Quality of life in patients with breast cancer before and after diagnosis: an eighteen months follow-up study

This was a prospective study of quality of life in breast cancer patients. The study was conducted in Imam Khomeini hospital during a one complete calendar year. Imam Khomeini hospital is the biggest teaching hospital in Tehran, affiliated to Tehran University of Medical Sciences. Annually about 600 to 700 both newly diagnosed and follow-up breast cancer patients are treated in Imam hospital. Imam hospital is a referral centre for most cancer patients from Tehran and other provinces. Medical consultants identified newly suspected breast cancer patients from May 2002 to May 2003. All patients were interviewed at this baseline stage. At baseline both patients and the interviewer were blind to the final diagnosis. It was assumed that being blind to the final diagnosis would provide more precise information on quality of life data. Women with confirmed histological diagnosis of breast cancer were further followed-up. There were no restrictions on patient selection with regard to histology of breast cancer, disease stage and demographic characteristics. First follow-up was scheduled three months after initial treatment and the second assessment was made one year following completion of the treatment course (18 months after pre-diagnosis stage). The course of second follow-up was completed on December 2004. Patients with progression and the end-stage cases were not followed-up. Socio-demographic data included age, education and marital status. Clinical data consisting of disease stage and initial management were extracted from case records. The Iranian Center for Breast Cancer approved the study and all interviews were carried out with patients' permissions.

Quality of life was measured using the EORTC QLQ-C30 and its supplementary breast cancer questionnaire (QLQ-BR23). The EORTC QLQ-C30 is a well-known instrument for measuring quality of life in cancer patients and contains 30 items that measures five functional scales, global quality of life and several cancer related symptoms. The QLQ-BR23 is a specific questionnaire containing 23 items measuring functioning and symptoms related to breast cancer. The questionnaires were administered at three points in time: baseline, after initial treatment and one year after completion of treatment. The psychometric properties of the Iranian version of both questionnaires are well documented [10, 11].

Data were analyzed using SPSS-13 and restricted to the patients that their quality of life data were available. Normality of data were examined and although distributions were slightly skewed but all skewness values were less than one allowing us to perform repeated measure ANOVA to examine changes in quality of life measures across three points in time. The P value of equal or less than 0.01 was considered significant. For comparing categorical data, chi-squared was used.

In all, 316 suspected breast cancer patients were interviewed at baseline (pre-diagnosis stage). Of these, 167 patients with breast cancer were followed-up. The mean age of breast cancer patients was 47.2 (SD = 13.5) years; most were married (69.4%), and have had primary or secondary education (66.5%). According to case records the vast majority of the cases (82.6%) underwent mastectomy and the disease stage was as follows: 17.4% local, 45.5% loco-regional and 37.1% metastasis. The demographic and clinical characteristics of the sample at three points in time are shown in Table 1. At first follow-up 150 breast cancer patients were re-interviewed and the remaining 17 patients were excluded from the study. Of these 17 patients, 6 patients were refused to be re-interviewed, 1 was terminally ill, 8 were lost and 2 were dead.

At the second follow-up 99 patients were interviewed and the remaining 51 patients were excluded from the study. Reasons for attrition were: dislike (n = 25), loss to follow (n = 10) and death (n = 16). Analysis showed that women who completed the entire study differed on age and educational level from the sample that dropped out of the study.

Table 2 shows patients' functioning and global quality of life as measured by the EORTC QLQ-C30. Physical functioning improved over time while there was deterioration in most of the other functioning scales.

Physical functioning was increased by 5.8 point after 18 months follow-up, which could be regarded remarkable improvement. Global quality of life scores showed a fluctuated picture: 59.2 at baseline, 71.3 at 3-months follow-up and 32.0 at third assessment.

The analysis showed that in all measures there were statistically significant differences in patients' symptom scores (Table 3). Compared to the baseline and three months assessments, symptoms including fatigue, pain and dyspnea were increased at 18 months follow-up assessment.

Fatigue as the most disturbing disease- and treatment-related symptom was increased sharply both at 3-months assessment and 18-months follow-up: 17.0 at baseline, 31.0 at 3-months follow-up and 36.0 at 18 months follow-up. Also at 3 and 18 months follow-ups there were higher levels of financial difficulties than baseline (22.1 and 23.1 versus 17.7).

Breast cancer patients' quality of life scores as measured by the EORTC QLQ-BR23 are shown in Table 4. Except for future perspective, there were significant deteriorations in all other patients' functioning scores over time compared to the baseline assessment.

Decreased body image was observed at 3 and 18 months follow-ups (61.4 and 60.8 respectively) compared to the baseline assessment (86.2).

Comparing the baseline assessment, an increased level of arm symptoms was observed at 3 months follow-up (17.2) that continued to be persistent at 18 months follow-up (24.8).