Biuletyn Polskiego

Towarzystwa Onkologicznego
NOWOTWORY
2022, tom 7, nr 5, 323–329
© Polskie Towarzystwo Onkologiczne
ISSN 2543–5248, e-ISSN: 2543–8077
Artykuł oryginalny / Original article www.nowotwory.edu.pl

Mental adaptation to cancer diagnosis and the health locus

of control in patients undergoing treatment
Marta Kulpa1, Agata Ciuba2, 3, Tomasz Duda1, Mariola Kosowicz4, Magdalena Flaga-Łuczkiewicz5,
Beata Stypuła-Ciuba6

1Department of Psychology and Medical Communication, Medical University of Warsaw, Warsaw, Poland
2Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
3Department of Social Medicine and Public Health, Doctoral School, Medical University of Warsaw, Warsaw, Poland
4Department of Psycho-oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
5Dialog Therapy Centre, Warsaw, Poland
6Department of Cancer & Cardio-Oncology Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland

Introduction. C  ancer diagnosis and treatment perspectives pose a serious emotional and behavioral burden for
the patient, and require adaptation strategies to be adapted.
Material and methods. T he research consisted of 569 patients aged 19 to 91 undergoing oncological treatment.
The study used the mini-MAC scale to measure mental adaptation to cancer and the MHLC scale to measure the health
locus of control.
Results. The strategy of anxiety preoccupation was highest in breast cancer. The strategy of helplessness and hope-
lessness achieved the highest value in breast and reproductive organ cancers. The fighting spirit strategy showed
the highest value in cancers of the digestive system. The positive re-evaluation strategy was the highest in cancers
of the head and neck, and digestive system.
Conclusions. Patients with breast cancer and reproductive organ cancers seem to be at greater risk of developing
destructive behavior, therefore extended psychological support has to be considered for these patients.

Key words:cancer, illness acceptance, quality of life, strategies for coping with the disease, pain management

Introduction may translate into difficulties in the relationship with the do-
Cancer and the need for treatment are significant sources ctor. In such situations, encouraging the patient to comply
of stress for the patient and their family. The crisis of cancer with medical recommendations and health education does
and its treatment pose a serious emotional and behavioral not bring the expected effect because it does not address all
burden for the patient, which may contribute to the deve- the causes of the patient’s difficulties [1]. Understanding how
lopment of anxiety-depressive disorders and the activation patient psychologically adapts to cancer and identification
of destructive coping strategies. A patient with anxiety-de- of the type of health locus of control in the patient enables for
pressive disorders and the feeling that they have no influence better planning of cooperation between doctor and patient. Si-
on their health often results in a lack of faith in the success multaneous patient education and psychotherapy, which can
of the therapy and low internal motivation for treatment; this develop constructive strategies for coping with the disease,

Jak cytować / How to cite:

Kulpa M, Ciuba A, Duda T, Kosowicz M, Flaga-Łuczkiewicz M, Stypuła-Ciuba B. Mental adaptation to cancer diagnosis and the health locus of control in patients
undergoing treatment. NOWOTWORY J Oncol 2022; 72: 275–281.

