Quality of life in breast cancer patients assessed using the EORTC

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ORIGINALES
Quality of life in breast cancer patients assessed
using the EORTC questionnaires
Juan Ignacio Arraras Urdaniz, José Juan Illarramendi Mañas, Martín Tejedor Gutiérrez,
Ruth Vera García, Elena Pruja Arteaga, Marta Marcos Oset,
Miguel Ángel Domínguez Domínguez and Juan José Valerdi Álvarez
Servicio de Oncología. Hospital de Navarra. Pamplona. Navarra.
The aim of the present study was to evaluate the quality of life in a sample of
breast cancer patients during treatment.
To that end, one hundred and seventy sev e n
consecutive patients at different stages of
the disease and who had previously undergone surgery were recruited. Patients completed the EORTC QLQ-C30 (version 2.0) and the
breast cancer module (QLQ-BR23) at three
different points of time during treatment
and follow-up. Demographic and clinical variables were also recorded. We have compared groups according to stage and surgery. We have studied the changes in their
quality of life over time.
The quality of life scores reflect moderate
limitations in some dimensions at the three
assessments. At the second and third assessment, there were also limitations related to treatment side effects. There were differences on most of the quality of
life dimensions between patients at different stages of the disease. The differences
between surgery modalities were limited
to body image. Quality of life seems relatively stable across the first and second assessments and has improved in some areas
at the third in the patients who have filled
in the three assessments (n = 141). Therapies thus cause some deterioration in quality of life at the second assessment,
which has improved by time of the third
assessment.
The quality of life scores and the clinical
variables indicate that the situation of these patients is generally satisfactory. A
comparison of scores over time of the patients who have filled in the three question-
Correspondencia: Dr. J. I. Arraras.
Oncology Department.
Hospital de Navarra.
C./Irunlarrea, 3.
31008 Pamplona. Navarra.
Correo electrónico: jiarraras@correo.cop.es
Recibido el 28-8-2000.
Aceptado para su publicación el 5-12-2000.
100
naires indicates that these women receive
treatment that, in general, they can tolerate adequately.
Key words: Quality of life, breast cancer, chemotherapy, radiotherapy, assessment.
Rev Oncología 2001; 3: 100-106.
Evaluación de la calidad de vida
en pacientes con cáncer de mama mediante los
cuestionarios
de la EORTC
El objetivo de este trabajo es evaluar la
calidad de vida de una muestra de pacientes con cáncer de mama durante el tratamiento.
Ciento setenta y siete pacientes con cáncer de mama en diferentes estadios de la
enfermedad y que habían recibido cirugía
previamente han contestado el cuestionario EORTC QLQ-C30 (versión 2.0) y el
módulo de mama QLQ-BR23 en 3 puntos a
lo largo del tratamiento y seguimiento.
Se han recogido además datos demográficos y clínicos. Se han comparado grupos
formados en función del estadio y la cirugía, y se han estudiado los cambios en
la calidad de vida a lo largo del tiempo.
Las puntuaciones de calidad de vida
muestran limitaciones moderadas en algunas dimensiones en las 3 evaluaciones. En la segunda y tercera medición
había también limitaciones relacionadas
con los efectos secundarios de los tratamientos. Se daban diferencias en la
mayoría de las dimensiones de calidad
de vida entre los pacientes agrupados
según los estadios de la enfermedad.
Las diferencias entre las modalidades
de cirugía se limitaban a la imagen corporal. La calidad de vida se ha mantenido relativamente estable entre la primera
y
segunda
medición,
y
ha
mejorado en algunas áreas en la tercera
en las pacientes que han completado las
3 mediciones (n = 141). Los tratamien-
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J. I. ARRARAS URDANIZ ET AL— QUALITY OF LIFE IN BREAST CANCER PATIENTS ASSESSED USING THE EORTC QUESTIONNAIRES
tos, por tanto, causan algún deterioro
en la calidad de vida de estos pacientes
en la segunda medición que mejora en el
momento de la tercera.
Las puntuaciones de calidad de vida y
las variables clínicas indican que la situación de estos pacientes es generalmente satisfactoria. Una comparación
de las puntuaciones a lo largo del tiempo de las pacientes que han completado
las 3 mediciones indica que reciben un
tratamiento que en general pueden tolerar adecuadamente.
Palabras clave: calidad de vida, cáncer de mama,
quimioterapia, radioterapia, evaluación.
INTRODUCTION
Breast cancer is the tumour site that has recei1-2
ved most attention in quality of life studies since it is the most frequent cancer among women.
