DOI: https://doi.org/10.14710/nmjn.v16i2.77151

Path Analysis of Impaired Well-Being in Patients with Advanced Cancer Undergoing Chemotherapy

*Thidarat Khamboon orcid scopus  -  Department of Nursing, Division of Adult Nursing, Faculty of Nursing, Naresuan University, Thailand
Intira Pakanta  -  Department of Nursing, Division of Adult Nursing, Faculty of Nursing, Naresuan University, Thailand
Open Access Copyright (c) 2026 Nurse Media Journal of Nursing
Creative Commons License This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Citation Format:
Abstract

Background: Well-being is an overall indicator of an individual’s health status. Psychological and somatic symptoms may negatively affect patients undergoing chemotherapy for advanced cancer. Previous studies have identified cancer-related symptoms and psychosocial factors associated with impaired well-being but have not fully explored the relationships among multiple symptoms and impaired well-being.

Purpose: This study aimed to develop and test a path model of the relationships between unpleasant symptoms and impaired well-being among patients undergoing chemotherapy for advanced cancer.

Methods: A cross-sectional secondary data analysis was conducted among 500 patients with advanced cancer who received treatment at a tertiary care hospital in the Lower Northern region of Thailand. Data included personal and clinical information and the Edmonton Symptom Assessment System (ESAS), which assessed pain, anxiety, nausea, shortness of breath, drowsiness, tiredness, depression, loss of appetite, and well-being. Impaired well-being was measured using the ESAS well-being item, ranging from 0 (best well-being) to 10 (worst possible well-being). Path analysis was used to examine the relationships between symptoms and impaired well-being.

Results: The final path model demonstrated a good fit to the data and explained 22.1% of the variance in impaired well-being (R² = .221). Loss of appetite had the strongest total effect on impaired well-being (β = 0.72, p < .001). Loss of appetite (β = 0.71, p < .001), depression (β = 0.31, p < .001), and shortness of breath (β = 0.21, p < .001) had significant direct effects. Anxiety, nausea, shortness of breath, pain, tiredness, and loss of appetite had indirect effects on impaired well-being.

Conclusion: The study provides an explanatory model of the relationships between symptoms and impaired well-being in patients undergoing chemotherapy for advanced cancer. The findings may help nurses design interventions that consider the multidimensional relationships among symptoms associated with impaired well-being and poor functional status.

 

Note: This article has supplementary file(s).

Fulltext |  Cover Letter
Cover letter
Subject
Type Cover Letter
  Download (15KB)    Indexing metadata
 common.other
STROBE Statement—Checklist
Subject
Type Other
  Download (32KB)    Indexing metadata
 Research Instrument
Manuscript PDF file
Subject
Type Research Instrument
  Download (582KB)    Indexing metadata
 Cover Letter
Cover letter PDF file
Subject
Type Cover Letter
  Download (166KB)    Indexing metadata
Email colleagues
Keywords: Advanced cancer; chemotherapy; impaired well-being; path analysis
Funding: Faculty of Nursing, Naresuan University

Article Metrics:

