Insult to Injury: Cross-Sectional Analysis of Preoperative Psychosocial Vulnerabilities in Adult Patients Undergoing Major Elective Cancer Surgery

Abstract

Background/Objectives: Psychosocial factors are not routinely screened for during the perioperative period, even though they significantly influence overall health. This study aimed to inventory the psychosocial vulnerabilities among patients undergoing cancer surgery. Methods: We conducted a cross-sectional analysis of a researcher-administered psychosocial screener implemented within a statewide health system between July 2023 and August 2025. A 45 min screener was offered to consecutive adult patients within two weeks before their major elective cancer surgery. Residential addresses were geocoded to assign neighborhood deprivation percentiles for the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI). Elevated psychosocial vulnerability was determined based on a model-based clustering approach, and a high deprivation index was defined as ≥75th percentile. Results: A total of 383 patients (37% response rate) completed the screener, including colorectal (40%), thoracic (36%), and surgical oncology (24%) patients, with a median age of 66 years (IQR, 57-73). Over half (52.0%, n = 199) reported ≥2 psychological and ≥2 social vulnerabilities. Younger patients (p = 0.021), non-white patients (p < 0.001), patients identifying as non-heterosexual (p = 0.014), without a partner (p < 0.001) or private insurance (p = 0.040), and those with lower household income (p < 0.001) were more likely to report elevated psychosocial vulnerability. Patients with elevated psychosocial vulnerability were more likely to reside in deprived neighborhoods (ADI: 34.0 vs. 29.0, p = 0.035; SVI: 0.35 vs. 0.27, p = 0.005). Conclusions: Patients undergoing major cancer surgery experience substantial psychosocial vulnerabilities, particularly those from socioeconomically disadvantaged neighborhoods. Future work should identify the psychosocial factors most predictive of poor surgical outcomes to guide targeted preoperative interventions.

Keywords: cancer surgery; health-related social needs; major surgery; neighborhood characteristics; prehabilitation; preoperative optimization; psychosocial vulnerability; social determinants of health.

Figure 1

Flow diagram of the study population.

Figure 2

Histogram of patient scores on the preoperative psychosocial screener, classified using a Gaussian mixture model with a loosened cutoff (P[high] $\ge$ 0.35). Patients were grouped into elevated psychosocial risk (red) and limited psychosocial risk (blue) based on their posterior probability of group membership. Vertical dashed lines indicate the mean score within each group.

Figure 3

Psychological and social domains reported by patients undergoing major elective cancer surgery, stratified by Social Vulnerability Index (SVI). Residential addresses were geocoded to the census tract level to determine each neighborhood’s national SVI percentile, with high deprivation defined as $\ge$75th percentile. To account for multiple comparisons across 27 psychosocial domains, a Benjamini–Hochberg correction was applied to control the false-discovery rate while maintaining statistical power. Reported q-values reflect the adjusted significance levels from Chi-squared or Fisher’s exact tests. Abbreviations: SVI, Social Vulnerability Index; BH, Benjamini–Hochberg; FDR, false-discovery rate.