The psychological significance of breast cancer is
important and it is a disease with a high survival
rate. In our province, Navarra, there is a Breast
3
Cancer screening programme that aims to detect
early stage tumours. This screening process
should result in a greater proportion of patients
receiving less agressive treatments and may lead
to a better prognosis. Quality of life in breast
cancer patients depends on medical variables like
the stage of the disease at the time of diagnosis,
the treatment modality administered, the likely
prognosis, and the rehabilitation opportunities
that are available. Psychological variables can also influence the adjustment of the patient to breast cancer, such as psychological distress (anxiety, depression, anger), changes in life
patterns, fears and concerns (recurrence, surgery), the point in the life cycle at which breast
cancer occurs, the personality of the patient,
previous indirect experience of breast cancer in a
relative
or
friend,
and
other
people’s
4,5
responses .
The influence of the different surgery modalities
is a subject for debate with reference to quality
of life. Historically it was thought that there
would be large differences between conservative
surgery and mastectomy on a variety of quality
of life domains. There are many studies on this
6
topic. Kiebert et al reviewed a group of studies
and report that quality of life is similar in different surgery modalities when assessed in the
early stages of the disease, with body image
being more affected in the mastectomy group.
These authors also note that there are conflicting
points of view on the influence of surgery on sexual functioning, partner relationship and other
7
domains. Schover found, in another review, that
in most of these studies women who had conserved their breasts had a better body image. Curran
8
et al assessed the quality of life of two samples
of early stage breast cancer patients treated with
radical mastectomy or breast conserving procedures, two years after the completion of the treatment. These authors observed significant benefits in body image and satisfaction with treatment
in the breast conserving patients and no differences in fear of relapse. Psychological variables like
fear
of
recurrence or personality traits could influence
the patient’s choice of surgery modality.
The European Organization for Research and Treatment of Cancer (EORTC) has a study group on
quality of life. One of the major tasks that this
study group has performed is the development of
questionnaires for the assessment of quality of life in international clinical trials. This study group
has created a combined assessment system composed of a generic, core questionnaire that evaluates issues common to different cancer sites
and treatments, and a range of supplementary
modules designed to assess specific issues, according to the type of treatment and disease site: breast,
9-11
lung, head and neck, oesophagus and others . A second generation of the core questionnaire, the EORTC
QLQ-C30, has been applied in multiple psychometric and clinical studies and a second version of
this questionnaire, the QLQ-C30 version 2.0, is
12-17
.
currently used
The aims of the present study were to assess clinical and sociodemographic data from a sample of
breast cancer patients who had passed through
the local breast cancer screening process, to
study quality of life at different times during treatment and the changes in health status over time, and to evaluate differences between subgroups based on stage of the disease. We also
wanted to assess the differences between subgroups based in different surgery modalities in
the subsample of early stages patients.
We expected the quality of life of this sample of
patients to be good during treatment, to find general differences and differences specific to breast
cancer areas, among subgroups at distinct stages
of the disease, and the differences among surgery
subgroups to be associated with psychological aspects such as body image. We also expected some
reductions in quality of life during the treatment
process that could be recovered in the follow-up
period.
MATERIALS AND METHODS
101
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TABLE 1. Contents of the core questionnaire
and the breast module
Core questionnaire QLQ-C30
Functioning scales*
Physical, role, cognitive, emotional, social, global quality
of life
Symptom scale and/or item**
Fatigue, nausea and vomiting, pain, dyspnoea, sleep
disturbance, appetite loss, constipation, diarrhoea
1 item on financial impact
Breast module QLQ-BR23
Functioning scales and/or items*
Body image, sexual functioning, sexual enjoyment, future
perspective
Symptoms scales and/or items**
Arm symptoms, breast symptoms, systemic therapy
side effects, upset by hair loss
*Scores ranging from 0 to 100, with a higher score representing
a higher level of functioning. **Scores ranging from 0 to 100,
with a higher score representing a higher level of symptoms and
side effects.
Patients
A initial sample of 183 consecutive breast cancer patients was addressed. These patients were initiating their
treatment at the Oncology Department of the Hospital of
Navarre from January of 1996 till June of 1997. Patients
had received surgery before entering the study (i.e., mastectomy, quadrantectomy or lumpectomy). The sample
included patients with local, loco-regional or metastatic
disease. Patients with local or loco-regional disease were
treated with radiotherapy, chemotherapy or a combination of both. Patients with metastatic disease received
chemotherapy-based treatment. All breast cancer patients initiating their treatment at the Oncology Department in this period of time were addressed with the exception of subjects whose life expectancy was less than
three months or with cognitive shortcomings, who were excluded. Their cognitive functions were assessed by a psychologist using selected questions from the Mini-Mental
18
State Examination .
