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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 91-99

Health-related quality of life of patients after breast cancer treatment: A cross-sectional study

1 Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of NINE, Post Graduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission29-Jul-2021
Date of Decision09-Aug-2021
Date of Acceptance24-Aug-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Budhi Singh Yadav
Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aort.aort_17_21

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BACKGROUND: Survival for breast cancer (BC) patients has improved significantly because of better treatment availability. However, patients may experience side effects after the completion of the treatment, which consequently affect their quality of life (QoL). The present study was planned to assess the QoL of BC patients after the completion of treatment.
SUBJECTS AND METHODS: One hundred patients of BC after the completion of treatment from the Department of Radiation Oncology, PostGraduate Institute of Medical Education and Research, Chandigarh, India, were enrolled in the study during December 2017 to December 2018. EORTC QLQ C30/+BR23 questionnaires were used to quantify the QoL of these patients.
RESULTS: The mean age of the participants was 49.35 ± 8.66 years. Mean global health status (GHS) QoL score was 64.6 ± 13.6. Functional scales, in most of the domains were high, whereas symptom scales were moderate to low for most items, showing better QoL. Pain (40.6 ± 19.1) and fatigue (54.8 ± 16.1) were the most disturbing symptoms. Patients exhibited higher scores for sexual functioning, whereas the least score was for future perspective.
CONCLUSIONS: There was significant overall improvement in the QoL of patients with BC after the completion of treatment regarding functional scales and symptom scales as per EORTC QLQ-C30 questionnaire. As per EORTC QLQ-BR23 questionnaire, there was deterioration of the QoL concerning future perspectives for functional scale and hair loss for symptom scales.

Keywords: Breast cancer, cancer treatment, quality of life

How to cite this article:
Kaur MD, Yadav BS, Dahiya D, Kaur S, Sharma A, Ghoshal S. Health-related quality of life of patients after breast cancer treatment: A cross-sectional study. Ann Oncol Res Ther 2021;1:91-9

How to cite this URL:
Kaur MD, Yadav BS, Dahiya D, Kaur S, Sharma A, Ghoshal S. Health-related quality of life of patients after breast cancer treatment: A cross-sectional study. Ann Oncol Res Ther [serial online] 2021 [cited 2022 Aug 8];1:91-9. Available from: http://www.aort.com/text.asp?2021/1/2/91/333302

  Introduction Top

Breast cancer (BC) is the most common cancer diagnosed in women both in the developed and developing countries. It represents 25% of all cancers. In India, BC has ranked No. 1 cancer among women with age-adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women.[1]

BC is the main cause of mortality among women globally. In developing countries, because of lack of BC screening, the diagnosis is made at an advanced stage as patients often ignore symptoms and usually seek treatment only when symptoms are worse.[2] Quality of life (QoL) is very important in BC survivorship because many patients receive some form of adjuvant therapy such as hormonal therapy for many years. Further, the long natural history of the disease makes treatment outcomes uncertain as to whether the patient will ever be cured.[3]

BC patients experience physical and psychosocial distress that adversely affects their QoL. QoL generally consists of number of domains, including physical functioning, psychological well-being, and social support.[4] The main goal of cancer treatment is improving the QoL of patients either by cure or alleviating the symptoms as much as possible. The treatment can lead to effects such as disturbed body image, restricted hand movements that interfere with the functional capacity, and directly affect the QoL. Every person perceives these side effects in a different way. It may affect the patient psychologically and physically. Psychologically, it can manifest through depression or anxiety and the feeling of embarrassment with occasional suicidal tendencies.[5] Hence, QoL assessment is important to detect and treat these physical or psychological manifestations.[6]

Keeping in mind the importance of QoL in BC patients and paucity of data from India, especially in the treated BC patients, this study was conducted to assess the QoL of treated BC patients and also to explore the association of various variables such as age at the time of survey, time since diagnosis, educational status, and monthly family income with QoL.

