141 of 291 patients completed the questionnaire, corresponding to a participation rate of 48%. After exclusion of the patients that had passed away at the time of the interview, the participation rate amounts to 59%. Figure 1 depicts the participation in the study with inclusion of the reasons for non-participation.
Flow-chart of participation and non-participation in the study
The majority of patients suffered from ovarian cancer (64%, n = 90). 23% (n = 32) were suffering from endometrial cancer, 9% (n = 13) from cervical cancer and further 4% (n = 6) from vulvar cancer.
Subjective lifestyle evaluation prior to the cancer diagnosis
Patients were initially asked to assess their lifestyle prior to the diagnosis of cancer (“Did you lead a healthy life prior to the diagnosis of cancer?”). 105 patients described their lifestyle as healthy, 12 patients as average and 23 as not healthy (Table 1). Patients claiming to have pursued a healthy lifestyle were evaluated regarding obesity, nutrition and physical activity. 54% (n = 57) were found to have a BMI ≥ 25 and were considered overweight. 26% (n = 27) consumed meat daily or several times per day, and 70% (n = 73) ate only one to two portions of fruits or vegetables per day. In 26% of the patients (n = 27), there was an obvious lack of activity (physical exercise less than one to two times per week).
Table 1 Self-assessment of lifestyle prior to malignancy
89% (n = 125) of the patients reported positive lifestyle changes of at least one of the factors evaluated (smoking, alcohol consumption, nutrition, physical activity, stress level).
Patients who modified their lifestyle positively were significantly younger than those who did not (58.4 versus 65.4 years; p = 0.03, Table 2).
Table 2 Lifestyle changes in relation to several variables
A lifestyle improvement was detected in 96% (n = 22) of the patients who described their own lifestyle as unhealthy prior to the diagnosis of cancer. 88% (n = 92) of those who claimed to have a healthy lifestyle prior to the cancer diagnosis were able to further improve their lifestyle (p = 0.5, Table 2).
Patients who used CAM treatments were significantly more likely to implement lifestyle improvements (p = 0.01, Table 2). Lower Body-Mass-Index (p = 0.2, Table 2) and a higher education level (p = 0.7, Table 2) showed a positive relation to lifestyle modifications.
Modification of individual lifestyle factors
A reduction in tobacco consumption was found in 63% (n = 12) of current and former smokers after the cancer diagnosis. Four patients reduced their tobacco intake and eight patients quit smoking completely.
91% (n = 129) of the patients regularly consumed alcohol prior to the cancer diagnosis. 84% (n = 109) drank alcohol up to three times per week and 16% (n = 20) drank alcohol daily. Overall, 47% (n = 61) reduced the consumption of alcohol after the diagnosis of a malignancy.
A similar reduction of alcohol intake was noted in patients with average alcohol consumption (up to 3x/week) and in patients with daily alcohol intake (p = 0.8, Table 3).
Table 3 Changes in alcohol consumption
Nutritional changes after the cancer diagnosis
65% (n = 92) of the patients described nutritional changes after the cancer diagnosis, particularly in the consumption of fruits/ vegetables, meat and oils/ nuts (Table 4). Furthermore, 9% (n = 12) of patients implemented special diets in order to optimize the oncological treatment effect. A reduction of sugars and carbohydrates, an oil- and protein-rich diet according to Johanna Budwig as well as the Dr. Coy diet and fasting (Rudolf Breuss cancer cure) were among the most frequently used diets. Only one patient underwent formal nutritional counseling.
Table 4 Nutritional modifications since the cancer diagnosis
Almost none of the patients consumed the recommended five servings of fruits/ vegetables per day (Deutsche Gesellschaft für Ernährung e.V., 2017). An insufficient intake was detected in 71% (n = 99) of the patients (≤ 2 portions of fruits/ vegetables daily). However, 52% (n = 51) of these patients reported an increased intake of fruits/ vegetables after making dietary adjustments after diagnosis (Table 5).
