Elsevier

The Breast

Volume 41, October 2018, Pages 120-126
The Breast

Survivorship issues as determinants of quality of life after breast cancer treatment: Report from a limited resource setting

https://doi.org/10.1016/j.breast.2018.07.003Get rights and content

Highlights

  • This is a study on QOL and survivorship issues in Indian women with breast cancer.

  • Survivors show an improvement in QOL with passage of time.

  • However their QOL remain poorer compared to those of healthy women.

  • Emotional distress, fatigue and premature menopause caused maximum disruption in QOL.

Abstract

Objectives

Quality of life (QOL) in breast cancer survivors is affected by various long term sequelae of breast cancer treatment. The present study was conducted with the objectives to estimate prevalence of various survivorship issues, and to identify those which are most predictive of limitations in QOL after completion of primary therapy.

Material &Methods

This study was conducted in 230 breast cancer survivors (BCs) and 112 controls at an academic centre in Northern India. Assessment of QOL was done by SF-36 and FACT-B questionnaires. Survivorship issues were noted from a checklist of 14 commonly reported symptoms. Main outcome measures were (1) frequencies of survivorship issues and QOL scores among three groups of survivors divided on the basis of time elapsed since treatment (<2, 2–5, and >5 year follow up) (2) Issues most predictive of limitations in QOL, identified by stepwise logistic regression analysis.

Results

Longer term BCs showed higher QOL scores as compared to those in early follow up. However their QOL scores remained poorer compared to healthy women. The most prevalent survivorship issues were fatigue (60%), restriction of shoulder movement (59.6%), body and joint pain (63.5%), chemotherapy induced cessation of menstruation (73.3%) and loss of sexual desire (60%). Issues which had maximum impact on QOL scores were emotional distress (r = −11.375), fatigue (r = −9.27) and premature menopause (r = −2.085) and its related symptoms.

Conclusion

Management of these issues should be priority areas for supportive care, especially in settings with limited resource.

Introduction

With a growing population of breast cancer survivors (BCs) worldwide [1], goal of therapy has changed from simply survival to enhancing patient's quality of life. Though there is no universal definition of QOL, the World Health Organization (WHO) defines QOL as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns [2]. It is a broad-ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and relationship to salient features of their environment. The QOL model provides a means of evaluating the impact of disease or treatment on all aspects of the patient's life.

There is quite an extensive body of literature on the QOL in BCs. Several studies have reported that BCs enjoy a fairly good overall health-related quality of life (HRQOL) [[3], [4], [5], [6]], where as many others have reported poorer health outcomes and reduced QOL [7,8]. Further these women face a number of long term sequelae of cancer treatment such as fatigue, pain, sleep disturbances, psychological distress, fear of recurrence, family distress, concerns with employment and finances, information needs with respect to follow-up, and uncertainty about the future etc. [[7], [8], [9]]. The QOL and survivorship issues are reported to vary among survivors from different race/ethnic groups as well as different resource settings. Maly et al. reported a lower quality of life in lower income women, whereas Ashing Giwa et al. reported that ethnic minorities generally, are diagnosed with more advanced disease and hence experience greater morbidity and mortality [10,11].

Breast cancer incidence in India has been increasing steadily in the last 30 years, and currently it ranks as number one cancer among Indian women [1,12]. The age adjusted incidence rate (AAR) is 25.8 per 100,000 women with the highest AAR of 41 per 100,000 reported from Delhi. The mortality rate is 12.7 per 100,000 women, [13]. Breast cancer occurs at a younger premenopausal age in India and disease peaks at 40–50 years of age [12,13]. Prevalence of TNBC in India is considerably higher [14], and nearly half the patients report in advanced stages [15,16]. Modified radical mastectomy (MRM) remains the most commonly performed procedure [15,16]. Mortality rates are high (5- year-survival of 66.1%), as compared to their western counterparts (5-year survival of 90%) [17], and is attributable to lack of adequate breast cancer screening, diagnosis of disease at advanced stages and unavailability of appropriate medical facilities.

BCs in India are largely an understudied population, and data on QOL and survivorship is very limited. The present study was planned with the objectives to understand the perspective of Indian BCs regarding their survivorship experience and to identify those issues which caused maximum limitation in their QOL. This information will be useful in planning targeted intervention, so as to make the best possible use of limited available resources.

