International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa SOCIAL AND BEHAVIORAL SCIENCES. Health Care Sciences ORIGINAL RESEARCH Influence of Behavioral and Social Factors on Gastric Cancer Incidence and Mortality Authors’ Contribution: Nikolov A.1 ABCDEFG , Georgieva L.2 DEFG A – Study design; 1 B – Data collection; Dental Clinic “Zahnzentrum Rudow“, Germany 2 C – Statistical analysis; Medical University – Sofia, Bulgaria D – Data interpretation; E – Manuscript preparation; F – Literature search; Received: 03.04.2023; Accepted: 07.05.2023; Published: 30.06.2023 G – Funds collection Abstract Background and The significance of the risk factors, including behavioral and social Aim of Study: characteristics of the patients, for the occurrence of stomach cancer is constantly increasing and largely determines the development and outcome of the disease. The aim of the study: to provide empirical data for the significance of behavioral and social factors on gastric cancer incidence and mortality. Material and Methods: Data from a study of gastric cancer patients (234 men and 144 women) examined at the Heidelberg University Clinic (Germany) were used. Risk factors, gastric cancer survival and mortality, factors of fatal outcome of gastric cancer patients were compared. Multiple binary logistic regression analysis was used to quantitatively assess their influence. To analyze the possible statistical significance between different groups, we used Fisher’s exact test and chi-squared test for the relationship between categorical variables and Student’s t-test. The significance level (rejecting the null hypothesis) is p<0.05. Results: The most common risk factors are lack of physical activity, smoking, accompanying cardiovascular diseases, as well as emotional stress. Unhealthy lifestyle increases the risk by 56.8%. With a lower but significant percentage are overweight and alcohol abuse. We found the presence of emotional stress in 25.3% of patients with stomach cancer. Jobs with primary mental work and high stress level increase the probability of negative outcome. Mainly mental work is associated with about 8 times the risk of death compared to physical work. The presence of stress increases the lethal risk about 3.2 times. Conclusions: Risk factors related to healthy lifestyle of the patients, including mental health, play an important role in the development of stomach cancer. They largely determine the status, disease control, treatment, survival and mortality of gastric cancer patients. Keywords: risk factors, survival and mortality, smoking, stress, physical inactivity, overweight, alcohol abuse Copyright: © 2023 Nikolov A., Georgieva L. Published by Archives of International Journal of Science Annals DOI and UDC DOI https://doi.org/10.26697/ijsa.2023.1.4 UDC 616-082:616-006 Conflict of interests: The authors declare that there is no conflict of interests Peer review: Double-blind review Source of support: This research did not receive any outside funding or support Information about Nikolov Alexander (Corresponding Author) – https://orcid.org/0000-0001-5414- the authors: 9378; alexander_nikolov1988@yahoo.de; PhD Student, Dental Clinic “Zahnzentrum Rudow“, Berlin, Germany. Georgieva Lidia – https://orcid.org/0000-0002-9320-9203; Doctor of Medical Sciences, MD, Professor, Medical University – Sofia, Sofia, Bulgaria. 40 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Introduction Malignant diseases, including stomach cancer, are The data were analyzed using statistical software IBM among the biggest health problems nowadays. Stomach SPSS Statistics 25.0 and MedCalc Version 19.6.3. In the cancer is the fifth most common cancer in the world and first part of the analyzes, we used descriptive statistics the third most common cause of death due to cancer. to analyze potential differences between patients with While behavior related risk factors (e.g., smoking, different characteristics. After that, the following tests alcohol abuse) were often investigated in previous were performed in order to analyze potential statistical research (den Hoed & Kuipers, 2016; Dong & Thrift, significance between the different groups: Fisher’s exact 2017), we suggest that socio-economic factors can also test and chi-square test for the relationship between play an important role and do not have to be neglected categorical variables and Student’s t-test or Mann- in prevention programs. For instance, early research Whitney. The level of significance at which the null suggest that stress influences the carcinogenic process hypothesis is rejected was p<0.05. Additionally, (Sklar & Anisman, 1981). Further study found that in Multiple binary logistic regression analysis was applied indigenous populations there is a higher burden of to establish the factors for fatal outcome from stomach stomach cancer (Arnold et al., 2014). Also ethnic- cancer and quantitative assessment of their influence. specific differences were found in an U.S. study Kolmogorov-Smirnov and Shapiro-Wilk test were (Camargo et al., 2011). performed to test the assumption of normal distribution There are several previous studies, which analyze the