Table 5 Nutrition before and after cancer diagnosis
Consumption of meat
Assuming 150 g meat per serving, eating meat is recommended to be limited to a maximum of two times per week (Deutsche Gesellschaft für Ernährung e.V., 2017). 72% (n = 102) reported consuming more than the recommended amount of meat, and 48% (n = 49) of these patients reduced the amount of meat eaten after diagnosis. 64% of the patients (n = 30) who had eaten meat daily prior to the diagnosis of cancer reduced the intake of meat after diagnosis, demonstrating the most pronounced reduction (Table 5).
There are no clear recommendations regarding the daily or weekly intake of fast food/ sweets (Deutsche Gesellschaft für Ernährung e.V., 2017). The majority of patients 88% (n = 122) reported eating fast food less than once per week. 60% (n = 84) of the patients stated that they ate sweets daily or more than twice per week. There was a more pronounced modification of the intake of sweets and fast food in patients who consumed these food groups frequently prior to the cancer diagnosis. 80% (n = 4) of the patients who consumed fast food more than twice per week (n = 5) changes their intake after the cancer diagnosis, the same was true for only 9% (n = 11) of the patients eating fast food less the once per week (n = 122). Similarly, 53% (n = 24) of the patient who ate sweets daily (n = 45) changed this after their cancer diagnosis, only 5% (n = 1) of patients who ate sweets less than once per week (n = 20) did the same (Table 5).
Table 6 shows the relation of age, BMI, use of CAM and educational degree to dietary changes following the diagnosis of cancer. Patients who implemented dietary changes were significantly younger (60.5 versus 64.8 years, p = 0.04, Table 6), more likely to be CAM users (p < 0.001, Table 6), had a lower Body-Mass-Index (p = 0.29, Table 6) and higher education levels (p = 0.11, Table 6).
Table 6 Dietary changes based in several variables
Physical activity changes after the cancer diagnosis
As shown in Fig. 2, 37% (n = 52) of the patients reported no changes in physical activity, 36% (n = 51) less exercise and 27% (n = 38) more exercise after the diagnosis of cancer. 76% (n = 39) of the patients who reduced their physical activity explained this reduction by a severe fatigue since diagnosis (“I can’t exercise a lot”, “I can’t exercise because I am physically not well enough”). Figure 3 depicts the level of physical exercise prior to the diagnosis of cancer as well as the modification in exercise thereafter. The patients who had previously exercised more than twice per week were most likely to reduce the level of their physical exercise (59%, n = 29). An increase in physical activity was reported in only 16% (n = 8) of this particular group of patients. Of the patients who had previously exercised once or twice per week, 20% (n = 10) increased their physical activity while 41% (n = 20) maintained the same level and 39% (n = 19) reported a reduction in physical exercise after diagnosis. In contrast, 47% (n = 20) of the patients who had previously exercised less than once per week increased the physical activity while 47% (n = 20) maintained the same level and 6% (n = 3) exercised less.
Changes in physical activity after the diagnosis of cancer
Physical activity before the cancer diagnosis and its modification after diagnosis
The relation of age, BMI, the use of CAM and the level of educational to the exercise modifications is summarized in Table 7. Patients who managed to increase their physical activity after diagnosis were significantly younger (57.4 versus 63.8 years, p = 0.004) and were more often cam-users (p = 0.009). Body-Mass-Index (p = 0.9) and educational level (p = 0.8) showed no relation to a change of physical activity.
Table 7 Exercise modifications based on different variables
Level of stress
This part of the questionnaire focused on the patients’ perception of stress prior to and after the diagnosis of cancer and the underlying reasons for this stress. Potential changes of the level of stress during the course of the disease and potential contributing factors were also analyzed.
