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Cancer-related post-treatment pain and its impact on health-related quality of life in breast cancer patients: a cross sectional study in Palestine

Cancer-related post-treatment pain and its impact on health-related quality of life in breast... Background: Post-treatment pain has been suggested as an important indicator for health-related quality of life (HRQOL) in patients with breast cancer. Therefore, this study was performed to examine the association between pain and its impact on HRQOL among breast cancer patients in Palestine. Also, this study aimed to determine the QOL profile for breast cancer patients and stated the factors associated with QOL. Methods: A correlational cross-sectional study was conducted from May 2016 to November 2016 at Al-Watani Hos- pital and An-Najah National University Hospital in the Nablus district in Palestine. The five-level EuroQol five-dimen- sional instrument (EQ-5D-5L) was used to examine HRQOL. Pain severity and interference were assessed using the Brief Pain Inventory (BPI). Multiple linear regression analysis was performed to determine the most important variables related with HRQOL. Results: One hundred and seventy patients were involved in this study. Overall, all participants were female, with a mean ± SD for age of 51.71 ± 11.11 years. The reported HRQOL of this study was measured by using the median EQ-5D-5L index score, which was 0.67 (interquartile range: 0.51–0.84). There were moderate negative correlations between EQ-5D-5L index score and pain severity score (r = − 0.58, p value < 0.001), and pain interference score (r = − 0.604, p-value < 0.001). Furthermore, univariate analysis showed that age, marital status, employment status, income, current condition of cancer, and post-treatment pain were associated with quality of life (p-value < 0.05). Regression analysis revealed that patients with high income (p-value = 0.003), patients with lower pain severity score (p-value < 0.001), and lower pain interference score (p-value = 0.018) were independently associated with high QOL. Conclusions: This is the first study to present important data regarding QOL by using the EQ-5D-5L instruments that may help healthcare providers to identify patients at risk of low QOL. Healthcare providers and health strategy mak- ers should be alerted to low level HRQOL among breast cancer patients with low income level, patients with post- treatment pain, especially in the state of severe pain, and the state of pain interfering with daily life to improve their HRQOL. Keywords: Breast cancer, Post-treatment pain, Health-related quality of life, Palestine *Correspondence: saedzyoud@yahoo.com; saedzyoud@najah.edu Division of Clinical and Community Pharmacy, Department of Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 2 of 9 Background Methods Breast cancer refers to a malignancy in women and in a Study design small percent in men, which arises from the epithelial tis- This cross-sectional study was conducted by using stand - sue of the breast tissue, representing approximately 10% ardised and validated assessment tools in women with of the total volume of the breast [1]. Breast cancer is the breast cancer from May 2016 to November 2016. second most common cancer globally, and also the most common malignancy between women that consists of Study setting 18% of all female cancers [1, 2]. Breast cancer has differ - This study was conducted in Al-Watani hospital and An- ent treatment methods, and these methods have different Najah National University hospital, Nablus, West Bank, effects on the patients and their life [3 ]. The treatment of Northern Palestine. These two hospitals serve as the breast cancer usually starts with surgery and radiotherapy, main referral hospitals for the northern districts of West and often involves chemotherapy or other drug therapies, Bank-Palestine and receive most cases of breast cancer such as hormonal treatment, either before or after sur- patients from all northern West Bank districts. gery [4]. Pain after treatment is a major clinical problem in breast cancer patients, and is one of the most common Study population complications affecting 25 to 60% of breast cancer patient The medical records of both hospitals in 2015 showed survivors [5]. Post-treatment pain is defined as the pain that the number of breast cancer patients in both hos- related to treatment body regions with duration of more pitals was around 600 patients in 1 year and around 300 than 3 months after treatment is completed [6]. Improving patients during the period of study. Each of both hospi- health-related quality of life (HRQOL) has become one of tals where study was conducted gave us a list with the the most essential goals of cancer therapy [7–9]. HRQOL names of breast cancer patients in order to assess their is a multidimensional instrument that includes the com- comfort for this study. prehension of the positive and the negative aspects of different dimensions such as the physical, emotional, cog - Sampling procedure and sample size calculation nitive and social domains, as well as pain/discomfort [10]. The Raosoft sample size calculating tool (an automated In Palestine, cancer is the second most common cause software program: http://www.raosoft.com/samplesize. of death, accounting for about 14.2% of all deaths in 2014, html) was used for sample size calculation. We assumed meaning that they are very common [11]. According to that 50% of women with breast cancer had a high QOL, the Ministry of Health records, breast cancer is the most which would give the maximum sample size. Further- common type of cancer in Palestine and the third most more, we used a 5% margin of error at a 95% confidence common type of cancer causing death (about 10.7%) after interval as recommended; the required sample size was lung and colon cancer [11]. Globally, there are many arti- calculated to be 170 women. Convenience sampling was cles that talk about post-treatment pain and HRQOL used to recruit participants. among breast cancer survivors [5, 6, 12–17]. In the Arab World and Palestine, there is no research related to the Inclusion and exclusion criteria post-treatment pain and its association with HRQOL Women aged 18  years and above who were treated for in breast cancer patients. Researches in Palestine about breast cancer >  12  months prior to the conduct of our breast cancer focused on the palliative care situation [18] study, and who agreed to be participants in this study and pharmacological treatment [19, 20]. Therefore, this were included. The only exclusion criteria were women study was performed to examine cancer-related post- who had a major psychiatric illness, and those with an treatment pain (pain severity and interference) and its extremely ill condition. impact on HRQOL in the different stages of breast can - cer in patients in Palestine. Also, this study aimed to Data collection instrument determine QOL profile among breast cancer patients and The data collection form consisted of four sections: stated the factors associated with QOL. Investigating and assessing QOL in breast cancer patients and the related 1. The first section was designed to obtain socio-demo - post-treatment pain will help medical teams and patients graphic data such as age, marital status, place of resi- to plan and develop spectacular pain management strate- dence, educational level, family monthly income, and gies to address common signs and symptoms, and pro- height and weight, to calculate body mass index (BMI). vide breast cancer patients with better health and good 2. The second section contained patient clinical data QOL. Also, this will assist in creating a complete system such as type of breast cancer, stage of breast cancer, in order to deal with current patients and future patients, duration of disease, and the types of management so that we can help to end the suffering of these patients. that the patient had undertaken. Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 3 of 9 3. The third section was based on the assessment of experience in statistical analysis) reviewed and evalu- post-treatment pain and discomfort among breast ated measurement items for face and content validity, cancer patients by using a well-known pain-meas- and clinical accuracy. Data collection forms were admin- uring scale which is called the Brief Pain Inventory istered to participants face-to-face by two medical stu- scale (BPI); [21]. The BPI was used to assess both dents. These researchers received training in investigation pain severity and pain interference with normal func- skills and research ethics at the College of Medicine and tioning. Items used in determination of pain sever- Health Sciences and from epidemiologists with expertise ity were worst pain in the last 24 h, least pain in the in quality of life research. In order to insure interviewer last 24 h, average pain in the last 24 h and pain right consistency, both of the interviewers interviewed the par- now. Seven items were designed to assess pain inter- ticipants closely with each other. The data collection form ference with general activity, walking ability, mood, was piloted on 15 patients (not included in the final study) normal work, sleep, relations with others, and enjoy- to assess questionnaire comprehension, clarity, and com- ment of life. Also, this scale determined pain location pletion time. The results of the pilot study were evalu - (head, right breast, left breast, abdomen, right upper ated critically and some minor modifications were made limb, left upper limb, back, knees, ankle and feet and accordingly for socio-demographic and clinical data. buttocks), pain relief by medication and percent- age of pain relief. Pain severity score was measured Ethical approval by the sum of 4 items of pain severity. Each item was The Institutional Review Board (IRB) of An-Najah scored as a number from 0 to 10, and the sum of National University (#20Mar2016) approved the study. these numbers gave the final pain severity score with Permission was obtained from the two selected hospitals the lowest value of 0 and the highest value of 40. In for allowing researchers to interview their patients. addition, pain interference score was measured by the sum of the 7 items of pain interference. Each item Statistical analysis was scored as a number from 0 to 10, and the sum of Analysis of data was done with the IBM Statistical Pack- these numbers gave the final pain interference score age for Social Sciences (SPSS, version). Continuous vari- with the lowest value of 0 and the highest value of ables were presented mainly as mean  ±  SD or medians 70. Permission was obtained from the Department of (lower–upper quartiles), and categorical variables were Symptom Research at the University of Texas to use both expressed as frequency and percentage. Normal- the Arabic Brief Pain Inventory in our study. ity of continuous data was checked by the Kolmogo- 4. The fourth section consisted of the EQ-5D instru - rov–Smirnov test. Continuous variables such as the ment to assess HRQOL. EQ-5D is a widely used EQ-5D-5L index score was tested for intra-individual dif- instrument for evaluation of the generic quality of life ferences by using the Kruskal–Wallis or Mann–Whitney [22]. EQ-5D is a preference-based HRQOL measure; test, as required. In addition, the Spearman correlation it includes one question for five dimensions: mobil - coefficient was used to assess the degree of association ity, self-care, normal activities, pain/discomfort, and between all scales. The significance level was determined anxiety/depression [23]. Moreover, the EQ-5D ques- at a p-value  <  0.05. Multiple linear regression analysis tionnaire also has a Visual Analog Scale (VAS); by was also used to determine independent associations using this scale, respondents can report and docu- with HRQOL. Variables (socio-demographic, clinical, ment their perceived health status by a grading sys- and pain severity and interference) that were significant tem ranged from 0 (the worst possible health status) in bivariate analysis were entered into regression models. to 100 (the best possible health status). The Arabic Cronbach’s alpha was assessed for each scale to check the version of EQ-5D [24] was provided by the Euro- scale’s internal consistency reliability. Qol Research Foundation [23] through registration on the EQ-5D online system (ID: 15804). This scale Results has been described in detail in many previous studies Socio‑demographic and clinical characteristics conducted by the principle investigator [25–27]. The One hundred and eighty-three patients were interviewed, EQ-5D index scores were calculated as illustrated and the response rate was 92.9%. In total, 170 patients elsewhere [27–31], using the EQ-5D-5L Crosswalk (all females; mean age 51.71  ±  11.11  years) with breast Index Value Calculator [32] based on the UK general cancer were recruited for the study. Of these, 67 (39.4%) population scoring algorithm. patients were aged between 50 and 59 years old. Ninety- one (53.5%) participants lived in villages and 132 (77.6%) were married. More than 80% of the participants were Academic experts (two clinical pharmacists with exper- housewives, and 75 (44.1%) participants lived in families tise in QOL research and one academic researcher with Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 4 of 9 with a moderate income level. The socio-demographic Cyclophosphamide  +  Adriamycin and Taxol which were data of the study participants are listed in Table 1. used in 96 (56.5%) and 80 (67.1%) patients, respectively. As shown in Table  2, the majority of patients had the “Total mastectomy with some or total removal of the axil- invasive ductal carcinoma (IDC) histopathological type lary lymph nodes surgery” was the most common type of breast cancer; with 159 (93.5%) patients having IDC com- surgery, used in 105 (61.8%) patients. The current breast pared with other types of breast cancer, like ductal car- cancer condition shows that 60 (35.3%) patients are cancer- cinoma in  situ (DCIS) and lobular ductal carcinoma free, 58 (34.1%) and 47 (27.6%) patients are at stage 1 and (LDC). With regard to breast cancer treatment, 165 stage 4, respectively, and 104 (61.2%) had received treat- (97.1%) patients were taking one or more chemotherapy ment in the last 3 months before participation in the study. agents, 139 (81.8%) patients had undergone breast sur- gery, 62 (36.5%) patients had received radiotherapy and Brief Pain Invitatory 59 (34.7%) patients had received hormonal therapy. The The median pain severity score was 14.50 (interquartile most commonly used chemotherapy protocols were range: 8.00–21.25), and the median pain interference Table 1 Socio-demographic status and health-related quality of life Variable n (%) Median EQ‑5D ‑5L index (1st percentile ‑3rd P value N = 170 percentile) Age (year) < 40 21 (12.4) 0.71 [0.54–0.77] 0.043 40–49 48 (28.2) 0.76 [0.55–0.88] 50–59 67 (39.4) 0.67 [0.45–0.84] > 60 34 (20.0) 0.58 [0.46–0.69] Residency