European Review for Medical and Pharmacological Sciences 2023; 27: 291-298

Cancer information overload and death anxiety

predict health anxiety
P. ERASLAN1, A. İLHAN2
1
Presidential Medical Unit, Psychiatry Outpatient Clinic, Ankara, Turkey
2
Department of Medical Oncology, UHS Dr. Abdurrahman Yurtaslan Ankara Oncology Research
and Training Hospital, Ankara, Turkey

Abstract. – OBJECTIVE: We aimed to inves- and include fear of death, pain, disability, and
tigate the relationship between health anxiety, disruption of relationships1. It is essential to dis-
cancer information overload and death anxiety tinguish between reasonable fears for the patient
in caregivers of inpatient cancer patients. and their relatives and more severe fears that may
PATIENTS AND METHODS: A total of 92 in-
patient cancer patients’ caregivers were includ- indicate the presence of an anxiety disorder and
ed the study. A sociodemographic information recommend appropriate interventions to relieve
form, Arabic Scale of Death Anxiety (ASDA), distress1.
Health Anxiety Scale (HAS), Cancer Information Health anxiety is the negative over-interpreta-
Overload Scale (CIO) were given to participants tion of ordinary bodily sensations without phys-
to respond. ical illness2. Patients previously diagnosed with
RESULTS: Participants with high HAS scores
were compared with those with low HAS scores;
hypochondriasis in the Diagnostic and Statistical
the rate of employed persons was less (n=16, Manual of Mental Disorders (DSM-IV) can now
34.8% vs. n=30, 65.2%, p=0.006), income sta- meet the criteria for somatic symptom disorder
tus was more likely to be very low/low (n=23, (SSD) or illness anxiety disorder (IAD) in the
50.0% vs. n=6, 13.0%, p<0.001) and research DSM-V3. Health anxiety is recognized under
on cancer was more common (n=39, 84.8%, the diagnoses of IAD and SSD in DSM-V3. The
p<0.001). Median (IQR) CIO [24.0 (21.75-28.0) vs. core feature of illness anxiety disorder is anxiety
13.5 (11.0-18.25), p<0.001] and ASDA total [69.0
(62.0-77.0) vs. 41.0 (33.75-58.0), p<0.001] scores due to misinterpretation of bodily symptoms or
were higher in the group with high HAS score believing that one is suffering from a severe ill-
than in the group with low HAS score. Multivar- ness2. Health anxiety is also involved in forming
iate logistic regression analysis revealed that a anxiety disorders and shapes its clinical appear-
moderate/high-income status [odds ratio (OR) ance as one of its components2,4.
0.114, 0.013-0.986 95% confidence interval (CI), Death anxiety can be defined as the conscious
p=0.049], CIO score (OR 1.354, 1.106-1.658 95%
CI, p=0.003) and ASDA total score (OR 1.079,
or unconscious fear of death with the thought that
1.021-1.141 95% CI, p=0.007) were independent death can happen at any time4. A systematic re-
predictive factors for a high HAS score. view analysis5 postulated that death anxiety plays
CONCLUSIONS: Death anxiety and CIO are an essential role in the development and severity
crucial determinants of health anxiety. More re- of depression, eating disorders, obsessive-com-
search in multi-dimensional design is needed pulsive, and various anxiety disorders. Although
to obtain additional information about the rela- extensive literature data is investigating the effect
tionship between death anxiety, CIO and health
anxiety. of death anxiety on life, there are limited studies6
examining death anxiety’s presence and effect on
Key Words: cancer patients and patients’ caregivers.
Cancer patients’ caregivers, Health anxiety, Cancer Death anxiety has been suggested as a fun-
information overload, Death anxiety. damental fear underlying the development and
course of health anxiety7. It was thought that the
sense of bodily threat was related to the patholog-
Introduction ical fear of death7. There are several theories on
the association between death and health anxiety,
The usual fears and uncertainties associated but few studies4 have empirically investigated
with a cancer diagnosis are often quite severe this association.