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help increase patient’s adherence to recommended treatment for one’s health as a result of one’s own behavior and personal
regimens and ensure they maintain them in the long term [2]. control over it. People with dominance of the internal sense
The theory of adaptation to neoplastic disease is based of health control are more assertive in the doctor-patient rela-
on the concept of stress in the cognitive-transactional cur- tionship, autonomous in making decisions about their health,
rent, according to Lazarus and Folkman (1984) [3]. The theory and have a higher sense of responsibility for their health con-
assumes that stress experienced as a result of the assessment dition. The internal locus of control is often associated with
of a stimulus as threatening (cancer disease), entails the use the pursuit of increasing the quality of life and health, as well as
of maladaptive methods of coping with stress, which in turn undertaking preventive behaviors aimed at maintaining health.
may lead to poorer mental adaptation to the disease. Greer The internal locus of control favors the initiation of pro-health
(2008) [4] defined a model of coping with stress that includes behaviors by an individual and taking responsibility for their
five main attitudes of adaptation to cancer: fighting spirit, own health. The external locus of health control manifests itself
avoidance / denial, fatalism / stoic acceptance, helplessness in two attitudes: belief in the influence of others on one’s health,
/ hopelessness, anxious preoccupation. The results of studies and belief in the impact of an accident on one’s health. The exter-
by Greer et al. (1989) [5] indicate that different types of ada- nal locus of control favors the delegation of responsibility for
ptation to a disease are associated with positive or negative one’s health to others, which may lower one’s own motivation
reactions, motivation to treatment, sense of health control, to undertake preventive and pro-health behaviors. The external
and compliance with medical recommendations. The fighting locus of health control is observed more frequently in chronically
spirit stance is associated with low external and high internal ill patients. The external locus of control may, however, positively
locus of control and high social support. The attitude of fata- affect the therapeutic process and compliance with medical
lism / stoic acceptance is related to the internal and external recommendations by placing the responsibility for the health
locus of control which can affect compliance with medical condition and all competences in this area onto the physician.
recommendations and cooperation with the attending phy- From a therapeutic point of view, the best situation is when
sician. In this attitude, emotional state should be monitored as the patient shows an ambiguous locus of control, i.e. an un-
depressive disorders with resignation and emotional indiffe- differentiated type, because at the same time the patient has
rence may develop, which may falsely give the image of stoic a strong conviction about the influence of others on his health
acceptance. The helplessness / hopelessness attitude manifests (doctor, physiotherapist, nurse), which favors compliance with
itself in a patient with a sense of hopelessness and helples- therapeutic recommendations and internal conviction, which
sness, passivity, anxiety, and depression, and is associated with mobilizes them to undertake effective pro-health activities
a high external locus of health control and low social support. and to remain in them [8, 9]. In Poland and around the world,
The attitude of anxious concern is manifested in the patient the most frequently used tool for diagnosing the type of health
with an anxious attitude towards diagnosis, the diagnostic locus of control is the MHLC Scale – Multidimensional Health Lo-
and therapeutic process, and often in hypochondriacal beha- cus of Control Scale by Kenneth A. Wallston, Barbara S. Wallston,
vior. The avoidance / denial attitude is often associated with Robert DeVellis (1976; 1978) in the Polish adaptation of Zygfryd
high anxiety, ambivalent reactions, difficulties in adherence Juczyński (2012).
to medical recommendations, and low motivation for treat- Many studies indicate that the emotional state of the pa-
ment. In terms of the type of coping strategy and the course tients and their way of coping with stress during the disease have
of disease process, it was found that people adopting attitudes a great influence on their engagement in therapy and the course
classified as fighting spirit showed a higher level of compliance of cancer treatment [10–14]. The assessment of depressive or
with medical recommendations and a longer period of re- anxiety disorders is insufficient in the psychological diagnosis
mission and survival than people using the strategy of stoic of a patient, therefore, it was expanded to other dimensions.
acceptance or a sense of helplessness / hopelessness [5, 6]. The aim of the study was to assess psychological adjustment to
The health locus of control and self-efficacy beliefs in crisis cancer in patients in the early stage of treatment, and to identify
situations are considered to be one of the most important those who present maladaptive strategies and to provide them
predictors of coping with a chronic disease, including cancer. with psychological care. The screening assessment of the way
Measure of the sense of health control is indicated by three of coping with stress and the type of localization of health
main cognitive beliefs: one’s own actions, the actions of others control enables the selection of targeted psychotherapeutic
in the environment, and chance. The type of beliefs about methods. In turn, these translate into better cooperation betwe-
the sense of health control is one of the psychological factors en the patient and the medical staff and increases chances for
determining the quality of coping with the disease, the choice the success of the oncological treatment. Therefore, the study
of health behaviors, and translates into the patient’s involvement used readily available standardized research questionnaires exa-
in the therapeutic process [7]. Rotter (1954) classified the site mining mental adaptation to neoplastic disease and the health
of health control as internal and external. The inner locus of he- locus of control. The universality of the selected questionnaires
alth control manifests itself in assigning more responsibility allows for future replication of the study and the creation of an

