ORIGINAL ARTICLE

High level of unmet needs and anxiety are associated with delayed

initiation of adjuvant chemotherapy for colorectal cancer patients

Li Zhu

& Yi Xin Tong

& Xiang Shang Xu

& Ai Tang Xiao

& Yu Jie Zhang

& Sheng Zhang

Received: 22 October 2019 / Accepted: 28 January 2020

The Author(s) 2020

Abstract

Aims Adjuvant chemotherapy is recommended for patients with curatively resected colorectal cancer. The aim of this study is to

evaluate the impact of unmet supportive care needs and anxiety on the initiation of postoperative adjuvant chemotherapy in

colorectal cancer patients.

Methods This is a retrospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met

the inclusion criteria were included. The Hospital Anxiety and Depression Scale (HADS) and modified 34-item Supportive Care

Needs Survey (SCNS-SF34) were applied to assess patient’s anxiety level and unmet needs. The time intervals between initiation

of adjuvant chemotherapy and operation were recorded. Factors associated with delayed initiation of chemotherapy were

investigated in univariate and multivariate analysis.

Results A total of 135 patients with colorectal cancer were included. In total, 16.3% (22/135) and 5.2% (7/135) reported

symptoms of anxiety and depression. In multivariate analysis, low to moderate income status, postoperative complications,

anxiety, and high level of unmet needs are independent risk factors for late initiation of chemotherapy.

Conclusions Our findings showed that psychological problems such as anxiety and high unmet supportive needs are correlated

with delayed initiation of adjuvant chemotherapy in colorectal cancer patients.

Keywords Colorectal cancer

Adjuvant chemotherapy

Delay initiation of chemot herapy

Patient’sneeds

Anxiety

Depression

SCNS-SF34

Introduction

Colorectal cancer (CRC) is the third most common cancer and

the fourth leading cause of c ancer death in the world [1].

Surgery together with adjuvant chemotherapy (AC) remains

the standard treatment for stage III colorectal cancer patients

and selected stag e II patients [ 2 –4]. The recently updated

National Comprehensive Cancer Network (NCCN) guidelines

suggested that the optimal timing to initiate postoperative ad-

juvant chemotherapies should be in/between 4 and 8 weeks

after operations [5]. A systematic and meta-analysis involving

15,410 colorectal patients demonstrated that a 4-week incre-

ment in time to adjuvant chemotherapy was associated with a

14% decrease in both overall survival (OS) and disease-free

survival (DFS) [6]. Another two large-scale retrospective

studies from the US and Netherlands National Cancer

Database also showed that a delay of 6–8 weeks between

surgery and adjuvant therapy would reduce survival in stage

II and III colorectal cancer patients [7, 8].

Electronic supplementary material The online version of this article

(https://doi.org/10.1007/s00520-020-05333-z) contains supplementary

material, which is available to authorized users.

* Sheng Zhang

szhang5@tulane.edu

Li Zhu

125683844@qq.com

Yi Xin Tong

yx_tong@126.com

Xiang Shang Xu

xsxu@tjh.tjmu.edu.cn

Ai T ang Xiao

pekjean@126.com

Yu Jie Zhang

1179204979@qq.com

Department of Gastrointestinal Surgery, Tongji Hospital, Tongji

Medical College, Huazhong University of Science and Technology,

Jie Fang Ave, No, Wuhan 1095, China

Supportive Care in Cancer

https://doi.org/10.1007/s00520-020-05333-z

Multiple factors including patient demographics, advanced

clinical stage, surgical techniques, and postoperative compli-

cations may correlate with the delay initiation of adjuvant

chemotherapy [9, 10]. The lack of relevant knowledge may

lead to patients’ distress and decease compliance to postoper-

ative chemotherapy [11]. Many reports indicated that individ-

ualized cancer patients suffer from emotional disorders includ-

ing anxiety and depression, which may compromise the effect

of treatments [12]. Meanwhile, high level of unmet supportive

care needs is prevalent among cancer survivors which may

have a negative impact on clinical management [13].

The impact of patients’ psychological status and level of

unmet needs on the start time of adjuvant chemotherapy has

not been studied. This study focuses on exploring clinical and

psychological factors associated with delayed initiation of ad-

juvant chemotherapy. We hypothesize that high level of anx-

iety and unmet supportive needs may lead to a delayed com-

mencement of postoperative adjuvant chemotherapy in colo-

rectal cancer patients.

