Background: Today, the quality of life studies has an important role in
health care especially in chronic diseases. Breast cancer has third
order among women\u2032s malignancies. Now, survival rate for this
cancer is long. However breast cancer has several complications that
affected the patient\u2032s life. Aims : The aim of this study was to
assess the quality of life in Breast cancer patients under
chemotherapy.  Setting and Design:  A cross-sectional study conducted
on 119 breast cancer patients that were admitted and treated in
chemotherapy ward of Namazi hospital in Shiraz city, south of Iran,
between Jan and Feb 2006.  Materials and Methods: The QLQ-C30
questionnaire was used to assess quality of life in these patients. 
Statistical Analysis: We used univariate methods. A multiple regression
analysis was performed to identify predictors of quality of life. 
Results: Mean age of patients was 48.27\ub111.42 with quality of life
total score 64.92\ub124.28. All symptoms scales had reverse
association with quality of life except appetite loss (P&gt;0.05) and
diarrhea (P=0.752). The results of the regression analyses showed that
only grade of tumor, occupational status, menopausal status, financial
difficulties and dyspnea were statistically significant in predicting
patients\u2032 quality of life.  Conclusion: In conclusion, this study
demonstrates the strength of the relationship between clinical and
sociodemographical factors and breast cancer patients\u2032 quality of
life. Psychological and financial support for women experiencing breast
cancer diagnosis may improve quality of life

