Jpn J Clin Oncol 2014;44(12)1150 – 1157 doi:10.1093/jjco/hyu144 Advance Access Publication 1 October 2014
Original Articles
Influence of Socioeconomic Status and BMI on the Quality of Life after Mastectomy in Bangladeshi Breast Cancer Patients in a Public Hospital Md. Mizanur Rahman1,*, Md. Abul Ahsan2, Nazratun Nayeem Monalisa3 and Khadiza Rahman4 1
Department of Surgical Oncology, National Institute of Cancer Research and Hospital, Dhaka, 2Department of Medical Oncology, Shaheed Shurwardy Medical College, Dhaka, 3Centre for Control of Chronic Diseases, ICDDRB, Dhaka and 4Department of Surgical Oncology, National Institute of Cancer Research and Hospital, Dhaka, Bangladesh *For reprints and all correspondence: Md. Mizanur Rahman, Department of Surgical Oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka-1212, Bangladesh. E-mail:
[email protected] Received June 9, 2014; accepted September 2, 2014
Objective: Quality of life after diagnosis and during treatment phases of breast cancer varies across individual to individual, country to country and from ethnicity to ethnicity. So factors affecting it are of growing research interest. The aim of the study was to investigate the influence of socioeconomic status and body mass index on the quality of life of breast cancer patients during the phases of treatment-before and after mastectomy. Methods: Two hundred and fifty-one women with breast cancer undergoing surgery were interviewed prior to and after mastectomy in National Institute of Cancer Research and Hospital, Dhaka from January 2012 to March 2013 using European Organization for Research and Treatment of Cancer Core Questionnaire (and QLQ-Br23). Socioeconomic factors like educational status, family income, occupation and body mass index were taken as investigating factors against global health status and breast cancer-related factors. Results: Significant reduction of the scores found that means deterioration of function in the following domains of the quality of life were found such as physical well-being (P ¼ 0.019), emotional well-being (P ¼ 0.035), cognitive status (P ¼ 0.05) and the breast-specific subscales like BRBI (body image), BRBS (breast symptoms), BRAS (arm symptoms); (P ¼ 0.013, 0.103, 0.015) was observed after surgery in lower income group. Worker group expressed also similar effect on the global health status/quality-of-life scales (P ¼ 0.05, 0.043, 0.021) and breast subscales (P ¼ 0.002, 0.027, 0.05), patients with lower body mass index also have a lower score also. Educational status does not affect the two groups. Younger age group patients expressed much distress. Conclusions: Improvement of family income, nutritional status and improvement of working environment might have an impact on the improvement of the quality of life of breast cancer patients during the phases of treatment. Key words: breast cancer – quality of life – socioeconomy – BMI – mastectomy
INTRODUCTION Breast cancer is by far the most frequent cancer among women with an estimated 1.38 million new cancer cases diagnosed in 2008 (23% of all cancers), and ranks second overall (10.9% of all cancers). It is now the most common cancer both in developed and developing regions with 690 000 new
cases estimated in each region (population ratio 1 : 4) (1). It is estimated that most of the breast cancer cases occur among women aged ,50 years (2). With the increasing numbers of breast cancer patients, the number of younger survivors of breast cancer is growing. Previous studies conducted in western countries indicated that younger women had better
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email:
[email protected]
Jpn J Clin Oncol 2014;44(12)
psychological morbidity and poorer quality of life (QOL) after breast cancer than older women (3,4). The main reasons might be worrying about body image and sexuality, psychological stress, anxiety, fear of recurrence, sleep dysfunction, fear of loss of fertility, pain, fatigue and impaired physical functioning (5).
