|Ahead of print
Quality of life and its predictors in Iranian women with breast cancer undergoing chemotherapy and radiotherapy
Fatemeh Mirzaei1, Azizeh Farshbaf-Khalili2, Roghaiyeh Nourizadeh1, Reza Eghdam Zamiri3
1 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Midwifery, Faculty of Nursing and Midwifery, Aging Research Institute, Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
3 Radiation Oncologist, Medical School, Tabriz University of Medical Sciences, Tabriz, Iran
|Date of Submission||17-Nov-2018|
|Date of Decision||05-Jun-2019|
|Date of Acceptance||07-Jun-2019|
Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz
Source of Support: None, Conflict of Interest: None
Background: Quality of life is an important indicator for quality of care. This study aimed to determine the quality of life (QOL) and its predictors in Iranian women with breast cancer who undergo chemotherapy and radiotherapy to design effective interventions in improving patients' QOL.
Methods: The cross-sectional study was conducted on 190 women with breast cancer who were referred to oncology centers for chemotherapy and radiotherapy in Arak city, the central part of Iran. The participants were recruited utilizing convenience sampling method in a period from April to July 2018. Data were collected using demographic and disease characteristics questionnaires, QOL-Cancer30, QOL-Breast Cancer 23, Illness Perception Questionnaire, and Supportive Care Needs Survey – Short Form 34. Multivariate linear regression was used to analyze data.
Results: The mean (standard deviation) score of cancer QOL was 57.1 (25.8). On the other hand, the mean (standard deviation) scores of the symptom and functional domains of breast cancer QOL were 43.3 (17.9) and 44.3 (21.7), respectively. Predictive variables for cancer QOL were spouse education, insurance coverage, type of surgery, type of treatment, supportive care needs, and illness perception. Predictive variables for the domain of symptoms of breast cancer QOL included spouse education, income, supportive care needs, and illness perception, while for the functional domain of breast cancer QOL, the predictive variables were the type of surgery, spouse age, supportive care needs, and illness perception.
Conclusion: Fulfilling supportive care needs, helping to understand the curative nature of cancer, as well as empowering complementary health insurances are among intervenable variables to improve QOL among women with breast cancer.
Keywords: Breast cancer, chemotherapy, quality of life, radiotherapy
Key Message: Meeting supportive care needs, and helping to reduce the perceived severity of cancer by health care providers to cope with the disease, and also empowering complementary health insurances by the health system and insurance companies would improve quality of life of Iranian women with breast cancer.
|How to cite this URL:|
Mirzaei F, Farshbaf-Khalili A, Nourizadeh R, Zamiri RE. Quality of life and its predictors in Iranian women with breast cancer undergoing chemotherapy and radiotherapy. Indian J Cancer [Epub ahead of print] [cited 2020 Oct 30]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=297033
| » Introduction|| |
Breast cancer is the most commonly occurring cancer in women and the second most common cancer overall. There were over 2 million new cases in 2018. In recent decades, due to the increased life expectancy and aging of the Iranian population, breast cancer has been reported to be the most common malignancy among Iranian women. The incidence rate of breast cancer in Iran is about 22.6/100,000.
Breast cancer can cause different complications in the patients' physical, psychological, economic, and social life., Furthermore, it can disturb patients' daily functional and social activities. All of these, along with probable complications of treatment and high-treatment costs, can decline patients' quality of life (QOL).
QOL is an individual's perception of his/her living conditions based on their prevailing culture and system of values and its affinity with their goals, expectations, norms, and priorities. QOL is categorized into six domains of physical health, mental state, level of independence, social communication, living environment, and spirituality. Assessing QOL among cancer patients can be used to evaluate the disabilities of different cancer-survivor groups and populations, to assess the quality of care, to screen the individuals who are at risk of psychosocial problems, and to follow-up those who survived from cancer., In general, QOL reflects the effect of health care or therapy, whose assessment can be used to plan supportive care interventions.
