REVIEW ARTICLE /SYNTHÈSE
Quality of life in advanced cervical cancer patients subjected to radiotherapy — a WHOQOL BREF questionnaire study
Qualité de vie des patientes atteintes d’un cancer du col de l’utérus de stade avancé soumises à une radiothérapie — étude basée sur le questionnaire WHOQOL BREF
M. Pasek · K. Urbański · L. Suchocka
Received: 27 September 2012; Accepted: 10 April 2013
© Springer-Verlag France 2013
AbstractAim: We hypothesized that: (1) the stage of malig- nancy, the patient’s age, and the occurrence of treatment- related side effects represent the strongest determinants of the quality of life in cervical cancer patients, and (2) the quality of life in this group is the lowest immediately after completing radiotherapy. Therefore, the aim of this study was to analyse the quality of life and its determinants at var- ious phases of therapeutic process in irradiation-treated patients with advanced cervical cancer.
Procedure: The study included 157 consecutive women with any stage of cervical cancer and who received teleradiother- apy under hospital conditions. The standardized WHOQOL BREF questionnaire was used. The survey was conducted three times: 1) on admission, 2) at discharge, and 3) at 5–6 months after completing radiotherapy.
Results: Cervical cancer women evaluated their general quality of life as rather good at all phases of the therapy regardless of the occurrence of treatment side effects, their age, and cancer stage. Available social support, ability to move, availability and quality of healthcare, and home envi- ronment were scored very high prior to the therapy and immediately thereafter, and still perceived satisfactory at 5–6 months following the treatment. The participants assessed their intimate relationships as satisfactory during
all phases of the treatment in spite of being rather dissatisfied with their sexual activity at 5–6 months following the ther- apy. Amongst various quality of life dimensions, physical functioning was scored the lowest, and social relationships the highest, but a decreasing tendency in the latter parameter could be observed during consecutive phases of the thera- peutic process.
Conclusion: Although the quality of life of cervical cancer patients is rather good throughout the consecutive phases of the therapy, some of its aspects which are not directly related to the disease (e.g. sexual functioning and social relation- ships) deserve particular attention.
Keywords Cervical cancer · Nursing · Psychological support · Quality of life · Radiotherapy
Résumé Objectifs : Nous émettons l’hypothèse suivante : 1) le stade de l’affection maligne, l’âge de la patiente et l’existence d’effets secondaires liés au traitement représen- tent les principaux facteurs déterminants de la qualité de vie des patientes atteintes d’un cancer du col de l’utérus ; 2) la qualité de vie de ce groupe est au plus bas immédiate- ment à la fin de la radiothérapie. Par conséquent, le but de cette étude consistait à analyser la qualité de vie et ses fac- teurs déterminants à divers stades du processus thérapeu- tique des patientes souffrant d’un cancer du col de l’utérus traitées par rayons.
Mode opératoire : La population de l’étude compte 157 femmes consécutives atteintes à divers degrés du cancer du col de l’utérus, ayant été traitées en téléradiothérapie à l’hôpital. Le questionnaire WHOQOL BREF standard a été utilisé. L’étude porte sur trois étapes : 1) à l’admission ; 2) à la sortie de l’hôpital ; 3) cinq à six mois après la fin de la radiothérapie.
Résultats : Les femmes atteintes d’un cancer du col de l’utérus ont jugé leur qualité de vie relativement satisfaisante à toutes les étapes de la thérapie, indépendamment de
M. Pasek (*)
Department of Nursing Oncology,
Maria Skłodowska-Curie Memorial Institute of Oncology, ul. Garncarska 11, 31–115 Cracow, Poland
e-mail : malgorzata_pasek@wp.pl K. Urbański
Department of Gynecological Oncology,
Maria Skłodowska-Curie Memorial Institute of Oncology, Cracow, Poland
L. Suchocka
Department of Psychotherapy and Psychology of Health, Catholic University of Lublin
DOI 10.1007/s11839-013-0413-7
l’existence d’effets secondaires liés au traitement, de leur âge et du stade d’avancement du cancer. Le soutien relationnel existant, la possibilité de se déplacer, la disponibilité et la qualité des soins, ainsi que l’environnement familial étaient notés très haut, avant la thérapie et immédiatement après.
