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Original Research (Original Article) 


Munirah Fetaini et al, 2020;4(3):635–644.

International Journal of Medicine in Developing Countries

Impact of breast cancer treatments on body image and quality of life in survivors

Munirah Fetaini1*, Abdulrahman Hawari1, Faisal Kaki1, Reem Ujaimi1, Hanaa Tashkandi1, Atlal AbuSanad1

Correspondence to: Munirah Fetaini

*King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Email: munirahfetaini [at] gmail.com

Full list of author information is available at the end of the article.

Received: 09 December 2019 | Accepted: 17 January 2020


ABSTRACT

Background:

Coping with the effects of cancer treatment is challenging. Among the post-treatment effects is an altered appearance that may impact the patient's Quality of life (QoL) negatively. Therefore, a better understanding of this issue is imperative to address it in an evidence-based framework. This study aimed to assess the impact of breast cancer treatments on body image and QoL in breast cancer patients from Saudi Arabia.


Methodology:

210 female patients were surveyed at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between November 2017 and June 2018. Subjects were considered eligible to participate if they were 18 years of age or older, had a histologically confirmed diagnosis of breast cancer, no evidence of recurrence or metastasis, and had no psychological problems at the time of the survey. European Organization for Research and Treatment of Cancer QLC-C30 and BR23 questionnaires were used to measure body image perception and QoL.


Results:

Among the participants, 60.0% underwent mastectomy with or without LN resection, 15.7% underwent a lumpectomy, and 24.3% did not undergo surgery. Eighty-one percent of the patients received chemotherapy before the intervention. The functional scales (C30 and BR23) showed no statistically significant differences between mastectomy and lumpectomy patients. The highest side effect score was observed with chemotherapy (60.64 ± 17.21), while the lowest with hormonal therapy (46.50 ± 19.46). Significantly more married patients had sleep disturbance versus unmarried (p = 0.039). Employed patients were more worried about their future perspectives.


Conclusions:

The study concludes that the body image was not affected by whether the patient had breast surgery or not, neither by the type of surgery. Furthermore, chemotherapy caused the highest side effect score.


Keywords:

Breast cancer; quality of life; chemotherapy; lumpectomy; mastectomy.


Introduction

Breast cancer (BC) is one of the most common cancers affecting women worldwide [1,2,3]. Around one million cases are diagnosed each year with breast cancer, and >50 % of the detected cases are in the developed countries [4,5]. In Arab countries, the incidence ranges from 9.5 to 50 cases per 100,000 women each year [3].

Its one of the leading causes of death in women around the world, with more than 400,000 deaths per year and the majority of deaths are in developing countries [35]. However, the survival of breast cancer patients has markedly extended because of the early detection and the new modalities of treatment [1,2,8]. It is estimated that 85% is the average 5-year survival rate of breast cancer patients in the developed countries, in contrast to the developing countries which is 50%–60%, and because of this better life expectancy, the effects of treatment on the quality of life (QoL) of the patients has become more pronounced [1,3,8].

Despite the advances over the past years in breast cancer diagnoses and therapy, it still has undesirable effects on social and physical functioning, and this is of a greater impact in developing countries [1,3]. Recently, measuring the QoL of patients with breast cancer has attracted much attention as an important factor in therapy outcome [1,2,6]. Mastectomy has a wide range of functional and emotional consequences, like depression, which has a prevalence of up to 56% in western countries [1]. Moreover, patients, who had a mastectomy, had lower body image and sexual functioning than patients who did not undergo surgery [2,9]. However, there is no significant difference between breast-conserving therapy and mastectomy in regards to different aspects of Quality of life (QoL) [6].

Many treatment types help in increasing survival but also have a negative impact on the QoL of the patients, such as surgery, systemic treatments, including chemotherapy, hormonal treatment, and new targeted antibody treatment and radiotherapy. Many studies demonstrated increased incidence of adverse effects of these treatments on QoL, which are either physical (pain, vomiting, and sleep disorders) or psychological (depression, anxiety, negative thinking, worrying about recurrence and death, fear of being lonely, sexual problems and poor perceived body-image) [1,2,4,6,8]. These negative impacts may persist for many years after treatment completion [3,4,9].

Many clinical trials have found that changes in QoL are linked to changes in clinical variables, such as survival [2,8]. It has been demonstrated that the assessment of QoL of cancer patients is associated with better treatment outcome and it could be considered as an important prognostic factor [2,8]. Age, level of education of the patient, support of a spouse, employment, and financial status, as well as the stage of the disease, influence the patients' QoL [2,6]. The European Organization for Research and Treatment of Cancer (EORTC) has invented different questionnaires for different cancers and in many languages [6,7,9].