THE EFFECTS OF BREAST CANCER ON PATIENTS Women facing a diagnosis of breast cancer frequently develop psychopathological disturbances during medical treatment or during follow-up (6), particularly anxiety, depression or both. After treatment, women are concerned by the threat of death, the risk of recurrence, their uncertainty for the future, physical and treatment related problems, fatigue, sexuality, body image, relationships and occupational difficulties (7). In this remission phase also called reentry transition, they are confronted with many individual challenges in reverting from ‘cancer patient’ back to ‘person’ and they have to cope with a new experience of the disease in a complex rehabilitation process (8). All these concerns can create psychosocial adjustment disturbances, including anxiety, depression, other affects or coping disabilities. Symptoms of anxiety can arise from follow-up medical examinations, post-traumatic symptom disorders when dealing with physical and mental changes, feelings of abandonment by professionals or isolation from the partner and family (9). Breast cancer patients experience physical symptoms and psychosocial distress that adversely affect their QOL. QOL generally consists of a number of domains including physical functioning, psychological well-being (such as levels of anxiety and depression) and social support. Their breast cancer experiences vary, but could include the following phases: diagnosis, primary treatment, genetic risk and its psychological management, special issues related to noninvasive breast cancer, recurrence, completing treatment and reentry to normal living, survivorship and palliation for advanced cancer (10). Breast cancer is a serious, stressful and life-threatening disease. It is assumed that the diagnosis of cancer evokes far greater distress than many other diseases, regardless of prognosis. Several studies have documented the significant disruptions in the patient’s QOL during the initial phases of the breast cancer diagnosis and its subsequent treatment. Patients undergoing a mastectomy have been observed to experience significant QOL changes at various levels: physical, functional and emotional domains of QOL. Studies have also identified the relationship between mastectomy and poor sexual adjustment and body image (11). Post-operative patients have been found to become more fearful and anxious, develop sleep difficulties and experience a reduction in interest and pleasure. Their concerns involve feelings of threat to life, fear of pain, fear of recurrence, cosmetic concerns, sexual attitudes, feelings of devaluation and loss of femininity. Follow-up comparison studies report 22 – 33% of the patients
1151
as having severe mood disturbances or depression 1 – 2 years after mastectomy (12). A number of factors may be associated with the health related quality of life of breast cancer patients after surgery. Age and types of treatment have been known to be significant high-risk factors for poor QOL (13). Previous studies suggested that younger women had greater psychological morbidity and poorer QOL after breast cancer than older women. However, such associations were only published in one study conducted in western countries. Very few workers acted on the factors affecting the various domains of QOL. Some works are available in the literature regarding educational and socioeconomic status had influence on the QOL. This study will cover influence of educational background, economical status of the family, patients’ general parameters such as body mass index (BMI) and occupation on the QOL of breast cancer patients during its phases of treatment.
PATIENTS AND METHODS Patients cytologically or histologically diagnosed as primary breast carcinoma who attended to surgical oncology department for surgical treatment, National Institute of Cancer Research and Hospital, Dhaka, Bangladesh from January 2012 to March 2013 were included in this study. This was a longitudinal study taking interview at two points. First interview was taken after their admission in the hospital before surgery and second interview was taken after 4 – 6 weeks of mastectomy when they attended for post-operative follow-up and for next phase of treatment (chemotherapy).This study was adopted using European Organization for Research and Treatment of Cancer (EORTC) designed questionnaires, which was approved by the institutional review board and ethical committee of our institution. All patients were well informed before giving their consent about the purpose of our study. Patients were between 20 and 70 years of age, had a diagnosis of breast cancer (Tumor profile T1 – T4—AJCC staging) had no other history of cancer. Patients with T3 and T4 tumor profiles were admitted for surgical intervention after receiving neoadjuvant chemotherapy as a part of our routine protocol. Patients were selected who were physically and emotionally able to complete the interview and to undergo a surgical intervention. Overall, 250 patients were invited to participate in this study by a female medical graduate who had training in breast cancer management with previous experience of research. Interview with physical examination and questionnaire were filled up in a separate room of surgical oncology department. In total, all patients provided their written informed consent and completed the questionnaires, including socio-demographic factors. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) consists of global health status/QOL and five functional scales: physical functioning (PF), role functioning (RF), cognitive functioning (CF), emotional functioning (EF) and social functioning (SF).
1152
Post-mastectomy quality of life
Also included are the symptom scales/items: fatigue (FA), nausea and vomiting (NV), pain (PA), dyspnea (DY), insomnia (SD), appetite loss (AP), constipation (CO), diarrhea (DI) and financial difficulties (FI). The score for each scale was obtained by calculating the average of the items completed by the patient and then applying a linear transformation to obtain an average score ranging from 0 to 100. INSTRUMENTS EORTC QLQ The EORTC QLQ-C30 version-3 is a self-reporting cancerspecific measure of QOL. It comprises a global health status/ QOL scale and five multi-item functional scales that evaluate physical, role, emotional, cognitive and social function. Six single items measure symptoms (dyspnea, insomnia, appetite loss, constipation and diarrhea), and three multi-item symptom scales assess fatigue, pain and nausea/vomiting. Of the 30 items, 28 are scored on four-point Likert scales and the remaining two items for the global health status/QOL scales are scored on seven-point scales. All scales were linearly transformed to a score from 0 to 100, with 100 representing the best global health status/QOL or functional status and 0 the worst symptom status (14). The Questionnaire was also validated in different studies (15). The Bangla version Questionnaire was supplied by EORTC authority and was used after getting their registration and approval. Scoring manual was also supplied by them, and calculations of the score were done against each variable (16). EORTC QLQ BREAST CANCER-SPECIFIC MODULE The EORTC QLQ breast cancer-specific module (EORTC QLQ-BR23) was used which include all breast cancer and its treatment related problems. It is composed of 23 questions assessing functional scales (body image, sexual activity and future perspective) and symptom scales related to treatment (systemic therapy side effects, breast symptoms, arm symptoms and upset by hair loss (17). It was also used in Bangla version. Scoring and interpreting methods are also included in the EORTC QLQ-C30 scoring manual (14,15). Data collection and entry: After the interview all relevant information was put over the data sheet. All the data were selected and taken in the already designed program of SPSS 19 in the principal investigator’s computer after getting scored by scoring manual.
