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Associations between cancer-related coping and depressive symptoms in oral cancer patients

BMC Psychology volume 13, Article number: 56 (2025) Cite this article

Abstract

Objectives

Specific coping styles have been found to influence several aspects of psychological health in various ways among cancer patients. Therefore, the aim of the current study was to examine whether different coping styles are associated with depressive symptoms in oral cancer patients.

Methods

The current cross-sectional study was conducted from May 2021 to October 2022 in Liaoning Province, China. A total of 229 patients were included. In addition to demographic and clinical information, the participants completed questionnaires on different coping styles and depressive symptoms. Multivariate linear regression was conducted to identify the influencing factors of depressive symptoms.

Results

The prevalence of depressive symptoms was 65.5% in oral cancer patients. Negative emotion and positive attitude coping explained an additional 50.1% of the variance in depressive symptoms. Negative emotion coping was significantly and positively associated with depressive symptoms (β = 0.596, p < 0.001), whereas positive attitude coping was significantly and negatively related to depressive symptoms (β=-0.275, p < 0.001). In addition, distant metastasis was associated with depressive symptoms (β = 0.084, p < 0.047).

Conclusions

In our sample, more than half of the oral cancer patients experienced depressive symptoms. Interventions based on decreasing negative coping and increasing positive coping should be implemented to help patients cope with mental health problems and achieve psychological adaptation after oral cancer diagnosis and treatment.

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Introduction

Oral cancer is a malignant neoplasm that can occur in the oral cavity. The oral cavity is defined as the anatomical space between the junction of the soft and hard palates and the imaginary coronal surface between the papillae of the peripheral margins of the tongue and the vermilion of the lips. More specifically, oral cancers can occur in the following subsites: lip, tongue, floor of mouth, buccal, hard palate, alveolar, retromolar trigone and soft palate [1]. Among oral cancers, squamous cell carcinoma is the most common histological type, accounting for more than 90% of all oral cancers [2]. Other histological types include oral sarcoma, salivary adenocarcinoma, and oral melanoma [3]. Data from GLOBOCAN 2022 indicated that oral cancer was the 16th most common malignant neoplasm in 2022, with almost 3.9 billion new cases and almost 1.9 billion deaths worldwide [4]. In China, it was estimated that 31,733 new cases of oral cancer were diagnosed, and 15,745 related deaths occurred in 2022 [5]. The increasing prevalence of oral cancer is becoming a major public health problem [6].

An oral cancer diagnosis can be considered life-threatening, as it often induces emotional, psychological, and social consequences and profoundly influences mental health [7, 8]. Furthermore, oral cancer treatments result in severe physical and functional impairments, including tongue function deficits [9], pain [10], oral mucositis [11], fatigue, and dysmorphic appearance [12], which are also associated with depressive symptoms. These treatments and the resulting oral dysfunction are associated with depressive symptoms, which have been reported in 18–41% in oral cancer patients [13, 14]. Studies have indicated that depressive symptoms negatively influence patients’ quality of life, disease management, and survival time [15, 16]. Several sociodemographic factors, such as age, sex, education, and socioeconomic status, are significantly associated with depressive symptoms in cancer patients [17,18,19]. Furthermore, clinical factors (e.g., histological type, cancer stage, and cancer metastasis) play important roles in the development of depressive symptoms [20, 21]. Studies have indicated that most patients do not receive formal psychotherapy because patients usually prefer to manage their symptoms alone or with informal social support [15, 22]. An increasing number of studies have shown that individual positive coping styles may effectively manage depressive symptoms in cancer patients [15, 17].

Coping with cancer is defined as the set of behavioural and cognitive responses implemented after cancer diagnosis in an attempt to mitigate its psychological impact [23]. According to Lazarus and Folkman’s transactional stress and coping theory [24], coping styles are associated with depressive symptoms. This theory states that before an individual decides on the appropriate coping strategies to utilize, the individual will appraise the level of stress caused by the situation. In other words, while a situation is considered an acceptable challenge, individuals with resources and abilities are likely to be able to overcome it through the use of a positive coping style. In contrast, if a situation is regarded as highly stressful, individuals may adopt a coping style characterized by avoiding or delaying the task [25]. Furthermore, studies have indicated that different coping styles are decisive in adjusting to a diagnosis of cancer and may influence the development of depression [26]. Specifically, positive coping can be related to decreases in depressive symptoms over time in cancer patients, whereas negative/avoidant coping can be associated with increases in depressive symptoms among cancer patients [27]. Therefore, this study assumed that different coping styles are associated with depressive symptoms in oral cancer patients.

Understanding and supporting coping styles can positively contribute to mental health in oral cancer patients. However, few studies have investigated the associations between different coping styles and depressive symptoms among oral cancer patients. Therefore, the present study aimed to examine the relationships between different coping styles and depressive symptoms among oral cancer patients.

