Interaction effect of comorbid depression and proactive positivity coping strategy on the 1-year survival of patients with advanced cancer: a nationwide multicentre study in South Korea

Abstract

Background: Comorbid depression and poor performance status are associated with increased mortality and reduced quality of life in patients with advanced cancer. Coping strategies based on “proactive positivity” may facilitate adaptation to functional decline and limited life expectancy. However, few studies have examined the impact of the interaction between depressive symptoms and coping strategies on survival outcomes in this population. This study investigated the associations of 1-year survival with the interaction between comorbid depression and proactive coping strategies, and performance status, in patients with advanced cancer. Methods: This was a secondary analysis of data from a multicentre randomized clinical trial of patients with advanced cancer (ClinicalTrials.gov Identifier: NCT03181854). A total of 144 patients who were aware of their cancer diagnosis were recruited from 12 tertiary hospitals across South Korea between October 2017 and October 2018. In this prospective cohort design, participants were stratified into subgroups with higher versus lower levels of baseline proactive coping (proactive positivity) and followed for 1 year to assess survival status. Demographic and socioeconomic data were collected via self-report questionnaires, while cancer diagnosis and treatment information was obtained from attending oncologists. Cancer-related physical functioning, depressive symptoms, and coping strategies were assessed at baseline and at 12 weeks using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scale, the Patient Health Questionnaire-9 (PHQ-9), and the Smart Management Strategy for Health Assessment Tool– short form (SAT-SF), respectively. Univariate Cox regression analyses were conducted to identify factors associated with 1-year survival, and a multivariate Cox proportional hazards model was developed to evaluate the predictive impact of performance status, depression, and the interaction between depression and proactive positivity. Results: In univariate Cox regression models, lower performance status (ECOG-PS = 2; hazard ratio [HR] = 2.33, 95% confidence interval [CI]: 1.25–4.34) and comorbid depression (PHQ-9 ≥ 10; HR = 2.76, 95% CI: 1.72–4.42) were associated with increased risk of not surviving for 1 year. In the multivariate model, among patients with lower proactive positivity (SAT-SF Core strategies score ≤ 66.66/100), comorbid depression was associated with a 363% higher risk of 1-year mortality compared to those without depression (adjusted HR = 4.63, 95% CI: 2.54–8.43). Conversely, the association between depression and 1-year survival was not statistically significant among patients with higher proactive positivity (SAT-SF score > 66.66/100). Conclusions: Comorbid depression is associated with a significantly higher risk of 1-year mortality in patients with advanced cancer who exhibit lower levels of proactive positivity, but not in those with higher levels of proactive coping. These findings highlight the importance of incorporating assessments of psychological resilience and coping strategies into the clinical management of advanced cancer. Trial registration: Registry (ClinicalTrials.gov); registration number (NCT03181854); study registration dates [first submitted (2017-06-07), first submitted that met QC criteria (2017-06-07), first posted (2017-06-09)] © The Author(s) 2025.