Woman with cancer: cross-sectional analysis of health-related quality of life and social supportABSTRACT:
Objective: To verify the correlation between perceived social support and health-related quality of life among women diagnosed with cancer.
Method: Analytical cross-sectional study conducted in 2019 with a sample of 119 women diagnosed with cancer treated at a reference hospital for oncological treatment in the southern region of Minas Gerais. Data collection was carried out through interviews and medical record analysis. The Medical Outcomes Study social support scale and the European Organization for Research and Treatment of Cancer quality of life questionnaire were used. Statistical analysis was performed using Spearman’s correlation test.
Results: There was a positive correlation between all types of social support and the emotional and social functions of quality of life. Emotional/information, affective, and positive social interaction supports were positively correlated with global health status and negatively correlated with appetite loss.
Conclusion: Higher social support scores were correlated with a better quality of life among the women with cancer assessed. By identifying the specific types of social support that can improve certain dimensions of quality of life, nursing professionals will be able to plan and implement interventions more effectively.
Descriptors:
Quality of life; Social support; Cancer; Women
RESUMO
Objetivo: Verificar a correlação do apoio social percebido e a qualidade de vida relacionada à saúde entre mulheres com diagnóstico de câncer.
Método: Estudo transversal do tipo analítico realizado em 2019 com uma amostra de 119 mulheres com diagnóstico de câncer, atendidas num hospital de referência para tratamento oncológico do Sul do Estado de Minas Gerais. A coleta de dados foi feita por meio de entrevista e análise de prontuário. Utilizou-se a escala de apoio social do Medical Outcomes Study e o questionário de qualidade de vida da Organização Europeia para Pesquisa e Tratamento do Câncer. A análise estatística foi feita por meio do teste de correlação de Spearman.
Resultados: Houve correlação positiva entre todos os tipos de apoio social e as funções emocional e social da qualidade de vida. Os apoios emocional/informação, afetivo e interação social positiva se correlacionaram positivamente com o estado de saúde global e negativamente com a perda de apetite.
Conclusão: Melhores escores de apoio social foram correlacionados a uma melhor qualidade de vida entre as mulheres com câncer avaliadas. Ao identificar os tipos específicos de apoio social que podem melhorar determinadas dimensões da qualidade de vida, os profissionais de enfermagem poderão planejar e executar intervenções de maneira mais eficaz.
Descritores:
Qualidade de vida; Apoio social; Câncer; Mulheres
RESUMEN:
Objetivo: Verificar la correlación del apoyo social percibido y la calidad de vida relacionada con la salud entre mujeres con diagnóstico de cáncer.
Método: Estudio transversal de tipo analítico realizado en 2019 con una muestra de 119 mujeres con diagnóstico de cáncer atendidas en un hospital de referencia para tratamiento oncológico del sur del estado de Minas Gerais. La recolección de datos se realizó mediante entrevista y análisis de historial médico. Se utilizó la escala de apoyo social del Medical Outcomes Study y el cuestionario de calidad de vida de la Organización Europea para la Investigación y el Tratamiento del Cáncer. El análisis estadístico se realizó mediante la prueba de correlación de Spearman.
Resultados: Hubo una correlación positiva entre todos los tipos de apoyo social y las funciones emocional y social de la calidad de vida. Los apoyos emocional/informativo, afectivo y de interacción social positiva se correlacionaron positivamente con el estado de salud global y negativamente con la pérdida de apetito.
Conclusión: Los mejores puntajes de apoyo social se correlacionaron con una mejor calidad de vida entre las mujeres con cáncer evaluadas. Al identificar los tipos específicos de apoyo social que pueden mejorar determinadas dimensiones de la calidad de vida, los profesionales de enfermería podrán planificar y ejecutar intervenciones de manera más eficaz.
Descriptores:
Calidad de vida; Apoyo social; Cáncer; Mujeres
INTRODUCTION
Cancer is the term given to several malignant diseases, commonly associated with the disordered growth of cells with the potential of invading adjacent organs or tissues. It is considered the greatest public health issue in the world, being one of the main causes of death and one of the main obstacles to increasing global life expectancy1.
The estimate for the years 2023 to 2025 in Brazil shows the emergence of 704,000 new cases of cancer, highlighting the growing need for prevention, control and treatment actions. The union between scientific knowledge and the understanding of the set of biopsychosocial factors that permeate the particularities of care is essential to make professional nursing care effective and of high quality1.
