Biomedical Research

Abstract

This study is to investigate the effect of chemotherapy on living quality, anxiety and immunity of patients with non-small-cell lung cancer. 78 patients with non-small-cell lung cancer treated with chemotherapy in hospital were selected randomly. The clinical effect of chemotherapy on patients was evaluated every two cycles. The living quality, anxiety and immunity of patients with lung cancer were graded. Before chemotherapy, the scores of living quality functional fields, fatigue and dyspnoea were high. There were 53.8% patients with anxiety. The score of SAS was 52.36 ± 6.42. After two cycles of chemotherapy, dyspnoea was obviously improved, while insomnia and loss of appetite were obviously increased. There were 73.1% patients with anxiety and the score of SAS was 52.36 ± 6.18, which were significantly increased compared with before chemotherapy. After four cycles of chemotherapy, the scores of body, role, emotion and social function were obviously reduced, while nausea and vomiting, loss of appetite, constipation and financial difficulty were worse. There were 80.8% patients with anxiety. The score of SAS was 55.27 ± 6.42. Compared with two cycles of chemotherapy, the difference was not statistically significant. Compared with before chemotherapy, the number of CD8+ was decreased, and the ratio of CD4+/CD8+ was increased. The physical status of part patients was relieved after chemotherapy, but their anxiety was quite obvious and their immunity and living quality were decreased. Medical worker should be timely evaluated patients’ living quality and emotional changes, provide a good job of health and prevention, and actively carry out psychological counselling for patients.

Keywords

Lung cancer, Chemotherapy, Quality of life, Anxiety, Immunity.

Introduction

At present, the whole world is faced with the same enemy, lung cancer, which has been the main cause of death of human with malignant tumor. According to different biological behaviour, lung cancer can be divided into small cell lung cancer and Non-Small-Cell Lung Cancer (NSCLC). The prevalence of non-small-cell lung cancer is up to more than 80% [1,2]. Now the lung cancer is advocated to adopt comprehensive multidisciplinary treatment that is mainly based on the stage of NSCLC. The treatment includes surgery, radiotherapy, chemotherapy, immunotherapy, traditional Chinese medicine, etc. [3]. Surgery is the first choice and the fundamental method for treating lung cancer. But about 65%~70% cases in the stages III, IV were not suitable to be done surgery. Even if the patients could be done surgery, about 70% cases would be recurrent and had cancer cell metastasis after surgery. Radiotherapy is only a local treatment, and cannot effectively solve the problem of cancer cell metastasis in the whole body. Therefore the radiotherapeutic effect has certain limitations in clinical practice. Chemotherapy in comprehensive treatment has been the first treatment for NSCLC. However, chemotherapy can not only kill tumor cells, but also kill normal cells and immune (resistant) cells. If only chemotherapy was performed in patients, it would bring about many symptoms, such as vomit, hair loss, anorexia, the reduction of blood cells, the decrease of immunity, and mental disease like depression [4-6]. To take positive measures to improve patients’ physical status, it is necessary to accurately control the effect of chemotherapy on physical status of patients with non-small-cell lung cancer. By combining many relevant materials with several years’ clinical experience, this research studied the physical status of 78 cases with non-smallcell lung cancer after chemotherapy.

Materials and Methods

Clinical materials

There were 78 cases in the observation group, including 48 male patients, 30 female patients, aged 38~70 years old, average age 58.2 ± 3.9 years old. There were no statistical differences in gender, age, and clinical manifestation of patients which were comparable (Table 1).

Table 1. Comparison of pre-treatment baseline.

Inclusion and exclusion criteria

Inclusion criteria: 1. patients were pathologically diagnosed with primary bronchial lung cancer for the first time and had not been treated with chemotherapy; 2. according to the international stage standard of lung cancer of NCCN in 2009, the patients were diagnosed in the stage III or IV; 3. physical score of KPS was not less than 70; 4. time of expected survival was more than 3 months; 5. the patients were willing to accept a questionnaire survey.

Exclusion criteria: 1. patients have history of mental illness; 2. after explained, patients still did not understand the questionnaire items; 3. patients had received an anti-anxiety treatment; 4. patients have a history of alcohol or drug dependence.

Methods

Chemotherapy protocols: First-line chemotherapy for nonsmall- cell lung cancer was given two kinds of drug protocols containing platinum (platinum+gemcitabine or vinorelbine, paclitaxel, pemetrexed, etc.). If the disease moved on, the patients would be given second-line chemotherapy (docetaxel, pemetrexed and so on). The rest were continuing the original protocol. After chemotherapy, the physical status of patients was evaluated every 2 cycles.

