The impact of comprehensive anti-stress preparation on clinical manifestations of preoperative anxiety in patients with breast cancer

Introduction. Any surgical intervention is a significant source of stress for patients. Various scales are commonly used to assess preoperative anxiety. Free cortisol levels in saliva may also serve as a laboratory marker of heightened anxiety. Activities such as sports, dancing, listening to music, painting, reading, and others can significantly reduce anxiety levels. A preoperative consultation with a physician that includes detailed information about the upcoming treatment may also help alleviate patient anxiety.

The objective was to evaluate the impact of comprehensive anti-stress preparation on the clinical manifestations of preoperative anxiety in patients suffering from breast cancer.

Materials and Methods. The study included 50 female patients with breast cancer scheduled to undergo radical mastectomy or radical breast resection. Patients in the main group received a comprehensive anti-stress preparation for surgery (n = 25). It included a detailed interview based on the results of a questionnaire survey using the questionnaire «Identification of the main preoperative anxiety factors by an anesthesiologist», developed by us at the MCSC named after A.S. Loginov. In the period before surgery, in order to reduce anxiety, patients were offered, at their discretion, additional physical activity (fitness, yoga, swimming, walks in the fresh air, etc.), engagement in their favorite activities (listening to music, reading books, drawing, etc.), as well as taking vitamin C 1000 mg per day. Patients in the control group did not receive any anti-stress preparation (n = 25). Anxiety levels were assessed using a custom-designed questionnaire, a visual analog scale (VAS), and free cortisol levels in saliva. In the perioperative period, the impact of the preparation on hemodynamic parameters, anesthetic requirements, and subjective postoperative pain levels was evaluated.

Results. Univariate analysis showed that, compared to the control group, patients in the main group had significantly lower subjective anxiety scores after consultation with the anesthesiologist (3 [2; 4] vs. 7 [6; 8]; p < 0.001). Patients in the main group also had significantly lower preoperative systolic and diastolic blood pressure values (p = 0.001 and p = 0.006, respectively). The median systolic BP in the main group was 138 [131; 148] mmHg, and the median diastolic BP was 78.5 [72; 82.5] mmHg. In the control group, the median preoperative systolic BP was 157.5 [147; 167] mmHg, and the diastolic BP was 88 [77; 94] mmHg. Patients in the main group required significantly lower doses of propofol during anesthesia induction to reach a BIS (Bispectral Index) value of 40 (1.8 [1.3; 2] mg/kg vs. 2.2 [2; 2.4] mg/kg; p = 0.002). Additionally, patients in the main group reported lower postoperative pain scores on the VAS (0.5 [0; 1.5] vs. 2 [2; 3]; p< 0.001).

Conclusion. Almost all patients experience increased anxiety before surgery, which was manifested by the high scores of the custom-designed questionnaire and the VAS before the conversation with the anesthesiologist, as well as the initially increased of free cortisol levels in saliva in patients of both groups. The use of the questionnaire «Identification of the main preoperative anxiety factors by an anesthesiologist» makes it possible to identify trigger points of increased anxiety of a patient with subsequent impact on them. Comprehensive conservative measures aimed at reducing patient anxiety can improve the perioperative period by decreasing the incidence of perioperative hypertension, reducing hypnotic drug requirements, and lowering subjective postoperative pain as assessed by the visual analog scale.

1. Bragin D. B., Astakhov A. A., Turchaninov A. Yu., Lebedeva Yu. V. Express test of situational anxiety in choosing premedication. Russian Journal of Anesthesiology and Reanimatology, 2023, no. 2, pp. 65–70. (In Russ.). https://doi.org/10.17116/anaesthesiology202302165.

2. Bragin D. B., Astakhov A. A., Turchaninov A. Yu., Lebedeva Yu. V. Express-test of situational anxiety as a basis for choosing premedication. Anesthesia and Resuscitation, 2023, no. 2, pp. 65–70. https://doi.org/10.17116/anaesthesiology202302165.

3. Baagil H., Baagil H., Gerbershagen M. U. Preoperative anxiety impact on anesthetic and analgesic use. Medicina (Kaunas), 2023, vol. 59, no. 12, pp. 2069. https://doi.org/10.3390/medicina59122069.

4. Baghele A., Dave N., Dias R. et al. Effect of preoperative education on anxiety in children undergoing day-care surgery. Indian J Anaesth, 2019, vol. 63, no. 7, pp. 565–570. https://doi.org/10.4103/ija.IJA_37_19.

5. Beglaryan N., Hakobyan G., Nazaretyan E. Vitamin C supplementation alleviates hypercortisolemia caused by chronic stress. Stress Health, 2024, vol. 40, no. 3, e3347. https://doi.org/10.1002/smi.3347.

6. Berth H., Petrowski K., Balck F. The Amsterdam preoperative anxiety and information scale (APAIS) – the first trial of a German version. Psychosoc Med, 2007, vol. 4, doc. 01. PMID: 19742298.