Cancer is permeated by stigma, being seen as a death sentence. Therefore, the impacts of the diagnosis can cause numerous emotional reactions in the sick person. In this sense, when analyzing the repercussions of this situation among the different genders, important risk factors are observed in females, causing vulnerability2. Culturally, the care of children, the sick, the elderly and the family environment is the responsibility of women. Thus, when the pillar of this care becomes ill, the entire family needs to be restructured, both to offer support for the woman’s emotional tensions and to establish the new functioning of the family dynamics3.
In view of the above, when diagnosed with cancer, a woman undergoes several emotional, physical and psychological changes, such as shock, fear, hopelessness, body disfigurement, lifestyle changes and reorganization of family roles, which can impact her health-related quality of life (HRQoL)2.
The term “health-related quality of life” (HRQoL) was constructed from the combination of two other concepts: quality of life and health4. Therefore, when the term is used as a reference in health sciences, it includes aspects related to illnesses, the impact of symptoms on the resulting capacities or limitations, functioning and perception of well-being4,5.
Among the aspects that can favor a better HRQoL, social support stands out, understood as the perceived availability of interpersonal resources capable of responding to the needs caused by stressful events6,7. The positive effect of social support on HRQoL occurs because social support can assist people in stressful situations, in such a way that the stress is mitigated and its negative effects are nullified or considerably reduced8.
In this context, the relationship between social support and HRQoL deserves to be highlighted because it is a relevant strategy for adaptation to the disease. In the case of women with cancer, social support plays a protective and recovery role, enabling them to face the different phases of their illness, treatment and recovery process, which, consequently, can improve their HRQoL9-11.
Despite the relevance of this relationship, previous studies have focused mainly on women with breast cancer or used tools to assess HRQoL that were not specifically developed for people with cancer9-11. These studies were conducted in Australia9, China10 and Iran11, indicating the need for further research in the Brazilian context. Deepening the understanding of the relationship between social support and HRQoL will allow nursing professionals to develop more precise and effective interventions, designed to the specific needs of the populations served. Therefore, the study can not only contribute theoretically, but also offer a practical basis for applying this knowledge in effective clinical interventions. Thus, this study aims to verify the correlation between perceived social support and health-related quality of life in women diagnosed with cancer.
METHOD
This is a cross-sectional, analytical study, which is part of a larger project authored by researchers of this study, called “Support for the care and quality of life of people with cancer”. The structure of this study followed the guidelines of the STROBE initiative (Strengthening the Reporting of Observational Studies in Epidemiology)12.
The study participants were women diagnosed with cancer, aged 18 years or older, living in the municipalities of the Alfenas-Machado and Alfenas-Guaxupé macro-regions of the State of Minas Gerais.
Data from individuals who underwent oncological treatment were used, stored in the Cancer Hospital Registry Information Department of a referral hospital for cancer treatment, located in a municipality in the South of Minas Gerais with a population of approximately 80,000 inhabitants. The average annual number of visits to this cancer hospital is 742.
The inclusion criteria were: age 18 years or older and confirmed diagnosis of cancer under treatment or monitoring. The exclusion criterion was the inability to answer the questionnaire (perceived by the interviewer based on the ability to provide personal information - name, date of birth, address and phone number - during the presentation of the research and invitation to participate). If the potential participant was unable to answer at least one of the questions, she would not be considered eligible to participate in the research. However, it is important to note that all the women invited were able to answer the personal information and were considered eligible.
The sample consisted of 119 women with cancer. The non-probabilistic convenience sampling technique was used, and the sample size was not calculated in advance. There were no losses among those who were invited and agreed to participate. The sample power calculation was based on a previous study on the quality of life of people with cancer for a significance level of α=0.05 and a sample size of n=119, resulting in an a priori statistical power of 1-β=78.16%13.
Data collection took place from March to December 2019, involving interviews and medical records analysis. Undergraduate and graduate students, duly trained by the researchers, recruited the participants at the Oncology Hospital before the routine consultation and conducted the interviews in person in private medical offices. The average duration of the interviews was approximately 30 minutes. The interviewers used tablets to record the participants’ responses, and the questionnaire was prepared via Google Forms®.
