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Health Qual Life OutcomesHealth Qual Life OutcomesHealth and Quality of Life Outcomes1477-7525BioMed Central London 73810.1186/s12955-017-0738-1ResearchPrevalence and its associated psychological variables of symptoms of depression and anxiety among ovarian cancer patients in China: a cross-sectional study Liu Chun Li pauldawson@example.com 1Liu Li pauldawson@example.com 2Zhang Yi pauldawson@example.com 3Dai Xiao Ze pauldawson@example.com 2http://orcid.org/0000-0002-4157-8023Wu Hui pauldawson@example.com 21 0000 0000 9678 1884grid.412449.eLibrary of China Medical University, Shenyang, Liaoning China 2 0000 0000 9678 1884grid.412449.eDepartment of Social Medicine, School of Public Health, China Medical University, Shenyang, Liaoning China 3 0000 0000 9678 1884grid.412449.eFirst Affiliated Hospital, China Medical University, Shenyang, Liaoning China 17 8 2017 17 8 2017 2263-29-05570 4 2017 9 8 2017 © The Author(s). 2017
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background
It is well known that cancer patients tend to have high levels of perceived stress and symptoms of depression and anxiety. However, there is less study on the association between perceived stress and symptoms of depression and anxiety among ovarian cancer patients in China. And the mediating effect of hope and resilience needs to be further studied. In this study, we aim to examine the prevalence of depression and anxiety symptoms, to analyze the association between perceived stress and symptoms of depression and anxiety, and to test whether hope and resilience mediate the association of perceived stress with symptoms of depression and anxiety among Chinese patients with ovarian cancer.

Method
A total of 220 questionnaires were distributed and collected from the First Affiliated Hospital of China Medical University and Shengjing Hospital of China Medical University. All participants in this study were ovarian cancer inpatients. After excluding the incomplete questionnaires, 198 questionnaires were valid for the analysis. Qualified patients were asked to response to the questionnaires including Hospital anxiety and depression scale (HADS), perceived stress scale (PSS-10), and the Herth hope scale and the resilience scale. Hierarchical regression analyses were used to test the associations among perceived stress, symptoms of depression and anxiety, and hope and resilience. Bootstrapping method was conducted to examine whether the indirect effect of hope and resilience was significant respectively.

Results
The prevalence of symptoms of depression and anxiety in ovarian cancer patients was 47.0% and 51.5% respectively. Perceived stress correlated significantly with symptoms of depression (r = 0.709, P < 0.01) and anxiety (r = 0.660, P < 0.01). Hope (a*b = 0.155, BCa 95% CI: 0.094, 0.223) partly mediated the association between perceived stress and symptoms of depression; similarly, hope (a*b = 0.129, BCa 95% CI: 0.048, 0.205) partly mediated the effect of perceived stress on symptoms of anxiety. However, resilience (a*b = 0.004, BCa 95% CI: -0.030, 0.040) did not mediate the association between perceived stress and symptoms of depression. And resilience (a*b = 0.041,BCa 95% CI: -0.013, 0.098) did not mediate the association between perceived stress and symptoms of anxiety.

Conclusions
The present study suggests that perceived stress might be one of the impact factors of symptoms of depression and anxiety, while hope might ease symptoms of depression and anxiety. In view of the role of hope, medical workers and patient caregivers should pay more attention to hope, and then to intervene perceived stress among patients with ovarian cancer.

Keywords
Symptoms of depressionSymptoms of anxietyPerceived stressHopeResilienceOvarian cancer patientsissue-copyright-statement© The Author(s) 2017
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Background
The incidence and mortality of ovarian cancer varies in different countries. It was estimated that, in 2016, there would be about 22,280 newly diagnosed cases of ovarian cancer and the death from ovarian cancer would be 14,240 in the United States [1]. It was forecasted that nearly 1480 females would be diagnosed with ovarian cancer in Australia, and approximately 1040 females would die of the disease in 2016. [2]. It was reported that Asian countries had diagnosed 110,526 cases of ovarian cancer, and China was the country with the highest number of cases (34,575 cases) [3]. As has been investigated, ovarian cancer is the first leading cause of death from gynecological cancers in China [4]. However, it is difficult to diagnose ovarian cancer at early stages (I/II) for most symptoms are nonspecific. Most of the patients with ovarian cancer are often diagnosed at advanced stages [5, 6]. Therefore, it is imperative to emphasize on ovarian cancer patients.

It is well known that cancer is a kind of disease which threatens one's health and lives severely. Patients who are suffering from cancer often have to tolerate not only physical pain, but also enormous emotional pressure and huge financial burden [7–12]. Some studies have indicated that symptoms of depression and anxiety were two common types of psychological disorders to cancer patients [13–16]. For example, the diagnosis and treatment of cancer is now mainly regarded as life stress, and this stress could cause or exacerbate relative psychological disorders. Furthermore, a study of meta-analysis has shown that the incidence (54.90% and 49.69%) of symptoms of depression and anxiety in Chinese cancer patients is obviously higher than that in the patients without cancer (17.50% and 18.37%) [17]. More notably, unrealized or untreated symptoms of depression and anxiety could adversely impact the control of morbidity, the adherence with treatment, the healing of illness, and the well-being of life quality [18–20].Thus, discovery and intervention of psychological symptoms of depression and anxiety and stress among cancer patients is considered as a very important topic to the local health authority.

It indicated that 30% to 70% ovarian cancer patients had varying degrees of anxiety syndromes [21, 22], and around 50% patients had clinical depressive symptoms [23]. The patients had to re-handle their relationship with their family members, friends and boss, and they were compelled to face with unknown disaster in job, family income, and lives. However, there are few studies concerning the level of prevalence of symptoms of depression and anxiety in Chinese patients who have been diagnosed with ovarian cancer.

