Background: Breast cancer is the most common type of cancer among women all over the world and breast cancer is a disease where quality of life (QOL) has become a part of evaluation criteria for cancer therapy. The aim of this study is to assess the quality of life (QOL) in breast cancer patients and its association with other factors. We used EORTC QLQ C30/+BR23 (European Organization for Research and Treatment of Cancer) Questionnaire to assess the quality of life of breast cancer patients. Method: Two hundreds consecutive patients of breast cancer from Department of Clinical Oncology Mayo Hospital KEMU Lahore during May 2009 to November 2009 were enrolled in this study. Results: The mean age of patients was 46.3±9.52 years with Global Health Status (GHS) quality of life score 48.33±27.77 In younger women better quality of life was observed. In univariare analysis, body image, emotional functioning showed positive relationship while breast symptoms, arm symptoms and up-set by hair loss showed a negative relationship with global health status QOL scale. In multivariate analysis fatigue, pain, body image, breast symptoms were found significant predictors of QOL in breast cancer patients. Conclusions: This study showed poor QOL index in breast cancer patients and also investigated the strength of relationship between GHS QOL and other demographic factors (age, marital status, education) with EORTC-QLQ-C-30/+BR23 subscales which were found significant.

Keywords: Breast Cancer Patients, Quality of life (QOL), EORTC QLQ-C30/+BR-23, Regression analysis

Corresponding author: Ibrahim M. School of Physiotherapy, Mayo Hospital Lahore Pakistan +92-300-4668681

Ibrahim_ap98@yahoo.com

Introduction

Breast cancer is the leading cause of cancer among women around the world [1]. Asia has experienced a higher rate of breast cancer than USA and Europe [2]. Pakistan faces a high disease burden of breast cancer with those who present their disease with very advanced stage. In Karachi, the breast cancer is 34.6% among all types of cancer according to Karachi Cancer registry [3]. Mastectomy, Radiotherapy and chemotherapy plus hormonal therapy are practical techniques for treatment of patients with breast cancer. The survival rate of breast cancer patients has increased due to better treatment methods and early detection of disease in women [4]. In spite of these effective treatment methods of breast cancer, the quality of life (QOL) of such patients is a debatable issue, because long-term radiotherapy or chemotherapy often results in loss of self confidence of breast cancer patients, women with breast cancer, especially younger patients, tend to suffer substantial disruption in their physical functioning [5], mental health and well-being [6-7], thus impair the QOL. Loss of breast after mastectomy also results in psychological, emotional problems [8]. Depression and anxiety are common psychiatric disorders among oncology patients and can have a significant impact on functioning of these patients [9], which effects QOL of patients. Young females of breast cancer also face sexual problems while receiving chemotherapy treatment after surgery [10]. Due to various psychological and psychosocial concerns, it has become much more important to study the quality of life for breast cancer survivors. Because of wide variability in QOL, identification of factors that render breast cancer women vulnerable to negative outcomes and poor QOL is essential [11].

World Health Organization (WHO) defines QOL as the individual’s conception of living condition in terms of culture and domain values in the society which are aimed at their goals, expectations, standard and interests, so quality of life has close relationship with physical, mental condition and personal belief, the extent of self reliance, mass communication and environment [12]. In a simple way, QOL is individual’s thought from life style according to her expectations and performance [13]. Breast Cancer in women is significant disease and one where the health professional have the potential to improve the quality of life. Measuring of quality of life helps to consider patient’s problem more seriously and to re-consider techniques of treatment [14].

A broad range of QOL assessment instruments are available which are used in clinical studies among breast cancer patients in Oncology [15], including FLIC (functional Living Index-Cancer) [16], the RSCL (Rotterdam Symptoms Check List) [17], and the CARES-SF (Cancer Evaluation System- Short Form) [18], however, the EORTC QLQ-C30/+BR23 is especially designed to quantify the HR-QOL (Health-Related Quality of Life) of breast cancer patients, which is internationally validated [20].

The aim of this study is to assess the quality of life (QOL) in breast cancer patients and its association with other factors.

Material & Method

Two hundred consecutive patients of breast cancer from Department of Oncology Mayo Hospital Lahore during May 2009 to November 2009 were recruited in this study. The target population was the registered females who undergone mastectomy and receiving regular treatment. We used European Organization for Research and Treatment of Cancer Core questionnaire + breast Module (EORTC QLQ-C30/+BR23; Psychosomatics 2001; 42:117-123) [19] to assess the QOL and demographic data included age, education, locality and marital status was taken on additional questionnaire. Written and verbal consent was taken from eligible patients who were willing to participate and to understand the purpose of study.

Quality of life (QOL) Assessment

EORTC QLQ C-30 is made of 30 items including five functional scales (physical, role, emotional, cognitive and social) and nine symptoms scale (fatigue, nausea and vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhea, financial difficulties) with one global health scale(GHS). The module BR-23 comprises 23 questions designed for assessing QOL of breast cancer, contains five functional scales (body image, sexual functioning, sexual enjoyment, future perspective), four symptom scales (systematic therapy side effect, breast symptom , arm symptom, upset by hair loss) [21].