The information collected during the interview included: 1) socioeconomic aspects (age, marital status, education, religion, and income perception); 2) current health status; 3) HRQoL using the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer - EORTC- QLQC 30; 4) social support, using the Medical Outcomes Study Social Support Scale (MOS-SSS).
Medical records were obtained from the reception staff member responsible for referring the participant for a routine consultation. With the medical records in hand, the interviewers collected the following information: radiotherapy, chemotherapy, surgery, metastasis and time of diagnosis. These clinical aspects were collected from the medical record because they are not always known by all individuals with cancer.
Regarding the EORTC-QLQC 30 scale, the instrument was developed by the European Organization for Research and Treatment of Cancer (EORTC) in 1986 and validated for Brazilian Portuguese in 200614. It has 30 items that assess various dimensions of HRQoL through five functional scales (physical, cognitive, emotional, social, and role functioning), three symptom scales (fatigue, pain and nausea/vomiting), an item assessing the financial impact of treatment and disease, five items that assess symptoms commonly reported by cancer patients: dyspnea, sleep disturbance, appetite loss, constipation and diarrhea and a Global Health Status and Quality of Life Scale (GHS/QoL)14.
To obtain the scores, the guidelines contained in the EORTC group manual were followed, calculating the scores for each domain, first transforming them into scores from 0 to 100 (the sum of the values of the alternatives indicated in each item in the scale, divided by the number of responses, is multiplied by 100). As proposed by the authors who created the scale, the interpretation of the scores should be done as follows: the closer to 100, the better the functionality of the person being assessed, which is reversed in the symptom scale, as the closer to 100, the greater the prevalence of symptoms in the individual15.
The MOS-SSS was used in this study to assess perceived social support among the participants. The original version of the MOS-SSS8 was translated into Portuguese and had its psychometric properties evaluated within the scope of the Pró-Saúde Study conducted in Rio de Janeiro16. The instrument consists of 19 items grouped into four dimensions, namely: material (four items), affective (three items), positive social interaction (three items) and emotional/information (eight items). The scores for each dimension of the MOS-SSS were determined using the simple arithmetic mean. To clarify, each response choice in the MOS-SSS has a corresponding value, i.e., never receives 1 point, rarely 2 points, sometimes 3 points, almost always 4 points and always 5 points. The scores in each dimension can range from 1 to 5, and the higher the score, the better the perception of social support. To calculate the scores, a response value is assigned to each item, and the score is calculated by summing all the responses and dividing by the total number of items in each dimension of the scale8.
The research obtained institutional approval from the Reference Cancer Hospital of the municipality, and was evaluated by the Research Ethics Committee of the Universidade Federal de Alfenas (UNIFAL), under opinion no. 2,816,020 and CAAE 94986418,4,0000,5142. The participants were duly informed about the objectives of the study, its possible risks and benefits, expected contributions and the ethical considerations involved. Subsequently, the Informed Consent Form (ICF) was provided, which the participants had the opportunity to read and clarify any doubts before signing. After formalizing the ICF, the data collection instrument was applied.
The data were entered into Microsoft Excel® and the data analysis was performed using the STATA® statistical package, version 17.0, at a 5% significance level. Regarding the reliability analysis, the internal consistency of the instruments was verified using Cronbach’s alpha. The results for the MOS-SSS domains were: material support (0.83), emotional/informational support (0.93), affective support (0.85) and positive social interaction (0.90). For the EORTC-QLQC 30 domains they were: physical function (0.73), role functioning (0.83), emotional function (0.79), cognitive function (0.57), social function (0.74), fatigue (0.81), pain (0.87), nausea/vomiting (0.76) and GHS/QoL (0.86). As the data distribution did not present normality according to the Kolmogorov-Smirnov test, the median values and the 25% and 75% percentiles were presented, both for QoL and for social support. Spearman’s correlation was used to show the existence of a correlation between HRQoL and social support domains.
RESULTS
Of the women with cancer who participated in the study, 50.42% (n=60) were elderly, 62.18% (n=74) reported having a partner, 59.66% (n=71) completed elementary school, 79.83% (n=95) were Catholic and 45.38% (n=54) reported a perception of good/very good income to meet their needs. Regarding health aspects, 59.66% (n=71) considered their current health status to be good/very good. Regarding cancer, 60.50% of the women (n=72) were diagnosed more than 12 months ago and 43.70% (n=52) had no record of metastases. Regarding treatment, 18.49% (n=22) underwent radiotherapy, 71.43% (n=85) chemotherapy, 32.77% (n=39) biopsy surgery, and 53.94% (n=63) surgery for tumor removal. It is worth noting that there were missing records in the medical files for treatment information, especially information on radiotherapy, as 60.05% of the women (n=72) did not have this data recorded (Table 1).
