Stress and Anxiety Before Biopsy, After Biopsy Results, and During Treatment in Patients With Suspected Bone or Soft Tissue Cancer

BIOPSY-STRESS is a single-center, prospective observational cohort study conducted at Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, in collaboration with the Department of Psychiatry. Approximately 100 eligible adults who are scheduled for clinically indicated biopsy because of a suspected solid tumor will be recruited consecutively.

Psychological assessments will be performed at three prespecified stages of routine clinical care: before biopsy, after the pathology result or diagnosis has been communicated to the participant, and at treatment initiation. The assessments will include the Hospital Anxiety and Depression Scale, the Perceived Stress Scale, and the Distress Thermometer.

Relevant demographic, clinical, and radiological information will be obtained from routine hospital records, the hospital information management system, the picture archiving and communication system, and patient files. Prespecified clinical variables will include age, sex, disease stage or extent, metastasis status, and treatment type. No additional biopsy, imaging examination, laboratory test, or other invasive procedure will be performed for research purposes. The study will not assign participants to a diagnostic or therapeutic intervention.

The primary objective is to compare within-participant changes in psychological stress and anxiety levels across the pre-biopsy, post-diagnosis, and treatment-initiation assessments. The secondary objective is to identify demographic and clinical factors associated with higher psychological stress or anxiety.

Participant characteristics and questionnaire scores will be summarized using appropriate descriptive statistics. Change across the three assessment points will be evaluated using repeated-measures analysis of variance when the relevant assumptions are satisfied or the Friedman test when those assumptions are not satisfied. Where appropriate, multivariable linear regression or linear mixed-effects models will be used to examine associations between psychological outcomes and prespecified demographic and clinical factors. Effect estimates and 95% confidence intervals will be reported.

Study data will be collected prospectively and stored in coded form with access restricted to authorized study personnel. Participation involves only questionnaires and collection of routine clinical information. Possible research-related burdens include temporary emotional discomfort and fatigue while completing the questionnaires. Participants may pause questionnaire completion or withdraw from the study. Participants with marked anxiety or depressive symptoms, or those who report suicidal ideation, will be referred for same-day psychiatric evaluation in accordance with the study safety plan.

Inclusion criteria

• Age 18 years or older.
• Scheduled for biopsy because of a suspected solid tumor.
• Able to understand and answer the study questionnaires.
• Able and willing to provide written informed consent before study participation.

Exclusion criteria

• History of previous malignancy.
• Current serious psychiatric disorder, including major depressive disorder or psychotic disorder.
• Cognitive impairment or communication difficulty that prevents valid completion of the study questionnaires.
• Severe general medical condition or need for emergency intervention that makes study participation inappropriate.