In recent years, positive psychology interventions have been explored by scientists to prevent mental disorders, and conquer disease, achieving a satisfactory life expectancy among oncology patients. Positive psychological resources include many variables such as self-efficacy, hope, resilience, optimism, self-esteem, and social support. Our previous studies have assessed the association of several positive psychological factors with symptoms of depression and anxiety in cervical cancer patients [24] or in newly diagnosed bladder/kidney cancer patients [25]. The present study aims to further assess the effect of perceived stress and two kinds of positive psychological variables (hope and resilience) on symptoms of depression and anxiety in ovarian patients.

For cancer patients, hope is a faith to conquer the disease. Individuals, who maintain high level of hope, will probably be more active in seeking treatment and will have more chances to recovery. Psychological resilience means effective response to a negative event. Cancer patients must constantly withstand a wide range of pressures to conquer or live with cancer. Thus psychological resilience is a vital ability. Therefore, hope and resilience are two indispensable abilities and psychological characteristics in the process of facing cancer. Several studies have provided evidence for the influence of positive psychological factors in cancer patients [25–28]. A literature suggested that higher level of hope predicted greater patient marital satisfaction among couples with advanced breast cancer [28]. Higher psychological flexibility significantly contributed to predict lower level of symptoms of depression and anxiety in patients with breast cancer [29]. A study indicated that psychological resilience, rather than hope, significantly associated with symptoms of depression and anxiety among early-stage bladder/kidney cancer patients [25]. However, whether hope and resilience associated with perceived stress, symptoms of depression and anxiety in ovarian cancer patients remains to be investigated further.

The aim of the study was to assess (1) the prevalence of symptoms of depression and anxiety in ovarian cancer patients from China. (2) Whether perceived stress is associated with symptoms of depression and anxiety in ovarian cancer patients. (3) The mediating role of hope and resilience between perceived stress and symptoms of depression and anxiety in ovarian cancer patients.

Methods
Ethics statement
The Committee for Human Trials of China Medical University has reviewed and provided the ethical approval for this study, and the trial procedures were in accordance with the ethical standards. All the patients have submitted their written consent after learning the study protocol. They were all voluntary and anonymous during the process. We protected the privacy of patients in dealing with personal data and maintained confidentiality of individual records.

Study design and recruitment criteria
From January 1, 2014 to December 31, 2015, we conducted a convenience sampling. We recruited patients with ovarian cancer from the First Affiliated Hospital of China Medical University and Shengjing Hospital of China Medical University, the two tertiary referral hospitals, which are important providers of cancer treatment services in Liaoning Province of China. The eligibility criteria for patient recruitment were (1) at least 18 years old; (2) being pathologically proven ovarian cancer; (3) aware of the cancer diagnosis; (4) able to communicate and answer the questionnaires in Chinese easily; (5) with clear consciousness and cognition. Exclusion criteria were (1) patients had a history of psychiatric problems (e.g. symptoms of depression or anxiety, or other psychiatric disorders) before cancer diagnosis; (2) patients had intellectual impairments; (3) patients had other active cancers.

The questionnaires were filled in the inpatient departments. All eligible patients were invited to participate by their oncologists or physicians. In principle, it is the ovarian cancer patient herself that fills out the questionnaire including demographic questions, Hospital anxiety and depression scale (HADS), perceived stress scale (PSS-10), the Herth hope scale and the resilience scale. The doctors reported the clinical variables according to the records of patients. If the patient is too old to need help, the doctor will read the questions and write the selection according to the patient's oral report without making any suggestions. After the patients were well-informed about the study, they began to fill in the questionnaire. Initially, a total of 220 patients were enrolled. Finally, we received effective responses from 198 ovarian cancer patients, and the effective response rate is 90%.

Measurements of symptoms of depression and anxiety
We choose Hospital Anxiety and Depression Scale (HADS) [30] to measure the degree of symptoms of depression and anxiety. This is a 14-item questionnaire including depression subscales (seven entries) and anxiety subscales (seven entries). Each item is rated on a four-point Likert scale (0 = completely not; 1 = a little bit; 2 = somewhat and 3 = very much). The total score of each subscale ranges from zero to 21 points. The higher the score is, the more significant symptom of anxiety and depression is. Zigmonfd and Snaith have recommended the cut-off values for both symptoms of depression and anxiety [30]. Each person is grouped according to a classification where a score of "less than 8" is within normal range, "8–10" indicates a possible clinical anxiety / depression and "more than 10" suggests a probable anxiety / depression mood disorder. The Chinese version of HADS has been widely used in previous studies with sufficient reliability [31, 32]. The internal reliability alpha valued for the symptoms of depression and anxiety in the current study were 0.848 and 0.764 respectively.

Measurement of perceived stress
Perceived stress was assessed with the Chinese version of Perceived Stress Scale (PSS-10) [33]. It is a 10-item questionnaire whose each item is rated on a 5-point Likert scale ranging from "never" to "always" (0 = Never so, 1 = hardly so, 2 = sometimes, 3 = so often, 4 = always.). Higher total score indicates higher level of pressure that the individual feels. Chinese version of PSS-10 has been used in Chinese population and demonstrated with sufficient reliability [34]. In our study, the Cronbach's alpha for the total scale was 0.854.

Measurement of hope
The Herth Hope Index (HHI) was used to assess patients' overall level of hope [35]. It is a questionnaire including 12 items. Each item is rated on a 4-point Likert scale (1 = strongly disagree; 4 = strongly agree) and total scores range from 12 to 48. Higher score reflects higher level of hope. In our study, Cronbach's alpha coefficient for the total scale was 0.840.

