The incidence for esophageal adenocarcinoma (EAC) was rising during the last decades (1). Mostly, EAC is arising from Barrett’s metaplasia due to chronical gastroesophageal reflux disease (GERD), while the physiological squamous epithelium is replaced by the metaplastic epithelium (2). However, the risk of EAC development is highly associated with the length of Barrett’s segment, with the highest association for long Barrett’s esophagus (BE) ≥3 cm with an annual cancer transition rate of 0.22% (3). Despite BE, nicotine abuse (4,5), obesity (6,7), and positive familiar history (8) are known risk factors for EAC development.
Psychological and social factors can be associated with tumor development, progression and convalescence. Also, the daily clinical praxis is characterized and dependent to patient’s personality traits and psychological stress factors. However, there is a discussion about the association of personality traits, depression, stressors and cancer development. Livelong personality stability is a long-term predictor for health conservation. The evidence of psychosocial risk factors in cancer development is controversial (9,10), as chronically stress is associated with impaired immunological functions, which might lead to cancer development (11). The Big Five Inventory-10 (BFI-10) cumulate the five main personality traits, neuroticism, extraversion, openness, conscientiousness and agreeableness (12). Persons with higher conscientiousness were associated with a healthier life style and a longer life time (13). Thereby, the BFI-10 consists of only 10 items and according to this the BFI-10 promises an easy and efficient processing by patients, e.g., cancer patients (14).
There are no studies available investigated EAC patients for their personality traits. Therefore, we present a large multi-center survey, characterizing EAC patients for the BFI-10, neuroticism, extraversion, openness, conscientiousness and agreeableness and we implemented this inventory for a large disease-defined cancer population.
We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/aoe-20-38).
Patients gave their written and informed consent to participate in this survey. The local ethic committee of the “Landesärztekammer Rheinland-Pfalz” approved this study in accordance with the Helsinki declaration (reference number: 837.095.11-7637) and informed consent was taken from all the patients. Patients with endoscopically and histologically confirmed EAC, at the age ≥18 years were eligible for this study. A total of 1,247 patients with EAC were found eligible for the study between 01/2013-12/2015, from which 839 (67.3%) completed the questionnaires. Reference groups (RG) with 1,134 individuals for gender and 2,116 individuals for age were used, which reflect the German general population (15-17).
The BFI-10 was answered by EAC patients “paper-pencil-based” in a multi-center survey retrospectively in a 10-item questionnaire (two for each item), which reflects the personality traits, neuroticism, extraversion, openness, conscientiousness and agreeableness (12). The questionnaire was developed from an original 44-item inventory. However, the 10-item inventory was introduced because of its higher acceptance and respondent’s time needed to conduct the questionnaire (14). The BFI-10 questionnaire is published open-access and can be used for any non-commercial research (14). Data were documented in a Redcap system (https://www.project-redcap.org). To consider age-specific personality traits, both cohorts were separated in 2 groups, representing individuals between the age of 30 to 60 years and older than 60 years (17).
Statistical analyses were performed using the Statistical Packages for the Social Sciences (SPSS v.24). Both, the study and the reference collectives were described descriptively. The five dimensions were calculated and expressed as mean ± standard deviation (SD). Differences between females and males as well as for age were analyzed by the Mann-Whitney test for the EAC-cohort. Reliability analyses were conducted through Cronbach’s alpha, because of the limited sample size and retrospective character in the EAC collective and through retest and follow-ups in the reference group. Both RG cohorts were compared with the EAC-cohort by analyzing the means, standard deviation and sample size (www.medcalc.org). A multivariate analysis was performed by a linear model for age, with personality traits as dependent and age as independent variables. P values less than 0.05 were considered as being statistically significant. Statistical correlations were calculated using the Person’s and Spearman’s correlation coefficient (R). Spearman’s R is a nonparametric measure of rank correlation. It analyzes how the relationship between two variables can be described. Because correlation coefficients like Pearson are sensible to very high/very low values, therefore robust coefficients like Spearman’s R can be used. It utilizes ranks instead of observed values.
The study group (EAC-cohort) consisted of 723 (86.2%) males and 116 (13.8%) females. Patient’s average age was 66.7 years (SD 9.7 years).