One approach to assess QOL is the needs' assessment. To improve the QOL of women with breast cancer, on-time identification, and fulfillment of their needs in different stages of treatment seem to be necessary. An essential requirement for Iranian cancer patients is illness perception and its survival rate. In the literature review, there is contradictory evidence on the relationship between illness perception and QOL of cancer patients.,,,,
Considering the high prevalence of breast cancer in Iran, and controversies in previous studies on the relationship between illness perception and cancer QOL, and regarding the increasing importance of QOL (as an essential indicator of evaluating the quality of care), the present study was conducted to provide suggestions to design suitable interventions which would improve their QOL.
| » Methods|| |
Study design and participants' characteristics
This study was a cross-sectional study carried out from April to July 2018. The inclusion criteria for the patients with breast cancer based on the recorded medical file irrespective of the stage, being 18–60 years old, undergoing chemotherapy or radiotherapy, having no chronic or systemic diseases, no history of mental disorders or other simultaneous cancers, and not undergoing chemotherapy or radiotherapy due to the relapse of the disease. The exclusion criteria were less than one month past the cancer diagnosis and experiencing stressful events (divorce, death of close relatives, loss of the job) over the past six months.
In the present study, the sample size was calculated using the formula. Based on the results of a study by Montazeri et al., in which m = 71.3, Standard Deviation (SD) = 25.6, α = 0.05 with a confidence interval of 95%, and d = 3.56, the sample size was calculated to be 190.
Once the study was approved by the ethics committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1395.965), the sampling was conducted via the convenience method. The researcher conducted the sampling by referring to public and private oncology centers of Arak, the central part of Iran. He evaluated the eligibility of the participants based on the inclusion and exclusion criteria and gave them sufficient information about the goal and the method of the study as well as the confidentiality of their data. In case of willingness to participate, signed informed consent form was obtained from the participants. Finally, 190 women with breast cancer undergoing chemotherapy and radiotherapy (100 participants from public centers and 90 from private centers) completed the demographic and disease characteristics questionnaire, Illness Perception Questionnaire (IPQ), the Supportive Care Needs Survey - Short Form (SCNS-SF34), plus European Organization for Research and Treatment of Cancer (EORTC) Quality of life Questionnaires (QLQ-C30 and QLQ-BR23) through interview. Some of the critical questions such as the type and grade of cancer and the nature of medicines were extracted from the patients' medical records.
Data collection tools
Demographic and disease characteristics questionnaire contained questions on age, husband's age, income, insurance coverage, residing place, marital status, number of children (if married), women's and their husband's education and jobs, type and grade of breast cancer, as well as the type of treatment and surgery.
The EORTC QLQ-C30 contains 30 questions evaluating QOL across five functional domains, nine symptom domains, and in a global health domain. The score of each domain varies from 0 to 100. Cronbach's α for the Persian version of the tool was calculated to be more than 0.7.
The EORTC QLQ-BR23 is a breast-specific module that comprises 23 questions and contains four functional domains and four symptom domains. In the functional domains, higher scores indicate better QOL, but in the symptom domains, higher scores represent more complaints by the patients about the disease and worse QOL. The participants were asked to score each item on a 4-point Likert scale (1: not at all, 2: a little, 3: much, 4: very much). All domains gained a score from 0 to 100. This questionnaire is considered as complementary for QLQ-C30. Cronbach's α for subscales of the Persian version of this instrument was 0.72–0.92.
To evaluate the illness perception of women with breast cancer, the Brief IPQ was utilized. It contains nine questions for assessing emotional and cognitive manifestations of the illness. The range of scores of the first eight questions varies from 1 to 10. Question 9 is an open-ended question on the three major causes of the disease. Cronbach's α for the Persian version was calculated to be 0.80, and the reliability coefficient, using the test–retest method, with a 6-week interval, was reported to be 0.42–0.75 for all domains.
