Influence of symptom burden on social alienation in lung cancer patients receiving chemotherapy: the chain mediating effect of perceived social support and positive psychological capital

Abstract

Background

Social alienation is prevalent among lung cancer (LC) patients undergoing chemotherapy. Although previous research has established an association between social alienation and symptom burden, the mechanisms underlying this relationship remain not fully understood.

Methods

This cross-sectional study used convenience sampling to select 378 LC patients undergoing chemotherapy from September 2022 to December 2023 at a tertiary care hospital in Guangzhou, China. Data collection was conducted using a proprietary Sociodemographic Information Questionnaire, MD Anderson Symptom Inventory (MDASI), Social Alienation Questionnaire, Perceptions of Social Support (PSS) Questionnaire, and Positive Psychological Capital (PPC) Questionnaire. To analyze chain-mediated effects, the PROCESS v3.3 Model 6 SPSS macro software was employed.

Results

The analysis revealed that the burden of symptoms significantly exacerbates social alienation, as evidenced in the mediation effects model (Bootstrap 95% CI: 0.031, 0.092). Furthermore, the burden of symptoms indirectly diminishes PSS (Bootstrap 95% CI: 0.019, 0.057) and PPC (Bootstrap 95% CI: 0.002, 0.020). It is crucial to note that both PSS and PPC significantly mediate the relationship between symptom burden and social alienation, as evidenced (Bootstrap 95% CI: 0.001, 0.011).

Conclusions

The impact of symptom burden on social alienation is moderated through PSS and PPC, manifesting both directly and indirectly. Moreover, the influence of PPC tends to mitigate the mediating role of PSS. Clinical interventions aimed at bolstering PSS and augmenting PPC may potentially alleviate social alienation and enhance the quality of life for patients undergoing chemotherapy for LC.

Introduction

LC remains the most prevalent and lethal form of malignant tumor globally, with approximately 2.5 million new diagnoses (12.4%) and 1.8 million fatalities (18.7%) reported [1]. In China, this cancer records the highest rates of incidence and mortality among all malignancies [2]. Notably, 33% of LC patients experience social alienation [3]. Social alienation includes psychological and behavioral signs of involuntary detachment and seclusion, arising from various influences that disrupt social interactions and behaviors [4]. A conceptual analysis describes this as objective social avoidance behavior and subjective negative emotional experiences [5]. The aging characteristics of the LC population result in lower physiological reserve capacity and decreased resilience, leading to high levels of symptom distress after chemotherapy. This impacts their ability to engage in social activities [6]. Additionally, under specific cultural contexts, LC is often mistakenly perceived as a “smoker’s disease“ [7]. This misconception exacerbates the stigmatization of smoking, resulting in social discrimination and prejudice [8]. These factors make LC patients undergoing chemotherapy more susceptible to feelings of social alienation, adversely affecting their mental and physical health, survival rates, and family mortality rates [9]. Therefore, this issue warrants significant attention.

Studies indicate that symptom burden is a major risk factor for social alienation [10]. Symptom burden encompasses the manifestation and severity of symptoms, as well as the degree of suffering they cause to patients. Persistent respiratory symptoms impair patients’ daily communication abilities and limit their participation in social activities for extended periods. Additionally, chemotherapy side effects, such as rashes and hair loss, make patients feel inferior and ashamed due to changes in self-image, reducing their willingness and ability to socialize [10,11,12]. Moreover, patients with a heavy symptom burden are more likely to experience impaired cognitive function, leading to feelings of isolation and social exclusion, which further exacerbate social alienation. Despite existing literature on the interplay between symptom burden and social alienation among LC chemotherapy patients, there remains a paucity of in-depth analysis concerning the underlying psychological mechanisms.

PSS is defined as an individual’s subjective evaluation and personal experience regarding the support they perceive [13]. Research has underscored the pivotal role of PSS in mitigating feelings of social alienation [14, 15]. When patients receive high levels of social support—including material assistance, emotional comfort, and informational support—they are more likely to feel respected, understood, and cared for. This support helps patients mitigate the negative effects of their illness, cope more positively, and engage better with the outside world, thereby exhibiting a lower sense of social alienation [16]. Furthermore, a higher symptom burden could lead to increased negative emotions, which diminish the perception of social support [17]. Symptom burden and PSS have been found to be strongly linked in empirical studies. As symptom burden intensifies, patients become more preoccupied with the impact and discomfort of their symptoms, which diminishes their sense of received support and heightens feelings of social alienation [17]. Although research has established that PSS is a critical factor in social alienation and has found a correlation between symptom burden and PSS, the specific mechanisms and dynamic interactions among these three variables remain unclear.

