Self-esteem and existential distress among patients with advanced cancer: mediation by a sense of control and meaning in life

Patients grappling with advanced cancer often face profound psychological challenges, with existential distress (ED) emerging as a significant component of their suffering. This distress stems from confronting mortality, potential loss of dignity, and the struggle to find meaning in life amidst illness. A recent study conducted in Southeast China has shed light on the intricate psychological mechanisms linking a patient’s self-esteem to their experience of existential distress, highlighting the crucial mediating roles of a sense of control and meaning in life. The findings underscore the importance of nurturing these psychological resources in clinical settings to better support individuals facing life-limiting illnesses.

The study, published in Frontiers in Psychology, surveyed 390 patients diagnosed with advanced cancer (Stage III or IV) from two tertiary hospitals. The research, which took place between July 2022 and March 2023, aimed to unravel how self-esteem, a fundamental aspect of an individual’s self-worth, influences the manifestation of existential distress. Existential distress is characterized by feelings of meaninglessness, isolation, anxiety about death, and a perceived loss of control, affecting a substantial proportion of cancer patients, estimated to be between 54% and 73%. This distress can exacerbate depression, diminish quality of life, and, in severe cases, increase the risk of suicidal ideation.

Understanding Existential Distress in Advanced Cancer

As cancer progresses, patients confront a cascade of challenges. Beyond the physical burden of symptoms and treatment side effects, there is the immense psychological weight of a life-limiting prognosis. This is where existential distress takes root. It is not merely sadness or fear; it is a deeper turmoil arising from the fundamental questions of life, purpose, and finitude. As noted by researchers Chen et al. (2022), existential distress captures the inner conflict when individuals’ core beliefs about meaning, dignity, and their place in the world are threatened. Vehling and Kissane (2018) further elaborate that this distress encompasses struggles with perceived meaninglessness, loss of dignity, and heightened death anxiety. The high prevalence of ED in cancer populations, coupled with its detrimental impact on psychological well-being and potential for suicide (Bovero et al., 2023; Salander, 2018), underscores the urgent need for effective interventions.

Self-Esteem as a Psychological Anchor

Self-esteem, defined as an individual’s overall sense of self-worth and positive self-regard (Niveau et al., 2021; Yang et al., 2019), has long been recognized as a crucial buffer against psychological adversity. The study’s findings align with previous research suggesting a negative correlation between self-esteem and existential distress (Wang et al., 2023). However, this study delves deeper by exploring the pathways through which this association operates in the specific context of advanced cancer patients in China. While some studies have focused on related constructs like demoralization, this research specifically targets existential distress as a distinct phenomenon. A recent Italian study by Scandurra et al. (2022) also pointed to lower self-esteem being associated with higher ED in prostate cancer patients, but the current study expands this to a broader population of advanced cancer patients and investigates underlying mechanisms.

The Mediating Roles of Control and Meaning

The study employed path analysis, a statistical technique that examines complex relationships between variables, to investigate the mediating roles of a sense of control and meaning in life. A sense of control, defined as the belief in one’s ability to influence their life and environment (Prasad et al., 2023), is vital for psychological well-being. Low control is often linked to feelings of powerlessness and hopelessness (Hodges and Winstanley, 2012), making it a significant vulnerability factor for ED (Bovero et al., 2018). Similarly, meaning in life, the subjective experience of purpose, significance, and understanding (Winger et al., 2016), has been consistently associated with lower distress levels in cancer patients (Vehling et al., 2011; Winger et al., 2016).

The researchers hypothesized that both a sense of control and meaning in life would act as mediators in the relationship between self-esteem and ED. This theoretical framework is partly grounded in Cognitive Adaptation Theory (CAT), which posits that individuals facing significant life challenges adapt by bolstering their self-esteem, maintaining a sense of control, and seeking meaning (Taylor, 1983).

Key Findings and Mechanisms

The analysis revealed that self-esteem was not only directly associated with ED but also indirectly influenced it through two critical psychological factors: sense of control and meaning in life. The study found that:

• Direct Association: Higher self-esteem was directly linked to lower levels of existential distress. This direct effect accounted for approximately 34.74% of the total association between self-esteem and ED. This suggests that a core aspect of self-worth directly contributes to an individual’s ability to cope with the existential challenges of advanced cancer.
• Mediation by Sense of Control: A sense of control significantly mediated the relationship between self-esteem and ED. Patients with higher self-esteem reported a greater sense of control, which in turn was associated with lower existential distress. This pathway accounted for approximately 15.21% of the total mediating effect. This implies that feeling capable of influencing one’s circumstances, a belief often bolstered by high self-esteem, acts as a protective factor against ED.
• Mediation by Meaning in Life: Similarly, meaning in life played a significant mediating role. Higher self-esteem was associated with a greater sense of meaning in life, which then correlated with reduced ED. This pathway explained about 63.31% of the total mediating effect, indicating that a strong sense of purpose is a powerful buffer against existential turmoil.
• Serial Mediation: Intriguingly, the study also identified a significant serial mediation pathway, where self-esteem influenced ED through sense of control, which then influenced meaning in life. This sequential pathway accounted for 21.48% of the total indirect effect. This suggests a dynamic interplay: a higher sense of self-esteem might foster a greater sense of control, which in turn enables individuals to more actively cultivate or perceive meaning in their lives, ultimately mitigating ED.

