Hostname: page-component-5d59c44645-klj7v Total loading time: 0 Render date: 2024-02-21T16:12:16.478Z Has data issue: false hasContentIssue false

Death anxiety in patients with primary brain tumor: Measurement, prevalence, and determinants

Published online by Cambridge University Press:  22 June 2021

Ashlee R. Loughan*
School of Medicine, Virginia Commonwealth University, Richmond, VA Massey Cancer Center, Richmond, VA
Mariya Husain
School of Medicine, Virginia Commonwealth University, Richmond, VA
Scott G. Ravyts
Department of Psychology, Virginia Commonwealth University, Richmond, VA
Kelcie D. Willis
Department of Psychology, Virginia Commonwealth University, Richmond, VA
Sarah Ellen Braun
School of Medicine, Virginia Commonwealth University, Richmond, VA Massey Cancer Center, Richmond, VA
Julia K. Brechbiel
Department of Psychology, Virginia Commonwealth University, Richmond, VA
Farah J. Aslanzadeh
Department of Psychology, Virginia Commonwealth University, Richmond, VA
Gary Rodin
Department of Psychiatry, University of Toronto, Toronto, ON, Canada Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
Dace S. Svikis
Department of Psychology, Virginia Commonwealth University, Richmond, VA
Leroy Thacker
Massey Cancer Center, Richmond, VA Department of Biostatistics, Virginia Commonwealth University, Richmond, VA
Author for correspondence: Ashlee R. Loughan, Virginia Commonwealth University and Massey Cancer Center, McGlothlin Medical Education Center, 1201 East Marshall Street, Room 12-213, P.O. Box 980070, Richmond, VA 23298-0070, USA. E-mail:



This study investigated death anxiety in patients with primary brain tumor (PBT). We examined the psychometric properties of two validated death anxiety measures and determined the prevalence and possible determinants of death anxiety in this often-overlooked population.


Two cross-sectional studies in neuro-oncology were conducted. In Study 1, 81 patients with PBT completed psychological questionnaires, including the Templer Death Anxiety Scale (DAS). In Study 2, 109 patients with PBT completed similar questionnaires, including the Death and Dying Distress Scale (DADDS). Medical and disease-specific variables were collected across participants in both studies. Psychometric properties, including construct validity, internal consistency, and concurrent validity, were investigated. Levels of distress were analyzed using frequencies, and determinants of death anxiety were identified using logistic regression.


The DADDS was more psychometrically sound than the DAS in patients with PBT. Overall, 66% of PBT patients endorsed at least one symptom of distress about death and dying, with 48% experiencing moderate-severe death anxiety. Generalized anxiety symptoms and the fear of recurrence significantly predicted death anxiety.

Significance of results

The DADDS is a more appropriate instrument than the DAS to assess death anxiety in neuro-oncology. The proportion of patients with PBT who experience death anxiety appears to be higher than in other advanced cancer populations. Death anxiety is a highly distressing symptom, especially when coupled with generalized anxiety and fears of disease progression, which appears to be the case in patients with PBT. Our findings call for routine monitoring and the treatment of death anxiety in neuro-oncology.

Original Article
Copyright © The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)



