Introduction
A cancer diagnosis is not only a somatic challenge but also a profound psychological stressor (Cordova et al., Reference Cordova, Riba and Spiegel2017; Peters et al., Reference Peters, Brederecke, Franzke, De Zwaan and Zimmermann2020; Tang et al., Reference Tang, Mangantig, Iskandar, Cheng, Yusuf and Jia2024). The disease itself, as well as its treatment and prognosis, often exerts a heavy emotional burden on patients and can lead to significant mental health problems. Despite the high psychological distress experienced by many cancer patients, psychiatric symptoms are frequently underrecognised and undertreated in oncological care (Kazlauskiene and Bulotiene, Reference Kazlauskiene and Bulotiene2020; Unseld et al., Reference Unseld, Zeilinger, Fellinger, Lubowitzki, Krammer, Nader, Hafner, Kitta, Adamidis, Masel, Preusser, Jäger and Gaiger2021; Gaiger et al., Reference Gaiger, Lubowitzki, Krammer, Zeilinger, Acel, Cenic, Schrott, Unseld, Rassoulian, Skrabs, Valent, Gisslinger, Marosi, Preusser, Prager, Kornek, Pirker, Steger, Bartsch, Raderer, Simonitsch‐Klupp, Thalhammer, Zielinski and Jäger2022). From a public health perspective, the psychological burden associated with cancer represents a substantial yet under-addressed component of the disease.
Post-traumatic stress has emerged as an issue of particular concern in cancer care. While post-traumatic stress symptoms (PTSS) refer to the overall trauma-related symptomatology, post-traumatic stress disorder (PTSD) refers to the formal diagnosis based on diagnostic guidelines. Studies demonstrate that PTSD is more prevalent among individuals with cancer than in the general population. Reported prevalence rates range widely (Wu et al., Reference Wu, Wang, Cofie, Kaminga and Liu2016; Kazlauskiene and Bulotiene, Reference Kazlauskiene and Bulotiene2020; Šimunović and Ljubotina, Reference Šimunović and Ljubotina2020; Zerbinati et al., Reference Zerbinati, Murri, Caruso, Nanni, Lam, De Padova, Sabato, Bertelli, Schillani, Giraldi, Fielding and Grassi2021; Goerling et al., Reference Goerling, Ernst, Esser, Haering, Hermann, Hornemann, Hövel, Keilholz, Kissane, Von Dem Knesebeck, Lordick, Springer, Zingler, Zimmermann, Engel and Mehnert-Theuerkauf2024; Jimenez-Labaig et al., Reference Jimenez-Labaig, Aymerich, Braña, Rullan, Cacicedo, González-Torres, Harrington and Catalan2024). This variation is likely to reflect differences in study methods, cancer types, diagnostic tools and sample characteristics. Nevertheless, the consistent finding is that PTSD is a significant mental health problem in oncology.
Previous research has identified several individual factors that may contribute to the development of PTSD in cancer populations. Among these are younger age, female sex, lack of social support or being unpartnered and a history of prior psychiatric illness (Swartzman et al., Reference Swartzman, Booth, Munro and Sani2017; Lin et al., Reference Lin, Kao, Pan and Liu2020; Goerling et al., Reference Goerling, Ernst, Esser, Haering, Hermann, Hornemann, Hövel, Keilholz, Kissane, Von Dem Knesebeck, Lordick, Springer, Zingler, Zimmermann, Engel and Mehnert-Theuerkauf2024). While some studies suggest a protective effect of higher socio-economic resources (Zhao et al., Reference Zhao, Mazanec and Rosenzweig2022; Zeilinger et al., Reference Zeilinger, Knefel, Schneckenreiter, Pietschnig, Lubowitzki, Unseld, Füreder, Bartsch, Masel, Adamidis, Kum, Kiesewetter, Zöchbauer-Müller, Raderer, Krauth, Staber, Valent and Gaiger2023), findings in this area are inconsistent (Kazlauskiene and Bulotiene, Reference Kazlauskiene and Bulotiene2020; Goerling et al., Reference Goerling, Ernst, Esser, Haering, Hermann, Hornemann, Hövel, Keilholz, Kissane, Von Dem Knesebeck, Lordick, Springer, Zingler, Zimmermann, Engel and Mehnert-Theuerkauf2024).