PPC, a critical construct formed during an individual’s developmental phase, comprises self-efficacy, hope, resilience, and optimism [18]. Previous studies indicate that psychological capital inversely predicts social alienation [19]. This favorable psychological condition serves as a buffer against the adverse impacts of negative emotions. Elevated psychological capital levels improve patients’ capabilities to garner support from their social networks, which in turn diminishes social alienation [20]. Additionally, research has shown a negative correlation between symptom burden and individual levels of hope and psychological resilience in LC chemotherapy patients [21, 22]. Patients frequently resort to negative coping mechanisms when confronted with pain and discomfort, which reduces their resilience and hope. Moreover, chemotherapy may stimulate the hypothalamic-pituitary-adrenal (HPA) axis, leading to increased cortisol levels that could impair brain reward pathways, further depleting psychological capital [23]. Thus, a more detailed examination of how PPC mediates the relationship between social alienation and symptom burden is imperative.

The stress process model suggests that an individual’s stress response is mediated by various factors, indicating that the impact of symptom burden on social alienation in LC patients undergoing chemotherapy is multifaceted [24]. With advancing age, the formation and sustenance of social networks serve as crucial protective mechanisms for the mental health of patients with LC [25]. Those with robust PSS experience greater comprehension and support, which cultivates a sense of security and belonging. This support network effectively mitigates the negative psychological impacts of chemotherapy, thereby boosting patients’ confidence and positive outlook. When lower-level needs are met, patients are more likely to pursue higher goals, transforming social support resources into psychological capital. Research has underscored the reciprocal influence between PSS and PPC [26, 27]. These elements, representing vital external and internal resources, synergistically enhance each other, thereby positively affecting the mental health of individuals [28].

The Stress Process Model serves is a key theoretical framework for elucidating the dynamics of individual mental health processes [24]. This model suggests that the progression from stressors to stress responses is dynamic, emphasizing the role of mediating factors such as personal resources and social support. In this study, a theoretical model is proposed to explore the relationships among symptom burden, social alienation, PSS, and PPC, with the latter two serving as mediators. Based on the Stress Process Theory, we present the following hypotheses: (H1) Symptom burden is directly and negatively correlated with social alienation; (H2) The relationship between social alienation and symptom burden may be moderated by effective social support; (H3) PPC may mediate the relationship between symptom burden and social alienation; (H4) Symptom burden may sequentially mediate the pathway leading to increased social alienation. The model diagram is shown in Fig. 1.

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Methods

Participants

This research employed a cross-sectional design and used convenience sampling to recruit 378 LC patients undergoing chemotherapy. Participants were selected from the oncology department of a tertiary care hospital in Guangzhou, China, between September 2022 and December 2023. The inclusion criteria included: (1) Patients diagnosed with primary LC through clinical pathology; (2) age ≥ 18 years; (3) eligibility for chemotherapy, with ≥ 1 cycle completed; (4) Karnofsky Performance Status (KPS) score ≥ 60; (5) voluntary participation and informed consent. The exclusion criteria were: (1) protective medicine; (2) individuals with consciousness or psychological disorders impeding cooperation; (3) severe organic diseases affecting vital organs such as the heart, brain, or kidneys.

This study utilized pwrSEM software for a post hoc statistical power analysis via the Monte Carlo simulation method [29]. The model was defined as a chained mediation model, with an input significance level set at α = 0.05. The results showed that the statistical power (1-β) was 0.87, exceeding the critical threshold of 0.80, thus confirming that the sample size met the statistical requirements.