The overall model fit was deemed good, with key indices such as the Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) exceeding 0.90, indicating that the proposed relationships accurately reflected the observed data. The total effect of self-esteem on ED was substantial, with the mediating pathways explaining the majority (65.26%) of this association.

Demographic and Clinical Context

The study cohort comprised 390 patients diagnosed with advanced cancer. The demographic profile revealed a significant proportion of patients were aged 59 or below (57.95%), with a majority being female (55.64%). A large majority were married (76.95%) and had received a primary school education or less (52.31%). Clinically, nearly 80% were diagnosed at Stage IV, and a high percentage (83.08%) were undergoing or had undergone chemotherapy. The duration of illness was predominantly within the first year for over half the participants (55.38%). These characteristics provide a valuable backdrop for understanding the lived experiences of these patients.

The average scores for existential distress, self-esteem, sense of control, and meaning in life were 13.80 (SD 4.58), 28.05 (SD 4.60), 16.64 (SD 5.85), and 39.50 (SD 5.54), respectively. Crucially, the correlational analysis confirmed the direction and strength of these relationships, showing significant negative correlations between ED and self-esteem (r = -0.667), sense of control (r = -0.569), and meaning in life (r = -0.754), all at p < 0.001. Positive correlations were observed between self-esteem and sense of control (r = 0.359), self-esteem and meaning in life (r = 0.547), and sense of control and meaning in life (r = 0.494).

Implications for Clinical Practice

The findings of this study carry significant weight for clinical practice in palliative care and oncology. Recognizing that existential distress is a prevalent and impactful aspect of advanced cancer, healthcare providers can leverage this research to develop more targeted and effective interventions. The study suggests that interventions aimed at bolstering self-esteem, fostering a sense of control, and enhancing meaning in life are likely to be beneficial.

This could involve:

• Promoting Self-Esteem: Encouraging patients to reflect on their past achievements, strengths, and positive qualities, perhaps through journaling or guided reminiscence therapy. Facilitating opportunities for patients to engage in activities that align with their values, even in modified forms, can also bolster self-worth.
• Enhancing Sense of Control: Empowering patients by providing them with clear information about their condition and treatment options, involving them actively in shared decision-making, and offering skills-based training for managing symptoms or daily activities. Even small gains in perceived autonomy can have a profound impact.
• Cultivating Meaning in Life: Supporting patients in exploring their life’s purpose, values, and legacy. This might involve facilitating conversations about spiritual beliefs, relationships, and contributions, or encouraging engagement in creative or reflective practices that help them find significance in their current experiences.

The serial mediation finding is particularly noteworthy, suggesting that interventions that foster a sense of control may indirectly contribute to finding meaning, which then alleviates distress. This highlights the interconnectedness of these psychological constructs and the potential for synergistic effects of interventions. For instance, helping a patient feel more in control of their pain management might empower them to participate more actively in family life, thereby reinforcing their sense of purpose and connection.

Limitations and Future Directions

While the study offers valuable insights, it is important to acknowledge its limitations. The cross-sectional design means that causal relationships cannot be definitively established. The use of convenience sampling may also limit the generalizability of the findings to other populations or cultural contexts. Furthermore, the reliance on self-report measures could introduce response biases.

Future research could benefit from longitudinal designs to track changes in these psychological factors over time and to establish causality more firmly. Mixed-methods approaches, incorporating qualitative data from interviews, could provide richer contextual understanding of patients’ experiences. Investigating these relationships in diverse cultural settings and with different cancer types would also be crucial for a comprehensive understanding.

Conclusion

This study makes a significant contribution to the understanding of existential distress among patients with advanced cancer. By demonstrating the direct and indirect pathways through which self-esteem influences ED, mediated by a sense of control and meaning in life, the research provides a robust framework for clinical intervention. The interconnectedness of these psychological resources underscores the need for holistic approaches that address not just the physical symptoms of cancer, but also the profound existential needs of patients. By nurturing self-esteem, fostering a sense of control, and cultivating meaning, healthcare providers can play a vital role in improving the quality of life and overall well-being for individuals facing the challenges of advanced cancer.