Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2012  |  Volume : 8  |  Issue : 2  |  Page : 272--276

Quality of life assessment in survivors of breast cancer


Shaqul Qamar Wani1, Talib Khan2, Ashraf M Teeli3, Nazir A Khan3, Saiful Yamin Wani4, Ashfaq-ul -Hassan5,  
1 Department of Radiation Oncology, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar, India
2 Department of Anaesthesiology, Intensive Care and Pain Management, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar, India
3 Department of Radiation Oncology, Sher -I- Kashmir Institute of Medical Sciences, Soura, Srinagar, India
4 Department of Medical Doctors, 53 Battalion CRPF HQ, Police Lines, Baramullah, India
5 Department of Clinical Anatomy, Sher -I- Kashmir Institute of Medical Sciences Medical College, Bemina, Srinagar, J and K, India

Correspondence Address:
Shaqul Qamar Wani
Department of Radiation Oncology, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar - 190 010, J and K
India

Abstract

Aim: The aim was to assess the health-related quality of life (HRQOL) and its temporal variation at first visit and subsequent visits among breast cancer patients. Design and Setting: The prospective study was carried out in Outpatient Department of Radiation Oncology, University Teaching and Tertiary Referral Hospital. Material and Methods: After clearance from the ethical committee and EORTC group, 81 surgically treated female breast cancer patients referred to the Outpatient Department of Radiation Oncology for chemoradiation and hormonal therapy were included in the study after informed written consent, irrespective of the age and stage of disease. The patients were interviewed as per the EORTC QLQ-C30 Questionnaire module at four levels at the first visit and at subsequent follow-up visits at 6, 12, and 24 months, respectively, and are still on follow-up. Statistical Analysis: The data collected were expressed as mean/raw score (RS), standard deviation (SD), and percent mean/scale score expressed on the linear transformation scale, derived as per the calculations and equations of the EORTC QLQ-C30 Scoring Manual. Intragroup comparison (IGC) was done at four levels/visits, a, b, c and d. A P-value of <0.05 was considered significant. Results: The mean age at presentation was 46.6 ± 10.2 years. The study showed that the physical functioning, role functioning, cognitive functioning, emotional functioning, social functioning, global health status, and symptomatology showed statistically significant improvement over time (P < 0.001). Conclusion: The survivors of female breast cancer over the long-term follow-up showed significant improvement and coping mechanisms involved in a majority of HRQOL parameters.



How to cite this article:
Wani SQ, Khan T, Teeli AM, Khan NA, Wani SY, Au. Quality of life assessment in survivors of breast cancer.J Can Res Ther 2012;8:272-276


How to cite this URL:
Wani SQ, Khan T, Teeli AM, Khan NA, Wani SY, Au. Quality of life assessment in survivors of breast cancer. J Can Res Ther [serial online] 2012 [cited 2021 Apr 13 ];8:272-276
Available from: https://www.cancerjournal.net/text.asp?2012/8/2/272/98986


Full Text

 Introduction



Female breast has always been symbolic of womanhood and ultimate fertility. Breasts not only have physical and functional value but psychological bearing as well. As a result, both disease and surgery of the breast evoke a fear of mutilation and loss of femininity besides being responsible for psychosocial behavioral problems. [1] While the first priority in the treatment of cancer must be tumor control, it is increasingly recognized that the effective management of patients should include techniques to maximize their sense of well being or quality of life (QOL). [2] Health-related quality of life (HRQOL) is a multidimensional concept that characterizes individuals' total well being and includes psychological, social, and physical dimensions. [3] In other words, physicians now have an opportunity to add life to years, as well as adding years to life. [4] There are various tools frequently used in oncology for measuring health-related quality of life, e.g., Short Form-36 (SF-36), European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30), Functional assessment of Cancer Therapy General (FACT-G), visual analogue scale-cancer (VAS-C), Hospital and Anxiety Depression Scale (HADS), Profile of Mood States (POMS), and Rotterdam Symptom Checklist (RSCL). [5]

