Quality of Life And Chemotherapy
Diminished quality of life is what I witnessed at Cedars and Tarzana hospitals as well as testimony from patients
Quality of Life of Cancer Patients Treated with Chemotherapy
International Journal of
Environmental Research
and Public Health
Article
Quality of Life of Cancer Patients Treated
with Chemotherapy
Anna Lewandowska 1,* , Grzegorz Rudzki 2 , Tomasz Lewandowski 3, Michał Próchnicki 4,
Sławomir Rudzki 5, Barbara Laskowska 1 and Joanna Brudniak 1
1 Institute of Healthcare, State School of Technology and Economics in Jaroslaw, 37-500 Jaroslaw, Poland;
barbara.laskowska917@gmail.com (B.L.); awelc@poczta.fm (J.B.)
2 Chair and Department of Endocrinology, Medical University of Lublin, 20-090 Lublin, Poland;
grzegorz.rudzki@orange.pl
3 Institute of Technical Engineering, State School of Technology and Economics in Jaroslaw,
37-500 Jaroslaw, Poland; tom_lew@interia.pl
4 I Department of Psychiatry, Psychotherapy and Early Intervention, Medical University of Lublin,
20-439 Lublin, Poland; michal.prochnicki@umlub.pl
5 I Chair and Department of General and Transplant Surgery and Nutritional, Medical University of Lublin,
20-090 Lublin, Poland; slawomir.rudzki@umlub.pl
* Correspondence: am.lewandowska@poczta.fm; Tel.: +48-698757926
Received: 18 August 2020; Accepted: 17 September 2020; Published: 23 September 2020
Abstract: Background: Life-quality tests are the basis for assessing the condition of oncological patients.
They allow for obtaining valuable information from the patients regarding not only the symptoms
of disease and adverse e ects of the treatment but also assessment of the psychological, social and
spiritual aspects. Taking into account assessment of the quality of life made by the patient in the course
of disease has a positive e ect on the well-being of patients, their families and their caregivers as well
as on satisfaction with the interdisciplinary and holistic oncological care. Methods: Apopulation-based,
multi-area cross-sectional study was conducted among patients with cancer in the study in order
to assess their life quality. The method used in the study was a clinical interview. Quality of life
was measured using the EQ-5D-5L Quality of Life Questionnaire, the Karnofsky Performance Status,
our own symptom checklist, Edmonton Symptom Assessment and Visual Analogue Scale. Results:
In the subjective assessment of fitness, after using the Karnofsky fitness index, it was shown that
28% (95% CI (confidence interval): 27–30) of patients declared the ability to perform normal physical
activity. In the assessment the profile, quality of life and psychometric properties of EQ-5D-5L, it was
shown that patients had the most severe problems in terms of self-care (81%, 95% CI: 76–89) and
feeling anxious and depressed (63%, 95% CI: 60–68). Conclusions: Cancer undoubtedly has a negative
impact on the quality of life of patients, which is related to the disease process itself, the treatment
used and the duration of the disease.
Keywords: cancer; quality of life; chemotherapy
1. Introduction
Contemporary oncology focuses not only on pharmacological treatment but also on a fuller
understanding of the experiences of patients and their families, prioritizing the allocation of resources
and planning and providing holistic care that will measurably a ect the quality of life [1,2]. The quality
of life in cancer is a dynamic, multidimensional concept, referring to all life aspects and needs of the
patient, continuously assessing balancing processes between the real situation and the ideal situation
at a given time [3–5]. Quality of life is a subjective feeling, mostly determined by individual needs,
beliefs, values and attitudes; moreover, it is a value that changes over time [6]. An analysis of the
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Int. J. Environ. Res. Public Health 2020, 17, 6938 2 of 16
literature shows that cancer patients can have very di erent categories of needs. The disease is an
unpleasant experience to which every person reacts individually. Mental reactions related to disease
and the patient’s needs depend on personality traits and the patient’s understanding of their new
situation. The mental state of the patient changes with time, disease progression and treatment, and a
positive attitude plays an important role in the recovery process [7–9].