Corresponding Author: Pınar Eraslan, MD; e-mail: drpinareraslan@gmail.com 291

 P. Eraslan, A. İlhan

Deadly diseases such as cancer diagnosis and form. The data of ninety-two participants who
concerns about death and health bring along filled out the study scales completely and con-
the search for information in the fight against sistently were evaluated.
cancer in patients and caregivers8. On the other
hand, the fact that the sources of information are
many and provide a large amount of informa- Instruments
tion has caused information overload9. Cancer
Information Overload (CIO) has been defined as Sociodemographic Information Form
feeling overwhelmed by excessive information A constructed demographic information form
about cancer in the information environment9. included questions about age, marital status (sin-
Being subjected to information intensively leads gle or married), number of children, comorbidi-
to more uncertainty and anxiety related to the ties (i.e., diseases such as hypertension, diabetes
subject for some people10. mellitus, osteoarthritis, migraine), educational
As far as we know, there is no study in the lit- time (total years of education at school), educa-
erature investigating the effects of cancer knowl- tional degree (primary / secondary / high school
edge and death anxiety on health anxiety. This or university), income level (what patients report
study was planned to investigate the relationship as very low, low, moderate or high, in their own
between health anxiety, CIO and death anxiety in opinion), employment status, and whether there
caregivers of inpatient cancer patients. is research on cancer (i.e., on the internet, maga-
zines, social media, or video streaming sites).

Patients and Methods Health Anxiety Scale (HAS)

The Health Anxiety Scale is a self-report scale
Study Design consisting of 18 items. The 14 items of the scale
This study was a cross-sectional observation- consist of statements containing quartet answers
al descriptive study conducted in the inpatient questioning the mental state of individuals. In
treatment unit of medical oncology department the remaining four questions, questions are asked
of Dr Abdurrahman Yurtaslan Ankara Oncology about the presumed serious illness of the individ-
Training and Research Hospital, a tertiary refer- uals. The scale scoring is between 0-3 for each
ral center. The study data was collected between item and the total score of the scale consists of
April 2021 and September 2021 after the local the arithmetic sum of each item. Scores above
Ethics Committee’s approval. the median indicate a high level of anxiety, and
scores below the median indicate a low level of
Study Population anxiety2.
The companions of patients diagnosed with
cancer and receiving inpatient treatment in the Arabic Scale of Death Anxiety (ASDA)
medical oncology clinic were included in the Arabic Scale of Death Anxiety (ASDA) is a
study. All participants were over 18 years of age, 5-point Likert-type self-report scale (1=not at
literate, and had no physical or mental disabili- all and 5=a lot) containing 20 items. The score
ty. Participants with a known cancer diagnosis obtained from the scale varies between 20 and
(current or past) and/or a history of psychiatric 100 points. A high score indicates increased
treatment (i.e., current or past treatments for death anxiety. There are five sub-dimensions:
depression, anxiety or psychotic disorder) were Fear of Death-Related Visual Stimuli (ASDA-1),
excluded from the study. Participants with se- Fear of Physical and Spiritual Pain Associated
vere and uncontrolled comorbidities (i.e., heart with Death (ASDA-2), Fear of Other Conditions
failure, chronic obstructive pulmonary disease, Reminding Death (ASDA-3), Fear of the Afterlife
neurological disease, liver failure or kidney fail- (ASDA-4), Fear of Dying Itself (ASDA-5)11.
ure) were excluded. A sociodemographic in-
formation form, Arabic Scale of Death Anxi- Cancer Information Overload Scale (CIO)
ety (ASDA), Health Anxiety Scale (HAS), and The Cancer Information Overload Scale (CIO)
Cancer Information Overload Scale (CIO), were consists of 8 items and has a 4-point Likert-type
given to participants to respond. A total of one rating ranging from strongly agree to strongly
hundred fifty participants were asked to com- disagree. A minimum of 8 and a maximum of 32
plete the study scales given to them in printed points can be obtained from the scale. The orig-