Evaluation
Patients completed the EORTC core questionnaire QLQ-C30
(version 2.0) and the breast cancer module QLQ-BR23 (table
191). Both instruments have been validated for use in Spain
2
1
.
In the core questionnaire, scores range from 0 to 100,
with higher scores representing a better level in the functioning scales and on the global scale, and higher disturbance on the symptom scales and domains. The module
scores also range from 0 to 100, with higher scores representing
a
higher level of functioning on the functioning scales and
domains, and a higher level of symptomatology on the
symptom scales and items. All the questions in both instruments referred to the previous week, except questions
on sexual functioning, which covered the previous four
weeks. The different scales and items of these instru-
102
ments were considered as the main endpoints of the
study.
After obtaining verbal consent, patients completed these
questionnaires at three different points: a) a baseline
questionnaire on the first day of treatment; b) on the last
day of the second chemotherapy cycle for patients who
received chemotherapy or a combined treatment, or on
the last day of radiotherapy for patients who only received this treatment modality, to study the effects of treatment, and c) in a follow-up visit one month after the
end of treatment, to study the cumulative effect of therapy and disease status after treatment had been completed. A psychologist was in charge of data recruitment.
Each patient tried to fill in the core and the module herself. If this was not possible but could be done with assistance, or if she so preferred, she was helped by the psychologist. Those cases in which the patient did not fill in
the questionnaire were considered as missing data, and
the reasons were recorded (a worsening in the physical
status, death, change in the initial treatment, administrative failure, patient’s refusal to answer). Those questionnaires in which 30% of the items were not answered were
excluded. For the first assessment we also recorded socio-demographic data: age, gender, marital status, level of
education; and clinical data: initial weight loss (none, lower and higher than 10%), stage of the disease (local, loco-regional and metastatic), surgery modality (lumpectomy, quadrantectomy and mastectomy). We recorded
the actual treatment received (radiotherapy, chemotherapy or combined) for the patients who completed the second assessment, and the treatment modality proposed
for patients who did not complete this second assessment. These sociodemographic and clinical data were taken from the clinical record. Performance status was assessed by the physician at the time of the three
22
assessments using the Karnofsky scale , and at the second
and
third
assessments the level of toxicity was evaluated using so23
me items of the Common Toxicity Criteria .
Treatment schedule
Chemotherapy was administered following standard
2
protocols: CMF (cyclophosphamide 600 mg/m days 1 and 8,
2
methotrexate 40 mg/m days 1 and 8, and 5 fluorouracil
2
600 mg/m days 1 and 8, every 28 days for 6 cycles),
2
FEC (5 fluorouracil, 600 mg/m ; cyclophosphamide, 600
2
2
m g / m ; epirubicin, 90 mg/m ; every 21 days for 6 cycles),
2
AC (doxorubicin, 60 mg/m ; cyclophosphamide, 600
2
m g / m ; every, 21 days for 4 cycles). Radiotherapy consisted on 50 Gy post conservative surgery with 10 Gy if
surgical margins were less than 1 cm.
Statistical analyses
A series of statistical tests was performed. We studied
the frequencies of the socio-demographic and clinical variables, and the quality of life scores. We performed
known-groups comparisons using one way analyses of variance (ANOVA). If the homoscedasticity test was not satisfactory (i.e., the Levene score was lower than 0.05),
we employed the Welch statistic to compare means. For
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J. I. ARRARAS URDANIZ ET AL— QUALITY OF LIFE IN BREAST CANCER PATIENTS ASSESSED USING THE EORTC QUESTIONNAIRES
comparisons of more than two groups (stage of the disease), we administered the Tukey contrast for the ANOVA,
and the Dunett T3 for the Welch statistic, to check which
groups the significant differences appeared between. We
have compared scores at the three assessments with the
core questionnaire and the module. We compared subgroups
based
on
the
stage
of
the
disease
(local, loco-regional and metastatic) at the time of the three assesments. We have selected patients with local and
loco-regional disease and have compared subgroups based on the type of surgery received (mastectomy versus
quadrantectomy and lumpectomy) at the first assessment. Changes in quality of life scores over time were cal-
TABLE 2. Characteristics of the sample
Characteristics
Patients 1
measurement
Patients 2
measurement
Patients 3
measurement
Age range 28-87 years
Civil status
Unmarried
Married
Separated
Widowed
Educational level
< than primary
Primary studies
Secondary
University
Stage
Local
Locoregional
Metastatic
Karnofsky 1
70-90
100
Karnofsky 2
70-90
100
Karnofsky 3
70-90
100
Weight loss
No
> 10%
< 10%
Surgery
Mastectomy
Cuadrantectomy
Lympectomy
Treatment
Radiotherapy
Combined
Chemotherapy
Toxicity 1
0-2
3-4
Toxicity 2
0-2
3
Number N
Percentage
Mean
SD
56
12.25
177
156
141
19
133
3
22
33
109
14
21
18.6%
61.6%
7.9%
11.9%
95
51
31
53.7%
28.8%
17.5%
culated and tested for statistical significance by means of
repeated ANOVA measurements, with the patients who
had filled in the instruments on all three occasions. We
compared the scores on the core and the breast cancer
questionnaires at the three assessments using T-tests for
related samples to see which pairs of the three assessments the significant differences appeared between. In all
the analysis performed in the present study, a
p-value of < 0.05 has been considered as statistically signific
a
n
t
.
