Anurag Bhai Patidar, Naseema Shafqat,   Anita

 

Abstract:

Introduction: The most common cancer among women in the world is breast cancer. The diagnosis of breast cancer and its type of treatment have a signicant impact on health and well-being and inuence quality of Life among breast cancer patients. Objective: To assess the Quality of Life among Breast Cancer Patients undergoing cancer treatment in selected cancer hospital, Bhopal. Methodology: Two hundred subjects were selected (100 in breast cancer group and 100 in healthy control group) through convenient sampling. Study participants were interviewed using standardized EORTC C30 and BR23 quality of life questionnaire. Results: Findings revealed that majority of the breast cancer patients were from 41-50 years age group, married, residing in urban areas, illiterate and housewives. Most of them had stage II cancer and were receiving chemotherapy. Mean score of physical functioning (57.73±23.94), role functioning (68.16±32.31), cognitive functioning (57±1.08), nausea and vomiting (30.17±36.13), pain (38±33.08); dyspnea (28±35.99), insomnia (41±39.60), body image (54.08±28.88), breast symptoms (30.08±24.56), arm symptoms (40.11±29.75) and upset by hair loss (54.33±40.94) indicated average QOL among breast cancer patients. Mean score for global health status (35.42± 21.40), emotional functioning (44±31.84), social functioning (33.83±32.52), fatigue (52.77±29.60), appetite loss (58±39), future perspective (35.67±37.38) and systemic therapy side effects (54.52±21.93) indicated poor QOL. Mean score of nancial difculties (77±32.03), sexual functioning (16.33±25.28) and sexual enjoyment (14±24.7) represented worst QOL among breast cancer patient. Conclusion: Patients having breast cancer had signicantly lower quality of life as compared to healthy subjects in the area of global health status, functional scale and symptom scales.

Keywords: EORTC C30 and BR23, quality of life, breast cancer patients

Corresponding author:

Dr Anurag Bhai Patidar, Associate Professor, Nursing College

All India Institute of Medical Sciences, Bhopal, MP.

Email: anuragpatidar@gmail.com

Introduction and Background

Breasts or mammary glands are not only the primary organ of milk production post pregnancy, but also the symbol of women’s body-image and appearance of femininity, beauty, sexuality and motherhood. The loss of breast or part of breast may affect a woman psychologically, socially and sexually.1

Worldwide incidence of breast cancer has been doubled since 1975. There is an estimated 18.1 million new cancer cases and 9.6 million cancer deaths in 2018 and breast cancer was declared as the second most common cancer among overall cancer. 2,3 Incidence of breast cancer patients are rapidly increasing in developed and developing countries. In the year 2012, Globocan cancer fact sheet presented a report about the prevalence of cancer in India and found out that the ve most common cancers were breast (14.3%), cervix (12.1%), mouth (7.6%), lung (6.9%) and colorectal cancer (6.3%). 2,4

Despite the rise in the prevalence of breast cancer, the survival rate of clients with breast cancer in most developed and developing countries has been increasing due to early detection and improved treatment. The standard treatment of breast cancer patients is surgery (mastectomy or breast conserving surgery) followed by different combinations of adjuvant treatments like chemotherapy, radiation therapy and hormone therapy.5

Breast cancer diagnosis and its subsequent therapy have an impact on the total health of women such as physical, psychological, social and nancial aspects of patient’s life. HRQOL (health related quality of life) is an extensive concept and includes physical, emotional, sexual, social and cognitive functions; symptoms of disease and treatment, health risks, functional status, social support and socioeconomic status.6 When a woman discovers that she is ill and diagnosed with breast cancer, may experience impairment in several areas of her life, including social functioning. Woman’s role in household, family, social, self-care and occupational activities may change after breast cancer diagnosis.

Measurement of Quality of life is important in breast cancer patients specially those who are undergoing cancer treatment because effect and side effect of any therapy impacts the life style and psychology of a patient. Most of the women with breast cancer are disturbed due to loss of body image which affects their quality of life. This study aimed to assess quality of life among breast cancer patients undergoing cancer treatment.