Studies assessing the clinical impact conclude that PTSD can interfere with treatment adherence, reduce patients’ engagement with care and impair quality of life (Swartzman et al., Reference Swartzman, Booth, Munro and Sani2017; Maraqa and Ahmead, Reference Maraqa and Ahmead2021). Moreover, accumulating evidence suggests that psychological distress may even interact with disease progression, physiological functioning and survival outcomes (Gaiger et al., Reference Gaiger, Lubowitzki, Krammer, Zeilinger, Acel, Cenic, Schrott, Unseld, Rassoulian, Skrabs, Valent, Gisslinger, Marosi, Preusser, Prager, Kornek, Pirker, Steger, Bartsch, Raderer, Simonitsch‐Klupp, Thalhammer, Zielinski and Jäger2022; Roche et al., Reference Roche, Cooper, Armstrong and King2023; Wu et al., Reference Wu, Wang, Zeng, Peng, Liu, Tian, Yao, Liang, Deng, Qiu, Ma, Liu and Hu2024; Zeilinger et al., Reference Zeilinger, Zrnic-Novakovic, Oppenauer, Fellinger, Knefel, Unseld, Wagner, Lubowitzki, Bartsch, Zöchbauer-Müller, Raderer, Staber, Valent and Gaiger2024; Song et al., Reference Song, Pang, He, Lu, Fang, Zhang, Cao, Jiao, Zhou, Qi, Gong, Wang, Li, Liu and Tang2025). Therefore, understanding the occurrence and impact of PTSS in cancer patients holds both scientific and clinical significance.
However, existing research into PTSS among cancer patients is fragmented, often restricted to small or diagnosis-specific samples, limiting generalisability and obscuring broader epidemiological patterns. Few studies have examined prevalence and correlates in large, heterogeneous cohorts using tools validated for oncology populations within real-world care settings. This study addresses these gaps by analysing routine screening data from over 4,000 adult outpatients with a wide range of cancer types. Specifically, this study aims to (a) estimate the prevalence of probable PTSD using the PTSS-8-Cancer scale, (b) examine associations with key socio-demographic and psychosocial variables and (c) identify subgroups with elevated prevalence to inform targeted prevention and service planning. By examining the prevalence, distribution and risk factors of PTSS in a large cohort of cancer patients, our findings aim to support mental health policy development and the integration of trauma-informed approaches into cancer care pathways.
Methods
This large-scale cross-sectional study was designed as a naturalistic, population-based screening within routine clinical practice, allowing for ecologically valid prevalence estimates of PTSD across a broad spectrum of cancer diagnoses.
Participants
This study included outpatients diagnosed with either a solid organ cancer or a haematologic neoplasm. To be eligible, participants had to be at least 18 years old and have sufficient German language skills and cognitive ability to understand the study materials.
Materials
PTSS were assessed using the German version of the Post-Traumatic Stress Scale 10-item version (Maercker, Reference Maercker, Hoyer and Margraf2010). This scale evaluates PTSD symptoms based on diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), which were relevant for most of the data collection period. However, following recent recommendations advocating for the use of the 8-item version of this scale in cancer populations (Zeilinger et al., Reference Zeilinger, Nader, Fuchs, Pietschnig, Knefel, Oberleiter, Unseld, Valent and Gaiger2025), the psychometrically validated PTSS-8-Cancer version was utilised for analysis in this study. Items are rated on a 4-point Likert scale. Higher values indicate a higher symptom burden in the past 7 days. The total score represents the sum of all item scores and ranges from 0 to 24. A cut-off score of 10 indicates probable PTSD.
In this sample, the PTSS-8-Cancer demonstrated good internal consistency (α = 0.82; ω t = 0.82). Additionally, a socio-demographic questionnaire was administered to gather patient characteristics.