Subjects and Methods

A cross-sectional survey was administered to female patients presented to oncology clinics, day-care unit, and medical/surgical wards at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between November 2017 and June 2018. Subjects were considered eligible to participate if they were 18 years of age or older, had a histologically confirmed diagnosis of breast cancer, had no evidence of recurrence or metastasis, and had no psychological problems at the time of the survey. Age, employment status, marital status, education, and income were assessed. Data of chemotherapy, radiotherapy, and surgery (mastectomy vs. breast-conserving surgery), reconstruction and any wound complications post-operatively were obtained. EORTC QLC-C30 and BR23 questionnaires were used to measure body image perception and QoL. Multivariate analysis was used to examine different variables impact and interactions with body image perception and QoL in breast cancer survivors.

Data were checked for completeness and errors were corrected. Categorical data were presented as frequencies and percentages and continuous data were presented as mean ± SD. Continuous data were checked for normality by using the Kolmogorov–Smirnov test and Shapiro–Wilk test, which revealed non-normal distribution. Comparison between breast surgery and no breast surgery groups for age was made by the Mann–Whitney U test and other demographic characteristics were done by the Chi-square test. Mastectomy and lumpectomy groups were compared in terms of medical treatment they received before and after the procedure by the Chi-square test. All functional and symptoms scales were transformed linearly as such that the scales ranged from 0 to 100. C30 functional scales, BR23 functional scales, C30 symptoms scales, and BR23 symptoms scales for all the patients, mastectomy group, and lumpectomy group were presented as mean ± SD. Mastectomy and lumpectomy cases were compared in terms of all scales by the Mann–Whitney U test. Scores of EORTC-QLQ-C30 and BR23 scales for all patients according to the type of therapy they received before and after the procedure was presented as mean ± SD. A chi-square test was done to observe the association of demographic variables with the C30 and BR23 scales.

The analysis was performed in a 95% confidence interval using the Statistical Package for Social Science, version 23.0 (IBM, Armonk, NY).


Results

Among the total of 210 study participants, 159 (75.7%) underwent breast surgery and the remaining 51 (24.3%) did not undergo breast surgery. The Chi-squared test showed no statistically significant difference between the demographic characteristics of patients undergone breast surgery versus did not undergo breast surgery (all p values > 0.05) (Table 1).

All patients received one or more therapies before and after breast surgery (mastectomy or lumpectomy, e.g., chemotherapy, biological therapy, hormonal therapy, and radiotherapy). It was observed that most of the patients received chemotherapy before (81.0%) and after (51.0%) the surgery. Chemotherapy was administrated more in the patients who had mastectomy compared to those who underwent a lumpectomy. All respective frequencies and percentages of medical therapies were presented in Table 2. There was no statistically significant difference between mastectomy and lumpectomy groups in terms of medical therapies they received (p values > 0.050) (Table 2).

Table 3 shows the mean ± SD scores in C30 functional scales, BR23 functional scales, C30 symptoms scales and BR23 symptoms scales for all study participants, mastectomy patients, and lumpectomy patients. Again, no statistically significant difference was observed between mastectomy and lumpectomy cases in terms of functional and symptoms scales (p values > 0.050) (Table 3).

Table 4 shows Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for all the patients according to the type of therapy they received before the procedure. The highest mean global health status score (75.93 ± 17.14) was observed in patients who received radiotherapy. The highest physical function (53.25 ± 17.30) and systemic therapy side effects score (57.25 ± 18.89) were observed among biological therapy recipients (Table 4).

Table 1. Demographic characteristics of all patients, patients underwent breast surgery, and patients did not undergo breast surgery and statistical comparison between them (n = 210).

All cases (n = 210), N (%) Undergone breast surgery (n = 159), N (%) Did not undergo breast surgery (n = 51), N (%) Odds ratio p-value
Age in years
Mean ± SD
49.10 ± 12.89 48.56 ± 13.10 50.73 ± 12.24 - 0.278
Employment
Employed
Unemployed
49 (23.3)
161 (76.7)
42 (26.4)
117 (73.6)
7 (13.7)
44 (86.3)
2.256 0.062
Marital status
Not married
Married
30 (14.3)
180 (85.7)
23 (14.5)
136 (85.5)
7 (13.7)
44 (86.3)
0.941 0.895
Have children
No
Yes
22 (10.5)
188 (89.5)
17 (10.7)
142 (89.3)
5 (9.8)
46 (90.2)
0.908 0.857

Table 2. Comparison between mastectomy and lumpectomy groups in terms of medical treatment received.

Overall (n = 210) Mastectomy (n = 126) Lumpectomy (n = 33) Odds ratio p-value
Medical treatment received N % N % N %
Before
Chemotherapy
Biological
Hormonal
Radiotherapy
170
31
58
84
81.0
14.8
27.6
40.0
104
21
30
50
82.5
16.7
23.8
39.7
26
2
12
13
78.8
6.1
36.4
39.4
0.786
0.323
1.829
0.988
0.619
0.123
0.145
0.976
After
Chemotherapy
Biological
Hormonal
Radiotherapy
107
23
55
15
51.0
11.0
26.2
7.1
18
30
10
2
14.3
23.8
7.9
1.6
17
2
11
2
51.5
6.1
33.3
6.1
0.997
0.387
1.600
0.748
0.994
0.205
0.266
0.716

Table 3. Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales overall, and mastectomy and lumpectomy cases.

