| 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 signicant impact on health and well-being and inuence 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 difculties (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 signicantly 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-specic 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 difculties) and a global health status/ QOL scale. 7,8
QLQ BR23 is a disease- specic 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 signicant 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 difculties 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.
|
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
|
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 signicantly higher (p<0.05) than breast cancer group on global health status and functional scale. It depicts that breast cancer signicantly 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 signicantly higher than control group on symptom scale. Therefore, it can be concluded that breast cancer patients have signicantly 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 signicantly higher (P<0.05) than cancer group on functional scale for all the items which reveals that breast cancer patients have signicantly 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 signicantly better (p<0.05) in age group 31-40 years and 41- 50 years whereas i t deteriorated signicantly in the younger age group (21- 30) as well as older age groups (51-60). Systemic therapy side effects were also found to be signicantly 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 signicantly associated with marital status. Mean score was signicantly 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 signicant at 0.001 level
Sexual functioning and sexual enjoyment were found to be signicantly associated with marital status. Mean score was signicantly 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 difculties were found to be signicantly associated with residence. It was signicantly higher (49.5±30.6) in the urban as compared to rural patients (36.3±32.2). Mean score for future perspective was signicantly 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 signicantly associated with income. Mean score on Global health status s ignicantly decreased with the advancement of the stage of breast cancer. Sexual enjoyment decreased signicantly (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 signicant (p>0.05).
Radiotherapy group scored signicantly (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 signicantly lower (31.7±33.3) followed by surgery group (33.3±43.6) Body image and future perspectives were found to be signicantly associated with income. Mean score of Global health status signicantly 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 signicantly and quality of life decreased with advancement of stage of cancer. The nancial difculties score also increased signicantly 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 difculties 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 signicantly 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 signicantly 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 inuenced 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 signicant factors contributing to for cancer patients should be developed which is based on the QOL tool for easy identication 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 signicantly 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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