  Materials and Methods Top

A total of 100 BC survivors (BCSs) from Stage I to ШA were included in the study. The survey took place in radiation oncology outpatient department of PostGraduate Institute of Medical Education and Research, Chandigarh, India, from December 2017 to December 2018. Patients were selected by means of nonprobability sampling and were interviewed during medical consultations.

Patients were eligible for the study after 3 months of completion of hospital-based treatment for BC and were on follow-up. Women with cognitive disability or speech, as well as patients without previous treatment, metastasis and those previously diagnosed with depression were excluded from the study.

Institute Ethics Committee approved the study. Before starting the interview, the researcher explained the study objectives and informed consent was taken to ensure that participation was voluntary and that answers would be anonymous and confidential.

Sociodemographic data, including age, education, marital status, type of family, habitant (rural/urban), income, occupation, and clinical data, were obtained from the patients and their records.

To assess QoL, EORTC QLQ C-30 was used. It consists of 30 items including five functional scales (physical, role, emotional, cognitive, and social) and nine symptoms scale (fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties) with one global health scale (GHS). The module BR-23 comprises of 23 questions designed for quantifying QoL of BC, including five functional scales (body image, sexual functioning, sexual enjoyment, and future perspective), and four symptom scales (breast symptom, arm symptom, and upset by hair loss). The EORTC QLQ-C30 and the QLQ-BR23 are questionnaires of QoL related to health, translated, and validated in Hindi; the use of both questionnaires was authorized by the EORTC.[7]

After gathering the information from participants, the raw scores for each subscale were calculated which was then transferred to 0–100 scales according to the guidelines of EORTC scoring manual. Higher score of any subscale reflects the better QoL or high level of functioning. On the other hand, in case of symptom scales, the higher scores imply the higher level of symptoms, which indicates a worse QoL. Authorization for the use of these instruments was taken through E-mail from the EORTC group.

Sample size

The calculated sample size for this study was 100 using the following formula:

n = Z1-α/22 p (1-P)/d2

Where, n = the minimum sample size, Z1-α/2 = standard normal variate (at 5% type 1 error (P < 0.05) it is 1.96, p = proportion of BC described by a previous study[8] (14%), d = absolute error or precision (5%).

Statistical method

Statistical analysis was carried out using the SPSS version 25 (Mumbai, India). Descriptive statistics were used to summarize sociodemographic and clinical characteristics of the participants. The ANOVA and independent t-test (parametric tests) was used for the categorical variables and the Bonferroni correction test was used for post hoc analysis for finding differences between groups.

  Results Top

Demographic and clinical characteristics

The mean age was 49.35 ± 8.66 years (mean ± standard deviation [SD]). Majority (77%) of participants were in the age group of <50 years [Table 1]. Most of the participants (84%) were married. A total 36% of the respondents had completed formal education while 22% were illiterate. Most of the respondents (85%) were homemakers.
Table 1: Demographic and clinical characteristics of the participants

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Quality of life scores

[Table 2] shows detailed QoL scores measured by QLQ-C30 and QLQ-BR23. The mean ± SD score for GHS was 64.6 ± 13.6. Among functional scales, more severe impairments were observed for future perspective (32.6 ± 24.1), body image (56.3 ± 22.5), and social functioning (52.1 ± 18.1). Regarding symptom scales, more severe impairments were observed for fatigue (54.8 ± 16.1), financial difficulties (61.0 ± 22.7), and upset by arm symptoms (42.6 ± 24.7).
Table 2: Quality of life scores for all participants (n=100)

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Quality of life and demographic and clinical variables

Physical functioning (P = 0.001), role functioning (P = 0.001), and cognitive functioning (P = 0.02) were better in the age group of <50 years [Table 3]. Although the score was higher in <50 years group also in other parameters, it was not significant. For the menopausal status, GHS and cognitive functioning was found statistically significant (P = 0.01). Premenopausal patients showed better level of functioning as compared to chemopausal and postmenopausal patients. Family income, educational status, and chemotherapy regimen had no impact on functional scale. Time since diagnosis was significant only for the physical functioning (P = 0.02) and BMI significantly affected the cognitive functioning (P = 0.01), as shown in [Table 3].
Table 3: Mean difference score of quality of life with demographic and clinical variable (n=100)