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obligatory screening battery of tests to assess patient functio- manual. The results after conversion to standardized scale can
ning in psycho-oncology clinics. be interpreted in the sten scale values from
​​ 1–10 sten, where
results in the range 1–4 sten are interpreted as low, 5–6 sten as
Material and methods average and results in the range 7–10 sten are considered high.
The study group The health locus of control was measured by the Multidi-
The study was carried out among 569 patients aged 19 to 91 mensional Health Locus of Control Scale (MHLC) by Kenneth
undergoing oncological treatment. The study was conducted A. Wallston, Barbara S. Wallston, Robert DeVellis (1976; 1978)
between January and December 2018. All patients included in the Polish adaptation of Zygfryd Juczyński (2012), which
in the study received psychological support during their stay measures 3 dimensions of the health locus of control: internal,
at the clinic. The study was voluntary, anonymous, and based external, i.e., the influence of others, and chance. The value
on a one-time measurement. of each of the dimensions is within 6–36 points, and the higher
the score, the stronger the belief to which the analysis relates.
Bioethics Committee
The research plan received a positive opinion from the Com- Statistical analysis
mittee of the Science Department of the Maria Sklodowska- The study population was divided into subgroups according
-Curie National Research Institute of Oncology and was entered to the differentiation criteria based on the type of cancer.
in the scientific plan, registration number 4.34/2018. The obtained results were analyzed statistically with the use
of statistical tests (t-student, single factor analysis of variance).
Variable measurement tools
The research questionnaire consisted of author-delivered Results
sociodemographic survey questions and standardized to- 569 patients (346 women and 223 men) aged 19 to 91 (mean
ols. Mental adaptation to cancer was measured with the use age 54) were examined. The most numerous group of stu-
of the Mini-Mental Adjustment to Cancer (mini-MAC) scale in died patients were those with breast cancer (30.05%) (fig. 1),
the Polish adaptation of Z. Juczyński 2012. then: patients with cancers of the head and neck (12.48%),
The scale allows for a determination of what strategies reproductive organs (12.48%), the digestive system (12.13%),
the examined patient adopts in relation to cancer. The scale and male genital (9.84%). The smallest groups were patients
consists of 29 items including four scales: with lymphatic system neoplasms (6.68%) and bone neopla-
• anxious preoccupation – perceiving the disease as some-
thing threatening, causing uncontrollable anxiety,
• fighting spirit – perceiving the disease as a challenge,
which involves taking actions to combat the disease,
2.28%
• helplessness / hopelessness – an attitude indicating pas- 6.68%
sive surrender to the disease, 30.05%
7.03%
• positive reevaluation – a perception of the disease which,
on the one hand, takes into account the seriousness
of the situation, and on the other – allows one to find
hope and appreciate past and present events in life. 7.03%

The results of the mini-MAC strategy are in the range

of 7–28 points, and the higher the score, the greater the intensi-
ty of a given cancer coping strategy. Using the mini-MAC scale, 9.84%
it is possible to also define two coping behaviors: constructive
and destructive, resulting from a combination of the above.
The constructive behavior includes the strategy of fighting spi-
rit and positive re-evaluation, and the destructive behavior in- 12.13% 12.48%
cludes the strategy of helplessness / hopelessness and anxious
preoccupation. The scale is used to assess adaptation to cancer, 12.48%
which translates into the behavior and emotions of the patient
during the treatment and rehabilitation process. breast lungs
The scale diagnoses adaptation strategies towards the di- head and neck soft tissues and
female genital organs the nervous system
sease: anxious preoccupation, helplessness / hopelessness,
digestive organs lymphomas
fighting spirit, positive re-evaluation. The results obtained from
urinary tract bines
our research were referred to the mean results of analogous
groups of patients included in the mini-MAC questionnaire Figure 1. Tumor location

325
sms (2.28%). Almost 60% of patients (335 people) came for 26.00
oncological treatment for the first time, while the remaining 24.00
patients were re-exposed due to recurrence of the cancer. 167 22.00
patients (29.35%) were economically active during oncological 20.00
treatment, 116 patients (20.39%) were on sick leave due to
18.00
illness, 87 patients (15.29%) were on a disability pension due
16.00
to disease, and 199 patients were retired (34.97%).
14.00
Figure 2 shows the mean intensity of stress coping styles
12.00
in subgroups based on cancer type. The analysis of the ad-
opted strategies as part of mental adaptation to neoplastic 10.00
soft female urinary lungs breast lym- digestive head bines
disease in the studied population of patients (fig. 2.) showed tissues genital tracts phomas organs and
and the organs neck
the mean value of fighting spirit rated as high, positive reeva- nervous
system
luation was also rated high (21.6), anxious preoccupation rated
medium (16.02) and helplessness / hopelessness rated low
anxious preoccupation (Mini MAC) fighting spirit (Mini MAC)
(12.67). The mean result in constructive strategies was 44.31
helplessness-hopelessness (Mini MAC) positive redefinition (Mini MAC)
which correspondents to 7th sten (high intensity) and mean
Figure 2. Cognitive coping responses by cancer type
result in destructive strategies was 28.69 which corresponds
to 4th sten (low intensity) (confidence level 0.01). Analysis
of the level of coping strategies in relation to the treatment 50.00
stage (fig. 2) showed that the anxious preoccupation was
45.00
significantly (t-student p = 0.014) higher during the first tre-
atment (19.4) than the next (15.41). No statistically significant 40.00

