Introduction
Advanced pancreatic and gastric cancers represent a major clinical challenge in oncology due to their poor prognosis, high symptom burden, and substantial impact on patients’ quality of life (QoL; Tang et al. Reference Tang, Von Ah and Fulton2018; Dose et al. Reference Dose, McCabe and Krecke2019). These malignancies are frequently diagnosed at advanced stages and are commonly managed with systemic chemotherapy, which aims to control disease progression but is often associated with significant physical and psychological side effects. Patients typically experience a wide range of symptoms, including pain, fatigue, gastrointestinal disturbances, nutritional impairment, and sleep disruption, which may be attributable both to the disease itself and to treatment-related toxicity (Seo et al. Reference Seo, Kim and Kang2016; Tang et al. Reference Tang, Von Ah and Fulton2018). The cumulative burden of these physical symptoms increases vulnerability to psychological distress. Patients with advanced pancreatic and gastric cancer frequently report elevated levels of emotional suffering, including anxiety, depression, and existential distress (Vergo et al. Reference Vergo, Nimeri and Mulcahy2014). In the context of persistent and unaddressed distress, individuals may experience a progressive erosion of meaning, loss of personal identity, and diminished sense of purpose, which in some cases may be associated with a desire for hastened death (Balaguer et al. Reference Balaguer, Monforte-royo and Porta-sales2016). These processes are further exacerbated by increasing dependence, functional decline, and uncertainty regarding prognosis, all of which may threaten patients’ sense of dignity. Dignity has been identified as a core dimension of the experience of serious illness and a fundamental component of patient-centered care (Balaguer et al. Reference Balaguer, Monforte-royo and Porta-sales2016). Loss of dignity has been associated with increased psychological suffering, reduced will to live, and poorer overall QoL in patients with advanced cancer (Zimmermann et al. Reference Zimmermann, Swami and Krzyzanowska2014). For this reason, the integration of psychosocial interventions aimed at preserving dignity and supporting patients’ sense of identity alongside medical treatment has become an important focus in oncology. Emerging evidence suggests that early integration of such interventions may contribute to improved psychological outcomes and, in some cases, enhanced overall well-being (Chochinov et al. Reference Chochinov, Kristjanson and Breitbart2011; Chochinov Reference Chochinov2013; Martínez et al. Reference Martínez, Arantzamendi and Belar2017).
Among dignity-conserving interventions, Dignity Therapy (DT), developed by Chochinov and colleagues (Chochinov Reference Chochinov2012), is a brief, structured psychotherapeutic approach designed to address psychological and existential distress in patients with advanced illness. Grounded in the Dignity Model for Terminally Ill Patients (Grassi et al. Reference Grassi, Caruso and Ventura2017), DT supports individuals in reflecting on meaningful aspects of their lives, reinforcing a sense of continuity and purpose, and creating a generativity document to be shared with loved ones. A substantial body of literature has demonstrated that DT is associated with high levels of patient satisfaction and may improve dignity, sense of meaning, spiritual well-being, and QoL in palliative care settings (Rossi Ferrario et al. Reference Rossi Ferrario, Miccinesi and Chiri2004). While DT was originally developed for patients receiving end-of-life care, an increasing number of studies have explored its applicability earlier in the disease trajectory, including during active oncological treatment. Emerging evidence suggests that DT may be both feasible and clinically meaningful for patients actively coping with cancer diagnosis and treatment-related challenges. For example, Vergo et al. (Reference Vergo, Nimeri and Mulcahy2014) demonstrated the feasibility and acceptability of DT in patients with stage IV colorectal cancer undergoing chemotherapy, reporting positive psychosocial outcomes. Similarly, Dose and Rhudy (Reference Dose and Rhudy2018) found that patients newly diagnosed with advanced cancer perceived DT as a valuable opportunity for emotional expression, personal reflection, and meaning-making during active treatment. More recent investigations have further supported the application of DT in non-terminal oncology populations. Lin et al. (Reference Lin, Guo and Xi2023), Kelly et al. (Reference Kelly, O’donoghue and Power2023), Xiao et al. (Reference Xiao, Chow and Choi2022), and Gonzalez-ling et al. (Reference Gonzalez-ling, Vázquez and Espinoza2022) reported beneficial effects on emotional distress, dignity, spiritual well-being, psychological symptoms, and QoL among patients receiving active cancer treatment. Consistent with these findings, a recent meta-analysis by Zhang et al. (Reference Zhang, Li and Hu2022) demonstrated that DT may contribute to improvements in hope, QoL, anxiety, and depression in cancer populations. Furthermore, qualitative research has highlighted how DT may facilitate emotional expression, identity preservation, relational connectedness, and meaning-making throughout the cancer experience (Buonaccorso et al. Reference Buonaccorso, Tanzi and Borreani2021). Recent reviews have likewise emphasized the growing interest in extending DT beyond traditional palliative care settings and into earlier phases of the illness trajectory, where patients are confronted with the psychological and existential challenges associated with diagnosis and treatment (Yanez et al. Reference Yanez, Vásquez-santillán and Morán2025). Collectively, these findings suggest that DT may represent a flexible and valuable supportive intervention across multiple stages of cancer care, extending well beyond its original end-of-life context.