Procedure

The research tool was developed into an electronic questionnaire and uploaded to the Wenjuanxing platform. Before the survey, the researcher provided an overview of the study’s objectives, importance, and confidentiality measures to the participants and departmental management. The research team received uniform training before administering a structured face-to-face survey. Respondents were expected to spend about 15 to 20 min completing the questionnaire. Patients were instructed to fill it out independently; those with poor reading skills received assistance from the researcher, who read the questions line by line. Disease-related information was obtained through patient consent, either by reviewing medical records or consulting with doctors. A viable answer percentage of 99.47% was achieved from the 378 appropriate responses to the 380 questionnaires distributed. The data collection process lasted 16 months. The study was approved by the relevant hospital ethics committee (202206SB-001-01), and informed consent was secured from all participants prior to their involvement.

Measures

Sociodemographic information questionnaire

The sociodemographic information questionnaire was designed by the researcher. Demographic characteristics included age, sex, religious belief, marital status, and education level. Disease-related data comprised chemotherapy cycle, course of disease, tumor type, disease stage, etc.

Symptom burden

The M.D. Anderson Symptom Inventory (MDASI-C) [30] at the Anderson Cancer Center and introduced to China by Wang et al. [31], was employed to assess symptom alleviation and burden among cancer patients. This tool includes six items focused on symptoms impacting daily activities and thirteen core symptom indicators. Specifically, the MDASI-Lung Cancer (MDASI-LC) module was used to evaluate LC-related symptoms, such as coughing, mucus production, blood in sputum, constipation, chest constriction, and weight loss. Both MDASI-C and MDASI-LC utilize an 11-point Likert scale, ranging from 0 (no symptoms or interference) to 10 (most intense symptoms or interference). The scale’s Cronbach’s α reliability coefficient was 0.922.

Social alienation

The Social Alienation Assessment Questionnaire, developed by Su et al., is designed to evaluate the level of social alienation in cancer patients [32]. The questionnaire contains four dimensions: self-isolation, loneliness, alienation, and meaninglessness, totaling 17 items. The Cronbach’s alpha for the questionnaire was 0.902, and the content validity index was 0.923, indicating strong reliability and validity.

Perceptions of Social Support Questionnaire (PSSQ).

The PSSQ, developed by Li et al. [33], measures the degree of social support perceived by individuals. It comprises twelve items spread across three dimensions: support from friends, family, and various social circles. Responses are gauged on a 7-point Likert scale, with 1 representing “Strongly Disagree” and 7 “Strongly Agree,” summing to a potential range of 12 to 84. The reliability of the scale is confirmed with a Cronbach’s α coefficient of 0.893.

Positive psychological capital questionnaire (PPQ)

The PPQ assesses levels of PPC [34] and has been validated within populations of LC patients [35]. This questionnaire includes 26 items divided into four domains: self-efficacy, resilience, hope, and optimism. It employs a 7-point Likert scale, where a response of 1 means “not at all likely,” and 7 means “very likely,” demonstrating high reliability with a Cronbach’s alpha of 0.930 in this study.

Statistical analysis

Data was analyzed using SPSS (version 27.0). The Shapiro-Wilk test initially evaluated data distribution for normality. Linear regression analysis was then applied to pinpoint independent predictors of social isolation. Additionally, Pearson correlation coefficients were calculated to explore inter-variable relationships. In the subsequent multiple linear regression analyses, significant covariates were controlled, and Hayes et al.‘s SPSS PROCESS macro version 3.3 was employed to analyze mediation, with symptom burden positioned as the independent variable and social isolation as the dependent variable. The mediation model’s significance was assessed via a bias-corrected non-parametric percentile bootstrap method (Model 6), utilizing 5,000 resamples to establish the 95% confidence interval (CI). A mediation effect was considered significant if the 95% CI did not include zero.

Results

General information about the participants

The study comprised 378 patients diagnosed with advanced LC, and Table 1 provides the descriptive statistics for each variable assessed. The patients’ median age was 58(49,64), the median chemotherapy cycle was 3(2,5), the median course of the disease was 9(5,12), and the median KPS score was 80 (70,90). Most patients (58.5%) were male, married (95.2%), had junior high school education or below (73.8%) and were metastatic (72.8%). In addition, 32% of the patients were non-religious, 31.5% had adenocarcinoma, 34.1% were classified as TNM stage IV, and 38.4% received the GP chemotherapy regimen.