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Sociodemographic and clinical variables with EORTC-QLQ-C30

The symptom scales, fatigue, and pain were statistically (P < 0.05) more in more than 50 years age group and postmenopausal patients [Table 4]. There was significant difference for financial impact with monthly family income and educational status. Patients who were illiterate and with monthly family income <10,000 Indian rupees had more financial difficulties. GHS score was more in postmenopausal women as compared to premenopausal women, and this difference was statistically significant [P < 0.05, [Table 4]].
Table 4: Mean differences between sociodemographic and clinical variables with EORTC-QLQ-C30 symptom scales (n=100)

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Sociodemographic and clinical variables with EORTC-QLQ-BR23 function scales

None of the functional scales were significant for factors such as the monthly income, education status, time since diagnosis, and BMI. With respect to the chemotherapy regimen, disturbed body image was present in the patients who received taxane and trastuzumab-based chemotherapy (P = 0.04) as compared to other regimens. For menopausal status, lower score was seen in body image, sexual functioning, sexual enjoyment, and future perspective scales in the postmenopausal patients as compared to premenopausal (P = 0.00). In young patients (<50 years), sexual functioning was also impaired significantly [P = 0.00, [Table 5]].
Table 5: Sociodemographic and clinical variables with EORTC-QLQ-BR23 function scales (n=100)

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Sociodemographic and clinical variables with BR23 symptom scales

Premenopausal patients were more upset by hair loss as compared to postmenopausal (P < 0.05). For BR23 symptom scales, the mean arm symptoms score was less among those who had 11–15 years of duration of disease, but this difference was nonsignificant. Breast symptoms score were higher among those who were more than 50 years again this difference was also not significant [Table 6].
Table 6: Mean differences between sociodemographic and clinical variables with BR23 symptom scales (n=100)

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  Discussion Top

In this cross-sectional study on 100 BCSs, we explored the important functional/symptoms scales as well as patient demographical and clinical characteristics that contributed to the overall QoL after the completion of their treatment. The QLQ-C30 and BR23 questionnaires were used to measure the QoL of patients. There was significant overall improvement in the QoL of patients regarding functional scales and symptom scales as per EORTC QLQ-C30 questionnaire. For the specific EORTC QLQ-BR23 questionnaire of BC, there was deterioration of the QoL concerning future perspectives for functional scale and hair loss for symptom scales.

The mean score (64.6 ± 13.6) of QoL in BC patients in the present study indicated that our patients had clinically good QoL when compared with EORTC QLQ-C30 reference value[9] (61.8 ± 24.6), which might be because the QoL got improved following the completion of BC treatment as patients tend to adjust to their life with time. This observation lies in line with other studies, which also observed that health-related QoL recovered after adjuvant treatment completion and no late effects existed for longer duration in the majority of patients.[10],[11] All the scales of functional dimension (physical, role, and cognitive) of EORTC QLQ-C30 showed higher scores indicating improved QoL except for social and emotional functioning. This could be explained by the fact that the BC had a significant effect on the emotional, social, and family life of these patients. Our results are consistent with the findings of others authors who also reported a significant improvement in the QoL on these different scales during follow-up.[12],[13]

The assessment of symptom scales with EORTC QLQ-C30, revealed decrease in the severity of symptoms for nausea/vomiting, diarrhea, constipation, insomnia, and loss of appetite. This could be explained by the fact that acute symptoms are observed for shorter duration during treatment but our patients had completed their treatment at least 3 months back, and by this time acute, side effects tend to subside. However, patients do experience other late symptoms such as fatigue, pain, and financial difficulties. These observations are consistent with the findings by Leeuwen et al., where they reported decline in the manifestation of acute symptoms after treatment completion but the chronic side effects (pain, dyspnea, insomnia, and fatigue) continued to be relevant for all survivors in the longer posttreatment phase.[14]