Prior to the diagnosis of cancer, 41% (n = 58) of the patients reported feeling stressed on a daily basis, 26% (n = 36) stated that they often felt stressed. 24% (n = 34) claimed that they were rarely stressed, 9% (n = 13) denied feeling stressed at all.
Patients could choose between pre-written answers and a free text option in order to assess potential stressors, resulting in 17 response options that were divided into different categories. The patient population evaluated for this study described career (56%, n = 72) as well as family-associated factors (51%, n = 65) as important contributors to an increased stress level. 36% (n = 46) of the patients attributed the increased stress level to poor time management on their own part (“I make too many appointments”, “I create too much stress for myself”). 5% (n = 7) reported prior major life events as the main source of stress, and 5% (n = 5) declined to answer.
Level of stress since the cancer diagnosis
77% (n = 108) of the patients reported a reduction in the stress level since the time of diagnosis, while 69% (n = 74) of these patients claimed to have reduced the level of stress through intentional lifestyle modifications. 14% (n = 20) noticed no changes, and 9% (n = 12) of the patients had a higher stress level after the diagnosis.
The level of stress based on the ordinal stress scale prior to and after diagnosis are depicted in Fig. 4 and Table 8. It shows that after the diagnosis of cancer, the level of stress diminishes in our study population. A division into low (1–3), moderate (4–7) and high (8–10) stress levels further confirms this observation (Table 8). There was a smaller proportion of patients with a high level of stress after diagnosis, underlining the reduction of the overall stress level (41% prior to, 4% after diagnosis) and an increase in the number of patients with a low stress level (14% prior to, 52% after diagnosis).
Change in stress-level since cancer-diagnosis
Table 8 Comparison of the stress level before and after the cancer diagnosis
Patients were asked to list all reasons for a change in their stress level as free text. All answers were divided into groups and are summarized in Table 9
Table 9 Reasons for decrease/increase in stress after diagnosis
A modification of the professional environment including a reduction in work hours or a leave of absence resulted in a stress reduction in the majority of patients (44%, n = 48). 43% (n = 47) attributed their lower stress level to mental lifestyle changes such as a consciously increased attentiveness to their own needs and wishes as well as the attempt to avoid mental stress due to external stressors. A reduced perception of stress due to separation/ divorce, children moving out or the death of a relative cared for by the patients was detected in 21% (n = 23) of the patients.
Patients who described an increase in stress typically attributed this stress to the underlying disease and in particular to a diminished physical capacity. 17% of the patients described a perceived increase in stress because of both family- and career-associated factors.
Application of methods to enhance relaxation
37% (n = 53) of the patients applied relaxation techniques prior to the cancer diagnosis, particularly yoga (n = 23), autogenous training (n = 22), progressive muscle relaxation (n = 21) and meditation (n = 14). Breathing therapy, hypnosis, energy strategies, Qi Gong, Shiatsu, silent prayers and Pilates were used less frequently.
55% (n = 77) of the patients stated that they pursued some type of relaxation technique, and 39% (n = 55) of the patients were still practicing this technique at the time of the questionnaire.
37% (n = 53) of the patients had been given a recommendation to participate in relaxation techniques.
Supportive company during the disease
Patients were questioned regarding their satisfaction with and deficits in the emotional support received during their illness.
98% (n = 138) stated that they received sufficient emotional support during their disease, particularly from friends and family (95%, n = 133). 74% (n = 103) reported feeling supported by the medical staff. Although there was a high level of satisfaction regarding the emotional support overall, 28% (n = 39) of the patients would have preferred even more intensive support, particularly from physicians (67%, n = 26) but also from family members and friends (44%, n = 17).
81% (n = 114) of the patients reported a positive personal development during the course of their disease. 74% (n = 104) felt a stronger appreciation for life, 72% (n = 102) focused more on their own needs, 56% (n = 79) reported an enhanced psychological strength, 42% (n = 59) felt a higher overall satisfaction with life, and 26% (n = 37) of the patients strengthened their faith/ spirituality.
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