Despite these promising findings, there remains a relative paucity of research specifically examining the application of DT in patients undergoing chemotherapy for cancers characterized by particularly poor prognoses, such as advanced pancreatic and gastric cancer. These populations share important clinical features, including high symptom burden, rapid disease progression, and significant psychosocial vulnerability, which make them especially relevant targets for dignity-preserving interventions. However, they have been relatively underrepresented in DT research. Furthermore, although previous studies have included mixed cancer samples, fewer investigations have focused on more clinically homogeneous groups or on the early phases of treatment, when patients are actively coping with diagnosis and treatment-related challenges rather than approaching end of life. In this context, the present exploratory study aims to extend the current literature by investigating the feasibility and potential impact of DT in patients with advanced pancreatic and gastric cancer undergoing chemotherapy. Specifically, the study evaluates changes in emotional distress, dignity-related distress, and QoL across 3 time points (baseline, post-intervention, and 1-month follow-up), in order to better understand the role of DT as a supportive intervention during the early phases of oncological treatment.
Methods
Participants
The sample consisted of 30 patients (mean age = 68.3 years, SD = 5.03) receiving chemotherapy for advanced pancreatic or gastric cancer, in both day-hospital and inpatient settings, recruited from the Oncology Department of the Istituto Ospedaliero of Fondazione Poliambulanza. Participants were diagnosed with either advanced pancreatic cancer or advanced gastric cancer; the presence of both conditions in the same patient was not required. Data were collected between June 2023 and December 2024. The study was approved by the Institutional Research Ethics Board (NP 5811) on 24 April 2023, and all eligible patients provided written informed consent prior to participation. Inclusion criteria were (1) diagnosis of advanced pancreatic or gastric cancer; (2) age ≥ 18 years; and (3) ability to understand the study protocol and provide informed consent. Exclusion criteria included a prior diagnosis of dementia or psychotic disorders according to DSM-5 criteria.
Materials
Dignity Therapy
DT is a brief, person-centered psychotherapeutic intervention aimed at alleviating psychological and existential distress in patients with advanced illness. Developed by Chochinov et al. (Reference Chochinov, Hack and Hassard2005), DT supports individuals in affirming their sense of dignity through guided life reflection, the transmission of meaningful memories, and the creation of a legacy document. The intervention was delivered across 3 sessions, with a frequency of approximately one session per week. In the first session, the therapist introduced the purpose of the intervention and conducted a recorded semi-structured interview, inviting the patient to reflect on meaningful life events, values, and messages for loved ones. The recorded material was transcribed and edited into a first-person narrative (generativity document). In the second session, the patient reviewed the draft and suggested revisions to ensure accuracy and authenticity. In the final session, the completed document was presented to the patient, who could choose to share it with family members or significant others. This session also provided an opportunity for therapeutic closure and reinforcement of meaning and continuity.
Distress Thermometer
Psychological distress was evaluated using the Distress Thermometer developed by the National Comprehensive Cancer Network. This single-item screening tool asks patients to rate their level of distress over the past week on a scale from 0 (no distress) to 10 (extreme distress), and is accompanied by a Problem List assessing practical, emotional, family, spiritual, and physical concerns. The Italian validated version was used, demonstrating good reliability and concurrent validity. A cut-off score of ≥4 indicates clinically relevant distress.
Patient Dignity Inventory
Dignity-related distress was measured using the Patient Dignity Inventory (PDI), a 25-item self-report questionnaire developed to assess threats to dignity in patients with advanced illness. The Italian validated version demonstrated excellent internal consistency (α = 0.94) and strong construct validity. Items are rated on a 5-point Likert scale (1 = not a problem to 5 = an overwhelming problem), with higher scores indicating greater dignity-related distress.