Decreased cognitive functioning was observed in patients with more than 50 years of age and after 10 years of disease diagnosis. However, these findings were not statistically significant. Chemotherapy drugs used in BC can cross the blood–brain barrier and have a direct neurotoxic effect on the brain by inducing damage to neurons, vascular endothelium, and a reduce the number of hippocampal proliferating cells leading to neurocognitive impairment.[15] Similar findings were also reported in other studies where cognitive impairment in patients with BC was observed even after 10 years of completion of their chemotherapy treatment.[16],[17] This is also described as chemobrain and it adversely affects QoL of BC patients.

There was increased level of fatigue, pain, and arm symptoms in patients with age more than 50 years that affected their QoL. It has also been reported in other studies that patients with BC experienced fatigue and pain as a result of cancer and its treatment such as surgery, chemotherapy, radiotherapy, and hormonal therapy.[18] In a longitudinal study, it was observed that fatigue and sleep disturbance were expressed as a symptom cluster. Hence, interventions targeting fatigue might be helpful in improving the QoL.[19]

In the present study, the functional scale by QLQ-BR23 showed higher scores and better QoL for sexual functioning and enjoyment. It could be because most of the participants were uncomfortable in sharing details regarding their sexual life. They were giving random response like “no problem”. These findings are in line with a previous study in which sexuality was considered to be a confidential issue and was not openly discussed.[20] Therefore, there is a need to pay more attention to sexual problems faced by Indian women with BC. Gaining patient's confidence and educating them about this problem can help identifying these types of issues.

Body image is an important aspect of QoL, especially in BC patients. In the current study, body image and future perspective showed the least score with worst QoL. Mastectomy has negative impact on the body image. In our society, breasts are the symbol of sexuality and beauty. Hair loss and arm symptoms were most disturbing among the patients in our study. Another study also found hair loss as the leading side effect that affected the QoL of the BC patients.[21]

We could not obtain a significant difference among different groups in most of the parameters of QLQ-BR-23 except for the menstrual status. Premenopausal women exhibited worse scores in sexual enjoyment, function, body image, and future perspectives than their counterparts-chemopausal and postmenopausal women. This could be because postmenopausal patients may be less active sexually and their desire may be less as the age increases. Another significant finding was the higher score for hair loss in the premenopausal group. No significant difference was observed for body image with age group. It might be because of some social factors and dress code followed in our society. Older patients may not be much conscious about their body image possibly. It cannot be concluded from this study because of less number of older patients (23%) included in the study. This observation is also consistent with the findings from another study where associations of age with body image were not seen.[22]

QoL in BCSs is compromised in different domains and these areas need attention. Patients of different age groups may exhibit different problems and need. QoL is an ever-changing phenomenon. In a study, it was emphasized that QoL was not static, and patients have altered QoL at different disease stages. It varies after diagnosis, before and after treatment and with long-term effects of cancer and treatment modalities.[23] In another study, it was observed that, if women were provided with social support during and after their treatment course, it could help them to address their problems during their survivorship phase and improve their QoL.[24]

This study has two main limitations. First, the patients were recruited from Northern India and the conclusions may not be applicable to the whole Indian populations as the need of the patients may vary with the region, religion and culture. Second, this was a cross-sectional study so it may not be possible to know about how QoL changes during the different phases from the diagnosis till follow-up. It will be pertinent to further assess the changes on heath-related QoL by using a longitudinal survey design.

  Conclusion Top

In this study, there was a significant overall improvement in the QoL of BC patients after completion of treatment regarding functional scales (except social functioning) and symptom scales by the EORTC QLQ-C30 questionnaire. For the specific EORTC QLQ-BR23 questionnaire of BC, there was a deterioration of the QoL concerning future perspectives for functional scale and hair loss for symptom scales. This study has shown that the evaluation of the QoL of cancer patients may help to improve their treatment as well as survivorship period.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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