Before chemotherapy, the general material of patients were recorded, including gender, age, BMI, KPS score, pathological types, lung cancer stages, chemotherapy protocols, degree of education, having or not having basic diseases, etc. EORTC QLQ-C30 [7] and Self-rating Anxiety Scale (SAS) [8] were adopted to investigate the status of patients before and after 2 cycles of chemotherapy in one week as well as after 4 cycles of chemotherapy in one week. Then the patients were explained how to answer the questionnaire survey. In the EORTC QLQC30 scales, the higher the score of function areas and overall body status got, the better the function status and living quality of the patients were. On the contrary, the higher the score of symptom fields got, the more the symptoms or problems of patients were [7]. In the SAS scale, according to Chinese norm, boundary value of SAS is 50. If the score of SAS is not less than 50, it would indicate that the patients have anxiety.

Evaluation of immunity: The limosis venous blood of patients was taken in the morning before chemotherapy and on the 14^th day after 4 cycles of chemotherapy. The limosis venous blood was detected by FACSCalibur (a type of flow cytometry). The detection method was the whole blood dissolving blood cells+monoclonal antibody (CD3+, CD4+, CD8+, and NK cells) (provided by the Kurt immunological technique agency in China). The experimental results were analysed by Cellouest software to examine the activity of Tlymphocyte subsets and NK cells.

Statistical method

The SPSS 16.0 statistical package for windows was adopted to analyse the data. The comparison of measurement data between all groups before chemotherapy adopted t to examine. One-factor analysis of variance was used to analyse the average number between all groups. Count data was tested by chi-square.

Results

Impact on quality of life

The score comparison of patients with lung cancer in all aspects of living quality was shown in Table 2. There was no statistical significance in cognitive function, fatigue and diarrhoea. Compared with before chemotherapy, after 2 cycles of chemotherapy, the scores of physical function, role function and social function in function fields were reduced, the scores of pain, nausea and vomiting in symptom fields increased, the scores of insomnia, appetite loss, abnormal stool and economic conditions also increased, and the score of overall living quality decreased. Compared with before chemotherapy, after 4 cycles of chemotherapy, the scores of physical function, role function, emotional function, social function in the function fields were significantly decreased, the scores of pain, nausea and vomiting in the symptom fields increased, the scores of insomnia, appetite loss, abnormal stool and economic conditions in the symptom fields improved, and the score of overall quality of life reduced.

Table 2. Compare of scores for EORTC QLQ-C30 in different periods of chemotherapy (Mean ± SD).

Influence of anxiety

Before and after 2 cycles of chemotherapy and after 4 cycles of chemotherapy, the number of patients with anxiety in 78 cases was respectively 42 cases (53.8%), 57 cases (73.1%), 63 cases (80.8%). The score of SAS was respectively 46.54 ± 5.46, 52.36 ± 6.18, 55.27 ± 6.42. The comparison of anxiety score between before chemotherapy and after 2 cycles of chemotherapy has statistical significance. The comparison between after 4 cycles of chemotherapy and before chemotherapy has statistical significance, too. But the comparison between after 2 cycles and 4 cycles of chemotherapy has no statistical significance.

Influence of immunity

Before chemotherapy, the differences among CD3+, CD4+, CD8+, CD4+/CD8+ ratio, and NK cells have no statistical significance. After chemotherapy, CD3⁺, CD4⁺, NK cells have no evident changes. Compared with before chemotherapy, the number of CD8⁺ was reduced (P=0.019). Compared with before chemotherapy, the ratio of CD4+/CD8⁺ was increased (P=0.015) (Table 3).

Table 3. Comparison of the immunologic function.

Discussion

The quality of life means the state of daily life, including the ability to accomplish daily life, such as physical activity, psychological activity, social life and satisfaction degree of patients to their own function as well as the control of disease [9]. The quality of life in the treatment of cancer was gradually showing its importance, as the important criteria for evaluating curative effect [10]. With chemotherapy going on, the dyspnoea of patients was improved significantly, but pain, appetite loss, insomnia, nausea and vomiting, and financial difficulties were gradually increased, and social function was decreased. Among them, appetite loss, and nausea and vomiting were related to lung cancer and the side effects of chemotherapy drugs and pain killers. The untoward reaction of chemotherapy drugs and patients’ emotional reaction in the treatment of lung cancer could lead to decrease of quality of sleep [11]. The physical status of patients with lung cancer and repeated treatment in hospital brought about obstruction of family life and social activities, and influence of social value. The economic expenses of patients with lung cancer were positively correlated with the severity of the disease [12]. Expensive medical expenses and the limited economic ability of patients has been a pair of prominent contradictions in the treatment.

