Cancer is well known to be a difficult disease, affecting patients and their families both physically and emotionally. Despite biomedical progress, cancer is still often considered synonymous with death, pain and suffering 1. It is argued that cancer is not just a single event with a certain end but a permanent condition characterized by ongoing ambiguity, potentially delayed or late effects of the disease or its treatment and concurrent psychological issues 2. Previous studies have demonstrated an increased risk for psychiatric morbidity among cancer patients 34. The prevalence of psychiatric disorders in cancer patients varies greatly among studies ranging from 9% to 60% 356, although in large studies using standardized psychiatric interviews and applying research diagnostic criteria the range narrows from 10% to 30% 7.

There are few studies that examined anxiety and depression in gastrointestinal cancer patients. Nordin et al. in their studies of gastrointestinal cancer patients have shown that overall 17% of gastrointestinal patients suffer from anxiety and 21% experience depression and that those with gastric cancer are more vulnerable to psychological distress in connection with the diagnosis than are colorectal cancer patients 89. They also showed that there are only minor changes over time in the average values of emotional well being in these patients 10. In addition they have indicated that levels of anxiety and depression at diagnosis could predict a similar status 6 months later 11. Importantly they found that patients' satisfaction with life, as defined in terms of the discrepancy between the perceived attainment and subjective importance of various life values, is associated with anxiety and depression 12. However, recent studies have reported that anxiety is more common in younger patients and depression in those who experience long-term hospitalization and that coping style might be an important factor in contributing to the level of anxiety and depression in gastrointestinal cancer patients 1314.

The incidence of esophageal and stomach cancer in Iran is high, well above the world average 15. It is the first leading cause of cancer related deaths in men and the second among women 16. This paper reports the results of a study that aimed to investigate about psychological state of Iranian gastrointestinal cancer patients; and to examine the relationship between various demographic and clinical factors and psychological distress in this group of patients. In particular this study aimed to investigate the role of knowledge about the cancer diagnosis and to compare anxiety and depression in patients who knew their cancer diagnosis and those who did not.

The main finding of the current study was the fact that we observed the lower levels of anxiety and depression in patients who did not know their cancer diagnosis. Similarly in Turkey and India it has been demonstrated that psychiatric disorders occur to lesser extent in patients who are not aware of their cancer diagnosis. The authors concluded that these patients had a more hopeful outlook to the outcome of treatment 2324. It is argued that since the majority of physicians in Iran do not inform caner patients about their true nature of illness, most patients who know their diagnosis obtain information indirectly, and thus this might lead to the higher level of emotional distress in patients who become aware of their illness 2526. However, a study of patients with advanced cancer suggested that awareness of prognosis does not itself cause depression 27.

The low level of knowledge of cancer diagnosis (48%) in this study was similar to those reported from Middle East countries 2829. One explanation for this finding could be due to the fact that in developing countries such as Iran the medical team cannot effectively address cancer patients' wishes and needs. The other main reason for not informing patients is that most people in Iran, as in many Middle East or Asian countries, interpret the diagnosis of cancer as equivalent to death and therefore patients' families may request physicians not to tell the patient the diagnosis and the word cancer 2526. A study in Nepal found that 63% of cancer patients were unaware of the nature of their disease while a survey of the general population showed that 80% of the respondents wanted to be informed if they were diagnosed with cancer 30. Similarly, cancer patients in Taiwan expressed a strong preference for health care professionals to inform them of disease related information before disclosing information to their family members 31. It has been suggested that the arguments that cancer patients from Asian cultures have different preferences regarding being informed of their cancer diagnosis and that family members have legitimate superior power in decision-making could not be supported from studies compiling data from these countries 32. However, evidence suggests that sensible disclosure of diagnosis and prognosis is important and satisfaction with information-giving is associated with a better quality of life 33. In addition, there seems to be a strong relationship between illiteracy and not knowing the diagnosis. The relevance of level of education and knowledge of cancer diagnosis seems worthwhile to be examined in the future studies. One might suggest that with regard to culture and resources of medical services in the Middle East there should be two different strategies for cancer disclosure: one for illiterate or less educated people and one for people with higher education.

There was no significant relationship between anxiety, depression and marital status, educational status and gender. A weaker association between demographic parameters and psychiatric morbidity has previously been noted in the presence of physical illness. It has been suggested that demographic differences that predispose to anxiety disorders after life events in the general population become less relevant when a very severe stressor such as cancer occurs 34.

There were no significant association between anxiety and depression and different gastrointestinal cancer site. In general when tumors develop in gastrointestinal tract, special problems in psychological adjustment are posed. Both patient and family may have to cope with severe eating problems, significant weight lost, nausea and vomiting, abdominal discomfort, diarrhea or constipation, as well as other disease related events that are difficult to manage. These problems result in immediate emotional distress and concerns 35. Since the sample in this study was consisted of heterogeneous gastrointestinal cancer patients, common symptoms and discomfort in these people can be a possible reason for lack of relationship between anxiety, depression and different types of the cancer studied. In addition the number of some cancers in the current study were very small and thus to have a better understanding we recommend that for future studies to include patients from only one type of gastrointestinal tract.

A significant relationship was observed between anxiety and age. This is in accordance with previous studies demonstrating that young people are more distressed than elderly patients by serious illnesses such as cancer 13.

In general, because of the frightening and potentially stigmatizing nature of the cancer and high prevalence of psychological distress among cancer patients, physicians should be aware of how much difficulties the patients experience. They should detect and treat problems earlier or refer the patient to the psychiatrists more appropriately. Untreated psychiatric disorder in the presence of co-morbid conditions may result in more frequent clinic visits, increased costs, extended hospitalizations, and reduce compliance and quality of life 36.

Overall 47.2% and 57% of patients with gastrointestinal cancer scored high on both anxiety and depression. Psychological distress was higher in those who knew their cancer diagnosis. It seems that the cultural issues and the way we provide information for cancer patients has an important role in their improved or decreased psychological status.

The author(s) declare that they have no competing interests.

AT was the main investigator and wrote the first draft of the manuscript. MAM contributed to patient recruitments. RR supervised the study. ZT contributed to the data collection. AM supervised the study, analyzed the data and wrote the final draft of the manuscript. SO contributed to the study design. All authors read and approved the final manuscript.