Material and Methods

It was a cross sectional descriptive study using a quantitative research approach. The study sample consisted of 200 females including 100 breast cancer patients and 100 healthy controls, selected through convenience sampling technique .The breast cancer patients group comprised of clinically stable patients aged between 21- 70 years, undergoing cancer treatment, who could read, write and understand Hindi or English and willing to participate in the study. Whereas the control group had healthy females accompanying breast cancer patients aged between 21-70 years.

Data was collected using structured questionnaire  for  sociodemographic i n f o r m a t i o n , c l i n i c a l p r o  l e a n d standardised tools (EORTC QLQ-C30 version 3.0 : QLQ-BR23) for assessing the health related quality of life. EORTC QLQ- C30 version 3.0 is 30 items disease-specic self-assessment instrument which contains ve functional   scales   (physical,   role, e m o t i o n a l , c o g n i t i v e a n d s o c i a l functioning), three symptom scales (fatigue, pain and nausea and vomiting), six single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and nancial difculties) and a global health status/ QOL scale. 7,8

QLQ BR23 is a disease- specic 23 items questionnaire for breast cancer patients varying in disease stage and treatment modality (i.e. surgery, chemotherapy, radiotherapy and hormonal treatment). The functional scale includes body image, sexual functioning, sexual enjoyment and future perspective whereas symptom scale includes systemic therapy side effects, breast symptoms, arm symptoms and upset by hair loss. 7 Scores range from 0 to 100 on both the scales. High score on functional and global score scale represents high QOL [Worst (0- 25); Poor (26-50); Average (51-75); Good (76-100)] but a high score for a symptom scale / item represents a high level of symptomatology/problems and low QOL [Good (0-25); Average (26-50); Poor (51- 75); Worst (76-100)]. Sexual functioning & Sexual enjoyment are functional scale but scoring is done and interpreted as symptoms scale.7, 8 Written permission was taken from the authors of tools. Content Validity and reliability of the tools were established before the data collection. Institutional ethical committee of Bhopal Memorial Hospital and Research Centre, Bhopal approved the study protocols. Administrative approval was obtained prior to data collection from the research setting. Informed written consent was taken from the study participants. Interview schedule was used to collect data using the study tools. Statistical analysis was done using Microsoft-excel, and SPSS version 20 Software.

Results

Sociodemographic Characteristics

As shown in table 1 most of the breast cancer patients (65%) and healthy females (58%) were in age group 41-60 years. Maximum subjects were followers of Hindu religion in both groups. Majority of the subject were married in breast cancer group (81 %) as well as in control group (79%). More than half of the subjects in breast cancer group (58%) as well as in control group (73%) were residing in urban areas.

 

Table 1: Socio demographic profile of cancer v/s control group

N=200

Sociodemographic Variables Cancer Group (n=100)

f/%

Control Group (n=100)

f/%

Statistics Chi square test

X2 (df) p

Age in years

21-30 years

31-40 years

41-50 years

51-60 years

60 years and above

 

05

12

38

27

18

 

09

16

34

24

17

X2 =2.14, P=0.70,

df=4

Religion Hindu Muslim

Christian

 

85

15

00

 

78

18

04

X2 =4.57, P=0.102

df=2

Marital Status Married Unmarried Widow

Divorced

 

81

02

17

00

 

79

08

12

01

X2 =5.48, P=0.139

df=3

Area of residence

Rural

Urban

 

42

58

 

27

73

X2 =5.85, P=.015*

df=1

Education Illiterate Primary Middle Secondary

Higher secondary Graduation

Post graduation

 

31

14

13

09

15

07

11

 

19

11

18

09

11

17

15

X2 =9.44, P=0.15

df=6

Occupation

Working

Housewife

 

23

77

 

37

63

X2 =4.66, P=0.03*

df=1

Family type

Joint family Nuclear

 

64

36

 

59

41

X2 =0.527,P=0.46

df=1

Family Monthly Income in rupees

3001-5000

5001-8000

8001-10000

Above 10000

 

33

17

13

37

 

20

11

16

53

X2 =7.62, P=0.06

df=3

 

*p value signicant at the level of 0.05

Clinical Profile

As shown in table 2 mean duration of illness was 22.15±23.31 months. Majority of the breast cancer patients (83%) had no family history of breast cancer and most (95%) of the patients had breast as the location of tumour. Half of the (56%) patients had stage II breast cancer and 45% of the breast cancer   patients   received   chemotherapy f o l l o w e d b y 2 4 % r e c e i v e d b o t h chemotherapy and surgery. Mean duration of present treatment was 3.91±3.24 months.