Measurement of resilience
The Resilience Scale (RS), developed by Nian Wagnild, was used to assess resilience [36]. The RS scale comprises 14 items. Each item was answered by using a 7-point Likert-type scale (1 = strongly disagree; 7 = strongly agree). Total score ranges from 14 to 98. Higher scores indicate higher level of resilience. The Chinese Resilience Scale has a good content reliability [37]. In this present study, Cronbach's alpha coefficient of total scale was 0.903.

Demographic and clinical characteristics
In our study, there are four demographic variables and four clinical variables. Age was divided into three types: "≤45", "46–55", and "≥56". Marital status was divided into two cases: "Married/living with a partner", "Single/widowed/divorced". Education level was divided into four levels: "Primary school", "Middle school", "High school", "Junior college or above". Family income (RMB: Yuan) included "≤1000", "1001–2000", "2001–3000", "3001–4000", and "≥4001". According to the International Federation of Gynecology and Obstetrics (FIGO) [38, 39], the study divided cancer stage into three types. Treatment type included "no treatment", "chemotherapy", "surgery", and "combined treatment (a combination of different kinds of treatment)". Whether the cancer is metastasis is also considered as a clinical variable.

Statistical analysis
All analysis was conducted by SPSS 17.0 for Windows. We used t-test and one-way ANOVA analysis to compare the difference of symptoms of depression and anxiety according to demographic and clinical groups. In addition, all statistical tests were two-sided (α = 0.05). We performed hierarchical linear regression analysis which tests the mediating effect by three steps. In the first step, the demographic and clinical variables were added. And we set dummy variables for the discontinuous variables. In the second step, perceived stress was added. In the third step, hope and resilience was added. In addition, we used bootstrapping method to examine whether the indirect effect of hope and resilience was significant. Perceived stress was modeled as independent variable, with symptoms of depression and anxiety as the outcomes, hope and resilience as mediators (as shown in Figure 1), and age and treatment type as covariates. The "c path" refers to the relationship between perceived stress and symptoms of depression and anxiety; the "a × b path" represents the mediation of hope and resilience. If the absolute value of "c' path" coefficiently shrinks than that of the "c path", the mediation role of hope and resilience may exist. Five thousand bootstrap samples were used to estimate the present study. We suppose that if bias-corrected and accelerated 95% confidence interval (BCa 95% CI) do not include 0, the mediation is significant.Fig. 1 Theoretical model of the mediating role of hope and resilience. (a) the relationship between perceived stress and hope and resilience; (b) the relationship of hope and resilience with depressive/anxiety symptoms after controlling the independent variables; (c') the association between perceived stress and depressive/anxiety symptoms after adding hope and resilience as mediators




Results
Patients' characteristics
Table 1 presented the patients' characteristics. The age of the patients (N = 198) ranges from 29 to 79 (Mean ± SD: 55.71 ± 9.03). Most of the patients (90.9%) were married or living with a partner. There are 72.8% of patients graduated from middle school or above. And only 18 patients (9.1%) earn more than 4000 Yuan per month. In relation to clinical variables, majority of patients (72.7%) were diagnosed at cancer stage III + IV, and 93.4% received chemotherapy or surgery, or combined treatment. 92.9% were free of metastases.Table 1 Demographic and clinical variables of participants (N = 198)

Variable	N	%	Mean ± SD	Median (Range)	
Demographic variables	198				
Age (years)			55.71 ± 9.03	55 (29–79)	
 ≤45	19	9.6			
 46–55	82	41.4			
  ≥ 56	97	49.0			
Marital status	
 Married/living with a partner	180	90.9			
 Single/widowed/divorced	18	9.1			
Educational level	
 Primary school	54	27.2			
 Middle school	73	36.9			
 High school	45	22.7			
 Junior college or above	26	13.1			
Income (Yuan per month)	
 ≤1000	27	13.6			
 1001–2000	70	35.3			
 2001–3000	59	29.8			
 3001–4000	24	12.1			
  ≥ 4001	18	9.1			
Clinical variables	
Cancer stage	
 I	35	17.7			
 II	19	9.6			
 III + IV	144	72.7			
 Treatment type	
 No treatment	13	6.6			
 Chemotherapy	59	29.8			
 Surgery	12	6.0			
 Combined treatment	114	57.6			
Metastasis	
 No	184	92.9			
 Yes	14	7.1			
HADS-Depression symptoms	93	47.0	7.01 ± 3.77	7 (0–21)	
 8–10	63	31.8			
  ≥ 11	30	15.2			
HADS-Anxiety symptoms	102	51.5	7.37 ± 4.17	8 (0–20)	
 8–10	60	30.3			
  ≥ 11	42	21.2			

HADS Hospital Anxiety and Depression Scale, SD Standard deviation




Table 2 provided the levels of symptoms of depression and anxiety, perceived stress, and hope and resilience. According to the cut-off values of Zigmond and Snaith [40], patients reported 8–10 HADS score were at the border level which is possible case; patients reported 11–21 HADS score were at high likelihood level which is probable case. The prevalence of symptoms of depression and anxiety in ovarian cancer patients was 47.0% (possible cases: 31.8%; probable cases: 15.2%) and 51.5% (possible cases: 30.3%; probable cases: 21.2%) respectively (N = 198). The mean scores of symptoms of depression and anxiety were 7.01 ± 3.77 and 7.37 ± 4.17. The mean values were 17.97 ± 4.83 for perceived stress, 35.44 ± 4.02 for hope and 37.20 ± 7.15 for resilience.Table 2 Descriptive statistics for symptoms of depression and anxiety, perceived stress, hope, and resilience (N = 198)

