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Health-related quality of life in patients with breast cancer surgery and undergoing chemotherapy in Ahmednagar district

 Department of Musculoskeletal Physiotherapy,Dr. Vithalrao Vikhe Patil Foundation's, College of Physiotherapy, Ahmednagar, Maharashtra, India

Date of Submission06-Mar-2019
Date of Acceptance14-Oct-2019
Date of Web Publication09-Jun-2020

Correspondence Address:
Surendra Kiran Wani,
Dr. Vithalrao Vikhe Patil Foundation's, College of Physiotherapy, Vilad Ghat, Ahmednagar - 414 111, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_154_19

 > Abstract 

Background: Breast cancer in India it varies from as low as 5 per 100,000 female populations per year in rural areas to 30 per 100,000 female populations per year in urban areas. Medical treatments of surgery, chemotherapy etc. for cancer usually precipitates with serious adverse effects affecting overall quality of life in physical, psychological and social aspects.
Objective of the Study: To evaluate health related quality of life in patients who had been followed up after the breast cancer surgery for chemotherapy at our hospital.
Methods: Quality of life was documented using European Organization of Research and Treatment for Cancer Quality of life Questionnaire-Cancer 30 (EORTC QOL-C30) and European Organization of Research and Treatment for Cancer Quality of life Questionnaire-Breast 23 (EORTC QOL-BR23).
Results: After analysis of EORTC QOL-C30 questionnaire, participants had maximum affection of cognitive, social and physical functions and reported high levels of pain, fatigue and insomnia. Domains of EORTC QOL-BR23, the such as worry about self body image, sexual dysfunction, upset by hair loss, systemic therapy side effects, breast and arm symptom were reported by maximum participants. Various domains of quality of life were maximally affected in patients of breast cancer surgery undergoing chemotherapy. Health care professionals in the field of Oncology should address the above mentioned domains of quality of life in Indian patients with breast cancer surgery undergoing chemotherapy.
Conclusion: Comprehensive cancer management plan should include psychological counseling, emotional support, physiotherapy care for pain and other musculoskeletal problems etc. along with medical treatment of patients with breast cancer.

Keywords: Breast cancer surgery, Chemotherapy, QLQ-BR23, QLQ-C30, Quality of life

How to cite this URL:
Kshirsagar AS, Wani SK. Health-related quality of life in patients with breast cancer surgery and undergoing chemotherapy in Ahmednagar district. J Can Res Ther [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=286249

 > Introduction Top

Many factors such as biological, social, and cultural issues are inter related to overall women health in India.[1] The prevalence of breast cancer is increasing in Indian females. Breast cancer is abnormal collection of mass, which exceeds its growth in uncoordinated fashion than healthy tissues in the breast. Previous literature reported the increasing incidence of breast cancer of around 1.67 million new cancer cases diagnosed in 2012 in the world with an annual incidence of approximately 144,000 new cases of breast cancers in India which can be a major cause of poor quality of life (QOL) of Indian women. In developed countries, the chances of survival from breast cancer have increased to 85% due to the presence of advance screening practices, awareness, and availability of the latest treatment options, and the survival rate in developing countries remains around only 50%–60% (WHO-IARC, 2008).[2] However, breast cancer in India it varies from as low as 5/100,000 female populations per year in rural areas to 30/100,000 female populations per year in urban areas.[3]

Due to increased medical awareness, screening strategies and early diagnosis and appropriate medical treatments for rural as well as urban population reduces mortality in patients with breast cancer which increases survival rate. Medical treatments of surgery, chemotherapy for cancer usually precipitates with serious adverse effects affecting overall QOL in physical, psychological, and social aspects.[4]

Indian women frequently report to hospital during various stages of cancer,[5] in which the time of diagnosis, initial stage of the treatment, and at the end of the treatment is the hard time for the patients physically and mentally. Maximum reported cases underwent breast surgery at different stages of cancer. Modified radical mastectomy is a usual choice of option in our clinical set up which is followed by repeated chemotherapy sessions for such patients. During this whole process from diagnosis to ongoing cancer treatment, patient's QOL is impaired significantly. Model of QOL proposes the objective and subjective indicators of broad range of life domains, and also includes individual values. It takes account of concerns that externally derived norms should not be applied without reference to individual differences.[6] If there is delay in the detection of breast cancer and solving the problems of the patients, this causes prolonged treatment and the increased duration of hospital stay and its cost which can affect the patient compliance and QOL.[7]