City 64 (37.6) 0.66 [0.52–0.83] 0.966 Village 91 (53.5) 0.68 [0.49–0.84] Palestinian refugee’s campaign 15 (8.8) 0.63 [0.45–1.00] Marital status Single 38 (22.4) 0.56 [0.41–0.67] < 0.001 Married 132 (77.6) 0.71 [0.54–0.88] Educational level Elementary 20 (11.8) 0.52 [0.41–0.77] 0.363 Preparatory 55 (32.4) 0.68 [0.58–0.85] Secondary 53 (31.2) 0.71 [0.54–0.88] Diploma 20 (11.8) 0.66 [0.32–1.00] Bachelor’s degree 10 (5.9) 0.66 [0.42–0.72] Uneducated 12 (7.1) 0.68 [0.47–0.70] Occupational status Private employee 16 (9.4) 0.74 [0.49–1.00] 0.294 Government employee 13 (7.6) 0.62 [0.32–0.72] Housewife 141 (82.9) 0.68 [0.52–0.84] Income level Low (less than 500 JD) 65 (38.2) 0.58 [0.41–0.74] 0.002 Moderate (500 JD–1000 JD) 75 (44.1) 0.70 [0.58–0.88] High (more than 1000 JD) 30 (17.6) 0.76 [0.53–0.88] Body mass index Underweight (< 18.5) 6 (3.5) 0.41 [(− 0.43)–0.68] 0.065 Normal weight (18.5–24.9) 48 (28.2) 0.60 [0.46–0.84] Overweight (25–29.9) 70 (41.2) 0.71 [0.58–0.84] Obese (> 30) 46 (27.1) 0.69 [0.44–0.85] Italic values indicate significance of p value (p < 0.05) Statistical significance of differences calculated using the Kruskal–Wallis test Statistical significance of differences calculated using the Mann–Whitney U test Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 5 of 9 Table 2 Cancer current condition and health-related quality of life Variable n (%) Median EQ‑5D ‑5L index (1st percentile ‑3rd percentile) P value N = 170 Type of breast cancer Invasive ductal carcinoma 159 (93.5) 0.67 [0.52–0.84] 0.419 Invasive lobular carcinoma 6 (3.5) 0.49 [0.25–0.77] Ductal carcinoma in situ 5 (2.9) 1.00 [0.81–1.00] Stage of cancer Stage 1 58 (34.1) 0.72 [0.55–0.85] 0.125 Stage 2 24 (14.1) 0.61 [0.52–0.77] Stage 3 40 (23.5) 0.67 [0.51–0.81] Stage 4 47 (27.6) 0.60 [0.37–0.88] Current condition Cancer-free 60 (35.3) 0.74 [0.55–0.85] 0.023 The tumor returned 30 (17.6) 0.62 [0.51–0.85] Active and receiving treatment 80 (47.1) 0.64 [0.37–0.77] Last time received treatment 0–3 months 104 (61.2) 0.65 [0.41–0.84] 0.310 3–12 months 16 (9.4) 0.59 [0.51–0.77] 1–2 years 24 (14.1) 0.74 [0.63–0.84] More than 2 years 26 (15.3) 0.67 [0.53–0.86] Post-treatment pain Yes 149 (87.6) 0.65 [0.48–0.80] 0.013 No 21 (12.4) 0.85 [0.58–1.00] Italic values indicate significance of p value (p < 0.05) Statistical significance of differences calculated using the Kruskal–Wallis test Statistical significance of differences calculated using the Mann–Whitney U test Unknown stage of cancer for one case score was 17.00 (interquartile range: 9.00–30.00). Reli- current condition of cancer and post-treatment pain ability values for these two subscales were good (Cron- (p-value  <  0.05). The study also showed no significant bach’s alpha = 0.895 and 0.879, respectively). differences between breast cancer patients in relation to their educational level, residency, occupation, BMI, and EQ‑5D health status, EQ‑5D‑5L index score, and EQV ‑ AS histopathological breast cancer type (p-value > 0.05). score There was a significant moderate negative correlation The reported HRQOL of this study was measured by between pain severity score and EQ-5D-5L index score using the median EQ-5D-5L index score, which was 0.67 (r  =  −  0.58, p-value  <  0.001). Also, there was signifi - (interquartile range: 0.51–0.84). Cronbach’s alpha for the cant moderate negative correlation between pain inter- EQ-5D-5L scale was 0.824, indicating satisfactory inter- ference score and EQ-5D-5L index score (r  =  −  0.604, nal consistency. The distribution of participants with p-value < 0.001). This study showed a moderate negative answers of no problem across the dimensions of EQ-5D correlation between EQ-VAS score on the one hand with was as follows: mobility 66 (38.8%), self-care 107 (62.5%), pain severity score (r = − 0.46, p-value < 0.001) and pain usual activities 87 (51.2%), pain/discomfort 44 (25.9), and interference score (r  =  −  0.53, p-value  <  0.001) on the anxiety/depression 81 (47.6%); (Fig. 1). We found that 25 other. Also, the study showed a moderate positive corre- (14.7%) women reported no problems with any dimen- lation between EQ-5D-5L index score and EQ-VAS score sion of EQ-5D. Furthermore, the median EQ-VAS was (r = 0.66, p-value < 0.001). 70.00 (interquartile range: 60.00–80.00). Regression analysis, using QOL score as a dependent variable and the covariates of age, marital status, employ- Univariate and multiple linear regression analyses ment status, income, current condition of cancer, pain As shown in both Tables  1 and 2, there were signifi - severity score, pain interference score, and post-treat- cant differences between breast cancer patients in rela - ment pain as independent variables revealed that patients tion to patient age, marital status, income level, the with high income (p-value  =  0.003), patients with lower Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 6 of 9 Health - Related Quality of Life EQ-5D DIMENSIONS No difficulty Slight difficulty Moderate difficulty Severe difficulty Unable to do/very severe Fig. 1 Distribution of health-related quality of life measures in different European Quality of Lifescale 5 (EQ-5D) dimensions pain severity score (p-value  <  0.001), and lower pain recurrent tumour and post-treatment pain. According interference score (p-value  =  0.018) were independently to the literature, EQ-5D was also used to assess HRQOL associated with high QOL. The factors significantly asso - among breast cancer patients in different countries [33– ciated with QOL according to multiple linear regression 35]. EQ-5D measured improvements and deteriorations analyses are summarised in Table 3. in HRQOL after treatment [36]. u Th s, EQ-5D seemed an appropriate tool for evaluation of HRQOL and possi- Discussion ble interventions to improve QOL among breast cancer This study provided an inclusive measurement of patients, especially after treatment [36]. HRQOL between breast cancer patients in Nablus, Pales- In our study, the EQ-5D score median among breast tine. In our study, EQ-5D QOL instrument was applied to cancer survivors in Palestine was 0.67 (interquartile measure HRQOL. Overall, the main socio-demographic range: 0.51–0.84); this compared to other studies which factors related to breast cancer HRQOL were old age, used the same instrument in Iran, Holland and Sweden, being a housewife, low income, being single, an active or with the following results: 0.69  ±  0.22 [33], 0.72  ±  0.29 Table 3 Patients characteristics associated with quality of life in multiple linear regression Variables Unstandardised coefficients (B) S.E Standardised coefficients (Beta) P value Age − 0.020 0.017 − 0.066 0.241 Marital status 0.052 0.041 0.077 0.205 Income level 0.064 0.023 0.163 0.006 The current condition − 0.023 0.019 − 0.074 0.222 Pain severity score − 0.011 0.002 − 0.353 < 0.001 Pain interference score − 0.007 0.001 − 0.350 < 0.001 Post-treatment pain − 0.010 0.051 − 0.012 0.842 Italic values indicate significance of p value (p < 0.05) FREQUENCY Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 7 of 9 at the end of treatment, 0.57 ± 0.29 12 months after the could be explained by the suggestion that receiving breast end of treatment [34], and 0.70 (95% confidence interval cancer treatment will induce post-treatment pain which (CI): 0.63–0.75) [35], respectively. Several socioeconomic interferes with patients’ functioning and quality of life factors and factors related to the healthcare system could [15, 46, 47]. affect HRQOL in many aspects. Some of these variations Post-treatment