All patients Mastectomy Lumpectomy p-value
Mean ± SD Mean ± SD Mean ± SD
C30 functional scales
Global health status
Physical function
Role function
Emotional function
Cognitive function
Social function
74.50
47.55
44.75
44.13
41.63
39.25
18.64
17.55
24.50
20.56
19.13
18.38
73.70
47.46
44.25
45.14
40.67
40.48
18.77
16.71
23.80
20.96
18.37
18.54
80.52
42.42
40.91
41.86
38.26
34.47
12.66
15.67
20.79
19.98
18.21
13.99
0.056
0.090
0.548
0.369
0.418
0.097
BR23 functional scales
Body Image
Sexual function
Sexual enjoyment
Future perspective
38.75
43.13
44.00
56.25
17.69
20.75
22.00
26.75
39.73
22.02
10.91
13.94
18.93
10.42
5.32
6.90
37.88
21.97
11.54
14.02
32.01
21.22
12.60
10.38
0.875
0.947
0.763
0.664
C30 symptoms scales
Fatigue
Nausea/ vomiting
Pain
Dyspnea
Sleep disturbance
Appetite loss
Constipation
Diarrhea
Financial difficulty
56.50
41.00
51.88
42.00
58.00
48.50
44.00
37.50
36.00
21.50
21.25
21.13
22.75
29.75
26.50
24.25
21.25
19.75
56.94
26.92
18.45
14.09
19.64
16.40
14.42
12.83
12.17
20.49
13.83
8.21
7.56
10.14
8.75
8.12
7.43
6.96
54.04
26.52
15.91
13.89
16.67
13.64
15.15
11.62
10.61
22.55
12.40
7.90
7.70
9.77
8.02
8.19
6.23
4.31
0.340
0.971
0.108
0.802
0.132
0.066
0.536
0.449
0.405
BR23 symptoms scales
SE of systemic therapy
Brachial symptoms
Hair loss annoyance
52.43
48.25
56.75
19.00
21.58
30.75
52.47
20.95
7.98
19.03
9.16
4.38
52.60
19.59
8.00
19.22
9.45
4.44
0.983
0.479
0.974

Table 5 shows Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for all patients according to the type of therapy they received after the procedure. Patients received radiotherapy was observed to have a highest mean physical function (55.35 ± 16.20), role function (53.38 ± 28.13), emotional function (50.00 ± 26.81), body image (50.81 ± 25.13), and future perspective score (68.25 ± 29.00). The lowest side effect score was seen in hormonal therapy (46.50 ± 19.46) patients, while the highest side effect score was observed in chemotherapy (60.64 ± 17.21) patients (Table 5).

Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for BCT and mastectomy patients according to the type of therapy they received before and the procedure was presented in Tables 6 and 7. No statistically significant association between C30 and BR23 scales score and age was observed (all p values > 0.05) (Table 8). Significantly more married patients had sleep disturbance compared to unmarried (OR 2.551, p = 0.039). Patients who have children were observed to have appetite loss more than their counterparts (OR 0.300, p = 0.038). Employed patients were more worried about the future perspective (OR 0.549, p = 0.019). Association of other parameters of C30 and BR23 scales with demographic characteristics was statistically not significant (p values > 0.050).


Discussion

BC usually necessitates combined oncologic treatments, where breast cancer therapy (BCT) is dependent on the stage of the disease. Breast conservation and mastectomy are surgical interventions commonly performed [10,11]. The most common method chosen today worldwide is the breast-conserving treatment, which lets women keep their organs, enjoy a better QoL, and is equally effective in treating the disease [1216]. Equal oncological safety of BCT and mastectomy has been demonstrated [17,18]. QoL associated with each surgical procedure had a big impact on the decision making among women, who be suitable for various oncological strategies. Data on future QoL based on the selected treatment should make this decision easier [10,11]. The current study aimed to explore the QoL among Saudi women treated for breast cancer and also assess if the QoL of women after a BCT procedure differs from the QoL of women treated with mastectomy and breast reconstruction in Saudi Arabia.

Breasts are one of the attributes of femininity and their loss in the case of breast cancer is a traumatic psychological experience. Women who had breast cancer are a specific population, where their feeling of discomfort due to the disease significantly affects their functioning in daily private, social and professional life [10,11,15].

BC is the most common type of cancer among Saudi females and accounted for more than 25% of all newly diagnosed cancer [19]. It has been estimated that BC is the ninth leading cause of death among females in the Kingdom of Saudi Arabia in the year 2010 [20]. The incidence of BC is expected to increase over the coming decades in Saudi Arabia due to the population’s growth and aging [21].

The overall global health score was higher than the international studies from Taiwan (64.4) [13], Nepal (52.8) [22], China (Shanghai) (61.5 ± 10.7) [23], Jordan (63.7) [24], and Sweden (65.1 ± 23.1) [25]. Inconsistent with Taiwan, Poland, and German studies, the current study reported no statistically significant difference between the BCT group and the mastectomy group regarding global health score [10,13,15].