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Analysis using linear regression

The dependent variable in our multiple linear regression study was social alienation. Sociodemographic characteristics, disease-specific components, symptom burden, PSS, and PPC were among the independent variables. Evaluation of collinearity among these independent variables indicated tolerances surpassing 0.1 and variance inflation factors (VIF) under 10, implying that the independent variables do not exhibit multicollinearity. The regression analysis findings demonstrated that social distancing among LC patients was significantly affected by symptom burden, PSS, and PPC. This influence remained evident even after accounting for sociodemographic variables and disease-specific factors (Table 2). Furthermore, factors such as chemotherapy cycles, disease duration, and KPS score also exhibited influence on social alienation.

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Correlations among symptom burden, PSS, PPC, and social alienation

Table 3 displays the average scores for symptom burden, social alienation, PSS, and PPC as 54.00 (36.00, 95.25), 51.00 (46.00, 57.00), 50.78 (14.17), and 82.00 (62.00, 95.00), respectively. Pearson correlation analysis shows that symptom burden is positively associated with social alienation (r = 0.427, P < 0.001) and inversely related to PSS (r=-0.578, P < 0.001) and PPC (r=-0.419, P < 0.001). Additionally, social alienation correlates significantly and negatively with PSS (r=-0.430, P < 0.001) and PPC (r=-0.350, P < 0.001), whereas PPC shows a strong positive correlation with PSS (r = 0.398, P < 0.001).

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Chain mediation effects analysis

Figures 2 and 3 illustrates a chain mediation model involving these four variables. Detailed analysis of the chain-mediated influences of PSS and PPC on symptom burden and social alienation is presented in Tables 4 and 5. The findings highlight:

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1. a.

(a) A significant direct effect of symptom burden on social alienation, recorded as 0.061 (Bootstrap 95% CI: 0.031, 0.092).

2. b.

(b) An indirect effect of symptom burden on social alienation through PSS, recorded as 0.038 (Bootstrap 95% CI: 0.019, 0.057).

3. c.

(c) An indirect effect of symptom burden on social alienation via PPC, measured at 0.009 (Bootstrap 95% CI: 0.002, 0.020).

4. d.

(d) A combined mediating effect of PSS and PPC on the relationship between symptom burden and social alienation, with a magnitude of 0.005 (Bootstrap 95% CI: 0.001, 0.011). The bias-corrected 95% CI for all pathways exclude zero, affirming statistical significance.

Discussion

This study investigated the mechanisms by which symptom burden fosters social alienation in LC patients, constructing a chain-mediated model to examine how PSS and PPC might mediate this effect. The analysis not only sheds light on the pathways linking symptom burden to social alienation but also provides empirical support for strategies to alleviate social alienation in these patients.

Our findings confirm a robust positive correlation between symptom burden and social alienation, thus supporting Hypothesis 1. This correlation aligns with prior research [3, 36, 37], which identifies symptom burden as a critical determinant of social alienation. A significant marker of social isolation is the diminution of social networks and interactions [38]. As the adverse effects of chemotherapy accumulate, patients endure compounded physical and psychological challenges. Symptoms such as dyspnea, cough, and loss of appetite directly diminish social capabilities [39], while weakened immune function and altered self-perception increase tendencies towards self-isolation. In some cultural settings, reintegration into society may trigger discrimination, intensifying feelings of isolation [40]. According to the stress process model, social alienation emerges as a response to the array of symptomatic stresses associated with the disease. This notion is further endorsed by White’s heuristic model of cognitive behavior, which posits that perceived alterations in physical appearance and functionality provoke adverse emotional reactions and avoidance behavior [4]. LC predominantly affects individuals aged 65–69, with age-related physiological decline heightening vulnerability to social disengagement [41]. The adverse effects of prolonged isolation extend to physical and mental health and can negatively influence treatment adherence. Evidence from a prospective cohort study underscores a significant link between social alienation and survival rates in LC patients [42]. Therefore, enhancing the management of chemotherapy-related symptoms and facilitating the re-establishment of social ties are essential for providing comprehensive emotional and psychological support to these patients.

