Risk factors for loneliness in patients with cancer: A systematic literature review and meta-analysis

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Abstract

Objective

To systematically review the literature on the severity and risk factors for loneliness in adult cancer patients.

Methods

We systematically reviewed quantitative studies addressing loneliness in cancer patients. Exclusion criteria were absence of a validated loneliness questionnaire, and studies that focused on loneliness determined by specific circumstances, and not cancer in general (e.g. appearance concerns, cultural and language barriers, requiring palliative care). We searched PsycINFO, CINAHL, Embase, Cochrane Library, and Pubmed in compliance with the predefined in- and exclusion criteria. The search, quality appraisal, and data extraction were performed by two independent reviewers. Weighted mean scores were calculated by using random effects adjusted inverse variance weighting.

Results

We included 15 studies. In 13 studies the UCLA loneliness scale was used (range 20–80; higher scores indicate higher loneliness). The weighted mean loneliness score was 38.26 (95% CI: 35.51–41.00), which corresponds to moderate loneliness. Time since diagnosis was positively associated with degree of loneliness. Other cancer-related factors, such as cancer site, treatment type, or stage of disease were not associated with loneliness. The non-cancer related determinants of loneliness in cancer patients that emerged from our review were being unmarried (people who have never been married, are widowed or divorced), and lack of psychological or social support.

Conclusion

Our findings suggest that the level of loneliness rises with increasing time after cancer diagnosis. Furthermore, social functioning emerged as a consistent theme, for which it was shown that lack of social support was associated with increasing levels of loneliness.

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.

References (58)

  • P.C. Britton et al.

    Reliability of the UCLA Loneliness Scale in opiate dependent individuals

    Journal of Personality Assessment

    (2007)
  • J.T. Cacioppo et al.

    Loneliness and health: potential mechanisms

    Psychosomatic Medicine

    (2002)
  • J.T. Cacioppo et al.

    Perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study

    Psychology and Aging

    (2010)
  • J.T. Cacioppo et al.

    Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses

    Psychology and Aging

    (2006)
  • E.A. Coleman et al.

    The effect of telephone social support and education on adaptation to breast cancer during the year following diagnosis

    Oncology Nursing Forum

    (2005)
  • J. De Jong Gierveld et al.

    Loneliness and social isolation

  • J. De Jong-Gierveld et al.

    The development of a rasch-type loneliness scale

    Applied Psychological Measurement

    (1985)
  • J. De Jong-Gierveld et al.

    Manual of the Lonenliness Scale

    (1999)
  • L. Deckx et al.

    Quality of life and loneliness in older cancer patients. Preliminary results of KLIMOP, a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands

    European Journal of General Practice

    (2013)
  • A.P. Dickens et al.

    Interventions targeting social isolation in older people: a systematic review

    BMC Public Health

    (2011)
  • P.A. Dykstra

    Older adult loneliness: myths and realities

    European Journal of Ageing

    (2009)
  • E. Ekwall et al.

    Recurrence of ovarian cancer-living in limbo

    Cancer Nursing

    (2007)
  • J. Fogel et al.

    Internet use and social support in women with breast cancer

    Health Psychology

    (2002)
  • C.M. Fokkema et al.

    Loneliness interventions among older adults: sense or nonsense?

    Tijdschr Gerontol Geriatr

    (2007)
  • T. Fokkema et al.

    Cross-national differences in older adult loneliness

    The Journal of Psychology: Interdisciplinary and Applied

    (2012)
  • G. Friedman et al.

    The experience of loneliness among young adult cancer patients

    Journal of Psychosocial Oncology

    (1989)
  • S. Fukui et al.

    The effect of a psychosocial group intervention on loneliness and social support for Japanese women with primary breast cancer

    Oncology Nursing Forum

    (2003)
  • B. Hensley et al.

    Life events and personality predicting loneliness among centenarians: findings from the Georgia centenarian study

    The Journal of Psychology: Interdisciplinary and Applied

    (2011)
  • M.E. Hewitt et al.

    From Cancer Patient to Cancer Survivor: Lost in Transition

    (2006)
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