Abdel-Khalek, AM (2005) Death anxiety in clinical and non-clinical groups. Death Studies. doi:10.1080/07481180590916371.CrossRefGoogle ScholarPubMed
Abdel-Khalek, AM (2011) The death distress construct and scale. OMEGA — Journal of Death and Dying 64(2), 171184. doi:10.2190/om.64.2.e.CrossRefGoogle Scholar
Adelbratt, S and Strang, P (2000) Death anxiety in brain tumour patients and their spouses. Palliative Medicine 14(6), 499507.CrossRefGoogle ScholarPubMed
American Psychiatric Association (2013) Diagnostic and Statistical Manual for Mental Disorders, 5th ed. Washington, DC: American Psychiatric Publishing Inc.Google Scholar
An, E, Lo, C, Hales, S, et al. (2018) Demoralization and death anxiety in advanced cancer. Psycho-Oncology 27(11), 25662572. doi:10.1002/pon.4843.CrossRefGoogle ScholarPubMed
Cella, DF and Tross, S (1987) Death anxiety in cancer survival: A preliminary cross-validation study. Journal of Personality Assessment 51(3), 451461. doi:10.1207/s15327752jpa5103_12.CrossRefGoogle ScholarPubMed
Conte, HR, Weiner, MB and Plutchik, R (1982) Measuring death anxiety: Conceptual, psychometric, and factor-analytic aspects. Journal of Personality and Social Psychology 43, 775785. doi:10.1037/0022-3514.43.4.775.CrossRefGoogle ScholarPubMed
DesRoches, C, Blendon, R, Young, J, et al. (2002) Caregiving in the post-hospitalization period: Findings from a national survey. Nursing Economics 20(5), 206221.Google ScholarPubMed
Dickstein, LS (1972) Death concern: Measurement and correlates. Psychological Reports 30, 563571. doi:10.2466/pr0.1972.30.2.563.CrossRefGoogle ScholarPubMed
DiMatteo, MR, Lepper, HS and Croghan, TW (2000) Depression is a risk factor for noncompliance with medical treatment meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine 160, 21012106. doi:10.1001/archinte.160.14.2101.CrossRefGoogle ScholarPubMed
Fine, HA, Dear, KBG, Loeffler, JS, et al. (1993) Meta-analysis of radiation therapy with and without adjuvant chemotherapy for malignant gliomas in adults. Cancer 71, 25852597. doi:10.1002/1097-0142(19930415)71:8<2585::AID-CNCR2820710825>3.0.CO;2-S.3.0.CO;2-S>CrossRefGoogle ScholarPubMed
Fox, SW, Lyon, D and Farace, E (2007) Symptom clusters in patients with high-grade glioma. Journal of Nursing Scholarships 39(1), 6167.CrossRefGoogle ScholarPubMed
Giovagnoli, AR, Silvani, A, Colombo, E, et al. (2005) Facets and determinants of quality of life in patients with recurrent high grade glioma. Journal of Neurology, Neurosurgery and Psychiatry 76, 562568. doi:10.1136/jnnp.2004.036186.CrossRefGoogle ScholarPubMed
Gonen, G, Kaymak, SU, Cankurtaran, ES, et al. (2012) The factors contributing to death anxiety in cancer patients. Journal of Psychosocial Oncology. doi:10.1080/07347332.2012.664260.CrossRefGoogle ScholarPubMed
Grossman, CH, Brooker, J, Michael, N, et al. (2018) Death anxiety interventions in patients with advanced cancer: A systematic review. Palliative Medicine 32(1), 172184. doi:10.1177/0269216317722123.CrossRefGoogle ScholarPubMed
Humphris, GM, Watson, E, Sharpe, M, et al. (2018) Unidimensional scales for fears of cancer recurrence and their psychometric properties: The FCR4 and FCR7. Health and Quality of Life Outcomes 16, 30. ScholarPubMed
Hutcheson, G and Sofroniou, N (1999) The multivariate social scientist. In The Multivariate Social Scientist: Introductory Statistics Using Generalized Linear Models. Newbury Park, CA: Sage Publishing.CrossRefGoogle Scholar
Janda, M, Steginga, S, Dunn, J, et al. (2008) Unmet supportive care needs and interest in services among patients with a brain tumour and their carers. Patient Education & Counseling 71(2), 251258.CrossRefGoogle ScholarPubMed
Krause, S, Rydall, A, Hales, S, et al. (2015) Initial validation of the death and dying distress scale for the assessment of death anxiety in patients with advanced cancer. Journal of Pain and Symptom Management 49(1), 126134. doi:10.1016/j.jpainsymman.2014.04.012.CrossRefGoogle ScholarPubMed
Kroenke, K, Spitzer, RL and Williams, JB (2001) The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 16(9), 606613.CrossRefGoogle ScholarPubMed
Lo, C, Hales, S, Zimmermann, C, et al. (2011) Measuring death-related anxiety in advanced cancer: Preliminary psychometrics of the death and dying distress scale. Journal of Pediatric Hematology/Oncology. doi:10.1097/MPH.0b013e318230e1fd.CrossRefGoogle ScholarPubMed
Loughan, AR, Lanoye, A, Aslanzadeh, F, et al. (2019) Fear of cancer recurrence and death anxiety: Unaddressed concerns for adult neuro-oncology patients. Journal of Clinical Psychology in Medical Settings 28, 1630.CrossRefGoogle Scholar
