A Systematic Review and Meta-analysis of Death Anxiety Among Iranian Patients With Cancer

Abstract

Death anxiety in cancer patients can cause and exacerbate mental disorders and affect the healing process and survival. In this study, percentage score of death anxiety among Iranian cancer patients was reported. The databases of Scopus, PubMed, ISI, MagIran, and Scientific Information Database were searched and 396 articles were retrieved. Twenty-three eligible studies were included in the analysis considering the inclusion criteria. Heterogeneity among selected studies was assessed through the Cochrane Q test and I² test. The percentage of death anxiety scores in Iranian patients with cancer was 59.91% (95% confidence interval: 51.57–62.24). The results of subgroup analysis showed that the percentage of death anxiety scores in patients with breast cancer was 67.55% (95% CI: 56.50–78.60) and in patients with other malignancies was 53.78% (95% CI: 50.20–57.36). Death anxiety is high among Iranian patients with cancer and counseling sessions to control and manage this challenge seems necessary.

Keywords

cancer death anxiety systematic review death anxiety

Introduction

Diagnosing cancer is a painful experience for patients, they are afraid of the word cancer because cancer is synonymous with death and untreated disease (Bibi & Khalid, 2020). Following the diagnosis of cancer, a deep psychological crisis occurs in the life of the patient and their family, which threatens their future (Bahrami et al., 2013). Due to anxiety, patients experience various problems such as pain, insomnia, physical discomfort and reduced quality of life, which if left untreated can lead to decreased life expectancy (Bibi & Khalid, 2020). Many cancer patients suffer from mental disorders that affect their treatment and recovery process and increase their mortality rate (Zhu et al., 2017). Advanced cancer is associated with fears and challenges associated with disease progression and burden of symptoms, dependence and disability, suffering and worries about death and dying (An et al., 2020).

Death is one of the most important issues in life that shapes a person’s thoughts and behavior. Having a near-death experience, facing a deadly illness, and witnessing the death of family members or friends may frighten us and lead to a review of our lifestyle and make our lives meaningful (Şahan et al., 2018). Because death is unavoidable and no one knows when and how it will die, it destroys human motivation and desire and leads to terror (Fitri et al., 2020). According to terror management theory, awareness of the inevitability of death has profound influence on various aspects of human thought, emotion, motivation, and behavior. Therefore, they try to manage this potential anxiety by maintaining faith in the absolute validity of their cultural worldview and self-esteem by living up to the standards of value that are part of their worldviews (Pyszczynski et al., 2015).

The effect of cancer as a life-threatening disease on death anxiety remains a challenge. Death anxiety does not have a common definition that is accepted by everyone, but it is considered as a kind of negative emotional reactions that result from predicting a situation in which the person does not exist (Salehi et al., 2016). Death anxiety is a relatively stable personality trait that reflects negative attitudes, feelings, and cognitions about one’s own death and dying or those of other important people, or the perception of death in general (Abreu-Figueiredo et al., 2019). It includes fear of the end-of-one’s existence, fear of the death process, fear of the unknown after death, and fear of the death of other important people (Draper et al., 2019). Death anxiety in these patients is a kind of double awareness because they have to balance between two opposing currents of thought: staying involved and enjoying the rest of their lives, while being aware of their physical deterioration and death (Colosimo et al., 2018). In addition to patients, patient caregivers also experience death anxiety. The results of a study showed that the percentage of death anxiety scores among caregivers of Iranian patients with cancer is 52.8%, which is slightly lower than the death anxiety of cancer patients themselves (Soleimani et al., 2017).

Various studies conducted in Iran on the death anxiety of cancer patients have reported different results. Given that the first step to solving any problem is to identify the problem, identifying the status of death anxiety in Iranian patients with cancer can provide the necessary solutions to control or prevent its adverse consequences. Accordingly, in this study, a systematic review and meta-analysis of the status of death anxiety in Iranian patients with cancer was reviewed and their percentage of death anxiety scores was estimated.

Methods

Search Strategy

This systematic review and meta-analysis study was performed to estimate the percentage of death anxiety scores among Iranian cancer patients based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009). Iranian (MagIran, Scientific Information Database (SID)) and international databases (Web of Science/ISI), PubMed and Scopus) were searched without time limit with the following keywords: Neoplasms, Carcinoma, Neoplasm*, Neoplasia*, Tumor*, Cancer*, Malignan*, Carcinoma*, Epithelioma*, death depression, death anxiety, Iran*. The references of the selected articles were reviewed for access to other articles.