Methods

Design and participants

The current study had a cross-sectional design and was conducted from May 2021 to October 2022 in Liaoning Province, China. Participants were recruited from the Affiliated Hospital of China Medical University via a convenience sampling method. The inclusion criteria were as follows: (1) diagnosed with oral cancer, (2) aware of their disease, (3) at least 18 years old or above, and (4) ability to communicate and write in Chinese fluently. Patients with a history of mental or cognitive disorders and other diseases, such as oral diseases and other cancers, were excluded. The procedures used in our survey were approved by the Committee on Human Experimentation of the First Affiliated Hospital of China Medical University (NO. 2021-430-2). Each eligible patient completed self-report questionnaires after providing informed consent for this study.

Sample size

The sample size was calculated using G*power 3.1.9.7. The minimum sample size required for multiple regression analysis was 171 based on a power (1-β) of 90%, a significance level (α) of 0.05, effect size of 0.15, and 15 predictor variables (coping style variables, sociodemographic and clinical variables). Initially, 250 oral cancer patients were recruited as potential participants. However, 20 patients refused investigation to participate, and one questionnaire was excluded because of invalid data (missing data > 30%). Therefore, our study included 229 oral cancer patients, thus yielding an effective response rate of 91.6%.

Participant recruitment procedures

In our study, the second author was responsible for participant recruitment. He contacted doctors who worked at the Affiliated Hospital of China Medical University. Then, the doctors directly recommended potential participants and explained the study’s purpose. Recruitment was performed in two steps. After obtaining informed consent, the questionnaire was administered to patients during hospitalization. Then, clinical information about patients was obtained through medical records. Non-responders were recontacted if no response was received after discharge. Each participant needed approximately ten minutes to complete the questionnaire.

Measures

Depressive symptoms

The current study adopted the Center for Epidemiologic Studies Depression Scale (CES-D) [28] to assess the degree of depressive symptoms among oral cancer patients. The CES-D includes twenty items that are scored using a four-point Likert scale ranging from 0 (“rarely or none of the time”) to 3 (“most or all the time”). The total score on the scale ranges from 0 to 60, and a score of 16 or above is regarded as “depressive symptoms.” The scale has been widely used and has good reliability and validity in the Chinese population [27]. In the current study, the Cronbach’s alpha for the CES-D was 0.925.

Coping

Coping style was measured via the Chinese version of the Mini-Mental Adjustment to Cancer (Mini-MAC) [29] scale among patients with oral cancer. The scale includes 29 items and assesses three coping styles, including negative emotion (16 items, e.g., ‘it is a devastating feeling’), positive attitude (9 items, e.g., ‘I am very optimistic’), and cognitive avoidance (4 items, e.g., ‘I distract myself when thoughts about my illness come into my head’). Each item is scored on a 4-point Likert scale ranging from 1 (“definitely does not apply to me”) to 4 (“definitely applies to me”). A higher subscale score indicates stronger use of the coping style. The Chinese version of the Mini-MAC scale has been found to exhibit good internal reliability and construct validity among cancer patients [27, 29]. In the present study, Cronbach’s alpha coefficient for negative emotion, positive attitude, and cognitive avoidance were 0.903, 0.741, and 0.758, respectively.

Demographic and clinical information

Sociodemographic data, including age, sex, body mass index (BMI), educational background, marital status, family per capita monthly income (CNY), smoking status, and current drinking status, were collected via a questionnaire. Clinical data, including histological type, cancer stage, family history, and distant metastasis status, were obtained from medical records.

Statistical analysis

SPSS version 20.0 for Windows (IBM Corp.) was used to perform all the statistical analyses in this study. Descriptive statistics were used to calculate the mean, standard deviation (SD), and range of the scores for each scale. T tests and one-way ANOVAs were used to examine group differences in depressive symptoms according to demographic and clinical variables.

Pearson’s correlation analysis was conducted to calculate the correlation coefficients (r) between coping styles and depressive symptoms. Visual and analytical techniques were used to check the normality of each variable. The variance inflation factor (VIF) was < 5 for all variables and the tolerance was > 0.2, thus indicating that there was no multicollinearity among variables. To identify the determinants of depressive symptoms, a two-block linear regression model was used. In the first block, if a demographic or clinical variable was significant at p < 0.05 in the univariate analysis, it was subsequently included as a covariant in the second block. In the second block, if a coping style was significant at p < 0.05 in the correlation analysis, it was included as an independent variable in the regression model. The adjusted R2 value was adopted to identify the coefficient of determination. The significance level was set at 0.05.