RESULTS
One hundred and seventy seven women completed
the baseline questionnaire, from a group of 183
who complied with the inclusion criteria. Six patients refused to participate in the study. One
hundred and fifty six women completed the second
assessment and 141 the third. The reasons for
not filling in the second and third assessment
questionnaires were: a change in the proposed
treatment for disease progression in twelve patients, significant detrimental changes in the patient’s physical status in twelve more patients,
death in one case, five patients refused to answer
the questionnaire, and there was administrative
failure in six other cases. All completed questionnaires included answers to more than 70% of the
TABLE 3. Quality of life scores according to QLQ-C30
at the three measurements
N 177
92.6
81
96
45.8%
54.2%
92.6
68
88
43.6%
56.4%
47
94
33.3%
66.7%
162
2
13
91.5%
1.2%
7.3%
78
70
29
44.1%
39.5%
16.4%
62
58
57
35%
32.8%
32.2%
90
66
57.8%
42.2%
127
14
90.1%
9.9%
N 156
N 141
Areas
95.4
Physical*
Emotional*
Cognitive*
Social*
Global*
Role*
Fatigue**
Nausea,
vomiting**
Pain**
Dispnoea**
Sleep
disturbance**
Appetite
loss**
Constipation**
Diarrhoea**
Financial
impact**
Mean
SD
Mean
SD
Mean
SD
84.63
71.61
89.92
92.09
71.18
90.49
15.63
19.74
23.10
15.30
16.48
18.76
15.96
20.97
87.05
74.20
87.29
94.76
73.18
90.49
16.88
20.92
19.51
16.08
13.22
17.68
17.67
20.64
93.20
79.79
91.25
94.92
78.84
91.37
11.03
14.50
18.43
15.11
15.42
15.70
15.12
17.08
2.45
12.43
3.01
8.72
18.27
11.93
4.49
10.47
2.35
13.16
16.96
8.56
0.23
4.96
0.71
1.97
12.72
4.83
25.42
32.96
23.93
29.52
22.69
25.61
8.85
11.86
3.01
20.79
23.10
13.42
10.68
14.31
3.42
22.71
27.07
12.66
6.62
7.33
0.95
13.93
19.14
5.55
4.70
15.38
2.99
10.96
1.89
8.70
Mean ± SD of the scores in the scales and items of the core
questionnaire, at the three measurements. *Funcional scales,
the scores range from 0 to 100, with a higher score representing a higher level of functioning. **Symptoms and side effects
scales and items, scores ranging from 0 to 100, with a higher
score representing a higher level of symptoms and side effects.
103
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TABLE 4. Quality of life scores in the BR23
at the three measurements
1.° measurement
2.a measurement
2.a measurement
Mean
SD
Mean
SD
Mean
SD
94.63
9.37
15.50
17.89
10.00
42.16
63.09
37.04
11.76
19.07
15.76
14.78
10.87
26.35
32.47
35.14
93.00
8.81
9.11
18.48
14.89
50.62
66.67
31.46
14.46
18.92
13.44
14.42
13.44
21.42
26.50
35.85
96.39
10.23
4.41
12.17
7.16
48.39
72.34
18.18
9.03
20.34
11.94
10.51
9.36
22.51
26.41
28.59
Areas
Body image*
Sexual funct.*
Arm symptoms**
Breast**
Systemic**
Sex enjoym.*
Future persp.*
Upset hair loss**
Mean ± SD of the scores in the scales and items of the breast
cancer module at the three measurements. Scores range from
0 to 100, with a higher score representing a higher level of functioning in the *areas, and a higher level of symptoms and side
effects in the **areas.
cial impact scales, and there were differences
relative to disnea at both assessments. There was
a worse quality of life in the metastatic group
than in the local and loco-regional ones in all these
analyses.