Quality of life is usually assessed subjectively by the patient, and if this is not possible, assessment
may be made by a doctor, nurse or caregiver. Life-quality tests are the basis for assessing the condition
of oncological patients. They allow for obtaining valuable information from the patients regarding
not only the symptoms of disease and adverse e ects of the treatment but also assessment of the
psychological, social and spiritual aspects. Taking into account assessment of the quality of life made by
the patient in the course of disease has a positive e ect on the well-being of patients, their families and
their caregivers as well as on satisfaction with the interdisciplinary and holistic oncological care [10–13].
Objective of the Work
The aim of the study was to assess the quality of life of cancer patients during oncological
chemotherapy treatment.
2. Data and Method
2.1. Study Design
A population-based, multi-area cross-sectional study was conducted among patients of the
Podkarpackie Oncology Centre, Clinical Provincial Hospital in Rzeszów in 2018–2020. Patients diagnosed
with cancer were invited to participate in the study in order to assess their life quality. Due to the small
sample size, it was important to include patients with fairly consistent characteristics.
Eligible patients were given an information package by their medical specialist, who was part of
the research group. The information package consisted of a letter that outlined the objectives of the
study and what participation would involve, a consent-to-contact form to be completed if patients were
interested in the study and a non-consent sheet. After informed consent was obtained, an interview
was conducted at the clinic by an interviewer who was part of the research group. The interview lasted
approximately 40 min. In the case of patient fatigue, the interview was divided into parts in order to
maintain the physical and mental comfort of the patients.
Participant Recruitment, and Inclusion and Exclusion Criteria
Eligible patients were identified from the department of oncology within three months of diagnosis.
Medical specialists who were part of the research group recruited patients for the study. The main
indicators of participation in the study were the diagnosis of cancer at least three months before the
study, life expectancy over 6 months, age over 18 years, chemotherapy treatment, no history of other
chronic diseases and awareness of the diagnosis. We recruited only patients with solid cancer since
patients with haematological malignancies tend to have a very di erent quality of life trajectory as
well as prognosis compared to those with solid tumours. We excluded from the study patients whose
cancer diagnosis was shorter than three months because the initial period of diagnosis and treatment is
associated with a huge psychological burden and the need to adapt to the new situation, which may
cause errors in the results. Patients who were too physically ill, too emotionally distressed, <18 years
of age or not literate in Polish were excluded. To avoid obtaining a very heterogeneous sample, we also
excluded those on hospice or home-based care or those taking only palliative care treatment for more
than 2 weeks.
After signing the informed consent form, information was obtained from patients regarding
their sociodemographic characteristics, family history of cancer, first symptoms attributable to cancer
perceived by the patient, symptom perception and reaction to early symptoms. At the same time,
patients were asked to complete the questionnaire concerning their health-related quality of life.
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Quality of life was measured using the EQ-5D-5L Quality of Life Questionnaire, the Karnofsky
Performance Status, our own symptom checklist, Edmonton Symptom Assessment and Visual
Analogue Scale. In the case of patients qualifying for curative surgical treatment, the initial interview
was performed in the month following discharge after surgery. Clinical records were also reviewed
to collect information about comorbidity at diagnosis, tumour characteristics at diagnosis, treatment
received, hospital consultations and exploratory procedures at follow-up.
2.2. Sample
The study included 800 patients, with 60%womenand 40%mendiagnosed with cancer, undergoing
chemotherapy treatment; 58% of rural residents and 42% of city residents participated in the study.
The average age of the patients was SD 54.52 (8.86) years. All patients were treated as intended by the
public health system.
Questionnaire for the Patient
The method used in the study was a clinical, direct, individual, structured interview, which was
in-depth and focused. The qualitative interview questionnaire was a standardized measuring
instrument and was verified by testing a group of 30 patients during the month. The questionnaire
has acceptable levels of internal consistency and test–retest reliability as well as construct validity.
It contained detailed and extensive instruction for the interview. The questionnaire was approved by
a clinical psychologist employed at the oncology clinic. It contained open-ended, single-choice and
multiple-choice questions, allowing to obtain recorded and epidemiological information as well as to
assess patient’s general condition, psychological, physical, everyday-life, sexual and spiritual needs,
as well as care needs.
2.3. Data on Quality of Life
Quality of life was measured using the EQ-5D-5L Quality of Life Questionnaire, the Karnofsky
Performance Status, our own symptom checklist, Edmonton Symptom Assessment and Visual
Analogue Scale.