Variables	Mean	SD	Range	N (%)	
HADS-Depression symptoms	7.01	3.77	0–21	93 (47.0)	
 8–10				63 (31.8)	
  ≥ 11				30 (15.2)	
HADS-Anxiety symptoms	7.37	4.17	0–20	102 (51.5)	
 8–10				60 (30.3)	
  ≥ 11				42 (21.2)	
PSS	17.97	4.83	4–30		
HHI	35.44	4.02	26–47		
RS	37.20	7.15	22–56		

HADS Hospital Anxiety and Depression Scale, HHI Herth Hope Index, PSS Perceived Stress, RS Resilience, SD Standard deviation




Associations of demographic and clinical variables with symptoms of depression and anxiety
As shown in Table 3, results revealed the symptoms of depression and anxiety scores in demographic and clinical variables. Educational level and cancer stage were significantly associated with symptoms of depression; educational level, income and cancer stage were significantly associated with symptoms of anxiety (p < 0.05). In addition, patients whose educational level was junior college or above had a lower level of symptoms of depression and anxiety than the patients whose educational level was high school or lower; Or in other words, the higher the educational level, the lower the level of symptoms of depression and anxiety is. Moreover, patients whose cancer stage was 'I' had a lower level of symptoms of depression and anxiety than those whose cancer stage was 'III' + 'IV' or 'II'. Furthermore, patients whose income per month was 1000 or more lower had higher level of symptoms of anxiety than the others.Table 3 Mean scores of symptoms of depression and anxiety according to demographic and clinical variables

Variables	HADS-Depression symptoms	F/t value	
P value	HADS-Anxiety symptoms	F/t value	
P value	
Demographic variables	
Age (years)		2.928	0.056		1.77	0.173	
 ≤45	5.53 ± 3.41			5.84 ± 3.50			
 46–55	6.68 ± 3.74			7.26 ± 4.20			
  ≥ 56	7.58 ± 3.79			7.77 ± 4.23			
Marital status		0.075	0.785		0.138	0.711	
 Married/living with a partner	7.03 ± 3.88			7.34 ± 4.23			
 Single/widowed/divorced	6.78 ± 2.62			7.72 ± 3.63			
Educational level		5.049	0.002		3.422	0.018	
 Primary school	8.26 ± 3.34			8.17 ± 3.95			
 Middle school	7.10 ± 3.79			7.64 ± 4.08			
 High school	6.56 ± 4.04			7.29 ± 4.61			
 Junior college or above	4.96 ± 3.23			5.12 ± 3.42			
Income (Yuan per month)		1.668	0.159		2.940	0.022	
 ≤1000	7.37 ± 3.26			9.07 ± 3.97			
 1001–2000	7.36 ± 3.83			7.34 ± 4.03			
 2001–3000	7.20 ± 4.29			7.29 ± 4.42			
 3001–4000	6.67 ± 2.79			7.67 ± 4.36			
  ≥ 4001	4.94 ± 3.23			4.83 ± 2.73			
Clinical variables	
Cancer stage		5.73	0.004		4.308	0.015	
 I	5.11 ± 3.08			5.54 ± 2.95			
 II	7.05 ± 2.66			8.11 ± 3.73			
 III + IV	7.47 ± 3.92			7.72 ± 4.37			
Treatment type		0.930	0.427		1.12	0.344	
 No treatment	5.54 ± 3.02			5.85 ± 2.67			
 Chemotherapy	7.20 ± 3.98			7.83 ± 4.22			
 Surgery	6.25 ± 3.02			6.25 ± 3.57			
 Combined treatment	7.16 ± 3.81			7.43 ± 4.32			
Metastasis		0.000	0.992		0.000	0.988	
 No	7.01 ± 3.87			7.38 ± 4.28			
 Yes	7.00 ± 2.15			7.36 ± 2.37			

HADS Hospital Anxiety and Depression Scale




Correlations between study variables
Pearson's correlation coefficients were calculated among perceived press, hope, resilience and symptoms of depression and anxiety. As shown in Table 4, symptoms of depression was negatively associated with the two positive psychological variables (hope: r = −0.668, P < 0.01; resilience: r = −0.373, P < 0.01). A similar pattern was also observed between symptoms of anxiety and the two variables (hope: r = −0.587, P < 0.01; resilience: r = −0.406, P < 0.01). Perceived Stress was significantly correlated with symptoms of depression (r = 0.709, P < 0.01) and symptoms of anxiety (r = 0.660, P < 0.01).Table 4 Correlation among symptoms of depression and anxiety, hope, resilience and perceived stress

Variables	HADS-Depression symptoms	HADS-Anxiety symptoms	HHI	RS	PSS	
HADS-Depression symptoms	1	0.812**	−0.668**	−0.373**	0.709**	
HADS-Anxiety symptoms		1	−0.587**	−0.406**	0.660**	
HHI			1	0.402**	−0.587**	
RS				1	−0.478**	
PSS					1	

HADS Hospital Anxiety and Depression Scale, HHI Herth Hope Index, PSS Perceived Stress, RS Resilience

*P < 0.05, **P < 0.01




Hierarchical regression analysis
Table 5 indicated the results of hierarchical regression analysis of symptoms of depression after controlling demographic and clinical variables. Perceived stress was significantly associated with symptoms of depression. Perceived stress explained 42.2% of the variance in symptoms of depression among ovarian cancer patients. Hope was negatively associated with symptoms of depression (β = −0.347, P < 0.01) and hope explained 7.4% of the variance in symptoms of depression. When hope and resilience were added, the regression coefficient for perceived stress diminished (from β = 0.710 to β = 0.498, P < 0.01). The results suggest that hope probably mediate the correlation between perceived stress and symptoms of depression partly.Table 5 Hierarchical linear regression for exploring the correlates of symptoms of depression