Most of the studies on QOL in breast cancer are from developed countries, where the image perception is strong and breast conservation rates are higher compared to developing nations. It could be hypothesized that patients from developing countries with lower socioeconomic strata may not have similar body image-related concepts and thus mastectomy could be an acceptable option in most patients. Patients undergoing breast conserving surgeries (BCS) require more precise radiation therapy (RT) treatment planning facilities, which are not widely available in many parts of developing countries. On the other hand, patients may have to travel longer distances, stay away from their native place for more than 2 months to receive RT after BCS, which in turn may have a negative impact on QOL. [6] Fewer studies have been carried out in India related to QOL among the breast cancer patients. Ours was the first study related to the temporal aspect of QOL among the breast cancer patients.

Breast cancer is emerging as a major concern in female populations of the Kashmir valley with its incidence showing an increasing trend. Many studies have been done on breast cancer regarding epidemiological analysis, and the clinical and pathological pattern of the disease, so keeping the impact of breast cancer and treatment on patients' life and functioning in mind, we planned to study the QOL in survivors of breast cancer patients in affected females of the Kashmir division of the Indian subcontinent with the following aims and objectives:



to assess the impact of breast cancer in females on HRQOL.to assess the temporal variation in these parameters at the first visit of the study and at subsequent follow-ups.

 Materials and Methods



The present prospective study titled "Quality of Life Assessment in Survivors of Breast Cancer" was conducted in the Outpatient Department of Radiation Oncology, after clearance from the institute's ethical/research committee and permission from EORTC.

Eighty-one female breast cancer patients who were surgically treated either by mastectomy or breast conserving surgery and then referred to the Department of Radiation Oncology for chemoradiation and hormonal therapy were included in the study after taking written informed consent from them irrespective of their age and stage of the disease. The patients were enrolled for the study when they were started on chemoradiation (first visit), and thereafter, patients were put on follow-up and assessed again at various visits as per the study protocol.

The patients were interviewed as per the EORTC QLQ-C30 questionnaire module at the first visit and at subsequent follow-up visits at 6, 12, and 24 months, respectively. The patients are still on the follow-up.

The EORTC QLQ-C30 questionnaire is composed of both multi-item scales and single-item measures, which range in score from 0 to 100. A high scale score represents a higher response level.

Statistical Analysis

The data collected were expressed as mean/raw score (RS), standard deviation (SD) and percent mean score (%MS) described as the scale score. The raw score, linear transformation, and scale score (%MS) were derived as per the calculations and equations of the EORTC QLQ-C30 scoring manual. [7],[8]

Further intragroup comparison (IGC) was done at four levels (a, b, c, and d) and was estimated by a paired sample t-test and Wilcoxon's sign rank test, and the overall difference was measured by Friedman's test and unstacked ANOVA. The statistical packages SPSS and Minitab were used for making inferences. A P-value of <0.05 was considered significant.

 Results



The physical functioning of the breast cancer patients was found to improve with time: at the first visit, it was 87.78 which increased to 93.64, 96.16, and 97.68 over the follow-up period of 6, 12, and 24 months, respectively. The change was significant with the P-value of 0.000, as shown in [Table 1].{Table 1}

The role functioning among the breast cancer patients varied positively with time which changed from 76.77 at the first visit to 78.03, 86.87, and 86.36 at follow-up visits at 6 , 12, and 24 months, respectively. The improvement in role functioning over the time was statistically significant with P-value of 0.001, as shown in [Table 2].{Table 2}

The symptomatology in the form of dyspnea decreased from the initial value of 7.58 at the first visit to 8.59, 3.03, and 2.02 at subsequent visits at 6, 12, and 24 months, respectively; this improvement was statistically significant with the P-value of 0.001, as shown in [Table 3].{Table 3}

As far as pain symptomatology is concerned, it decreased from 23.23 at the first visit to 20.20, 8.08, and 3.54 at subsequent follow-up visits at 6, 12, and 24 months, respectively; this improvement was statistically significant with a P-value of 0.000 as shown in [Table 4].{Table 4}