Results

Characteristics of participants

The mean age of all participants was 57.03 (SD = 13.38) years. Younger participants (44–45 years) had more severe depressive symptoms than did people aged 65–74 years (p = 0.030). Approximately 60% of the patients were male. More than 89% of the subjects were married/cohabiting, and these individuals reported higher levels of depressive symptoms (p = 0.012) than those who were single/divorced/widowed/ separated. Only 18.3% of patients had a junior college degree, and 11.4% had a college degree or higher. More than 60% of patients had a monthly income lower than 3000 yuan. A total of 81.2% and 16.2% of patients were diagnosed with squamous cell carcinoma and adenocarcinoma, respectively, and patients diagnosed with adenocarcinoma reported higher depressive symptom scores (p = 0.001) than did those with squamous cell carcinoma. In addition, only four patients were diagnosed with oral sarcoma, and two patients were diagnosed with oral melanoma. A total of 73.4% of the oral cancer patients were diagnosed with stage I disease, and more than 90% of patients reported no family history or distant metastasis. However, patients without distant metastasis reported less severe depressive symptoms (p = 0.001) than did those with distant metastasis. The detailed results are presented in Table 1.

Table 1 ANOVA’s and t test to analyse differences in the level of depressive symptoms according to sociodemographic and clinical variables among oral cancer patients
Full size table

Levels of depressive symptoms and different coping styles

The prevalence of depressive symptoms was 65.5% in patients with oral cancer (as measured by the proportion of patients with a CES-D score ≥ 16). The mean score on the CES-D was 19.37 (SD = 9.71). The mean scores on the Mini-MAC subscales were 23.87 (SD = 3.22), 32.01 (SD = 7.89), 26.20 (SD = 3.63), and 11.02 (SD = 1.95) for the negative emotion, positive attitude, and cognitive avoidance subscales, respectively.

Correlations among depressive symptoms and different coping styles

Table 2 presents the correlations of negative emotion, positive attitude, and cognitive avoidance coping styles with depressive symptoms. Negative emotion coping was positively correlated with depressive symptoms (r = 0.729, p < 0.01). Positive attitude coping was negatively associated with depressive symptoms (r=-0.519, p < 0.01). Cognitive avoidance coping was not significantly correlated with depressive symptoms (r = 0.019, p > 0.05).

Table 2 Pearson correlations between different coping styles and depressive symptoms among oral cancer patients
Full size table

Influencing factors for depressive symptoms

The results of the multiple linear regression analysis are shown in Table 3. In model 1, the results revealed that variations in age, marital status, histological type, and distant metastases accounted for 10.3% of the variance (F = 6.255, p < 0.001) in depressive symptoms among oral cancer patients. In model 2, negative emotion coping and positive attitude coping were included as independent variables, resulting in a significant increase in the variance explained, 61.2% (F = 52.444, p < 0.001). In other words, negative emotion coping and positive attitude coping explained an additional 50.1% of the variance in depressive symptoms. In this model, negative emotion coping was significantly and positively associated with depressive symptoms (β = 0.596, p < 0.001), whereas positive attitude coping style was significantly and negatively related to depressive symptoms (β=-0.275, p < 0.001). In addition, distant metastasis was significantly associated with depressive symptoms (β = 0.084, p < 0.047).

Table 3 Results of linear regression for depressive symptoms among oral cancer patients
Full size table

Discussion

The present study investigated the prevalence of depressive symptoms and examined the impact of different coping styles on depressive symptoms among oral cancer patients. In our study, the prevalence of depressive symptoms was 65.5%. However, there was considerable variability between patients depending on sociodemographic factors, clinical factors, and different coping styles. Thus, the prevalence of depression in patients with oral cancer has been reported to be approximately 24.8% before treatment and 17.1-20.4% at the five-year follow-up [13]. Owing to oral function deficits and facial deformities, oral cancer patients are vulnerable to depressive symptoms throughout their cancer experience. Therefore, more attention should be devoted to psychological health problems among oral cancer patients.

Our study revealed that negative emotion coping and positive attitude coping were significantly associated with depressive symptoms in oral cancer patients. Specifically, oral cancer patients with a negative emotion coping style tended to experience more depressive symptoms. Individuals with a negative emotion coping style tend to adopt a negative self-appraisal, aimed at escaping the threat or related emotions. Negative self-appraisal is associated with psychological distress after cancer diagnosis [30]. Furthermore, helplessness/hopelessness and anxious preoccupation, which are negative emotions that patients use to address their disease, are associated with less appreciation of positive aspects of existence and less enjoyment of their lives. Jimenez-Fonseca et al. [31] reported that cancer patients with diffuse worry and anxious emotions were vulnerable to depressive symptoms. In addition, negative emotions associated with cancer diagnosis and treatment can induce chronic autonomic overstimulation, which can have deleterious effects on hypothalamic‒pituitary‒adrenal (HPA) axis function and the immune system [32]. Other studies have also revealed that cancer patients with depressive symptoms have dysfunctional HPA axes at the time of their initial cancer diagnosis [33, 34].