Procedure
Data collection was conducted as part of a routine screening at the Department of Internal Medicine I, Division of Haematology and Hemostaseology and Division of Oncology, Medical University of Vienna at the General Hospital of Vienna. During their waiting time, patients were handed out a questionnaire to screen for psychological disorders and assess psychosocial characteristics (e.g., household income). As this was a real-world sample from an ambulatory cancer care centre, the patients varied in terms of disease stage and treatment. The response rate for completing the questionnaire was 78%, with the primary reasons for non-participation being a lack of interest or time constraints. Participants who agreed to participate provided written informed consent prior to participation. The study protocol was approved by the Institutional Ethics Committee at the Medical University of Vienna (EC Nr: 473/2006, 1241/2021). The data used in this study were collected between 2013 and 2023.
Statistical analysis
Complete data on the PTSS-8-Cancer were available for n = 3,992 participants. For cases with ≤2 missing items, missing values were imputed using the individual case mean, resulting in a total sample of N = 4,103.
Descriptive statistics were used to characterise the sample, with percentages and means reported. Prevalence rates of probable PTSD were calculated as the percentage of participants scoring above the cut-off. Variables used for the following analyses were chosen based on previous literature and data availability. A Mann–Whitney U test was conducted to assess age differences between participants with probable PTSD and those with a negative screening.
A Chi-square test was used to explore the relationship between PTSD (probable PTSD vs negative screening) and the presence of previous psychiatric illnesses and sex. For assessing the relationship between sex and PTSD, item 4 was not considered in scoring, as it has been identified as a source of sex bias in past research on cancer patients (Zeilinger et al., Reference Zeilinger, Nader, Fuchs, Pietschnig, Knefel, Oberleiter, Unseld, Valent and Gaiger2025). In order to explore the relationship between socio-economic patient characteristics and PTSD (probable PTSD vs negative screening), a chi-square test was employed for education (≤upper secondary education/≥post-secondary education), income (<€1,300/≥€1,300) and family status (single/in a partnership). Effect sizes were interpreted according to Cohen’s guidelines (Reference Cohen1988). All analyses were performed using IBM SPSS Statistics (Version 29).
Results
Sample characteristics
The sample comprised N = 4,103 (50.4% female) participants who had a haematological disease (21.2%) or a solid tumour (78.8%). Participants’ ages ranged between 18 and 96 years (M = 59.2, SD = 14.2). Sample characteristics are displayed in Table 1. Within the 9.5% of participants who reported a previous psychiatric illness, only 67.4% provided information on the specific type of illness. Among those, the most frequently reported diagnoses were depressive disorder (69.5%), occupational burnout (8.4%) and panic disorder (6.5%). The most frequent types of solid tumours were breast cancer, lung cancer and soft tissue tumours (see Table 2).
Socio-demographic characteristics of the sample
Table 1 Long description
Characteristics are reported as counts in the column labeled n and percentages in the column labeled percent. Marital status includes single, widowed and divorced at 1,386 and 35.9 percent, and married slash partnered at 2,477 and 64.1 percent. 2,612 and 71.8 percent of participants reported having children. Living area is rural at 969 and 26.3 percent, and urban at 2,722 and 73.7 percent. Highest educational level is lower secondary education at 379 and 10.1 percent, upper secondary education at 1,692 and 45.1 percent, post secondary education at 729 and 19.4 percent, and university college at 949 and 25.3 percent. Monthly household income is less than 800 Euro at 151 and 4.5 percent, 800 to 1300 Euro at 680 and 20.4 percent, 1300 to 2200 Euro at 1,059 and 32.9 percent, and greater than 2200 Euro at 1,400 and 42.1 percent. Employment is unemployed at 332 and 8.9 percent, employed slash self employed at 1,521 and 40.4 percent, and retired at 1,895 and 50.6 percent. 351 and 9.5 percent of participants reported having had a previous psychiatric illness.