In the RG (gender) 503 (44.4%) individuals were males and 631 (55.6%) females. Average age was 53.3 years (SD 18.4 years) (15). In the RG (age) 1,272 individuals were males and 1,295 (50.4%) were females. Average age was 47.5 years (SD 17.3 years) (17).
Patients with EAC showed significantly higher values for neuroticism (2.94 in EAC-cohort vs. 2.82 in the RG), but lower values for openness (3.25 in EAC-cohort vs. 3.40 in the RG) and extraversion (3.2 in EAC-cohort vs. 3.35 in the RG) (Table 1).
Gender-specific personality traits
Investigating neuroticism, the mean value of males was 2.89 (SD 0.87), while females had a mean value of 3.21 (SD 0.88) in the EAC-cohort. The RG had a mean value of 2.22 (SD 0.79) for neuroticism in males and 2.58 (SD 0.92) in females, which was significantly different between the two collectives (P=0.00).
The EAC-cohort showed a mean value for agreeableness of 3.13 (SD 0.79) for males and 3.32 (SD 0.80) for women, while the RG had a mean value of 3.39 (SD 0.78) for males and 3.49 (SD 0.81) for females. The differences between the two collectives were significant (P=0.04) (Table 2).
Age-specific personality traits
Neuroticism was affected by age in the study collective. The mean value for the age-group 36–65 years was 3.08 (SD 0.88) and 3.37 (SD 0.83) in the reference group. In the age-group >65 years, the mean value was 2.89 (SD 0.88) in the EAC-group and 3.56 (SD 0.89) for the reference group. The reference group was characterized by increased values for neuroticism with age; the EAC-group was not.
While also extraversion, agreeableness, conscientiousness, and openness were significantly affected by age in the reference group, the EAC-cohort did not show significant differences for these personality traits (Table 3), which was confirmed by multivariate analyses, showing neuroticism significantly (P=0.006) decreased by age (Table 4).
Statistical correlations of personality traits in EAC patients
To investigate the robustness and the reliability of the raised Big Five values in the EAC-cohort, the values of the single dimensions were correlated by Spearman’s correlation (Table 5). The reliability could be obtained, as specific correlations between items, e.g., neuroticism and extraversion, which were found to correlate.
Personality traits in regard to the EAC diagnosis
From 753 patients, who answered the questionnaire, the time point of the first diagnosis of EAC was documented. The median time between EAC diagnosis and the survey was 56 months (range, 1–227 months). Therefore, these patients represented a long-term survival EAC-cohort. The cohort was stratified in 88 patients (11.7%), who answered the questionnaire less than 18 months and in 665 patients (88.3%), who answered the questionnaire more than 18 months after their EAC diagnosis. The majority of the questioned patients had a relatively long-time interval of more than 18 months between their first tumor diagnosis and the time point of the survey. However, there were no significant differences between the personality traits of patients with a short time interval compared to patients with a long-time interval between EAC diagnosis and the survey (Table 6).
A survey, investigating the personality traits of a large EAC patient cohort was conducted for the first time, using the BFI-10. Thereby, individuals with EAC showed significantly higher values for neuroticism and significantly lower values for the items openness and extraversion. Limitations of this study were the fewer females in the EAC-cohort (13.8%) compared to RG (55.6% and 50.4%), which was due to the specification of this tumor entity, which is predominant in males. Personality traits are dependent on cultural behavior and community habits and therefore only valid in a specific geographic region, e.g., the German population. Concerning the reliability, the RG used a retest setting, which was not performed in the EAC-cohort. Therefore, the robustness and the reliability were calculated by Spearman’s-R. The patients investigated in this survey displayed a long-time interval between EAC diagnosis and the time point of the survey. As personality traits are assumed to be unstable during life time and are affected by life threating events, like cancer diagnosis, the investigated cohort is mostly homogeneous, as 88.3% of all patients had the survey more than 18 months after EAC diagnosis. Nevertheless, higher levels in neuroticism were still present in long-term survivors, assuming a long-lasting limitation of these patients.