 

Table 2: Clinical Profile of the breast cancer female patients

N=100

score for fatigue was 52.77±29.60 which shows poor quality of life and the mean score for nancial difculties was 77±32 which represents worst quality of life.

As shown in table 4 mean quality of life score of breast cancer patients on BR 23 questionnaire indicate average quality of life in terms of body image, poor for future perspective and worst for sexual functioning and sexual enjoyment in the functional scale. On symptoms scale, quality of life was poor in terms of systematic therapy side effects and being upset by hair loss.

Clinical Profile Variables f/%
Family H/O breast cancer

Yes

No

17

83

Location of tumour

Nipple Breast Axilla

Near breast

01

95

01

03

Stage Stage I Stage II Stage III

Stage IV

09

56

28

07

Type of treatment Chemotherapy Radiation therapy Hormonal therapy Surgery

Chemotherapy plus surgery

45

03

20

08

24

 

Table 3:Mean Quality of life score of breast cancer female patient on C30 Questionnaire

N=100

  Quality of life of breast cancer female patients

Table 3 illustrates that mean global health status score was 35.41±21.39 which indicates poor quality of life. Breast cancer patients scored 44±31.84 and 33.83±32.52 on emotional functioning and social functioning respectively which shows poor quality of life. On functional scale, mean score of physical, cognitive and role functioning score represents average quality of life similarly; on the symptom scale, the mean scores for nausea vomiting (30.17±36.13), pain (38±33.08), dyspnoea (28±35.99) and insomnia (41±39.6) represent average quality of life. Mean

Minimum Score-0, Maximum Score-100

C 30 Quality of life Scales Mean score ± SD
Global Health Status 35.41±21.39
Functional Scales Physical Functioning Role Functioning Emotional functioning Cognitive functioning

Social functioning

57.73±23.94

68.16±32.31

44±31.84

57±31.08

33.83±32.52

Symptoms Scale

Fatigue

Nausea and vomiting Pain

Dyspnoea Insomnia Appetite loss Constipation Diarrhoea

Financial difculties

52.77±29.60

30.17±36.13

38±33.08

28±35.99

41±39.6

58±39

23.6±34.9

16.33±29.4

77±32

 

Comparison of mean quality of life score between cancer group and control group on EORTC C 30 Questionnaire: As shown in table 5 mean score of the control group was signicantly higher (p<0.05) than breast cancer group on global health status and functional scale. It depicts that breast cancer signicantly reduced the quality of life as compared to healthy controls in the area of global health status and functional scale. Similarly, mean score of the cancer group was signicantly higher than control group on symptom scale. Therefore, it can be concluded that breast cancer patients have signicantly lower quality of life as compared to healthy subjects

Table 4: Mean Quality of life score of breast cancer female patient on BR 23 Questionnaire N=100

BR 23 Quality of life Scales Mean Score ± SD
Functional Scales Body Image Sexual functioning Sexual enjoyment

Future perspective

 

54.08±28.88

16.3±25.2

14±24.7

35.67±37.38

Symptoms Scale

Systemic therapy side effects Breast symptoms

Arm symptoms Upset by hair loss

 

54.52±21.93

30.08±24.56

40.11±29.75

54.33±40.94

 

Table 5: Comparison of mean Quality of life score between cancer group and control group on C 30 Questionnaire