of patients. Mastectomy for demography and social status following variables were considered. Age, BMI, home address, economic status (monthly income), educational status, occupation and marital status (Table 1) were taken into consideration. DATA ANALYSIS/STATISTICAL METHOD Linear transformation was used to standardize the raw scores of the QOL parameters so that all scores ranged from 0 to 100. In accordance with the scoring manual, the questionnaire items of the QLQ-C30 and the QLQ-BR23 were grouped into scales in the categories global health status QOL, functional scales and symptom scales. The demographic factor was the patient’s age at the time of primary diagnosis. Patients’ age was median-dichotomized into two categories: 40 years and .40 years. We checked the distributions of scores at baseline: global health status, functional scales, body image, arm and breast symptoms. Also, QOL scores were ordinal scaled. Statistical analysis was carried out using SPSS version 19 (statistical package for social sciences v V19, SPSS Inc., Chicago III, IL, USA), categorical variables were expressed in frequency and percentage and x 2 test was used to determine the association among categorical variables. T test was used to determine the difference between any two variables or factors. A P value 0.05 was taken as statistically significant. PATIENTS CHARACTERS The mean age of the 250 participating patients was 44.7 years, SD was 9.82 (range: 21 – 67), 57.2% postmenopausal, 92% housewives, 48.6% educated (included reading and writing Table 1. Socio-demographic profile of the patients P valuea
Description
Age
40 years
98 (39.2)
34.8 + 5.13
.40 years
152 (60.8)
51.16 + 6.02
Marital status
Married
238 (95.2)
70.77 + 19.77 0.217
Unmarried Area of residence Dhaka Outside Dhaka
12 (4.8) 164 (65.6) 86 (34.4)
92.42 + 7.78
Illiterate
128 (51.2)
Literate
122 (48.8)
Family income
BMI
10 000b taka 180 (72)
b
55.08 + 5.54
0.004
0.045
76.58 + 11.32 61.04 + 12.3
0.033
79.7 + 9.94
.10 000 taka
70 (28)
18.5
52 (20.8)
18.16 + 1.22
.18.5
198 (79.2)
23.98 + 2.84
BMI, body mass index. x . 10 000 taka ¼ 120$.
a 2
62.30 + 12.54
20 (8)
Education
RESULT
67.17 + 11.74 0.232
79.7 + 9.94
Housewife
0.047
62.30 + 12.54
230 (92)
Occupation
Worker
Two hundred and fifty women with breast cancer were included in the study. The mean age was 50 + 9 years with a range of 21 – 80 years. Geographically, patients from every corner of the country were included, though they were described as Dhaka and non (outside)-Dhaka group. Twelve (4.8%) were single and among the married women, 87% had children. Right and left sides were involved almost equally. Family history of breast cancer was positive in 3.1%
Frequency (%) Mean + SD
Variables
0.001
Jpn J Clin Oncol 2014;44(12)
capacity), 72% of the patients’ family income was ,10 000 taka (120$) and described in Table 1. QUALITY OF LIFE QOL was evaluated by the QLQ-C30, Version 3.0 of the EORTC Study Group on QOL. The questionnaire is composed of the global health status/QOL Scale and five functional scales that evaluate physical functioning, role functioning, emotional functioning, cognitive functioning and social functioning. Higher mean scores on these scales represent better functioning and QOL. The additional module QLQ-BR23 contains breast cancer-specific scales. Here, the three subscales such as body image, arm symptoms and breast symptoms were used. Higher mean values on the arm- and breast-symptom scales indicate an increased extent of symptoms. Higher mean scores on the body image scale of the QLQ-BR23 represent better functioning.