pain in breast cancer patients remains resulted from differences in socio-demographic and clini - clinically especially during the first few years follow - cal characteristics of the participants such as: age, resi- ing treatment [48, 49]. Many patients experience severe dency, marital status, occupation, income level, current post-treatment pain that significantly interferes with condition of the tumour, and post-treatment pain. their functionality and quality of life [50–52]. All treat- According to our results, increased age was associated ment modalities of cancer have the ability to cause pain with lower HRQOL among breast cancer patients. Simi- [15]. The pain aetiology for breast cancer is categorised larly, many previous studies concluded the same find - as: tumour-induced pain, treatment-induced pain such as ings [37]. One of these studies, a study from Malaysia, side effects from chemotherapy, or post-procedural and stated that QOL in breast cancer strongly varies by age post-surgical pain, and comorbidity-related pain such as as an important component of general health status [38]. constipation and thrombophlebitis [15, 53, 54]. Among Younger patients reported significantly better HRQOL breast cancer patients, the prevalence of post-treatment compared to older ones, possibly due to the short dura- pain may be much higher; according to our study, 87.6% tion of disease and fewer complications. of patients with breast cancer suffered from post-treat - One possible explanation is that older patients age, as ment pain. These results were much higher than the find - the disease progresses, and will experience a poor social ings reported by Forsythe and colleagues, with more than life with an increased rate of depression and physical 30% of breast cancer patients reporting above average inactivity, which could lead to high pain and fatigue level pain after treatment [55]. and thus lower QOL scores [39]. This observation was In this study, we found that post-treatment pain was also reported by Merom et al. [40], who described physi- significantly associated with low levels of HRQOL. cal inactivity as being high among Palestinian women. Patients who experienced pain after breast cancer treat- u Th s, older patients who present with more symptoms of ment reported lower EQ-5D scores. These findings were depression and anxiety and physical inactivity will con- confirmed by the results of Kroenke and Theobald [56]. tribute to the lower QOL [41]. Many studies also demonstrate that pain in breast cancer Our data showed in relation to marital and finan - is associated with a lower HRQOL, especially in high lev- cial status that being single and having a low income els of pain severity and pain interference, while good pain level were significantly associated with poor QOL (i.e. management led to an improved QOL [42, 57, 58]. Pain lower EQ-5D scores). Low income level was also con- interference mostly affected normal work, walking ability, firmed as being an important factor related to impaired mood, sleep and general activity. Our results showed that HRQOL among breast cancer patients in other stud- post-treatment pain did not negatively affect HRQOL ies [37]. Another study about HRQOL in breast can- alone, but was also the most significant determinant of cer patients was performed in Lithuania, and showed a HRQOL among breast cancer patients. In summary, our good QOL level in patients who were married and lived results indicated that patients who had chronic pain after in families with fewer financial difficulties compared breast cancer treatment reported fatigue, anxiety, depres- with patients who were single and with poor economic sion, sleep disturbances and impaired HRQOL. Receiving status [42]. Also, being single was negatively associated a combined treatment for breast cancer, such as surgery, with HRQOL, these results further support the idea that chemotherapy, and regional radiotherapy, was related to a strong family relationship, close communication, and a higher risk of developing chronic pain. The identifica - positive emotional and social support given by the part- tion of those breast cancer patients who are at high risk ner had a significant effect on improving QOL in breast of developing chronic pain after the completion of breast cancer patients [42–44]. Therefore, good social support cancer treatment is hugely important in order to provide from family and friends and good financial status may adequate pain relief, establish interventions which aim to significantly improve the QOL in breast cancer patients reduce the adverse consequences of breast cancer treat- [45]. ment, restore functionality and support healthy life in According to our study, current breast cancer condition long-term breast cancer patients. was significantly related to impaired HRQOL in breast cancer patients. Patients experiencing recurrent cancer Strengths and limitations or undergoing active cancer treatments reported a lower This study has many strong points in that it is the first HRQOL than those who are cancer-free. These findings study about HRQOL among breast cancer patients Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 8 of 9 Competing interests conducted at West Bank in Palestine; also, the informa- The authors declare that they have no competing interests. tion was gathered by face-to-face interviews to get more reliable and complete data. Also, the current study meas- Availability of data and materials The datasets used and/or analysed during the current study available from the ured the impact of pain on HRQOL by using the global corresponding author on reasonable request. BPI and EQ-5D scales. However, in our study, we found a number of limitations that should be focused on. One Consent for publication All patients agreed to the anonymous use of their socio-demographic and of these limitations, the cross-sectional study type of this clinical data for research purposes. study, may prevent us from developing a good cause— effect relationship between post-treatment pain and Ethics approval and consent to participate The IRB of An-Najah National University (#20 Mar 2016) approved the study. HRQOL. Another limitation is that this study was held Permission was obtained from the two selected hospitals for allowing in Nablus city, which represents only one section of the researchers to interview their patients. Participation in the study was voluntary entire Palestinian West Bank. Lastly, gathering study data and all respondents gave verbal informed consent to their involvement in the study. This study protocol was approved (including the verbal consent pro- via a face to-face interviews may have a negative outcome cess) by the IRB and did not require written consent according to IRB criteria. as the researchers can influence participant’s answers, leading to less reliable data. Funding sources No funding was received in preparation of this study. Conclusions Publisher’s Note This is the first study to present important data regard - Springer Nature remains neutral with regard to jurisdictional claims in pub- ing QOL by using the EQ-5D-5L instruments that may lished maps and institutional affiliations. help healthcare providers to identify patients with breast Received: 11 September 2017 Accepted: 15 November 2017 cancer who are at risk of low QOL. Our current study identified a number of significant associated factors that should be considered when dealing with breast cancer patients. 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Cancer-related post-treatment pain and its impact on health-related quality of life in breast cancer patients: a cross sectional study in Palestine