The symptom in the form of fatigue improved over the study period from 33.84 at the first visit to 27.61, 9.60, and 3.20 at 6, 12, and 24 months, respectively, and this change was statistically significant with a P-value of 0.000 as shown in [Table 5].{Table 5}

The symptom secondary to sleep disturbance, insomnia, improved over the study period from 33.84 at the first visit to 24.24, 7.58, and 2.53 at subsequent follow-up visits at 6, 12, and 24 months, respectively, and the change was significant statistically with a P-value of 0.000 as shown in [Table 6].{Table 6}

The symptom in the form of appetite loss did improve over the study period from the score of 21.21 at the first visit to 10.10, 4.04, and 1.01 at subsequent follow-up visits at 6, 12, and 24 months, respectively. This change was statistically significant with a P-value of 0.000 as shown in [Table 7].{Table 7}

The symptom scale of nausea and vomiting improved over the study period from a scale of 15.91 at the first visit to 5.81, 1.77, and 0.51 at subsequent visits at 6, 12, and 24 months, respectively, with a statistically significant improvement with a P-value of 0.000 as shown in [Table 8].{Table 8}

The symptom in the form of constipation though decreased in score from 11.11 at the first visit to 6.06, 1.01, and 1.01 over the follow-up period of 6, 12, and 24 months, respectively, and this decrease was statistically significant with a P-value of 0.000 as shown in [Table 9].{Table 9}

The symptom in the form of diarrhea though decreased in score from 8.08 at the first visit to 5.56, 2.02, and 1.01 over the study follow-up period of 6, 12, and 24 months, respectively, and this decrease was statistically significant with a P-value of 0.000 as shown in [Table 10].{Table 10}

The cognitive functioning in breast cancer patients showed a significant improvement in score from 86.62 at the first visit to 92.42, 94.95, and 96.46 over the follow-up period of 6, 12, and 24 months, respectively. This improvement was statistically significant with a P-value of 0.000 as shown in [Table 11].{Table 11}

The functional status in the form emotional functioning improved from the scale score of 52.53 at the first visit to 58.46, 61.24, and 61.49 at subsequent visits at 6, 12, and 24 months, respectively; also, this change was statistically significant with a P-value of 0.001 as shown in [Table 12].{Table 12}

The social functioning score showed a significant improvement over a study period as it improved from 56.06 at the first visit to 75.51, 75.51, and 77.53 at 6, 12, and 24 months, respectively. This change was statistically significant with a P-value of 0.000 [Table 13].{Table 13}

The patient faced more financial difficulties initially during the treatment which decreased with the follow-up time. The score decreased from 41.41 at the first visit to 26.77 at the 24-month follow-up visit which was statistically significant with the P-value of 0.000 [Table 14].{Table 14}

The global health status showed a significant improvement; the scale score changed from 53.54 at the first visit to 61.24, 65.91, and 71.59 at 6, 12, and 24 months, respectively. The improvement was statistically significant with a P-value of 0.000 as shown in [Table 15].{Table 15}

 Discussion



The age at presentation among the studied breast cancer patients was 46.6 ±10.2 years; this age of presentation was in accordance with the study of other investigators. [9],[10],[11],[12] All the patients were treated by combined modality treatment (100%; n = 81) in the form of surgery and chemoradiotherapy. However, hormonal therapy was received by all ER/PgR positive status patients.