The connection between personality and predisposition for a malignant disease has been discussed for decades. A correlation between personality traits and cancer development was described first in the 1960s (18). The majority of publications have not indicated a significant correlation between the development of malignant disease and certain personality traits. One of the largest studies, analyzing 29,595 Swedish twins, between 15 and 48 years, did not found a correlation between the items neuroticism and extraversion and a certain type of cancer (19). However, most recent studies, focused at the association between neuroticism, extraversion and the development of malignant disease (20-22).
In patients with cancer in general, severe psychological issues and problems, might arise in the course of diagnosis, therapy and stigmatization with associated uncertainty regarding the therapeutic success. However, there are studies that suggest a correlation between compliance and personality traits, especially neuroticism (23-25).
The implementation of a psycho-oncological co-treatment is important for cancer patients as almost a third suffer from considerable psychological issues, especially of anxiousness and/or depression associated with cancer (26). A Danish prospective study had shown that higher levels of neuroticism were associated with higher distress in female patients with breast cancer, and therefore, associated with higher rates of depression in these patients (27). Nevertheless, psycho-oncological care is not offered sufficiently to the majority of cancer patients and need to be implemented in ambulant and hospital therapy settings (28). Comprehensive concepts need to be conducted to cover patients regardless of gender, age, socio-economic status, and comorbidities. A sufficient psycho-oncologic care will result in a better therapy adherence and quality of life, as well as in a reduced morbidity and mortality rate. Lung cancer patients with a psychological comorbidity were shown to have a decreased overall survival than mentally healthy patients (29). Quality of life related outcome is a powerful tool in survival prediction. In esophageal cancer (T2 and T3), an increased quality of life was associated with better cancer related survival (30). As surgery is the only curative therapy in EAC patients, quality of life will drop off after esophagectomy (31). However, quality of life will rise after operation, but physical and role functioning are still impaired 6 and 12 months after operation (31,32). This is in accordance with our results for personality traits, which still differed from normal values 56 months after EAC diagnosis.
Hengarnter et al. assessed the BFI-10 in a short questionnaire, to investigate, whether the outcome was beneficial for prevention purposes and came to the conclusion, that higher scores in neuroticism and conscientiousness were significantly associated with lower socioeconomic status and social resources, leading to an unhealthier behavior of the prospects (33,34). However, in our study no data were available to predict, whether the socioeconomic status, educational level, personal relationships, and employment status confound the results between the EAC and the German general population cohort.
In a large meta-analysis of 11 studies with a total of 19,941 individuals, brought evidence that greater openness was associated with lower all-cause mortality risk with an odds ratio of 0.88 (35). However, other large epidemiological studies did not find any association between cancer risk, cancer prognosis and personality traits (36,37). Elevated values for neuroticism were correlated negatively, while higher values for extraversion were correlated positively with patients’ compliance (25). In older cancer survivors, neuroticism might be associated with increased depression and anxiety. In general, neuroticism is associated with common mental disorders, as neurotic persons react more intensively to stressors and tends to be moody, have depression mood, and are self-conscious (38,39). Therefore, increased neuroticism should be targeted, to overcome the increased depression rates in these patients (40). However, Chow et al. included a heterogeneous cancer patient cohort and did not focus to a disease-defined cancer population than our study. Whereas, age was associated with increased values for neuroticism in the reference cohort, it was associated with decreased values in the EAC-cohort, which was confirmed in a multivariate analysis (17). The EAC-cohort is shaped by increasing age and the disease itself. Both, age and the disease impair alterations in personality traits and potentially overlay these developments.
Cancer patients show altered personality traits, than the healthy general population. The implementation of the BFI-10 in clinical diagnostics, like a nutritional risk score evaluation, could be a useful tool. Personality traits covered by the BFI-10 survey might identify patients with a risk of lower therapy adherence, aftercare or for intensive psychological co-treatment. These patients could benefit from a closer implementation of psycho-oncological care right after their cancer diagnosis. Additionally, the divergence in personality traits in late aftercare patients reflect the responsibility of the health care system, to figure out, which special patient group still need support by an ongoing psycho-oncological advice or by almoner. Whether personality traits changes during cancer diagnosis and long-time care, and whether the BFI-10 is suitable to identify healthcare gaps and drawing definitive causal conclusions, needs to be investigated in a longitudinal design in the future.