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Post-treatment pain has been suggested as an important indicator for health-related quality of life (HRQOL) in patients with breast cancer. Therefore, this study was performed to examine the association between pain and its impact on HRQOL among breast cancer patients in Palestine. Also, this study aimed to determine the QOL profile for breast cancer patients and stated the factors associated with QOL. Methods: A correlational cross-sectional study was conducted from May 2016 to November 2016 at Al-Watani Hos- pital and An-Najah National University Hospital in the Nablus district in Palestine. The five-level EuroQol five-dimen- sional instrument (EQ-5D-5L) was used to examine HRQOL. Pain severity and interference were assessed using the Brief Pain Inventory (BPI). Multiple linear regression analysis was performed to determine the most important variables related with HRQOL. Results: One hundred and seventy patients were involved in this study. Overall, all participants were female, with a mean ± SD for age of 51.71 ± 11.11 years. The reported HRQOL of this study was measured by using the median EQ-5D-5L index score, which was 0.67 (interquartile range: 0.51–0.84). There were moderate negative correlations between EQ-5D-5L index score and pain severity score (r = − 0.58, p value < 0.001), and pain interference score (r = − 0.604, p-value < 0.001). Furthermore, univariate analysis showed that age, marital status, employment status, income, current condition of cancer, and post-treatment pain were associated with quality of life (p-value < 0.05). Regression analysis revealed that patients with high income (p-value = 0.003), patients with lower pain severity score (p-value < 0.001), and lower pain interference score (p-value = 0.018) were independently associated with high QOL. Conclusions: This is the first study to present important data regarding QOL by using the EQ-5D-5L instruments that may help healthcare providers to identify patients at risk of low QOL. Healthcare providers and health strategy mak- ers should be alerted to low level HRQOL among breast cancer patients with low income level, patients with post- treatment pain, especially in the state of severe pain, and the state of pain interfering with daily life to improve their HRQOL. Keywords: Breast cancer, Post-treatment pain, Health-related quality of life, Palestine *Correspondence: saedzyoud@yahoo.com; saedzyoud@najah.edu Division of Clinical and Community Pharmacy, Department of Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 2 of 9 Background Methods Breast cancer refers to a malignancy in women and in a Study design small percent in men, which arises from the epithelial tis- This cross-sectional study was conducted by using stand - sue of the breast tissue, representing approximately 10% ardised and validated assessment tools in women with of the total volume of the breast [1]. Breast cancer is the breast cancer from May 2016 to November 2016. second most common cancer globally, and also the most common malignancy between women that consists of Study setting 18% of all female cancers [1, 2]. Breast cancer has differ - This study was conducted in Al-Watani hospital and An- ent treatment methods, and these methods have different Najah National University hospital, Nablus, West Bank, effects on the patients and their life [3 ]. The treatment of Northern Palestine. These two hospitals serve as the breast cancer usually starts with surgery and radiotherapy, main referral hospitals for the northern districts of West and often involves chemotherapy or other drug therapies, Bank-Palestine and receive most cases of breast cancer such as hormonal treatment, either before or after sur- patients from all northern West Bank districts. gery [4]. Pain after treatment is a major clinical problem in breast cancer patients, and is one of the most common Study population complications affecting 25 to 60% of breast cancer patient The medical records of both hospitals in 2015 showed survivors [5]. Post-treatment pain is defined as the pain that the number of breast cancer patients in both hos- related to treatment body regions with duration of more pitals was around 600 patients in 1 year and around 300 than 3 months after treatment is completed [6]. Improving patients during the period of study. Each of both hospi- health-related quality of life (HRQOL) has become one of tals where study was conducted gave us a list with the the most essential goals of cancer therapy [7–9]. HRQOL names of breast cancer patients in order to assess their is a multidimensional instrument that includes the com- comfort for this study. prehension of the positive and the negative aspects of different dimensions such as the physical, emotional, cog - Sampling procedure and sample size calculation nitive and social domains, as well as pain/discomfort [10]. The Raosoft sample size calculating tool (an automated In Palestine, cancer is the second most common cause software program: http://www.raosoft.com/samplesize. of death, accounting for about 14.2% of all deaths in 2014, html) was used for sample size calculation. We assumed meaning that they are very common [11]. According to that 50% of women with breast cancer had a high QOL, the Ministry of Health records, breast cancer is the most which would give the maximum sample size. Further- common type of cancer in Palestine and the third most more, we used a 5% margin of error at a 95% confidence common type of cancer causing death (about 10.7%) after interval as recommended; the required sample size was lung and colon cancer [11]. Globally, there are many arti- calculated to be 170 women. Convenience sampling was cles that talk about post-treatment pain and HRQOL used to recruit participants. among breast cancer survivors [5, 6, 12–17]. In the Arab World and Palestine, there is no research related to the Inclusion and exclusion criteria post-treatment pain and its association with HRQOL Women aged 18  years and above who were treated for in breast cancer patients. Researches in Palestine about breast cancer >  12  months prior to the conduct of our breast cancer focused on the palliative care situation [18] study, and who agreed to be participants in this study and pharmacological treatment [19, 20]. Therefore, this were included. The only exclusion criteria were women study was performed to examine cancer-related post- who had a major psychiatric illness, and those with an treatment pain (pain severity and interference) and its extremely ill condition. impact on HRQOL in the different stages of breast can - cer in patients in Palestine. Also, this study aimed to Data collection instrument determine QOL profile among breast cancer patients and The data collection form consisted of four sections: stated the factors associated with QOL. Investigating and assessing QOL in breast cancer patients and the related 1. The first section was designed to obtain socio-demo - post-treatment pain will help medical teams and patients graphic data such as age, marital status, place of resi- to plan and develop spectacular pain management strate- dence, educational level, family monthly income, and gies to address common signs and symptoms, and pro- height and weight, to calculate body mass index (BMI). vide breast cancer patients with better health and good 2. The second section contained patient clinical data QOL. Also, this will assist in creating a complete system such as type of breast cancer, stage of breast cancer, in order to deal with current patients and future patients, duration of disease, and the types of management so that we can help to end the suffering of these patients. that the patient had undertaken. Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 3 of 9 3. The third section was based on the assessment of experience in statistical analysis) reviewed and evalu- post-treatment pain and discomfort among breast ated measurement items for face and content validity, cancer patients by using a well-known pain-meas- and clinical accuracy. Data collection forms were admin- uring scale which is called the Brief Pain Inventory istered to participants face-to-face by two medical stu- scale (BPI); [21]. The BPI was used to assess both dents. These researchers received training in investigation pain severity and pain interference with normal func- skills and research ethics at the College of Medicine and tioning. Items used in determination of pain sever- Health Sciences and from epidemiologists with expertise ity were worst pain in the last 24 h, least pain in the in quality of life research. In order to insure interviewer last 24 h, average pain in the last 24 h and pain right consistency, both of the interviewers interviewed the par- now. Seven items were designed to assess pain inter- ticipants closely with each other. The data collection form ference with general activity, walking ability, mood, was piloted on 15 patients (not included in the final study) normal work, sleep, relations with others, and enjoy- to assess questionnaire comprehension, clarity, and com- ment of life. Also, this scale determined pain location pletion time. The results of the pilot study were evalu - (head, right breast, left breast, abdomen, right upper ated critically and some minor modifications were made limb, left upper limb, back, knees, ankle and feet and accordingly for socio-demographic and clinical data. buttocks), pain relief by medication and percent- age of pain relief. Pain severity score was measured Ethical approval by the sum of 4 items of pain severity. Each item was The Institutional Review Board (IRB) of An-Najah scored as a number from 0 to 10, and the sum of National University (#20Mar2016) approved the study. these numbers gave the final pain severity score with Permission was obtained from the two selected hospitals the lowest value of 0 and the highest value of 40. In for allowing researchers to interview their patients. addition, pain interference score was measured by the sum of the 7 items of pain interference. Each item Statistical analysis was scored as a number from 0 to 10, and the sum of Analysis of data was done with the IBM Statistical Pack- these numbers gave the final pain interference score age for Social Sciences (SPSS, version). Continuous vari- with the lowest value of 0 and the highest value of ables were presented mainly as mean  ±  SD or medians 70. Permission was obtained from the Department of (lower–upper quartiles), and categorical variables were Symptom Research at the University of Texas to use both expressed as frequency and percentage. Normal- the Arabic Brief Pain Inventory in our study. ity of continuous data was checked by the Kolmogo- 4. The fourth section consisted of the EQ-5D instru - rov–Smirnov test. Continuous variables such as the ment to assess HRQOL. EQ-5D is a widely used EQ-5D-5L index score was tested for intra-individual dif- instrument for evaluation of the generic quality of life ferences by using the Kruskal–Wallis or Mann–Whitney [22]. EQ-5D is a preference-based HRQOL measure; test, as required. In addition, the Spearman correlation it includes one question for five dimensions: mobil - coefficient was used to assess the degree of association ity, self-care, normal activities, pain/discomfort, and between all scales. The significance level was determined anxiety/depression [23]. Moreover, the EQ-5D ques- at a p-value  <  0.05. Multiple linear regression analysis tionnaire also has a Visual Analog Scale (VAS); by was also used to determine independent associations using this scale, respondents can report and docu- with HRQOL. Variables (socio-demographic, clinical, ment their perceived health status by a grading sys- and pain severity and interference) that were significant tem ranged from 0 (the worst possible health status) in bivariate analysis were entered into regression models. to 100 (the best possible health status). The Arabic Cronbach’s alpha was assessed for each scale to check the version of EQ-5D [24] was provided by the Euro- scale’s internal consistency reliability. Qol Research Foundation [23] through registration on the EQ-5D online system (ID: 15804). This scale Results has been described in detail in many previous studies Socio‑demographic and clinical characteristics conducted by the principle investigator [25–27]. The One hundred and eighty-three patients were interviewed, EQ-5D index scores were calculated as illustrated and the response rate was 92.9%. In total, 170 patients elsewhere [27–31], using the EQ-5D-5L Crosswalk (all females; mean age 51.71  ±  11.11  years) with breast Index Value Calculator [32] based on the UK general cancer were recruited for the study. Of these, 67 (39.4%) population scoring algorithm. patients were aged between 50 and 59 years old. Ninety- one (53.5%) participants lived in villages and 132 (77.6%) were married. More than 80% of the participants were Academic experts (two clinical pharmacists with exper- housewives, and 75 (44.1%) participants lived in families tise in QOL research and one academic researcher with Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 4 of 9 with a moderate income level. The socio-demographic Cyclophosphamide  +  Adriamycin and Taxol which were data of the study participants are listed in Table 1. used in 96 (56.5%) and 80 (67.1%) patients, respectively. As shown in Table  2, the majority of patients had the “Total mastectomy with some or total removal of the axil- invasive ductal carcinoma (IDC) histopathological type lary lymph nodes surgery” was the most common type of breast cancer; with 159 (93.5%) patients having IDC com- surgery, used in 105 (61.8%) patients. The current breast pared with other types of breast cancer, like ductal car- cancer condition shows that 60 (35.3%) patients are cancer- cinoma in  situ (DCIS) and lobular ductal carcinoma free, 58 (34.1%) and 47 (27.6%) patients are at stage 1 and (LDC). With regard to breast cancer treatment, 165 stage 4, respectively, and 104 (61.2%) had received treat- (97.1%) patients were taking one or more chemotherapy ment in the last 3 months before participation in the study. agents, 139 (81.8%) patients had undergone breast sur- gery, 62 (36.5%) patients had received radiotherapy and Brief Pain Invitatory 59 (34.7%) patients had received hormonal therapy. The The median pain severity score was 14.50 (interquartile most commonly used chemotherapy protocols were range: 8.00–21.25), and the median pain interference Table 1 Socio-demographic status and health-related quality of life Variable n (%) Median EQ‑5D ‑5L index (1st percentile ‑3rd P value N = 170 percentile) Age (year) < 40 21 (12.4) 0.71 [0.54–0.77] 0.043 40–49 48 (28.2) 0.76 [0.55–0.88] 50–59 67 (39.4) 0.67 [0.45–0.84] > 60 34 (20.0) 0.58 [0.46–0.69] Residency City 64 (37.6) 0.66 [0.52–0.83] 0.966 Village 91 (53.5) 0.68 [0.49–0.84] Palestinian refugee’s campaign 15 (8.8) 