The relationships between symptom clusters and contributing factors in patients with esophageal cancer: structural equation modelling based on theory of unpleasant symptoms

The caring behaviors of nurses play a crucial role in improving the quality of care in hospitals. This study aimed to investigate the symptom clusters of patients with esophageal cancer undergoing radiotherapy or chemoradiotherapy, as well as the relationship among symptom clusters, NLR (neutrophil to lymphocyte ratio), ALB (albumin), anxiety, depression, social support, self-care, and self-efficacy through structural equation modeling based on the theory of unpleasant symptoms (TOUS). A cross-sectional study was conducted from December 2021 to December 2023 among 310 patients with esophageal cancer at a general hospital in Jiangsu Province. Data were collected using a general information questionnaire, five scales including the esophageal cancer symptom assessment, scales of anxiety and depression, social support, self-care and self-efficacy, and NLR, ALB levels test. Collected data were analyzed by IBM SPSS v26.0 and AMOS 24.0. A total of 289 valid questionnaires for each scale (five scales) were collected. The study identified four distinct symptom clusters: reflux cough (severity score: 17.85 ± 5.74), dysphagia (severity score: 16.66 ± 4.52), adverse reaction (severity score: 10.87 ± 3.78), and energy deficiency (severity score: 15.1 ± 3.33). These symptom clusters demonstrated significant correlations with NLR, ALB, psychological states, social support, self-care, and self-efficacy (all P < 0.01). Symptom clusters exerted significant negative effects on both self-care (β = -0.194, P = 0.007) and self-efficacy (β = -0.363, P = 0.007). Furthermore, social support fully mediated the effect of symptom clusters on self-efficacy (total effect: P = 0.001), and ALB levels fully mediated the effect of symptom clusters on self-care (total effect: P = 0.001). Social support alleviates symptom clusters through direct or indirect effects in esophageal cancer patients undergoing chemoradiotherapy. Similarly, ALB levels improve self-care ability by modulating symptom severity and boosting self-efficacy. Future studies should investigate the differential impacts of social support types (family, medical staff, peers) and nutritional interventions (e.g., family involvement, multidisciplinary collaboration) on specific symptom cluster-self-efficacy pathways.