Method

Study design and participants

In a single tertiary referral hospital, data from patients with

colorectal cancer who underwent adjuvant chemotherapy be-

tween April 2017 and November 2018 were retrospectively

collected and analyzed. Patients aged over 18 years who met

the following inclusion criteria were recruited in the study: (1)

histopathologically confirmed diagnosis of colorectal cancer

(sites of the original were classified as colon and rectum); (2)

are aware they will receive adjuvant chemotherapy and can

communicate with our medical professional team. The exclu-

sion criteria were (1) diagnosis of other malignancies; (2) pa-

tients already received neoadjuvant therapy; (3) plan to re-

ceive adjuvant chemotherapy in other hospitals; (4) with con-

current psychiatric disorder or other mental problems and fail

to communicate with our team members. Ethical approval for

the study was obtained from the institutional medical ethics

committee. Informed consent was signed by all participants.

Data collection

The following information was collected for analysis: (1) de-

mographic characteristics such as age, gender, education sta-

tus, socioeconomic status, patients’ performance status (ac-

cording to classification of the Eastern Cooperative

Oncology group) [14], and site of origin; (2) clinical or labo-

ratory characteristics such as neutrophil to lymphocyte ratio

(NLR), serum tumor markers as carcinoembryonic antigen

(CEA) and carbohydrate antigen 19-9 (CA19-9), tumor size,

differentiation, invasion depth (T), presence of lymph node

metastases (N), presence of distant metastases (M), treatment,

and surgical approach; (3) postoperative information such as

postoperative complication (according to the Clavien-Dindo

criteria [15]), length of stay, readmission, types of adjuvant

chemotherapy, and initiation timing of chemotherapy.

Anxiety/depression and supportive needs

measurement

Hospital Anxiety and Depression Scale (HADS) was applied

to assess self-reported symptoms of anxiety and depression.

The HADS consists of 14 items: 7 for anxiety and 7 for de-

pression. Participants answered the questions on a 4-point

Likert scale. The total score for each scale ranges from 0 to

21. The cut-off value for definite cases of anxiety and depres-

sion is a score ≥ 11 [16, 17]. Supportive care needs for cancer

patients were measured by the modified 34-item Supportive

Care Needs Survey (SCNS-SF34). The modified version was

adapted from the validated mandarin version of SCNS-SF34

with questions chosen from item 2–14, 17, 20–26, 28, and 29

[18]. We add 12 items specifically concerning relevant needs

for chemotherapy to the modified version of SCNS-SF34. The

modified SCNS-SF34 assesses cancer patients’ needs in five

domains: physical and daily living (4 items), psychological

(10 items), patient care and support (6 items), health systems

and information (7 items), and chemotherapy (7 items)

(Supplemental Table 1). Participants will indicate their level

of need for the help for each item on a 5-point Likert scale: 1 =

no need, not applicable; 2 = no need, satisfied; 3 = low need;

4 = moderate need; 5 = high need. A standardized Likert-

summated score for each item ranging from 0 to 100 was

calculated, with higher scores representing higher levels of

need for help [18].

The Chinese version of HADS and modified SCNS-SF34

questionnair es were distributed to recruited participants in

48 h after administration. Two colorectal surgeons conducted

the communication and explanation for patients with difficul-

ties in understanding the items in each questionnaire. We col-

lected all the questionnaires before discharge of the patients.

Outcomes and follow-up

The primary endpoint of this study was the starting time of

postoperative adjuvant chemotherapy. The secondary end-

point was the completion time and rate of adjuvant chemo-

therapy. We also evaluated the factors associated with delayed

initiation of AC using multivariable analysis. We defined “ear-

ly initiation” as the initiation of AC < 4 weeks and “delayed

initiation” as the initiation of AC ≥ 8 weeks. The total follow-

up period is 12 months. This study was approved by the ethics

committees of Tongji hospital. The purpose and content of the

study were explained to t he participants. All participants

signed the informed consent and confidentiality was assured.