Selection of Studies and Data Extraction

The two authors independently reviewed the titles and abstracts of the articles and screened and selected eligible studies. Inclusion criteria were: observational articles, access to the full text of the article, publication of the article in Persian or English, observability of the study, and conducting the study on cancer patients. Qualitative studies, clinical trials, reviews and letters to the editor as well as gray literature were not analyzed. Finally, 53 were selected to extract information. The extracted information included the first author of the article, year of article publication, sample size, place of study, bias score of articles and percentage of death anxiety score in each study. In all selected studies, death anxiety was measured using the Templer death anxiety instrument. In two studies, the answers were in the 5-point Likert scale (strongly agree to disagree), and in the rest of the studies, the answers were in two states (yes and no). Due to the difference in scoring, the raw score of death anxiety became the standard score (Rezaei et al., 2020).

Quality Assessment

To assess the methodological quality of selected studies, the Newcastle Ottawa Scale (NOS) was used. The tool has three sections that focus on methodological quality of each study, comparability, and outcomes and statistical analysis, respectively (Lo et al., 2014). Based on the final score, the articles were divided into three categories in terms of quality: poor (score less than 3), moderate (score 4–6), and excellent (score 7–9). Any disagreements between the reviewers were resolved by consensus.

Statistical Analysis

In this study, all statistical analyzes were performed using STATA software version 12. Since death anxiety scores were converted to percentages, a binomial distribution was used to combine the selected studies. I² index and Cochran’s Q test were used to investigate the heterogeneity between the selected studies. Considering that in all studies, I² index was more than 75% (I² value> 75% is considered as high heterogeneity) and Cochran Q test was also significant (significance level for this test was considered 0.1), the random effects model was computed to estimate the pooled effect. To ensure the stability of the results, sensitivity analysis was used. Subgroup analysis was performed (by type of cancer) to assess the source of heterogeneity between studies. Univariate meta-regression test was performed to examine the relationship between the percentage of death anxiety scores and the mean age, year of publication and sample size of selected studies. Moreover, publication bias was assessed by the funnel plot and Eger test.

Results

In the initial search, 130 articles from national databases and 163 articles from international databases were obtained. After removing duplicates, the titles and abstracts of the remaining 144 articles were reviewed. After deleting irrelevant papers, 23 observational studies were included in the analysis (Figure 1).

Figure 1.

Article selection and screening flowchart.

The lowest and highest sample sizes were related to Salehi et al. (2016) and Baboland & Barghi Sheida (2017) studies, respectively. Also, the highest and lowest percentage of death anxiety scores were related to the studies of Farahbakhsh Beh et al. (2019) and Shirkavand et al. (2018), respectively. 14 studies were published in Persian and nine in English. Five studies were performed exclusively on patients with breast cancer and the rest of the studies were performed on different groups of cancer patients. More details are provided in Table 1.

Table 1.

The Characteristics of Selected Papers.

Author(s)	Year	Sample Size	Place	Type of Cancer	% Score	Quality Score
Salmanian and Marashian	2021	200	Abadan	Breast	61.6	6
Ranjbar Hajabadi et al	2020	96	Golestan	All type	55.3	4
Sharifi Saki et al	2020	397	Tehran	Breast	68.6	5
Mousavi, Khaleghkhan, and Mirmahdi	2019	100	Shiraz	All type	55.3	5
Salehi & Rabiee	2020	148	Shahrekord	All type	35.6	6
Madadi Ardekani and Kamkar	2020	150	Shiraz	All type	49.6	6
Esfahan	2019	100	Shiraz	All type	70	5
Farahbakhsh Beh, Mehrinejad A, and Moazedian	2019	300	Tehran	Breast	85.3	4
Salehi, Mohsenzade, Arefi, Salehi Zahabi, and Amirifard N	2019	101	Kermanshah	All type	64.7	5
Karampour et al	2018	118	Ahvaz	Breast	64.5	4
Mikaeili et al	2018	93	Ardabil	Lung	65.2	4
Darmarani Khamoushi and Moradi	2018	150	Kermanshah	All type	44	4
Hedayatizadeh Omran et al	2018	100	Sari	All type	55.9	5
Nezami, Dashti, Alilou, and Heidari	2018	128	Esfahan	Breast and cervical	53.6	7
Nezami, Dashti, Alilou, and Heidari	2018	32	Esfahan	Gastrointestinal	48.6	7
Shirkavand, Abbaszadeh, Borhani, and Momenyan	2018	185	Tehran	All type	44.6	5
Kamyab Mansori, Dolatian, Shams, and Nasiri	2017	230	Tehran	Gynecologic	55.9	4
Babolan and Barghi Sheida	2017	612	Ardabil	All type	58.3	4
Masoudi, Hatami, Modares, and Bani	2016	367	Mashhad	All type	52.1	4
Soleimani, Lehto, Negarandeh, Bahrami, and Sharif Nia	2016	330	-	All type	50.1	5
Valikhani and Firouzabadi	2016	70	Shiraz	All type	58.5	5
Salehi, Mohsenzade, and Arefi	2016	48	Kermanshah	Breast	60.2	5
Khezri, Bahreyni, Ravanipour, and Mirzaee	2015	200	Bushehr	All type	53.8	5

