Quality of life for cancer chemotherapy patients at PZAGA Mahajanga hospital

INTRODUCTION

Cancer chemotherapy is one of the mainstays of cancer treatment. In the curative setting, it either shrinks the tumor before surgery (neoadjuvant chemotherapy) or reduces the risk of recurrence (adjuvant chemotherapy). In the palliative setting, it stabilizes the tumor, relieves symptoms and improves physical conditions.¹ Chemotherapy is often associated with side effects that increase physical and psychological distress, thereby altering patients' quality of life (QoL). Beyond survival, QoL is an important measure of treatment effectiveness. Ineffective chemotherapy or chemotherapy that is associated with a number of adverse effects can significantly impair QoL.^2,3

According to the World Health Organization, QoL is "an individual's perception of his or her place in existence, in the context of the culture and value system in which he or she lives, in relation to his or her goals, expectations, norms, and concerns".⁴ It is a multidimensional concept whose measurement is subjective and requires standardized instruments. In oncology, QoL has become increasingly important in research.⁵ Valid and reliable questionnaires have been developed to assess QoL. On the one hand, knowing patients' QoL helps to improve their symptoms, well-being and life expectancy, and to better manage treatment toxicities. On the other hand, QoL is an important factor in therapeutic decisions in metastatic cancer.⁶

Cancer is a major public health problem in Madagascar. According to the Global Cancer Observatory (GLOBOCAN) report for 2020, cervical cancer (18.2%), breast cancer (15.2%), and prostate cancer (9.9%) are the most common cancers.⁷ The administration of chemotherapy is a routine activity in cancer departments in Madagascar. It can be assumed that patients who benefit from chemotherapy are not spared from side effects that can have a negative impact on their QoL. To our knowledge, few studies on QoL in oncology have been reported in the Malagasy literature.⁸

The aim of the present study was to describe the QoL of cancer patients treated with cancer chemotherapy at the Oncology Department in Mahajanga.

METHODS

Study characteristics and population

This was a prospective descriptive study conducted between November 1, 2019 and October 31, 2020 (12 months). It involved patients followed at the Oncology Department of the Professeur Zafisaona Gabriel University Hospital in Mahajanga, Madagascar. Patients with any type or stage of cancer were included. Patients who had not received chemotherapy for their cancer and patients who refused to participate or were unsuitable for the study were excluded. Finally, patients with cancer who had received at least one course of chemotherapy and who were fit and willing to participate in the study were selected.

Assessment tool and data collection

Data were collected using a pre-designed questionnaire either at the patient's bedside or in a consultation room. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) version 3.0 was used.⁹ The EORTC QLQ-C30 is a cancer-specific questionnaire consisting of 30 items grouped into several scales: a global health scale, five functional scales (physical, social, cognitive, emotional, and role functioning), eight symptom scales (fatigue, pain, nausea and vomiting, dyspnea, appetite loss, insomnia, constipation, and diarrhea), and a financial difficulties scale. Scores on each subscale range from 0 to 100. A high score on the overall health and functional scales represents a better quality of life. A high score on the symptom and financial hardship scales represents poor QoL.

Statistical analysis

The collected data were entered into a database using Microsoft Excel® 2013. The Statistical Package for Social Studies SPSS® version 20 was used for analysis.

Ethical considerations

Ethical approval for this study was obtained from the University of Mahajanga. The study complied with the principles of the Declaration of Helsinki.

Informed consent

Written informed consent was obtained from all subjects before the study. Each patient was informed of the objectives of the study, the use of the data for scientific purposes, and the expected duration of participation. For patients under 18 years of age, the study was explained to the parents or guardians and their consent was required. Confidentiality of the information collected was maintained.

RESULTS

During the study period, 178 patients were followed for cancer. One hundred thirty-two patients had never received chemotherapy or refused to participate in the study. A total of 46 patients were included. The clinical characteristics of these patients are shown in Table 1.

The sex ratio was 0.24. The mean age of the patients was 48.02±14.16 years, with a median of 50 years and extremes of 14 and 74 years. Sixteen patients (34.78%) were diagnosed with breast cancer. Table 2 shows mean QLQ-C30 scores by gender. Table 3 shows the mean scores by type of cancer diagnosed.