The Supportive Care Needs Survey - Short Form (SCNS-SF34) developed by Boyes et al. contains 34 items evaluating the supportive care needs in domains including physical and daily living (5 items), psychological state (10 items), patient care and support (5 items), health system and information (11 items), and sexuality (3 items). The participants were asked to score each item on a 5-point Likert scale (1 = no need/not applicable, 2 = no need/satisfied, 3 = low need, 4 = moderate need, and 5 = high need). Higher scores indicated more needs. Cronbach's α of the Persian version of the scale was more than 0.90, and its reliability was 0.90.
Data were analyzed using SPSS software (version 24). For data analysis, descriptive and analytical statistics including frequency, percentage, mean (standard deviation: SD), Chi-square, independent t-test, the Pearson correlation coefficient, and one-way Analysis of variance (ANOVA) were utilized. Then, to determine the QOL predictors, later to control the effect of confounding variables, the independent variables with the P value <0.2 in the bivariate tests were introduced into the multivariate linear regression model using Backward strategy.
| » Results|| |
The participants' mean (SD) age was 46.9 (8.8) years (range 18-60 years), and the majority (95.4%) had insurance. Most of the participants (82.7%) were married. Almost half had an insufficient level of income. A total of 83.1% of the respondents were housewives. Among women with breast cancer, 48.4% and 51.5% were under treatment with chemotherapy and radiotherapy, respectively. Most of the participants, 76.5%, had undergone mastectomy surgery [Table 1]. The studied participants were under treatment from less than 1–15 months.
|Table 1: Demographic and disease characteristics of women with breast cancer undergoing chemotherapy and radiotherapy|
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Cancer quality of life
The mean (SD) of cancer QOL was 57.1 (25.8) out of 100, which were 50.5 (25.9) and 62.2 (24.3) for the chemotherapy and radiotherapy groups, respectively. The difference between the two groups was statistically significant (P = 0.001) [Table 2].
|Table 2: Mean scores of cancer quality of life (QLQ-C30) in women with breast cancer undergoing chemotherapy and radiotherapy|
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In bivariate comparisons, the cancer QOL had a significant relationship with the number of children (P = 0.04), spouse's age (P = 0.04), insurance coverage (P = 0.003), education (P = 0.03), spouse's education (P = 0.03), type of treatment (P = 0.001), and type of breast malignancy (P = 0.03).
Breast cancer quality of life
The mean (SD) of the symptoms' domain of breast cancer QOL was 43.3 (17.9) out of 100. A significant relationship was observed between the symptoms' domain of breast cancer QOL and income (P = 0.03), plus the spouse's education (P = 0.008) [Table 3].
|Table 3: Mean scores of functional and symptom domains of breast cancer quality of life (QLQ-BR23)|
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The mean (SD) of the functional domain of breast cancer QOL was 44.3 (21.7) out of 100. The functional domain of breast cancer QOL had a significant relationship with spouse's age (P = 0.04), marital status (P = 0.01), type of breast malignancy (P = 0.006), stage of the disease (P = 0.009), and type of surgery (P < 0.001) [Table 3].
The results revealed a significant relationship between cancer QOL and symptom as well as functional domains of breast cancer QOL on the one hand and supportive care needs and illness perception on the other (P < 0.05).
Predictors of QOL
Once the variables with P < 0.2 were introduced into the multivariate linear regression model, the predictive variables for cancer QOL included spouse's education, insurance coverage, type of surgery, type of treatment, supportive care needs, and illness perception.
Predictive variables for the symptoms' domain of breast cancer QOL included spouse's education, income, supportive care needs, and illness perception. Also, predictive variables of the functional domain of breast cancer QOL included the type of surgery, spouse's age, supportive care needs, and illness perception [Table 4].
|Table 4: Predictors of quality of life in women with breast cancer (n=190)|
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| » Discussion|| |
Cancer quality of life
In this study, the mean (SD) of cancer QOL was 57.1 (25.8). Similar to the present investigation, Bekele in Eastern Africa reported that QOL mean score in women with breast cancer undergoing chemotherapy and radiotherapy was 52.5. However, in two studies conducted in Malaysia and Iran, on women with breast cancer undergoing chemotherapy and radiotherapy, the mean (SD) scores of QOL were reported as 65.7 (21.4) and 64.92 (11.42), respectively, clearly higher than the present study values., In an Indian study, the mean (SD) scores of QOL in women with breast cancer was reported to be 42.24 (10.23), which was lower than the present study levels. Such a discrepancy may be due to the differences in the inclusion criteria, stage of the disease, as well as differences in family and psychosocial support.