The calculated raw scores then transferred to 0-100 scales. Higher score of any subscale reflects the better QOL or high level of functioning. On the other hand, in the case of symptom scales, the higher scores imply the higher level of symptoms which indicates a worst quality of life [22-24].

Statistical Method

Statistical analysis was carried out using SPSS v-16 (Statistical Package for Social Sciences, V.16, SPSS Inc., Chicago III USA), categorical variables were expressed in frequency and percentage, and Chi-square test was used to determine the association among categorical variables. Pearson Correlation Coefficient was used to measure the strength of relationship between different sub-scales of quality of life (QOL) and global health status (GHS). Multiple regression model was also used to determine the effect of different factors on global health status, where GHS was taken as dependent variables and demographic factors & sub-scales of QOL index were taken explanatory variables in regression model [25]. t-test was used to determine the difference between any two variables or factors. A P ≤ 0.05 was taken as statistical significant value.

Results

A total of 200 breast cancer patients completed the data sheet and QOL inventories. The mean age of patients was 46.3±9.52 years.

Table 1: shows an over view of demographic characteristics of breast cancer Patients. 188(94%) were house keepers while 12(6%) were formally employed. Employed showed a better quality of life (p<0.05) than house keepers. 136(68%) subjects were aged <50years; 64(32%) were aged ≥ 50 years, subjects aged < 50 years showed a better quality of life (p<0.05), 162(81%) were married 144(72%) were illiterate, 110(55%) were form urban areas, most of subjects were form poor families. Fig 1, 2, 3

The mean global health status (GHS) score was 48.33±27.77. Results of both questionnaires (QLQ-C-30/+BR23) were summarized in Table2. For the functioning scales and Global Health Status (GHS) scale, a higher score corresponds to better quality of life, for the symptoms scales, higher score indicates a poor quality of life [26]. The best functional outcomes were found for social functioning and role functioning subscale, where as emotional functioning was found lowest subjects were suffered from dyspnoea, pain and fatigue, other factors Insomnia, appetite loss and diarrhea were found less severe. In Br-23 questionnaire, sexual functioning and sexual enjoyment showed a better score while higher score of Breast symptom, arm symptom and up-set by hair loss showed lower quality of life.

Emotional functioning (r=0.37, p=0.008), Dyspnoea (r=0.426, p=0.002), Body Image (r=0.355, p=0.011) showed significant positive relationship with Global QOL. Whereas Breast Symptoms (r=-0.511, p=0.000), Arm symptoms (r=-0.304, p= 0.032) and up-set by hair loss (r=-0.354, p= 0.012) were showed reverse relationship with global QOL scale.

In multivariate regression analysis, Fatigue, Nausea & Vomiting, Pain, Dyspnoea, Constipation, Body Image, Breast Symptoms, and education of patients are significant predictors of QOL of breast cancer patients (Table 3), other demographic factors were not found significant predictors of QOL in this study.

Discussion

The mean score of HR-QOL (QLQ C-30) in breast cancer patients indicated that our patients had clinically poorer GHS-QOL in comparison with other data [4,11,27]. According to results showed by QLQ C-30, women aged < 50 years had a better quality of life than women aged ≥ 50 years. Some studies but not all indicated that younger women have better quality of life [28, 29] in breast cancer diagnosis. Most of the subjects were housekeepers or unemployed, the results are different from other studies, where most of the patients were employed [26, 30, 31]

In our study employed women showed better quality life. The reason of better quality of life in employed women is that employed women has better social relationship, financially independent and well conscious about her health status than housekeeper[32]. Concerning QOL of married women vs unmarried which was not significantly different, this is also supported by other studies [33]. In this study no significant difference could be detected in global QOL with respect to education, monthly income of family and residential status of patients [4]. Global QOL had found significant relationship (p<0.05) with emotional functioning, Dyspnea, body image and inverse relationship (p<0.05) with breast symptoms. Arm symptoms and upset by hair loss the results are consistent with other studies [26]. This may be concluded that symptoms scales both in EORTC C-30 and BR-23 reporting the health problems of breast cancer patients.

In multivariate regression analysis (Table 3), physical, role, social functioning had no significant effect on GHS QOL (P>0.05), our results are not supported by other studies [34], whereas body image, future perspective and breast symptoms had significant impact on GHS QOL (P<0.05). Concerning demographic factors (age, education, marital status) only education was detected a significant predictor of GHS QOL [33].

Our results faced certain limitations like small sample size, cross sectional study design, absence of comparable control (women without breast cancer), absence of certain aspects of QOL [35] and several aspects of morbidity including pain, range of motion and sensory complaints of affected arm [36, 37], grade of tumor, duration of disease, pre-post surgery comparison was not considered which were very necessary to evaluate the better QOL. Separate studies should be conducted in younger breast cancer patients and older women to determine the effect of age on breast cancer survivors. Prospective studies are needed to investigate the influence of demographic and clinical factors on QOL. The effect of radiotherapy and chemotherapy on QOL was not investigated in this study; future research should be addressed the effect of radiotherapy and chemotherapy on QOL. Further more; Researchers should identify the need of Psych-Oncological concepts, which affect the QOL of breast cancer patients [38]. No grant or financial and support was received to conduct the study. Our results are preliminary and not conclusive.