	HADS-Depression symptoms	
Variables	Step 1(β)	Step 2(β)	Step 3(β)	
Block 1	
Age	0.145	0.171**
	0.124*
	
"Middle school" vs "Primary school"	−0.148	0.007	−0.014	
"High school" vs "Primary school"	−0.206*
	0.022	0.018	
"Junior college or above" vs "Primary school"	−0.221*
	−0.061	−0.065	
Cancer stage "II" vs "I"	0.160	0.129*
	0.112*
	
Cancer stage "III + IV" vs "I"	0.222*
	0.193**
	0.163**
	
Block 2	
PSS		0.710**
	0.498**
	
Block 3	
HHI			−0.347**
	
RS			−0.032	

F
	2.223**
	15.399**
	18.486**
	
Adjusted R2
	0.085	0.539	0.615	
△R2
	0.155**
	0.422**
	0.074**
	
*P < 0.05, **P < 0.01


HADS Hospital Anxiety and Depression Scale, HHI Herth Hope Index, PSS Perceived Stress, RS Resilience




Then we examined the mediating effect by bootstrapping method. As shown in Table 6, perceived stress had a significant correlation with symptoms of depression. Perceived stress was negatively correlated with hope and resilience (the "a path"). Hope correlated with symptoms of depression negatively and significantly (the "b path"). However, resilience did not show significant correlation with symptoms of depression. BCa 95% CI for a × b of hope excluding 0 indicated its significant mediation when it was added in the model (the "c' path"). In contrast, BCa 95% CI for a × b of resilience including 0 indicated its insignificant mediation. We used formula (a × b/ c) to calculate the proportion of mediation. The proportion of hope mediating effect was 29.18% for perceived stress.Table 6 Bootstrapping test of the indirect effect whether hope and resilience act as potential mediators in the correlation between perceived stress and symptoms of depression

Mediators	c	a	b	c'	a × b (BCa 95% CI)	
HHI	0. 530**
	−0.479**
	−0.319**
	0.373**
	0.155 (0.094, 0.223)	
RS	−0.718**
	−0.006	0.004 (−0.030, 0.040)	
**P < 0.01




Table 7 showed the results of hierarchical regression analysis of symptoms of anxiety after controlling demographic and clinical variables. Perceived stress was significantly associated with symptoms of anxiety. Perceived stress explained 37.5% of the variance in symptoms of anxiety among ovarian cancer patients. Hope was negatively associated with symptoms of anxiety (β = −0.267, P < 0.01) and explained 5.8% of the variance in symptoms of anxiety. However, resilience did not show significant correlation with symptoms of anxiety. When hope and resilience were added, the regression coefficient for perceived stress diminished (from β = 0.670 to β = 0.464, P < 0.01). That is to say hope may have a partly mediating effect on the relationship between perceived stress and symptoms of anxiety.Table 7 Hierarchical linear regression for exploring the correlates of symptoms of anxiety

	HADS-Anxiety symptoms	
Variables	Step 1(β)	Step 2(β)	Step 3(β)	
Block 1	
Age	0.160*	0.185**	0.142*	
"Middle school" vs "Primary school"	−0.042	0.105	0.079	
"High school" vs "Primary school"	−0.078	0.137	0.139*	
"Junior college or above" vs "Primary school"	−0.146	0.004	−0.018	
"1001–2000" vs "1000"	−0.190	−0.154	−0.169*	
"2001–3000" vs "1000"	−0.155	−0.211*	−0.233**	
"3001–4000" vs "1000"	−0.106	−0.156*	−0.129	
"4001" vs "1000"	−0.201*	−0.060	−0.035	
Cancer stage "II" vs "I"	0.194*	0.165*	0.148*	
Cancer stage "III + IV" vs "I"	0.175*	0.148*	0.135*	
Block 2	
PSS		0.670**	0.464**	
Block 3	
HHI			−0.267**	
RS			−0.115	

F
	2.046*	12.217**	13.592**	
Adjusted R2
	0.074	0.477	0.535	
△R2
	0.144*	0.375**	0.058**	

HADS Hospital Anxiety and Depression Scale, HHI Herth Hope Index, PSS Perceived Stress, RS Resilience

*P < 0.05, **P < 0.01




Then we examined the mediating effect by bootstrapping method. As shown in Table 8, perceived stress had a significant correlation with symptoms of anxiety. Perceived stress negatively correlated with hope and resilience (the "a path"). Hope correlated with symptoms of anxiety negatively and significantly (the "b path"). BCa 95% CI for a × b of hope excluding 0 indicated its significant mediation when it was added in the model (the "c' path"). In contrast, BCa 95% CI for a × b of resilience including 0 indicated its insignificant mediation. We used formula (a × b/ c) to calculate the proportion of mediation. The proportion of hope mediating effect was 22.89% for perceived stress.Table 8 Bootstrapping test of the indirect effect whether hope and resilience act as potential mediators in the correlation between perceived stress and symptoms of anxiety

Mediators	c	a	b	c'	a × b (BCa 95% CI)	
Hope	0.565**
	−0.471**
	−0.266**
	0.400**
	0.129 (0.048, 0.205)	
resilience	−0.696**
	−0.057	0.041 (−0.013, 0.098)	
**P < 0.01




Discussion
The prevalence of symptoms of depression is 47.0% and the prevalence of symptoms of anxiety is 51.5% in Chinese patients with ovarian cancer.A meta-analysis indicated that the prevalence of symptoms of depression and anxiety in Chinese cancer patients was 54.90% and 49.69% [17]. Mielcarek P [40] assessed Poland patients with advanced ovarian cancer. They found that the level of symptoms of anxiety was higher than the level of symptoms of depression. And the prevalence of pathological anxiety was the highest (74%) prior to surgery. Watts S [41] quoted an evidence of the prevalence of symptoms of depression (25.34%, 22.99%, and 12.71%) and symptoms of anxiety (19.12%, 26.23%, and 27.09%) in ovarian cancer patients across pretreatment, on-treatment and post-treatment in a systematic review and meta-analysis article. Moreover, Melanie A Price [42] had done a prospective cohort study and found the clinical depressive symptoms was 5.9%, clinical anxiety symptoms was 15% in 798 Australian ovarian cancer patients. There is no doubt that population-based sample is one of the factors that may affect the different results among our study and previous studies. In the developed countries, the improved recognition of mental health disorders from ovarian cancer patients may lead them actively to seek for mental health treatment and other support services. However in China, the level of symptoms of depression and anxiety is relatively low. In contrast, the recognition of psychological disease from ovarian cancer patients in the developing countries is still need to be improved.