The functional status among the female breast cancer patients in the form of physical functioning improved from the scale score of 87.78 at the first visit to 93.64, 96.16, and 97.68 over the follow-up period of 6, 12, and 24 months, respectively. The temporal change was highly significant (P = 0.000). This improvement in the physical functioning score was in coincidence with the study of other investigators. [13],[14],[15],[16],[17]

The role functioning score showed a statistically significant (P = 0.001) improvement among the breast cancer patients and varied positively with time and changed from the scale score of 76.77 at the first visit to 78.03, 86.87, and 86.36 at follow-up visits at 6, 12, and 24 months, respectively. The improvement was found to be better among younger patients. However, the role functioning improved at the long-term follow-up at 2 years; this shift in temporal improvement coincides with the findings of other investigators. [15],[18],[19]

The emotional functioning improved from the scale score of 52.53 at the first visit to 58.46, 61.24, and 61.49 at subsequent follow-up visits at 6, 12, and 24 months, respectively; also, this change was statistically significant (P = 0.001), and the temporal improvement over time was in accordance with other investigators. [15],[17],[20],[21],[22]

The cognitive functioning in breast cancer patients showed a significant change with improvement from 86.62 to 92.42, 94.95, and 96.46 over a follow-up period of 6, 12, and 24 months, respectively. This change was statistically significant (P = 0.000), and was in concordance with the findings of other investigators. [23],[24]

The social functioning showed a significant improvement over the study period; the score improved from 56.06 at the first visit to 75.51, 75.51, and 77.53 at 6, 12, and 24 months, respectively. This change was statistically significant (P = 0.000). This improvement in social functioning was due to the strong social support provided to the patient by the family and relatives as is routine in most of Kashmiri families. This improvement in social functioning was in accordance with other investigators. [17],[24] However, Ganz et al. [15] showed that social functioning remained unchanged with long-term follow-ups.

The financial difficulties which the patient faced were initially there for the treatment and decreased with the follow-up time. The score decreased from 41.41 at the first visit to 26.77 at the follow-up visit at 24 months. This improvement in the financial difficulties was statistically significant (P = 0.000). This was due to the fact that the initial financial burden of treatment was more which progressively decreased with time and was in accordance with the findings of other investigators. [19],[24]

The global health status showed a significant improvement; the scale improved from 53.54 at the first visit to 61.24, 65.91, and 71.59 at follow-up visits at 6, 12, and 24 months, respectively. This improvement was statistically significant (P = 0.000). The significant improvement in the global health status was in accordance with other investigators. [19],[24],[25]

The main reason for the improvement in majority of scale scores and subsequent coping mechanism in these patients was the familial support and care provided in the hours of stress.

 Conclusion



The survivors of breast cancer over the long-term follow-up showed a significant improvement in a majority of scores in terms of functional status, symptomatology scale, and global health status. Overall, this study showed coping mechanisms involved in various HRQOL parameters in the female breast cancer patients of the Kashmir valley of the Indian subcontinent.