differences were observed in the level of remaining strate- 35.00

gies. The strategy of helplessness and hopelessness achieved
30.00
a higher value during the next treatment due to recurrence
25.00
of the tumor and was 12.70, while during the first treatment it
was 12.65. The fighting spirit strategy was comparable during 20.00 soft female urinary lungs breast lym- digestive head bines
the first (22.86) and subsequent oncological treatment (22.5), tissues genital tracts phomas organs and
and the organs neck
and the positive reevaluation strategy was similar in the first nervous
treatment (21.58) as the subsequent treatment (21.68). Con- system
constructive strategies destructive strategies
structive strategies during the first treatment reached 44.63
and during the next treatment 44.14, which translates into Figure 3. Coping strategies by cancer type

7th sten. The destructive strategies reached a value of 29.10

during the first treatment, and a value of 28.11 during the next
treatment, which translates into 4th sten. en the groups were present. The highest levels of destructive
Figure 3 presents the coping strategies in subgroups based strategies were achieved in breast cancers (30.68) and can-
on cancer type. The analysis of coping strategies in relation cers of the reproductive organs (29.76), and the lowest values
to the type of neoplasms (fig. 3) showed that anxious pre- were found in cancers of the lymphatic system (24.92) (ANOVA
occupation was highest in breast cancer (18.1) and lowest in p = 0.001).
lymphatic system neoplasms (ANOVA p = 0.003). The strategy Figure 4 shows the health locus of control in subgro-
of helplessness and hopelessness achieved the highest value ups based on cancer type. The analysis of the locus of health
in breast (13.8) and reproductive organ cancers (13.74) (ANOVA control (fig. 4) showed that the mean severity of the internal
p = 0.003). The fighting spirit strategy showed the highest sense of health control was 24.83 and that the external locus
value in cancers of the digestive system (23.86) and the lowest of health control was 26.92, while the belief that health control
value in lung cancers (21.1), however, the observed differences depends on the influence of chance reached a mean value
were not statistically significant. The positive re-evaluation stra- of 24.17 in the study population. The conviction about internal
tegy was the highest in cancers of the head and neck (22.27), control (fig. 4) was highest in patients with head and neck (26.8)
and digestive system (22.06), and the lowest value was found and lung cancer (25.9), and lowest in patients with cancer
in cancers of the lung (20.85) and the lymphatic system (20.91). of the lymphatic system (23.16) (ANOVA p = 0.014).
The differences were not statistically significant. The belief about external control (fig. 4) was highest in
Constructive strategies (fig. 3) showed the highest levels patients with head and neck cancers (28.9) and lowest in pa-
in tumors of the digestive system (45.60) and the lowest in tients with lymphatic system tumors (24.55) (ANOVA p = 0.033).
lung tumors (42.9). No statistically significant differences betwe- The belief that health control (fig. 4) depends on chance was