Regarding the scores of the EORTC QLQ - C30 domains, it was observed that all domains of the functional scale presented medians of at least 80 points, and for role functioning and social functioning, the median was 100 points, indicating better quality of life scores in these domains. Regarding the symptom scale, it was observed that the median was zero points for the following symptoms: pain, nausea/vomiting, dyspnea, appetite loss, constipation, and diarrhea. The median for sleep disturbance was 33.33 points and for fatigue it was 11.11 points, indicating that the worst quality of life scores were identified for these symptoms. The median for financial difficulty was also zero points, while the global health status median was 75 points (Table 2).
Regarding the MOS-SSS, the median for all dimensions of the scale was 5 points. The 25th percentile was 4.5 points for material support and 5 points for affective support, indicating better social support scores for these dimensions (Table 3).
Table 4 presents the results of the correlation analysis between the EORTC QLQ-C30 domains and the MOS-SSS social support dimensions. It was observed that emotional and social functions correlated positively with all dimensions of social support, indicating that the better the perception of material support, emotional/informational support, affective support and positive social interaction, the better the perception of quality of life. The Global Health Status and Quality of Life (GHS/QoL) showed a positive correlation with the dimensions of emotional/informational support, affective support and positive social interaction, indicating that the better the perception of these types of support, the better the perception of overall quality of life (Table 4).
Regarding the symptom scale, a negative correlation was observed between appetite loss and the dimensions of emotional/informational support, affective support and positive social interaction. Considering that the lower the scores on the symptom scales, the better the perception of quality of life, the negative correlation observed indicates that the better the perception of emotional support/information, affective support and positive social interaction, the lower the appetite loss score, that is, the better the quality of life related to this symptom (Table 4).
DISCUSSION
In general, as observed in other studies, better social support scores were correlated with better quality of life among women with cancer9-11. In the study using data from the Australian Longitudinal Study on Women’s Health, 1428 women with all types of cancer were evaluated and the results demonstrated that a higher level of social support was significantly associated with better health-related quality of life9.
Similar results were found in a study conducted in China with a sample of 431 women with breast cancer. In this study, besides the direct positive effect of social support on quality of life, social support mediated the influence of resilience on quality of life10.
Of the studies found9-11, only one11 used the MOS-SSS. This study conducted with 223 Iranian women, revealed that only positive social interaction was associated with the quality of life domains. Positive social interaction can have a positive impact on the health and recovery of these women, through the engagement in several enjoyable social activities for the person, resulting in less distress and anxiety, which can allow the woman to forget about cancer11.
In a study conducted in Germany17, with an epidemiological profile similar to this study, high scores were reported on the EORTC QLQ-30, highlighting an important parallel between the high frequency of quality of life reported by the participants and that reported by German women, who live in a healthcare system with broad access to quality care.
Specifically regarding the correlation between emotional/information support and emotional and social functions, appetite loss and GHS/QoL, it can be stated that emotional/information support from close individuals, family, friends or healthcare professionals during the processes of diagnosis, treatment and possible discharge is a very important aspect for the psychological well-being of the individual, reducing anxiety and feelings of loneliness, in such a way that it significantly contributes to the neoplastic care process18.
The relation between emotional/information support and the domains that make up the HRQoL was also found in the study conducted with 545 women with breast cancer living in the United States. Emotional/information support was able to improve the social, emotional and functional well-being of women diagnosed and undergoing cancer treatment, acting as a buffer and removing additional concerns about their diagnosis, which can help to preserve emotional function. In the same study, material support correlated with the social, emotional and functional well-being of women with cancer, which can be explained by the fact that having people available to provide resources in daily life, such as offering rides to medical appointments or helping with daily tasks, can have a positive impact on several areas of HRQoL19.