N = 4103.
a For calculation of percentages, missing values were excluded.
b Reflects the number and percentage of participants answering ‘yes’ to this question.
Types of cancer/neoplasms in the patient sample
Table 2 Long description
Cancer types are listed with counts and percentages for women, men, and the total sample, with women numbered 2,060 and men numbered 3,032, for a total sample of 4,092. Total sample counts and percentages by cancer type are: thyroid 29 and 0.7 percent; brain 150 and 3.7 percent; pancreas 219 and 5.4 percent; haematological 869 and 21.2 percent; female genital organs 43 and 1.1 percent; lung 454 and 11.1 percent; stomach or oesophagus 128 and 3.1 percent; head and neck 266 and 6.5 percent; soft tissue 374 and 9.1 percent; breast 648 and 15.8 percent; testis 44 and 1.1 percent; kidney, urinary tract, or bladder 193 and 4.7 percent; colon or rectum 322 and 7.9 percent; hepatobiliary 135 and 3.3 percent; malignant melanoma 81 and 2.0 percent; prostate 107 and 2.6 percent; other solid tumour 30 and 0.7 percent. Women counts and percentages include breast 633 and 30.7 percent, haematological 407 and 19.8 percent, lung 215 and 10.4 percent, and soft tissue 180 and 8.7 percent. Men counts and percentages include haematological 462 and 22.7 percent, lung 239 and 11.8 percent, soft tissue 194 and 9.5 percent, head and neck 193 and 9.5 percent, and colon or rectum 188 and 9.3 percent. Female genital organs has values only for women, and testis and prostate have values only for men. Cancer type information is missing for 11 participants, indicated by the footnote marker on the total sample column header.
a Information on cancer type was missing for n = 11 participants.
Prevalence rates of PTSD symptoms
In the total sample, 1,334 (32.5%) participants met the criteria for a suspected diagnosis of PTSD. The mean PTSS-8-Cancer score was 8.23 (SD = 5.29, range = 0–24). The prevalence of suspected PTSD diagnosis by cancer site showed that the prevalence was highest in patients with breast cancer (39.7%), cancer of the female genital organs (37.2%) and head and neck cancer (36.1%). The lowest rates were found in patients with testis cancer (20.5%) and kidney/urinary tract/bladder cancers (26.4%). The prevalence of PTSD according to cancer types is depicted in Fig. 1.
Prevalence of post-traumatic stress symptoms per cancer type. The figure shows the percentage of patients with significant PTSD symptoms, categorised per cancer type.
Patient characteristics associated with PTSD symptoms
Results indicated a significant age difference between participants with suspected PTSD (M Rank = 1,975.34) and those with a negative PTSD screening (M Rank = 2,088.93), U = 1,744,653.50, Z = −2.88, p = 0.004, r = −0.04, indicating that participants with suspected PTSD were younger than those with a negative screening. There was a significant relationship with a small effect size between a previous psychiatric illness and PTSD symptoms. Sex was significantly associated with PTSD. Women were more likely than men to report PTSD symptoms above the diagnostic threshold, with a small effect. No significant relationship was found between educational level and PTSD symptoms.
Individuals with an income below the minimum wage screened positive for PTSD more frequently than those with higher income. Furthermore, single, widowed or divorced individuals were more likely to report PTSD symptoms than individuals married or in a partnership. Chi-square test results are displayed in Table 3.
Associations between patient characteristics and suspected PTSD
Table 3 Long description
Associations with suspected PTSD are reported for five variables using columns for chi squared, degrees of freedom, sample size n, p value, and phi. Sex has chi squared 67.69, df 1, n 4,103, p less than .001, and phi 0.13. Education has chi squared 0.18, df 1, n 3,749, p less than .001, and phi minus 0.01. Income has chi squared 13.91, df 1, n 3,326, p less than .001, and phi minus 0.07. Relationship status has chi squared 10.31, df 1, n 3,863, p less than .001, and phi minus 0.05.