N=200

C 30 Quality of life Scale Mean Score ± SD Statistics
Cancer Group n=100 Control group n=100
Global Health Status 35.41±21.39 71.83±20.85 P=0.001**,

t=12.19,df=198

Functional Scales Physical Functioning 57.73±23.94 93±10.98 P=0.0001**,

t=13.39,df=198

Role

Functioning

68.16±32.31 97.5±10.69 P=0.0001**,

t=8.62, df=198

Emotional functioning 44±31.84 80.33±19.90 P=0.0001**,

t=9.67, df=198

Cognitive functioning 57±31.08 83.83±18.26 P=0.0001**,

t=7.44 df=198

Social

functioning

33.83±32.52 77±26.24 P=0.0001**,

t=10.33, df=198

Symptoms Scale Fatigue 52.77±29.60 15.33±17.85 P=0.0001**,

t=10.83, df=198

Nausea and vomiting 30.17±36.13 3.5±10.67 P=0.0001**,

t=7.07 df=198

Pain 38±33.08 6.5±13.58 P=0.0001**,

t=8.80, df=198

Dyspnoea 28±35.9 2.66±10.24 P=0.0001**,

t=7.10, df=198

Insomnia 41±39.59 11±23.23 P=0.0001**,

t=6.53df=198

Appetite loss 58±38.95 13.67±22.76 P=0.0001**

,t=9.82, df=198

Constipation 23.66±34.9 5±14.50 P=0.0001**,

t=4.94df=198

Diarrhoea 16.33±29.39 3.33±11.11 P=0.0001**,

t=4.13df=198

Financial difficulties 77±32.02 49.66±40.60 P=0.0001**,

t=5.28, df=198

 

 Comparison of mean quality of life score between cancer group and control group on BR 23 Questionnaire: Table 6 illustrates that control group scored signicantly higher (P<0.05) than cancer group on functional scale for all the items which reveals that breast cancer patients have signicantly lower quality of life as compared to healthy controls in the area of body image, sexual functioning, sexual enjoyment and future perspective.

Association of selected Sociodemographic variables with quality of life among female breast cancer patients: Cognitive functioning was signicantly better (p<0.05) in age group 31-40 years and 41- 50 years whereas i t deteriorated signicantly in the younger age group (21- 30) as well as older age groups (51-60). Systemic therapy side effects were also found to be signicantly associated with age. Mean score was highest in the age group of 51-60 years which represents poor quality of life whereas it was lowest in the age group of 31-40 years. (Table-7) Global health status was found to be signicantly associated with marital status. Mean score was signicantly higher in the unmarried group.

 

Table 6: Comparison of mean Quality of life score between cancer group and control group on BR 23 Questionnaire

N=200

BR 23 Quality of life scales Mean Score ± SD T Statistics
Cancer Group n=100 Control group n=100
 

Functional Scale

Body Image 54.08±28.88 96.83±9.38 P=0.0001**,t=14.07,df=198
Sexual functioning 16.3±25.2 35.33±32.93 P=0.0001**,t=4.58,df=198
Sexual enjoyment 14±24.7 35.66±33.91 P=0.0001**,t=5.16,df=198
Future perspective 35.67±37.38 83±26.16 P=0.0001**,t=10.37,df=198
 

Symptoms Scale

Systemic therapy side effects 54.52±21.93 18.14±17.76 P=0.0001**,t=12.89,df=198
Breast symptoms 30.08±24.56 1.92±5.78 P=0.0001**,t=11.16,df=198
Arm symptoms 40.11±29.75 7±11.88 P=0.0001**,t=10.33,df=198
Upset by hair loss 54.33±40.94 10.33±22.57 P=0.0001**,t=9.41,df=198

 

**P Value highly signicant at 0.001 level

Sexual functioning and sexual enjoyment were found to be signicantly associated with marital status. Mean score was signicantly higher for sexual functioning (20.2±26.5 v/s 0±0), and sexual enjoyment (17.3±26.4 v/s 0±0) in the married group as compared to unmarried group which represents worst quality of life. E m o t i o n a l f u n c t i o n i n g a n d nancial difculties were found to be signicantly associated with residence. It was signicantly higher (49.5±30.6) in the urban  as compared  to rural  patients (36.3±32.2). Mean score for future perspective was signicantly higher (43.1±38.9) in the urban as compared to rural patients (25.4±32.7).

Body image and future perspectives were found to be signicantly associated with income. Mean score on Global health status s ignicantly decreased with the advancement of the stage of breast cancer. Sexual enjoyment decreased signicantly (P<0.05) with the advancement of stage of cancer.

