The aim of this study was the comprehensive assessment
and comparison of quality of life in operable Turkish breast
cancer patients receiving two different adjuvant chemotherapy
regimens.
World Health Organization (WHO) defines QOL as
“individuals’ perceptions 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 ” [26]. An instrument based on this conceptual
framework, WHOQOL-100, had been concurrently developed
across several countries and cultures while retaining
similar psychometric properties and structure. It is available
in several culture-specific and language-specific versions.
A 26-item, short form of this instrument (WHOQOLBREF)
had been developed for pragmatic reasons and has
been shown to have similar psychometric properties to the
WHOQOL-100 [19,20].
Today, in evaluating QOL, there is general agreement
on the following points:
- we need to measure the QOL of cancer patients and
its variations, possibly in relation to the clinical evolution
of the disease and to treatments administered to the patients;
- a multidimensional approach should be preferred, so
as to correctly interpret the observed variations of QOL,
i.e. if they depend on well-being, social role, physical
performance, psychological distress, etc.;
- the evaluation must be performed by the patient; no
other person can have an exact perception of the patient’s
QOL, as it depends on his/her feeling, intelligence, philosophy
of life, perceptions, and so on;
- a valid tool is mandatory: every scale must be tested
for reliability and validity.
The WHOQOL-BREF is a sound, cross-culturally valid
assessment of QOL, as reflected by its 4 domains: physical,
psychological, social and environmental. BDI and STAI
are complementary tools evaluating different aspects of
psychological status of patient. All of these scales have
reliable and validated Turkish versions.
The principal finding of this research is that MRM and
married patients had poor quality of life due to depression.
Neither type and adverse effects of chemotherapy regimen
nor age and education affected quality of life and psychometric
scores. Quality of life studies following breastconserving
therapy (BCT) or mastectomy has revealed that
mastectomy patients had significantly lower body image,
role, and sexual functioning scores and their lives were
also more disrupted than BCT patients. In one study,
mastectomy patients felt more self-conscious and ashamed
of their body. In a more recent study, anxiety, depression,
and self-esteem were also worse for mastectomy patients
[27,28]. So QOL was found to be useful for clinical decisionmaking
processes during local treatment investigations.
Our research did not include QOL data with a related breast
module such as FACT-B or EORTC QOL-BR23 because
there was no Turkish validation of them at the time of the
study [29-31].
Certain limitations must be regarded in the interpretation
of this study. The sample size was relatively small. Additionally,
a selection bias should be recognised, as more
patients with stage III and MRM were received FEC
according to the nonrandomized research setting, so the
results could have been misinterpreted as if the chemotherapy
regimen, itself, had disrupted QOL of patients.
Most of the QOL studies have been done with breast
carcinoma survivors or during primary treatment and
metastatic setting until recently. To date, a few studies with
adjuvant chemotherapy has been reported. Posttraumatic
stress disorder, conditioned nausea, emesis, and distress as a consequence of sights, smells, and tastes triggered by
reminders of their treatment, sexual problems, body image,
lymphedema with/without numbness that interfere with
functioning have been reported as long-term psychological
and medical sequelaes [18,23,32-35]. QOL is now considered
an important secondary endpoint, particularly in cancer
clinical trials, together with the traditional primary clinical
endpoints. In metastatic setting, HRQOL factors such as
appetite loss besides known clinical factors have been
found to be significant prognostic factors for survival [36-38]. In conventional chemotherapy trials, global quality of
life has been shown to be maintained during the treatment
period, although selected aspects of HRQOL have been
impaired over time. But a dose-intensive adjuvant regimen
induces a higher, despite transient, psychological distress
in early breast cancer patients [35,39-41]. Although research
indicates a survival advantage for married persons living
with a chronic disease such as cancer due to higher socioeconomic
status with better access to healthcare and a
protective benefit through increased social support networks,
association between marital status and quality of life of
cancer patients has not been thoroughly explored. In our
study, not the type of chemotherapy itself but the type of
operation (MRM) and the marital status (married women)
were found to be the significant factors affecting depression
scores and HRQOL. In recent years, body image has
emerged as an important factor, with breast-conserving
therapy patients being more satisfied with their appearance
and having higher life-style scores. A married woman with
MRM may not only feel less attractive and sexually active
as a wife, but also role functioning (work, hobbies, daily
habits) and contact with people may be more limited [27,28,42-44]. More researches are needed to identify the link
between marital status, treatment and HRQOL of breast
cancer patients. So, all these informations are important
when advising women patients of the expected HRQOL
consequences of treatment regimens and should help clinicians
and their patients make informed treatment decisions.
In conclusion, continued monitoring and clinical interventions
to address common symptoms associated with
diagnosis and treatment should be considered to improve
physical and emotional functioning before, during and after
the primary treatment for breast cancer.
ACKNOWLEDGEMENTS
We thank Prof. Dr. Hüray Fidaner (Dokuz Eylül University
School of Medicine, Department of Psychiatry),
who died in August 2002, for the kind comments on the
design and conduction of the study.
We would also like to acknowledge the contribution of
Meliha Diriöz (Dokuz Eylül University School of Medicine,
Department of Psychiatry), Ahmet Alacacıoğlu and Zuhal
Başkan (Dokuz Eylül University Institute of Oncology,
Department of Clinical Oncology, Division of Medical
Oncology), and Yücel Demiral (Dokuz Eylül University
School of Medicine, Department of Public Health) for his kind support of statistical analysis.
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