European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30
QoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). This 30-item instrument evaluates functional domains, symptom burden, and global health status. The validated Italian version was administered according to EORTC guidelines. Scores are transformed to a 0–100 scale, with higher scores on functional and global QoL scales indicating better functioning, and higher scores on symptom scales indicating greater symptom burden.
Study design
This exploratory longitudinal study was conducted across 3 assessment phases. Eligible patients were identified by the oncology team during routine clinical care and were subsequently approached by members of the psycho-oncology service, who provided study information and obtained written informed consent before enrolment. DT was delivered by licensed psychologists with specific training in psycho-oncology and previous experience in the administration of DT. Whenever feasible, outcome assessments were conducted by psycho-oncology clinicians not directly involved in delivering the intervention, in order to reduce potential assessment bias.
At baseline (T0), participants completed a questionnaire collecting sociodemographic and clinical data, along with standardized measures assessing emotional distress (Distress Thermometer), dignity-related distress (PDI), and QoL (EORTC QLQ-C30). Participants then underwent the standard 3-session DT protocol. Sessions were scheduled at approximately weekly intervals and the intervention was completed within 21–23 days for all participants. Minor scheduling adjustments were occasionally required to accommodate chemotherapy appointments, hospitalization schedules, or temporary changes in patients’ clinical conditions; however, no participant who completed the study deviated substantially from the planned 3-week intervention timeframe.
At the end of the intervention (T1), all outcome measures were re-administered. A follow-up assessment (T2) was conducted approximately 1 month after completion of DT to reassess emotional distress, dignity-related distress, and QoL. Given the limited follow-up period, this assessment was intended to provide information on short-term trajectories rather than long-term effectiveness. Brief qualitative feedback was also collected at T1 and T2 as descriptive contextual information, as detailed below.
Qualitative feedback collection and analysis
In addition to quantitative assessments, participants were invited to provide brief qualitative feedback regarding their experience of DT. Feedback was collected at completion of the intervention (T1) and again at the 1-month follow-up assessment (T2).
Participants were invited, through structured open-ended prompts, to describe aspects of the intervention they found meaningful, useful, or challenging, and to share reflections on its perceived impact on their emotional experience and coping with illness. Feedback was collected during clinical encounters conducted by psycho-oncology clinicians and documented in written notes immediately after the sessions. Audio-recordings and verbatim transcriptions were not performed.
Given the exploratory nature of the study, qualitative data were not analyzed using a formal qualitative methodology. Instead, participants’ comments were reviewed descriptively to identify recurring topics related to the subjective experience and perceived usefulness of DT. These observations were used to contextualize the quantitative findings and should therefore be interpreted as descriptive rather than as results of a formal qualitative analysis.
Statistical analysis
Continuous variables were expressed as means and standard deviations, while categorical variables were reported as counts and percentages. In addition to descriptive statistics, exploratory inferential analyses were conducted to assess within-subject changes over time. Paired-sample t-tests were used to compare scores between baseline (T0), post-intervention (T1), and follow-up (T2). Effect sizes (Cohen’s d) were calculated to estimate the magnitude of observed changes. Due to the unavailability of individual-level change scores, effect sizes were estimated using pooled standard deviations and should therefore be considered approximate. Given the exploratory design and absence of a control group, all findings were interpreted with caution.
Results
A total of 53 patients were initially recruited for the study. Of these, 23 patients (43%) did not complete the intervention because of clinical deterioration, death, or withdrawal of consent. The final sample consisted of 30 participants who completed all 3 assessment time points (T0, T1, and T2). The mean age of the sample was 68.03 years (SD = 5.01; range 60–77). Most participants were female (n = 17; 56.7%), while 13 (43.3%) were male. Regarding marital status, 66.7% of participants were married (n = 20), while 33.3% were cohabiting (n = 10). No participants were single, separated, divorced, or widowed. In terms of educational level, 66.7% had completed middle school (n = 20), and 33.3% had completed high school (n = 10). With regard to employment status, 56.7% of participants were retired (n = 17), 40.0% were employed (n = 12), and 3.3% were unemployed (n = 1). Finally, 50.0% of participants had metastatic pancreatic cancer (n = 15), and 50.0% had metastatic gastric cancer (n = 15).
Emotional distress
Emotional distress, as measured by the Distress Thermometer, showed a significant reduction over time. Scores decreased from baseline (T0: M = 6.67, SD = 1.47) to post-intervention (T1: M = 3.13, SD = 1.43), with this reduction being statistically significant (p < .001) and associated with a large effect size (d ≈ 2.42). At follow-up (T2: M = 3.50, SD = 1.53), distress levels remained significantly lower compared to baseline (p < .001; d ≈ 2.10), suggesting maintenance of the observed improvement over time.