SD: standard deviation

SD: standard deviation

DISCUSSION

Global health status/quality of life

The mean global health status score was 70.83. This score is generally higher than those reported by other authors. Randriamanovontsoa et al. found a mean score of 57.1 in a study of QoL in Malagasy patients with non-metastatic breast cancer published in 2020.⁸ In Ethiopia, Abegaz et al and Wondie et al reported a score of 52 in 2018 and 54 in 2020, respectively.^10,11 The global health status of the patients in our study seems to be better than that reported by these authors. Moreover, the mean score we found is similar to the best results in the literature, including those observed in Saudi Arabia in 2019 (score=67.4) and Indonesia in 2023 (score=68.05).^12,13

Women had a higher score than men (72.3 vs. 64.81). In the study by Wondie et al, the mean score was higher in women (56.3 vs. 51.9 in men).¹¹ El Mokhallalati et al. reported a similar result (60.30 vs. 56.37 in men) in Palestine in 2022.¹⁴ Derogar et al reported a lower score for women (74.9 vs. 77.2 for men) in a Swedish study.¹⁵ Given the disparity in results, further research is needed to confirm or refute a possible association between gender and global health status.

Functional scales

For physical activity, the mean score was 82.9. In the previous Malagasy study, this score was 77.3.⁸ The score found in our study is higher than those observed in Ethiopia (score=53), Saudi Arabia (score=50.28) and Palestine (score=58.78).^11,14,16 On the other hand, it is not different from European data, including the 2017 study by Hinz et al in Germany, with a score of 70.6.¹⁷ Patients' QoL with regard to physical activity is good. Regular exercise should be recommended to patients undergoing cancer chemotherapy and maintained as long as it is not limited by comorbidities and side effects. In particular, it has a positive effect on psychological barriers and prevents social isolation.¹⁸

Regarding role functioning, the mean score was 76.45. This result is similar to that reported by Randriamanovontsoa et al (score=75.8) and overall higher than other studies.^8,12,17 This result reflects a good functional QoL for the patients. Functional domain includes work and leisure activities. Increasing cancer symptoms may affect patients' ability to perform these roles. This domain may also be affected by cognitive decline and misunderstanding by employers.¹⁹

During chemotherapy, the occurrence of emotional disturbances such as some degree of anxiety, fear and depression is considered a normal phenomenon. However, high levels of anxiety are negatively correlated with QoL. Participants in our study had a mean emotional functioning score of 78.08. This result is consistent with data observed in China and Europe.^15,20,21 African studies have reported scores below 70.^10,11,22 Our result reflects good QoL in this domain.

The cognitive function score was high in our study and in previous studies.^8,15,21,23 Although the adverse effects of chemotherapy on cognitive function have been recognized, complaints are often subjective. Objective assessments do not always show impairment, and when they do, it is usually mild.²⁴

In our study, the highest score was attributed to social functioning (score=95.2). Chemotherapy can lead to social isolation and changes in patients' personality and self-esteem. In the literature, social functioning QoL is often the worst among functional scales.^17,20,22 The results of our study are characterized by better QoL in social functioning. This could be explained by good psychological and social support from the patient's family, relatives and friends. Social support is a reliable resource to help patients cope with anxiety and uncertainty.²⁵

Symptom scales

For fatigue, the mean score was 25.6. In Ethiopia, the mean score was 47.4 in 2018 and 52.5 in 2020.^10,11 In Asian studies, scores were 42.5 in Saudi Arabia, 50.70 in Palestine, and 34 in China.^12,14,20 In the European literature, reported scores are generally above 40.^17,21 Our results indicate a good QoL for the patients. In addition to chemotherapy, malnutrition and anemia may predispose to fatigue.

For nausea and vomiting, the mean score was 11.23. This value is not far from the previous Malagasy study (score=18.8) and German studies (score=11.2).^8,17 In other studies, the results are variable, but the values observed are generally higher than ours.^11,13,20 This finding leads us to conclude that chemotherapy-induced nausea and vomiting may have little impact on patients’ QoL. The occurrence of symptoms may be influenced by age, gender, toxic habits, anxiety, history of nausea and vomiting, and the type of chemotherapy used.²⁶

Pain is one of the most feared side effects by patients. It is often nociceptive, but can also be neuropathic or mixed.²⁷ In our study, the mean score was 20.29. In the study by Derogar et al. in Sweden and Finck et al. in Colombia, the scores were 18.9 and 17.9, respectively, which is comparable to ours.^15,23 On the other hand, our score is much lower than that of other studies.^{8,12,16,17,20} This result indicates an adequate QoL in relation to pain. This could reflect either a high pain tolerance or a "negligible" intensity of pain experienced by patients.

For dyspnea, the mean score was 4.35. This value is comparable to those reported in Indonesia (score=7.24) and Colombia (score=9).^13,23 Higher scores were observed in other studies such as Ethiopia (score=27.6), Sweden (score=16.3), Germany (score=26.6) and China (score=17.2).^11,15,17,20 Our study is notable for its low dyspnea score, suggesting good respiratory QoL in patients.

In our study, the mean score for insomnia was 19.57. This result is not different from that reported by Derogar et al (score=17.5).¹⁵ In the African literature, mean scores are generally above 30.^10,11,22 In the Asian literature they are generally above 25.^12,14,16 In other European studies, scores are generally higher than those found in our study.^17,21 This score is therefore lower than in most studies and indicates a good quality of life in terms of sleep.