The EQ-5D-5L Quality of Life Assessment questionnaire includes questions about walking ability,
self-care, daily activity, pain and discomfort, anxiety and depression. The questions relate to the day on
which the questionnaire was completed by the patient; one of 5 responses was selected for each scale.
The Karnofsky Performance Status (KPS) is a method for determining physical functioning
using a metric assessment of the degree of functional independence expressed as a single number.
This assessment is placed on a scale from 0 to 100: 0 meaning death to 100 meaning fully active. It is
assumed that higher scale values correspond to better fitness and a higher quality of life. The results
obtained with this scale in relation to oncological patients highly correlate with the survival time.
The symptom checklist is used to measure the impact of cancer treatment on the occurrence of
psychological and physical symptoms. The psychological factor includes the following symptoms:
nervousness, depression, diculty sleeping, anxiety and diculty concentrating. The physical factor
includes the following symptoms: loss of appetite, fatigue, nausea, pain and hair loss.
The Edmonton Symptom Assessment System (ESAS) is a simple, important and reliable tool
designed to assess the quality of life of cancer patients. It includes visual-analogue scales to assess
symptoms: pain, activity, nausea, anorexia, well-being, dyspnoea, depressed mood, anxiety, vomiting
and constipation. All items are scored on an 11-point scale, with 0 being no symptoms and 10 being
the highest severity of the symptom.
The Visual Analogue Scale (VAS) is a reliable tool used to measure the severity of pain. Cyclically
repeated measurements of pain intensity using the VAS scale enable the assessment of the e ectiveness
of analgesic treatment. The scale is a 10-cm ruler where 0 is no pain at all, 1–3 is mild pain, 4–6 is
moderate and 7–10 is severe.
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Ethical Considerations
The study was approved by the Bioethics Committee at the University of Rzeszów (Resolution No.
2017/12/4). Participation in the study was voluntary and anonymous, and respondents were informed
of their right to refuse or withdraw from the study at any time. Each participant was informed about
the purpose of the study and the time of completion of the study.
2.4. Data Analysis
All data obtained were collected and analysed with Prism 4.0 software. Descriptive statistics and
confidence intervals were used to analyse participant characteristics, demographics and prevalence of
needs. Statistical characteristics of continuous variables are presented in the form of arithmetic means,
standard deviations and medians. Statistical characteristics of step and qualitative variables were
presented in the form of numerical and percentage distributions. Cronbach’s composite scales and
the subscales were used to assess internal consistency. The relations between unmet needs and quality
of life were analysed using linear regression. The correlations were determined using the Pearson
test, while 2 was used for the comparison between the groups. Significance was assessed at the level
of p < 0.05. The repeatability of answers to individual questions was assessed using Kappa Cohen
statistics. Missing data were excluded from all analyses.
3. Results
3.1. Baseline Demographics
The study group consisted of 60% women and 40% men. The mean age of the respondents was SD
54.52 (8.86). The youngest person was 26 years old, and the oldest was 75 years old. Table 1 presents
other descriptive statistics identifying the studied group.
Of the respondents, 35% (95% CI: 32–39) declared they detected symptoms of cancer on their
own, 33% (95% CI: 29–37) had their symptoms detected by a doctor and 13% (95% CI: 10–19) declared
accidental detection of the disease. Prophylactic examinations contributed to detection of cancer in
19% (95% CI: 12–23) of the respondents. The reasons for visiting a doctor were nodules and lumps for
28% (95% CI: 22–31) of respondents, pain for 23% (95% CI: 20–29), a chronic weakness for 15% (95% CI:
12–19), bleeding for 20% (95% CI: 15–23) and increased temperature for 5%. Some patients declared
that they had not experienced any disturbing symptoms (15%, (95% CI: 12–19). According to the
results of a simple analysis of the level of a cancer diagnosis for the use of prophylactic examinations
and self-observation, there was a statistically significant relation to sex and education. Women and
better-educated people used prophylactic examinations more often and paid more attention to
disturbing symptoms (p = 0.05). Among the factors that may have contributed to disease, patients listed
successively genetic factors (70%, 95% CI: 68–73), smoking (51%, 95% CI: 46–59), improper diet (19%,
95% CI: 15–26) alcohol (17%, 95% CI: 15–24), chemical compounds (11%, 95% CI: 8–17), numerous
sexual relations (8%, 95% CI: 2–12), viruses (6%, 95% CI: 2–12) and bacteria (4%, 95% CI: 2–12).