Article Info
Section: Articles
Language : EN
Most cited articles
Predicting Factors of Interpersonal and Situational Influences for Performing Stretching Exercises Based on Pender’s Model Mental Distress in Rural Areas of Indonesia Work-Related Fatigue Factors among Hospital Nurses: An Integrative Literature Review The Lived Experiences of Mentoring Nurses in Malaysia Attitudes, Belief, and Barriers of Indonesian Oncology Nurses on Providing Assistance to Overcome Sexuality Problem More cited articles
  1. American Cancer Society. (2024, August 8). Opioids for cancer pain. https://www.cancer.org/cancer/managing-cancer/side-effects/pain/cancer-pain/opioid-pain-medicines-for-cancer-pain.html
  2. Battat, M., Omair, N., WildAli, M. A., Alkaissi, A., Salameh, H. T., Amer, R., Koni, A. A., &
  3. Zyoud, S. E. H. (2023). Factors associated with palliative care symptoms in cancer patients in Palestine. Scientific Reports, 13(1), 16190. https://doi.org/10.1038/s41598-023-43469-0
  4. Chinda, M., Jaturapatporn, D., Kirshen, A. J., & Udomsubpayakul, U. (2011). Reliability and validity of a Thai version of the Edmonton Symptom Assessment Scale (ESAS-Thai). Journal of Pain and Symptom Management, 42(6), 954–960. https://doi.org/10.1016/j.jpainsymman.2011.02.020
  5. Crombeen, A. M., & Lilly, E. J. (2020). Management of dyspnea in palliative care. Current Oncology, 27(3), 142–145. https://doi.org/10.3747/co.27.6413
  6. Döner, A., Bilgin, A., Öcalan, S., Kovancı, M. S., & İnanç, M. (2025). Spiritual well-being and psychological resilience in outpatients receiving chemotherapy: The multiple mediating role of symptoms. European Journal of Oncology Nursing, 79, 103009. https://doi.org/10.1016/j.ejon.2025.103009
  7. Du, Y. (2024). The influence of cultural factors on cancer patients: A study of treatment choices,
  8. health beliefs, and recovery processes in East Asian countries. Journal of Natural Science, Biology and Medicine, 15(3), 585-593
  9. Ehret, C., & Jatoi, A. (2021). Should loss of appetite be palliated in patients with advanced cancer? Current Treatment Options in Oncology, 22(4), 1-7. https://doi.org/10.1007/s11864-021-00829-0
  10. Götze, H., Friedrich, M., Taubenheim, S., Dietz, A., Lordick, F., & Mehnert, A. (2020). Depression and anxiety in long-term survivors 5 and 10 years after cancer diagnosis. Supportive Care in Cancer, 28(1), 211–220. https://doi.org/10.1007/s00520-019-04805-1
  11. Grassi, L., Caruso, R., Riba, M. B., Lloyd-Williams, M., Kissane, D., Rodin, G., McFarland, D., Campos-Ródenas, R., Zachariae, R., Santini, D., Ripamonti, C. I., & ESMO Guidelines Committee. (2023). Anxiety and depression in adult cancer patients: ESMO clinical practice guideline. ESMO Open, 8(2), 101155. https://doi.org/10.1016/j.esmoop.2023.101155
  12. Gupta, K., Walton, R., & Kataria, S. P. (2021). Chemotherapy-induced nausea and vomiting: Pathogenesis, recommendations, and new trends. Cancer Treatment Research Communications, 26, 100278. https://doi.org/10.1016/j.ctarc.2020.100278
  13. Hariyanto, T. I., & Kurniawan, A. (2021). Appetite problem in cancer patients: Pathophysiology, diagnosis, and treatment. Cancer Treatment Research Communications, 27, 100336. https://doi.org/10.1016/j.ctarc.2021.100336
  14. Hui, D., & Bruera, E. (2017). The Edmonton Symptom Assessment System 25 years later: Past, present, and future developments. Journal of Pain and Symptom Management, 53(3), 630–643. https://doi.org/10.1016/j.jpainsymman.2016.10.370
  15. Hui, D., Maddocks, M., Johnson, M. J., Ekström, M., Simon, S. T., Ogliari, A. C., Booth, S., & Ripamonti, C. (2020). Management of breathlessness in patients with cancer: ESMO clinical practice guidelines. ESMO Open, 5(6), e001038. https://doi.org/10.1136/esmoopen-2020-001038
  16. International Agency for Research on Cancer (IARC). (2022). GLOBOCAN 2022: Estimated cancer incidence, mortality and prevalence worldwide in 2022. Retrieved August 19, 2025, from https://gco.iarc.who.int/media/globocan/factsheets/populations/900-world-fact-sheet.pdf
  17. International Agency for Research on Cancer(IARC). (2022). GLOBOCAN 2022: Thailand fact sheet. World Health Organization. https://gco.iarc.who.int/
  18. Kang, H. (2021). Sample size determination and power analysis using the G*Power software. Journal of Educational Evaluation for Health Professions, 18, 1-12. https://doi.org/10.3352/jeehp.2021.18.17
  19. Khamboon, T., & Pakanta, I. (2021). Intervention for symptom cluster management of fatigue, loss of appetite, and anxiety among patients with lung cancer undergoing chemotherapy. Asia-Pacific Journal of Oncology Nursing, 8(3), 267–275. https://doi.org/10.4103/2347-5625.311003
  20. Khamboon, T., Pakanta, I., Suwanmongkol, P., & Ardkhitkarn, S. (2023). The Influence of unpleasant symptoms on functional status of advanced cancer patients receiving chemotherapy. Journal of Nursing and Health Sciences, 16(3), 85-96
  21. Lenz, E. R., & Pugh, L. C. (2018). The theory of unpleasant symptoms. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (pp. 179–214). Springer