0.63 [0.45–1.00] Marital status Single 38 (22.4) 0.56 [0.41–0.67] < 0.001 Married 132 (77.6) 0.71 [0.54–0.88] Educational level Elementary 20 (11.8) 0.52 [0.41–0.77] 0.363 Preparatory 55 (32.4) 0.68 [0.58–0.85] Secondary 53 (31.2) 0.71 [0.54–0.88] Diploma 20 (11.8) 0.66 [0.32–1.00] Bachelor’s degree 10 (5.9) 0.66 [0.42–0.72] Uneducated 12 (7.1) 0.68 [0.47–0.70] Occupational status Private employee 16 (9.4) 0.74 [0.49–1.00] 0.294 Government employee 13 (7.6) 0.62 [0.32–0.72] Housewife 141 (82.9) 0.68 [0.52–0.84] Income level Low (less than 500 JD) 65 (38.2) 0.58 [0.41–0.74] 0.002 Moderate (500 JD–1000 JD) 75 (44.1) 0.70 [0.58–0.88] High (more than 1000 JD) 30 (17.6) 0.76 [0.53–0.88] Body mass index Underweight (< 18.5) 6 (3.5) 0.41 [(− 0.43)–0.68] 0.065 Normal weight (18.5–24.9) 48 (28.2) 0.60 [0.46–0.84] Overweight (25–29.9) 70 (41.2) 0.71 [0.58–0.84] Obese (> 30) 46 (27.1) 0.69 [0.44–0.85] Italic values indicate significance of p value (p < 0.05) Statistical significance of differences calculated using the Kruskal–Wallis test Statistical significance of differences calculated using the Mann–Whitney U test Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 5 of 9 Table 2 Cancer current condition and health-related quality of life Variable n (%) Median EQ‑5D ‑5L index (1st percentile ‑3rd percentile) P value N = 170 Type of breast cancer Invasive ductal carcinoma 159 (93.5) 0.67 [0.52–0.84] 0.419 Invasive lobular carcinoma 6 (3.5) 0.49 [0.25–0.77] Ductal carcinoma in situ 5 (2.9) 1.00 [0.81–1.00] Stage of cancer Stage 1 58 (34.1) 0.72 [0.55–0.85] 0.125 Stage 2 24 (14.1) 0.61 [0.52–0.77] Stage 3 40 (23.5) 0.67 [0.51–0.81] Stage 4 47 (27.6) 0.60 [0.37–0.88] Current condition Cancer-free 60 (35.3) 0.74 [0.55–0.85] 0.023 The tumor returned 30 (17.6) 0.62 [0.51–0.85] Active and receiving treatment 80 (47.1) 0.64 [0.37–0.77] Last time received treatment 0–3 months 104 (61.2) 0.65 [0.41–0.84] 0.310 3–12 months 16 (9.4) 0.59 [0.51–0.77] 1–2 years 24 (14.1) 0.74 [0.63–0.84] More than 2 years 26 (15.3) 0.67 [0.53–0.86] Post-treatment pain Yes 149 (87.6) 0.65 [0.48–0.80] 0.013 No 21 (12.4) 0.85 [0.58–1.00] Italic values indicate significance of p value (p < 0.05) Statistical significance of differences calculated using the Kruskal–Wallis test Statistical significance of differences calculated using the Mann–Whitney U test Unknown stage of cancer for one case score was 17.00 (interquartile range: 9.00–30.00). Reli- current condition of cancer and post-treatment pain ability values for these two subscales were good (Cron- (p-value  <  0.05). The study also showed no significant bach’s alpha = 0.895 and 0.879, respectively). differences between breast cancer patients in relation to their educational level, residency, occupation, BMI, and EQ‑5D health status, EQ‑5D‑5L index score, and EQV ‑ AS histopathological breast cancer type (p-value > 0.05). score There was a significant moderate negative correlation The reported HRQOL of this study was measured by between pain severity score and EQ-5D-5L index score using the median EQ-5D-5L index score, which was 0.67 (r  =  −  0.58, p-value  <  0.001). Also, there was signifi - (interquartile range: 0.51–0.84). Cronbach’s alpha for the cant moderate negative correlation between pain inter- EQ-5D-5L scale was 0.824, indicating satisfactory inter- ference score and EQ-5D-5L index score (r  =  −  0.604, nal consistency. The distribution of participants with p-value < 0.001). This study showed a moderate negative answers of no problem across the dimensions of EQ-5D correlation between EQ-VAS score on the one hand with was as follows: mobility 66 (38.8%), self-care 107 (62.5%), pain severity score (r = − 0.46, p-value < 0.001) and pain usual activities 87 (51.2%), pain/discomfort 44 (25.9), and interference score (r  =  −  0.53, p-value  <  0.001) on the anxiety/depression 81 (47.6%); (Fig. 1). We found that 25 other. Also, the study showed a moderate positive corre- (14.7%) women reported no problems with any dimen- lation between EQ-5D-5L index score and EQ-VAS score sion of EQ-5D. Furthermore, the median EQ-VAS was (r = 0.66, p-value < 0.001). 70.00 (interquartile range: 60.00–80.00). Regression analysis, using QOL score as a dependent variable and the covariates of age, marital status, employ- Univariate and multiple linear regression analyses ment status, income, current condition of cancer, pain As shown in both Tables  1 and 2, there were signifi - severity score, pain interference score, and post-treat- cant differences between breast cancer patients in rela - ment pain as independent variables revealed that patients tion to patient age, marital status, income level, the with high income (p-value  =  0.003), patients with lower Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 6 of 9 Health - Related Quality of Life EQ-5D DIMENSIONS No difficulty Slight difficulty Moderate difficulty Severe difficulty Unable to do/very severe Fig. 1 Distribution of health-related quality of life measures in different European Quality of Lifescale 5 (EQ-5D) dimensions pain severity score (p-value  <  0.001), and lower pain recurrent tumour and post-treatment pain. According interference score (p-value  =  0.018) were independently to the literature, EQ-5D was also used to assess HRQOL associated with high QOL. The factors significantly asso - among breast cancer patients in different countries [33– ciated with QOL according to multiple linear regression 35]. EQ-5D measured improvements and deteriorations analyses are summarised in Table 3. in HRQOL after treatment [36]. u Th s, EQ-5D seemed an appropriate tool for evaluation of HRQOL and possi- Discussion ble interventions to improve QOL among breast cancer This study provided an inclusive measurement of patients, especially after treatment [36]. HRQOL between breast cancer patients in Nablus, Pales- In our study, the EQ-5D score median among breast tine. In our study, EQ-5D QOL instrument was applied to cancer survivors in Palestine was 0.67 (interquartile measure HRQOL. Overall, the main socio-demographic range: 0.51–0.84); this compared to other studies which factors related to breast cancer HRQOL were old age, used the same instrument in Iran, Holland and Sweden, being a housewife, low income, being single, an active or with the following results: 0.69  ±  0.22 [33], 0.72  ±  0.29 Table 3 Patients characteristics associated with quality of life in multiple linear regression Variables Unstandardised coefficients (B) S.E Standardised coefficients (Beta) P value Age − 0.020 0.017 − 0.066 0.241 Marital status 0.052 0.041 0.077 0.205 Income level 0.064 0.023 0.163 0.006 The current condition − 0.023 0.019 − 0.074 0.222 Pain severity score − 0.011 0.002 − 0.353 < 0.001 Pain interference score − 0.007 0.001 − 0.350 < 0.001 Post-treatment pain − 0.010 0.051 − 0.012 0.842 Italic values indicate significance of p value (p < 0.05) FREQUENCY Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 7 of 9 at the end of treatment, 0.57 ± 0.29 12 months after the could be explained by the suggestion that receiving breast end of treatment [34], and 0.70 (95% confidence interval cancer treatment will induce post-treatment pain which (CI): 0.63–0.75) [35], respectively. Several socioeconomic interferes with patients’ functioning and quality of life factors and factors related to the healthcare system could [15, 46, 47]. affect HRQOL in many aspects. Some of these variations Post-treatment pain in breast cancer patients remains resulted from differences in socio-demographic and clini - clinically