Loneliness in Pre and Post-operative Cancer Patients A Mini Review

This review explored the experience of hospitalization and the experience of cancer patients who were undergoing Ear Nose and Throat [ENT] surgery. Hospitals, which were designed with treatment and healing in mind, are known to be the source of uncontrollable noise, physicians who talk in a language that patients do not understand. Entering the hospital as a patient, one becomes part of that very complex system, which may include being treated as a ‘nonperson,’ not getting enough information, and losing control of daily activities. Hospitalized patients’ social contact is limited to interaction with the medical staff which thus become a key factor in determining the quality of care, and whether the patients can successfully cope with the stress of their hospitalization experience. Loneliness was found to be associated with a range of negative physical health outcomes such as dementia, increased blood pressure, suicidal thinking and unhealthy and damaging behaviors such as smoking, excess alcohol consumption and lack of exercise leading and contributing to increased mortality. Being, both, hospitalized and in the midst of a frightening illness they experience loneliness and isolation.

with the stress of their hospitalization experience [9][10][11]. By definition, this interaction is imbalanced; the patients are quite powerless, often passive, weak and in pain and due to their illness are dependent on the medical staff-physicians, nurses, and supporting staff -which are in complete control of the patient's daily life. Those medical people are endowed with the knowledge, authority and power, and are consequently so very influential on the patient while he or she is hospitalized [8,12].
Surgery, which some people undergo, includes multiple stressful concerns about one's physical condition, painful procedures and post-operative pain, worries about survival and recovery, and separation from family and friends while the person recovers, is in isolation, or is not allowed to have visitors. Research indicated that even surgeries that may be considered "minor" may evoke strong psychological reactions in patients [13]. It was found that during the waiting period for surgery and even more so following one, the patient's world undergoes a great 'reduction' in scope and his psychological world become egocentric [14]. Surgery evokes fears such as anxiety due to anticipated pain and physical discomfort, and sometimes fears about having a serious and life-threatening illness or dying [14,15].
Hospitals, which were designed with treatment and healing in mind, are known to be the source of uncontrollable noise [16]. It was compared to the loudness of heavy traffic which can damage one's hearing after just eight hours of exposure [17]. That noise not only disturbs patients' sleep, but especially for post op patients whose sensitivity to pain is increased, it may contribute to increased requests for pain medication [3,18]. Following surgery, and while struggling with the effects of anesthesia, pain and healing, with the exception of friends almost everyone around the patient is in a position of superior knowledge and power. That may add to the patient's stress and may enhance the pain that he attempts to cope with [3]. While physicians care about their patients we can commonly see in hospitals depersonalization, where patients are seen as if they are broken machines needing to be fixed without the medical staff needing to pay much heed to their emotional and psychological needs which are closely related to post surgery healing. As was repeatedly demonstrated stress adds to reduce the body's immune functioning and thus delays the healing of wounds, it heightens pain and increases the possibility of post-operative infections [13].
Research demonstrated that the greater the stress and anxiety pre-operatively, the slower and more complicated the post-operative recovery [19]. And inversely, when anxiety is low, social support high, and positive outlook is high before surgery, there are positive physical and psychological effects post surgically [20]. "There is certainly ample evidence that social support can moderate the effects of psychological stress; in addition, a number of studies have shown relationships between social support and dimensions of autonomic, endocrine, and immune function, with family ties appearing to be a key source of support related to physiological functioning" [13].