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 Cancer information overload and death anxiety predict health anxiety

inal scale is one-dimensional and evaluates the of the patients, respectively. Research behavior
information load of the person regarding cancer. on cancer was common (n=55, 59.8%). Median
A high score on the scale indicates information (IQR) scores of CIO, HAS, and ASDA-Total
overload9. were 21.0 (13.0-25.0), 28.0 (14.25-31.0), and 60.5
(40.25-73.0), respectively. The main characteris-
Ethical Considerations tics and median study scale scores of the partic-
Approval was obtained from the local Ethics ipants are shown in Table I.
Committee (UHS Dr Abdurrahman Yurtaslan When participants with high HAS scores were
Ankara Oncology Training and Research Hos- compared with those with low HAS scores, the
pital Clinical Research Ethics Committee, Ap- rate of employed persons was less (n=16, 34.8%
proval Date: 21/04/2021, Document No.: 2021- vs. n=30, 65.2%, p=0.006), income status was
04/1127). All participants signed an informed more likely to be very low/low (n=23, 50.0%
consent form before enrolment in the study. vs. n=6, 13.0%, p<0.001) and research on can-
cer behavior was more common (n=39, 84.8%,
p<0.001). In terms of other sociodemographic
Statistical Analysis parameters, the group with a high HAS score
Statistical analysis was performed using SPSS showed similar characteristics to the group with
software version 24.0 (IBM Corp., Armonk, NY, a low HAS score. Median (IQR) CIO [24.0 (21.75-
USA). Nonparametric data were presented as 28.0) vs. 13.5 (11.0-18.25), p<0.001] and AS-
median (interquartile range-IQR), and categorical DA Total [69.0 (62.0-77.0) vs. 41.0 (33.75-58.0),
data were presented as frequency (percentage). p<0.001] scores were higher in the group with
Two groups were created as patients with a HAS high HAS score than in the group with low HAS
score greater than or less than the median. Groups score. Comparative statistical analysis results in
created according to HAS score were compared terms of sociodemographic parameters and medi-
using Pearson’s Chi-square test and Mann-Whit- an study scale scores of low HAS and high HAS
ney U test for categorical and nonparametric groups are shown in Table II.
numerical data. Multivariate logistic regression Multivariate logistic regression analysis, in-
analysis was performed using variables with a cluding factors that may predict a high HAS
p-value below 0.05 due to univariate analysis to score, revealed that a moderate/high-income
determine independent factors predicting a high status [odds ratio (OR) 0.114, 0.013-0.986 95%
HAS score. All statistical tests were two-sided, confidence interval (CI), p=0.049], CIO score
and p-values <0.05 were considered statistically (OR 1.354, 1.106-1.658 95% CI, p=0.003) and
significant. ASDA total score (OR 1.079, 1.021-1.141 95%
CI, p=0.007) were independent predictive fac-
tors for a high HAS score. The multivariate
Results logistic regression analysis results, including
factors that may predict a high HAS score, are
Ninety-two caregivers accompanying the pa- shown in Table III.
tient diagnosed with cancer and receiving in-
patient treatment were included in the study.
Median age of the participants was 44.5 (IQR Discussion
36.0-52.0) years. The majority of the partici-
pants (n=50, 54.3%) were female. Median ed- In this study, we aimed to reveal the predictor
ucational time was 11.0 (IQR, 8.0-15.0) years, factors of health anxiety in caregivers of inpatient
and the ratios of educational degree of primary/ cancer patients. We found that income status,
secondary school and high school/university death anxiety and CIO were independent predic-
were 30.4% (n=28) and 69.6% (n=64). The ma- tive factors for a high health anxiety scale score.
jority of the participants (n=65, 70.7%) were To our best knowledge, there is no literature
married. Income status determined by the indi- data concerning the relationship between health
viduals according to their own statements was anxiety, death anxiety and CIO in cancer pa-
very low/low and moderate/high for 29 (31.5%) tients’ caregivers. Our study is the first study on
and 63 (68.5%) participants. Of the participants, this issue and contributes to literature knowl-
22 (23.9%), 47 (51.1%), 14 (15.2%) and 9 (9.8%) edge. The relationship between death anxiety and
were spouses, parents, siblings and children health anxiety has been subjected to research in

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 P. Eraslan, A. İlhan

Table I. Main characteristics and median study scale scores of the participants.