1153
Tables 2 and 3 show that almost all parameters described here in M1 phase have higher score than M2) phase. We wanted to highlight influence of socioeconomic parameters like family income, educational and occupational status and nutritional status like BMI on QOL parameters like PF, EF, CF. Other parameters of breast cancer-specific scales [BRBI (body image), BRBS (breast symptoms) and BRAS (arm symptoms)] such as body image, breast symptoms and arm symptoms were also included. ECONOMY In the global health status, all parameters like physical functioning, emotional functioning and cognitive functioning were significantly reduced in the post-operative period (P , 0.05) after losing their breast among the poorer sectional of people. On the contrary in the group of patients from relatively richer family (earning 120$ (10 000 taka) per month) all parameters were much lower after mastectomy. Breast cancer-related symptoms show similar picture in the patients from lower earning families.
QOL PARAMETERS Health related QOL was measured on two points along with breast-related problems. They were categorized as premastectomy (M1) and post-mastectomy (M2) groups.
EDUCATION Though 51.2% of this study group were illiterate, among the literate group, a large section of women were from reading
Table 2. QOL and global health status Oncological factors with patient numbers
PF2 (physical functioning)
EF2 (emotional functioning)
CF (cognitive functioning)
a
b
P value
M1
M2
P value
M1
M2
P value
40 years (98)
55.65
50.96
0.196
55.09
47.09
0.163
59.05
59.73
0.196
.40 years (152)
64.05
59.36
0.122
63.86
55.49
0.045
67.45
68.13
0.083
T1 and T2 (110)
45.05
40.36
0.373
44.86
36.49
0.415
49.13
48.45
0.399
T3 and T4 (140) (advanced stage)
81.45
76.76
0.039
81.26
72.89
0.015
85.53
84.85
2.19
10 000 takac (180)
74.25
69.56
0.019
76.1
65.39
0.035
78.99
70.92
0.05
.10 000 taka (70)
52.25
47.56
0.277
54.06
50.17
0.287
56.99
48.92
0.300
Literate (122)
62.65
57.96
0.100
64.57
61.05
0.125
67.39
59.32
0.172
Illiterate (128)
63.85
59.16
0.085
65.77
62.25
0.139
68.64
60.57
0.159
Worker (20)
84.25
79.56
0.05
86.17
82.65
0.043
88.99
80.92
0.021
Housewife (230)
42.25
37.56
0.434
44.17
40.65
0.414
46.99
38.92
0.441
M1
M2
Age
Tumor size
Family income
Education
Occupation
BMI 18.5 (52)
48.60
43.91
0.331
50.57
47.05
0.339
52.00
52.68
0.344
.18.5 (198)
77.8
73.11
0.011
77.77
76.25
0.024
82.59
74.52
0.027
QOL, quality of life. a M1, Pre-mastectomy. b M2, Post-mastectomy. c 10 000 taka ¼ 120$.
1154
Post-mastectomy quality of life
Table 3. Breast cancer patients’ follow-ups functioning and symptoms scores as measured by the EORTC QLQ-BR23a (n ¼ 250) Oncological factors with patient numbers
BRBI (body image)
BRBS (breast symptoms)
BRAS (arm symptoms)
M1a
M2b
P value
M1
M2
P value
M1
M2
P value
,40 years (98)
63.17
54.88
0.269
67.40
64.29
0.287
67.40
55.05
0.287
.40 years (152)
71.57
63.28
0.173
75.80
72.69
0.197
75.80
63.50
0.118
T1 and T2 (110)
52.57
44.28
0.386
56.80
53.69
0.409
56.80
44.50
0.409
T3 and T4 (140)
88.97
80.68
0.045
93.20
90.09
0.026
93.20
80.09
0.043
10 000 taka (180)
81.77
73.48
0.013
85.95
82.84
0.103
85.90
73.65
0.015
.10 000 taka (70)
59.77
51.48
0.273
63.95
60.84
0.326
63.95
51.70
0.326
Literate (122)
70.17
61.88
0.133
74.40
71.29
0.193
74.40
62.10
0.134
Illiterate (128)
71.37
63.08
0.175
75.60
72.49
0.182
75.55
63.25
0.199
Worker (20)
91.77
83.48
0.002
54.00
50.89
0.027
96.00
83.70
0.050
Housewife (230)
44.23
36.98
0.443
96.00
92.89
0.446
54.00
41.70
0.433
,18.5 (52)
56.12
47.83
0.358
60.35
57.24
0.37
60.35
48.05
0.370
.18.5 (198)
85.32
77.03
0.046
89.55
86.44
0.05
89.55
77.25
0.074
Age
Tumor size
Family income
Education
Occupation
BMI
EORTC QLQ-BR23, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire breast cancer-specific module. a M1, pre-mastectomy. b M2, post-mastectomy.