During the assessment of occurrence of cancer in the families of the respondents, it was shown that
the most frequently indicated occurrence of cancer was breast cancer among subjects’ mothers (30%,
95% CI: 25–35), while among their fathers, it was lung (19%, 95% CI: 13–23) and colorectal cancer (15%,
95% CI: 13–23).
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Table 1. Descriptive statistics of the examined group of patients.
Demographic Data Total
N = 800
Sex
women (N/%) 480/60%
men (N/%) 320/40%
The Age of the Study Group
SD 54.53 (8.86)
95% CI <26; 75>
Place of Residence
city (N/%) 336/42%
village (N/%) 464/58%
Financial Situation
very good (N/%) 80/10%
good (N/%) 344/43%
average (N/%) 280/35%
bed (N/%) 96/12%
Age Groups
39–41 (N/%) 120/15%
42–52 (N/%) 200/25%
53–63 (N/%) 296/37%
64–75 (N/%) 184/23%
Education of the Study Group
higher education (N/%) 64/8%
secondary education (N/%) 264/33%
vocational education (N/%) 360/45%
primary education (N/%) 112/14%
Marital Status
married (N/%) 512/64%
widowed (N/%) 184/23%
unmarried (N/%) 104/13%
Source of Income
professionally active (N/%) 584/73%
annuity (N/%) 160/20%
retirement (N/%) 56/7%
Times of Illness
3–12 m. (N/%) 184/23%
1–2 y. (N/%) 136/17%
3–5 y. (N/%) 480/60%
Type of Cancer
breast (N/%) 240/30%
uterine (N/%) 192/24%
lung (N/%) 160/20%
colorectal (N/%) 160/20%
bone(N/%) 48/6%
Number of Chemotherapy Cycles
2 (N/%) 224/28%
3–5 (N/%) 344/43%
6 (N/%) 232/29%
3.1.1. Psychological Impact—Questionnaire and Wellbeing
Of the patients, 38% (95% CI: 32–39) reacted with shock to their diagnosis, 37% (95% CI: 32–39)
could not believe in the diagnosis, 22% (95% CI: 20–25) had a breakdown due to the received news
Int. J. Environ. Res. Public Health 2020, 17, 6938 6 of 16
and 3% (95% CI: 2–6) felt helpless; 48% (95% CI: 39–51) used the help of a psychologist during their
illness, and 10% (95% CI: 9–13) used the help of a psychiatrist. During the disease, patients received
support mostly from their closest relatives: spouse (62%, 95% CI: 59–69) and children (22%, 95% CI:
19–29). Support received from medical and nursing sta was appreciated by 17% (95% CI: 12–19) of
patients. According to the results of a simple analysis of the level of frequency of using professional
help and the support received, there was a statistically significant relation to the sex of the respondents.
Women significantly more often than men used the professional help of a psychologist or psychiatrist
and received support from their children. The di erences were statistically significant (p = 0.03).
The duration of disease did not significantly a ect feelings of sadness and depression in the studied
patients (p = 0.5). More than half of the respondents (65%) declared that they could cope with cancer,
and 42% (95% CI: 38–49) accepted the disease. The vast majority of respondents said that they were
motivated to fight the disease (57%, 95% CI: 51–60). Despite illness, 22% (95% CI: 18–27) of patients
declared enjoying life, 13% (95% CI: 10–17) had lowered self-esteem, 8% (95% CI: 3–9) felt guilt,
35% (95% CI: 32–39) felt anger, 12% (95% CI: 8–16) felt ashamed of cancer and 30% (95% CI: 28–39) felt
depressed. Almost half (47%, 95% CI: 42–49) of the respondents admitted to feeling more anxious.