Conclusion

In conclusion our study had identified the strength of relationship and consistency between certain demographic factors and QOL of breast cancer patients. Better counseling and financial support with high quality medical services may improve the QOL of breast cancer patients.

We would like to thanks all the patients who participated in the study and Rabia Kaniz Student, School of Physiotherapy who helped in data collection. A very special thanks to Professor Dr. Sheharyar , Department of Clinical Oncology for his permission to conduct the study.

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Table 1: Demographic factors in patients under study

Variables

Description

Frequency

Mean ±SD

P Value

Age

<50 years

136(68%)

46.62±27.53

P<0.05

≥50 years

64 (32%)

42.30± 31.83

Marital status

Unmarried

38(19%)

53.69±32.89

P>0.05

Married

162(81%)

49.79±27.32

Area of residence

Rural

90(45%)

39.58±32.89

P>0.05

Urban

110(55%)

52.45±24.49

Occupation

Housewife

188 (94%)

47.69±28.53

P<0.05

Worker

12(6%)

58.33±17.47

Education

Illiterate

144(72%)

47.49±22.44

P>0.05

Literate

56(22%)

52.73±25.33

Family monthly

Rs.<15,000

154(77%)

43.56±28.63

P>0.05

income

Rs. ≥15,000

46(23%)

46.79±29.67

Table 2: EORTC QLQ-C30/+BR-23 subscales and their correlation with GHS in patients

Variables

Mean ± SD

Correlation Value

P Value

Physical Functioning

56.40±27.41

.203

.156

Role Functioning

61.00±41.87

.201

.161

Emotional Functioning

46.16±37.01

.370

.008 *

Cognitive Functional

60.66±28.12

.248

0.082

Social Functioning

77.33±31.36

.131

.363

Fatigue

73.55±25.48

-.202

.159

Nausea and vomiting

28.00±25.27

.213

.137

Pain

51.00±34.41

-.164

.254

Dyspnoea

62.67±44.49

.426

.002 *

Insomnia

34.67±36.24

.030

.834

Appetite Loss

42.67±42.61

.047

.746

Constipation

20.00±33.67

-.121

.402

Diarrhea

5.33±15.59

.244

.088

Financial Difficulties

50.00±40.55

.166

.249

Body Image

70.50±31.42

.355

.011 *

Sexual Functioning

92.33±20.26

.012

.394

Sexual Enjoyment

93.33±20.20

.020

.889

Future Perspective

22.00±28.26

.033

.819

Systematic Therapy Side effect

55.90±17.47

-.155

.284

Breast Symptoms

33.00±31.13

-.511

.000 *

Arm Symptoms

65.33±31.39

-.304

.032

Upset by Hair Loss

83.33±35.15

.354

.012 *

Global Health Status (QOL)

48.33±27.77

Table 3: Predictors of quality of life (QOL) by using linear regression model

Full Model

Final Model

B

Std. Error

P-value

B

Std. Error

P-value

(Constant)

13.488

49.681

.789

-31.056

26.966

.257

Physical Functioning

.337

.254

.198

.380

.188

.04

Role Functioning

.227

.130

.095

.200

.104

.043

Emotional Functioning

.050

.110

.651

—-

——

—-

Cognitive Functional

.099

.172

.572

—–

——

—-

Social Functioning

-.159

.164

.343

—-

——

—–

Fatigue

-.235

.192

.234

-.325

.142

.028

Nausea and vomiting

.403

.169

.026

.482

.131

.001

Pain

.467

.269

.096

.492

.187

.012

Dyspnoea

.154

.087

.091

.248

.062

.000

Insomnia

.163

.112

.159

—–

—–

——

Appetite Loss

.183

.091

.056

—–

—–

—-

Constipation

-.297

.125

.027

-.289

.086

.002

Diarrhea

.167

.262

.530

—-

—–

—-

Financial Difficulties

.030

.099

.764

—–

——

—–

Body Image

.255

.187

.188

.283

.110

.014

Sexual Functioning

.127

.621

.840

—–

——

—–

Sexual Enjoyment

-.259

.655

.696

—–

—–

—-

Future Perspective

-.176

.125

.172

-.287

.105

.010

Systematic Therapy Side effect

-.222

.233

.350

—–

—-

—-

Breast Symptoms

-.203

.157

.208

-.288

.099

.006

Arm Symptoms

-.247

.175

.172

—–

—–

—-

Upset by Hair Loss

.130

.120

.290

—–

—-

—–

area of residence

-1.864

7.309

.801

——

—-

—-

occupation of the patient

7.898

18.794

.678

—–

—-

——-

education of the patient

11.274

7.504

.147

12.684

4.732

.011

marital status

-4.798

6.028

.435

——

—–

—-

Fig 1

Fig 2

Fig 3