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/aoe-20-38
Data Sharing Statement: Available at http://dx.doi.org/10.21037/aoe-20-38
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aoe-20-38). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All participants provided their written informed consent to participate in this study. The local ethic committee of the “Landesärztekammer Rheinland-Pfalz” approved this study in accordance with the Declaration of Helsinki (as revised in 2013) (reference number: 837.095.11-7637) and informed consent was taken from all the patients.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
- Collaborators GBDM. Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1684-735. [Crossref] [PubMed]
- Spechler SJ. Clinical practice. Barrett's Esophagus. N Engl J Med 2002;346:836-42. [Crossref] [PubMed]
- Pohl H, Pech O, Arash H, et al. Length of Barrett's oesophagus and cancer risk: implications from a large sample of patients with early oesophageal adenocarcinoma. Gut 2016;65:196-201. [Crossref] [PubMed]
- Gray MR, Donnelly RJ, Kingsnorth AN. The role of smoking and alcohol in metaplasia and cancer risk in Barrett's columnar lined oesophagus. Gut 1993;34:727-31. [Crossref] [PubMed]
- Menke-Pluymers MB, Hop WC, Dees J, et al. Risk factors for the development of an adenocarcinoma in columnar-lined (Barrett) esophagus. The Rotterdam Esophageal Tumor Study Group. Cancer 1993;72:1155-8. [Crossref] [PubMed]
- Kubo A, Corley DA. Body mass index and adenocarcinomas of the esophagus or gastric cardia: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 2006;15:872-8. [Crossref] [PubMed]
- Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med 2005;143:199-211. [Crossref] [PubMed]
- Chak A, Lee T, Kinnard MF, et al. Familial aggregation of Barrett's oesophagus, oesophageal adenocarcinoma, and oesophagogastric junctional adenocarcinoma in Caucasian adults. Gut 2002;51:323-8. [Crossref] [PubMed]
- Dahl AA. Link between personality and cancer. Future Oncol 2010;6:691-707. [Crossref] [PubMed]
- Schwarz S, Messerschmidt H, Doren M. Psychosocial risk factors for cancer development. Med Klin (Munich) 2007;102:967-79. [Crossref] [PubMed]
- Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res 2014;58:193-210. [Crossref] [PubMed]
- Goldberg LR. An alternative “description of personality”: the big-five factor structure. J Pers Soc Psychol 1990;59:1216-29. [Crossref] [PubMed]
- Roberts BW, Kuncel NR, Shiner R, et al. The Power of Personality: The Comparative Validity of Personality Traits, Socioeconomic Status, and Cognitive Ability for Predicting Important Life Outcomes. Perspect Psychol Sci 2007;2:313-45. [Crossref] [PubMed]
- Rammstedt B, John OP. Measuring personality in one minute or less: A 10-item short version of the Big Five Inventory in English and German. J Res Pers 2007;41:203-12. [Crossref]
- Rammstedt B, Kemper CJ, Klein MC, et al. Eine kurze Skala zur Messung der fünf Dimensionen der Persönlichkeit: 10 Item Big Five Inventory (BFI-10). Methoden, Daten, Analysen 2013.233-49. (MDA).
