Among the 12 symptoms included in this study, the symptom prevalence ranged from 20.69–70.94%, with more than half of them having a symptom prevalence > 40%. The top five symptom prevalence rates were fatigue (70.94%), pain (55.67%), worry (49.28%), lack of appetite (45.81%), and vomiting (42.86%). This result indicates gastric cancer patients experience multiple symptoms, consistent with a similar study among patients with breast cancers[12]. The high incidence of fatigue symptoms may be because it is cancer, a chronic and consumptive disease that causes patients to suffer from physical exertion, intake reduction, uncomfortable symptom trouble, and negative psychology, especially in gastric cancers receiving chemotherapy. This suggests that healthcare professionals should pay attention to the symptom performance of gastric cancer patients during treatment and develop effective interventions, to reduce the symptom burden of patients during treatment.
It was shown that patients with gastric cancer can suffer from multiple symptoms at the same time. Meanwhile, these symptoms appear in symptom clusters which often aggravate the burden of gastric cancer patients. Therefore, symptom research based on the theory of symptom experience modeling is particularly important. In this study, 12 symptoms of gastric cancer patients were analyzed using EFA, which showed that three major symptom clusters existed among gastric cancer patients, namely, the emotional-sickness symptom cluster, the energy deficiency symptom cluster, and the digestive tract symptom cluster. There are few studies on symptom clusters of gastric cancer patients. In our study, two of the three symptom clusters, the emotional-sickness symptom cluster, and the energy deficiency symptom cluster were the same as similar clusters in studies of patients with breast cancer and lung cancer patients receiving chemotherapy[40, 41].
In this study, the emotional-sickness symptom cluster includes six symptoms: worry, fatigue, sadness, sleep disturbance, pain, and nausea. First, the formation of this symptom cluster is primarily due to surgical trauma, anesthesia, and treatment-induced neuroendocrine changes and immune-inflammatory responses. These factors lead to a high incidence of symptoms such as fatigue, pain, and sleep disturbance, and can also trigger negative emotions such as worry and sadness[42]. Second, nausea is more common in gastric cancer patients in the short term after surgery. This is because the gastrointestinal function has not fully recovered post-operation, necessitating measures such as gastrointestinal decompression, dietary restrictions, fasting, as well as enteral and parenteral nutritional support in the short term. Therefore, nursing staff should actively intervene by enhancing the assessment and management of postoperative pain in gastric cancer patients. They should encourage early oral intake, and mobilization, and ensure adequate perioperative nutrition intake. Additionally, utilizing a range of psychological therapies such as music therapy, traditional Chinese medicine, relaxation therapy, and progressive muscle relaxation methods can help alleviate the emotional-sickness symptom cluster in gastric cancer patients.
The energy deficiency symptom cluster is likely linked to factors such as preoperative gastrointestinal preparation, surgical stress, and postoperative fasting. In this study, the energy deficiency symptom cluster consisted of four symptoms: bloating, shortness of breath, numbness, and constipation. Feeling bloat, a common complication post-laparoscopy is often associated with issues like CO2 retention, incomplete intestinal cleansing, and adverse reactions to anesthetic drugs[43]. Research indicates that gastric cancer patients may experience shortness of breath and numbness following chemotherapy due to the disease itself, the impact of chemotherapy drugs, and the inflammatory response mediated by interleukins[44]. Research has shown that erosion of cancer cells and functional deterioration can lead to constipation[45]. Additionally, factors such as reduced roughage intake decreased physical activity, and the use of chemotherapy drugs may further exacerbate constipation in gastric cancer patients. Therefore, the study suggests that nursing staff should prioritize patient education. This includes educating patients and their families about the potential side effects of chemotherapy drugs and empowering them with the knowledge and skills to self-monitor and manage their symptoms at home. Furthermore, nursing staff should guide patients on strategies such as increasing dietary fiber intake, ensuring sufficient hydration, and promoting regular bowel habits to help prevent and alleviate constipation issues.
The emergence of the digestive tract symptom cluster may be associated with gastrointestinal mucosal damage, and abnormal release of inflammatory mediators, and neurotransmitters[46]. This symptom cluster includes lack of appetite and vomiting and is more prevalent in gastric cancer patients and those undergoing chemotherapy[47]. A study revealed that vomiting was the only identified and consistent symptom in this symptom cluster[48]. It was also reported that common chemotherapy drugs like methotrexate, along with treatment regimens, can lead to nausea and vomiting, subsequently causing oral mucositis and lack of appetite[49]. Additionally, the GI symptom cluster may lead to the energy deficiency symptom cluster.