Section snippets

Material & methods

This study was conducted in the department of surgery at an academic centre in Delhi, Northern India from March 2014–July 2017. The study was approved by the Institutional research board and Ethics committee. Breast cancer survivors who had completed their primary treatment of breast cancer (surgery, radiotherapy, chemotherapy) and were coming for follow up care were enrolled in the study. A written informed consent was obtained from all the participants. Patients with metastatic, recurrent, or

Results

Two hundred and eighty six breast cancer survivors were evaluated for inclusion in the study. Thirty one survivors did not meet the inclusion criteria due to recurrent or metastatic disease, ischaemic heart disease, hypothyroidism, severe osteoarthritis etc. In 18 women data collection could not be completed. Seven survivors declined consent. Finally 230 survivors completed the study. Of these 105 patients were in Group I, 70 patients in Group II and 55 patients in Group III. QOL assessment was

Demographic and Clinical profile of the study population

The mean age of the survivors was 49.76 ± 9.58 years. Maximum number of survivors (33%) were in 41–50 year age group. Majority of the survivors were married (87.8%) and were housewives (89%). One hundred and thirty one (56.9%) patients were premenopausal at diagnosis while 99 (43.04%) were postmenopausal. Ninety six (73.3%) developed premature menopause following chemotherapy. Stage II was the most common stage of presentation (49.6%). Stage III accounted for 43% while 7.4% had stage I disease.

Survivorship issues

The most commonly reported issues in the total population of survivors were fatigue (60%), restriction of shoulder movement (59.6%), body and joint pain (63.5%), chemotherapy induced cessation of menstruation (73.3%) and loss of sexual desire (60%). The most prevalent issues in group I survivors were cessation of menstruation and fatigue. While cessation of menstruation in premenopausal women continued to affect over 70% patients in the following years, other major concerns for Group II and

FACT-B scores among breast cancer survivors

Assessment of QOL on FACT-B instrument showed that survivors with a longer duration of follow up enjoyed better QOL. Survivors in Group II and III had significantly higher scores than Group I. FACT-G score (sum total of physical well being, functional well being, social well being and emotional well being) and Trial outcome index (TOI) scores (sum total of physical and functional well being and breast specific subscale) too were highest in group II patients. As regards various subscale, Group I

Discussion

Concept of cancer survivorship care, as a distinct phase of cancer treatment is relatively new in the developing world. India has a growing population of breast cancer survivors, but the resources to deal with their needs are very limited. Hence to be cost effective it is important to identify areas, which cause most disruption in their QOL. Results of this study provide some useful insights about the priority areas for survivorship care.

The most commonly reported symptoms in our population of

Conclusion

This study showed that QOL scores are better in longer term survivors of breast cancer than those in early follow up. However in survivors (>5 years follow up), deterioration occurs in some areas like restriction of shoulder movement, body and joint pains and memory loss. Issues which cause maximum limitation in QOL are emotional distress, fatigue, and premature menopause and should be appropriately addressed in supportive care services.

In settings with limited resources, provision of dedicated

Funding

No funding involved: This research did not receive any specific grant for funding in the public, commercial, or not -for – profit sectors.

Conflicts of interest

Authors declare no conflict of interest in the publication of this article.

References (49)

  • D.M. Conde et al.

    Quality of life in Brazilian breast cancer survivors age 45-65 years: associated factors

    Breast J

    (2005)
  • J. Bower et al.

    Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life

    J Clin Oncol

    (2000)
  • K.R. Yabroff et al.

    Burden of illness in cancer survivors: findings from a population-based national sample

    J Natl Cancer Inst

    (2004 Sep 1)
  • J.R. Bloom et al.

    Then and now: quality of life of young breast cancer survivors

    Psycho Oncol

    (2004)
  • R.C. Maly et al.

    Quality of life over 5 years after breast cancer diagnosis among low-income women: effects of Race/ethnicity and patient physician communication

    Cancer

    (2015)
  • K.T. Ashing-Giwa et al.

    Understanding the breast cancer experience of women: a qualitative study of African American, Asian American

    Latina and Caucasian Canc Survivors Psychooncol

    (2004)
  • S. Malvia et al.

    Epidemiology of breast cancer in Indian women

    Asia Pac J Clin Oncol

    (2017)
  • Anonymous

    Three year report of population based cancer registries 2012–2014

    (2016)
  • G.S. Sandhu et al.

    Prevalence of triple-negative breast cancer in India: systematic review and meta-analysis

    J Global Oncol

    (2016)
  • D. Sandhu et al.

    Profile of breast cancer patients at a tertiary care hospital in north India

    Indian J Canc

    (2010)
  • Nene BM, Selmouni F, Lokhande M, Hingmire SJ, Muwonge R, Jayant K, Sankaranarayanan R Patterns of Care of Breast Cancer...
  • C. Allemani et al.

    Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population- based registries in 71 countries

    Lancet

    (2018)
  • www.facit.org/LiteratureRetrieve.aspx?ID=42249 (Accessed March...
  • www.encephuk.org/documents/docs/SF36form (Accessed March...
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