  22. Lertpanit, P., Methipisit, P., Wuthironarith, V., Panpoklang, S., & Namvongprom, A. (2021). Associated severity of common clinical symptoms with anxiety and depression among patients with advanced cancer. Songklanagarind Journal of Nursing, 41(3), 1–12
  23. Lewandowska, A., Rudzki, G., Lewandowski, T., Próchnicki, M., Rudzki, S., Laskowska, B., & Brudniak, J. (2020). Quality of life of cancer patients treated with chemotherapy. International Journal of Environmental Research and Public Health, 17(19), 6938. https://doi.org/10.3390/ijerph17196938
  24. Li, Y., Jiang, Q., & Wang, L. (2021). Appetite regulation of TLR4-induced inflammatory signaling. Frontiers in Endocrinology, 12, 777997. https://doi.org/10.3389/fendo.2021.777997
  25. McKenzie, E., Zhang, L., Chan, S., Zaki, P., Razvi, Y., Tsao, M., & others. (2020). Symptom correlates of dyspnea in advanced cancer patients using the Edmonton Symptom Assessment System. Supportive Care in Cancer, 28(2), 87–98. https://doi.org/10.1007/s00520-019-04787-0
  26. Milliron, B. J., Packel, L., Dychtwald, D., Klobodu, C., Pontiggia, L., Ogbogu, O., Barksdale, B., &
  27. Deutsch, J. (2022). When eating becomes torturous: Understanding nutrition-related cancer treatment side effects among individuals with cancer and their caregivers. Nutrients, 14(2), 356. https://doi.org/10.3390/nu14020356
  28. National Cancer Institute of Thailand. (2022). Hospital-based cancer registry annual report
  29. Department of Medical Services, Ministry of Public Health
  30. National Cancer Institute. (2022, October 14). Cancer staging. U.S. Department of Health and Human Services. Retrieved February 6, 2026, from https://www.cancer.gov/about-cancer/diagnosis-staging/staging
  31. Olson, K., Hayduk, L., & Thomas, J. (2014). Comparing two approaches for studying symptom clusters: Factor analysis and structural equation modeling. Supportive Care in Cancer, 22(1), 153-161. https://doi.org/10.1007/s00520-013-1965-6
  32. Palang, C., & Nunuan, P. (2020). Social support and adaptation of cancer patients receiving services at the National Cancer Institute: Case study research. Thai Cancer Journal, 40(2), 62–75
  33. Phenwan, T., Peerawong, T., & Tulathamkij, K. (2019). The meaning of spirituality and spiritual well-being among Thai breast cancer patients: A qualitative study. Indian Journal of Palliative Care, 25(1), 119–123. https://doi.org/10.4103/IJPC.IJPC_101_18
  34. Puicharoen, W. (2025). Development of a model to promote family or caregiver engagement in the care of cancer patients in Sathing Phra District, Songkhla Province. Journal of Primary Health Research, 1(2), 162–177. https://he05.tci-thaijo.org/index.php/J_PHR/article/view/5531
  35. Savisit, W., Homchampa, P., & Sirithanawutichai, T. (2022). Family-based palliative care model for advanced cancer patients in community settings in the northeast, Thailand. Journal of the Medical Association of Thailand, 105(9), 883–895
  36. Savisit, W. (2023). Psychological and quality of life of the advanced cancer patients receiving palliative care in communities in the northeast region of Thailand. Primary Health Care Journal (Northeastern Edition), 38(1), 141–155. https://doi.org/10.14456/phcne.2023.14
  37. Shrestha, N. (2020). Detecting multicollinearity in regression analysis. American Journal of Applied Mathematics and Statistics, 8(2), 39–42. http://pubs.sciepub.com/ajams/8/2/1
  38. Suavansri, P., Pichayayothin, N., Espinosa, P. R., et al. (2022). Well-being in Thailand: A culturally driven grounded inquiry exploration of a complex construct. Applied Research in Quality of Life, 17, 3327–3347. https://doi.org/10.1007/s11482-022-10067-7
  39. Suedee, N., Pongthavornkamol, K., Sriyuktasuth, A., & Siritanaratkul, N. (2015). Symptom experiences and their influences on functional status in hematological malignancy patients receiving chemotherapy. Nursing Science Journal of Thailand, 33(2), 29–40. https://he02.tci-thaijo.org/index.php/ns/article/view/42259
  40. Sung, H., Ferlay, J., Siegel, R.L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660
  41. Torres, S., Bayoumi, A., Liu, G., Abrahao, A. B. K., Mitsakakis, N., Krahn, M., & Trudeau, M. (2022). Abstract P4-10-22: Patient reported symptoms and functional status in breast cancer. Cancer Research, 82(4_Supplement), P4-10-22–P14-10-22. https://doi.org/10.1158/1538-7445.sabcs21-p4-10-22
  42. Wang, J., & Wang, X. (2019). Structural equation modeling: Applications using Mplus (2nd ed.). Wiley
  43. Woradet, S., Chaimay, B., Putthanachote, N., Sarakarn, P., & Kaewmafai, J. (2025). Quality of life and factors associated with quality of life among patients with lung cancer in Northeastern Thailand. Asian Pacific Journal of Cancer Prevention, 26(2), 565-572. https://doi.org/10.31557/APJCP.2025.26.2.565
  44. Yang, E. J., Lee, K. S., Lim, M. C., Baek, J. Y., Han, J. Y., Yu, E. S., & Chung, S. H. (2021). Symptom perception and functioning in patients with advanced cancer. PLoS ONE, 16(2), e0245987. https://doi.org/10.1371/journal.pone.0245987

Last update:

No citation recorded.

Last update: 2026-08-31 23:05:14

No citation recorded.