Moghimi-Dehkordi, B

Pourhoseingholi, MA

Safaee, A

Tabatabaee, HR

Zeighami, B

Bioline International

Indian Journal of Cancer | July–September 2008 | Volume 45 | Issue 3 107107 CMYKPredictors of quality of life in breast cancer patients under chemotherapySafaee A1, Moghimi-Dehkordi B2, Zeighami B3, Tabatabaee HR4, Pourhoseingholi MA51,2,5Department of HSR, Research Center of Gastroenterology and Liver Diseases, Shahid Beheshti University (MC), Tehran, 3,4Department of Epidemiology. Faculty of Health School. Shiraz University of Medical Sciences, Shiraz, Iran.Correspondence to: Dr. Azadeh Safaee, E-mail: azadesafaee@yahoo.comAbstractBACKGROUND: Today, the quality of life studies has an important role in health care especially in chronic diseases. Breast cancer has third order among women’s malignancies. Now, survival rate for this cancer is long. However breast cancer has several complications that affected the patient’s life. AIMS: The aim of this study was to assess the quality of life in Breast cancer patients under chemotherapy. SETTING AND DESIGN: A cross-sectional study conducted on 119 breast cancer patients that were admitted and treated in chemotherapy ward of Namazi hospital in Shiraz city, south of Iran, between Jan and Feb 2006. MATERIALS AND METHODS: The QLQ-C30 questionnaire was used to assess quality of life in these patients. STATISTICAL ANALYSIS: We used univariate methods. A multiple regression analysis was performed to identify predictors of quality of life. RESULTS: Mean age of patients was 48.27±11.42 with quality of life total score 64.92±24.28. All symptoms scales had reverse association with quality of life except appetite loss (P>0.05) and diarrhea (P=0.752). The results of the regression analyses showed that only grade of tumor, occupational status, menopausal status, fi nancial diffi culties and dyspnea were statistically signifi cant in predicting patients’ quality of life. CONCLUSION: In conclusion, this study demonstrates the strength of the relationship between clinical and sociodemographical factors and breast cancer patients’ quality of life. Psychological and fi nancial support for women experiencing breast cancer diagnosis may improve quality of life.Key words: Breast cancer, functioning scales, symptoms scales, quality of life, QLQ-C30OriginalArticleIntroductionQuality of life (QOL) is a very frequently applied concept nowadays.[1] It is a subjective concept and its definitions and the sub concepts involved have varied. QOL has been defined as the subjective evaluation of life as a whole or the patient's appraisal and satisfaction with their current level of functioning compared with what they perceive to be possible or ideal.[2] In a simple way, QOL is individual imaginations or thoughts from life style according to his/her objectives, expectations, standards and preferences. QOL is a multidimensional construct encompassing perceptions of both positive and negative aspects of dimensions such as physical, emotional, social and cognitive functions, as well as the negative aspects of somatic discomfort and other symptoms produced by a disease or its treatment.[2]Today, quality of life survey is an important issue in health care, especially oncological researches .Cancer affects on different aspects of QOL and at present time, cancer disease is a major problem in Iran and whole of the world. Among these cancer diseases, breast cancer is the most common cancer in women.[3] During last decades, survival rates for breast cancer have increased as a result of earlier detection and increased use of adjuvant therapy.[4] Women may also receive radiation therapy and/or chemotherapy plus systemic hormonal therapy for breast cancer treatment depending on stage and estrogen receptor status at diagnosis. Long-term consequences of therapy include painful and often debilitating lymph edema due to surgery or radiation therapy consequently, these patients are engaged with cancer and its outcomes and effects, for a long time. Therefore, it is critical for health care professionals to become familiar with the impact of a breast cancer diagnosis and its treatment on patient's QOL.[3] The aim of this study was to assess breast cancer patients' QOL and recognize the factors that affect QOL.Indian Journal of Cancer | July–September 2008 | Volume 45 | Issue 3108108 CMYKMaterials and MethodsWe conducted a cross-sectional study on 119 random samples of breast cancer patients that were admitted and treated in the chemotherapy ward of Namazi hospital in Shiraz city, south of Iran between December 2005 to February 2006. This center is a referral center in south of province. Any patients with a new diagnosis of breast cancer, according to pathology report, under chemotherapy were eligible to enter the study.The exclusion criteria were: cancer diagnosis less than two months; recurrent of breast cancer cognitive impairment; other previous or concurrent malignancies.We used QLQ-C30 questionnaire to assessment QOL in these patients. This questionnaire is a valid and reliable questionnaire for evaluation of quality of life in Iran.[5] The QLQ-C30 questionnaire is a self-report multidimensional general cancer-specific questionnaire, which was designed to assess QOL in cancer patients. The QLQ-C30 proved useful in many clinical trials, because it assesses the main factors influencing HRQOL of patients with cancer.[5-7] The QLQ-C30 is multidimensional, made up of 30 items (five functional domains: physical, role, emotional, cognitive, and social, one global QOL domain, three symptom domains: fatigue, nausea-vomiting, pain, and six single items). The scores are transformed into 0-100 point scales. In the case of the five functional scales and the global QOL scale, the high score means: ‘high level of functioning or global QOL’. On the other hand, in the case of symptom scales and single items, the higher score implies the higher level of symptoms or problems.