This study validates that PSS and PPC mediate the relationship between symptom burden and social alienation in patients with LC, supporting Hypotheses 2 and 3. PSS, encompassing the extent and perception of support received by individuals, primarily involves subjective evaluations [43]. The results confirm that symptom burden negatively predicts levels of PSS, aligning with previous research [44]. Research indicates that inflammatory cytokines and various hormonal responses elicited by chemotherapy agents like TNF-α and IL-6 can exacerbate anxiety, depression, and loneliness, thus impeding the internalization of social support [45]. Additionally, PSS exhibited a negative correlation with social isolation. According to Hyland et al., limitations in accessing emotional, material, and informational support can reduce patients’ feelings of belonging, thereby fostering social isolation [44]. Additionally, sustained psychosocial stress might disrupt endocrine and immune functions via the autonomic nervous system, potentially affecting tumor treatment efficacy and perpetuating a detrimental cycle [46]. Increased psychological capital was found to be instrumental in recognizing and navigating internal conflicts, thereby enhancing social network connectivity. Conversely, higher levels of social alienation were linked to psychological distress, including symptoms of anxiety and depression [4, 40]. Evidence suggests that robust psychological capital can elicit positive patient responses such as optimism, adaptability, and resilience in facing challenges. These adaptive responses are crucial in accepting the reality of symptom burden and physiological alterations, fostering a positive attitude towards illness management, and reducing feelings of alienation [41]. To bolster the well-being of LC patients, prioritizing interventions that enhance social support is crucial. This strategy should encompass the formation of structured support groups and the training of healthcare providers to promote effective social interactions. Additionally, implementing psychological interventions aimed at strengthening coping mechanisms and resilience is recommended.

The research demonstrates that PSS and PPC serve as chain mediators in the interaction between symptom burden and social alienation among LC patients, confirming Hypothesis 4. According to the stress process model [47], social support and individual traits mediate the emergence of psychosocial stress. The traditional buffering hypothesis regarding social support corroborates that PSS is a positive predictor of PPC [48]. Consistently, the relationship between PSS and PPC was maintained across the sample of LC patients receiving chemotherapy, reinforcing findings from prior studies [49, 50]. Symptom burden post-chemotherapy influenced social alienation through multiple dimensions. Externally, an increased symptom burden prompted patients to fixate on their physical discomfort and the disruptions imposed on their daily activities, thereby diminishing their PSS [51]. This external focus not only impaired their capacity to acknowledge and value external social support but also internally obstructed the development of psychological resources such as hope, optimism, and self-confidence, culminating in adverse coping mechanisms and a depletion of positive psychological resources [52].

Furthermore, the study uncovered a psychological mechanism by examining shifts in the values of chain mediating effects. We observed that enhanced PPC slightly mitigated the mediating influence of PSS between symptom burden and social alienation. PPC represents the internal positive assets that patients accrue over their disease trajectory [53]. Resource conservation theory posits that individuals safeguard their extant resources under stress [54]. Strengthened traits such as optimism and self-efficacy in patients were associated with improved coping abilities, reducing reliance on external social support. This observation aligns with findings from Lai et al. [55], which suggest that while PSS is crucial in reducing social alienation, patients with higher PPC tend to depend more on their intrinsic resources for self-regulation. LC patients uniquely experience psychological strain from heightened mortality anxiety, smoking-related stigma, and respiratory distress [56, 57], leading them to lean more on internal mechanisms to manage psychological distress and social stigmatization. It is imperative for healthcare providers to prioritize the psychological welfare of LC patients receiving chemotherapy by customizing social support to individual needs. For those exhibiting substantial PPC, efforts should focus on bolstering self-management and cultivating internal resources. Moreover, nurturing support networks among patients could amplify their sense of social belonging through shared experiences and mutual coping methods.

Research implications and limitations

This research elucidates the chain-mediated roles of PSS and PPC in modulating the interaction between symptom burden and social alienation among LC patients. This exploration significantly enriches the theoretical framework in mental health domains and offers practical insights for medical practitioners. The results highlight the essential function of enhancing psychological capital and fostering social support to improve overall life quality and strengthen social bonds for these individuals.

However, the study presents several limitations that warrant consideration. The use of a cross-sectional design restricts the ability to establish causal relationships among the variables examined. Furthermore, reliance on convenience sampling could introduce selection bias, which may affect the extrapolation of the results to broader populations. Future studies should consider longitudinal designs and employ randomized sampling methods across multiple centers to enhance the robustness and applicability of the results.