and writing capacity to primary school level, QOL parameters did not differ much among both the groups. OCCUPATION Majority (80%) of the women in this series are housewives, they had expressed lower score in all categories (PF, EF and CF) and breast cancer-related findings (P , 0.05) than the working groups including staffs of school and office staffs. The working groups performed well and scores are mostly .80 and ,0.05. BODY MASS INDEX Though 20% of the women were undernourished with BMI ,18.5, they performed badly with poor score in all compartments of the global health status score as well as in the breast cancer-related symptoms. On the contrary women with good health and nutritional status (BMI .18.5) tolerated the surgery well and they did not have much effect after surgery on all compartments of QOL (P , 0.05). They have scores .75 in all parameters of examined QOL.
DISCUSSION Today, QOL surveys are an important issue in health care, especially in oncological research. Cancer affects different aspects of QOL and currently it is a major problem all over the world. The time of diagnosis, the initial stages of treatment and the months following completion of treatment are difficult times for patients both physically and emotionally. During these periods, poor adjustment and decreased QOL in breast cancer patients can easily occur (18). Therefore, it is critical for health care professionals to become familiar with the impact of a breast cancer diagnosis and its treatment on patients’ QOL (19,20). This study examined the QOL among breast cancer patients in Bangladeshi population especially in the underprivileged section and the influencing factors for the QOL were investigated before and after mastectomy. Study was done in a public hospital where almost all patients from underprivileged section of the society received their treatment. Results from these analyses suggested that women .40 years old, employed, higher family monthly income and average health in consideration with nutrition (BMI .18.5) manifested better score of QOL in many situations
Jpn J Clin Oncol 2014;44(12)
significantly in terms of the assessment. Lower TNM stage (early cancer) did not show good QOL which are in contradiction to other studies. Park et al. (13) reported breast cancer survivors in Korea had higher scores in terms of physical well-being, social wellbeing, functional well-being and breast cancer subscale. On the contrary, previous several studies suggested that the older age patients are related to higher QOL (3,21,22). A study conducted in the USA showed that younger breast cancer patients are associated with problems with respect to partner relationships, sexual functioning and body image and less adaptive coping strategies and the younger patients were more likely to have chemotherapy than older patients. Therefore, they were related to lower overall QOL than older breast cancer patients (22). There are evidences of better score in lower age group also (5), which are explained by differences in population background, source of subjects, sample size and by change. In our observation, patients with advanced cancer had a higher QOL score, possibly as they are harboring the disease for a longer period had undergone adjusting mechanism, moreover, they received chemotherapy in the meantime. Educational status did not reflect much in our series. Almost both the groups of literate and illiterates have scored almost similarly. Of course in our study even in the literate groups, majority are below school final levels, very few crossed the college level, so it was a limitation of the study. It is observed in a Korean study that advanced stage cancer, lower education and income are associated with lower QOL. Patients having higher educational levels and more income were more likely to have better access to information and resources for problem solving as well as better coping skills, which might explain better QOL among women with higher socioeconomics. Moreover, higher education would more likely to get education and information about breast cancer and its management, which would be helpful to improve the QOL among patients. Advanced stage cancer is related to more pain and chemotherapy treatment, and serious physical activity as well as more psychological problems. Therefore, advanced stage cancer, lower education and income may impact the QOL of breast cancer patients (5). RELATIONSHIP BETWEEN QOL AND ECONOMIC BURDEN ITEMS STUDY IN THE USA
IN A
For the baseline socio-demographic and treatment characteristics, the effects on QOL were as follows: higher education, never married status and receipt of chemotherapy were associated with higher QOL scores. Six Breast Cancer Finances Survey (BCFS) economic burden items (motivation to work, productivity of work, quality of work, days missed from work, change in spouse/partner’s income and sacrificing things like vacations) were each significantly associated with QOL after controlling for baseline socio-demographic and treatment characteristics. The final model for QOL scores included three BCFS economic burden items and two socio-demographic and treatment
1155