Perception of future perspective was good in both groups, but when mean scores were compared (57.7 in the BCT and 55.7 in the mastectomy groups), it looks that patients after BCT can better cope with the fear of cancer return. This is consistent with German study, where patients after BCT can better cope with the fear of cancer recurrence (55.7 BCT vs. 46.7 Mastectomy) [15]. While it is in contrast with Poland's study, where patients after mastectomy can better cope with the fear of cancer recurrence (33 BCT vs. 66 Mastectomy) [10]. Overall, the better the future perspective, the higher the global QoL.

In the current study, there was no significant effect of surgical modality on all domains of the functional scales of EORTC-QLQ-C30 and QLQ-BR23 (C30 and BR23). These findings are consistent with Taiwan study except for body images, where they reported that women who underwent BCT had better body image than those who received mastectomy (p = 0.005) [13]. While in Poland study, women who had BCT reported lower Physical functioning (78 vs. 87, p < 0.0001), Role functioning (85 vs. 91, p = 0.02), Sexual functioning (18 vs. 26, p = 0.02), and Sexual enjoyment (33 vs. 51, p = 0.003) than women who had mastectomy, even that body images was better among BCT group than mastectomy group (79 vs. 71, p = 004) [10]. Furthermore, in the German study, women with BCT had better physical functioning (p = 0.03), role functioning (p = 0.04), body images (p < 0.0001), and sexual activity (p = 0.003) than women who had mastectomy [15]. Different findings are explained by differences in country, culture, and societal relations.

On the other hand, the symptoms scales (C30 and BR23) in the current study showed significant differences for two of the parameters—“Diarrhea” and “Brachial symptoms.” While in Poland's study, there was a significant difference between BCT and mastectomy for fatigue and appetite loss, where the BCT group showed a higher score for these two symptoms comparing with mastectomy group (33 vs. 24, p = 0.009) and (9 vs. 2, p = 0.04), respectively [1].

Radiation therapy (RT) after breast-conserving surgery is the main plan of care for most breast cancer patients because RT significantly decreases breast cancer return [26,27]. However, many women will refuse RT due to several reasons; “fearing the unknown,” “having burning,” “damaging internal organs,” and “anticipating fatigue”[28]. Fear of how RT influence QoL both during and after RT could lower the compliance with treatment and, finally, increase the chance of cancer return [27,29]. In the current study, the highest mean global health status score before the procedure was observed in patients who received radiotherapy. While, patients received radiotherapy after the procedure was observed to have the highest mean physical function, role function, emotional function, body image, and future perspective score.

Table 4. Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for all patients according to the type of therapy they received before the procedure.

Scales Type of therapy
Chemotherapy (n = 170) Biological (n = 31) Hormonal (n = 58) Radiotherapy (n = 84)
Mean SD Mean SD Mean SD Mean SD
C30 functional scales
Global health status
Physical function
Role function
Emotional function
Cognitive function
Social function
72.86
48.20
46.00
43.88
41.75
40.25
18.64
17.15
24.88
20.38
19.38
19.25
71.86
53.25
48.75
42.56
43.13
42.75
15.86
17.30
29.00
19.63
18.50
18.50
73.86
48.10
46.38
43.19
41.00
40.75
19.29
18.40
27.38
21.13
19.63
20.75
75.93
49.40
45.63
41.69
41.63
41.88
17.14
18.35
26.38
20.44
19.50
21.13
BR23 functional scales
Body Image
Sexual function
Sexual enjoyment
Future perspective
39.69
42.88
44.00
57.00
18.00
21.13
22.50
27.00
45.38
44.75
43.25
54.00
20.25
20.88
20.75
27.50
40.81
42.00
43.25
57.00
20.50
20.88
22.75
26.00
39.38
40.50
41.25
55.75
18.75
19.25
20.75
27.75
C30 symptoms scales
Fatigue
Nausea/ vomiting
Pain
Dyspnea
Sleep disturbance
Appetite loss
Constipation
Diarrhea
Financial difficulty
18.50
41.75
52.38
42.75
59.00
50.25
45.50
39.50
36.00
7.92
22.00
21.00
22.50
30.00
25.25
25.00
22.50
19.50
20.17
48.00
58.13
46.00
63.75
58.75
44.25
40.25
38.00
8.83
26.00
23.00
26.00
30.75
27.00
24.00
26.25
23.25
16.92
36.63
54.13
40.00
53.50
43.50
38.25
33.25
41.00
8.58
18.75
23.63
21.50
29.75
27.25
17.75
15.00
24.25
18.17
38.88
51.75
42.00
56.50
48.00
40.50
35.75
38.50
8.50
21.50
22.25
21.75
30.25
27.00
22.00
20.00
22.75
BR23 symptoms scales
SE of systemic therapy
Breast symptoms
Brachial symptoms
Hair loss annoyance
54.86
-
49.00
60.25
18.25
-
21.75
30.50
57.25
-
48.42
65.50
18.89
-
20.33
30.25
50.25
-
54.17
51.75
21.29
-
24.17
31.25
51.04
-
49.50
56.25
19.32
-
23.08
31.75

Table 5. Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for all patients according to the type of therapy they received after the procedure.