The vast majority of respondents did not blame anybody for their illness. Patients who felt such
resentment named their doctor (12%, 95% CI: 8–15), family (3%, 95% CI: 1–6), themselves (3%, 95% CI:
1–6) and God (16%, 95% CI: 10–21). Most respondents (87%, 95% CI: 81–93) had positive thoughts
about their lives, but only 30% (95% CI: 28–36) of patients had plans for the future. As many as 48%
(95% CI: 42–51) feared for their future. According to the results of a simple analysis of the level of
frequency of coping with the disease and motivation to fight the disease, there was a statistically
significant relation to the sex of the respondents and the stage of the disease. Women more often than
men declared being motivated and coping with the disease. Patients su ering for more than 3 years
had less motivation to fight the disease and more often felt fear of the future. The di erences were
statistically significant (p = 0.01). In the course of statistical analyses, it was noticed that the duration
of disease significantly influenced assessment of the quality of life of the studied patients (p = 0.01),
as opposed to their age (p = 0.53). The duration of the disease did not significantly a ect feelings of
depression in the studied patients (p = 0.05).
3.1.2. Impact on Social Interactions
In the vast majority of respondents (37%, 95% CI: 31–42), relations with family did not change
due to the disease and they were good, and 15% (95% CI: 11–18) of respondents defined them as very
good and even better than before. Some patients claimed that it was the disease that made them closer
to their family and friends (15%, 95% CI: 8–19). On the other hand, growing distance from their family
a ected 20% (95% CI: 14–22) of respondents. For 13% (95% CI: 8–16), no changes within relationships
occurred. During the disease, relationships with partners changed for the better in 28% (95% CI: 18–30)
of patients, deteriorated in 23% (95% CI: 18–26) and remained unchanged in 49% (95% CI: 43–50).
The research showed that 46% (95% CI: 46–50) of surveyed patients limited social contacts due to cancer,
while 54% (95% CI: 53–55) of patients declared the opposite. When asked about the values important
to them before their illness, the patients mentioned family (90%, 95% CI: 88–92), health (72%, 95% CI:
70–73), work (67%, 95% CI: 65–70), money (47%, 95% CI: 44–49), respect (35%, 95% CI: 33–37) and trust
(27%, 95% CI: 26–29). Values that were important for the respondents during their illness were health
(87%, 95% CI: 86–89), family (57%, 95% CI: 55–59), money (17%, 95% CI: 16–19), trust (17%, 95% CI:
16–19) and respect (10%, 95% CI: 6–14). Relationships with family and friends were not significantly
related to the age, sex or the place of residence of the respondents, but the relation of the duration of
the disease to relationships with children was confirmed (p = 0.01).
3.1.3. Symptoms
When assessing well-being during treatment, the majority of patients (72%, 95% CI: 70–77) stated
that they felt well, while 28% (95% CI: 21–31) of patients declared that they felt unwell. Most of the
Int. J. Environ. Res. Public Health 2020, 17, 6938 7 of 16
patients (42%, 95% CI: 36–49) assessed their health as average, 37% (95% CI: 32–40) as good and 22%
(95% CI: 18–26) as poor; 28% (95% CI: 23–32) of patients experienced high stress related to the disease.
When asked if they felt attractive and satisfied with their appearance, the vast majority of patients
responded negatively (71%, 95% CI: 69–79). Only 40% (95% CI: 38–46) of patients used various forms
of improving their appearance. The vast majority of respondents (65%, 95% CI: 63–69) admitted that
they were not satisfied with their sex life. According to the results of a simple analysis of the level
of self-assessment of attractiveness and the use of various methods of improving one’s appearance,
there was a statistically significant relationship between the sex of the respondents and the duration of
illness. Women more often than men felt unattractive and more often used the opportunity to improve
their appearance. Patients who were ill for more than 3 years often felt unattractive. The di erences
were statistically significant (p = 0.03).