Therefore, nursing staff should routinely evaluate gastrointestinal symptoms in gastric cancer patients, assessing the frequency and severity of lack of appetite and vomiting, and monitoring symptom changes to adjust the treatment plan in time. Gastric cancer patients should promptly adjust their dietary structure and resume oral feeding, water intake, and enteral nutrition as soon as possible after surgery, supplementing with parenteral nutrition when needed. In cases of vomiting, gastric cancer patients should temporarily fast and gradually reintroduce a diet once symptoms subside. This approach can help alleviate digestive tract symptoms, ensure sufficient energy intake, and mitigate the energy deficiency symptom cluster.
The level of fear of disease progression in 203 patients with gastric cancer was at a moderate to high level. The results showed that 74.9% of gastric cancer patients had psychological dysfunction, consistent with Zhu et al. and significantly higher than Goebel S et al.[50] studying adult ambulatory patients with brain cancer (42%). 146 patients developed psychological dysfunction, related to the majority of patients receiving chemotherapy in our study. Adverse effects such as nausea and vomiting associated with chemotherapy may further aggravate patients' fear of the disease and treatment. This is the first study that specifically examines patients with gastric cancer concerning the association between symptom clusters and fear of disease progression. This is important because uncomfortable symptoms can be physically and mentally exhausting, affect patients' daily lives and social lives, and cause patients to feel anxious and depressed about their disease. Meanwhile, there is no immediate effect of the treatment, and then patients lose confidence, are overwhelmed, and lack enthusiasm for subsequent treatment[51]. Patients develop a higher symptom burden and disturbance and fear and anxiety about prognosis. The above reasons suggest that medical staff should pay more attention to the psychological plague of patients and provide more psychological counseling to patients, such as helping to develop hobbies, divert attention, restore social skills, etc., to help patients reduce their fear of recurrence or progression of the disease.
The quality of life of 203 gastric cancer patients was not high, consistent with the findings of Ahn[52]. This result indicates that patients' quality of life was affected to a certain extent after suffering from the disease, and there is still much room for improvement. Moreover, the scores of the dimensions of FWB and EWB were lower than other dimensions, suggesting that the patients' function and feelings were more affected by the disease. Quality of life is affected by several factors. In terms of functional well-being, patients are vulnerable to fatigue due to the uncomfortable symptoms lasting for a long period and intensity caused by the disease and treatment, which affects normal work and life[53]. Concerning emotional well-being, symptom clusters and financial pressure increased the psychological burden of patients, which led to negative emotions such as depression, and reduced the level of patients' quality of life[54]. In conclusion, the level of quality of life of the patients was moderate, with much room for improvement. The scores of the dimensions differed considerably, especially the low scores of FWB and EWB, which could be given more attention。
Physical status and symptom clusters were affecting factors of quality of life in gastric cancer patients in this study (P < 0.05). The higher the physical status score, the worse self-care and mobility and the lower the quality of life of gastric cancer patients. Under the framework of the International Classification of Functioning, Disability, and Health (ICF), the worse the physical state in gastric cancer patients, the more limited the body structure and function, activity, and participation[55]. A previous meta-analysis showed that appropriate aerobic exercise can alleviate patients' fatigue and improve their physical state to enhance the quality of life of gastric cancer patients[56]. Therefore, moderate exercise intervention, nutritional support, and psychological support are clinically recommended to improve patients' quality of life.
The results showed that the score of severity of symptom clusters was negatively correlated with the total score of quality of life. In other words, the higher the severity of symptom clusters, the worse the quality of life of the patients. Dong et al.[57] studying advanced cancer patients also showed that symptom clusters were negatively correlated with quality of life. Multiple symptom clusters may affect gastric cancer patients at the same time and act synergistically to further compromise the patient's life. This study suggests that the management of emotional-sickness symptom clusters, energy deficiency symptom clusters, and digestive tract symptom clusters in gastric cancer patients should attract the attention of medical staff and allow patients and their families to participate in the management of symptom clusters. In clinical nursing practice, the dietary patterns of gastric cancer patients should be adjusted in time. The patient's oral food and water intake, as well as enteral nutrition supplementation, should be resumed as soon as possible after surgery. When necessary, parenteral nutrition is combined to relieve the patient's gastrointestinal symptoms and ensure energy intake. Meanwhile, clinical nursing staff should strengthen patients' exercise and psychological rehabilitation, such as giving full play to positive thinking therapy, aerobic exercise, and relaxation therapy to improve patients' emotional-sickness symptom cluster and energy deficiency symptom cluster, to enhance patients' quality of life.
The total score of fear of disease progression, physical health dimensions, and quality of life all showed significant negative correlations. The higher the level of fear of disease progression, the lower the level of quality of life, consistent with Zhang et al.[58] studying 1,749 cancer inpatients. Zhang et al. showed that the degree of fear of disease progression was negatively correlated with the physical, emotional, and social aspects of health-related quality of life of gastric cancer patients, which interacted with each other. Medical staff can improve the level of psychological dysfunction in patients through psychological care and mindfulness to improve quality of life.