Our results have provided direct evidence that perceived stress significantly associated with symptoms of depression and anxiety in ovarian cancer patients. Pranjic N [43] who is from Bosnia and Herzegovina pointed out the high level of distress in cancer patients still needs further attention, powerful intervention and effective treatment. A research [44] suggested that cancer-related fatigue correlated with perceived stress, anxiety and pain severity. It is noteworthy that the results also indicated symptoms of anxiety mediate the association between perceived stress and cancer-related fatigue. A few studies concentrate on symptoms of post-traumatic stress disorder and its association with adult attachment and symptoms of depression in ovarian cancer patients [45, 46]. Then, besides symptoms of depression and anxiety which have been mainly studied in our paper, ovarian cancer patients might also have post-traumatic stress disorder or adult attachment in some extent. Hill EM [47] recruited one hundred ovarian cancer patients and assessed the role of social support seeking on mental health including symptoms of depression and stress. However, the author had not assessed the association among stress and symptoms of depression and anxiety. There are several studies showing a beneficial impact of cognitive-behavioral therapy (CBT) on symptoms of depression and anxiety and insomnia experienced by individuals with cancer [48–50].

Our results showed that hope and resilience were negatively associated with symptoms of depression and anxiety among ovarian cancer patients. And hope played a partly mediating role on the association between perceived stress and symptoms of depression. Similarly, hope partly mediated the effect of perceived stress on symptoms of anxiety. Some of our findings were in accordance with previous studies. Sjoquist KM [51] found that trait hope was negatively correlated with symptoms of depression and anxiety in ovarian cancer patients who have done chemotherapy. Since the level of hope may play a significant role in relieving symptoms of depression and anxiety of ovarian cancer patients, it is necessary to attempt to implement some intervention programs or strategies to help patients maintain and foster hope. For example, nurses can help cancer patients to maintain hope by talking with them, showing special warmth and compassion. And the doctor intervention programs will be also important. The doctors should encourage patients to maintain hope, and build long-term relationship with their ovarian cancer patients by social media tools to answer their questions, send them medical advice, and even tweet them inspiring stories.

As for demographic and clinical variables, this study indicated that patients whose education level was primary school, or patients who were diagnosed at in "III + IV" stage had a more higher level of symptoms of depression than the others; patients whose education level was primary school or patients whose income was 1000 Yuan or lower, or patients who was diagnosed at in "III + IV" stage had a higher level of symptoms of anxiety than the others. Similarly, Hall AE [52] reported that demographic characteristics such as financial burden caused by cancer were significant factors affecting the level of symptoms of depression and anxiety among hematological cancer survivors.

There are some limitations: firstly, we used a convenience sample from only two tertiary referral hospitals. Secondly, it is a cross-sectional study from which we could not draw comparable results across time. Thirdly, we only focused on the symptoms of depression and anxiety; other psychological disorders such as post-traumatic stress disorders, obsession and inferiority have not been investigated. Fourthly, in the present study, heterogeneous issues might affect the associations between variables. In the regression analysis, we have controlled the variables that have significant impact such as cancer stage. However, other variables such as treatment type, social status, times of surgery, times of hospitalization have not been controlled. Despite of limitations, we have drawn important evidence on the effect of perceived stress on symptoms of depression and anxiety in Chinese patients with ovarian cancer. We also have tested whether hope and resilience mediate the effect of perceived stress on symptoms of depression and anxiety by bootstrapping method.

Conclusions
Firstly, the prevalence of symptoms of depression and anxiety in Chinese patients with ovarian cancer was 47.0% (possible cases: 31.8%; probable cases: 15.2%) and 51.5% (possible cases: 30.3%; probable cases: 21.2%) respectively. Educational level and cancer stage were significantly associated with symptoms of depression and anxiety. In addition, income was significantly associated with symptoms of anxiety. Secondly, the results of hierarchical regression analyses suggested that perceived stress was associated with symptoms of depression and anxiety significantly. Thirdly, bootstrapping test suggested that hope partly mediated the effect of perceived stress on symptoms of depression; and similarly hope had a partly mediating effect on the relationship between perceived stress and symptoms of anxiety. Therefore, we should pay more attention to hope, relieving symptoms of depression and anxiety, and then consider intervening perceived stress among patients with ovarian cancer. Furthermore, the effectiveness and mechanism of intervention should be explored in the next study.

Abbreviations
HADSHospital Anxiety and Depression Scale

HHIThe Herth hope Index

PSSPerceived Stress Scale

RSThe Resilience Scale

Acknowledgements
The authors would like to thank all the staffs in the First Affiliated Hospital of China Medical University and Shengjing Hospital of China Medical University who helped to get the written informed consent about the conduct of this survey and to distribute the questionnaires to the patients.

Funding
No funding.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions
HW conceived, designed and performed the experiments. CL and LL analyzed, interpreted the data and wrote the paper. HW, CL, YZ, XD and LL performed literature searches, acquisition of the data. All authors have read and approved the final manuscript.