- Rammstedt B, Kemper CJ, Klein MC, et al. Big Five Inventory (BFI-10). Zusammenstellung sozialwissenschaftlicher Items und Skalen. Available online: https://doi.org/ [Crossref]
- Rammstedt B. The 10-item Big Five Inventory: Norm values and investigation of sociodemographic effects based on a German population representative sample. Eur J Psychol Assess 2007;23:193-201. [Crossref]
- Kissen DM, Eysenck HJ. Personality in male lung cancer patients. J Psychosom Res 1962;6:123-7. [Crossref] [PubMed]
- Hansen PE, Floderus B, Frederiksen K, et al. Personality traits, health behavior, and risk for cancer: a prospective study of Swedish twin court. Cancer 2005;103:1082-91. [Crossref] [PubMed]
- Schapiro IR, Ross-Petersen L, Saelan H, et al. Extroversion and neuroticism and the associated risk of cancer: A Danish cohort study. Am J Epidemiol 2001;153:757-63. [Crossref] [PubMed]
- Nakaya N, Tsubono Y, Hosokawa T, et al. Personality and the risk of cancer. J Natl Cancer Inst 2003;95:799-805. [Crossref] [PubMed]
- Nakaya N, Bidstrup PE, Saito-Nakaya K, et al. Personality traits and cancer risk and survival based on Finnish and Swedish registry data. Am J Epidemiol 2010;172:377-85. [Crossref] [PubMed]
- Lahey BB. Public health significance of neuroticism. Am Psychol 2009;64:241-56. [Crossref] [PubMed]
- Hollier JM, Hinojosa-Lindsey M, Sansgiry S, et al. Clinical and psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy. BMC Gastroenterol 2014;14:107. [Crossref] [PubMed]
- Arai S, Nakaya N, Kakizaki M, et al. Personality and gastric cancer screening attendance: a cross-sectional analysis from the Miyagi Cohort Study. J Epidemiol 2009;19:34-40. [Crossref] [PubMed]
- Mehnert A, Brahler E, Faller H, et al. Four-week prevalence of mental disorders in patients with cancer across major tumor entities. J Clin Oncol 2014;32:3540-6. [Crossref] [PubMed]
- Waxler JL, O'Brien KE, Delahanty LM, et al. Genetic counseling as a tool for type 2 diabetes prevention: a genetic counseling framework for common polygenetic disorders. J Genet Couns 2012;21:684-91. [Crossref] [PubMed]
- Keller M, Sommerfeldt S, Fischer C, et al. Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach. Ann Oncol 2004;15:1243-9. [Crossref] [PubMed]
- Sikjær MG, Lokke A, Hilberg O. The influence of psychiatric disorders on the course of lung cancer, chronic obstructive pulmonary disease and tuberculosis. Respir Med 2018;135:35-41. [Crossref] [PubMed]
- Alghamedi A, Buduhan G, Tan L, et al. Quality of life assessment in esophagectomy patients. Ann Transl Med 2018;6:84. [Crossref] [PubMed]
- Reynolds JV, McLaughlin R, Moore J, et al. Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone. Br J Surg 2006;93:1084-90. [Crossref] [PubMed]
- Parameswaran R, Blazeby JM, Hughes R, et al. Health-related quality of life after minimally invasive oesophagectomy. Br J Surg 2010;97:525-31. [Crossref] [PubMed]
- Hengartner MP, Kawohl W, Haker H, et al. Big Five personality traits may inform public health policy and preventive medicine: Evidence from a cross-sectional and a prospective longitudinal epidemiologic study in a Swiss community. J Psychosom Res 2016;84:44-51. [Crossref] [PubMed]
- Schupp J, Gerlitz JY. Big Five Inventory-SOEP (BFI-S). Zusammenstellung sozialwissenschaftlicher Items und Skalen. doi: 10.6102/zis54.[Crossref]
- Ferguson E, Bibby PA. Openness to experience and all-cause mortality: a meta-analysis and r(equivalent) from risk ratios and odds ratios. Br J Health Psychol 2012;17:85-102. [Crossref] [PubMed]
- Chida Y, Hamer M, Wardle J, et al. Do stress-related psychosocial factors contribute to cancer incidence and survival? Nat Clin Pract Oncol 2008;5:466-75. [Crossref] [PubMed]
- Nakaya N, Hansen PE, Schapiro IR, et al. Personality traits and cancer survival: a Danish cohort study. Br J Cancer 2006;95:146-52. [Crossref] [PubMed]
- Ormel J, Jeronimus BF, Kotov R, et al. Neuroticism and common mental disorders: meaning and utility of a complex relationship. Clin Psychol Rev 2013;33:686-97. [Crossref] [PubMed]
- Thompson ER. Development and validation of an International English Big-Five Mini-Markers. Personality and Individual Differences 2008;45:542-8. [Crossref]
- Chow PI, Shaffer KM, Lohman MC, et al. Examining the relationship between changes in personality and depression in older adult cancer survivors. Aging Ment Health 2020;24:1237-45. [PubMed]
Cite this article as: Gaisendrees C, Kreuser N, Lyros O, Becker J, Schumacher J, Gockel I, Kersting A, Thieme R. Classification of personality traits using the Big Five Inventory-10 in esophageal adenocarcinoma patients. Ann Esophagus 2020;3:22.