Perceived dignity
Perceived dignity, assessed through the PDI, showed a marked decrease in total scores across time points, indicating a reduction in dignity-related distress. Mean scores declined from T0 (M = 37.1, SD = 3.03) to T1 (M = 27.9, SD = 1.79), with a statistically significant difference (p < .001) and a very large effect size (d ≈ 3.77). A further decrease was observed at follow-up (T2: M = 25.4, SD = 12.86), which remained significantly lower than baseline levels (p < .01; d ≈ 1.22). However, the higher variability observed at T2 suggests greater heterogeneity in patient responses at follow-up.
Quality of life
QoL, measured through the EORTC QLQ-C30 global score, remained generally stable across time points. The mean score showed a slight decrease from 61.06 at T0 to 58.4 at T1, followed by a return to values comparable to baseline at T2. Inferential analyses were not conducted for QoL due to incomplete data availability. Overall, these findings suggest changes over time in emotional distress and dignity-related distress, while QoL remained stable. However, given the study design, no causal relationship between the intervention and the observed changes can be established.
Descriptive qualitative feedback
Participants’ descriptive feedback indicated that the intervention was generally perceived as meaningful and manageable despite the demands of chemotherapy. The opportunity to reflect on personal values, life experiences, and messages for loved ones was frequently described as helpful in supporting emotional adjustment during treatment. These observations were not derived from a formal qualitative analysis and are presented only as contextual information supporting the interpretation of the quantitative findings.
Discussion
This exploratory study investigated the feasibility and potential impact of DT in patients with advanced pancreatic and gastric cancer undergoing active chemotherapy. The findings indicate a significant reduction in emotional distress and dignity-related distress over time, alongside a general stability in QoL. From a quantitative perspective, emotional distress showed a marked and statistically significant decrease from baseline to post-intervention, with a large effect size, and this reduction was maintained at follow-up. Similarly, dignity-related distress demonstrated a substantial decline across time points, with very large effect sizes observed between baseline and post-intervention, and a sustained, although more variable, improvement at follow-up. These results suggest that patients experienced meaningful changes in psychological and existential domains during the study period. These findings are consistent with previous literature indicating that DT may support emotional well-being, dignity, and meaning in patients with advanced illness (Chochinov et al. Reference Chochinov, Hack and McClement2002; Hall et al. Reference Hall, Goddard and Opio2011; Julião et al. Reference Julião, Oliveira and Nunes2014). Importantly, the present study extends existing research by examining the application of DT during the early phases of treatment, rather than in end-of-life contexts. While DT was originally developed for palliative care settings, emerging evidence suggests that it can be effectively integrated into earlier stages of the disease trajectory, including during active chemotherapy. The present results align with prior studies in patients receiving active oncological treatment, including the work by Dose and Rhudy (Reference Dose and Rhudy2018), who described DT as meaningful and acceptable shortly after diagnosis, and Gonzalez-ling et al. (Reference Gonzalez-ling, Vázquez and Espinoza2022), who reported improvements in psychological symptoms and QoL among patients with lung cancer experiencing emotional distress. Together, these findings support the growing view that DT may have relevance beyond end-of-life care and can address psychosocial needs that emerge earlier in the cancer trajectory. A key consideration concerns the interpretation of the observed changes. Given the single-group design and the absence of a control condition, it is not possible to attribute these improvements exclusively to DT. The reductions in distress and improvements in perceived dignity may reflect a combination of factors, including the natural course of psychological adaptation, the effects of medical treatment, symptom stabilization, and the supportive context in which care was delivered. Therefore, the findings should be interpreted as indicative of associations rather than causal effects. The pattern observed in QoL, which remained relatively stable over time, may further support this interpretation. It is possible that the physical burden associated with chemotherapy counterbalanced potential psychological improvements, limiting observable changes in global QoL scores. Alternatively, QoL instruments may be less sensitive to short-term existential or emotional changes, which are more directly captured by measures such as the Distress Thermometer and the PDI. An important aspect emerging from this study is the potential need to adapt DT when applied to patients in earlier phases of the illness trajectory. Unlike end-of-life contexts, patients undergoing active treatment shortly after diagnosis may not yet be oriented toward life closure or legacy construction. In this phase, DT may function less as an intervention focused on life completion and more as a meaning-centered approach that supports identity continuity, emotional processing, and coping with uncertainty. This interpretation is consistent with the qualitative findings reported by Buonaccorso et al. (Reference Buonaccorso, Tanzi and Borreani2021), who identified identity preservation, emotional expression, and meaning-making as central processes facilitated by DT in cancer populations. The narrative and reflective components of DT may help patients maintain a sense of coherence and personal meaning