Ces facteurs étaient toujours jugés satisfaisants cinq à six mois après le traitement. Les participantes ont jugé leurs relations intimes satisfaisantes pendant toutes les phases du traitement, malgré une relative déception quant à leur acti- vité sexuelle cinq à six mois après la thérapie. Parmi les critères de qualité de vie, le fonctionnement physique était noté le plus bas et les relations sociales le plus haut. Ce der- nier critère enregistrait cependant une tendance à la baisse durant les phases consécutives du processus thérapeutique.
Conclusion: Bien que la qualité de vie des patientes atteintes d’un cancer du col de l’utérus soit plutôt satisfaisante tout au long des phases consécutives de la thérapie, certains aspects, indirectement liés à la maladie (comme l’activité sexuelle et les relations sociales), méritent une attention particulière.
Mots clésCancer du col de l’utérus · Soins infirmiers · Soutien psychologique · Qualité de vie · Radiothérapie
Introduction
In general, malignancy and the associated oncological ther- apy constitute a situation best described as a crisis requiring effort to preserve one’s health and life. Oncological patients develop an array of coping mechanisms aimed at counter- acting the stress associated with diagnosis, management, and prognosis. Benner and Wrubel [4] identified factors that are able to directly influence the development of protec- tive mechanisms. These include personal history, clinical sit- uation with regards to the following phases: pre-diagnostic, diagnostic, therapeutic, remission, relapse, passing away, and death, as well as body characteristics, individual speci- ficity of the patient, determinants of seeking and accepting support, temporariness, stress, and coping mechanisms of healthcare providers [4].
Recovery is the principal objective of every treatment.
However, in the case of cancer patients, the more advanced clinical stage of the disease and the presence of metastases are associated with poorer prognosis and lower probability of recovery. Under such circumstances, providing care and support aimed at enabling the continuation of a meaningful life becomes one of therapeutic priorities in the face of the experienced discomfort, disability, and other disease-related issues.
Understanding the impact of the disease on the patient and his/her positive and negative emotions, as well as the identification of needs and problems associated with
the disease and its therapy should constitute an important part of healthcare planning. Consequently, improvement of patient’s quality of life should be included by the med- ical personnel amongst the principal goals. Quality of life is understood as individual’s perception of his/her posi- tion in the context of culture and system of values; it is a complex outcome of physical health of an individual, and his/her mental status, social relationships, degree of independence, and the relationship with surrounding environment.
Cervical cancer is one of the most common female malig- nancies. Approximately 80% of affected patients are sub- jected to radiotherapy, alone or in combination with surgery.
Consequently, studying the quality of life of women with cervical cancer who were treated by irradiation is of vital importance.
We hypothesized that the stage of malignancy, along with patient’s age and the occurrence of treatment-related side effects, represent the strongest determinants of the quality of life in cervical cancer patients. Moreover, we supposed that the quality of life in this group is the lowest immediately after completing radiotherapy. Therefore, the aim of this study was to analyse the quality of life and its determinants at various phases of therapeutic process in hospitalized patients with advanced cervical cancer treated by means of radiotherapy.
Patients and methods
The study was performed in six cancer centres in Poland (Warsaw, Cracow, Gliwice, Kielce, Lublin, and Bialystok) between June 2004 and December 2005.
The study included 157 consecutive women with any stage of cervical cancer who received teleradiotherapy under hospital conditions. Patients who were irradiated under ambulatory conditions were excluded as were those with incomplete follow-up documentation. Demographical and clinical characteristics of the examined group are pre- sented in Tables 1–3.
The standardized WHOQOL BREF questionnaire was used. Additionally, in order to evaluate the demographic and the clinical characteristics of patients, a questionnaire developed by the authors was used. It contained 19 questions and was completed by the researcher based on the conversa- tion with the hospitalized patient and on her medical documentation.
The survey was conducted three times: 1) phase 1 –on admission, 2) phase 2–at discharge, and 3) phase 3–at 5 to 6 months after completing radiotherapy. At phase 3, ques- tionnaires were sent by mail to all those who had taken part in the previous phases.