The preservation of emotional function, achieved through assistance in solving emotional problems and meeting individual needs, plays a crucial role in maintaining the emotional well-being of individuals. This approach contributes to effective integration into the individual’s social network, resulting in the reduction or elimination of adverse symptoms, such as appetite loss. The ability to impact global health status and quality of life is therefore remarkable20.
Material support was correlated with emotional function and social function. One possible explanation for this relationship may lie in the fact that people who are part of the social network of women with cancer and provide practical resources and material assistance influence feelings of irritation, tension and other negative emotions, mitigating them and promoting the integration of these women into their daily family life and social activities. The provision of financial resources to those in vulnerable situations emerges as a key element to facilitate access to medication, treatments and to deal with the various adversities that arise in the daily life of people with cancer. The correlations identified in the study seem to be grounded on this dynamic21.
Positive social interaction and affective support were correlated with emotional function, social function, loss of appetite and GHS/QoL, that is, the presence of people with whom to relax, have fun, as well as demonstrations of love and affection were able to positively impact negative feelings, maintain family integration and social activities of women, reduce symptoms and improve GHS/QoL. Thus, the support and encouragement of close people play an important role, as they ensure significant changes in feelings and behaviors, helping in the experience of this period of uncertainty20.
Quality of life plays a fundamental role in the human experience, being particularly important in periods of high stress, since it is associated with significant and positive impacts on emotional and physical health and well-being. However, despite the evidence identified in this study, there is a lack of literature that addresses the role of social support in the quality of life of women with cancer17,20,21.
The socioeconomic characterization of the participants in this study shows a predominance of cancer in elderly women. Studies have concluded that aging is one of the main risk factors for the development of cancer, such as breast cancer, in addition to the late discovery of the neoplasia, which corroborates the data of this study, since the majority of participants are elderly and received the diagnosis after more than 12 months22-23.
Considering the educational level of the study participants, the majority completed elementary school and 5% of the participants are illiterate. These data are important factors, since educational level helps determine how much a person with cancer is able to receive, process and understand information related to their health status. This is essential for the individual to be able to understand the information conveyed by healthcare professionals, enabling them to take actions that promote their health and well-being24.
Furthermore, people with cancer go through situations that demand preserved mental functions, both due to the diagnosis received, changes in family routine, adherence to a new treatment, and understanding the risks, benefits, and objectives of the proposed therapy. In this way, understanding the disease increases, facilitating the process of acceptance and adaptation to a new situation, bringing a sense of control and the completion of tasks related to healthy behaviors and adherence to treatment24,25.
Regarding the clinical conditions of participants in cancer treatment, it is observed that most women underwent surgeries to totally or partially remove the organ affected by cancer. These surgical procedures can be referred to as mutilating, such as mastectomy, and can affect women's self-esteem, causing distortions in their self-image, which generates significant desolation. Other significant impacts resulting from different treatment modalities, such as chemotherapy and radiotherapy, including alopecia, loss of eyelashes, and episodes of nausea, also affect women. However, it is worth noting that this study did not allow the analysis of data related to such treatments due to the lack of information recorded26.
It is important to highlight that the small sample size, from a hospital in a municipality in southern Minas Gerais, limits the results generalization. Moreover, the lack of information about cancer treatment in most of the medical records is also a limitation. On the other hand, it is worth noting that the data were collected by a properly trained team and that the instruments used are validated to represent the events studied, providing results allowing to understand the relationship between social support and the various aspects of HRQoL.
Longitudinal studies are recommended for future research to identify how these variables may influence the improvement of care for women with cancer. Qualitative studies are also suggested to discuss the issue and enhance the understanding and perception of HRQoL and social support.
CONCLUSION
It is concluded that, among women with cancer diagnosis, better social support scores were correlated with better quality of life, as there was a positive correlation between the GHS/QoL, the emotional and social functions and all dimensions of social support, and a negative correlation between dimensions of appetite loss and the emotional/information support, affective support and positive social interaction.
The contribution of the study to nursing practice in caring for women with cancer, in the context of education and clinical practice, lies in the fact that, by showing how specific types of social support can improve particular dimensions of quality of life, nurses will be able to plan and implement more individualized interventions by creating care plans that address the needs of these women.
Acknowledgments
To the Foundation for Research Support of the State of Minas Gerais (Fundação de Amparo à Pesquisa do Estado de Minas Gerais) - Fapemig (Call 001/2018 - Universal Demand; APQ-01304-18).
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