Support Care Cancer

Statistical analyses

All continuous variables were presented as medians

(range) and analyzed with the chi-square test or Mann-

Whitney U test. Categorical variables were reported as

whole numb ers an d per cent ages. The receiv er ope ration

curve (ROC curve) method w as used to det ermine the

cut-off value of modified SCNS-SF34 score as “low need”

and “ high need.” The Kaplan-Meier method was used to

evaluate potential predictive factors for delayed initiation

of adjuvant chemotherapy. Only factors with p value < 0.1

in univariate analysis were included in the final multivar-

iate analysis model. M ultivariate Cox regression was

employed to identify indepe ndent predic tive fac tors for

delayed initiation of chemotherapy. All statistical tests

were performed in the SPSS version 21 (IBM, Armonk,

NY, USA) with a significance level of p va l ue < 0.05 .

Results

Patient baseline and clinicopathological

characteristics

One hundred fifty-three patients were recruited and consid-

ered eligible for this study. After screening based on inclu-

sion and exclusion criteria, 135 patients were successfully

followed up and included i n final study. The median age of

included patients was 55.00 ± 9.73 and most patients were

men (100/135, 74.1%). A total of 73.3% (99/135) patients

were dia gnosed with rec tum cancer an d 26.7% (36 /135)

were colon cancer. All patients underwent laparoscopic

operati on a nd 1 3. 3% ( 18/ 1 35 ) of t hem w er e co n ver te d to

open operation. In total, 4.4% (6/135) patients suffered

from ≥ grade 3 postoperative complications and the median

hospital stay is 16 ± 4.7 days. The median time between

adjuvant chemotherapy and operation was 28 ± 14.9 days.

The proportions of patients receiving AC within 4 weeks

and 8 weeks were 59.3% (80/135) and 94.1% (127/135),

respectively. A total of 73.3% (99/135) completed full cy-

cles of adjuvant chemotherapy. Other information was

summarized in Table 1.

Prevalence of anxiety, depression, and supportive

care needs

Among 135 c olorectal cancer patie nts, 16.3% (22/135)

and 5.2% (7/135) reported symptoms of anxiety and de-

pression (HADS-anxiety or HADS-depression score ≥ 11)

(Table 2). The average SCNS-SF34 standardized score of

the patients was 54.2 ± 7.3. Half of the top 10 needs items

were from the chemotherapy-related domain, two were

from the patient care and support domain, and other three

Table 1 The demographic and clinicopathological characteristics of

patient

Variable Total (n =135)

Baseline characteristics

Age, median (IQR), year 55.00 ± 9.73

Gender

Male

Female

74.1% (100/135)

25.9% (35/135)

ECOG status

8.1% (11/135)

91.9% (124/135)

Education

Illiterate/primary school

High school/undergraduate

26.7% (36/135)

73.3% (99/135)

Socioeconomic status

Low to moderate income

High income

78.5% (106/135)

21.5% (29/135)

Smoking

Yes

30.4% (41/135)

69.6% (94/135)

Alcohol

Yes

25.9% (35/135)

74.1% (100/135)

Clinicopathological parameters

Location

Colon

Rectum

26.7% (36/135)

73.3% (99/135)

T stage (pT)

0.7% (1/135)

15.6% (21/135)

55.6% (75/135)

28.1% (38/135)

N stage (pN)

55.6% (75/135)

29.6% (40/135)

14.8% (20/135)

Tumor size (IQR) cm 3.80 ± 1.30

Differentiation

Well

Medium

Poor

9.6% (13/135)

63.7% (86/135)

26.7% (36/135)

Blood NLR (IQR) 2.41 ± 1.75

Serum CEA

Normal

Elevated

73.3% (99/135)

26.7% (36/135)

Serum CA19-9

Normal

Elevated

84.4% (114/135)

15.6% (21/135)

Operation

Laparoscopic

Conversion to laparotomy

86.7% (117/135)

13.3% (18/135)

Postoperative parameters

Complication

Grades 1 and 2

86.7% (117/135)

8.9% (12/135)

Support Care Cancer

are of physical and daily living, psychological and health

system, and information domain, respectively. The t en

most frequently reported common unmet needs were

listed in Table 3. Compared with patients with low unm et

needs, patients with higher unmet needs showed signifi-

cant lower percentage of early initiation of AC < 4 w eeks

(25.9% vs 81.5%) and higher percentage of delayed initi-

ation of AC ≥ 8weeks(14.8%vs0%).

Factors associated with the timing to adjuvant

chemotherapy

Risk factors identified f rom univariate analysis were

showninTables4 and 5. Kaplan-Meier analysis showed

that socioeconomic status, serum CEA, postoperative

complications, HADS-anxiety status, HADS-depression

status, and SCNS-SF34 score were significantly associat-

ed with early initiation (< 4 weeks) and delayed initiation

(≥ 8 weeks) of adjuvant chemotherapy.