while navigating a highly unstable and demanding clinical phase (Ando et al. Reference Ando, Morita and Akechi2010). The descriptive feedback collected in this study provides additional support for this interpretation. Participants frequently described DT as a meaningful opportunity to express important thoughts, reconnect with personal values, and strengthen relational bonds (McClement et al. Reference McClement, Chochinov and Hack2007). These observations are consistent with previous research highlighting the role of narrative and dignity-conserving interventions in fostering psychological resilience and a sense of personal continuity. Despite these promising findings, several limitations must be acknowledged. The small sample size and the exploratory nature of the analyses limit the generalizability of the results. The absence of a control group precludes causal inference, and the high attrition rate (43%) may have introduced selection bias, as patients who completed the study may differ from those who withdrew because of clinical deterioration or other factors. Furthermore, the greater variability observed in dignity-related distress at follow-up suggests heterogeneity in patient responses over time, which warrants further investigation. In addition, effect sizes were estimated using pooled standard deviations due to the unavailability of individual-level change scores and should therefore be interpreted as approximate. The relatively short follow-up period also limits conclusions regarding the persistence of these effects over time. In conclusion, this study provides preliminary evidence that DT can be feasibly implemented during active chemotherapy and may be associated with improvements in emotional and dignity-related outcomes in patients with advanced pancreatic and gastric cancer. These findings support the potential role of DT as a supportive, meaning-centered intervention early in the cancer trajectory. Future research employing controlled designs and larger samples is needed to clarify the specific contribution of DT and to identify the optimal conditions for its integration into standard oncological care.
Conclusion
This exploratory study provides preliminary evidence that implementing DT early in the treatment trajectory – shortly after diagnosis and during active chemotherapy – is feasible and acceptable for patients with advanced pancreatic or gastric cancer. The observed reductions in emotional distress and improvements in perceived dignity suggest that DT may support psychological and existential adaptation during demanding phases of oncological treatment. These findings extend current knowledge by indicating that DT, traditionally used in palliative and end-of-life contexts, can also be integrated into earlier stages of cancer care. Participants described DT as a meaningful opportunity to reflect on personal values, reinforce identity, and strengthen relational connections, highlighting its potential relevance in populations facing poor prognoses. However, given the exploratory design, small sample size, and absence of a control group, these findings should be interpreted with caution. Further controlled studies are needed to confirm these preliminary observations, clarify the specific contribution of DT, and determine its optimal timing and delivery within standard oncological care. If supported by future research, the early integration of DT may represent a valuable addition to patient-centered, dignity-oriented supportive care.
Study limitations
Despite the promising observations, several limitations must be acknowledged. First, the relatively small sample size (N = 30) limits the generalizability of the findings and reduces the statistical power of the analyses. Second, the single-group design and the absence of a control condition represent important methodological limitations, as they preclude causal inferences. The observed changes in emotional distress and perceived dignity may reflect a combination of factors, including the natural course of psychological adaptation, the effects of ongoing medical treatment, symptom stabilization, and the supportive care context. The high attrition rate (43%) represents an additional limitation and may have introduced selection bias, as patients who completed the study could differ systematically from those who withdrew due to clinical deterioration or other factors. Furthermore, although exploratory inferential analyses were conducted, effect sizes were estimated using pooled standard deviations due to the unavailability of individual-level change scores and should therefore be interpreted as approximate. The study did not account for individual differences in coping style, psychological resilience, or family involvement, which may have influenced patient outcomes. In addition, the relatively short follow-up period does not allow conclusions regarding the long-term persistence of the observed changes. Finally, qualitative data were collected to support the interpretation of quantitative findings; however, these data were not analyzed using a formal qualitative methodology and should therefore be considered descriptive. Future research should prioritize larger, controlled studies to confirm these preliminary findings and to further clarify the potential contribution of DT within standard oncological care. Additional investigations may also explore broader outcomes, including treatment adherence, caregiver burden, patient–physician communication, and longer-term psychological adjustment.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Funding
This study was made possible through the financial support of Ricerchiamo Onlus Association, Brescia, Italy.
Competing interests
The authors declare none.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The present study was approved by the Ethics Committee of Brescia, Italy, approval no. 5811 on 24 April 2023.
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