of the metric variables. role of socio-economic factors on the incidents and mortality of gastric cancer (Dong & Thrift, 2017; Kim Results et al., 2020; Sarkar et al., 2022; Song et al., 2015; Tonelli Distribution of Potential Risk Factors in Gastric et al., 1997). However, they are relatively few in number Cancer Patients and the results are mainly contradictory to each other. The results of the comparative analysis of the frequency Moreover, they do not look into factors such as job type distribution of potential risk factors among the patients or stress level on the probability of having gastric cancer are summarized in Table 1. The results suggest that the or of negative outcome. most common factor is lack of physical activity (79.5%), Medical and social support factors are important for the followed by smoking (53.6%) and accompanying quality of life of oncology patients (Nikolov & cardiovascular diseases (45.5%). With lower but Georgieva, 2022). noticeable frequency are overweight (18.6%) and Understanding the role of socio-economic factors on alcohol abuse (6.7%). incidence and mortality can contribute improving the Table 1 health care of groups in the society, which are most Frequency Distribution of Potential Risk Factors prone to have high incidence and high mortality rate. The aim of the study. To provide empirical data for the Patients Indicators significance of behavioral and social factors on gastric Person (n) Percentage (%) cancer incidence and mortality. In particular, we focus Physical activity on the analyses of the role of the factors, which affect Yes 77 20.5 the increase of life expectancy and quality of life of No 298 79.5 stomach cancer patients, as well as we discuss potential Smoking mitigation of the negative mental and social impacts of Yes 200 53.6 the disease. No 173 46.4 Cardiovascular Materials and Methods diseases In order to address the research questions, we have Yes 142 45.5 conducted a retrospective clinical-epidemiological No 170 54.5 study with 378 people diagnosed with gastric cancer. Unhealthy eating The study focusses on a comparative analysis of Yes 124 33.1 behavioral, socio-medical, epidemiological and No 251 66.9 psychosocial aspects of gastric cancer. The data were Presence of collected at the University Clinic in Heidelberg, stress* Germany, using especially design questionnaire. To Yes 108 28.6 create the data set, we have used documents from the No 270 71.4 University Clinic over a 13-year period, including Higher education patient examination reports, pathological examinations, Yes 92 24.6 discharge information and other clinical documents. No 282 75.4 Information on the following variables was collected: Overweight health-related behavior and social characteristics of the Yes 70 18.6 patients, accompanying diseases, as well as No 306 81.4 psychosocial context and self-reported opinion about Alcohol abuse their own health assessed using a standardized Yes 25 6.7 questionnaire. The final sample consists of 234 (61.9%) No 350 93.3 men and 144 (38.1%) women. Note. *According to self-reported patient’s opinion. 41 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa The mean age of the patients was M=62.11 (SD=12.71) diseases were 95 (66.9%) male and 47 (33.1%) female. years, ranging between 24 and 93 years old. A The results of the analyzes of the further risk factors significant gender differences is found only for the show no statistically significant relationship between presence of accompanying cardiovascular diseases – the gender and the indicators of physical activity, smoking, relative share in men is statistically significantly greater unhealthy diet, presence of stress, education, overweight than that those of women, χ2 (1, N=312)=3.945, p=0.049 and alcohol abuse. (see Table 2). Among the patients with cardiovascular Table 2 Analysis of the Relationship between Gender and Cardiovascular Disease Absence of cardiovascular diseases Presence of cardiovascular diseases Gender People (n) Percentage (%)* People (n) Percentage (%)* Male 95 55.9 95 66.9 Female 75 44.1 47 33.1 Note. *Percentage (%) refers to the relative frequency of each of the gender group within the patients with or without cardiovascular diseases (e.g., 55.9% of the patients without cardiovascular diseases were male). Concomitant cardiovascular diseases were, as expected, The results comparative analysis of survived and more common in the age groups 60-74 and 75+ years old, deceased patient groups with regard to various socio- while in the two younger groups – 15-44 and 45-59 years economic characteristics and health-related behavior of old – they were less common. Interestingly, unhealthy the patients show significant differences in age, eating prevails among the oldest patients (75+ years) and education, marital status, type of work, smoking and has a significantly smaller relative share in the 45-59 age alcohol abuse. The deceased patient group has group. The presence of the self-reported stress dominates statistically significantly higher average age, a higher among the oldest patients (75+ years) and has a percentage of smokers, university graduates, alcohol significantly