7. Bradt J., Dileo C., Shim M. Music interventions for preoperative anxiety. Cochrane Database Syst Rev, 2013, vol. 6, CD006908. https://doi.org/10.1002/14651858.CD006908.pub2.

8. Brody S., Preut R., Schommer K. et al. A randomized controlled trial of high dose ascorbic acid for reduction of blood pressure, cortisol, and subjective responses to psychological stress. Psychopharmacology (Berl), 2002, vol. 159, no. 3, pp. 319–324. https://doi.org/10.1007/s00213-001-0929-6.

9. Çalışkan E., Aksoy N. The relationship between preoperative anxiety level and postoperative pain outcomes in total hip and knee replacement surgery: a cross-sectional study. J Perianesth Nurs, 2025, vol. 40, no. 1, pp. 76–82. https://doi.org/10.1016/j.jopan.2024.03.010.

10. Eberhart L., Aust H., Schuster M. et al. Preoperative anxiety in adults – a cross-sectional study on specific fears and risk factors. BMC Psychiatry, 2020, vol. 20, no. 1, pp. 140. https://doi.org/10.1186/s12888-020-02552-w.

11. Facco E., Stellini E., Bacci C. et al. Validation of visual analogue scale for anxiety (VAS-A) in preanesthesia evaluation. Minerva Anestesiol, 2013, vol. 79, no. 12, pp. 1389–1395.

12. Goldstein D. S., Kopin I. J. Evolution of concepts of stress. Stress, 2007, vol. 10, no. 2, pp. 109–120. https://doi.org/10.1080/10253890701288935.

13. Kennedy E., Niedzwiedz C. L. The association of anxiety and stress-related disorders with C-reactive protein (CRP) within UK Biobank. Brain Behav Immun Health, 2021, vol. 19, pp. 100410. https://doi.org/10.1016/j.bbih.2021.100410.

14. Kharod U., Panchal N. N., Varma J. et al. Effect of pre-operative communication using anaesthesia information sheet on pre-operative anxiety of patients undergoing elective surgery-A randomised controlled study. Indian J Anaesth, 2022, vol. 66, no. 8, pp. 559–572. https://doi.org/10.4103/ija.ija_32_22.

15. Lavedán Santamaría A., Masot O., Canet Velez O. et al. Diagnostic concordance between the visual analogue anxiety scale (VAS-A) and the state-trait anxiety inventory (STAI) in nursing students during the COVID-19 pandemic. Int J Environ Res Public Health, 2022, vol. 19, no. 12, pp. 7053. https://doi.org/10.3390/ijerph19127053.

16. Lu S., Wei F., Li G. The evolution of the concept of stress and the framework of the stress system. Cell Stress, 2021, vol. 5, no. 6, pp. 76–85. https://doi.org/10.15698/cst2021.06.250.

17. Musa A., Movahedi R., Wang J. C. et al. Assessing and reducing preoperative anxiety in adult patients: A cross-sectional study of 3661 members of the American Society of Anesthesiologists. J Clin Anesth, 2020, vol. 65, 109903. https://doi.org/10.1016/j.jclinane.2020.109903.

18. Pereira L., Figueiredo-Braga M., Carvalho I. P. Preoperative anxiety in ambulatory surgery: The impact of an empathic patient-centered approach on psychological and clinical outcomes. Patient Educ Couns, 2016, vol. 99, no. 5, pp. 733–738. https://doi.org/10.1016/j.pec.2015.11.016.

19. Salzmann S., Euteneuer F., Kampmann S. et al. Preoperative anxiety and need for support - A qualitative analysis in 1000 patients. Patient Educ Couns, 2023, vol. 115, 107864. https://doi.org/10.1016/j.pec.2023.107864.

20. Shin K. J., Lee Y. J., Yang Y. R. et al. Molecular mechanisms underlying psychological stress and cancer. Curr Pharm Des, 2016, vol. 22, no. 16, pp. 2389–2402. https://doi.org/10.2174/1381612822666160226144025.

21. Sotelo J. L., Musselman D., Nemeroff C. The biology of depression in cancer and the relationship between depression and cancer progression. Int Rev Psychiatry, 2014, vol. 26, no. 1, pp. 16–30. https://doi.org/10.3109/09540261.2013.875891.

22. Tolksdorf W. Der präoperative stress. forschungsansätze und behandlungsmethoden [preoperative stress. research approach and methods of treatment]. Anasthesiol intensivmed notfallmed schmerzther, 1997, vol. 32, Suppl 3, S318–S324. https://doi.org/10.1055/s-2007-995183.

23. Volkan B., Bayrak N. A., Ucar C. et al. Preparatory information reduces gastroscopy-related stress in children as confirmed by salivary cortisol. Saudi J Gastroenterol, 2019, vol. 25, no. 4, pp. 262–267. https://doi.org/10.4103/sjg.SJG_493_18.