During assessment of the symptoms, the most frequently reported symptoms were fatigue, lack of
appetite, diculty sleeping, constipation and pain (Table 2). By assessing the severity of individual
ailments according to the ESAS scale, it was shown that the highest severity of symptoms was related
to constipation and fatigue. In assessing pain intensity on the VAS scale, the mean was 73% (95% CI:
69–75). The percentage of patients assessing their average pain in the last week as mild was 34% (95% CI:
30–36), as moderate was 56% (95% CI: 53–57) and as severe was 10% (95% CI: 8–12). Pain occurred
in 39% (95% CI: 33–42) of patients in one place, 31% (95% CI: 28–36) in two places and 30% (95% CI:
29–31) in three or more places. Pain was located in the back (28%, 95% CI: 21–33), abdomen (16%,
95% CI: 14–19), arms (11%, 95% CI: 6–19), hips (19%, 95% CI: 16–22), knees (9%, 95% CI: 6–12), chest
(18%, 95% CI: 16–19), feet (8%, 95% CI: 6–9), neck (7%, 95% CI: 6–9), and elbows or hands (9%, 95% CI:
6–10), and generalized pain occurred in 14% (95% CI: 8–16) of patients. According to the results of a
simple analysis of the frequency and type of ailments, there was a statistically significant relation to
the duration of illness. Patients su ering for more than 3 years more often experienced fatigue and
pain, while patients with a shorter history of illness more often experienced constipation and lack of
appetite. The di erences were statistically significant (p = 0.03). As disease progressed, the number of
symptoms reported by patients increased and their health assessment worsened. Using the Pearson
test, the relations between the following variables were checked: disease duration and the number
of reported symptoms (r = 0.08; M = 4.1), and disease duration and health self-assessment (r = 0.01).
The obtained values did not confirm the relationship between the adopted variables.
Table 2. Symptoms checklist.
Symptoms
Times of Illness
p
Sex
p
3–12 Months 1–2 Years 3–5 Years Women Men
Characteristics N/%
Fatigue 33/18% 41/30% 365/76% 0.03 107/22% 144/45% 0.02
Pain 61/33% 23/17% 288/60% 0.03 389/81% 234/73% 0.41
Change in skin condition 83/45% 54/40% 197/41% 0.88 168/35% 211/66% 0.01
Weight loss 64/35% 37/27% 125/26% 0.54 187/39% 122/38% 0.91
Loss of appetite 131/71% 34/25% 139/29% 0.03 346/72% 250/78% 0.88
Nausea 86/47% 35/26% 86/18% 0.35 216/45% 154/48% 0.54
Vomiting 86/47% 30/22% 82/17% 0.88 235/49% 186/58% 0.91
Constipation 120/65% 20/15% 120/25% 0.03 317/66% 195/61% 0.44
Diarrhea 46/25% 16/12% 96/20% 0.54 91/19% 58/18% 0.91
Abdominal pains 101/55% 29/21% 91/19% 0.55 235/49% 186/58% 0.55
Headaches 64/35% 20/15% 48/10% 0.88 91/19% 58/18% 0.91
Dizziness 57/31% 39/29% 86/18% 0.88 130/27% 106/33% 0.55
Loss of hair 156/85% 88/65% 216/45% 0.41 427/89% 282/88% 0.44
Depression 101/55% 44/32% 322/67% 0.54 139/29% 186/58% 0.91
Diculty sleeping 107/58% 23/17% 106/22% 0.54 91/19% 58/18% 0.71
Anxiety 105/57% 48/35% 331/69% 0.44 149/31% 154/48% 0.91
Diculty concentrating 15/8% 10/7% 106/22% 0.09 101/21% 93/29% 0.74
Fear for the future 53/29% 50/37% 379/79% 0.01 168/35% 243/76% 0.01
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3.1.4. Performance Status
In the subjective assessment of fitness, after using the Karnofsky fitness index, it was shown that
28% (95% CI: 27–30) of patients declared the ability to perform normal physical activity, 45% (95% CI:
43–47) were able to take care of themselves, 49% (95% CI: 48–50) required periodic assistance, and 13%
(95% CI: 8–16) required care and assistance (Table 3). Moreover, during the last month, 59% (95% CI:
58–60) of patients had to reduce their regular activity and 41% (95% CI: 38–45) reported that they were
unable to work for medical reasons. Patients with a shorter history of illness more often reported
incapacity to work (p = 0.01).
Table 3. The Karnofsky performance status.