326
 29.00 is analogous to those obtained in the presented study, which
28.00 shows that the use of adaptive strategies such as focusing
27.00 on planning or focusing on the positives are associated with
26.00 a positive attitude towards the disease and, at the same time,
25.00 with a lower intensity of negative emotions. In the study,
24.00 the attitude of the fighting spirit was highest in patients with
23.00 diagnosed cancers of the digestive system, while the attitude
22.00 of positive re-evaluation was achieved in patients with head
21.00 and neck neoplasms.
20.00 soft female urinary lungs breast lym- digestive head bines The second, destructive attitude is characterized by anxiety,
tissues genital tracts phomas organs and
and the organs neck a sense of helplessness / hopelessness, which translates into
nervous a lack of faith in recovery and low involvement in the therapeutic
system
internal (MHLC) others (MLHC) chance (MLHC)
process. A study by Wootten et al. (2007) [17] indicates that focu-
sing on emotions is associated with poorer mental adaptation.
Figure 4. Health locus of control by cancer type
A similar result was obtained in the presented study – the use
of strategies such as catastrophizing, rumination, and blaming
28.00
27.50 oneself and others is associated with a higher severity of anxiety
27.00 and a greater tendency to perceive the situation as threatening,
26.50 and thus with poorer adaptation to the disease. The passive
26.00 strategy was related to the external locus of the sense of con-
25.50
trol, which means that the patient has a low sense of their own
25.00
24.50 influence on the situation, and expects that the medical staff
24.00 will be directive and will take care of them. On the other hand,
23.50 in the case of failure of oncological treatment, patients hold third
23.00 parties responsible. In the study, the attitude of helplessness /
active sick leave sickness pension pension
internal (MHLC) others (MLHC) chance (MLHC) hopelessness was highest in breast and reproductive organ
Figure 5. Health locus of control by professional activity cancers, and anxious preoccupation was also the highest among
breast cancer patients.
highest in patients with neoplasms of soft tissues and the nervo- High anxious preoccupation and a sense of helplessness
us system (25.98), and the lowest level was achieved in patients / hopelessness in the case of cancers related to female sexual
with neoplasms of the urinary system (21.8) (ANOVA p = 0.039). characteristics can have multiple causes. The disease strictly
Figure 5 shows the dimensions of health locus of control affects the perception of a woman’s body, her attractiveness,
in subgroups based on professional activity. The conviction physicality, quality of life in a sexual sense, and the possibility
about internal control (fig. 5) was highest in professionally ac- of having children, as well as disturbing the hormonal balance.
tive patients (25.31) and the lowest in patients who were on It should also be taken into account that cancers related to
a pension (24.51) or retired (24.53) (no statistical significance). female characteristics also affect intimate relationships, which
Belief about an external control (fig. 5) was highest in patients on may translate into a fear of rejection and loneliness.
a pension (27.78) and the lowest in professionally active patients A study by Chojnacka-Szawłowska (2012) [3] confirmed
(26.04) (ANOVA p = 0.002). The belief that health control (fig. 5) that patients initiating constructive strategies of coping with
depends on the case was the highest in patients on disability cancer were characterized by a higher quality of life and a bet-
(24.80) or retired (24.78), and the lowest level was achieved in ter prognosis in terms of both survival and remission periods.
professionally active patients (23.41) (no statistical significance). These studies also confirmed that active and confrontational
strategies have a greater impact on increasing the quality of life
Discussion than strategies with a predominance of passivity and resigna-
Cancer diagnosis and the prospect of oncological treatment tion. The research by Watson (1999) [18] showed that the type
have a negative impact on a patient’s emotional state, causing of attitude taken by patients towards the disease, as well as
an increase of anxiety. The stress associated with the disease the rates of depression, correlate with the survival of patients
requires developing adaptation strategies [15]. Most often, with neoplastic diseases. Breast cancer patients adopting an
patients run two extreme strategies: constructive and de- attitude of helplessness / hopelessness or showing a high
structive. Patients with a constructive strategy are positive, level of depression have a significantly lower quality of life
fight the disease, and are oriented towards a cure. Roesch et and have a significantly lower chance of 5-year survival. A study
al. (2005) [16] found that better mental adaptation to cancer is by Ośmiałowska (2021) also shows that breast cancer patients
associated with the use of task-oriented strategies. This result choosing constructive strategies of coping with the disease