Scales Type of therapy
Chemotherapy (n = 107) Biological (n = 23) Hormonal (n = 55) Radiotherapy (n = 15)
Mean SD Mean SD Mean SD Mean SD
C30 functional scales
Global health status
Physical function
Role function
Emotional function
Cognitive function
Social function
71.86
50.90
49.25
46.63
43.50
40.88
19.07
18.00
25.25
21.81
20.75
18.88
76.71
46.10
49.50
40.75
44.63
41.25
16.86
16.00
28.13
17.75
18.00
22.75
76.07
44.20
39.50
42.81
42.00
38.63
18.21
15.30
20.25
20.94
18.88
19.00
76.64
55.35
53.38
50.00
43.38
53.38
18.00
16.20
28.13
26.81
17.63
26.88
BR23 functional scales
Body Image
Sexual function
Sexual enjoyment
Future perspective
41.19
41.75
42.00
56.75
17.94
19.38
20.75
26.50
38.88
36.38
36.00
49.00
14.31
16.00
12.75
26.75
38.50
45.50
46.75
55.50
18.69
23.25
24.75
25.25
50.81
40.00
39.25
68.25
25.13
18.38
19.00
29.00
C30 symptoms scales
Fatigue
Nausea/ vomiting
Pain
Dyspnea
Sleep disturbance
Appetite loss
Constipation
Diarrhea
Financial difficulty
62.75
47.75
54.50
44.75
60.75
54.75
46.50
42.50
35.50
21.33
22.25
21.50
23.00
30.00
28.00
25.50
24.00
18.75
60.83
40.75
56.50
35.75
54.25
45.75
35.75
49.00
35.75
25.42
25.38
21.25
18.25
33.50
25.75
19.75
28.75
18.25
51.25
33.38
46.88
41.25
55.00
37.75
41.25
31.75
38.25
19.83
17.38
19.63
23.25
26.50
22.00
19.50
14.00
21.00
63.33
44.13
59.13
50.00
53.25
40.00
38.25
40.00
38.25
24.75
23.63
14.50
23.25
29.75
22.75
18.50
20.75
20.75
BR23 symptoms scales
SE of systemic therapy
Breast symptoms
Brachial symptoms
Hair loss annoyance
60.64
42.38
49.58
65.75
17.21
16.56
22.42
30.25
54.04
41.56
54.75
63.75
19.04
14.31
22.58
34.25
46.50
40.44
50.75
52.00
19.46
18.56
22.08
29.75
57.61
50.44
61.08
69.25
24.32
22.38
23.25
32.50

Table 6. Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for mastectomy and lumpectomy patients according to the type of therapy they received before the procedure.