characteristics: reports of adverse changes in motivation to work, missed days from work and sacrificing things like vacations were significantly associated with higher QOL scores (23). QOL AMONG NEWLY DIAGNOSED PATIENTS Initial diagnosis has been shown to evoke a state of shock, fear and disbelief, thus creating not only a psychological crisis but an existential one as well (24). Most women experience at least some psychosocial distress during the course of their breast cancer diagnosis. The level of distress varies from woman to woman and can vary for the individual patient over the course of diagnosis. Cancer-related distress can be expected to dissipate with time for the majority of women diagnosed with cancer. For others, however, such distress may interfere substantially with comfort, QOL and the ability to make appropriate treatment decisions and adhere to treatment (20,25). QOL AFTER MASTECTOMY There are limited studies on QOL of breast cancer after mastectomy particularly very few works are available on the factors influencing the QOL. The post-operative period is generally associated with increased amount of physical discomfort and pain. This, therefore, reflects on the functional aspects, such as the inability to work, troubles meeting the needs of the family, work being less fulfilling, etc. This is also seen in the results of an Indian study where the functional well-being of women showed significant deterioration after surgery. On the other hand, not much effect was observed on social, functional and emotional well-being in contrast to earlier results (26). This probably reflected the social and cultural fabric of India where social and family support are very well provided when someone is in distress, though similar results have been reported by studies from other countries as well (27). In the above-mentioned Indian study results of multivariate analysis showed no significant difference in overall QOL except for patients undergoing modified radical mastectomy (MRM) and for those ,50 years of age. This is in contrast to the literature where surgery is found to affect psychological well-being (26) or overall QOL (20 – 23) of women undergoing surgery for breast cancer. Despite a small number of their patients undergoing breast conservation therapy (14%), the difference in QOL between these and the women undergoing MRM was evident in univariate and multivariate analysis. Women undergoing MRM were found to have significant deterioration in physical and functional well-being, breastspecific subscale (28). COGNITIVE FUNCTIONING Patients with breast cancer frequently complain of problems in their memory and concentration. In this series, as like other parameters cognitive function of the breast cancer patients also affected by age, family income, occupation and BMI. Though
1156
Post-mastectomy quality of life
in this series it is demonstrated that it reduced much after mastectomy affected by above-mentioned factors, literacy status could not affect much. Women from higher earning family, workers and with good nutrition performed better cognition. Empirical evidence is accumulating that cognitive problems are associated with use of surgery and chemotherapy. Ahles et al. (29) and Cimprich (30) examined attention and reported decrements in attention related tasks in older, but not in younger breast cancer patients. Tamoxifen has also been found to negatively affect cognition (31) in a sample of women aged 57–75. As cognitive problems interact with fatigue, pain, depression and sleep quality in their impact on functioning, interventions to improve cognition (and/or reduce these other symptoms) could lead to improvements in other domains. Examination of longterm cognitive effects of adjuvant treatment using validated neuropsychological batteries and evaluation of fatigue prior to and after surgery and adjuvant therapy is warranted. Improving cognition may also have long-term effects on survival, since impaired cognitive status has been associated with poorer survival, controlling for age, stage and treatment (32). PHYSICAL FUNCTION AND PAIN Although many have hypothesized that breast conservation results in better post-treatment functioning than mastectomy, in reviewing the literature we found that adjusted physical function scores were not significantly different by treatment group, but rather, largely related to women’s general premorbid level of illness (32,33). The physical function outcome of treatment relates to use of axillary node dissection (34). In one series, the cumulative risk of having arm problems 2 years post-treatment were three times higher (95% CI 1.94 – 4.67) among women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. Arm problems after axillary dissection were reported by up to 60% of women and had a consistent negative impact on long-term functional abilities (35). Using a decision analytic approach, Parmigiani et al. (36) also noted that axillary dissection had an overall negative impact on the quality-adjusted survival of 60-year-old women. Other researchers have noted that long-term decrements in physical function can affect activities of daily living that are critical to an older woman’s ability to live independently. Thus, in a Medicare population, the risks of axillary surgery may outweigh any benefits in guiding adjuvant therapy or of more detailed knowledge of prognosis (37). Sentinel node biopsy has been shown to have lower morbidity than axillary dissection, and may be particularly useful in older patients. Final conclusions about the value of axillary dissection will rest on the accuracy of sentinel biopsy and women’s preferences (38).