Conclusion

The findings reinforce the critical roles of PSS and PPC as intermediary mechanisms in the relationship between symptom burden and social alienation in patients undergoing chemotherapy for LC. Importantly, an enhancement in psychological capital tends to diminish the mediating influence of social support on social alienation, suggesting a nuanced interaction between these factors that merits further investigation. These insights deepen our understanding of the psychological mechanisms that contribute to social alienation. Therefore, it is imperative for interventions to focus on strengthening these elements to effectively address social alienation in LC patients worldwide.

Data availability

The datasets used and/or analyses during the current study are available from the corresponding author on reasonable request.

References

Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229–63.

Zheng RS, Chen R, Han BF, et al. Cancer incidence and mortality in China, 2022. Chin J Oncol. 2024;46:221–31. Chinese.

Song C, Yao L. The experience of Social Alienation in Elderly Lung Cancer patients: a qualitative study. Asian Nurs Res (Korean Soc Nurs Sci). 2024;18:281–7.

Wu Y, Yan Z, Fornah L, Zhao J, Wu S. The mediation effect of social support between stigma and social alienation in patients with stroke. Front Public Health. 2023;11:1290177.

Liang Y, Hao G, Wu M, Hou L. Social isolation in adults with cancer: an evolutionary concept analysis. Front Psychol. 2022;13:973640.

Liang X, Liu MW, Zhang L, et al. Analysis of the incidence trend and age change of lung cancer in some regions of the world. China cancer. 2022;31:683–92. Chinese.

McLaughlin-Barrett S, Brunelli VN. Did you smoke? Addressing stigma in lung cancer. Respirology. 2021;26:1018–20.

Occhipinti S, Dunn J, O’Connell DL, Garvey G, Valery PC, Ball D, et al. Lung Cancer Stigma across the Social Network: patient and caregiver perspectives. J Thorac Oncol. 2018;13:1443–53.

Nicholson NR, Feinn R, Casey EA, Dixon J. Psychometric evaluation of the social isolation scale in older adults. Gerontologist. 2020;60:e491–501.

Thapa A, Chung ML, Wu J-R, Latimer A, Lennie TA, Mudd-Martin G, et al. Mediation by Fatalism of the Association between Symptom Burden and Self-Care management in patients with heart failure. J Cardiovasc Nurs. 2024;39:229–36.

Mody GN, Stover AM, Wang M, King-Kallimanis BL, Jansen J, Henson S, et al. Electronic patient-reported outcomes monitoring during lung cancer chemotherapy: a nested cohort within the PRO-TECT pragmatic trial (AFT-39). Lung Cancer. 2021;162:1–8.

Varma A, Weinstein J, Seabury J, Rosero S, Zizzi C, Dilek N, et al. Patient-reported impact of symptoms in lung cancer (PRISM-LC). Transl Lung Cancer Res. 2023;12:1391–413.

Dour HJ, Wiley JF, Roy-Byrne P, Stein MB, Sullivan G, Sherbourne CD, et al. Perceived social support mediates anxiety and depressive symptom changes following primary care intervention. Depress Anxiety. 2014;31:436–42.

Adams RN, Mosher CE, Winger JG, Abonour R, Kroenke K. Cancer-related loneliness mediates the relationships between social constraints and symptoms among cancer patients. J Behav Med. 2018;41:243–52.

He YK, Liu YF, Cai RT, et al. Visual analysis of the research hotspots and trends of social isolation based on Citespace. J Math Med. 2023;36:744–53. Chinese.

Lei H, Tian X, Jin Y-F, Tang L, Chen W-Q, Jiménez-Herrera MF. The chain mediating role of social support and stigma in the relationship between mindfulness and psychological distress among Chinese lung cancer patients. Support Care Cancer. 2021;29:6761–70.

Ma J, Ma FY, Liu M, et al. Influencing factors of self-perceived burden of postoperative lung cancer patients and their correlations with social support. Chin J Clin Oncol Rehabilitation. 2024;31:179–86. Chinese.

Cui CY, Wang Y, Zhang Y, Chen S, Jiang N, Wang L. The development and validation of the psychological capital questionnaire for patients with Cancer the psychological capital questionnaire. BMC Cancer. 2021;21:1194.