 

Table 7: Association of age with mean C 30 Quality of Life Scale score among breast cancer patient

N=100

C 30 Quality of life Scale score Age Category (in years) F

Statistic

21-30 n=05 31-40 n=12 41-50 n=38 51-60 n=27 >60 n=18  
Global Health Status 24.9±14.4 36.1±18.5 35.9±25.8 33.6±18.7 39.4±18.7 F=0.49

P=0.74

Functional Scales score Physical

Functioning

61.3±28.8 74.4±14.4 57.7±24.9 52.1±22.4 54.1±24.8 F=2.05

P=0.09

Role

Functioning

63.3±27.3 73.6±18 61.8±36.3 74.6±32.8 69.4±31.4 F=0.75

P=0.56

Emotional

functioning

23.3±17 47.2±34.6 50.2±32.5 37.9±31.1 43.5±31.6 F=1.17

P=0.32

Cognitive

functioning

46.7±29.8 77.8±24.9 62.7±30.8 45.1±29.2 51.9±31.2 F=3.18

P=0.01*

Social

functioning

20±18.3 45.8±39 32.9±33.6 29.6±25.5 38±37.8 F=0.82

P=0.51

Symptoms

Scale score

Fatigue 55.6±29.4 46.3±30.6 46.2±30.2 61.3±30.8 57.4±24.2 F=1.31

P=0.27

Nausea and vomiting 50±37.3 33.3±42.6 30.7±39.9 22.2±26.9 33.3±35.7 F=0.75

P=0.56

Pain 53.3±32 33.3±35.5 37.7±35.4 36.4±33.6 39.8±27.5 F=0.35 P=0.84
Dyspnoea 46.7±50.5 16.6±30.1 27.2±35.3 32.1±37.5 26±35.3 F=0.73

P=0.57

Insomnia 40±27.8 33.3±40.2 42.1±42.9 39.5±41.3 46.3±34.5 F=0.2

P=0.94

Appetite

loss

66.7±40.8 50±41.3 47.4±43.5 70.4±29.7 64.8±35.2 F=1.77

P=0.14

Constipatio

n

46.7±44.7 11.1±29.6 21.1±34.1 33.3±39.2 16.7±26.2 F=1.73

P=0.15

Diarrhoea 40±43.5 2.8±9.6 11.4±24.8 20.9±32.2 22.2±34.3 F=2.16

P=0.07

Financial

difficulties

86.7±18.3 77.8±35.8 81.6±33.5 72.8±29.3 70.4±34.1 F=0.61

P=0.65

 

Correlation of duration of illness with items on functional and symptom scales was found to be mildly positive except systemic therapy side effects, arm symptoms, and upset by hair loss however; it was not statistically signicant (p>0.05).

Radiotherapy group scored signicantly (p<0.05) highest (66.7±33.3) on upset by hair loss followed by chemotherapy plus s u r g e r y g r o u p ( 6 3 . 9 ± 4 3 . 8 ) a n d chemotherapy group (62.2±38.6) whereas h o r m o n a l t h e r a p y g r o u p s c o r e d signicantly lower (31.7±33.3) followed by surgery group (33.3±43.6) Body image and future perspectives were found to be signicantly associated with income. Mean score of Global health status signicantly decreased (P 0.05) with the advancement of stage of cancer. This can also be observed in Sub scale of emotional functioning that the quality of life in emotional nding decreased with advancement of stage of cancer. Even the score of symptoms such as dyspnoea, insomnia, appetite loss increased signicantly and quality of life decreased with advancement of stage of cancer. The nancial difculties score also increased signicantly with advancement of stage of breast cancer (Table-8).