Perry et al. reported that the implementation of QOL assessment into clinical practice for breast cancer treatment has a high potential to benefit the patients in the Western population.[8] However, Shandiz et al. (2017) reported the poor QOL in women having breast cancer. However, limited literature is available to describe the QOL inpatients underwent breast surgery undergoing chemotherapy in the Indian population. Hence, due to the diagnosis of cancer, surgery and continued chemotherapy treatment, the patient may land up with associated signs and symptoms which can affect the QOL in Indian women. Therefore, the purpose of this study was to evaluate the health-related QOL in patients operated with breast cancer and undergoing chemotherapy by administering cancer-specific questionnaire - European Organization for Research and Treatment of Cancer QOL Questionnaire-Breast 23 (EORTC QOL-BR23) and breast cancer-specific questionnaire - EORTC QOL Questionnaire-Cancer 30 (EORTC QOL-C30) in India in rural set up.

 > Materials and Methods Top

Research setting and study participants

Approval for this study was sought from the Institutional Ethical Committee of College of Physiotherapy. This study was performed in the Department of Oncology in our Hospital. A total of 50 patients of age above the age of 20 years, who were followed up for ongoing chemotherapy after breast cancer surgery were included in this study. After taking informed and written consent, the two questionnaires were administered to evaluate QOL. Fifty patients wanted to participate and gave their written consent. However, patients those were not interested to participate and patients undergone radiation therapy or on hormone therapy were excluded from the study.

Demographic characteristics along with medical history data regarding breast cancer were gathered from the medical records of the corresponding participants. The duration of the diagnosis of breast cancer and duration of surgery were also noted.


The EORTC QOL-C30 version 3.0 is a cancer specific measure of Health-Related QOL. It consist of 30 items to assess physical, role, emotional, cognitive and social functioning, global health status or QOL scales, fatigue, pain, nausea and vomiting, dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties, and global health status/QOL. This scale is reliable and valid as there was acceptable good Cronbach's alpha score of 0.846 for EORTC QOL QOL-C30.[9]

EORTC QOL-BR23 is a breast-specific module that comprises 23 questions to assess body image, sexual functioning, sexual enjoyment, future perspective, systemic therapy side effects, breast symptoms, arm symptoms, and upset of hair loss. This scale is valid as the Cronbach's alpha score for QOL-BR23 was 0.873 with strong internal reliability.[9]

 > Results Top

The mean age of participants was 54.02 ± 10.86 year mean duration of breast surgery at which the cancer-specific questionnaire was administered was 67.6 ± 20.02 days (i.e., postoperative modified radical mastectomy duration). Mean duration of diagnosed breast cancer was 4.6 ± 1.2 months.

Cancer-specific QOL questionnaire-C30 had higher scores of pain domain and other domains such as fatigue, cognitive functioning, social functioning, insomnia, and physical functioning also had high score (i.e., more than 50). Cancer-specific QOL questionnaire-C30 the item role functioning and emotional functioning had minimum score and the symptom scale which includes nausea/vomiting, constipation, and diarrhea, had high minimum scores and appetite, dyspnea had minimum scores which was <50% [Table 1].
Table 1: Breast cancer specific Quality of life - health status scores

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The data acquired from other breast cancer-specific scale, i.e., QOL questionnaire-BR23, the item upset by hair had high maximum score, thereafter items like systemic therapy side effect and body image had maximum score which was more than 50. The functional scale of QOL questionnaire-BR23 the item sexual functioning had zero score and sexual enjoyment was not applicable.

 > Discussion Top

The present study evaluated cancer-related QOL using EORTC-QOL-C30 and breast cancer-specific QOL using EORTC-QOL questionnaire-BR23.

Findings from the symptom scale and global health status of EORTC-QOL-C30 questionnaire demonstrated poor overall health and QOL due to the presence of various symptoms among the participants. Maximum impairment of cognitive, social, and physical function was observed in participants undergoing chemotherapy after the surgery which may be due to the various adverse effects of chemotherapy.

Various domains of function and symptom scales of breast cancer-specific QOL-EORTC-QOL questionnaire-BR23 also demonstrated a maximal affection.

