 1.085 0.279
Multiple cancer diagnosis 0.499 0.453 0.052 1.101 0.272
Time interval between index visit and index diagnosis 20.001 0.004 20.018 20.373 0.710
Active disease status 0.429 0.267 0.075 1.610 0.108
Advanced disease 0.503 0.272 0.087 1.852 0.065*
Brain metastasis 0.207 0.647 0.015 0.320 0.749
Surgery (past # 2 months) 0.612 0.391 0.073 1.565 0.118
Chemotherapy (past # 2 months) 20.120 0.273 20.021 20.437 0.662
Radiotherapy (past # 2 months) 0.937 0.472 0.093 1.987 0.048†
Other therapy (past # 2 months) 0.404 0.276 0.069 1.468 0.143
Psychiatric factors
Diagnosis
Depressive disorder Reference
Sleep-wake disorder 22.277 0.336 20.357 26.771 ,0.001‡
Adjustment disorder 21.248 0.356 20.182 23.501 ,0.001‡
Anxiety disorder 20.467 0.498 20.045 20.937 0.349
Delirium 0.062 0.841 0.003 0.073 0.942
Bipolar disorder 20.908 0.673 20.063 21.349 0.178
Other 20.935 0.584 20.076 21.600 0.110
None 23.275 0.879 20.170 23.725 ,0.001‡
HADS-D 0.384 0.025 0.597 15.227 ,0.001‡
HADS-A 0.374 0.022 0.645 17.276 ,0.001‡
PHQ-9 Item 9 ($1) 0.266 0.593 0.021 0.449 0.654
Health-related quality of life
FACT-G PWB 20.270 0.016 20.611 216.402 ,0.001‡
FACT-G SWB 20.029 0.021 20.066 21.412 0.159
FACT-G EWB 20.299 0.019 20.594 215.623 ,0.001‡
FACT-G FWB 20.237 0.021 20.471 211.239 ,0.001‡
Somatic pain
PPI 1.216 0.109 0.476 11.163 ,0.001‡

P , 0.1 is considered significant.

EWB = emotional well-being; FACT-G = Functional Assessment of Cancer Therapy-General; FWB = functional well-being; HADS =
Hospital Anxiety and Depression Scale, A = anxiety symptoms, D = depressive symptoms; PHQ-9 = Patient Health Questionnaire-9;
PPI = Present Pain Intensity; PWB = physical well-being; SE = standard error; SWB = social/family well-being.
* Significant findings at P , 0.1.
†
Significant findings at P , 0.05.
‡
Significant findings at P , 0.001.

weeks. Nonetheless, no case of suicide attempt or radiotherapy; sleep-wake and adjustment disorders
completed suicide was reported. (compared with depressive disorder); and scores on the
Results showed age; female genital cancer (compared HADS-D and HADS-A, the FACT-G, and the PPI
with breast cancer); advanced disease; recent were associated with the DT scores. After adjusting for

600 Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021

 Kim et al.

TABLE 3. Multiple Linear Regression Analysis Using the Distress Thermometer Scores of 454 Patients With Cancer as a Dependent Variable
Variables Unstandardized coefficients Standardized coefficients t P
Coefficient (B) SE Beta
Demographic factors
Age 0.005 0.009 0.022 0.558 0.577
Male 20.068 0.271 20.011 20.252 0.801
Cancer-related factors
Index cancer site
Breast Reference
Digestive system 0.508 0.316 0.082 1.609 0.108
Thorax 0.230 0.399 0.023 0.576 0.565
Hematolymphoid 0.253 0.472 0.020 0.535 0.593
Urinary and male genitalia 20.948 0.614 20.059 21.543 0.124
Female genitalia 1.417 0.639 0.078 2.218 0.027*
Other 1.124 0.579 0.072 1.941 0.053
Active disease status 20.300 0.289 20.052 21.040 0.299
Advanced disease 0.002 0.276 0.000 0.007 0.995
Surgery (past # 2 months) 0.278 0.300 0.034 0.928 0.354
Chemotherapy (past # 2 months) 20.300 0.234 20.052 21.281 0.201
Radiotherapy (past # 2 months) 0.428 0.346 0.042 1.234 0.218
Other therapy (past # 2 months) 0.312 0.223 0.053 1.402 0.162
Psychiatric factors
Diagnosis
Depressive disorder Reference
Sleep-wake disorder 20.266 0.288 20.041 20.926 0.355
Adjustment disorder 20.236 0.279 20.034 20.846 0.398
Anxiety disorder 0.052 0.376 0.005 0.139 0.889
Delirium 0.900 0.652 0.049 1.381 0.168
Bipolar disorder 0.314 0.492 0.023 0.638 0.524
Other 20.157 0.465 20.012 20.338 0.736
None 21.229 0.723 20.060 21.701 0.090
HADS-D 0.036 0.039 0.056 0.929 0.354
HADS-A 0.170 0.036 0.294 4.791 ,0.001‡
Health-related quality of life
FACT-G PWB 20.105 0.022 20.240 24.757 ,0.001‡
FACT-G SWB 0.013 0.016 0.030 0.829 0.407
FACT-G EWB 20.046 0.025 20.101 21.826 0.069
FACT-G FWB 20.058 0.025 20.114 22.365 0.019*
Somatic pain
PPI 0.347 0.110 0.136 3.159 0.002†