In the multivariate analysis, socioeconomic status, postop-

erative complications, HADS-anxiety status, and high unmet

supportive needs were identified as independent prognostic

factors associated with early initiation and delayed initiation

of adjuvant chemotherapy. For early initiation of chemother-

apy, high income (p = 0.012), no anxiety (p =0.009),andlow

unmet needs (p < 0.001) were significantly associated with

early initiation of AC. For delayed chemotherapy ≥8weeks,

low to moderate income (HR = 2.159, p = 0.001), presence of

postoperative complications (HR = 2.263, p = 0.006), and

high unmet needs (HR = 2.905, p < 0.001) were independent

risk factors. The details of multivariate analysis were listed in

Tables 4 and 5.

Conclusions

Discussion of the results

A retrospective study was performed to evaluate clinical char-

acteristics as well as psychological factors related to early and

delayed initiation of adjuvant chemotherapy in colorectal can-

cer patients. Our results demonstrated that low unmet needs

status is significantly correlated with early initiation of AC

(HR = 4.162) while high unmet supportive needs is an inde-

pendent risk factor for delayed initiation AC (HR = 2.905). In

addition, high-income status (HR = 1.880) and no anxiety sta-

tus (HR = 3.881) are correlated with early initiation of AC. A

low to moderate income status (HR = 2.159) and presence of

postoperative complication (HR = 2.263) are independent risk

factors for delayed initiation of AC.

The initiation of chemotherapy treatment may have impact

on patients’ psychological and physical states. Smooth transi-

tion to postoperative adjuvant chemotherapy is critical in co-

lorectal cancer treatment. Although currently there is no con-

sensus on the exact time to initiate adjuvant chemotherapy, it

is generally agreed that the start time of chemotherapy should

be no later than 8 weeks after operation [5–9]. The potential

reasons for the delay of chemotherapy generally lie in the

following aspects: patient-related factors such as lower socio-

economic status, female gender, and older age; treatment-

related factors such as postoperative complications, surgical

approach (open vs laparoscopic), and chemotherapy reagents;

Table 2 The prevalence of anxiety and depression and supportive needs

of patient

Variable Total (n =135)

Anxiety and depression

HADS-anxiety score

8–10

≥ 11

61.5% (83/135)

22.2% (30/135)

16.3% (22/135)

HADS-depression score

8–10

≥ 11

72.6% (98/135)

22.2% (30/135)

5.2% (7/135)

SCNS-SF34 standardized score 54.2 ± 7.3

Low need (SCNS-SF34 score < 56)

High need (SCNS-SF34 score ≥ 56)

60.0% (81/135)

40.0% (54/135)

HADS, Hospital Anxiety and Depression Scale; SCNS-SF34, 34-item

Supportive Care Needs Survey

Table 1 (continued)

Variable Total (n =135)

≥ Grade 3 4.4% (6/135)

Hospital stay, median, days 16 ± 4.7

Time between AC and operation, median, days 28 ± 14.9

AC within 4 weeks

Yes

59.3% (80/135)

40.7% (55/135)

AC within 8 weeks

Yes

94.1% (127/135)

5.9% (8/135)

AC regimen

CapeOX

SOX

Capecitabine/S-1

FOLFOX6

Other

83.0% (112/135)

8.1% (11/135)

3.7% (5/135)

3.0% (4/135)

2.2% (3/135)

AC complete rate

Yes

73.3% (99/135)

26.7% (36/135)

CI, confidence interval; IQR, interquartile range; EC OG,Eastern

Cooperative Oncology group; CEA, carcinoembryonic antigen; CA19-9,

carbohydrate antigen; NLR, neutrophil to lymphocyte ratio; AC, adjuvant

chemotherapy

Support Care Cancer

Table 3 Ten most frequently reported unmet needs (modified SCNS 34)

Rank Modified SCNS-SF34 item Domain Average score N (%) of unmet

needs

1 Item 29, being informed the reason to receive chemotherapy after surgery

and common side effects

Chemotherapy 73.6 ± 23.8 113/135 (85.7%)