On the analysis of global health status or QOL in Indian patients with postoperative breast cancer undergoing chemotherapy had mean scores of 45.94 ± 13.03, i.e., <50 on Likert grading demonstrating poor QOL.

In our setup, Indian patients with breast cancer surgery undergoing chemotherapy had maximum difficulty (approximately 65%) in concentrating on things such as reading newspaper or watching television and in remembering things suggesting impaired cognitive function among them. These participants were found to be disturbed socially (by approximately 65%), i.e., they felt that their physical condition or medical treatment interfered with their family life and social activities. In addition, all patients had had trouble in doing strenuous activities and taking long walk and short walk outside of the house, and some patients needed to stay in bed or chair during the day (physical function impaired by 55%). However, role function and emotional function was limited in doing either their work or other daily activities and also limited in pursuing their hobbies or other leisure time activities and the emotional functioning as they felt tense, worried, irritable, and depressed due to their condition. Role functioning was impaired by 35% and emotional was impaired by 33%).

Another component, i.e., symptom scale of EORTC QOL-C30 questionnaire showed that patients had pain, fatigue; insomnia, and it interferes with their daily activities significantly. Other associated symptoms such as dyspnea, appetite, nausea/vomiting, constipation, and diarrhea financial difficulties were present to some extent in such population.

This study assessed breast cancer-specific QOL using EORTC QOL-BR23 questionnaire also includes two component-functional scale and symptom scale. Participants had maximum worry about their body image, i.e., patients feels physically less attractive and less feminine and they are even dissatisfied with their body and then therefore, they were worried about their health in future. The item of sexual functioning and had zero score as these patients were not interested in sex and was sexually inactive.

Almost all the patients were significantly upset by hair loss due to ongoing chemotherapy (upset by hair loss affection was by 76%). Most of the patients were having systemic therapy side effect as the patients had symptoms such as dry mouth, food and drink tastes different than usual, their eyes was painful, irritated or watery, they had loss of hair, some patients were ill or unwell, some patients had hot flushes and headaches.

One of the important findings of this component was in relation to arm and breast symptoms (arm symptoms were 49% and breast symptoms were 45%). Maximum patients had pain and swelling in their arm, shoulder, hand, and breast, they also had difficulty to raise their arm and moving it sideways and even the area of the breast which was affected was oversensitive and had skin problem as the area affected was itchy, dry, and flaky.

The present study demonstrated the poor QOL in terms of various domains as explained above. Similar findings were published by Alawadi and Ohaeri in the year 2009 a study carried out on Kuwaiti women's having breast cancer.

In this study, we found that in EORTC QOL questionnaire-C30, the component cognitive functioning and social functioning had high scores in accordance with the previous study.[10] However, physical and role functioning found the lowest score showing maximum affection, and our findings showed average affection of these functions.[10] In the same study authors found-future perspective and body image better in Kuwaiti women's in contraction with our findings of maximum affection and worry about body image and Indian patients were not much worried about future perspective as they were not hopeful for better life in their future and thought of having less life expectancy later.[10]

Almost similar findings were demonstrated by Chen et al. in the year 2018 in eastern China women with breast cancer using QOL questionnaire-C30. They also found lower scores in sexual functioning and sexual enjoyment, while in our study, we found zero score may be because of the side effects of chemotherapy or in India mostly women's do not like to discuss about their sexual life as it is a private topic and it should not be discussed publicly; therefore, they must have been selected any random answer.[11]

Homaee Shandiz et al. found the highest levels for fatigue and insomnia in the Iranian population with breast cancer similar to our findings. In their study, they found symptom such as nausea/vomiting, appetite loss more frequently, but our study was not observed frequently.[12] Gokgoz et al. in the year 2011 in turkey population found the highest score for fatigue, financial difficulties, insomnia, and pain and for breast cancer-specific symptoms it was about hair loss, systemic therapy side effects, arm symptoms, and breast symptoms similarly among the symptom scale we found the highest score for pain, fatigues, and insomnia and for breast cancer-specific scale hair loss, systemic therapy side effects, arm symptoms, and breast symptoms had high scores, but we did not find high scores for financial difficulties as in our they got free schemes for the cancer surgery. Authors found emotional functioning better in such population similar to our results which reflects the same maybe because of stable mental status due to acceptance of cancer and its ill effects after its cure.