Parameter N %

Age§ 44.5 (36.0-52.0)

Gender Male 42 45.7
Female 50 54.3
Employment Status Employed 46 50.0
Unemployed 46 50.0
Educational time§ 11.0 (8.0-15.0)
Educational degree Primary/Secondary school 28 30.4
High school/University 64 69.6
Marital status Single 27 29.3
Married 65 70.7
Income status Very low/low 29 31.5
Moderate/High 63 68.5
Child number§ 1.5 (0.0-2.0)
Kinship type Spouse 22 23.9
Others 70 76.1
Comorbidity Yes 16 17.4
No 76 82.6
Research on cancer Yes 55 59.8
No 37 40.2
CIO score§ 21.0 (13.0-25.0)
HAS score§ 28.0 (14.25-31.0)
ASDA Total score§ 60.5 (40.25-73.0)
  ASDA-1§ 13.5 (9.0-17.0)
  ASDA-2§ 17.0 (13.0-20.0)
  ASDA-3§ 9.5 (6.0-13.75)
  ASDA-4§ 10.0 (6.0-11.0)
  ASDA-5§ 9.0 (6.25-11.0)

Were given as median (IQR); CIO, cancer information overload scale; HA, health anxiety scale; ASDA, Arabic Scale of Death
§

Anxiety.

non-cancer diseases for many years, but not on Death anxiety may be an underlying factor
cancer patients or caregivers. In a study12 evaluat- for the etiopathogenesis of health anxiety and
ing 162 general medical outpatients, patients who vice versa. Implicit death anxiety can negatively
met the diagnostic criteria for hypochondriasis affect caregiving, manifesting as intolerance of
(n=49) scored significantly higher on the fear of uncertainty, emotional distress, and health anxi-
death scale than patients without hypochondriasis ety in the caregiver. Another anxiety disorder that
(n=113). It was interpreted that the fear of death can lead to health and death anxiety, depressive
is an integral part of hypochondriasis with these mood, and a previous or current health threat
results12. A review4 that included six studies eval- may also be variables that affect the relationship.
uating the relationship between fear of death and We also excluded the participants with severe
hypochondriasis announced a positive associa- mental or physical illness or psychiatric treatment
tion between death anxiety and hypochondriasis. history.
In the study of Noyes et al12, age was negative- Few studies12 show that witnessing someone
ly associated with hypochondriasis and fear of else’s non-cancer illness precipitates health anx-
death. The effects of sociodemographic variables iety. One study13 found that participants with
such as age and gender on hypochondriasis and a seriously ill parent had significantly higher
death anxiety were not analyzed in most previous self-reported health anxiety than healthy parents.
studies4. In our study, only income status was an However, whether their anxiety is attributed to
independent predictor of health anxiety among genetic risk factors for these diseases or whether
sociodemographic variables. Poor economic con- the participants’ indirect disease experiences pre-
ditions may create health anxiety by preventing ceded their health concerns is unclear13. Although
patients and caregivers from accessing all treat- it has been suggested that the diagnosis of a
ment opportunities. life-threatening illness such as cancer, witnessing

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 Cancer information overload and death anxiety predict health anxiety

Table II. Comparative analysis results in terms of sociodemographic parameters and study scale scores, grouped according to
the participants’ Health Anxiety score (< median vs. > median).