EWB = emotional well-being; FACT-G = Functional Assessment of Cancer Therapy-General; FWB = functional well-being; HADS =
Hospital Anxiety and Depression Scale, A = anxiety symptoms, D = depressive symptoms; PHQ-9 = Patient Health Questionnaire-9;
PPI = Present Pain Intensity; PWB = physical well-being; SE = standard error; SWB = social/family well-being.
* Significant findings at P , 0.05.
†
Significant findings at P , 0.01.
‡
Significant findings at P , 0.001.

all other variables, however, we found that female
genital cancer, the HADS-A scores, and the PPI scores
had a positive relation with the DT scores, whereas
scores on PWB and FWB showed a negative relation.
The predominance of women in our sample was
related to breast cancer being the most prevalent index
cancer diagnosis among all types of cancers. This pre-
dominance is further explained by a previous study that
found women are more likely to desire psychological
support and to make use of mental health services.24
Therefore, women might have visited our psycho-
oncology clinic more often than men did, thus leading
to the female predominance of the subjects, although
we found no relation between sex and distress level.
Meanwhile, younger patients reported more psycho-
logical distress, as preceding research has consistently
suggested. When being diagnosed with cancer for the
first time, younger patients would cope in less adaptive

Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021 601

Correlates for Distress in Cancer Patients
ways and have more psychosocial risk factors for psy-
chological distress.25 However, in our study, the asso-
ciation between age and distress did not remain
significant after adjusting for all other variables.
As one of the cancer-related risk factors, female
genital cancer was associated with higher levels of
distress than breast cancer, which is also known for its
adverse psychological outcomes. Previous studies have
reported that patients with gynecological cancer are at
greater risk of distress than those with breast cancer26
and prostate cancer.27 Our finding supported a previ-
ous hypothesis that specific types of cancer could affect
the level of distress in patients with cancer.7 Meanwhile,
advanced disease status which covers metastatic cancer
and recurrence was not associated with distress level
although local recurrence of cancer could be extremely
stressful to patients.28 On the other hand, the preva-
lence of distress was found to be the same regardless of
cancer stages.8,29
Among the anticancer treatment modalities, only a
history of recent radiotherapy was associated with the
DT score, which was concordant with a previous
finding that patients with cancer undergoing multiple
radiotherapy sessions exhibit a high prevalence of
psychological distress. However, the distress is thought
to be associated with cancer and cancer-related factors
rather than the radiotherapy itself.30 Indeed, anticancer
treatments have been associated with psychological
distress, such as depression, anxiety, and sleep distur-
bance.16,31 However, treatment-related factors did not
remain significant after the multivariate regression
analysis.
Patients with sleep-wake or adjustment disorder
reported relatively lower levels of distress than those
diagnosed with depressive disorder. In addition, pa-
tients who visited the psycho-oncology clinic and were
diagnosed with no psychiatric disorder experienced less
distress than depressive patients. Depressive disorder
has been recognized as the most prevalent psychiatric
illness in patients with cancer since the 1960s.4,32 Clin-
ical attention is required for patients with cancer and
depression because depression can have a significant
impact on patients’ overall quality of life.33 Moreover,
evidence of a bidirectional relation between cancer and
depression has been reported.34 Thus, psychiatric
intervention for depressive disorder might have a
certain role in disease progression and/or life expec-
tancy. In our study, psychiatric diagnoses and the
HADS-D scores did not show a significant relation with
602 Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021
the DT score in the multivariate analysis. On the con-
trary, the positive relation between the HADS-A and
the DT scores was observed before and after statistical
adjustment. The beta coefficient of the HADS-A scores
was the highest among the 4 other variables that
remained after multiple regression, indicating that the
impact of anxiety on psychological distress exceeded
that of other risk factors, such as female genital cancer,
PWB or FWB, and pain. Earlier studies have also noted
that psychological distress is more closely related to
anxiety symptoms than to depressive symptoms in pa-
tients with cancer.35,36 Hence, anxiety of patients with
cancer should be regarded as a significant correlate of
psychological distress.
Another finding was that the severity of somatic
pain was significantly associated with the distress level.
A previous study reported that pain is significantly
associated with psychiatric symptoms, such as depres-
sion, anxiety, and emotional distress.37 Patients with
cancer reportedly experience greater psychological
distress as pain intensity increases, whereas diminishing
pain intensity is related to a decreasing level of distress,
suggesting a direct association between cancer-related
pain and psychological distress.37 Moreover, this
direct relation is further proved by a longitudinal study
that concluded that improving depressive symptoms
has a significant impact on pain relief when patients are
being treated for cancer-related pain for over a year.38
A notable finding is that the treatment of depression
can more reliably lead to pain relief than can pain
management lead to alleviation of depression. Somatic
pain is one of the most common yet debilitating
symptoms of patients with cancer, but patients are
often reluctant to report its severity to their oncologists
because of fear of being diagnosed of disease progres-
sion or recurrence, being considered weak or drug-
dependent, and the side effects of pain treatment,39
which could lead to the underestimation of pain in-
tensity and distress from the pain. Therefore, patients
who have a risk of somatic pain should be assessed
simultaneously for pain and psychological distress.
Clinicians need to pay more attention to the psycho-
logical aspects of somatic pain as potentially essential
components in cancer pain management.
PWB and FWB were associated with lower psy-
chological distress in patients with cancer. Research has
assessed the relation between HRQOL and psychologi-
cal distress; the PWB subscale of the FACT-G reflects
cancer-related fatigue, somatic pain or discomfort, and