The participation in this study was voluntary and anony- mous. All participants expressed a written, informed consent before starting any procedure. The study protocol was accepted by the local bioethics committee at the Maria Sklodowska-Curie Memorial Institute of Oncology Cancer Centre in Cracow.
Statistical analysis was performed using Statistica PL 7.0 package (StatSoft®, Tulsa OK, United States). Continuous variables were presented as arithmetic means, standard deviations, and median values. The significance of time course differences among continuous variables was tested by the Friedman ANOVA test. Additionally, Spearman’s rank coefficient of correlation (R) was calculated between the given variables. The statistical significance of all tests was defined asP≤0.05.
Results
The overall quality of life scores increased significantly with the phases of the study. Quality of life was perceived as poor prior to radiotherapy, moderate at the end of the treatment and slightly better at 5-6 months after its completion. This assessment was strictly related with the phases of the study (P< 0.00001, Table 4). Our patients scored the quality of their social relationships as moderate. Significant differences in this parameter were documented between consecutive phases of the study, with the lowest value observed at phase 3 (P= 0.00001).
The power of most of the correlations between the global scores of quality of life and various spheres of functioning at phase 1 was moderate (0.3≤R< 0.5). Of note is the presence of a significant correlation between the overall quality of life and its environmental dimension, which was observed during all three phases of this study. At phase 2, a strong and Table 1 Demographical characteristics of the study group
(n= 157).
Parameter n %
Age (years)
below 30 3 1.91
31-40 11 7.01
41-50 53 33.76
51-60 55 35.03
61-70 25 15.92
Over 71 10 6.37
Education
Incomplete primary 1 0.64
Primary 42 26.75
Vocational 42 26.75
Secondary 57 36.31
University 15 9.55
Marital status
Not married 10 6.37
Married 102 64.97
Separated 1 0.64
Divorced 12 7.64
Widowed 30 19.11
Common-law 2 1.27
Source of income
Professional work 48 30.57
Disability pension 33 21.02
Retirement pension 35 22.29
Unemployment compensation benefit 10 6.37
Other 31 19.75
Place of residence (distance from oncology centre)
Up to 5 km 7 4.46
6-15 km 5 3.18
16-30 km 7 4.46
31-45 km 18 11.46
Above 45 km 120 76.44
Table 2 Clinical characteristics of the study group (n= 157).
Parameter n %
Histopathology
Squamous cell carcinoma 3 95.54
Adenocarcinoma 11 0.64
Adenosquamous carcinoma 53 3.82
Clinical stage (FIGO)
IA 1 0.64
IB 42 26.75
IIA 42 26.75
IIB 57 36.31
IIIA 15 9.55
IIIB 10 6.37
IVA 102 64.97
IVB 1 0.64
Not available 10 6.37
Table 3 Therapeutic process of the study group (n= 157).
Parameter n %
Total dose of irradiation
32-49 Gy 3 95.54
50-54 Gy 11 0.64
55-64 Gy 53 3.82
Combined treatment
Yes 122 77.71
No 35 22.29
Prior surgical procedure due to cervical cancer
Yes 37 23.57
No 120 76.43
significant correlation was documented between the overall quality of life score and the general health status. The power of remaining associations was moderate, but all of them proved significant (P ≤ 0.05). Similar to phase 2, a strong correlation between the global quality of life and the assess- ment of general health status was observed at phase 3. More- over, there was a strong association of overall quality of life and its physical, psychological and environmental dimension.
Neither patients’age nor the stage of their disease influ- enced significantly their global quality of life during all phases of the study. Similarly, no significant correlations were observed between the phase of therapy and general health status, and physical, psychological, social, and envi- ronmental dimensions of the quality of life in cervical cancer patients (R< 0.1).
Relationships between various measures of WHOQOL questionnaire determined during consecutive phases of this study are summarized in Table 5. Strong, significant correla- tions were observed between the psychological and environ- mental dimensions determined in phases 1 and 2, 1 and 3, and 2 and 3.
Discussion
The aim of this study was to analyse longitudinal changes in the quality of life of women with cervical cancer who were treated with irradiation. The patients were surveyed three times: prior to the therapy, immediately thereafter, and after 5-6 months following the treatment, in order to identify potential changes in the global quality of life, as well as in the evaluation of general health status and biological, psy- chosocial, and cultural functioning. Similar methodological standards were used in several previous studies dealing with the problem in question [10,13–17].