years and older. In other studies, older women undergoing breast conservation have reported better body image (and mental health) 2-years post-treatment compared with the women who had undergone mastectomy, although results have been inconsistent. National estimates of breast reconstruction rates following mastectomy demonstrate lower use among older women, with only 1.3 to 4.1% of women over age 70 having reconstruction compared with 17.9% of younger women. There is a paucity of data on sexual feelings and outcomes in older women with breast cancer. In our own research, we observed that 15.1% of women had been sexually active prior to breast cancer diagnosis and that many women reported that breast cancer had either a ‘very negative’ or ‘somewhat negative’ impact on their sexual feelings and interest (38). Interestingly, better educated women report that breast cancer has a greater impact on their lives than their less well educated counterparts, but the oldest women (75þ years) rate breast cancer as having less of an impact on their lives than younger women (67 – 74 years). The experience of having breast cancer has also been noted to have positive effects on women’s lives, and feeling a sense of purpose in life has been found to have a greater impact on QOL than breast cancer itself (39).
CONCLUSION Cancer survivors’ QOL was doubly affected by socioeconomic distress and cancer worries. Lower family income, nutritional status, occupation and age affects the QOL more after mastectomy in breast cancer patients in this study. All have a negative impact. Patients’ general health as nutritional parameter (BMI) expressed as a good indicator. Undernourished women had a gross negative impact on the QOL. These were considered to be universally common, but there might be some cross-cultural difference in the relationship between familial burden, income, occupation with the patients’ QOL. It is well documented in the literature that education interventions must be developed within a socio-cultural context and tailored to fit the patient’s culture, educational needs, lifestyle, education level and socioeconomic status. Good QOL also influences survival. So cancer education, healthy life, nutritional improvement and engagement of the women in works would improve the QOL of breast cancer patients after mastectomy even in the poorer sections of the people. Additional research is needed to understand dynamic interactions between cancer survivorship, comorbidities, aging per se, poverty, ethnicity and the processes of interaction with the medical care system in producing the observed outcomes of care.
Acknowledgements BODY IMAGE AND SEXUALITY In the multicenter EORTC trial of mastectomy versus breast conservation (plus tamoxifen) there was a trend toward better body image 1 year after treatment among women of age 70
We acknowledge and pay our gratitude to research and planning division, Director General Office, Ministry of Health, Government of Bangladesh for delivering a grant to carry out this project.
Jpn J Clin Oncol 2014;44(12)
Funding Funding for this work was provided by Research and Planning Division, Directorate of Health, Ministry of Health and Family Welfare, Government of Bangladesh.
Conflict of interest statement None declared.
References 1. IARC (2008). GLOBOCAN 2008. Breast Cancer Incidence, Mortality and Prevalence Worldwide in 2008 Summary. France: International Agency for Research on Cancer, http:// globocan.iarc.fr/factsheet.asp (12 December 2012, date last accessed). 2. American Cancer Society (2003). Cancer facts and figures. Atlanta, GA: American Cancer Society. 3. Avis NE, Crawford S, Manuel J. Quality of life among younger women with breast cancer. J Clin Oncol 2005;23:3322 –30. 4. Al-Naggar RA, Nagi NM, Ali MM, et al. Quality of life among breast cancer patients in Yemen. Asian Pac J Cancer Prev 2011;12: 2335 – 41. 5. Fang-Rong S, Ming L, Xia Z, Ya-Hong F, Long-Shu Z, You-Guo C. Health-related quality of life among breast cancer patients and its influencing factor in a Chinese population. Asian Pacific J Cancer Prev 2012;13:3747–50. 6. Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ 2005;330:702. 7. Kornblith AB, Ligibel J. Psychosocial and sexual functioning of survivors of breast cancer. Semin Oncol 2003;30:799– 813. 8. Carver CS. Enhancing adaptation during treatment and the role of individual differences. Cancer 2005;104(Suppl 11):2602–7. 9. Dolbeault S, Cayrou S, Bre´ dart A, et al. The effectiveness of a psycho-educational group after early-stage breast cancer treatment: results of a randomized French study. Psychooncology 2009;18: 647 – 56. 10. Hewitt M, Herdman R, Holland J, editors. Meeting psychosocial needs of women with breast cancer. Washington DC: The National Academies Press, National Research Council 2004;229 –33. 11. Stanton AL, Krishnan L, Collins CA. Form or function? Part 1. Subjective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy. Cancer 2001;91:2273 –81. 12. Maguire GP, Lee EG, Bevington DJ, Kuchemann CS, Crabtree RJ, Cornell CE. Psychiatric problems in the first year after mastectomy. Br Med J 1978;1:963– 5. 13. Park BW, Lee S, Lee AR, et al. Quality of life differences between younger and older breast cancer patients. J Breast Cancer 2011;14:112–8. 14. Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365–76. 15. Sprangers MA, Groenvold M, Arraras JI, et al. The European Organization for Research and Treatment of Cancer breast cancerspecific quality of life questionnaire module: first results from a three-country field study. J Clin Oncol 1996;14:2756 –68. 16. King MT. The interpretation of scores from the EORTC quality of life questionnaire QLQ-C30. Qual Life Res 1996;5:555 –67.