Study limitations

The limitation of the study was that we were not able to assess the QOL at various stages of breast cancer individually, which can be a future scope of the study and even sample size was small. Another limitation could be-we considered only patients having breast cancer surgery following only chemotherapy, but no other treatments such as radiotherapy and hormone therapy. One of the limitations is that the population taken is only from our district so it may not be applicable for whole Indian population but can be used as the reference data of various QOL domains in Indian population.

Future scope of the study is that QOL-C30 and QOL-BR23 needs to be validated for the Indian population in Marathi language.

Clinical implication

The advantage of the study is that health care professionals will be aware of how much the QOL of the patients is affected due breast cancer and chemotherapy so that instead of only focusing on improving the health of the patients by treatment they can focus on different domains and help them. They can counsel the patients psychologically and socially and support them emotionally and adding physiotherapy care for pain management can also be beneficial and all this can improve the acceptance of the patients toward their disease and help them improving their QOL.

 > Conclusions Top

The negative effect on various domains of QOL was observed in patients with breast cancer underwent breast surgery and undergoing chemotherapy. The reference data of each domain of EORTC QOL-C30 and QOL-BR23 among Indian patients with breast cancer surgery undergoing chemotherapy is presented in this study for future reference.

Financial support and sponsorship

Dr. Vitthalrao Vikhe Patil Foundation's, College of Physiotherapy, Vilad Ghat, Ahmednagar.

Conflicts of interest

There are no conflicts of interest.

 > References Top

Kowsalya R, Manoharan S. Health status of the Indian women-a brief report. MOJ Proteomics Bioinform 2017;5:1-4.  Back to cited text no. 1
Gokgoz S, Sadikoglu G, Paksoy E, Guneytepe U, Ozcakir A, Bayram N, et al. Health related quality of life among breast cancer patients: A study from Turkey. Global Journal of Health Science 2011;3:140-52.  Back to cited text no. 2
Agarwal G, Pradeep PV, Aggarwal V, Yip CH, Cheung PS. Spectrum of breast cancer in Asian women. World Journal of Surgery 2007;31:1031-40.  Back to cited text no. 3
Bahreinian A, Radmehr H, Mohammadi H, Mousavi MR. The effectiveness of the spiritual treatment group on improving the quality of life and mental health in women with breast cancer. Journal of Research on Religion and Health 2017;3:64-78.  Back to cited text no. 4
Weigelt B, Peterse JL, Van't Veer LJ. Breast cancer metastasis: Markers and models. Nature Reviews Cancer 2005;5:591-5.  Back to cited text no. 5
Velanovich V, Szymanski W. Quality of life of breast cancer patients with lymphedema. The American Journal of Surgery 1999;177:184-8.  Back to cited text no. 6
Ibbotson T, Maguire P, Selby P, Priestman T, Wallace L. Screening for anxiety and depression in cancer patients: the effects of disease and treatment. European Journal of Cancer 1994;30:37-40.  Back to cited text no. 7
Perry S, Kowalski TL, Chang CH. Quality of life assessment in women with breast cancer: benefits, acceptability and utilization. Health and Quality of Life Outcomes 2007;5:24.  Back to cited text no. 8
Zawisza K, Tobiasz-Adamczyk B, Nowak W, Kulig J, Jędrys J. Validity and reliability of the quality of life questionnaire (EORTC QLQ C30) and its breast cancer module (EORTC QLQ BR23). Ginekologiapolska 2010;81:262-7.  Back to cited text no. 9
Alawadi SA, Ohaeri JU. Health–related quality of life of Kuwaiti women with breast cancer: A comparative study using the EORTC Quality of Life Questionnaire. BMC Cancer 2009;9:222.  Back to cited text no. 10
Chen Q, Li S, Wang M, Liu L, Chen G. Health-related quality of life among women breast cancer patients in eastern China. BioMed Research International 2018;2018:1452635.  Back to cited text no. 11
Shandiz FH, Karimi FZ, Anbaran ZK, Abdollahi M, Rahimi N, Ghasemi M. Investigating the quality of life and the related factors in Iranian women with breast cancer. Asian Pacific journal of cancer prevention: APJCP 2017;18:2089-92.  Back to cited text no. 12


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