All our participants were offered the same therapeutic standards, i.e. were hospitalized in an oncological centre due to cervical cancer and were treated with radiotherapy.
The distribution of age and the histopathological character- istics of the cervical cancers in our group was similar to those of previous studies [14,15].
Irrespective of the phase of this study, the overall quality of life scores of our patients were rather high. At phase 1, i.e.
Table 4 Global quality of life, general health status and selected functional dimensions of the study participants (n= 157).
Stage Mean SD Median P-value
Global quality of life
Stage 1 3.4710 0.92799 4.0000 0.3646
Stage 2 3.5871 0.67215 4.0000
Stage 3 3.4204 0.84828 4.0000
General health status
Stage 1 2.4387 1.04499 2.0000 <0.00001
Stage 2 3.1161 0.96668 3.0000
Stage 3 3.3654 0.93039 4.0000
Physical dimension
Stage 1 12.8178 1.89119 12.8000 0.71333
Stage 2 12.6463 1.78043 12.5714
Stage 3 12.5162 1.97358 12.5714
Psychological dimension
Stage 1 13.3724 2.28291 14.0000 0.90884
Stage 2 13,6013 2,16170 14,0000
Stage 3 13.3299 2.24052 13.3333
Social relationships
Stage 1 14.5393 2.67001 14.6667 0.00001
Stage 2 14.7140 2.65050 14.6667
Stage 3 13.6263 2.92872 13.3333
Environment
Stage 1 13.6301 2.08674 13.7143 0.22694
Stage 2 13.7758 1.97020 14.0000
Stage 3 13.3738 2.20948 13.5000
Answer scale: 1 to 5, where 1–very poor, 5–very good (global quality of life and general health); 4 to 20, where 4–very poor, 20–very good (other dimensions); results processed based on WHOQOL PL short version key.
prior to therapy, the global quality of life was strongly corre- lated with psychosocial functioning and environment. Addi- tionally, it significantly influenced the quality of life at phase 2, along with physical and environmental components of the latter. At phase 2, immediately after completing the therapy, the global level of the quality of life correlated with general health status, physical and psychosocial functioning, social relationships and environment; moreover it affected the qual- ity of life determined 5-6 months thereafter. At phase 3, the overall quality of life was strongly correlated with general health status, as well as with physical and psychosocial func- tioning, social relationships and environment. Moreover, the evaluation of physical and psychosocial functioning at phase 1 and 2, and social relationships and environment at phase 1 showed moderate effect on the global quality of life assess- ment at this phase. The results of previous studies, including our survey, suggest that the overall quality of life in cervical cancer patients is modulated by their mental functioning rather than by clinical characteristics of the disease [18,19].
In one study, the mood of the participants improved signifi- cantly between three months and one year after surgical ther- apy of gynaecological neoplasms [13].
The women participating in our study evaluated their gen- eral quality of life as rather good despite the occurrence of treatment side effects, their age, and cancer stage. Also other authors found that the assessment of the general quality of life as well as physical, emotional, and social functioning of ovarian cancer patients is not directly related to their health state and does not differ from that of malignancy-free sub- jects [22]. The participants of one study expressed a signifi- cant improvement in the quality of life despite a worsening of their physical functioning and of their general mood [16].
However, several other experiments demonstrated that the occurrence of side effects, and particularly early and late toxicity, can have an influence on the quality of life [2,6].
Very high scores of available social support, ability to move (physical activity), availability and quality of health- care, and home environment recorded prior to the therapy and immediately thereafter, as well as high scores of those
variables documented 5-6 months following the treatment could be reflected by high subjective evaluation of the qual- ity of life. The results of previous studies confirm that the quality of life is associated with general life activity. Almost 88% of patients who participated in one of such studies were capable of self-care [21]. According to some authors [5], physical state and diminished capacity may induce a feeling of psychological and social limitations. However, the hierar- chy of values changes in life-threatening situations, prioritiz- ing close relationships and metaphysical values.