In the analysis performed with the breast module
and the stage variable, at the time of the first assessment there were differences in the systemic
therapy
side
effect scale (in favour of the local and loco-regional groups), the body image scale (better in the
TABLE 5. Repeated measures ANOVA
N-141
Variable
PF
items. The socio-demographic and clinical characteristics of the sample can be seen in table 2. In
this sample, married women with a primary level
of education are predominant. There are more patients in the initial stages of the disease (local and
loco-regional) than with advanced disease. In performance status, the highest value (100) is predominant at each point of time, and the
three assessments have similar means. A large
part of the sample had experienced no weight
loss, and the most frequent surgery is conservative (quadrantectomy and lumpectomy). Similar
numbers of patients received each treatment modality and the treatments proposed were usually
carried out. The toxicity scores are higher at the
second than the third assessment.
Quality of life scores at the pre-treatment assessment indicate a moderate level of impairment
in global quality of life, emotional and sexual
functioning, and future perspective, and in sleep
disturbance. There were also some problems with
pain, fatigue, constipation and arm symptoms.
The other scales and items, such as body image,
physical functioning and others, suggest a good
quality of life. At the second assessment, there
were problems in similar areas as well as in breast symptoms and systemic therapy side effects,
and at the third assessment, less problems were
evident (tables 3 and 4).
In the analysis in which the stage of the disease is
considered as a grouping variable, the results of
the known group comparisons in the core questionnaire show significant differences between
the three assessments relative to physical functions, role, pain, fatigue, and global scales, and to
loss of appetite. Also, at the first assessment
there were differences on the emotional scale, at
the second on the nausea and vomiting and finan-
104
EF
CF
QL
FA
NV
PA
CO
BIMAGE
FUTURE
ARM
SYSTEM
BREAST
Mean
p
Differences
85.95
88.51
93.19
71.33
74.29
79.78
89.00
87.23
91.25
73.87
74.70
78.84
15.44
16.31
11.03
2.12
3.54
0.23
11.58
9.57
4.96
13.23
13.47
7.32
94.91
93.79
96.39
64.30
67.37
72.34
14.81
8.58
4.41
9.65
14.15
7.16
17.37
18.08
12.17
0.000
Between 1 and 3
0.000
Between 2 and 3
Between 1 and 3
0.029
Between 2 and 3
Between 2 and 3
0.000
Between 1 and 3
0.001
Between 2 and 3
Between 1 and 3
0.006
Between 2 and 3
Between 1 and 3
0.000
Between 2 and 3
Between 1 and 3
0.010
Between 2 and 3
Between 1 and 3
0.034
Between 2 and 3
Between 2 and 3
0.011
Between 1 and 3
0.000
Between 1 and 2
Between 1 and 3
Between 2 and 3
Between 1 and 2
Between 1 and 3
Between 2 and 3
Between 1 and 3
Between 2 and 3
0.000
0.000
Results of the repeated measures ANOVA with the core and
the module. The significant differences between measurements are indicated. Core questionnaire: PF: physical func.;
EF: emotional func.; CF: cognitive func.; QL global; FA: fatigue;
NV: nausea and vomiting; PA: pain; CO: constipation. Module
scales: BIMAGE: body image; ARM: arm symptoms; SYSTEM:
systemic ther.; BREAST: breast symptoms. Items: FUTURE: future perspective.
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local than in the metastatic group), and in the future perspective item (better in the local than in
the loco-regional group). The ANOVA results at
the time of the second assessment show that there are significant differences in body image (better in the local than in the metastatic group),
systemic therapy side effects (better in the local
than in the loco-regional group, and also better in
the local and loco-regional than in the metastatic
group), and breast symptoms (better at the initial
stages). In the ANOVA with the module at the time
of the third assessment, according to the stage of
the disease, there are differences in the arm
symptoms and systemic therapy side effects scales, with the metastatic group showing poorer
scores
than
the
local
and
loco-regional ones.
In the analysis with surgery as a grouping variable carried out at the first assessment of the subsample of patients in initial stages, there is a difference in the appetite loss item of the core
questionnaire, and a difference on the body image
scale of the module, with poorer scores in both
areas in the mastectomy group compared to the
quadrantectomy and lumpectomy patients.