2 Item 31, the common side effects of chemotherapy and how to handle them Chemotherapy 73.4 ± 25.0 105/135 (77.8%)

3 Item 8, fears about the cancer spreading Psychological 70.2 ± 25.6 104/135 (77.0%)

4 Item 28, being informed about the foods for recovery and foods to avoid Chemotherapy 68.8 ± 23. 2 104/135 (77.0%)

5 Item 27, being informed about things you can do to help yourself to get well Health system and

information

68.2 ± 26.8 96/135 (71.1%)

6 Item 30, the time to start chemotherapy and how many cycles to receive Chemotherapy 68.2 ± 27.4 96/135 (71.1%)

7 Item 20, cost of surgery and chemotherapy Patient care and support 67.8 ± 27.2 98/135 (72.6%)

8 Item 18, financial support and insurance coverage for my disease and treatment Patient care and support 66.6 ± 27.8 96/135 (71.1%)

9 Item 4, not being able to do the things you used to do Physical and daily living 64.8 ± 26.6 95/135 (70.4%)

10 Item 32, emotional scared of chemotherapy Chemotherapy 64.8 ± 27.8 94/135 (69.6%)

SCNS-SF34, 34-item Supportive Care Needs Survey

Table 4 Univariate and

multivariate analysis for factors

effecting early initiation (<

4 weeks) of AC

Variables Univariate HR p value Multivariate HR p value

Age

≥ 75

<75

1(Ref)

1.176 0.625

Socioeconomic status

Low to moderate income

High income

1(Ref)

2.389 < 0.001

1(Ref)

1.880 0.012

Education

Illiterate/primary school High school/undergraduate 1 (Ref)

1.318 0.294

Cancer TYPE

Rectal

Colon

1(Ref)

1.332 0.236

Serum CEA

Elevated

Normal

1(Ref)

1.475 0.156

Serum NLR

≥ 2.4

<2.4

1(Ref)

1.366 0.221

Complication

Yes

1(Ref)

3.807 0.009

HADS-anxiety

Yes (≥ 11)

No (< 11)

1(Ref)

5.081 0.020

1(Ref)

3.881 0.009

HADS-depression

Yes (≥ 11)

No (< 11)

1(Ref)

5.866 0.079

SCNS-SF34 score

High need

Low need

1(Ref)

4.577 < 0.001

1(Ref)

4.162 < 0.001

HR, hazard ratio; CEA, carcinoembryonic antigen; AC, adjuvant chemotherapy; NLR, neutrophil to lymphocyte

ratio; NS, not significant

Support Care Cancer

social and psychological factors such as lack of insurance,

lack of social support, and insufficient knowledge on chemo-

therapy [10, 19–22]. In our study, we found that low income

status and postoperative complications negatively correlated

with the initiation of chemotherapy in colorectal cancer pa-

tients, whi ch is in accordance wi th the present reports. In

addition, we for the first time explored and demonstrated that

anxiety status and high unmet needs may also correlate with

the initiation time of chemotherapy.

Studies have also shown t hat most cancer patients ex-

perience certain level of emotional distress such as anxi-

ety and d e pr es si on [23]. It has been reported that the psy-

chological problems such as anxiety and depression may

lead to negative outcome in cancer perioperative treatment

such as decreased adherence to oral chemotherapy [24].

Meanwhile, cancer patients suffered from various physical

and psychological needs when they started chemotherapy

[25]. Advanced stage, higher levels of distress, younger

age, and woman gender are some predictors for higher

level of supportive needs [26]. In our study, we found that

colorectal cancer patients experience certain level of anx-

iety (16.3%) and depression (5.2%). Patients without anx-

iety tend to start AC w ithin 4 we eks (HR = 3.881) . It

could be reasonable that patients suffered from anxiety

may be afraid of postoperative chemotherapy and l ead to

the early delayed initiation. In addition, we also explored

the prevalence of unmet supportive needs of colorectal

cancer patients with modified SCNS-SF34 (simplified

Chinese version) [18]. Our results supported our hypoth-

esis that higher u nmet needs status is a risk fac tor for

delayed initiation of postoperative chemotherapy.

Although previous studies showed t hat the perceived un-

met needs of cancer patients are associated with poor psy-

chological status and lower quality of life [27], our study

for the first time showed that higher unmet needs post-

poned the initiation of postoperative chemotherapy.