impaired physical activity. Our finding on the associa-
tion between the PWB subscale and distress level seems
in line with previous reports: An improvement in fatigue
is significantly associated with a reduction of distress in
patients with lung cancer40; pain is associated with
distress37; physical limitations in patients with colorectal
cancer affect the degree of psychological distress.17 The
FWB subscale of the FACT-G addresses patients’ life
satisfaction and acceptance of cancer, which enable
them to maintain their regular activities. In women
with breast cancer, life satisfaction and psychological
distress are correlated.41 A recent review of the
research on acceptance of cancer indicated that
acceptance is significantly associated with lower gen-
eral distress, cancer-specific distress, depression, and
anxiety.18 However, the relation between HRQOL
and distress could be indirect: Psychological distress
mediates the association between personality traits
and HRQOL in young healthy adults.42 In addition,
the definition of psychological distress in preceding
research includes a wide range of unpleasant
emotional experiences. Therefore, caution should be
taken when interpreting our results on the significant
association between distress level and HRQOL.
Study Limitations and Clinical Implications
There are several caveats that concern the interpreta-
tion of our results. First, directional interpretations of
relations between psychological distress and correlates
are limited because this is a retrospective study. Second,
patients included were mostly composed of middle-
aged women with breast cancer who presented to the
psycho-oncology clinic. Most patients who visited the
clinic reported a high prevalence of suicidal ideation
and could be assumed to experience more distress
than those who were not referred, which limit gener-
alizability of our results. Third, several potential risk
factors for psychological distress such as low socio-
economic status or comping strategies25 were not fully
included in the study. Finally, patients with missing
data accounted for 38.6% of overall patients. They were
3 years older than those with complete patient data and
more likely to have metastatic brain tumor, hemato-
logic malignancy, male and female genital cancer, and
lower level of social/family well-being and emotional
well-being. On the other hand, they were less likely to
have chemotherapy in recent 2 months and to have
suicidal ideation. Results from multivariate analysis
Journal of the Academy of Consultation-Liaison Psychiatry 62:6, November/December 2021
Kim et al.
might be different if they were included, considering
more patients with female genitalia cancer were pre-
sent. Nonetheless, our study has several strengths as
well. We included a variety of correlates of psycho-
logical distress, covering demographic, cancer-related,
and psychiatric factors, as well as HRQOL and so-
matic pain. Moreover, a large number of Korean can-
cer survivors were evaluated by consultation-liaison
psychiatrists at a psycho-oncology clinic, and relevant
clinical scales were used.
Because a high score on the DT could be associated
with several clinical correlates, health professionals
who are involved in cancer treatment should be
encouraged to screen for psychological distress and
refer those with a significant distress to mental health
providers. Only a small portion of patients were found
to be referred when significant distress was detec-
ted.43,44 Moreover, we suggest that patients with cancer
be provided with a regular evaluation for distress by the
DT during treatment programs because the DT could
represent clinically relevant impression of overall
severity of mental health problems. The field of
consultation-liaison psychiatry could provide medical
patients with appropriate psychiatry services as well as
offer medical professionals high-quality education.
CONCLUSION
Patients with cancer who are referred to a psycho-
oncology clinic experience more distress if they have a
female genital cancer, low HRQOL, severe anxiety, or
severe somatic pain.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
at https://doi.org/10.1016/j.jaclp.2021.05.007.
Conflicts of Interest: The authors declare that they
have no conflict of interest.
Funding: This research did not receive any specific
grant from funding agencies in the public, commercial, or
not-for-profit sectors.
Acknowledgments: The authors would like to thank
Hyung-Don Kim, MD, PhD for his assistance with the
medical chart review and confirmation of cancer-related
variables.
603
Correlates for Distress in Cancer Patients
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