[8-10]Sociodemographic data included age, education, occupation and marital status, and Clinical data including grade of tumor, metastasis, type of treatment, type of first treatment, co-morbidity, type of treatment, type of first treatment, duration of disease and status of menopause gathered by additional questionnaire. The study protocol has been approved in ethical committee of Shiraz University of medical science. Before the interview survey, the interviewer explained the purpose of these questions to all eligible individuals and requested their participation. We used univariate methods such as Kruskalwallis, Mann-Whitney U and Spearman correlation tests. A multiple regression analysis was performed to identify predictors of QOL. For this procedure, the global QOL score of the EORTC QLQ-C30 was treated as the dependent variable. Sociodemographic, medical characteristics and symptom of disease were entered as explanatory factors in the model.[11-13] All calculation performed using SPSS.V.13.ResultsTotal of 119 patients with breast cancer were interviewed. The demographic and clinical characteristics of the baseline sample are shown in [Table 1]. The mean age was 48.27 (SD=11.42) years, and most of the patients were married (73.9%). The level of education in our study sample was relatively low concerning employment status, most of women were housekeeper or retired and only 17.6% were employed before the cancer was diagnosed.The mean score for the global health status for breast cancer patients was 64.92±11.42. The best functional outcomes were found for the cognitive and social functioning subscales and emotional functioning scored the lowest. Breast cancer patients were suffered from insomnia, fatigue and pain. Other symptoms such as diarrhea, constipation, dyspnea, nausea and vomiting and appetite loss were reported less severity [Table 2]. In univariate analysis, among demographic factors (such as age, education, marital status and occupation) only occupational status was associated with Global Quality of life, and employed women had better QOL Table 1: Distribution of demographic and clinical characteristics and association with quality of life score in subjects under studyVariable  Number % P valueAge <35 14 11.8 0.185  35-50 55 46.2  >50 50 42.0Education Illiterate and primary 68 57.1 0.824  Diploma and lower 41 34.5  University 10 8.4Occupation Employee 21 17.6 0.036  Housekeeper and  98 82.4 retired Marital status Married 88 73.9 0.655  Other 31 26.1Duration of  <4 month 47 39.5 0.017disease 4-12month 41 34.4  >12 month 31 26.1Metastasis Yes 26 21.8 0.824  No 93 78.2Grade of tumor Well differentiated 40 33.6 <0.0001  Moderately  50 42.0 differentiated   Poorly differentiated 29 24.4Safaee A, et al.: Quality of life in breast cancer patientsIndian Journal of Cancer | July–September 2008 | Volume 45 | Issue 3 109109 CMYKTable 2: Mean and standard deviation of EORTC QLQ-C30 subscale scores and their correlation with global health status in breast cancer patientsScales  Mean  Standard Correlation P value (%) deviation coeffi cient  Functioning Physical  57.31  23.76  0.230  0.012Role 65.27  34.89  0.107  0.240Emotional 56.26 30.84 0.273 0.003Cognitive 72.27 27.47 0.337 <0.0001Social 69.61 32.95 0.133 0.148SymptomsFatigue 41.74 26.91 -0.219 0.016Nausea and vomiting 16.39 28.37 -0.244 0.007Pain 33.19 28.25 -0.287 0.002Dyspnea 16.25 27.05 -0.192 0.036Insomnia 43.7 40.65 -0.216 0.018Appetite loss 22.69 36.29 -0.059 0.524Constipation 14.85 29.34 -0.258 0.005Diarrhea  3.92  16.34  0.092  0.319Global health status  64.92  11.42  1.00  -Table 3:  Predictors of quality of life by using linear regression model   Full model   Final modelVariable β SE (β)  P value  β SE (β)  P valuePhysical functioning -0.121 0.136 0.377 - - -Role functioning 0.026 0.095 0.786 - - -Emotion functioning -0.021 -0.026 0.827 - - -Cognitive functioning 0.221 0.105 0.038 - - -Social functioning -0.222 0.123 0.073 - - -Fatigue  -0.065 0.112 0.562 - - -Nausea and vomiting -0.110 0.080 0.175 - - -Pain  -0.162 0.109 -0.142 - - -Dyspnea -0.161 0.082 -0.177 -0.091 0.046 0.01Insomnia  -0.079 0.055 0.156 - - -Constipation  0.011 0.080 0.895 - - -Financial diffi culties -0.109 0.053 0.044 -0.059 0.029 0.03Grade of tumor -16.05 3.1 <0.0001 -15.74 2.75 <0.0001Duration of disease 6.711 5.568 0.231 - - -Menopause 6.498 4.294 0.134 6.66 2.43 0.01Occupation 7.643 5.500 0.168 8.86 3.19 0.01First treatment -7.199 5.300 0.178 - - -(P=0.036). Duration of disease was significantly related to QOL score of patients. In other words, those with duration of disease less than four months reported significantly lesser global QOL score (P=0.017). Results of univariate analysis show significant differences in global QOL scores, where patients with poor grade have the worst (P<0.0001). No significant association observed between QOL and other clinical factors (such as metastasis of tumor, type of treatment, type of first treatment, comorbidity, duration of disease and status of menopause). All symptoms scales had reverse association with QOL except appetite loss (P=0.285) and diarrhea (P=0.752). Also, QOL in breast cancer patients was affected by financial difficulties (P=0.019).The results of the regression analyses showed that only grade of tumor, occupational status, menopausal status, financial difficulties and dyspnea were statistically significant in predicting patients’ QOL [Table 3]. Duration of disease, and other symptom scales were not significant. DiscussionThis study demonstrates the consistency and strength of the relationship between grade of tumor, occupation, dyspnea, menopause status and financial difficulties and breast cancer patients’ quality of life. The strongest Safaee A, et al.: Quality of life in breast cancer patientsIndian Journal of Cancer | July–September 2008 | Volume 45 | Issue 3110110 CMYKinfluence on QOL in our study was grade of tumor.These assessments showed that the emotional functioning score and the physical scores were lower compared to the other QOL subscale scores. This might be due to the fact that patients were informed about their cancer diagnosis. Facing a life-threatening illness and the uncertainty of treatment outcomes is psychologically distressing. During the active phase of treatment physical functioning has an enormous impact on QOL. Patients may experience acute side effect of the treatment in addition to cancer-related symptoms which can be emotionally distressing and debilitating. Previous studies have demonstrated the relationship between physical factors and emotional distress.