The repeated ANOVA measurements show significant differences within the core questionnaire on
the cognitive functioning scale (with better scores at the third assessment than at the second),
and in six more scales and the domain of constipation (in all of these areas, scores are better at
the third assessment than at the other two). In
the module, there are significant differences on
the body image scale (better scores at the third
than at the second assessment), arm symptoms
(better scores at the third than at the other two
assessments, and also better scores at the second
than at the first), systemic therapy side effects
(better scores at the third than at the other two
assessments, and at the first than at the second),
breast symptoms (better scores at the third than
at the second and first assessments) and the future perspective item (better scores at the third
than at the first time of assessment) (table 5).
DISCUSSION
In this article we have presented the results of a
quality of life study carried out with a sample of
breast cancer patients in different stages of the
disease. In this study the quality of life scores
and the clinical variables indicate that the situation of these patients is generally satisfactory.
One aspect of this study that we wish to highlight
is the high degree of co-operation that we received from both the patients and professionals at
our hospital in carrying out this quality of life re-
search. We obtained a high degree of compliance
at all three assessments, which is significant if
we compare it with other quality of life studies.
This excellent compliance level may also have been a consequence of the relatively good physical
status of these patients, and the small amount of
changes that occurred in the proposed treatment
protocols.
In this study, the clinical and socio-demographic
data are representative of the situation of the
breast cancer patients in our setting. There is a
large proportion of patients in the early stages of
disease (local and loco-regional). This could well
be attributable to the Breast Cancer Screening
Process that is being carried out in our province,
Navarra.
The performance status data were high for all three assessments, the toxicity scores were moderate and the initial weight loss was low. These
data indicate that the physical functioning of the
patients was good throughout treatment. The quality of life questionnaires before treatment also
indicate that the status of these patients was good. The limitations in emotional functioning, sleep
disturbance and concern about the future could be
considered as normal. The low level of sexual
functioning may be a consequence of both disease
and treatment. At the second and third assessments, the quality of life scores were also good.
There were moderate limitations in areas related
to treatment side effects.
There are contrasts in most of the quality of life
dimensions assessed among patients at different
stages of disease. These differences may be due
to the fact that patients in each stage, besides having different characteristics of the disease, were also receiving different surgery and treatment
modalities. Among the quality of life dimensions,
there is a higher level of concern about the future
in the advanced stages since patients in this group
may be aware that their disease is progressive and
has a worse prognosis. A better body image in the
initial stages could be a consequence of these patients
more often receiving conservative surgery.
There are few differences in the analysis based
on surgery modality with the patients in early
stages of the disease, which focuses on body image.
Among
other reasons, this may be due to the high quality
of the surgery performed. These results are consistent with the outcomes of other studies revie13
wed by Kiebert and Kaasa , as outlined in the introduction, where agreement can be found about
differences between the different surgery modalities with respect to body image.
The results of the repeated ANOVA measurements
show that the quality of life of these patients is
105
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REV ONCOLOGÍA, VOLUMEN 3, NÚMERO 2, MARZO-ABRIL 2001
stable between the first and second time of assessment in most areas of the questionnaire and
the module, improves in some areas at the third,
and does not worsen in any area. These improvements at the third assessment may be a consequence of the termination of treatment and also of
patients becoming emotionally adapted to the disease. Treatments provoke specific detrimental
changes at the second time of assessment and a
moderate improvement at the third. These data
indicate that treatments are tolerated adequately.
We assume that there were no improvements between the first and second assessments since most
of the tumours were at an early stage, and patients initially had a high level of functioning, and
their disease had disappeared with surgery. There
is a progressive adaptation to surgery across all
three assessments, with better body image and
arm symptoms at the later assessments.
In conclusion, most patients’ disease was detected
at an early stage, probably due to the screening
process, and quality of life scores were generally
good at each assessment during the medical treatment. However, some reductions were noted at the
time of the second assessment, with scores on the
third (follow-up) occasion often being better than at
either the second or the first assessment. There
are contrasts in most of the quality of life dimen-
106
sions assessed among patients at different stages
of the disease. The only difference according to
surgical modality in the early stage patients was
that conservatively-treated (e.g. lumpectomy and
quadrandectomy) patients fared better than radically-treated (mastectomy) patients on body image.
Acknowledgements
This study has received the support of the Health Department of the Gobierno of Navarra. Grant numbe
42/97.
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