Scales Mastectomy Lumpectomy
Chemo Bio Hormone Radio Chemo Bio Hormone Radio
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
C30 functional scale Global health status 73.21 18.21 72.14 14.79 73.79 19.29 75.00 15.86 83.64 13.50 85.71 20.21 78.57 15.21 81.86 16.14
Physical function 48.15 16.25 50.00 16.20 47.15 18.15 47.90 16.40 39.30 10.95 52.50 24.75 40.00 12.60 46.15 19.05
Role function 45.50 23.63 42.25 24.88 46.63 27.63 46.00 25.25 33.88 11.88 50.00 35.38 37.50 19.25 36.50 18.75
Emotional function 44.44 20.81 40.50 14.19 41.88 21.31 40.63 19.81 40.19 18.38 56.25 44.19 43.25 19.13 38.44 18.75
Cognitive function 40.38 18.25 39.88 15.13 37.88 18.13 41.25 19.25 32.13 14.13 56.25 26.50 35.38 16.75 34.63 16.25
Social function 41.25 19.25 44.00 18.00 41.25 20.00 43.50 20.50 32.13 9.88 43.75 26.50 37.50 13.00 34.63 13.63
BR23 Functional scales Body image 40.25 19.31 46.13 21.63 43.13 23.94 40.38 20.81 34.81 16.88 43.75 26.50 38.00 14.94 36.06 14.69
Sexual function 42.88 21.38 44.63 21.50 47.88 21.00 42.50 20.50 39.25 24.38 62.50 17.63 41.63 24.00 40.38 18.50
Sexual enjoyment 42.25 21.50 43.75 21.50 45.25 22.00 40.75 20.50 41.75 25.75 50.00 0.00 45.50 27.00 43.25 19.75
Future perspective 55.50 27.75 47.50 27.25 57.50 26.50 54.50 29.25 50.00 25.00 62.50 17.75 52.00 19.75 52.00 19.00
C30 symptoms scale Fatigue 57.75 20.25 57.50 18.08 52.75 23.50 56.33 20.17 51.17 21.75 58.33 47.17 49.33 18.25 53.17 25.33
Nausea/ vomiting 41.00 21.25 41.63 19.88 36.25 18.13 38.00 20.25 35.75 15.13 43.75 26.50 32.25 12.50 37.50 22.25
Pain 27.88 12.75 29.13 13.25 30.00 12.13 26.75 11.88 23.25 11.25 18.75 8.88 24.00 9.88 22.13 10.38
Dyspnea 43.00 22.50 40.50 21.50 43.25 23.50 43.50 20.75 35.75 19.75 50.00 35.25 35.50 16.75 36.50 19.50
Sleep disturbance 59.50 30.75 60.75 31.25 53.25 31.25 54.50 30.50 42.75 27.75 62.50 53.00 52.00 29.00 57.75 33.00
Appetite loss 50.50 27.25 58.25 24.25 42.50 29.50 49.00 26.75 35.75 13.25 25.00 0.00 41.75 22.25 42.25 27.75
Constipation 45.00 25.50 44.00 26.00 39.25 18.25 43.00 23.75 35.75 19.75 37.50 17.75 31.25 11.25 36.50 22.00
Diarrhoea 40.75 23.75 38.00 25.75 32.50 13.25 37.50 22.25 35.75 19.75 25.00 0.00 29.25 9.75 28.75 9.50
Financial difficulty 35.75 19.75 37.00 23.25 40.00 24.25 37.50 22.75 35.75 19.75 37.50 17.75 37.50 16.75 34.50 16.25
BR23 symptoms scales SE of systemic therapy 54.29 18.29 54.75 14.79 48.11 21.82 50.71 18.71 44.89 21.43 64.29 50.50 50.61 22.18 49.18 23.14
Breast symptoms 42.00 17.00 40.75 12.44 40.00 17.81 40.13 16.00 48.19 22.19 59.38 13.25 46.38 20.75 44.25 20.94
Brachial symptoms 49.92 21.58 48.42 18.58 53.08 24.83 49.33 22.92 52.42 27.50 66.67 47.17 50.67 25.00 48.08 25.25
Hair loss annoyance 58.25 30.50 58.00 33.50 46.50 29.75 54.25 31.75 40.00 22.25 87.50 17.75 45.50 29.25 47.75 30.50

Table 7. Mean ± SD scores of EORTC-QLQ-C30 and BR23 scales for BCT mastectomy and lumpectomy patients according to the type of therapy they received after the procedure.

Scales Mastectomy Lumpectomy
Chemo Bio Hormone Radio Chemo Bio Hormone Radio
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
C30 functional scale Global health status 71.07 19.93 77.79 16.21 75.00 19.21 80.71 16.14 80.29 8.93 78.57 10.07 80.50 18.36 71.43 0.00
Physical function 51.10 16.80 43.60 15.60 45.65 15.80 54.50 16.90 46.20 18.50 67.50 3.55 37.75 12.10 62.50 10.60
Role function 47.75 24.38 45.88 29.63 42.88 18.75 42.50 26.50 49.25 23.13 56.25 26.50 30.63 15.13 62.50 17.63
Emotional function 48.00 22.13 38.88 15.38 46.44 21.38 52.50 28.31 45.94 24.50 68.75 26.50 36.94 21.00 62.50 35.38
Cognitive function 40.63 18.63 41.63 16.00 44.13 18.75 41.25 16.75 44.88 21.63 50.00 35.38 33.00 15.13 56.25 26.50
Social function 42.88 19.75 39.63 19.75 40.38 18.75 55.00 25.88 35.25 14.13 43.75 26.50 33.00 12.88 50.00 17.63
BR23 Functional scales Body image 41.44 19.31 35.75 13.31 41.06 21.69 50.00 29.31 44.13 18.13 46.88 22.13 34.06 12.94 43.75 26.50
Sexual function 40.75 18.38 36.13 17.00 48.75 24.25 40.00 17.50 44.88 18.25 50.00 0.00 46.63 25.63 37.50 17.63
Sexual enjoyment 40.75 19.50 36.25 13.00 45.25 24.50 39.00 18.25 46.25 24.75 50.00 0.00 53.25 28.25 37.50 17.75
Future perspective 56.50 28.75 44.50 25.00 58.25 24.75 67.50 29.00 61.75 21.75 75.00 0.00 47.75 20.75 62.50 17.75
C30 symptoms scale Fatigue 62.33 19.92 56.50 24.17 53.58 18.67 59.17 24.67 61.75 24.83 83.33 11.75 44.67 21.17 75.00 23.58
Nausea/ vomiting 46.13 20.88 38.88 23.38 34.13 17.63 43.75 22.25 50.00 20.25 43.75 26.50 29.50 11.50 43.75 26.50
Pain 26.88 12.88 28.50 14.00 27.50 10.63 25.00 5.88 25.00 13.25 31.25 8.88 17.00 6.25 31.25 8.88
Dyspnea 44.25 22.75 36.00 17.50 45.75 24.75 50.00 23.50 51.50 27.25 50.00 35.25 34.00 16.75 62.50 17.75
Sleep disturbance 62.25 31.00 50.00 30.75 58.25 25.75 47.50 24.75 54.50 31.00 100.00 0.00 45.50 27.00 100.00 0.00
Appetite loss 55.75 27.25 47.25 24.00 40.75 24.00 40.00 24.25 44.00 30.00 25.00 0.00 29.50 10.00 37.50 17.75
Constipation 44.25 25.75 39.00 21.25 44.25 20.50 40.00 17.50 53.00 26.25 25.00 0.00 31.75 11.75 25.00 0.00
Diarrhoea 43.75 25.00 47.25 28.25 32.50 13.25 37.50 17.75 38.25 23.50 37.50 17.75 27.25 7.50 25.00 0.00
Financial difficulty 37.25 21.25 36.00 19.50 39.25 21.50 40.00 24.25 31.00 11.00 37.50 17.75 31.75 11.75 50.00 0.00
BR23 symptoms scales SE of systemic therapy 60.18 18.29 51.57 17.32 47.14 17.82 53.57 23.86 63.64 16.96 71.43 40.39 42.21 22.64 71.43 40.39
Breast symptoms 44.13 17.75 40.63 13.06 41.44 19.75 52.50 24.50 39.00 17.06 50.00 26.50 42.06 20.38 56.25 17.69
Brachial symptoms 48.83 22.08 54.17 21.75 54.75 22.25 56.67 24.75 48.50 26.25 66.67 47.17 42.42 22.50 87.50 17.67
Hair loss annoyance 65.25 30.75 58.75 34.00 45.75 27.50 62.50 32.75 65.00 31.00 62.50 53.00 58.25 35.25 62.50 53.00