For appetite loss, the mean score was 15.22. In the literature, scores are generally higher.^8,20 Loss of appetite can be explained by the cancer itself and is exacerbated by chemotherapy. It can lead to physical weakness and weight loss, thereby reducing QoL and survival.¹⁶ Appropriate dietary and nutritional management is essential throughout cancer treatment.

For constipation, the score was 13.04, which is similar to the previous Malagasy study (score=13.9).⁸ The score is comparable to several studies such as those conducted in Germany (score=14.8), Indonesia (score=16.26), Palestine (score=16.71) and Colombia (score=17.9).^13,14,17,23 The score is lower than that reported in Ethiopia (score=30.9) and Saudi Arabia (score=35.83), but higher than that reported in Sweden (score=5.4).^11,15,16 These observations illustrate the heterogeneity of results. The incidence of constipation depends on the type of chemotherapy. It may be promoted by a depressive syndrome or by treatments such as opioids and psychotropic drugs.²⁸

Diarrhea is one of the most worrisome side effects because of its impact on QoL. Its incidence depends on the dose and the chemotherapy molecule used. In our study, the mean score was 2.17. In the literature, mean scores vary from 8 to 44 in Africa and from 7 to 47 in Asia.^{8,10-13,16,20,22} In Western countries they are much higher than in our study.^15,17,21 Our study is characterized by a lower diarrhea score than those reported in the literature. This may indicate that diarrhea has little impact on patients’ QoL.

Financial difficulties

In the assessment of financial difficulties, the mean score was 42.03. In the study by Randriamanovontsoa et al, the score was 39.7. In Ethiopia, the score was 69.6 in 2018 and 67.1 in 2020.^10,11 In Tunisia, the score was 71 in 2019.²² In developed countries, the score as 4.4 in Sweden, 6.2 in Australia, 27.9 in Germany, and 34.6 in China.^15,17,20,29 Cancer is a challenge in low-income countries due to difficult access to care and treatment and limited logistics to maintain QoL.³⁰

This study has limitations. Because the number of participants was very limited, it was not possible to perform a subgroup analysis to identify the determinants of QoL. This will be the subject of another larger study. Nevertheless, the present study was the first to assess the QoL of patients undergoing cancer chemotherapy for all cancer sites in Madagascar. It provides new information on the knowledge of QoL in oncology in the literature.

CONCLUSION

Patients had good QoL in terms of global health status. For the functional scales, QoL was excellent in the social domain. For the symptomatic scales, the results were characterized by a lower impact of diarrhea, dyspnea and insomnia on QoL, in contrast to the literature. In terms of financial difficulties, QoL was poor. At the end of the study, good psychological support from healthcare professionals and social and emotional support from relatives are necessary during chemotherapy. Routine assessment of symptoms and QoL can help guide treatment and follow-up of cancer patients.