Loughan, AR, Aslanzadeh, FJ, Brechbiel, J, et al. (2020) Death-related distress in adult primary brain tumor patients. Neuro-Oncology Practice 7(5), 498506. doi:10.1093/nop/npaa015.CrossRefGoogle ScholarPubMed
Miller, S, Lo, C, Gagliese, L, et al. (2011) Patterns of depression in cancer patients: An indirect test of gender-specific vulnerabilities to depression. Social Psychiatry and Psychiatric Epidemiology 46, 767774. doi:10.1007/s00127-010-0246-7.CrossRefGoogle ScholarPubMed
National Brain Tumor Society (2020) Quick Brain Tumor Facts. Available at: Scholar
Neel, C, Lo, C, Rydall, A, et al. (2015) Determinants of death anxiety in patients with advanced cancer. BMJ Supportive and Palliative Care 5(4), 373380. doi:10.1136/bmjspcare-2012-000420.CrossRefGoogle ScholarPubMed
Osoba, D, Aaronson, NK, Muller, M, et al. (1997) Effect of neurological dysfunction on health-related quality of life in patients with high-grade glioma. Journal of Neuro-Oncology 34(3), 263278.CrossRefGoogle ScholarPubMed
Pelletier, G, Verhoef, MJ, Khatri, N, et al. (2002) Quality of life in brain tumor patients: The relative contributions of depression, fatigue, emotional distress, and existential issues. Journal of Neuro-Oncology 57(1), 4149. doi:10.1023/A:1015728825642.CrossRefGoogle ScholarPubMed
Postolică, R, Enea, V, Dafinoiu, I, et al. (2019) Association of sense of coherence and supernatural beliefs with death anxiety and death depression among Romanian cancer patients. Death Studies 43(1), 919. doi:10.1080/07481187.2018.1430083.CrossRefGoogle ScholarPubMed
Randazzo, DM, McSherry, F, Herndon, JE, et al. (2017) A cross sectional analysis from a single institution's experience of psychosocial distress and health-related quality of life in the primary brain tumor population. Journal of Neuro-Oncology. doi:10.1007/s11060-017-2535-4.CrossRefGoogle ScholarPubMed
Rodin, G, Lo, C, Rydall, A, et al. (2018) Managing Cancer and Living Meaningfully (CALM): A randomized controlled trial of a psychological intervention for patients with advanced cancer. Journal of Clinical Oncology 36(23), 24222432. doi:10.1200/JCO.2017.77.1097.CrossRefGoogle ScholarPubMed
Rouse, C, Gittleman, H, Ostrom, QT, et al. (2016) Years of potential life lost for brain and CNS tumors relative to other cancers in adults in the United States, 2010. Neuro-Oncology 18(1), 7077. doi:10.1093/neuonc/nov249.CrossRefGoogle ScholarPubMed
Royal, KD and Elahi, F (2011) Psychometric properties of the death anxiety scale (DAS) among terminally ill cancer patients. Journal of Psychosocial Oncology 29(4), 359371. doi:10.1080/07347332.2011.582639.Google ScholarPubMed
Shapiro, GK, Mah, K, de Vries, F, et al. (2020) A cross-sectional gender-sensitive analysis of depressive symptoms in patients with advanced cancer. Palliative Medicine 34(10), 14361446. doi:10.1177/0269216320947961.CrossRefGoogle ScholarPubMed
Sharif, SP, Lehto, RH, Nia, HS, et al. (2018) Religious coping and death depression in Iranian patients with cancer: Relationships to disease stage. Supportive Care in Cancer 26(8), 25712579. doi:10.1007/s00520-018-4088-2.CrossRefGoogle ScholarPubMed
Sherwood, P, Given, B, Given, C, et al. (2004) Caregivers of persons with a brain tumor: A conceptual model. Nursing Inquiry 11(1), 4353.CrossRefGoogle ScholarPubMed
Sherwood, PR, Given, BA, Given, CW, et al. (2006) Predictors of distress in caregivers of persons with a primary malignant brain tumor. Research in Nursing & Health 29(2), 105120. doi:10.1002/nur.20116.CrossRefGoogle ScholarPubMed
Shi, C, Lamba, N, Zheng, LJ, et al. (2018) Depression and survival of glioma patients: A systematic review and meta-analysis. Clinical Neurology and Neurosurgery. doi:10.1016/j.clineuro.2018.06.016.CrossRefGoogle ScholarPubMed
Shinn, EH, Taylor, CLC, Kilgore, K, et al. (2009) Associations with worry about dying and hopelessness in ambulatory ovarian cancer patients. Palliative and Supportive Care 7(3), 299306. doi:10.1017/S1478951509990228.CrossRefGoogle ScholarPubMed
Spitzer, RL, Kroenke, K, Williams, JB, et al. (2006) A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 30(8), 772779.Google Scholar
Tabachnick, BG and Fidell, LS (2012) Using Multivariate Statistics, 6th ed. New York, NY: Harper and Row. doi:10.1037/022267.Google Scholar
Templer, DI (1970) The contruction and validation of a Death Anxiety Scale. The Journal of General Psychology 82, 165177. doi:10.1080/00221309.1970.9920634.CrossRefGoogle Scholar