smaller relative share in the age group 15- abusers, married and persons having a job with mainly 44 years old. The group of patients between 15 and 44 mental work. The survived patient group has a years old has a significantly higher percentage of statistically significantly lower average age and lower graduates than the other age groups. share of non-smokers, are rather persons with secondary With regard to their marital status, the study participants or primary education, not abusing alcohol, are divorced were divided into 4 groups: married – 185 people or or single, and persons with jobs that include mainly 48.9%, single – 108 people or 28.6%, divorced – 44 physical work. For the rest of the indicators, the people or 11.6% and widowed – 41 people or 10.8%. difference between the two considered groups is not Marital status does not correlate with indicators of statistically significant. physical activity, cardiovascular disease, unhealthy diet The results of a multiple binary regression analysis that and presence of stress. A statistically significant analyzed the factors that potentially influence fatal relationship between marital status and smoking was outcome from stomach cancer are summarized in found: the widowed and married patients have Table A. significantly higher rates of smokers than single patients Marital status has the greatest influence – the risk of fatal do. Higher education has a significantly higher relative outcome for married compared to not married persons is share of married persons and consequentially a about 257 times greater. On second place as an indicator significantly smaller share for unmarried. Overweight is the type of work, with the risk of a fatal outcome being and alcohol abuse were significantly more among about 27 times greater for those performing primarily married persons and significantly less among unmarried mental work compared to those with primarily physical persons. work. Further factors with significant influence are Factors that Affect the Fatal Outcome smoking behavior, alcohol abuse and higher education. Just over the half of the patients (51.9%) in the sample With borderline significance (p<0.10) are the indicators were still alive at the time point of the study, 182 (48.1%) age and unhealthy diet. were dead. Before comparing the groups of deceased and In order to consider the combined influence of the studied survived participants with regard to their socio-economic indicators and eliminate possible confounding factors, characteristics, we first compared them regarding clinical we put the variables all together in the regression severity. For this purpose, the tumor stage indicator, equation and applied the “Backward conditional” known for its objectivity and in formativeness, was used. procedure. The achieved percentage of correct answers The results of the performed Fisher-Freeman-Halton from the classification table was 86.5. Thus, in the final exact test show no statistically significant difference in version of the equation (p<0.001), five of the studied the frequency distribution of patients by the categories of indicators remain – marital status, type of work, presence the tumor stage indicator, meaning that the two groups of stress, smoking and age. The obtained results give us were statistically equal in terms of clinical severity. This reason to claim that, compared to unmarried, widowers is a good prerequisite for correctly performing the have about 70 times higher risk of dead, married – about subsequent comparisons. 47, and divorced – about 7 times. Mainly mental versus 42 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa mainly physical work is associated with about 8 times the in groups with low socio-economic status (Sarkar et al., risk of death. The presence of stress increases the lethal 2022; Uthman et al., 2013). risk about 3.2 times, and smoking – about two times. Thirdly, in our study, it is suggested that social support Smoking is associated with an approximately 2.1-fold and education may influence the development of the increased risk of death, and a 1-year increase in age disease to some extent. In an early study conducted by increases the risk of death by approximately 2.0%. Siegrist & Siegrist (1987) with 1,444 patients with gastric cancer, this hypothesis could not be confirmed. Discussion Therefore, we provide empirical evidence for the role of This study analyses the influence of behavioral and these factors. socio-economic factors on gastric cancer incidence and Asplund et al. (2021) found no prognostic influence for mortality based on a retrospective study. gender or education, which is matched by our study. Firstly, unhealthy behavior impacts the probability for Results were similar for 3-year disease-specific gastric cancer. Smoking is commonly found to be a risk mortality. factor for gastric cancer in both our study and previous Fourthly, in our study, we hypothesize that compared to one (e.g., Dong & Thrift, 2017; Popp et al., 2022). Also, office workers, unemployed and physically active our study confirms that alcohol consumption and abuse individuals have an increased risk of gastric cancer. In increase