Wu C, He C-Y, Yan J-R, Zhang H-L, Li L, Tian C, et al. Psychological capital and alienation among patients with COVID-19 infection: the mediating role of social support. Virol J. 2023;20:114.

Guo Y-F, Wang K-F, Cross W, Lam L, Plummer V, Li J. Quality of life in cancer patients with different preferences for nurse spiritual therapeutics: the role of psychological capital. J Adv Nurs. 2022;78:991–1000.

Erdemsoy Karahan B, Izgu N. Impact of symptom burden and self-efficacy on functional status in advanced breast cancer patients: a path analysis. Nurs Health Sci. 2023;25:354–64.

Li Y, Ni N, Zhou Z, Dong J, Fu Y, Li J, et al. Hope and symptom burden of women with breast cancer undergoing chemotherapy: a cross-sectional study. J Clin Nurs. 2021;30:2293–300.

Braun TP, Szumowski M, Levasseur PR, Grossberg AJ, Zhu X, Agarwal A, et al. Muscle atrophy in response to cytotoxic chemotherapy is dependent on intact glucocorticoid signaling in skeletal muscle. PLoS ONE. 2014;9:e106489.

Aneshensel CS, Mitchell UA. The stress process: its origins, Evolution, and Future. In: Johnson RJ, Turner RJ, Link BG, editors. Sociology of Mental Health: selected topics from forty years 1970s-2010s. Cham: Springer International Publishing; 2014. pp. 53–74.

Miller KJ, Mesagno C, McLaren S, Grace F, Yates M, Gomez R, Exercise. Mood, Self-Efficacy, and Social Support as predictors of depressive symptoms in older adults: Direct and Interaction effects. Front Psychol. 2019;10:2145.

Huang Y, Lin X, Yang J, Bai H, Tang P, Yuan GF. Association between psychological capital and depressive symptoms during COVID-19: the mediating role of perceived social support and the moderating effect of employment pressure. Front Public Health. 2023;11:1036172.

Zhou J, Wu B, Su L, Ma X. The influence of Tai Chi on the death anxiety of elderly people living alone: the chain mediating effect of social support and psychological capital. Front Psychol. 2023;14:1303524.

Chen G, Zhang G, Yang Y, Zhang J, Hu Y. Relationship between negative life events and Depressive Symptoms for Chinese College students: the mediating role of rumination and moderating role of Perceived Social Support and Psychological Capital. Psychol Res Behav Manag. 2023;16:271–82.

Sim M, Kim S-Y, Suh Y. Sample size requirements for simple and complex mediation models. Educ Psychol Meas. 2022;82:76–106.

Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle MT, Morrissey M, et al. Assessing symptom distress in cancer patients: the M.D. Anderson symptom inventory. Cancer-am Cancer Soc. 2000;89:1634–46.

Wang XS, Wang Y, Guo H, Mendoza TR, Hao X-S, Cleeland CS. Chinese version of the M. D. Anderson symptom inventory: validation and application of symptom measurement in cancer patients. Cancer-am Cancer Soc. 2004;101:1890–901.

Su SS, Dong YM, Zheng W, et al. Development and psychometric test of social isolation Assessment Questionnaire for cancer patients. J Nurs. 2023;30:51–6. Chinese.

Li J, Mo PKH, Wu AMS, Lau JTF. Roles of self-stigma, social support, and positive and negative affects as determinants of depressive symptoms among HIV infected men who have sex with men in China. Aids Behav. 2017;21:261–73.

Zhang k, Zhang S, Dong YH. Positive psychological capital:measurement and relationship with mental health. J Psychol Behav Res. 2010;8:58–64. Chinese.

Han S, Zhang L, Li Q, Wang X, Lian S. The effects of laughter yoga on perceived stress, Positive Psychological Capital, and Exercise Capacity in Lung Cancer Chemotherapy patients: a pilot randomized Trial. Integr Cancer Ther. 2023;22:15347354231218271.

Ashi N, Kataoka Y, Takemura T, Shirakawa C, Okazaki K, Sakurai A, et al. Factors influencing social isolation and loneliness among lung cancer patients: a cross-sectional study. Anticancer Res. 2020;40:7141–5.