Table 8. Association of demographic variables with C30 and BR23 scales for all patients.

Scales Age* Marital status** Have children*** Employment****
OR p-value OR p-value OR p-value OR p-value
C30 functional scale Global health status 0.893 0.251 1.135 0.559 0.718 0.117 1.194 0.128
Physical function 1.108 0.236 1.173 0.257 1.008 0.956 0.867 0.151
Role function 1.182 0.236 1.157 0.563 1.263 0.342 1.282 0.123
Emotional function 0.844 0.087 0.804 0.228 1.182 0.311 1.159 0.119
Cognitive function 1.134 0.434 1.756 0.183 1.627 0.159 1.094 0.609
Social function 1.134 0.469 0.868 0.617 0.608 0.078 0.881 0.508
BR23 Functional scales Body image 1.063 0.541 1.098 0.636 0.989 0.952 0.889 0.325
Sexual function 1.198 0.453 - 1.787 0.377 0.979 0.928
Sexual enjoyment 0.423 0.083 - 0.996 10.444 0.142 1.366 0.504
Future perspective 0.681 0.104 0.887 0.762 0.752 0.450 0.549 0.019
C30 symptoms scale Fatigue 1.502 0.208 1.004 0.994 1.209 0.712 0.839 0.624
Nausea/ vomiting 0.843 0.335 0.848 0.586 1.061 0.834 1.031 0.878
Pain 0.928 0.690 0.650 0.186 0.745 0.371 0.772 0.194
Dyspnea 0.726 0.262 0.811 0.680 2.132 0.207 1.010 0.974
Sleep disturbance 1.305 0.196 2.551 0.039 1.262 0.453 1.190 0.458
Appetite loss 1.332 0.287 2.084 0.194 0.300 0.038 1.117 0.723
Constipation 0.807 0.342 0.688 0.324 0.675 0.284 0.602 0.067
Diarrhoea 0.634 0.161 2.428 0.168 0.689 0.501 1.124 0.711
Financial difficulty 0.718 0.295 1.189 0.749 0.839 0.710 1.011 0.977
BR23 symptoms scales SE of systemic therapy 0.906 0.126 0.889 0.280 1.081 0.481 1.010 0.878
Breast symptoms 1.262 0.044 0.827 0.325 0.967 0.851 0.784 0.058
Brachial symptoms 1.007 0.948 0.934 0.705 0.994 0.973 1.124 0.259
Hair loss annoyance 0.693 0.091 1.452 0.281 0.796 0.466 1.434 0.109

Several studies have shown that the chemotherapy has a huge negative impact on the QoL of cancer patients [3032]. After chemotherapy, patients have low general well-being, extra physical discomfort symptoms, decreased motility, increased sleep, sexual dysfunction, and decreased social participation and work capabilities, compared to before chemotherapy [30,31]. Several studies have reported that breast cancer patients generally have anxiety, depression [3335], nervousness, uncertainty [36], and reduced body and social functions [37]. All of these affect the confidence of patients to face the disease and all aspects of QoL [30]. In the current study, the highest side effect score was observed in chemotherapy patients.