[14-16] After the completion of cancer treatment, patients are usually able to return to a level of physical functioning consistent with that of their pre-cancer diagnosis.[16]Concerning demographic factors (age, education, and marital status) the subgroups did not differ from one another. Some research, but not all, indicates that younger women may suffer poorer QOL following a breast cancer diagnosis.[17,18] Unfortunately, age definitions vary across studies. This association wasn't seen in our study. In line with other findings, in the present study, employment status was significantly associated with QOL.[4,16]Postmenopausal women had better QOL. This relation may be confounded by effect of age. Our findings suggest that financial status may also play an important role in determining QOL. Developing a chronic illness or having a spouse with chronic illness like cancer would mean loss of that day's income, and extra expenditures and influence many aspects of life.[19,20]However, the regression model explained only 73.6% of the variance. There may be other variables, such as toxicity or symptom distress, which have not been sufficiently considered in this study.Interpretation of our data must consider some limitations (e.g. sample size and study design). The cross-sectional design allowed identification of several factors associated with QOL, although causal inferences could not be made. Factors related to QOL impairment were identified (e.g. grade of tumor, occupation, financial difficulties, and etc.). The findings of this study should be the target of further research, emphasizing the need for interventional studies that minimize the negative impact of the disease symptoms on the QOL in women with breast cancer. Prospective studies are needed to evaluate the influence of other factors (education, socioeconomic status, type of surgery, quality of partner relationship) on QOL. Future research should include a comparable group of women without breast cancer, seeking to identify whether QOL and its associated factors are similar among women with and without breast cancer.ConclusionIn conclusion, this study demonstrates the consistency and strength of the relationship between clinical and sociodemographical factors and breast cancer patients’ quality of life. Psychological and financial support for women experiencing breast cancer diagnosis may improve QOL. AcknowledgmentsWe would like to thank the staff of the Chemotherapy ward of Namazi Hospital for their valuable collaboration in this study and EORTC quality of life group for their permission to use of QLQ-C30 questionnaire. ReferencesBillingham LJ, Abrams KR, Jones DR. Methods for the analysis of 1. quality of life and survival data in health technology assessment. Health Technol Asess 1999;3:1-152.Lehto US, Ojanen M, Kellokumpu-Lehtinen P. Predictors of quality 2. of life in newly diagnosed melanoma and breast cancer patients. Ann Oncol 2005;16:805-16.Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Hölzel D. 3. Predictors of quality of life of breast cancer patients. Acta Oncol 2003;42:710- 8.Ganz PA, Kwan L, Stanton AL, Krupnick JL, Rowland JH, Meyerowitz 4. BE, et al. Quality of life at the end of primary treatment of breast cancer: First results from the moving beyond cancer randomized trial. J Natl Cancer Inst 2004;96:376- 87. Safaee A, Dehkordi BM. Validation Study of a Quality of Life 5. (QOL) questionnaire for use in Iran. Asian Pac J Cancer Prev 2007;8:543-6.Bjordal K, de Graeff A, Fayers PM, Hammerlid E, van Pottelsberghe 6. C, Curran D, et al. A 12 country fi eld study of the EORTC QLQ-C30 (Version 3.0) and the head and neck cancer specifi c module (EORTC QLQ-H and N35) in head and neck patients: EORTC Quality of Life Group. Eur J Cancer 2000;36:1796-807.Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez 7. 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;85:365-76.Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bot-8. tomley A, on behalf of the EORTC Quality of Life Group. EORTC QLQ-C30 Scoring Manual, 3rd ed. Brussels: EORTC; 2001.Toth G, Sakaguchi T, Mikami Y, Hirose H, Tsukuda M. 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Quality of life 5-10 years breast cancer 19. survivors diagnosed between age 40 and 49. Health Quality Life Outcomes 2004;2:25-9.Pandey M, Thomas BC, SreeRekha P, Ramdas K, Ratheesan K, 20. Parameswaran S, et al. Quality of life determinants in women with breast cancer undergoing treatment with curative intent. World J Surg Oncol 2005;3:63-72.Safaee A, et al.: Quality of life in breast cancer patientsSource of Support: Shiraz University of Medical Sciences, Confl ict of Interest: None.Dispatch and return notification by E-mail The journal now sends email notification to its members on dispatch of a print issue. The notification is sent to those members who have provided their email address to the association / journal office. The email alerts you about an outdated address and return of issue due to incomplete / incorrect address. 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Predictors of quality of life in breast cancer patients under chemotherapy

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