The quality of life of disease-free Brazilian breast cancer survivors

La calidad de vida de brasileñas sobrevivientes del cáncer de mama

A qualidade de vida de brasileiras sobreviventes ao câncer de mama

Abstracts

O objetivo deste estudo foi comparar a qualidade de vida de mulheres que sobreviveram ao câncer de mama e de mulheres que não tiveram a doença, e identificar os fatores associados. Trata-se de um estudo transversal no qual o grupo de comparação envolve as sobreviventes de câncer de mama com idade entre 40 e 69 anos. Foram incluídas 154 mulheres, 70 sobreviventes do câncer de mama e 84 sem a doença. O questionário SF-36 foi utilizado para avaliar a qualidade de vida. O teste Qui-Quadrado e os modelos lineares multivariados foram utilizados para comparar os grupos. A média estimada dos componentes físicos e mentais foi significativamente melhor para o grupo que sobreviveu à doença (51,10 e 52,25, respectivamente) quando comparado ao grupo sem câncer (47,26 e 47,93, respectivamente). O estudo indicou que as sobreviventes do câncer de mama tinham melhor qualidade de vida quando comparadas a mulheres sem a doença.

Neoplasias da mama; Qualidade de vida; Questionários; Enfermagem oncológica

ORIGINAL ARTICLE

The quality of life of disease-free Brazilian breast cancer survivors

La calidad de vida de brasileñas sobrevivientes del cáncer de mama

Priscila Bernardina Miranda Soares^I; Jair Almeida Carneiro^II; Leandro Augusto Rocha^III; Renata Cristina Ribeiro Gonçalves^IV; Daniella Reis Barbosa Martelli^V; Marise Fagundes Silveira^VI; Hercílio Martelli Júnior^VII

^IMedical Oncologist at Santa Casa, Montes Claros. Montes Claros, MG, Brazil. [e-mail]

^IIStudent in Health Science, Universidade Estadual de Montes Claros. Montes Claros, MG, Brazil. [e-mail]

^IIIMedicine School Student, Faculdades Unidas do Norte de Minas. Montes Claros, MG, Brazil. [e-mail]

^IVNurse in the Oncology Department of Santa Casa de Misericórdia, Montes Claros, MG, Brazil. [e-mail]

^VMaster in Health Science, Universidade Estadual de Montes Claros. Montes Claros, MG, Brazil. [e-mail]

^VIDoctor, PhD in Health Science. Post Graduate Program in Health Science, Universidade Estadual de Montes Claros. Montes Claros, MG, Brazil. [e-mail]

^VIIDoctor, PhD in Health Science. Post Graduate Program in Health Science, Universidade Estadual de Montes Claros. Montes Claros, MG, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

The objective of this study was to compare the quality of life of women who survived breast cancer and women who have not had the disease, and to identify associated factors. It is cross-sectional study in which the comparison group includes survivors of breast cancer aged between 40 and 69 years. One hundred and fifty-four women were included, 70 with breast cancer and 84 without the disease. The SF-36 was used to evaluate quality of life. The chi-square test and multivariate linear models were used to compare the groups. The estimated mean physical and mental components were significantly better for the group who survived the disease (51.10 and 52.25, respectively) compared to the group without cancer (47.26 and 47.93, respectively). The study indicates that survivors of breast cancer had a better quality of life compared to women without the disease.

Descriptors: Breast neoplasms. Quality of life. Questionnaire. Oncologic nursing.

RESUMEN

Se apuntó a comparar la calidad de vida de mujeres sobrevivientes al cáncer de mama con la de mujeres que no sufrieron la enfermedad, e identificar los factores asociados. Estudio transversal en el que el grupo de comparación envuelve a las sobrevivientes de cáncer de mama con entre 40 y 69 años. Fueron incluidas 154 mujeres, 70 sobrevivi-entes del cáncer de mama y 84 no afectadas. El cuestionario SF-36 fue utilizado para evaluar la calidad de vida. El test Chi-cuadrado y los modelos lineales multivariados fueron utilizados en la comparación de los grupos. La media estimada de los componentes físicos y mentales fue significativamente mejor para el grupo que sobrevivió a la enfermedad (51,10 y 52,25, respectivamente), en comparación al grupo sin cáncer (47,26 y 47,93, respectivamente). El estudio indicó que las sobrevivientes al cáncer de mama tenían mejor calidad de vida comparadas con aquellas que no padecieron la enfermedad.

Descriptores: Neoplasias de la mama. Calidad de vida. Cuestionarios. Enfermería oncológica.

INTRODUCTION

Breast cancer (BC) is the most common malignancy among women, comprising 22% of all cases worldwide⁽¹⁾. It has been reported that over one million women are diagnosed annually⁽²⁾. With the development of techniques for early diagnosis and more effective treatment, the number of cancer survivors in the long term has grown exponentially over the past 20 years⁽³⁾. The most recent survivorship data from the National Cancer Institute indicate there are over 11.4 million North American cancer survivors, and that 23% of all cancer survivors in that country are BC survivors⁽⁴⁾.