Conversely, our results indicated that a positive attitude coping style was a protective factor against depressive symptoms. This result was also reported in patients with other cancers, such as those with breast cancer [35] or haematological diseases [27]. Individuals with a positive attitude regard cancer as a challenge and usually face a strong fighting spirit and determination to cope with their illness. Moreover, a positive attitude helps individuals actively seek support from family and friends to buffer stress [15, 36], thereby enabling them to effectively manage depressive symptoms. Therefore, a positive attitude is an essential coping style for oral cancer patients to combat mood disorders and enhance well-being and quality of life.

For sociodemographic factors, the results of the regression analysis (model 1) revealed that oral cancer patients who are married/cohabiting are at a greater risk of developing depressive symptoms. In general, patients tend to receive more family support; they are less likely to experience depressive symptoms than single, divorced, widowed, or separated patients are. However, operation and radiation treatment in oral cancer patients results in facial scars and deficits, and these deficits disfigure patients’ facial appearance and speech difficulties [37, 38], which might cause appearance and sexual distress and affect intimate relationships. In Chinese culture, patients usually receive more care from their partner and family. However, the whole family perceives considerable pressure due to cancer, as Chinese patients who are married need to raise children and care for the aged. The exigent condition inevitably results in more distress among married oral cancer patients.

In terms of clinical factors, compared with squamous cell carcinoma, adenocarcinoma is usually diagnosed as advanced cancer [39], and adenocarcinoma patients have more metastatic tendencies than squamous cell carcinoma patients do [40]. In addition, previous studies reported that, compared with patients with adenocarcinoma, patients with squamous cell carcinoma have superior survival benefits [41]; thus, patients with adenocarcinoma are at risk for a low quality of life and mental problems. Patients with distant metastasis tend to have more depressive symptoms, which has been confirmed among other cancer patients [42]. Distant metastasis is one of the worst adverse events that can occur among cancer patients, as it can worsen physical and psychological health [43].

Clinical implications

Some practical implications should be highlighted. The current study reported that more than half of oral cancer patients suffer from depressive symptoms. However, most cancer patients do not receive formal psychotherapy because patients usually prefer to manage their symptoms alone with coping strategies [15, 22]. Our study suggested that a positive coping style could effectively manage depressive symptoms, whereas a negative coping style could increase the level of depressive symptoms. Therefore, coping style interventions should be provided for oral cancer patients to improve their psychological health. For example, music may be a safe and effective coping style for psychological management. A previous meta-analysis reported that music coping interventions may be beneficial tools for reducing negative emotions among cancer patients [44]. In addition, social support interventions could increase confidence and the ability to adopt positive coping skills in response to disease-induced stress [45].

Limitations

This study also has several limitations. First, this study was a cross-sectional design, and causal inferences could not be drawn. Further research should use a longitudinal design to confirm these associations. Second, convenience sampling was used in the present study, which limits the representation of the study.

Conclusion

In summary, our results revealed high depressive symptoms among oral cancer patients. Furthermore, coping style was a significant factor for depressive symptoms. Specifically, a negative emotion coping style was found to contribute to depressive symptoms, whereas a positive attitude coping style was beneficial for decreasing depressive symptoms among oral cancer patients. Therefore, implementing interventions to reduce negative coping and increase positive coping can help patients improve their ability to achieve psychological adaptation after cancer diagnosis and treatment.

Data availability

The dataset and materials in this study are available from the corresponding author upon reasonable request.

Abbreviations

BMI:

Body Mass Index

CES-D:

Center for Epidemiologic Studies Depression Scale

Mini-MAC:

Mini-Mental Adjustment to Cancer

SD:

Standard Deviation

VIF:

Variance Inflation Factor

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Acknowledgements

All authors would like to thank the research fellows who participated in the study’s data collection, management, and analysis. All authors read and approved the final manuscript.

Funding

This work was supported by the Doctoral Research Initiation Fund of Wannan Medical College (No. X600100117) and University Research Project of Anhui Province (No. 2024AH053457).

Author information

Authors and Affiliations

  1. School of Humanities and Management, Wannan Medical College, Wuhu, Anhui, 241002, PR China

    ChunYing Cui

  2. School of Public Health, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China

    Lie Wang

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Contributions

CCY and LW conceived and designed the study. CCY and LW collected the data. CCY analyzed the data. CCY drafted the article. CCY and LW revised the paper.

Corresponding author

Correspondence to ChunYing Cui.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the committee on Human Experimentation of the First Affiliated Hospital of China Medical University (NO. 2021-430-2), and the study procedures followed ethical standards. All participants provided informed consent to participate. All methods were carried out in accordance with relevant guidelines and regulations.

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Cui, C., Wang, L. Associations between cancer-related coping and depressive symptoms in oral cancer patients. BMC Psychol 13, 56 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02392-x

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BMC Psychology

ISSN: 2050-7283

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