Anxiety is inner unrest or unfounded fear that lacks obviously objective reasons [13-15]. Anxiety is the most common psychological characteristics in patients with lung cancer, but it is also easy to be ignored and underestimated by medical worker [16]. Excessive anxiety has a negative effect on the cancer outcome and quality of life of patients. The study found that with chemotherapy going on, anxiety of the patients with lung cancer was gradually increased. It was taken into consideration that it was related to symptom aggravation, poor physical status, short life span of prognosis and deterioration of economic conditions.

The immune function of the body is closely related to the occurrence and development of tumor. When the immune function of the host is low or suppressed, the incidence of tumor is increased. When tumor is growing, the immune function of patients would be further inhibited. In general, cellular immunity plays an important role in anti-tumor response, which is mainly derived from T cell subsets and NK cells. Class I restrictive T cells are mostly CD8⁺ cells, TLymphocytes. It can also secret lymphatic factors that enable tumor cells to be directly dissolved. Class II restrictive T cells are mostly CD4⁺ T-helper cells (Th). It produces lymphatic factors, which activate other effector cells to produce inflammatory reactions and mediate their effect. T cell subsets can be detected in the peripheral blood and infiltrating cells around tumor. NK cells are a special subgroup of lymphocytes, which are large granular lymphocytes, null cells. NK cells, class III T lymphocytes, are not dependent on thymus, antibodies, without MHC restriction and presensitization, which can secret cytotoxic factors to kill tumor cells. NK cells as the first line of defense take on the task of innate immunity. The experimental results of the study showed that compared with before chemotherapy, CD3⁺, CD4⁺, the ratio of CD4⁺/CD8⁺, and NK cells after chemotherapy were reduced, which revealed that chemotherapy has an inhibiting effect on cellular immunity. Therefore, killing tumor cells and protection of the body's immunity play the same important role in the process of tumor treatment.

Conflict of Interest Statement

All co-authors have seen and agree with the contents of the manuscript and there is no conflict of interest.

References

1. Zakany J, Chihara G, Fachet J. Effect of lentinan on tumor growth in murine allogeneic and syngeneic hosts. Int J Cancer 1980; 25: 371-376.
2. Li Y, Zhang XR, Sun Y. Development of chemotherapy on non-small-cell lung cancer (in Chinese). Oncology Prog 2006; 4: 333-341.
3. Dong GZ, Wang WD, Duan YZ, Sun JG, Chen ZT. Relationship analysis between treatment and prognosis of lung cancer (in Chinese). Chinese J Cancer Prevent Treat 2007; 7: 544-547.
4. Ma Y. Lymphoma patients how to take good care of themselves after chemotherapy (in Chinese). Cancer Front 2014; 4: 58-61.
5. Zhou YL. Nursing and diet of patients with tumor after chemotherapy (in Chinese). China Foreign Med Treat 2008; 15: 127-128.
6. Jiang XF. Common complications and nursing strategies of patients with tumor after chemotherapy (in Chinese). Contemp Med 2015; 13: 101-102.
7. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993; 5: 365-376.
8. Zhang MY. Rating scale handbook of psychiatry. Changsha: Hunan Science and Technol Press 2003; 7: 35-39.
9. Gotay CC, Korn EL, McCabe MS, Moore TD, Cheson BD. Quality-of-life assessment in cancer treatment protocols: research issues in protocol development. J Natl Cancer Inst 1992; 84: 575-579.
10. Kannan G, Rani V, Ananthanarayanan RM, Palani T, Nigam N. Assessment of quality of life of cancer patients in a tertiary care hospital of South India. J Cancer Res Ther 2011; 7: 275-279.
11. Fiorentino L, Rissling M, Liu L, Ancoli S. The symptom cluster of sleep, fatigue and depressive symptoms in breast cancer patients: severity of the problem and treatment options. Drug Discov Today Dis Models 2011; 4: 167-173.
12. Gridelli C, Ferrara C, Guerriero C, Palazzo S, Grasso G. Informal caregiving burden in advanced non-small cell lung cancer: the HABIT study. J Thorac Oncol 2007; 2: 475-480.
13. Bottomley A. Anxiety and the adult cancer patient. Eur J Cancer Care (Engl) 1998; 7: 217-224.
14. Roth AJ, Massie MJ. Anxiety and its management in advanced cancer. Curr Opin Support Palliat Care 2007; 1: 50-56.
15. Stark DP, House A. Anxiety in cancer patients. Br J Cancer 2000; 83: 1261-1267.
16. Montazeri A, Milroy R, Hole D, McEwen J, Gillis CR. Anxiety and depression in patients with lung cancer before and after diagnosis: findings from a population in Glasgow, Scotland. J Epidemiol Community Health 1998; 3: 203-204.