Over the last two decades, could be observed reduction in rates of mortality from breast cancer and cervix in countries of Europe and North America^(5-6). However, the situation has been different in developing countries. In Latin America, BC mortality has increased, and cervical cancer, although declining mortality in some countries, it is still responsible for expressive number of deaths in women⁽⁷⁾. In Brazil, studies, of trend of mortality from BC and cervix are concentrated in capital cities or States of the Federation, being little known mortality profile these causes in midsized cities^(8-11). Recently, it was demonstrated that BC was the main cause of cancer-related death for women in Juiz de Fora, Brazil. Trend analysis using the polynomial regression model showed a decrease in mortality due to uterine cervical cancer (p = 0.001) and an increase in mortality due to breast cancer (p = 0.035) over the course of the time series⁽¹²⁾.

With this rise in survival rates, the interest of researchers and health professionals has greatly increased concerning the impact of chronic diseases, particularly cancer, and their treatments on the quality of life (QOL) of these survivors⁽¹³⁾. Several studies linking BC and QOL have shown that the diagnosis and treatments can have social, physical, emotional and psychological repercussions which affect women with breast cancer, which may contribute to a wide variety of side effects that are closely related to poor QOL outcomes^(14-16). Nevertheless, other studies which have assessed QOL in women with BC in different socio-cultural contexts have shown that as the years pass, the QOL of women with BC becomes comparable to that of women without BC^(17-18). Notes that there are few studies assessing the QOL in Brazilian women BC survivors⁽¹⁹⁾.

Considering that sociodemographic and clinical differences may influence QOL, this study aims to compare the QOL of Brazilian women who have survived BC with that of women without BC.

METHOD

A cross-sectional study was carried out with one group of BC survivors and one group without cancer for comparison. It included 154 women, 70 with breast cancer and 84 without cancer. BC group was selected from private (49 women) and public services (21 women) in the North of Minas Gerais (Brazil). The participants without cancer were selected from among teaching staff, public servants, housewives and autonomous women. Inclusion criteria for BC group: age 40-69 years, not currently undergoing any cancer treatment for at least a year, and without history of other malignant tumors. Inclusion criteria for control group: age 40-69 years, without history of cancer.

All participants were interviewed in order to assess their socio-demographic and clinical features such as age, parity, marital status, ethnicity and age at menarche. Clinical characteristics of the BC group included tumor stage, histopathological type, whether they had chemotherapy or radiation therapy, type of surgery, and the time elapsed since BC diagnosis.

Clinical and socio-demographic characteristics were compared between the groups. QOL was assessed using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire, a generic tool for evaluating QOL⁽²⁰⁾, with eight components condensed into two summaries: a physical component summary (PCS) and a mental component summary (MCS). The questionnaires were administered by one of the investigators through interviews. Data were transferred to SPSS^® 17.0. Women without cancer and with BC were compared using the chi-square test. Measurements were performed to describe the eight dimensions of the SF-36 as well as summarising physical and mental components through univariate analysis. Multivariate generalised linear models were used in order to analyse data. These statistical models were used to identify the factors that had affected the subjects' QOL, with adjustments made for confounding variables. A p-value of 0.05 was considered statistically significant. The study was approved by the Research Ethics Board of the University. Each interviewee signed an informed consent form before the interview (# 1957/2010).

RESULTS

Table 1 presents socio-demographic and clinical features of the 154 participants. In the BC group, stage II was more frequently found (55.7%). Mastectomies had been performed on 55.7%. 44.3% had undergone breast conservation therapy and 18.6% of these women had postmastectomy breast reconstruction. Most of the group had undergone chemotherapy (81.4%). It was observed that more than 75.0% of this group had res among women without cancer were found in terms been diagnosed at least five years beforehand. The QOL of physical functioning components (79.8) and social scores are shown in Table 2. The highest QOL scores functioning (73.7), while role-physical (56.5) and vitaliamong women who had survived BC were observed in ty (62.6) scored the lowest. Mean PCS and MCS scores terms of physical functioning components (82.9) and were 50.3 and 53.9, respectively for women with BC; social functioning (87.7), while role-physical (69.9) and for the women without cancer, these scores were 47.6 vitality (73.9) scored the lowest. The highest QOL sco-and 47.9, respectively.