Brown CE, Jecker NS, Curtis JR. Inadequate Palliative Care in Chronic Lung Disease. An issue of Health Care Inequality. Annals Am Thorac Soc. 2016;13:311.

Takemura T, Kataoka Y, Okazaki K, Sakurai A, Imakita T, Ikegaki S, et al. Influence of social determinants of health on patients with advanced lung cancer: a prospective cohort study. BMJ Open. 2018;8:e023152.

Cotterell N, Buffel T, Phillipson C. Preventing social isolation in older people. Maturitas. 2018;113:80–4.

Yıldız K, Koç Z. Stigmatization, discrimination and illness perception among oncology patients: a cross-sectional and correlational study. Eur J Oncol Nurs. 2021;54:102000.

Leung B, Shokoohi A, Bates A, Ho C. Patient-reported psychosocial needs and psychological distress predict survival in geriatric oncology patients. J Geriatric Oncol. 2021;12:612–7.

Takemura T, Kataoka Y, Ashi N, Shirakawa C, Okazaki K, Sakurai A, et al. Influence of social isolation and loneliness on the prognosis of advanced lung cancer patients: a prospective cohort study. Support Care Cancer. 2022;30:6045–53.

Liu B, Wu X, Shi L, Li H, Wu D, Lai X, et al. Correlations of social isolation and anxiety and depression symptoms among patients with breast cancer of Heilongjiang province in China: the mediating role of social support. Nurs Open. 2021;8:1981–9.

Kelly A, Small BJ, Gray JE, Chiappori A, Creelan BC, Tanvetyanon T, et al. Loneliness as a mediator of the relationship of social cognitive variables with depressive symptoms and quality of life in lung cancer patients beginning treatment. Psycho-oncology. 2019;28:1234–42.

Golaszewski NM, LaCroix AZ, Godino JG, Allison MA, Manson JE, King JJ, et al. Evaluation of social isolation, loneliness, and Cardiovascular Disease among older women in the US. JAMA Netw Open. 2022;5:e2146461.

Loneliness. and social isolation increase cancer incidence in a cohort of Finnish middle-aged men. A longitudinal study. Psychiatry Research. 2021;299:113868.

Pearlin LI. The life course and the stress process: some conceptual comparisons. J Gerontol B Psychol Sci Soc Sci. 2010;65B:207–15.

Thoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52:145–61.

Hong YT, Lin Y-A, Pan YX, Lin JL, Lin XJ, Zhang J, et al. Understanding factors influencing demoralization among cancer patients based on the bio-psycho-social model: a systematic review. Psychooncology. 2022;31:2036–49.

Zhou J, Wu B, Su L, Ma X. The influence of Tai Chi on the death anxiety of elderly people living alone: the chain mediating effect of social support and psychological capital. Front Psychol. 2024;14:1303524.

Dunsmore VJ, Neupert SD. Social isolation, coping efficacy, and social well-being over time in patients with lung cancer. J Behav Med. 2024;47:927–34.

Fan J, Chang Y, Li L, Jiang N, Qu Z, Zhang J, et al. The relationship between medical staff burnout and subjective wellbeing: the chain mediating role of psychological capital and perceived social support. Front Public Health. 2024;12:1408006.

Luthans F, Avolio BJ, Avey JB, Norman SM. Positive psychological capital: measurement and relationship with performance and satisfaction. Pers Psychol. 2007;60:541–72.

Whitman MV, Halbesleben JRB, Holmes IVO. Abusive supervision and feedback avoidance: the mediating role of emotional exhaustion. J Organizational Behav. 2014;35:38–53.

Lai LH, Sun RN, Tang YY, et al. Relationship between social exclusion and relapse tendency in female drug rehabilitation patients. Chin Mental Health J. 2024;38:880–5. Chinese.

Yang Y, Qian X, Tang X, Shen C, Zhou Y, Pan X, et al. The links between symptom burden, illness perception, psychological resilience, social support, coping modes, and cancer-related worry in Chinese early-stage lung cancer patients after surgery: a cross-sectional study. BMC Psychol. 2024;12:463.

Williamson TJ, Garon EB, Shapiro JR, Chavira DA, Goldman JW, Stanton AL. Facets of stigma, self-compassion, and health-related adjustment to lung cancer: a longitudinal study. Health Psychol. 2022;41:301–10.