Table 5 Univariate and

multivariate analysis for factors

effecting delayed initiation (≥

8 weeks) of AC

Variables Univariate HR p value Multivariate HR p value

Age

<75

≥ 75

1(Ref)

0.932 0.798

Socioeconomic status

High income

Low to moderate income

1(Ref)

1.979 0.002

1(Ref)

2.159 0.001

Education

High school/undergraduate

Illiterate/primary school

1(Ref)

1.136 0.526

Cancer type

Colon

Rectal

1(Ref)

1.014 0.944

Serum CEA

Normal

Elevated

1(Ref)

1.376 0.118

Serum NLR

<2.4

≥ 2.4

1(Ref)

1.131 0.527

Complication

Yes

1(Ref)

2.451 0.002

1(Ref)

2.263 0.006

HADS-anxiety

No (< 11)

Yes (≥ 11)

1(Ref)

2.046 0.004

HADS-depression

No (< 11)

Yes (≥ 11)

1(Ref)

2.984 0.017

SCNS-SF34 score

Low need

High need

1(Ref)

3.182 < 0.001

1(Ref)

2.905 < 0.001

HR, hazard ratio; CEA, carcinoembryonic antigen; AC, adjuvant chemotherapy; NLR, neutrophil to lymphocyte

ratio; NS, not significant

Support Care Cancer

It has been estimated that up to 50% of patients may expe-

rience a variety of physical and psychological disorders after

diagnosis of cancer and during chemotherapy [28, 29]. Our

results indicated that cancer patients experienced high level of

unmet needs and may need support and practical help in the

management of chemotherapy. Adjuvant chemotherapy is the

standard treatment for stage III colorectal cancer patients after

curative operation. There are few reports that have studied the

techniques for improvement of chemotherapy adherence in

patients with colorectal cancer. Furthermore, previous studies

failed to prove the effectiveness of interventions in reducing

the unmet needs in cancer patients [30]. In our study, there are

a rather large proportion of patients with low education

(26.7% illiterate/primary school) that might have certain bias

in the questionnaires and might impede future educational

intervention. Literatures reported that the proportion of low

educational level (illiterate/primary school) of cancer patients

in China varies from 20 to 50% [31–34], which is in accor-

dance with our study. The educational level of cancer patients

in China is generally in low level compared with that in de-

veloped countries. Therefore, personalized education and

family member support program may be beneficial for colo-

rectal cancer patients to a better management and adherence of

adjuvant chemotherapy.

Limitations

The present study has several limitations that should be taken

into consideration. First, a relatively small number of patients

were included in this study. Second, due to the retrospective

setting, our study might inevitably have selection bias and

some data might be missing. Third, we need further verifica-

tion of the reliability of the modified SCNS-SF34 scale. In

addition, information of outcome measurements, such as qual-

ity of life, patients’ satisfaction, and patient-reported adher-

ence, were not evaluated in our study. Therefore, further per-

spective study with a larger sample size and more outcome

measurements are needed to validate the finding of our study

and further explore the effectiveness of individualized patient

education program.

Conclusion and clinical implications

Despite the limitations mentioned above, there are still

many valuable implications of this retrospective study.

First, to the best of our knowledge, our study f or the first

time indicated that high level of unmet needs and anxiety

contributed to delayed initiation of adjuvant chemotherapy

in pati ents with col orectal cancer. Second, our findings

suggested that individualized education program to relieve

patients’ anxiety and improve unmet needs might be effec-

tive in improving chemotherapy initiation and adherence.

Based on our results and limitations, we hypothesized that

cancer patients’ unmet need would have negative impact

on chemotherapy adherence. Furthermore, we will further

confirm the conclusion in a future w ell-designed random-

ized controlled trial and investigate various interventi ons

to enhance patients’ adherence in chemotherapy.

Acknowledgments The authors thank Ms. Cheng Chen for English

grammatical correction of this manuscript.

Author contributions All authors participated in the study design. All

authors have agreed on the final version and meet the major criteria

recommended by the ICMJE (http://www.icmje.org/). In detail, Li Zhu

conceptually designed the study and wrote the draft. Yi Xin Tong and

Xiang Shang Xu collected the relevant data and followed up the patients.

Ai Tang Xiao and Yu Jie Zhang performed stati stical analysis and

interpretation of the data. Sheng Zhang revised the manuscript and final

approval.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of

interest.

Ethical approval This study was approved by the ethics committee of

Tongji Hospital, Tongji Medical College, Huazhong University of

Science and Technology.

Open Access This article is licensed under a Creative Commons

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need to obtain permission directly from the copyright holder. To view a

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