Table 3 shows that a multivariate general linear model analysis of PCS and MCS scales was performed. It was necessary to adjust the groups with and without BC because they were not comparable due to the variables of age, ethnicity, marital and menopausal status. We observed there was a significant difference between the groups with and without BC regarding PCS (p=0.009) and MCS (p=0.022), in favor of BC survivors. The best PCS (β=3.51) and MCS (β=4.32) scores were for the group of BC survivors. Mean estimated PCS scores was significantly better for the group with BC (51.1) compared to those without cancer (47.56). When comparing MCS scores of both groups, they were different again, revealing a mean of 52.25 for women with BC and 47.93 for women without cancer. Considering only the BC survivors (Table 4), we observed that marital status was significant (p=0.019) between the groups, and the mean estimated MCS scores for the groups without a partner and with a partner were 39.00 and 43.77, respectively.

DISCUSSION

BC promotes physical, social and emotional changes in the lives of these women. The measurement of the QOL can determine the impact of the disease and the treatment promotes these life allowing patients able to mitigate these alternatives make clear changes compared with women without cancer⁽¹⁹⁾. These impacts are mostly negative and are present in all periods and even after treatment for follow up⁽²¹⁾. Our main objective was to compare the QOL of female BC survivors with that of women without cancer, using the SF-36 survey. Several previous studies have used the SF-36 to study the QOL of BC patients^(17,22). In our study, we observed that when analyzing all the dimensions of the SF-36 in women with and without BC, physical functioning and social functioning had the best scores in both groups. These findings are consistent with those of previously published studies on different populations of BC survivors^(22-23), which emphasized the importance of psychological support and physical therapy in reducing the need for further cancer treatment⁽²⁴⁾. Meanwhile, vitality scored lowest in both groups in our study. This was also confirmed by another study⁽²³⁾.

When we carried out the multivariate-adjusted analyses, comparing both groups, PCS and MCS scores were significantly better for the BC survivors compared with the control group, with mean PCS and MCS scores of 51 and 52, respectively for the cancer group. The mean PCS and MCS scores observed⁽¹⁷⁾ were 50, which is a similar result to our findings, indicating good QOL scores. Another study⁽²⁵⁾ has also recorded good QOL scores for German women with BC, reporting a global health score that was similar to that of the general population. We observed that age showed no association with QOL. However, previous studies have identified age as a predictor of QOL^(17,26).

There is evidence that women who are satisfied with their partners report feeling better psychologically⁽¹⁵⁾. In our multivariate-adjusted analysis, BC survivors living without partners had a worse QOL (with a mean MCS score of 39.0 versus 43.7 for those living with a partner). This finding is in accordance with a study that has shown that BC survivors who had a partner had reported a better QOL⁽²⁷⁾. Other study⁽²⁸⁾ reported that the mean scores for QOL showed that women who were married or lived with a partner demonstrated better general health and wellbeing. On the other hand, found no association between QOL and marital status⁽¹⁷⁾.

The relationship between adjuvant chemotherapy and QOL was examined, and we observed no statistically significant difference between the groups regarding global QOL. These findings are in accordance with a study from Korea⁽²⁹⁾. However, in a large longitudinal study⁽¹⁷⁾, reported poor QOL for women who had received systemic adjuvant therapy. These findings suggest the effects of adjuvant therapy persist many years after chemotherapy completion. There is controversy in relevant literature over whether the type of surgery received is related to QOL^(30-31). It was observed during a QOL study⁽³²⁾ using SF36, recruited 75 Brazilian female BC survivors and found that, after multivariate analysis, breast conservation therapy was negatively correlated with physical aspects of QOL. In this study, the type of surgery had no impact on the global QOL. We have speculated these results might reflect a homogeneous division between the groups in the number of mastectomies (n=39) and of breast conservation therapy (n=31).

The limitations of this study include the small sample size, the cross-sectional design, and the fact that the groups which were assessed had distinctive characteristics that may have positively influenced the reports of the group of cancer survivors, since most of these women represented a group that has easier access to medical care and good educational and socio-economic status.

CONCLUSION

In conclusion, our study indicates that, surprisingly, the BC survivors had a better QOL (in terms of the PCS and the MCS) when compared to women without cancer, suggesting there is a need for further research on the subject, since most other authors have reported worse or equal QOL for BC survivors compared to women without BC. We believe that this is the first Brazilian case-control study which has used the SF-36 in order to assess breast cancer survivors and women without cancer, indicating a better QOL in all dimensions for those who have had breast cancer. Perhaps the explanation can be given by the fact that these women have found support from their families and health professionals, and have found greater meaning in life after cancer. Knowing that the multifactorial etiology has cancer, it is a need for further studies in other Brazilian regions assessing the QOL in patients with breast cancer survivors for the purpose of analysis and comparison.

Recebido: 03/06/2012

Aprovado: 06/07/2012

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Correspondence addressed to:

Hercílio Martelli Júnior

Rua Olegário da Silveira, 125/201 - Centro

CEP 39400-092 – Montes Claro, MG, Brazil

Publication Dates

• Publication in this collection
  15 Mar 2013
• Date of issue
  Feb 2013

History

• Received
  03 June 2012
• Accepted
  06 July 2012