the risk of gastric cancer. Our study confirms the study by Kuwahara et al. (2010), the type of work and also the role of a healthy lifestyle including healthy education was not associated with the risk of gastric eating, smoking cessation, low alcohol consumption and cancer. In a recent study, Sarkar et al. (2022) found that adequate physical activity, which were found to play an gastric cancer cases more commonly held jobs in important role in cancer prevention also in previous unskilled labor (compared to professional occupation). research (e.g., den Hoed & Kuipers, 2016). The role of Therefore, we have provided here additional empirical healthy eating was also analyzed in further previous evidence about the relationship between the type of work studies. The results of an early study indicate that “hard and the risk of cancer or a negative outcome from it, even grains, food with high sodium-chloride concentration, or though our results do not align completely with the surfactants” might favor the gastric carcinoma (Correa et results provided by Sarkar et al. (2022). al., 1975). A high intake of salted, pickled or smoked According to the data from our study, it is suggested that foods, as well as dried fish and meat and refined the survival rate is lower in gastric cancer patients with carbohydrates are thought to significantly increase the lower socio-economic status. Looking at 42 other studies risk of developing stomach cancer, while fibre, fresh on the relationship between survival rates of gastric vegetables and fruit appear to be inversely proportional cancer patients and SOC we observed that most studies to the risk. According to healthy stomach cancer consistently also reported that patients with lower SOC prevention programs, proper dietary habits should be had lower survival rates than patients with high SOC (see implemented from childhood by increasing the intake of overview by Kogevinas & Porta, 1997; Tabuchi, 2020). vegetables (Compare et al., 2010). This was also This study has several limitations. The localization of the observed in our study. Diet and lifestyle, proper nutrition study is limited to the University Clinic in Heidelberg, and improving people’s awareness level is vital for early Germany, and the sample of study participants by diagnosis and timely treatment of gastric cancer, individual groups is not large enough. Nevertheless, there especially in people with family burden and genetic is a definite trend that is obtained in the study. predisposition (Kim et al., 2020; Yusefi et al., 2018). Our study confirms this dependence. The study highlights Conclusions therefore the importance of efforts to control the global The most pronounced risk factor that we found in the burden of stomach cancer by reducing alcohol and conducted study is an unhealthy lifestyle (unhealthy diet tobacco use as well as to promote overall a healthier and, accordingly, overweight, lack of physical activity), lifestyle. A combination of such treatments with other which increases the risk of stomach cancer by 56.8%. measures, such as proposed oral treatment (Hoff et al., Unhealthy lifestyle factors include the systematic use of 1998) or similar approaches can be explored in further alcohol, cigarettes and narcotics. In this way, the risk of studies. stomach cancer increases up to 6 times. Therefore, Secondly, low socio-economic status is associated with education and promotion of a healthy lifestyle is still a an increased risk of morbidity and mortality from many very effective way to prevent gastric cancer and negative diseases. A number of studies have observed associations outcomes of it. between gastric cancer incidence and education, Secondly, as a risk factor, we can point to the presence of occupation, and income as indicators of socioeconomic emotional stress, which we found in 25.3% of patients status. In 36 studies, an increased risk of gastric cancer with stomach cancer. Therefore, in addition to physical was observed in the lowest socioeconomic statuses health, also mental health should be increasingly put on compared to the highest (see meta-analyses by Uthman focus of health care. This fact deserves particular et al., 2013). Although the association between gastric attention, as it is likely to increase as technology cancer incidence and income level is evident, it does not advances. reach statistically significant levels. In conclusion, it can be noted that the risk of gastric cancer incidence is higher 43 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Ethical Approval evidence. IARC Scientific Publications, 138, 177- The study protocol was consistent with the ethical 206. https://pubmed.ncbi.nlm.nih.gov/9353665/ guidelines of the 1975 Declaration of Helsinki as Kuwahara, A., Takachi, R., Tsubono, Y., Sasazuki, S., reflected in a prior approval by the Institution’s Human Inoue, M., & Tsugane, S. (2010). Socioeconomic Research Committee. status and gastric cancer survival in Japan. Gastric Cancer, 13, 222-230. Funding Source https://doi.org/10.1007/s10120-010-0561-4 This research did not receive any outside funding or Nikolov, A., & Georgieva, L. (2022). Significance of