Low HAS (n = 46) High HAS (n = 46)

Parameter N % N % p

Age§ 42.0 (35.75-51.0) 46.5 (36.25-53.0) 0.560

Gender Male 21 45.7 29 63.0 0.142
Female 25 54.3 17 37.0
Employment Status Employed 30 65.2 16 34.8 0.006
Unemployed 16 34.8 30 65.2
Educational time§ 11.0 (11.0-15.0) 11.0 (8.0-15.0) 0.250
Educational status Primary/secondary school 10 21.7 18 39.1 0.112
High school/University 36 78.3 28 60.9
Marital status Single 17 37.0 10 21.7 0.169
Married 29 63.0 36 78.3
Income status Very low/low   6 13.0 23 50.0 < 0.001
Moderate/High 40 87.0 23 50.0
Child number§ 1.0 (0.0-2.0) 2.0 (1.0-2.25) 0.072
Kinship status Spouse   9 16.9 13 28.3 0.464
Others 37 80.4 33 71.7
Comorbidity Yes 6 13.0 10 21.7 0.410
No 40 87.0 36 78.3
Research on cancer Yes 16 34.8 39 84.8 < 0.001
No 30 65.2   7 15.2
CIO score§ 13.5 (11.0-18.25) 24.0 (21.75-28.0) < 0.001
ASDA Total score§ 41.0 (33.75-58.0) 69.0 (62.0-77.0) < 0.001

Were given as median (IQR); CIO, cancer information overload scale; HA, health anxiety scale; ASDA, Arabic Scale of Death
§

Anxiety.

someone else’s illness, or exposure to threatening volved in the care of their loved ones. Thus, they
health information can trigger health anxiety14, might have acquired more medical knowledge
only one study15 has so far been conducted to that relieved their health concerns15.
assess whether having a cancer patient raises sig- The diagnosis of an incurable disease can trig-
nificant concerns about one’s health. In this study, ger death anxiety as a profound existential crisis,
which included 207 participants, health anxiety as the present and future life of both patients and
severity did not differ between participants with their families is threatened6. Worries about death
and without indirect cancer experience, which is can alienate and negatively affect communica-
not in line with the results of previous studies15 tion between family members of patients with
in non-cancer areas. This result was interpreted life-threatening diseases such as cancer6. There
as that the participants might have been more in- are very few studies6 on death anxiety in can-

Table III. Results of multivariate logistic regression analysis including factors that may predict a high Health Anxiety Scale
score.

95% CI

Parameter OR SE Lower Upper p

Employment Status (Employed vs. Unemployed) 0.310 0.876 0.056 1.728 0.182
Research on cancer (Yes vs. No) 1.798 0.997 0.255 12.703 0.556
Income status (Moderate/High vs. Very low/low) 0.114 1.101 0.013 0.986 0.049
CIO score 1.354 0.103 1.106 1.658 0.003
ASDA Total score 1.079 0.028 1.021 1.141 0.007

OR, Odds Ratio; SE, standard error; CI, Confidence Interval; CIO, cancer information overload scale; ASDA, Arabic Scale of
Death Anxiety. Note. R2adj = 0.782 (N = 92; p < 0.001).

