Risk factors for loneliness in patients with cancer: A systematic literature review and meta-analysis
Introduction
With advances in early detection and cancer treatments, numbers of cancer survivors are rising (Maddams et al., 2009). Whereas cancer used to be a fatal disease, it is now developing towards a chronic or even curable disease (Hewitt et al., 2006, Pavlic et al., 2009). The growing group of cancer survivors mandates attention to quality of life and psychosocial consequences of cancer and its treatment (Stanton, 2012). Traditionally, the consequence of cancer and cancer treatment that is evaluated most often is survival. The consequences on quality of life, however, are less clear. An important aspect of quality of life is loneliness. Loneliness is defined as “an unpleasant experience that occurs when a person's network of relationships is felt to be deficient in some important way” (Peplau and Perlman, 1982). Central to loneliness is that it is a subjective and negative experience (De Jong Gierveld et al., 2006).
It has been shown that loneliness, social isolation, and social support reflect related but distinct concepts (Tomaka et al., 2006). Whereas loneliness is a subjective and negative experience, social isolation is an objective situation and refers to the absence of relationships with other people (Dykstra, 2009). Hence, socially isolated persons are not necessarily lonely, and lonely persons are not necessarily socially isolated (De Jong Gierveld et al., 2006). Similarly, persons with adequate social support might still be lonely and vice versa. Whereas loneliness refers to the subjective experience of deficits in social relations, social support refers to the availability of interpersonal resources (Perlman and Peplau, 1984). Furthermore, social support includes several types of support ranging from emotional, to informational and instrumental support (Tomaka et al., 2006).
The consequences of loneliness are not to be taken lightly. As aptly put by Masi et al., “loneliness influences virtually every aspect of life” (Masi et al., 2011). Loneliness is a risk factor for numerous health disorders, ranging from elevated blood pressure and poorer sleep quality (Cacioppo et al., 2002) to diminished immunity (Pressman et al., 2005), abnormal ratios of circulating white blood cells (Cole, 2008), anxiety (Russell et al., 1980), and depression (Cacioppo et al., 2006). Furthermore, Penninx et al. found that during a 29-month follow-up and after controlling for age, gender, chronic diseases, alcohol use, smoking, self-rated health, and functional limitations, loneliness predicted all-cause mortality (Penninx et al., 1997). This finding was also supported by two studies that are more recent (Luo et al., 2012, Newall et al., 2012). The other way around is also true; health disorders are also risk factors for the onset of and continuation of loneliness (Penninx et al., 1999, Savikko et al., 2005).
From this point of view, it has been shown that loneliness is an important concern for patients with cancer (Wells and Kelly, 2008). Qualitative studies have shown that especially the period after the initial treatment is characterized by feelings of loneliness (Ekwall et al., 2007, Rosedale, 2009). Furthermore, two studies in cancer patients that aimed to refine the Distress Thermometer problem list included loneliness as an additional item because patients identified it as an important source of distress (Brennan et al., 2011, Tuinman et al., 2008).
Previous studies have shown that life stressors significantly predict loneliness (Cacioppo et al., 2010, Hensley et al., 2011). Hence, patients with cancer might be particularly vulnerable to becoming lonely.
Because loneliness is a negative experience, and it is associated with a large spectrum of negative consequences, it is important to gain insight in the occurrence of loneliness in patients with cancer. As a first step, we decided to systematically review the existing literature. To our knowledge, a systematic literature review on the severity and risk factors for loneliness in patients with cancer has not yet been published. The aim of this review is to gain insight in the severity and factors associated with loneliness in patients with cancer.
Section snippets
Information sources and search strategy
Pubmed, Embase, PsycINFO, Cochrane Library and CINAHL databases were searched for articles published before 24 September 2013. The search was based on combinations of database-specific subject headings. For Pubmed, Cochrane Library and CINAHL, these were ‘social isolation’ in combination with ‘neoplasms’. The term social isolation was used because social isolation and loneliness have often been used interchangeably (Dickens et al., 2011) and in MeSH terms loneliness is a subheading of social
Results of the search
The final search identified 968 unique hits. Only 15 studies met the inclusion criteria for the review (see Fig. 1 and Table 1).
In 13 of the selected studies the UCLA loneliness scale was used. The UCLA loneliness scale is a 20-item rating scale that measures the subjective experience of loneliness on a four-point Likert scale. The UCLA loneliness scale was originally developed and validated among college students. The first version consisted of 20 negatively worded items (Russell et al., 1978
Discussion
Based on a systematic and extensive review of the literature, we evaluated loneliness in cancer patients after identifying 15 studies that met our inclusion criteria. The weighted average of loneliness among patients with cancer was 38.26 (95% CI: 35.51–41.00). This corresponds to a moderate degree of loneliness, following to the commonly used categorization mentioned above. None of the cancer-related factors were clearly associated with increasing levels of loneliness. However, there is an
Conflict of interest
The authors have no funding or conflicts of interest to disclose.
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