References

1Daniel F Roses. Roses The Breast Cancer. New York: Churchill Livingstone; 1999.
2Donovan K, Sanson-Fisher RW, Redman S. Measuring quality of life in cancer patients. J Clin Oncol 1989;7:959-68.
3Roger D, McEwen J, Beaglehole R, Tanaka H. Oxford textbook of public health. 4th ed. Vol. 2. United Kingdom: Oxford University Press; 2002.
4Boini S, Briançon S, Guillemin F, Galan P, Hercberg S. Impact of cancer occurrence on health related QOL: A longitudinal pre-post assessment. Health Qual Life Outcomes 2004;2:4-14.
5Bottomley A. The cancer patient and quality of life. Oncologist 2002;7:120-5.
6Munshi A, Dutta D, Kakkar S, Budrukkar A, Jalali R, Sarin R, et al. Comparison of early quality of life in patients treated with radiotherapy following mastectomy or breast conservation therapy: A prospective study. Radiother Oncol 2010;97:288-93.
7Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European organization for research and Treatment of cancer QLQ-C30: A quality of life instrument for use in international clinical trial in oncology. J Natl Cancer Inst 1993;85:365-76.
8Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A. on behalf of EORTC Quality of life group. European organization for research and Treatment of cancer QLQ-C30 scoring manual. 3 rd ed. Brussels: EORTC; 2001.
9Saxena S, Rekhi B, Bansal A, Bagga A, Chintamani, Murthy NS. Clinicomorphological patterns of breast cancer including family history in New Delhi hospital, India - a cross- sectional study. World J Surg Oncol 2005;3:67-74.
10Raina V, Bhutani M, Bedi R, Sharma A, Deo S, Shukla NK et al. Analysis of early breast cancer (EBC) cases at IRCH, AIIMS, New Delhi. ASCO Annual Meeting Proceedings (Post-Meeting Edition). J Clin Oncol 2004;22 (14 suppl):686. (Meeting Abstracts)
11Fakhro AE, Fateha BE, Al-Asheeri N, Al-Ekri SA. Breast cancer: Patient characteristics and survival analysis at Salmaniya medical complex, Bahrain. East Mediterr Health J 1999;5:430-9.
12Hazrah P, Parshad R, Dhir M, Singh R. Factors associated with attrition in patients with breast cancer: A retrospective study. Natl Med J India 2007;20:230-3.
13Hjermstad MJ, Fayers PM, Bjordal K, Kaasa S. Health-Related Quality Of Life In the General Norwegian Population Assessed By The European Organization For Research And Treatment of Cancer Core Quality-Of-Life Questionnaire: The QLQ-C30 (+3). J Clin Oncol 1998;16:1188-96.
14Hjermstad MJ, Fossa SD, Bjordal K, Kaasa S. Test/retest study of the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire. J Clin Oncol 1995;13:1249-54.
15Ganz PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE, Belin TR. Quality of Life in Long-Term, Disease-Free Survivors of Breast Cancer: A Follow-up Study. J Natl Cancer Inst 2002;94:39-49.
16Montazeri A, Vahdaninia M, Harirchi I, Ebrahimi M, Khaleghi F, Jarvandi S. Quality of life in patients with breast cancer before and after diagnosis: An eighteen months follow-up study. BMC Cancer 2008;8:330-5.
17Spigel DR, Winer EP. Quality of Life in Breast Cancer Survivors. Outcomes research in review. J Clin Outcomes Manag 2002;9:123-6.
18Holzner B, Kemmler G, Kopp M, Moschen R, Schweigkofler H, Dunser M, et al. Quality Of Life in Breast Cancer Patients-Not Enough Attention for Long-Term Survivors? Psychosomatics 2001;42:117-23.
19Fehlauer F, Tribius S, Mehnert A, Rades D. Health-related quality of life in long term breast cancer survivors treated with breast conserving therapy: Impact of age at therapy. Breast Cancer Res Treat 2005;92:217-22.
20Feher S, Maly RC. Coping with breast cancer in later life: The role of religious faith. Psychooncology 1999;8:408-16.
21Pandey M, Thomas BC, Ramdas K, Ratheesan K. Early effect of surgery on quality of life in women with operable breast cancer. Jpn J Clin Oncol 2006;36:468-72.
22Brandberg Y, Michelson H, Nilsson B, Bolund C, Erikstein B, Hietanen P, et al. Quality of Life in Women With Breast Cancer During The First Year After Random Assignment To Adjuvant Treatment With Marrow-Supported High-Dose Chemotherapy With Cyclophosphamide, Thiotepa, And Carboplatin Or Tailored Therapy With Fluorouracil, Epirubicin, And Cyclophosphamide: Scandinavian Breast Group Study 9401. J Clin Oncol 2003;21:3659-64.
23Monti DA, Mago R, Kunkel EJ. Practical Geriatrics: Depression, Cognition, and Anxiety among Postmenopausal Women with Breast Cancer. Psychiatr Serv 2005;56:1353-5.
24Safaee A, Moghimi-Dehkordi B, Zeighami B, Tabatabaee HR, Pourhoseingholi MA. Predictors of quality of life in breast cancer patients under chemotherapy. Indian J Cancer 2008;45:107-11.
25Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Hölzel D. Quality of Life Following Breast-Conserving Therapy or Mastectomy: Results of a 5-Year Prospective Study. Breast J 2004;10:223- 31.