support. palliative care for the quality of life for oncology patients. International Journal of Science Annals, References 5(1-2), 39-43. https://doi.org/10.26697/ijsa.2022.1-2.4 Arnold, M., Moore, S. P., Hassler, S., Ellison- Popp, S., Mang, T., & Scharitzer, M. (2022). Einfluss des Loschmann, L., Forman, D., & Bray, F. (2014). Rauchens auf den Gastrointestinaltrakt [Influence The burden of stomach cancer in indigenous of smoking on the gastrointestinal tract]. Die populations: A systematic review and global Radiologie, 62(9), 772-780. assessment. Gut, 63(1), 64-71. https://doi.org/10.1007/s00117-022-01017-3 https://doi.org/10.1136/gutjnl-2013-305033 Sarkar, S., Dauer, M. J., & In, H. (2022). Socioeconomic Asplund, J., Gottlieb-Vedi, E., Leijonmarck, W., disparities in gastric cancer and identification of a Mattsson, F., & Lagergren, J. (2021). Prognosis single SES variable for predicting risk. Journal of after surgery for gastric adenocarcinoma in the Gastrointestinal Cancer, 53, 170-178. Swedish Gastric Cancer Surgery Study https://doi.org/10.1007/s12029-020-00564-z (SWEGASS). Acta Oncologica, 60(4), 513-520. Siegrist, K., & Siegrist, J. (1987). Psychosocial factors in https://doi.org/10.1080/0284186X.2021.1874619 the course of gastric cancer. Scandinavian Camargo, M. C., Anderson, W. F., King, J. B., Journal of Gastroenterology, 22(Sup133), 90-92. Correa, P., Thomas, C. C., Rosenberg, P. S., https://doi.org/10.3109/00365528709091027 Eheman, Ch. R., & Rabkin, C. S. (2011). Sklar, L. S., & Anisman, H. (1981). Stress and cancer. Divergent trends for gastric cancer incidence by Psychological Bulletin, 89(3), 369-406. anatomical subsite in US adults. Gut, 60(12), https://doi.org/10.1037/0033-2909.89.3.369 1644-1649. https://doi.org/10.1136/gut.2010.236737 Song, H., Held, M., Sandin, S., Rautelin, H., Compare, D., Rocco, A., & Nardone, G. (2010). Risk Eliasson, M., Söderberg, S., Hallmans, G., factors in gastric cancer. European Review for Engstrand, L., Nyrén, O., & Ye, W. (2015). Medical and Pharmacological Sciences, 14(4), Increase in the prevalence of atrophic gastritis in 302-308. https://pubmed.ncbi.nlm.nih.gov/20496539/ adults aged 35 to 44 years in Northern Sweden Correa, P., Haenszel, W., Cuello, C., Tannenbaum, S., & between 1990 and 2009. Clinical Archer, M. (1975). A model for gastric cancer Gastroenterology and Hepatology, 13(9), 1592- epidemiology. The Lancet, 306(7924), 58-60. 1600. https://doi.org/10.1016/j.cgh.2015.04.001 https://doi.org/10.1016/S0140-6736(75)90498-5 Tabuchi, T. (2020). Cancer and socioeconomic status. In Den Hoed, C. M., & Kuipers, E. J. (2016). Gastric K. Kondo (Ed.), Social Determinants of Health in cancer: How can we reduce the incidence of this Non-communicable Diseases. Springer Series on disease? Current Gastroenterology Reports, Epidemiology and Public Health (pp. 31-40). 18(7), 34. https://doi.org/10.1007/s11894-016-0506-0 Springer. https://doi.org/10.1007/978-981-15- Dong, J., & Thrift, A. P. (2017). Alcohol, smoking and 1831-7_4 risk of oesophago-gastric cancer. Best Practice & Tonelli, F., Valanzano, R., Monaci, I., Mazzoni, P., Research. Clinical Gastroenterology, 31(5), 509– Anastasi, A., & Ficari, F. (1997). Restorative 517. https://doi.org/10.1016/j.bpg.2017.09.002 proctocolectomy or rectum-preserving surgery in Hoff, P. M., Pazdur, R., Benner, S. E., & Canetta, R. patients with familial adenomatous polyposis: (1998). UFT and leucovorin: A review of its Results of a prospective study. World Journal of clinical development and therapeutic potential in Surgery, 21, 653-659. the oral treatment of cancer. Anti-Cancer Drugs, https://doi.org/10.1007/s002689900289 9(6), 479-490. Uthman, O. A., Jadidi, E., & Moradi, T. (2013). https://pubmed.ncbi.nlm.nih.gov/9877235/ Socioeconomic position and incidence of gastric Kim, E. Y., Jun, K. H., Kim, S. Y., & Chin, H. M. cancer: a systematic review and meta-analysis. (2020). Body mass index and skeletal muscle Journal of Epidemiology & Community Health, index are useful prognostic factors for overall 67(10), 854-860. https://doi.org/10.1136/jech- survival after gastrectomy for gastric cancer: 2012-201108 Retrospective cohort study. Medicine, 99(47), Yusefi, A. R., Bagheri Lankarani, K., Bastani, P., e23363. Radinmanesh, M., & Kavosi, Z. (2018). Risk https://doi.org/10.1097/MD.0000000000023363 factors for gastric cancer: A systematic review. Kogevinas, M., & Porta, M. (1997). Socioeconomic Asian Pacific Journal of Cancer Prevention: differences in cancer survival: A review of the APJCP, 19(3), 591–603. https://doi.org/10.22034/APJCP.2018.19.3.591 44 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Table A Ratio of Risks and Studied Potential Factors for Gastric Cancer Mortality Cite this article as: Nikolov, A., & Georgieva, L. (2023). Influence of behavioral and social factors on gastric cancer incidence and mortality. International Journal of Science Annals, 6(1), 40–45. https://doi.org/10.26697/ijsa.2023.1.4 The electronic version of this article is complete. It can be found online in the IJSA Archive https://ijsa.culturehealth.org/en/arhiv This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/deed.en). 45