Sexual function is an important determinant of the quality of life, particularly in the case of genital tumours. Our cervi- cal cancer patients subjected to radiotherapy assessed their intimate relationships as satisfactory during all phases of this study. However, the scores of their sexual activity were inconclusive prior to the therapy and immediately thereafter and rather negative at 5-6 months following the treatment. In one study analysing the quality of life related to sexual func- tion in cervical cancer women [7], more than 25% of irradi- ated patients assessed their sexual life as poorer, although 80% of them did not report any changes in their partners’ attitude. Nonetheless, more than 33% of participants experi- enced a shift in the perception of their bodies [7]. In another study [21], women between 24 and 76 years of age were surveyed 6 and 24 months following radiotherapy or che- moradiotherapy. As many as 74% of the participants declared that their sexual function was poorer as compared to that prior to the disease [21]. Finally, a third of patients participating in one recently published study did not feel their sex life had changed following treatment, while a quar- ter felt that it had [3]. According to some researchers [12], the deprivation of sexual function occurs more frequently amongst cervical cancer patients subjected to radiotherapy than in those treated surgically by means of radical hysterec- tomy. However, as stated recently, further studies are war- ranted to assess the influence of the various types of cancer therapies in regard to their effect on sexuality [20].
In our study, self-evaluation of the examined women was satisfactory at all treatment phases. This confirms the Table 5 Correlation between selected variables determined during consecutive stages of the study.
Variable Stage 1 vs. Stage 2 Stage 2 vs. Stage 3 Stage 1 vs. Stage 3
R P-value R P-value R P-value
Global quality of life 0.4646 <0.00001 0.3128 0.00007 0.2710 0.00065
General health status 0.3105 0.00009 0.2735 0.00060 0.2708 0.00068
Physical dimension 0.4982 <0.00001 0.5104 <0.00001 0.4703 <0.00001
Psychological dimension 0.5949 <0.00001 0.5345 <0.00001 0.5042 <0.00001 Social relationships 0.4721 <0.00001 0.5345 <0.00001 0.5315 <0.00001
Environment 0.6212 <0.00001 0.5606 <0.00001 0.5083 <0.00001
R–Spearman’s rank coefficient of correlation.
findings of previous studies [8,9] according to which the level of self-evaluation among women suffering from cervi- cal cancer is similar to that of healthy ones. However, one recently published study revealed that the self-image percep- tion after cancer treatment is an unmet need and needs to be addressed in women with gynaecological malignancies [20].
Our study showed that neither the age of the examined patients nor the stage of their malignancies influenced the self-evaluation of the quality of their life at any phase of our study. This is consistent with previously published find- ings [6,13,18].
Recovery of the patient understood in terms of his/her phys- ical health is the principal objective of oncological manage- ment. It is also important, however, to maintain emotional balance. Consequently, properly organized psychotherapy, ori- ented at strengthening mental, emotional and spiritual well- being with consideration of addressing individual needs, beliefs, objectives and situations, as well as patient’s resources and his/her psychophysiological responses is crucial [1,11].
Involvement in therapeutic decisions and good communica- tion with medical personnel are reflected by higher satisfaction and quality of life of oncological patients [9].
The fact that our findings were obtained in a relatively large cohort of cervical cancer patients undoubtedly repre- sents a strong point of this study. However, there is also one potential limitation: due to limited availability of oncological resources in Poland, most of our participants were treated as inpatients. This is quite rare in developed countries nowa- days, and one should keep it in mind when generalizing our findings to other groups of cervical cancer patients.
Conclusion
In conclusion, this study showed that cervical cancer women evaluate their general quality of life as rather good at all phases of the therapy regardless of the occurrence of treat- ment side effects, their age, and cancer stage. Available social support, ability to move, availability and quality of healthcare, and home environment are scored very high prior to the ther- apy and immediately thereafter, and still perceived satisfac- tory 5-6 months following the treatment. Cervical cancer patients subjected to radiotherapy assess their intimate rela- tionships as satisfactory during all phases of the treatment in spite of being rather dissatisfied with their sexual activity at 5-6 months following the therapy. Amongst various quality of life dimensions, physical functioning is scored the lowest, and social relationships the highest, but a decreasing tendency in the latter parameter can be observed during consecutive phases of the therapeutic process.
Conflict of interest statement:the author doesn’t have any conflict of interest to declare.
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