especially during the first few years follow - cal characteristics of the participants such as: age, resi- ing treatment [48, 49]. Many patients experience severe dency, marital status, occupation, income level, current post-treatment pain that significantly interferes with condition of the tumour, and post-treatment pain. their functionality and quality of life [50–52]. All treat- According to our results, increased age was associated ment modalities of cancer have the ability to cause pain with lower HRQOL among breast cancer patients. Simi- [15]. The pain aetiology for breast cancer is categorised larly, many previous studies concluded the same find - as: tumour-induced pain, treatment-induced pain such as ings [37]. One of these studies, a study from Malaysia, side effects from chemotherapy, or post-procedural and stated that QOL in breast cancer strongly varies by age post-surgical pain, and comorbidity-related pain such as as an important component of general health status [38]. constipation and thrombophlebitis [15, 53, 54]. Among Younger patients reported significantly better HRQOL breast cancer patients, the prevalence of post-treatment compared to older ones, possibly due to the short dura- pain may be much higher; according to our study, 87.6% tion of disease and fewer complications. of patients with breast cancer suffered from post-treat - One possible explanation is that older patients age, as ment pain. These results were much higher than the find - the disease progresses, and will experience a poor social ings reported by Forsythe and colleagues, with more than life with an increased rate of depression and physical 30% of breast cancer patients reporting above average inactivity, which could lead to high pain and fatigue level pain after treatment [55]. and thus lower QOL scores [39]. This observation was In this study, we found that post-treatment pain was also reported by Merom et al. [40], who described physi- significantly associated with low levels of HRQOL. cal inactivity as being high among Palestinian women. Patients who experienced pain after breast cancer treat- u Th s, older patients who present with more symptoms of ment reported lower EQ-5D scores. These findings were depression and anxiety and physical inactivity will con- confirmed by the results of Kroenke and Theobald [56]. tribute to the lower QOL [41]. Many studies also demonstrate that pain in breast cancer Our data showed in relation to marital and finan - is associated with a lower HRQOL, especially in high lev- cial status that being single and having a low income els of pain severity and pain interference, while good pain level were significantly associated with poor QOL (i.e. management led to an improved QOL [42, 57, 58]. Pain lower EQ-5D scores). Low income level was also con- interference mostly affected normal work, walking ability, firmed as being an important factor related to impaired mood, sleep and general activity. Our results showed that HRQOL among breast cancer patients in other stud- post-treatment pain did not negatively affect HRQOL ies [37]. Another study about HRQOL in breast can- alone, but was also the most significant determinant of cer patients was performed in Lithuania, and showed a HRQOL among breast cancer patients. In summary, our good QOL level in patients who were married and lived results indicated that patients who had chronic pain after in families with fewer financial difficulties compared breast cancer treatment reported fatigue, anxiety, depres- with patients who were single and with poor economic sion, sleep disturbances and impaired HRQOL. Receiving status [42]. Also, being single was negatively associated a combined treatment for breast cancer, such as surgery, with HRQOL, these results further support the idea that chemotherapy, and regional radiotherapy, was related to a strong family relationship, close communication, and a higher risk of developing chronic pain. The identifica - positive emotional and social support given by the part- tion of those breast cancer patients who are at high risk ner had a significant effect on improving QOL in breast of developing chronic pain after the completion of breast cancer patients [42–44]. Therefore, good social support cancer treatment is hugely important in order to provide from family and friends and good financial status may adequate pain relief, establish interventions which aim to significantly improve the QOL in breast cancer patients reduce the adverse consequences of breast cancer treat- [45]. ment, restore functionality and support healthy life in According to our study, current breast cancer condition long-term breast cancer patients. was significantly related to impaired HRQOL in breast cancer patients. Patients experiencing recurrent cancer Strengths and limitations or undergoing active cancer treatments reported a lower This study has many strong points in that it is the first HRQOL than those who are cancer-free. These findings study about HRQOL among breast cancer patients Abu Farha et al. Asia Pac Fam Med (2017) 16:7 Page 8 of 9 Competing interests conducted at West Bank in Palestine; also, the informa- The authors declare that they have no competing interests. tion was gathered by face-to-face interviews to get more reliable and complete data. Also, the current study meas- Availability of data and materials The datasets used and/or analysed during the current study available from the ured the impact of pain on HRQOL by using the global corresponding author on reasonable request. BPI and EQ-5D scales. However, in our study, we found a number of limitations that should be focused on. One Consent for publication All patients agreed to the anonymous use of their socio-demographic and of these limitations, the cross-sectional study type of this clinical data for research purposes. study, may prevent us from developing a good cause— effect relationship between post-treatment pain and Ethics approval and consent to participate The IRB of An-Najah National University (#20 Mar 2016) approved the study. HRQOL. Another limitation is that this study was held Permission was obtained from the two selected hospitals for allowing in Nablus city, which represents only one section of the researchers to interview their patients. Participation in the study was voluntary entire Palestinian West Bank. Lastly, gathering study data and all respondents gave verbal informed consent to their involvement in the study. This study protocol was approved (including the verbal consent pro- via a face to-face interviews may have a negative outcome cess) by the IRB and did not require written consent according to IRB criteria. as the researchers can influence participant’s answers, leading to less reliable data. Funding sources No funding was received in preparation of this study. Conclusions Publisher’s Note This is the first study to present important data regard - Springer Nature remains neutral with regard to jurisdictional claims in pub- ing QOL by using the EQ-5D-5L instruments that may lished maps and institutional affiliations. help healthcare providers to identify patients with breast Received: 11 September 2017 Accepted: 15 November 2017 cancer who are at risk of low QOL. Our current study identified a number of significant associated factors that should be considered when dealing with breast cancer patients. 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Asia Pacific Family MedicineSpringer Journals

Published: Nov 21, 2017

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