327
achieve a higher quality of life score compared to those who treatment, patients often have to make what is referred to as
chose destructive coping strategies [19]. an “informed consent” decision about medical and therapeutic
It was found in the study that professionally active people procedures. Patients with an internal locus of control over
show the highest sense of internal locus of control and agen- their health and a high sense of self-efficacy make decisions
cy, and achieve the lowest values of external sense of health faster and are consistent in those decisions. Self-efficacy is
control and the influence of chance. This result indicates that associated with an internal locus of control and intrinsic mo-
patients working professionally during treatment function tivation, which translates into higher patient engagement
better emotionally and have a better network of social support, in the treatment process and a positive attitude toward it;
which ultimately translates into belief in their own agency. This moreover, it is also associated with lower rates of treatment
group of patients also shows a lower preoccupation with anxie- interruptions or treatment withdrawal due to patient decisions.
ty and a sense of helplessness / hopelessness compared to Analysis of the results from our research shows that the asses-
patients who are not professionally active for various reasons. sment of the type of coping strategies and the health locus
During the first treatment, patients were most often anxio- of control in cancer patients are important factors influen-
us, while during the second treatment, the helplessness / cing their functioning. The finding of maladaptive strategies
hopelessness strategy was most often presented. Clinically, and the external sense of health control in the patient should
this translates into the fact that when confronted with a cancer be an indication for psychological care because the consequ-
diagnosis, patients need psychological support and education, ences of such strategies are reactive and anxiety-depressive
while during recurrence, therapy very often requires psychiatric disorders. This will enable the patient to be provided with
treatment due to the development of a depressive syndrome. clinical assistance before major depressive disorders develop.
The obtained results indicate the good mental adaptation The possibility of modulating the onset of depressive symp-
of patients to the disease, especially in its first stage. Thus, toms, especially in high-risk oncology patients, has been pre-
the results provide guidance on what actions should be taken viously noted by Ghanem et al. (2020) [24]. Screening patients
into account when planning medical and psychological inte- with the mini-MAC and MHLC tests should be one of the most
rventions to support the process of treatment. First, it is worth important elements in the prevention of depression and anxie-
encouraging patients to deal with the disease in a constructive ty disorders in patients.
way – planning further actions, learning about the course
of the disease, and the treatment process. It is also worth enco- Conclusions
uraging patients to look at current events in a broader context, • Patients with breast cancer and reproductive organs can-
not to treat the current disease as a situation in which they cers seem to be at greater risk of developing destructive
are helpless. When patients are willing to blame themselves or copying strategies, therefore, extended psychological sup-
others for the situation, it is worth redirecting their attention port has to be considered for those patients.
to other less stressful events, reevaluating and looking for • Because professionally active patients use more construc-
positives despite the disease. Patients are recommended to tive coping strategies, it would probably be beneficial to
join associations of cancer patients, where they will receive support oncological patients in staying occupationally
support, a corrective positive experience of functioning with active, at least partially.
the disease, and with others whom they co-create a support • Education and psychological support during first treat-
group. However, the relationship between acceptance of ill- ment should focus on interventions addressing anxiety,
ness, quality of life, and pain still needs further investigation. while during next treatments coping with helplessness /
It has been constantly confirmed that patients with breast hopelessness should be taken in account.
cancer and female and male genital cancers who have a high • The type of implemented coping strategy and the health
level of illness acceptance and a positive illness perception locus of control in cancer patients are important factors influ-
display a better quality of life and overall functioning [20–22]. encing their functioning during the treatment of the disease.
A study by Kulpa et al. (2019) [23] indicates that constructi- • Screening patients with the mini-MAC and MHLC tests
ve coping strategies translate into the ability to better coping should be one of the most important elements in the pre-
with illness-related stress, internal locus of health control, hi- vention of depression and anxiety disorders in patients.
gher quality of life, and greater patient confidence in treatment
success. Patients with low self-efficacy often have comorbid Conflict of interest: none declared
anxiety and depressive disorders. Anxiety strategies are associa-
ted with an external locus of health control, anxiety disorders, Agata Ciuba
Maria Sklodowska-Curie National Research Institute of Oncology
and depressive disorders, as well as greater sensitivity to pain
Cancer Epidemiology and Primary Prevention Department
and more frequent episodes of intractable pain. The internal ul. Wawelska 15B
locus of control is associated with a sense of empowerment 02-034 Warszawa, Poland
and higher decision-making; this is important because during e-mail: agata.ciuba@pib-nio.pl

328
Received: 22 Oct 2021 cancer: A systematic review. Psychooncology. 2018; 27(3): 734–747,
Accepted: 29 Jun 2022 doi: 10.1002/pon.4509, indexed in Pubmed: 28748624.
13. Kurita K, Garon EB, Stanton AL, et al. Uncertainty and psychological
adjustment in patients with lung cancer. Psychooncology. 2013; 22(6):
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