Based on the analysis, the pooled percentage score of death anxiety in Iranian patients with cancer was 59.91% (95% confidence interval [CI]: 51.57–52.24). The results of subgroup analysis showed that the percentage of death anxiety scores in patients with breast cancer was 67.55% (95% CI: 56.50–78.60) and in patients with other malignancies was 53.78% (95% CI: 20.3–50.57). Heterogeneity was 93.5% in breast cancer studies and 74.5% in other cancer studies (Figure 2).

Figure 2.

Death anxiety score in Iranian cancer patients. The midpoint of each line shows the percentage score of death anxiety scores in each study and the diamond represents the overall score for all studies.

The results of meta-regression showed that there was no relationship between the percentage of death anxiety score and the year of publication of articles (p = 0.472) and the sample size of studies (p = 0.479). In sensitivity analysis, none of the studies alone had a significant effect on the pooled percentage scores of death anxiety. Also, the publication bias was not significant (p = 0.071) (Figure 3).

Figure 3.

Meta-regression of death anxiety score based on sample size (A) and year of publication (B). Circles indicate the weight of the study.

Discussion

The findings of the present study showed that the percentage score of death anxiety scores among Iranian patients with cancer is moderate to high. The percentage of death anxiety scores in this study was higher than the studies performed on cancer patients in Turkey (40.8%) (Gonen et al., 2012) and Taiwan 49.65% (Tang et al., 2011), which could be due to differences in demographic, context, culture and beliefs of the mentioned communities. Death anxiety is influenced by various factors such as gender, age, education, marital status, public health, cultural differences, experiences of death and dying, and religious aspects (Daradkeh & Fouad Moselhy, 2011; Lehto, 2009; Lester et al., 2007).

Death is an inevitable phenomenon in the lives of all people, but people with deadly diseases such as cancer experience more death anxiety than other chronic patients (Bibi & Khalid, 2020). Studies show that death anxiety scores in Iranian patients with cancer are higher than patients with multiple sclerosis (Mohammadizadeh et al., 2017) and cardiovascular patients (Soltani et al., 2016) and lower than patients undergoing hemodialysis (Fathi et al., 2016; Shafaii et al., 2017).

The results of a study showed that the percentage of death anxiety scores among caregivers of Iranian patients with cancer is 52.8%, which is slightly lower than the death anxiety of cancer patients themselves (Soleimani et al., 2017). The percentage of death anxiety scores was higher among patients with breast cancer than other cancers. Breast cancer is considered a frightening and tragic event for many women, so that these patients show a wide range of feelings of sadness, anxiety about death, confusion and anger (Salehi et al., 2016). Women with breast cancer lose an organ that symbolizes their gender and femininity after a mastectomy. This issue disrupts a person’s body image, reduces self-confidence and attractiveness, and then causes anxiety, depression and despair for patients (Nezami et al., 2018).

One of the treatments for breast cancer is a mastectomy in which the female breast(s), which are a symbol of femininity, are removed and the body image of the patient is completely destroyed, and the person always sees this physical defect and lives with this problem. If in other cancers the appearance of patients does not change. Therefore, the finding that death anxiety in this group of patients is higher than other patients is to be expected. Various studies have shown that patients with breast cancer experience high levels of depression and anxiety, post-traumatic stress disorder, adjustment disorders, loss of self-esteem, body image problems, and fear of cancer recurrence and death (Soleimani et al., 2020; Mehrabani et al., 2016)

Selected studies were conducted between 2015 and 2021. During this time, the percentage of death anxiety scores among Iranian cancer patients had not changed. One of the reasons for this finding is that there is no intervention or psychological counseling for cancer patients in the inpatient wards. It is recommended that in addition to drug treatment, other complementary methods be used to reduce death anxiety in cancer patients (Nezami et al., 2018). The lack of a change in death anxiety scores in recent years indicates that complementary programs have not been performed for cancer patients and that more emphasis has been placed on medication, or if it has been done, it has not been effective.

Implications for Practice

Death anxiety is high among Iranian patients with cancer, and it seems necessary to hold counseling sessions and mental health education workshops, open discussion sessions to hear the comments and problems of these patients and try to solve them. Given that some patients cope with death in positive and adaptive ways, but others are unable to cope effectively and develop a paralyzing fear that completely disrupts their lives, providing spiritual and end-of-life care to control death anxiety in these patients, especially breast cancer patients, seems necessary.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Reza Ghanei Gheshlagh

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