1157
17. Young S, Sung-Won K, Chan Yeong H, et al. Comparison of quality of life based on surgical technique in patients with breast cancer. Jpn J Clin Oncol 2014;44:22 –7. 18. Terol MC, Lopez-Roig S, Rodriguez-Marin J. Differences in quality of life: longitudinal study with cancer patients receiving chemotherapy treatment. An Psicol 2000;16:111–22. 19. Engel J, Kerr J, Schlesinger-Raab A, et al. Predictors of quality of life of breast cancer patients. Acta Oncol 2003;42:710– 8. 20. Theofilou P. Quality of life outcomes in patients with breast cancer. Oncol Rev 2012;6:e2 7– 11. 21. Ganz PA, Rowland JH, Desmond K, et al. Life after breast cancer: understanding women’s health-related quality of life and sexual functioning. J Clin Oncol 1998;16:501–14. 22. Kwan ML, Ergas IJ, Somkin CP, et al. Quality of life among women recently diagnosed with invasive breast cancer: the Pathways Study. Breast Cancer Res Treat 2010;123:507–24. 23. Karen M, Andres A, Lauren H, Patrick M, Maria P. Does economic burden influence quality of life in breast cancer survivors? Gynecol Oncol 2012;124:437 –43. 24. Thomas BC, Pandey M, Ramdas K, Nair MK. Psychological distress in cancer patients: hypothesis of a distress model. Eur J Cancer Prev 2002;11:179–85. 25. Massie MJ, Holland JC. Psychological reactions to breast cancer in the pre- and post-surgical period. Semin Surg Oncol 1991;7:320– 5. 26. Cui Y, Shu XO, Gao Y, et al. The long-term impact of medical and socio-demographic factors on the quality of life of breast cancer survivors among Chinese women. Breast Cancer Res Treat 2004;87: 135– 47. 27. Lee CO. Quality of life and breast cancer survivors. Psychosocial and treatment issues. Cancer Pract 1997;5:309– 16. 28. Manoj P, Bejoy CT, Kunnambath R, Kuttan R. Early effect of surgery on quality of life in women with operable breast cancer. Jpn J Clin Oncol 2006;36:468–72. 29. Ahles TA, Saykin AJ, Furstenberg CT, et al. Neuropsychologic impact of standard-dose systemic chemotherapy in long-term survivors of breast cancer and lymphoma. J Clin Oncol 2002;20:485– 93. 30. Cimprich B. Age and extent of surgery affect attention in women treated for breast cancer. Res Nurs Health 1998;21:229– 38. 31. Paganini-Hill A, Clark LJ. Preliminary assessment of cognitive function in breast cancer patients treated with tamoxifen. Breast Cancer Res Treat 2000;64:165– 76. 32. Goodwin JS, Samet JM, Hunt WC. Determinants of survival in older cancer patients. J Natl Cancer Inst 1996;88:1031 –38. 33. Ashing-Giwa K, Ganz PA, Petersen L. Quality of life of African-American and white long term breast carcinoma survivors. Cancer 1999;85:418–26. 34. Beaulac SM, McNair LA, Scott TE, LaMorte WW, Kavanah MT. Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg 2002;137:1253– 7. 35. Mandelblatt J. Variations in breast cancer treatment in older medicare beneficiaries: is it black or white? Cancer 2002. 36. Parmigiani G, Berry DA, Winer EP, Tebaldi C, Iglehart JD, Prosnitz LR. Is axillary lymph node dissection indicated for earlystage breast cancer? A decision analysis. J Clin Oncol 1999;17:1465– 73. 37. Hack TF, Cohen L, Katz J, Robson LS, Goss P. Physical and psychological morbidity after axillary lymph node dissection for breast cancer. J Clin Oncol 1999;17:142– 9. 38. Mandelblatt J, Figueiredo M, Cullen J. Outcomes and quality of life following breast cancer treatment in older women: when, why, how much, and what do women want? Health Qual Life Outcomes 2003; 1:45. 39. Tomich PL, Helgeson VS. Five years later: a cross-sectional comparison of breast cancer survivors with healthy women. Psychooncology 2002;11:154–69.