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 P. Eraslan, A. İlhan

cer patients and their caregivers. In a study6 of interaction and communication between patients
300 family caregivers caring for cancer patients, and healthcare providers. The information load
moderate death anxiety and decreased quality of can significantly determine when health concern
life was reported in caregivers, and quality of life goes from compliant to maladaptive13. A certain
was inversely related to death anxiety (r=0.30, level of health concern can be adaptive as it
p<0.001). While some individuals can cope with motivates individuals to take appropriate action
their fear of death positively and adaptively, oth- (e.g., take prescription drugs) or seek neces-
ers may not cope effectively, leading to para- sary medical attention 24. Adequate information
lyzing fear and the development of maladaptive about cancer can be adaptive, such as cancer
coping mechanisms16. A strong correlation was screening behavior. Excessive health informa-
found between death anxiety and psychopathol- tion overload was positively associated with low
ogy in 200 treatment-seeking participants with education level, low health literacy, poor infor-
various mental disorders17. Our study found that mation seeking skills, and low socioeconomic
death anxiety positively predicted health anxiety, status25. Increasing well-planned information
in line with the literature. It has been suggested systems, increasing health literacy, and digital
that treatments focused on reducing death anxi- and media literacy can play an active role in
ety will also improve overall symptoms18. preventing information overload. As a result of
As in other anxiety disorders, there are safety being a developing country and a society with
behaviors in health anxiety disorder, such as low health literacy, we thought that the CIO in
avoidance, checking, searching for information caregivers might have triggered health anxiety
in textbooks or the internet, and requests for in our study. The caregivers of cancer patients
reassurance. Such safety behaviors can result in receiving inpatient treatment in our study pop-
severe economic costs, such as repeated medical ulation experience the complex treatment pro-
consultations and testing19. Another finding in cess in the hospital environment, witnessing the
our study is that CIO is an independent positive difficulties experienced by their patients and
predictive factor for health anxiety. The vast other patients. The search for information about
majority of cancer patients use the internet as the disease and treatment is seen in caregivers
their primary source of information8. However, as well as patients. In our study, 84.8% of the
it is challenging to provide cancer patients with participants stated that they were doing research
appropriate information about their disease and about cancer from the internet and other news
treatment9. Content analysis show that cancer sources. Also, research on cancer was common
news is heavily therapeutic, some cancers are in participants with high health anxiety but was
portrayed disproportionately with their realities, not an independent predictive factor for a high
and 36-40% of science news exaggerates find- health anxiety score. Conversely, excessive anx-
ings, omitting critical conditional statements, iety about their health may also lead to informa-
such as whether they represent the target au- tion-seeking behavior, resulting in information
dience20. Although it is essential to learn about overload and increased death anxiety. Our find-
cancer to prevent it, some people may experi- ings point to further studies on the role of death
ence more uncertainty and anxiety when ex- anxiety and information load about cancer in the
posed to information intensively10. Information development of health anxiety.
overload can lead to poor information manage- The cross-sectional nature of this descriptive
ment, stress, and uncertainty, preventing people study limits its ability to understand change over
from making rational decisions10. Information time. Factors such as the patients’ symptoms, the
overload has been shown 21 to hinder primary severity of the condition requiring hospitaliza-
caregivers’ decision making, cause confusion tion, the stage of the disease, and the patients’
and create anxiety. Information obtained from performance status may affect the fear of death
non-medical sources causes an increase in the and anxiety of illness. In addition, the type of
use of advanced examinations and may cause treatment that patients are receiving may also
additional health risks and economic burdens22. have a modifying effect on the results. One study6
Sources such as other people, the media, in- showed that the type of treatment was a signifi-
ternet surfing, and advertising are just a few cant predictor of death anxiety, and caregivers of
sources of potentially frightening information. both untreated and radiation-treated patients had
A study23 of online health information behaviors higher death anxiety than caregivers of patients
found that information overload impairs active who had surgery and chemotherapy. In our study,

296
 Cancer information overload and death anxiety predict health anxiety

factors related to the patient and the disease were Ethics Approval
not considered. Although the limitations of the The study has been performed under the ethical standards
current study, our findings contribute significant- of the Declaration of Helsinki. Approval was obtained from
ly to the knowledge of the literature as it is the the local Ethics Committee (UHS Dr Abdurrahman Yur-
taslan Ankara Oncology Training and Research Hospi-
first study to investigate the knowledge burden tal Clinical Research Ethics Committee, Approval Date:
of health anxiety about death anxiety and cancer. 21/04/2021, Document No.: 2021-04/1127).
This study can also be a starting point for new
prospective, longitudinally, and multi-dimension-
al designed studies on the same aspect of caregiv- Informed Consent
ers’ health anxiety, considering comprehensive Informed consent was obtained from all individual partici-
factors (i.e., factors related to caregivers, patients, pants included in the study..
and diseases).

ORCID ID
Conclusions Pınar Eraslan: 0000-0001-6271-8139; Ayşegül İlhan: 0000-
0002-0333-1388.
This is the first study to examine the relation-
ship between health anxiety, which is assumed
to be exacerbated by the intense adverse emo-
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