ACKNOWLEDGEMENTS

Authors would like to thank the oncology team at PZAGA Hospital in Mahajanga.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Neugut AI, Prigerson HG. Curative, life-extending, and palliative chemotherapy: new outcomes need new names. Oncologist. 2017;22(8):883-5.
2. 2. Hassen AM, Taye G, Gizaw M, Hussien FM. Quality of life and associated factors among patients with breast cancer under chemotherapy at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. PLoS One. 2019;14(9):e0222629.
3. 3. Lang-Rollin I, Berberich G. Psycho-oncology. Dialogues Clin Neurosci. 2018;20(1):13-22.
4. 4. World Health Organization. What quality of life? The WHOQOL Group. World Health Organization Quality of Life assessment. World Health Forum. 1996;17(4):354-6.
5. 5. Kim K, Yoon H. Health-related quality of life among cancer survivors depending on the occupational status. Int J Environ Res Publ Heal. 2021;18(7):3803.
6. 6. Mokhtari-Hessari P, Montazeri A. Health-related quality of life in breast cancer patients: review of reviews from 2008 to 2018. Health Qual Life Outcomes. 2020;18(1):338.
7. 7. The Global Cancer Observatory. Madagascar-GLOBOCAN 2020 [fact-sheets]. Available at: https://gco.iarc.fr/today/data/factsheets/populations/450-madagascar-fact-sheets.pdf. Accessed 23 February 2024.
8. 8. Randriamanovontsoa NE, Razakanaivo M, Andrianandrasana NOTF, Razafiarisoa V, Rafaramino F. Quality of life for patients undergoing chemotherapy for non-metastatic breast cancer. AJOL. 2020;22(3):626-36.
9. 9. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, 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(5):365-76.
10. 10. Abegaz TM, Ayele AA, Gebresillassie BM. Health related quality of life of cancer patients in Ethiopia. J Oncol. 2018;2018:1467595.
11. 11. Wondie Y, Hinz A. Quality of life among Ethiopian cancer patients. Supp Care Cancer. 2020;28(11):5469-78.
12. 12. Imran M, Al-Wassia R, Alkhayyat SS, Baig M, Al-Saati BA. Assessment of quality of life (QoL) in breast cancer patients by using EORTC QLQ-C30 and BR-23 questionnaires: a tertiary care center survey in the western region of Saudi Arabia. PLoS One. 2019;14(7):e0219093.
13. 13. Perwitasari DA, Purba FD, Candradewi SF, Dania H, Muhammad Irham L, Noor Faridah I, et al. Quality of life of cancer patients during chemotherapy in Indonesia: a comparison of EORTC QLQ-C30 and EQ-5D-5L, based on patients’ characteristics. Int J Clin Pract. 2023;2023:9357299.
14. 14. ElMokhallalati Y, Alaloul E, Shatat M, Shneewra T, El Massri S, Shaer O, et al. The symptom burden and quality of life in cancer patients in the Gaza Strip, Palestine: a cross-sectional study. PLoS One. 2022;17(1):e0262512.
15. 15. Derogar M, van der Schaaf M, Lagergren P. Reference values for the EORTC QLQ-C30 quality of life questionnaire in a random sample of the Swedish population. Acta Oncol. 2012;51(1):10-6.
16. 16. Zamel ON, Inocian EP, Alshehry AS, Tumala RB, Patalagsa JG, Alsaleh KA. Quality of life among breast and colon cancer patients before and after first-cycle chemotherapy. J Holist Nurs. 2021;39(2):116-25.
17. 17. Hinz A, Weis J, Faller H, Brähler E, Härter M, Keller M, et al. Quality of life in cancer patients-a comparison of inpatient, outpatient, and rehabilitation settings. Support Care Cancer. 2018;26(10):3533-41.
18. 18. Elshahat S, Treanor C, Donnelly M. Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review. Int J Behav Nutr Phys Act. 2021;18(1):50.
19. 19. Fangel LMV, Panobianco MS, Kebbe LM, Almeida AM, Gozzo TO. Qualify of life and daily activities performance after breast cancer treatment. Acta Paul Enferm. 2013;26(1):93-100.
20. 20. Chen Q, Li S, Wang M, Liu L, Chen G. Health-related quality of life among women breast cancer patients in Eastern China. Biomed Res Int. 2018;2018:1452635.
21. 21. Charalambous A, Kouta C. Cancer related fatigue and quality of life in patients with advanced prostate cancer undergoing chemotherapy. Biomed Res Int. 2016;2016:3989286.
22. 22. Khalladi R, Gargouri I, Zedini C, Ben Saad H. Quality of life of Tunisian patients with lung cancer: descriptive study. Tunis Med. 2019;97(5):626-38.
23. 23. Finck C, Barradas S, Zenger M, Hinz A. Quality of life in breast cancer patients: associations with optimism and social support. Int J Clin Health Psychol. 2018;18(1):27-34.
24. 24. Országhová Z, Mego M, Chovanec M. Long-term cognitive dysfunction in cancer survivors. Front Mol Biosci. 2021;8:770413.
25. 25. Li CC, Chen ML, Chang TC, Chou HH, Chen MY. Social support buffers the effect of self-esteem on quality of life of early-stage cervical cancer survivors in Taiwan. Eur J Oncol Nurs. 2015;19(5):486-94.
26. 26. Dranitsaris G, Molassiotis A, Clemons M, Roeland E, Schwartzberg L, Dielenseger P, et al. The development of a prediction tool to identify cancer patients at high risk for chemotherapy-induced nausea and vomiting. Ann Oncol. 2017;28(6):1260-7.
27. 27. Reis-Pina P, Sabri E, Birkett NJ, Barbosa A, Lawlor PG. Cancer-related pain: a longitudinal study of time to stable pain control and its clinicodemographic predictors. J Pain Symptom Manag. 2019;58(5):812-23.
28. 28. Dzierżanowski T, Mercadante S. Constipation in cancer patients -An update of clinical evidence. Curr Treat Options Oncol. 2022;23(7):936-50.
29. 29. Mercieca-Bebber R, Costa DS, Norman R, Janda M, Smith DP, Grimison P, et al. The EORTC Quality of Life Questionnaire for cancer patients (QLQ-C30): Australian general population reference values. Med J Aust. 2019;210(11):499-506.
30. 30. Moten A, Schafer D, Farmer P, Kim J, Ferrari M. Improving cancer care in developing settings. J Glob Health. 2014;4(1):010304.