2-Loneliness
Loneliness is prevalent and common which recent estimates suggest that it is experienced by up to 32% of adults [11,21]. Being social creatures, humans' quality of life is intimately intertwined with social intercourse. Consequently, social disconnection negatively affects our psychological, physiological and even spiritual well-being [22]. Social connection is good and important to our health, but it is not just relationships that we are after, as we also need mutual concern and caring for those relationships to be satisfactory [23,24].
Loneliness transcends age, gender, race, marital or socio-economic status and it may be both persistent and continuous or short lived [25,26,8]. The correlates of loneliness include sadness and depression (Boothet al., 1992; Hawkley et al, 2010) as well as low life satisfaction (Riggio et al., 1993) [27][28][29]. Hostility, alcoholism, poor selfconcept, and psychosomatic illnesses were also linked to loneliness [26]. Loneliness can severely compromise the quality of life of people, especially of the ill. Loneliness was found to be associated with a range of negative physical health outcomes (Shankar et [28,[30][31][32]. Research indicates that psychological factors are clinically significant and are correlated with immune-related health outcomes, including infectious diseases, cancer, autoimmune diseases, and HIV, as well postoperative healing and pain [33,34]. Entering the hospital as a patient, one becomes part of that very complex system, which may include being treated as a 'nonperson,' not getting enough information, and losing control of daily activities [35]. It is common for the hospitalized to become identified by their illness. It is not uncommon to hear a physician telling the nurse to 'attend to the multiple fractures in room…'. Patients' identities, comments and questions, and emotional needs are often ignored by the hospital staff [36]. Brock (1997, 1998) found consistent differences in the reported experiences of loneliness between North American men and women [37,38]. Women's socialization in the Western world prepares them more than men to engage in self-reflection, expressing their emotions, and being tuned into what they feel and how they act [39,40]. Cancer patients may experience difficulties in interpersonal relationships due to the various constraints and restrictions imposed by their illness. As they experience a decreased ability to cope with the disease, the quality of their social interactions also decreases [41,42]. Patients afflicted with cancer describe feeling helpless, hopeless, and they typically lack the social and emotional support that they so desperately need, which may contribute to a decreased knowledge that they can address the situation, and that often results in feelings of loneliness and alienation [8,43]. Rokach and Brock (1997) developed a scale, not to measure the intensity of loneliness, but to explore the qualitative dimensions of loneliness. Briefly, it includes five dimensions. Emotional distress, which captures the pain, suffering and turmoil of loneliness can be predicted by the sense of coherence and sex [37]. Women, which are socialized to express their feelings more than men do may report higher rates of emotional distress, but not actually differ from men in how they experience loneliness and pre and post-operative issues [44]. The second dimension of loneliness is Social inadequacy and alienation which addresses one's social inadequacy, unsuccessful and consequently engagement in selfgenerated social detachment that are part of the loneliness experience [45].
Growth and discovery, the third of Rokach and Brock's loneliness dimensions, captured the growth-enhancing and enriching aspects of loneliness and the increased feelings of inner strength and self-reliance that follow. It is expected that people afflicted with cancer, and are just before or after surgery, would not score highly on this dimension, as their entire being is geared towards survival and coping with the looming threat, rather than be concerned about personal growth. Interpersonal isolation has been recognized as significantly affecting poor health so much as that its negative effects were compared to cigarette smoking, high blood pressure, obesity, and sedentary lifestyle [35,46,47]. As can be intuitively expected, when one does not feel secure in his ability to understand, predict and in some way control his environment and body, one may experience an enhanced feeling of isolation and alienation. Self-alienation, the last of the five factors which comprise the experience of loneliness, describes a numbness, a detachment from one's self possibly leading to immobilization. It may be expected, intuitively, that when one is unsure of his world as the situation may be when hospitalized and undergoing surgery, one would be susceptible to experience numbness and selfdetachment. Illness may be a crisis for the ill person, a time of fear and loneliness. Serious Illness such as cancer may cause a redefinition of one's identity, and the relationship between the person and himself may also be affected [42,48].
In conclusion, Serious illness, surgery and the process of hospitalization-in addition to uncertainty and anxietyand those often negatively and significantly affect their pain level, discomfort, and healing. It behooves us, as a society and especially those entrusted with healing people, to address those emotional issues, just as the medical needs are dealt with. Although there are mental health professionals in hospitals, the mission of the establishment is to look after the physical ailments of patient and attend to their pain and illness. Research that was reviewed in this article clearly demonstrates he need to attend to patients' emotional, cognitive and spiritual needs.

3-Conflict of Interest
The authors declare no conflict of interest.

4-Ethical Approval
This work did not involve the use of animals and therefore ethical approval was not necessarily required.