Regarding the association between demographic data and EORTC-QLQ-C30 and QLQ-BR23, married patients had significantly more sleep disturbance compared to unmarried (OR -= 2.551, p = 0.039), patients who have children were observed to have appetite loss more than their counterparts (OR = 0.300, p = 0.038), and employed patients were more worried about the future perspective (OR = 0.549, p = 0.019). On the other hand, there was no significant association of other parameters of C30 and BR23 scales with demographic characteristics (p values > 0.05).

In Poland's study, the assessment of their health status and sexual functioning were worse among younger patients, after both BCT and mastectomy, than in older patients [11]. While Pacian et al. reported that breast cancer patients aged 45–50 years better assessed their functioning in all domains, compared with older women [37]. Fobair et al. [38] reported a statistical significance in the correlation between the assessment of patients' appearance and marital status, where the unmarried patients after BCT assessed their appearance as better to a higher degree than those who were married.

Some limitations of the study should be reported. The patients were treated in one healthcare facility in Jeddah. Moreover, the sample size was small to draw general conclusions concerning the comparison of subgroups. The generalizability to other clinics and regions of the country cannot be assessed.


Conclusion

The global QoL among Saudi breast cancer women treated with BCT or mastectomy is high and does not vary between groups. The perception of future perspective is good in both groups, where it looks that patients after BCT can better cope with the fear of cancer return. Further studies with different nations, larger sample sizes, multicenter and different regions are needed to detect all the challenges and design the appropriate strategies to optimize care of patients with breast cancer.


List of Abbreviations

EORTC European Organization for Research and Treatment of Cancer
QoL Quality of life
RT Radiation therapy

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

This research was approved by the unit of biomedical ethics, research committee at King Abdulaziz University on 3/7/2018, and the reference number is 382-18.


Author details

Munirah Fetaini1, Abdulrahman Hawari1, Faisal Kaki1, Reem Ujaimi1, Hanaa Tashkandi1, Atlal AbuSanad1

  1. King Abdulaziz University Hospital, Jeddah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Fetaini M, Hawari A, Kaki F, Ujaimi R, Tashkandi H, AbuSanad A. Impact of breast cancer treatments on body image and quality of life in survivors. IJMDC. 2020; 4(3): 635-644. doi:10.24911/IJMDC.51-1575122675


Web Style

Fetaini M, Hawari A, Kaki F, Ujaimi R, Tashkandi H, AbuSanad A. Impact of breast cancer treatments on body image and quality of life in survivors. http://www.ijmdc.com/?mno=76023 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1575122675


AMA (American Medical Association) Style

Fetaini M, Hawari A, Kaki F, Ujaimi R, Tashkandi H, AbuSanad A. Impact of breast cancer treatments on body image and quality of life in survivors. IJMDC. 2020; 4(3): 635-644. doi:10.24911/IJMDC.51-1575122675



Vancouver/ICMJE Style

Fetaini M, Hawari A, Kaki F, Ujaimi R, Tashkandi H, AbuSanad A. Impact of breast cancer treatments on body image and quality of life in survivors. IJMDC. (2020), [cited March 29, 2020]; 4(3): 635-644. doi:10.24911/IJMDC.51-1575122675



Harvard Style

Fetaini, M., Hawari, . A., Kaki, . F., Ujaimi, . R., Tashkandi, . H. & AbuSanad, . A. (2020) Impact of breast cancer treatments on body image and quality of life in survivors. IJMDC, 4 (3), 635-644. doi:10.24911/IJMDC.51-1575122675



Turabian Style

Fetaini, Munirah, Abdulrahman Hawari, Faisal Kaki, Reem Ujaimi, Hanaa Tashkandi, and Atlal AbuSanad. 2020. Impact of breast cancer treatments on body image and quality of life in survivors. International Journal of Medicine in Developing Countries, 4 (3), 635-644. doi:10.24911/IJMDC.51-1575122675



Chicago Style

Fetaini, Munirah, Abdulrahman Hawari, Faisal Kaki, Reem Ujaimi, Hanaa Tashkandi, and Atlal AbuSanad. "Impact of breast cancer treatments on body image and quality of life in survivors." International Journal of Medicine in Developing Countries 4 (2020), 635-644. doi:10.24911/IJMDC.51-1575122675



MLA (The Modern Language Association) Style

Fetaini, Munirah, Abdulrahman Hawari, Faisal Kaki, Reem Ujaimi, Hanaa Tashkandi, and Atlal AbuSanad. "Impact of breast cancer treatments on body image and quality of life in survivors." International Journal of Medicine in Developing Countries 4.3 (2020), 635-644. Print. doi:10.24911/IJMDC.51-1575122675



APA (American Psychological Association) Style

Fetaini, M., Hawari, . A., Kaki, . F., Ujaimi, . R., Tashkandi, . H. & AbuSanad, . A. (2020) Impact of breast cancer treatments on body image and quality of life in survivors. International Journal of Medicine in Developing Countries, 4 (3), 635-644. doi:10.24911/IJMDC.51-1575122675