Discussion
This large-scale cross-sectional study assessed PTSS in a sample of 4,103 cancer patients. This makes it one of the most comprehensive investigations to date into the prevalence of PTSD and its psychosocial correlates across a wide range of cancer types. We found that approximately one-third of patients (32.5%) met the threshold for probable PTSD based on the PTSS-8-Cancer scale, indicating a substantial psychological burden in this population. Importantly, elevated PTSS rates were not confined to a single cancer type but were particularly pronounced among patients with breast cancer (39.7%), female genital cancers (37.2%) and head and neck cancer (36.1%). These findings not only highlight the clinical relevance of PTSS in oncology but also carry epidemiological implications: given that one in three patients may be affected, the cumulative burden on population health and healthcare systems is considerable.
While these findings largely underscore existing literature, the rates observed in the present study are overall higher (Lin et al., Reference Lin, Kao, Pan and Liu2020; Šimunović & Ljubotina, Reference Šimunović and Ljubotina2020; Zerbinati et al., Reference Zerbinati, Murri, Caruso, Nanni, Lam, De Padova, Sabato, Bertelli, Schillani, Giraldi, Fielding and Grassi2021; Goerling et al., Reference Goerling, Ernst, Esser, Haering, Hermann, Hornemann, Hövel, Keilholz, Kissane, Von Dem Knesebeck, Lordick, Springer, Zingler, Zimmermann, Engel and Mehnert-Theuerkauf2024; Jimenez-Labaig et al., Reference Jimenez-Labaig, Aymerich, Braña, Rullan, Cacicedo, González-Torres, Harrington and Catalan2024). Our findings also draw attention to underrecognised groups, such as patients with head and neck tumours, whose psychological distress may be underestimated in routine care. Head and neck cancers, often involving visible disfigurement and impairments in speech or swallowing, appear to impose a distinct psychological burden (Jimenez-Labaig et al., Reference Jimenez-Labaig, Aymerich, Braña, Rullan, Cacicedo, González-Torres, Harrington and Catalan2024). The high prevalence observed in cancers affecting women may, in part, reflect gender-related vulnerability to trauma but may also be linked to the profound impact of these diagnoses on body image, femininity and identity (Wu et al., Reference Wu, Wang, Cofie, Kaminga and Liu2016; Zerbinati et al., Reference Zerbinati, Murri, Caruso, Nanni, Lam, De Padova, Sabato, Bertelli, Schillani, Giraldi, Fielding and Grassi2021). Conversely, the lower prevalence of PTSD among testicular cancer patients, despite being an exclusively male cohort, could be associated with more favourable prognoses and younger age at diagnosis, although further research is needed to clarify these mechanisms.
The study found several factors associated with PTSS. Younger age was associated with increased symptomatology, a finding supported by existing studies indicating that younger patients may have fewer coping resources and perceive greater disruption to life trajectory (Wu et al., Reference Wu, Wang, Cofie, Kaminga and Liu2016; Swartzman et al., Reference Swartzman, Booth, Munro and Sani2017; Lin et al., Reference Lin, Kao, Pan and Liu2020). Women also reported more PTSS, consistent with the broader PTSD literature and previous cancer-specific research (Kazlauskiene and Bulotiene, Reference Kazlauskiene and Bulotiene2020; Goerling et al., Reference Goerling, Ernst, Esser, Haering, Hermann, Hornemann, Hövel, Keilholz, Kissane, Von Dem Knesebeck, Lordick, Springer, Zingler, Zimmermann, Engel and Mehnert-Theuerkauf2024). The role of sex in this regard may be partially explained by biological vulnerability and differences in emotional processing or disclosure. Furthermore, women tend to be more open than men when it comes to disclosing psychological symptoms.
Patients who were single, widowed or divorced also demonstrated a higher prevalence of PTSD. While this supports the view that social support serves as a buffer against psychological distress (Mitchell et al., Reference Mitchell, Antoni, Shaffer and Kim2023), the literature remains inconclusive, with some studies reporting that relationship status alone is an insufficient proxy for actual social support quality (Kazlauskiene and Bulotiene, Reference Kazlauskiene and Bulotiene2020; Chu et al., Reference Chu, Wong and Lu2021). Future research should prioritise nuanced assessments of relational dynamics and perceived support.