Ethics approval and consent to participate
The study was approved by the Committee for Human Trials of China Medical University. Participants took part in the study after providing written informed consent.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References
1. SEER Cancer Statistics Factsheets: Ovary Cancer. National Cancer Institute. Bethesda, MD, Websites: http://seer.cancer.gov/statfacts/html/ovary.html. Accessed 5 Jan 2016.
2. Australian Institute of Health and Welfare 2016. Australian Cancer Incidence and Mortality (ACIM) books: Ovarian Cancer. Websites: https://ovarian-cancer.canceraustralia.gov.au/statistics. Accessed 5 Jan 2016.
3. Razi S  Ghoncheh M  Mohammadian-Hafshejani A    The incidence and mortality of ovarian cancer and their relationship with the human development index in Asia Ecancermedicalscience 2016 10 263-29-0557/ecancer.2016.628 27110284 
4. Wang B  Liu SZ  Zheng RS    Time trends of ovarian cancer incidence in China Asian Pac J Cancer Prev 2014 15 191 263-29-0557/APJCP.230.255.87.(662)437-8250 
5. Rossing MA  Wicklund KG  Cushing-Haugen KL  Weiss NS   Predictive value of symptoms for early detection of ovarian cancer Natl Cancer Inst 2010 102 222 263-29-0557/jnci/djp500 
6. Chene G  Penault-Llorca F  Robin N    Early detection of ovarian cancer: tomorrow? A review J Gynecol Obstet Biol Reprod (Paris) 2013 42 5 11 10.1016/j.jgyn.2012.10.011 23182787 
7. Burrai F  Micheluzzi V  Bugani V   Effects of live sax music on various physiological parameters, pain level, and mood level in cancer patients: a randomized controlled trial Holist Nurs Pract 2014 28 5 301 263-29-0557/HNP.0000000000000041 25099983 
8. Cheng KK  Lee DT   Effects of pain, fatigue, insomnia, and mood disturbance on functional status and quality of life of elderly patients with cancer Crit Rev Oncol Hematol 2011 78 2 127 263-29-0557/j.critrevonc.2010.03.002 20403706 
9. Al QM  Al KM   Prevalence of symptoms and quality of life among Jordanian cancer patients Clin Nurs Res 2016 25 2 263-29-0557/1054773814564212 25550305 
10. Chino F  Peppercorn J  Jr DHT    Self-reported financial burden and satisfaction with care among patients with cancer Oncologist 2014 19 4 263-29-0557/theoncologist.2013-0374 24668333 
11. Nipp RD  Powell E  Chabner B    Recognizing the financial burden of cancer patients in clinical trials Oncologist 2015 20 6 572 263-29-0557/theoncologist.2015-0068 25986245 
12. Azzani M  Roslani AC  Su TT   The perceived cancer-related financial hardship among patients and their families: a systematic review Support Care Cancer 2014 23 3 889 263-29-0557/s00520-014-2474-y 25337681 
13. Mitchell AJ  Chan M  Bhatti H    Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies Lancet Oncol 2011 12 160 263-29-0557/S1470-2045(11)70002-X 21251875 
14. Massie MJ   Prevalence of depression in patients with cancer J Natl Cancer Inst Monogr 2004 32 57 71 10.1093/jncimonographs/lgh014 
15. Hotopf M  Chidgey J  Addington-Hall J    Depression in advanced disease: a systematic review part 1. Prevalence and case finding Palliat Med 2002 16 81 97 10.1191/02169216302pm507oa 11969152 
16. Stark DP  House A   Anxiety in cancer patients Br J Cancer 2000 83 1261 1263-29-0557/bjoc.2000.1405 11044347 
17. Yang YL  Liu L  Wang Y    The prevalence of depression and anxiety among Chinese adults with cancer: a systematic review and meta-analysis BMC Cancer 2013 13 263-29-0557/1471-2407-13-393 23967823 
18. McCorkle R  Pasacreta J  Tang ST   The silent killer: psychological issues in ovarian cancer Holist Nurs Pract 2003 17 300 263-29-0557/00004650-200311000-00005 14650572 
19. Wen Q, Shao Z, Zhang P, et al. Mental distress, quality of life and social support in recurrent ovarian cancer patients during active chemotherapy. Eur J Obstet Gynecol Reprod Biol. 2017;216:85-91. doi:10.1016/j.ejogrb.2017.07.004.
20. García-Llana H  Remor E  Del Peso G    The role of depression, anxiety, stress and adherence to treatment in dialysis patients' health-related quality of life: a systematic review of the literature Nefrologia 2014 34 637 657 25259819 
21. Norton TR  Manne SL  Rubin S   Prevalence and predictors of psychological distress among women with ovarian cancer Clin Oncol 2004 22 919 926 10.1200/JCO.2004.07.028 
22. Hipkins J  Whitworth M  Tarrier N   Social support, anxiety and depression after chemotherapy for ovarian cancer: a prospective study Br J Health Psychol 2004 9 569 263-29-0557/1359107042304542 15509362 
23. Bodurka-Bevers D  Basen-Engquist K  Carmack CL   Depression, anxiety, and quality of life in patients with epithelial ovarian cancer Gynecol Oncol 2000 78 302 263-29-0557/gyno.2000.5908 10985884 
24. Yang YL  Liu L  Wang XX    Prevalence and associated positive psychological variables of depression and anxiety among Chinese cervical cancer patients: a cross-sectional study PLoS One 2014 9 e94263-29-0557/journal.pone.0094804 24722558 
25. Yang YL  Liu L  Li MY    Psychological disorders and psychosocial resources of patients with newly diagnosed bladder and kidney cancer: a cross-sectional study PLoS One 2016 11 e0155263-29-0557/journal.pone.0155607 27191964 