 

Table 8: Association of stage of cancer with mean C 30 Quality of Life Scale score among breast cancer patients

N=100

C 30 Quality of life Scale score Stage of Breast cancer F Statistics
Stage I

n=09

Stage II

n=56

Stage III

n=28

Stage IV

n=07

Global Health Status 53.7±30.1 33.8±18.6 34.5±22.9 28.6±15.9 F=2.70

P=0.04*

Functional

Scales score

Physical

Functioning

69.6±16.7 58.7±25.2 52.9±24.3 54.3±15.6 F=1.21

P=0.31

Role

Functioning

92.6±16.9 69.1±32 60.2±31.9 61.9±40.5 F=2.5

P=0.06

Emotional

functioning

65.7±34.2 46.3±30.6 36.3±31.9 28.6±25.8 F=2.72

P=0.04*

Cognitive

functioning

74.1±29 58.3±30.8 51.7±32.8 45.2±23 F=1.56

P=0.20

Social

functioning

57.4±29 33.0±32.7 32.1±33 16.7±19.2 F=2.36

P=0.07

Symptoms

Scale score

Fatigue 37±26.6 49.2±29.6 62.3±28.2 63.5±28.5 F=2.5

P=0.06

Nausea and

vomiting

25.9±32.4 31.5±36.6 27.4±38 35.7±35.2 F=0.17

P=0.9

Pain 25.9±23.7 34.5±31.7 45.8±36.4 50±36 F=1.46

P=0.2

Dyspnoea 3.7±11.1 25.6±32.4 34.5±42 52.4±42.4 F=3

P=0.03*

Insomnia 18.5±29.4 35.1±36.7 52.4±41.9 71.4±40.5 F=3.83

P=0.02*

Appetite loss 48.1±33.8 51.2±39.1 66.7±39.5 90.5±16.3 F=3.02

P=0.03*

Constipation 11.1±23.6 24.4±36.8 27.4±36.3 19±26.2 F=0.54

P=0.6

Diarrhoea 11.1±33.3 18.4±31.7 13.1±24.6 19.1±26.2 F=0.32

P=0.81

Financial

difficulties

48.2±37.7 80.9±29 75±33.5 90.5±25.2 F=3.4

P=0.02*

 

Discussion

Diagnosis of breast cancer is a disastrous situation for a woman. It has variety of impact on various aspects of life leading to deteriorated quality of life. The present study explored the various aspects of quality of life among breast cancer patients.

Most of the breast cancer patients (65%) in poor QOL15. Data on sexual functioning and sexual enjoyment indicated worst QOL among breast cancer patients. Lobo et al. also the present study were in the age group of concluded that, the practice of sexual 41-60 years. Other descriptive studies also found that, majority of the breast cancer patient were in the age group 41-60 years.9,10

The present study showed that breast cancer female patients had poor global health status/QOL. Emotional functioning and social functioning of the breast cancer patients were also found to be poor. Mean score on symptom scales showed worst and poor QOL in nancial difculties and appetite loss area respectively whereas intercourse and satisfaction affected most of the breast cancer patients’ quality of life14. On contrary Dubashi et al reported higher functional scores of sexual function and sexual enjoyment which indicated better QOL.16 Functional scale of BR23 sexual enjoyment decreased signicantly with the advancement of stage of cancer. Gokgoz S also revealed that, breast cancer patients had lower QOL score for sexual functioning with advanced stages.17 pain,  dyspnea nausea vomiting and

Nursing Implications: Nursing care plan insomnia showed average QOL. A number of cross-sectional studies and population based surveys have revealed that breast cancer women had below average and signicantly poor quality of life. A recent study revealed that 82.3% of breast cancer patients had low QOL scores on symptoms scale.11

This study revealed that, global health status indicated poor quality of life among breast cancer patient. Malathi GN et al also concluded in their study that majority of breast cancer patients had low quality of life scores.12 The most important domains on symptoms scale; fatigue, insomnia and pain inuenced the QOL of breast cancer patients.13 Lobo et al also reported similar ndings. Scoring for future perspective and loss of body image indicates poor QOL among breast cancer patients.14 Kaur N et al also reported worse QOL and loss of body image as signicant factors contributing to for cancer patients should be developed which is based on the QOL tool for easy identication of the problems and to provide nursing care accordingly. Nurse administrator can emphasize that the nurses have to play the role of counsellor, advocate, guide and facilitator for breast cancer patients to improve the QOL of them.

Conclusion : The present study revealed that patients having breast cancer had signicantly lower quality of life as compared to healthy subjects in the area of global health status, functional scale and symptom scales.

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