Lower income was another significant correlate of PTSS, reinforcing findings that socio-economic vulnerability amplifies the psychological burden of illness (Zhao et al., Reference Zhao, Mazanec and Rosenzweig2022) and also impedes access to care (Zeilinger et al., Reference Zeilinger, Lubowitzki, Unseld, Schneckenreiter, Heindl, Staber, Raderer, Valent, Zöchbauer-Müller, Bartsch, Prager, Jaeger and Gaiger2022). In contrast, education level showed no significant association, echoing mixed findings in the literature and suggesting that financial strain may play a more direct role than educational attainment in modulating trauma-related distress. Interestingly, although prior psychiatric history was associated with PTSD, the effect size was modest. This suggests that while prior psychological vulnerability contributes to PTSS risk, the cancer experience itself may act as a distinct and potent traumatic event, supporting the conceptualisation of cancer as a trauma in its own right (Cordova et al., Reference Cordova, Riba and Spiegel2017).
From a clinical standpoint, the small effect sizes associated with socio-demographic predictors underscore that no group is categorically ‘low-risk’. While certain characteristics can help to identify individuals who may be more vulnerable, a universal screening approach is warranted to ensure that no distressed patient is overlooked. Additionally, emerging evidence suggests that the risk for psychological distress is not static but evolves over time through complex interactions among biological, psychological and social factors (Knefel et al., Reference Knefel, Zeilinger, Lubowitzki, Krammer, Unseld, Bartsch, Fuereder, Jäger, Kiesewetter, Krauth, Raderer, Staber, Valent and Gaiger2023), underscoring the need for longitudinal research into PTSS trajectories and their prognostic relevance.
Strengths and limitations
A key strength of this study is its large, heterogeneous sample drawn from routine clinical practice, enhancing the ecological validity and generalisability of findings. The use of the PTSS-8-Cancer scale, a version adapted for oncology settings, also provides a measure tailored to the population studied.
However, limitations should be acknowledged. PTSD was assessed using a self-report screening tool rather than a structured clinical interview, which may inflate prevalence estimates compared to diagnostic assessments (Swartzman et al., Reference Swartzman, Booth, Munro and Sani2017). Due to limited data availability, we did not account for time since diagnosis, type of treatment, adverse childhood experiences or experiences that patients attributed their symptoms to. Future research should explore how these factors relate to the outcome and the direction of their association.
Moreover, the PTSS-8 is based on DSM-III criteria, which differ from current conceptualisations of PTSD (e.g., DSM-5), particularly regarding the emphasis on re-experiencing and cognitive symptoms. While the scale remains psychometrically sound, future studies should employ up-to-date diagnostic tools for greater diagnostic precision.
Conclusion
This study provides robust evidence that PTSS are common among cancer patients, with approximately one-third of individuals in a large, diverse clinical sample screening positive for probable PTSD. Elevated PTSS rates were particularly evident in patients with breast cancer, female genital cancers and head and neck cancers, pointing to the need for increased psychosocial attention in these subgroups. While associations with age, sex, income, relationship status and prior psychiatric history were statistically significant, effect sizes were small, suggesting that psychological distress is broadly distributed and not confined to specific demographic profiles.
These findings highlight the value of universal psychosocial screening and trauma-informed care in oncology settings. Integrating routine mental health assessments into cancer care may facilitate earlier identification and support for patients experiencing distress. As cancer care continues to evolve, a holistic approach that addresses the full biopsychosocial needs of patients will be essential to improving quality of life and may also help in improving clinical outcomes.
Availability of data and materials
The data that support the findings of this study are openly available in The Open Science Framework (OSF; https://doi.org/10.17605/OSF.IO/DR2HU).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration. Ethical approval was granted by the ethics committee of the Medical University of Vienna (EC Nr: 473/2006; 1241/2021).
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