26. Wu HX  Zhong H  Xu YD    Psychological and behavioral intervention improves the quality of life and mental health of patients suffering from differentiated thyroid cancer treated with postoperative radioactive iodine-131 Neuropsychiatr Dis Treat 2263-29-0557 1060 27194911 
27. Costa AL, Heitkemper MM, Alencar GP, et al.Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer. Cancer Nurs. 2016. [Epub ahead of print]PMID: 27171810.
28. Rock EE  Steiner JL  Rand KL    Dyadic influence of hope and optimism on patient marital satisfaction among couples with advanced breast cancer Support Care Cancer 2263-29-0557 2263-29-0557/s00520-014-2209-0 24687536 
29. Berrocal Montiel C  Rivas Moya T  Venditti F    On the contribution of psychological flexibility to predict adjustment to breast cancer Psicothema 2016 28 266 271 27448259 
30. Zigmond AS  Snaith RP   The hospital anxiety and depression scale Acta Psychiatr Scand 1983 67 361 263-29-0557/j.1600-0447.1983.tb09716.x 6880820 
31. Zhang GH  Xu MZ  Jin HY   Factorial structure of the hospital anxiety and depression scale in outpatients with somatic disease Chin J Clin Psychol 2006 14 591 592 
32. Rajandram RK  Ho SMY  Samman N    Interaction of hope and optimism with anxiety and depression in a specific group of cancer survivors: a preliminary study BMC Res Notes 2011 4 263-29-0557/1756-0500-4-519 22123081 
33. Cohen S  Kamarack T  Mermelstein R   A global measure of perceived stres J Health Soc Behav 1983 24 385 263-29-0557/2136404 6668417 
34. Zheng W  Wang Y  Guo Z    Reliability and validity of the Chinese version of perceived stress scale J Shanghai Jiaotong Univ 2263-29-0557 1451 
35. Herth K   Development and refinement of an instrument to measure hope Schol Inquiry Nurs Pract 1991 5 39 51 
36. Wagnild G   A review of the resilience scale J Nurs Meas 2009 17 105 263-29-0557/1061-3730.255.87.(662)437-8250 
37. Zhang T  Li H  Wang D   Psychological resilience and its influencing factors among breast cancer patients Chin J Public Health 2015 31 263 267 
38. Pecorelli S   Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium Int J Gynaecol Obstet 2009 105 103 263-29-0557/j.ijgo.2009.02.012 19367689 
39. American Joint Committee on Cancer. Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., editors. AJCC cancer staging manual. 7th ed. New York, NY: Springer. 2010: 395–402.
40. Mielcarek P  Nowicka-Sauer K  Kozaka J   Anxiety and depression in patients with advanced ovarian cancer: a prospective study Psychosom Obstet Gynaecol 2016 37 57 67 10.3109/0167482X.2016.1141891 
41. Watts S  Prescott P  Mason J    Depression and anxiety in ovarian cancer: a systematic review and meta-analysis of prevalence rates BMJ Open 2015 5 e007263-29-0557/bmjopen-(662)437-8250 26621509 
42. Price MA  Butow PN  Costa DS    Prevalence and predictors of anxiety and depression in women with invasive ovarian cancer and their caregivers Med J Aust 2010 193 S52 S57 21542447 
43. Pranjic N  Bajraktarevic A  Ramic E   Mater Sociomed. Distress and PTSD in patients with cancer: cohort study case Materia Socio Medica 2016 28 12 16 10.5455/msm.(662)437-8250 27047260 
44. Ho RT  Kwan TT  Cheung IK    Association of Fatigue with perceived stress in Chinese women with early stage breast cancer awaiting adjuvant radiotherapy Stress Health 2015 31 214 263-29-0557/smi.2548 26252247 
45. Shand LK  Brooker JE  Burney S    Symptoms of posttraumatic stress in Australian women with ovarian cancer Psychooncology 2015 24 190 263-29-0557/pon.3627 25044162 
46. Adellund Holt K  Jensen PT  Gilså Hansen D    Rehabilitation of women with gynaecological cancer: the association between adult attachment, post-traumatic stress disorder and depression Psychooncology 2016 25 691 263-29-0557/pon.3996 26449611 
47. Hill EM   Quality of life and mental health among women with ovarian cancer: examining the role of emotional and instrumental social support seeking Psychol Health Med 2016 21 551 263-29-0557/13548506.2015.1109674 26549407 
48. Xiao F, Song X, Chen Q, et al. Effectiveness of psychological interventions on depression in patients after breast cancer surgery: a meta-analysis of randomized controlled trials. Clin Breast Cancer. 2016; doi:10.1016/j.clbc.2016.11.003. [Epub ahead of print]
49. Aricò D  Raggi A  Ferri R   Cognitive behavioral therapy for insomnia in breast cancer survivors: a review of the literature Front Psychol 2016 7 1263-29-0557/fpsyg.2016.(662)437-8250 
50. Jassim GA  Whitford DL  Hickey A  Carter B   Psychological interventions for women with non-metastatic breast cancer Cochrane Database Syst Rev 2015 5 CD008729 
51. Sjoquist KM  Friedlander ML  O'Connell RL    Hope, quality of life, and benefit from treatment in women having chemotherapy for platinum-resistant/refractory recurrent ovarian cancer: the gynecologic cancer intergroup symptom benefit study Oncologist 2263-29-0557 1263-29-0557/theoncologist.2013-0175 24107972 
52. Hall AE  Sanson-Fisher RW  Carey ML    Prevalence and associates of psychological distress in haematologicalcancer survivors Williamson A Support Care Cancer 2263-29-0557 4263-29-0557/s00520-016-3282-3 27245984


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