In our study, cancer QOL was lower in the chemotherapy group than in the radiotherapy group. Previous studies also reported lower QOL in chemotherapy patients when compared to the radiotherapy group., It seems that the passage of time off the disease's diagnosis and increase in patient's stability can mitigate the adverse effects on the patient's QOL.
Predictors of quality of life
Supportive care needs were one of the predictors of cancer QOL along with symptoms and functional domains of breast cancer QOL. It suggests that women with unmet supportive care needs had a lower QOL. This finding is in line with the results of previous studies.,, Overall, needs assessment is one of the most critical approaches to evaluate the QOL.,
Illness perception was another predictor of cancer QOL as well as the symptoms and functional domains of breast cancer QOL. It indicates that patients with higher illness perception had a lower QOL. According to El-Jawahri et al. in Massachusetts, the United States, patients with an accurate and correct perception of the nature and outcome of their disease at the final stages of advanced gastrointestinal cancers reported having worse QOL and more anxiety. Similar to the present study, the results of an Iranian research study on patients with gastrointestinal cancer showed that those who were not aware of their disease's diagnosis had better QOL. Also, in another Iranian study, physical and social domains of cancer QOL were better among those who were not aware of their condition.
In the present study, cancer QOL and the functional domain of breast cancer QOL were lower in women with mastectomy when compared to lumpectomy. Since in most societies and cultures, breasts are considered as the symbols of sexuality and feminine identity, mastectomy, especially in younger women, harms their mental health and QOL. Other studies have also reported a relationship between mastectomy and low QOL., However, in two studies in Japan and Malaysia, no significant association was observed., The age of the participants probably causes it. The mean ages of women in these studies were 51.8 and 58.9 years, respectively, which were higher than in the present study.
The current study indicated insurance coverage as another predicting factor for cancer QOL. In line with our study, a Chinese study reported that insurance coverage was associated with financial stress and patients' QOL. However, according to two other studies in Iran, and China, no significant relationship was reported between insurance coverage and cancer QOL., The difference in the results could be due to the difference in the insurance policy and because of the economic conditions of the studied population. In this study, the income of half of the participants was reported to be insufficient. Note that care should be provided based on medical needs, not on financial contributions.
According to our research, higher education of spouses improved the participants' QOL, probably due to its financial merits.
Income status was one of the predictors of the symptoms' domain of breast cancer QOL, suggesting that the increase in income level reduced systemic effects, breast and arm symptoms, and being upset by hair loss. It can be said that possibly appropriate financial status of the patients had facilitated their access to desirable medical services and better cares.
Spouse's age was considered to be another predictor of the functional domain of breast cancer QOL. It means that those participants with older husbands had a lower QOL. According to the authors' search, no study existed to reject or confirm this finding. So, its effect on breast cancer QOL should be taken into account in future studies.
The strengths of the present study included the use of standard questionnaires, large sample size, and reporting the results in detail for each questionnaire. Our research had limitations in its design, however. Since it was a cross-sectional study, the relationships did not necessarily indicate a causal relationship between the mentioned variables.
| » Conclusion|| |
Meeting supportive care needs, helping to understand the curable nature of cancer, and fortifying complementary health insurances should be considered as some of the intervenable variables in improving QOL among women with breast cancer.
Implications for practice: The findings of this study indicated the need for designing appropriate interventions based on complementary health insurances, supportive care needs, and illness perception to assess the extent of their effectiveness in improving QOL of women with breast cancer.
Financial support and sponsorship
Tabriz University of Medical Sciences financed this work (Grant code: IR.TBZMED.REC.1395.965).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]