Degree of
Eciency
Description
Duration of Illness p
3–12 Months 1–2 Years 3–5 Years Together
Characteristics N/%
100 Normal condition, no complaints or symptoms 10/5% 14/10% 24/5% 48/6% 0.41
90 State of normal activity, slight complaints and
symptoms of the disease 36/20% 34/25% 154/32% 224/28% 0.01
80 Almost active state (requires some e ort);
slight complaints and symptoms of the disease 2/1% 14/10% 48/10% 64/8% 0.41
70 State of inability to perform work or proper
activity, with the ability to self-service 40/22% 42/31% 278/58% 360/45% 0.01
60
Condition requiring periodic care,
while preserved the ability to independently
fulfill most of your daily needs
46/25% 49/31% 297/62% 392/49% 0.01
50 A condition that requires frequent care and
frequent medical interventions 10/5% 14/10% 48/10% 72/9% 0.41
40 State of failure and need for special care 2/1% 2/1% 100/21% 104/13% 0.41
30 State of severe insuciency, indications
for hospitalization 0/0% 0/0% 24/5% 24/3% 0.41
20 Serious illness, absolute necessity of
hospitalization and providing supportive care 0/0% 0/0% 24/5% 24/3% 0.41
10 The state of sudden increase in the threat to life 0/0% 0/0% 24/5% 24/3% 0.41
0 Death 0/0% 0/0% 0/0% 0/0% 0
No connection between the type of cancer of the subjects and the occurrence of restrictions in
everyday basic activities was confirmed. A strong correlation between the occurrence of restrictions in
everyday basic activities and the number of di erent chemotherapy cycles was confirmed (Table 4).
Table 4. Impact of physical ailments related to the disease on limitations in everyday basic activities.
Symptoms
Number of
Chemotherapy Cycles p
Type of Cancer
p
2 3–5 6 Breast Uterine Lung Colorectal Bone
Characteristics N/%
Impact of illness
symptoms on
restrictions in daily
activities
no limit 29/
13%
45/
13%
35/
15%
0.001
161/67% 165/86% 113/71% 122/76% 33/69%
partly 107/ 0.994
48%
265/
77%
172/
74% 58/24% 10/5% 29/18% 32/20% 11/23%
completely 88/
39%
34/
10%
25/
11% 21/9% 17/9% 18/11% 6/4% 4/8%
3.1.5. Impact of Duration of Disease
ESAS scores varied depending on the patient group in terms of activity, appetite and somnolence.
A measurement e ect was observed in all ESAS positions; somnolence worsened (p = 0.011) in patients
with longer illness and remained stable in patients with shorter disease history. Appetite improved
among patients who had been ill for a longer period compared to a shorter period (p = 0.025; p = 0.033).
Activity assessed by ESAS improved among patients with longer disease history (p < 0.0001).
When asked about their self-esteem and quality of life, the vast majority of patients assessed them
as average (67%, 95% CI: 64–69). In the assessment of the profile, quality of life and psychometric
Int. J. Environ. Res. Public Health 2020, 17, 6938 9 of 16
properties of EQ-5D-5L, it was shown that patients had the most severe problems in terms of self-care
(81%, 95% CI: 76–89) and feeling anxious and depressed (63%, 95% CI: 60–68). A lower percentage
of no problems in all 5 dimensions of EQ-5D-5L was found in patients with longer disease history.
The mean of a single EQ-5D-5L index was 0.65 (95% CI: 0.63–0.67). Sociodemographic characteristics
of the patients were negatively correlated with a single EQ-5D-5L index, while in patients with longer
disease history, a single EQ-5D-5L index was stable and significantly increased (Table 5). In the course
of statistical analyses, it was noticed that the duration of disease significantly influenced the assessment
of the quality of life of the studied patients (p = 0.01), as opposed to their age (p = 0.53).
Table 5. EQ-5D-5L profile of patients by di erent disease stages.
Duration of Illness 3–12 Months 1–2 Years 3–5 Years
Questionnaire EQ-5D-5L Characteristics N/%
Mobility
No problems 107/58% 73/54% 250/52%
Slight problems 37/20% 39/29% 129/27%
Moderate problems 27/15% 14/10% 43/9%
Severe problems 10/5% 7/5% 29/6%
Unable to walk about 3/2% 3/2% 29/6%
Self-Care
No problems 164/89% 109/80% 360/75%
Slight problems 13/7% 16/12% 58/12%
Moderate problems 2/1% 6/4% 24/5%
Severe problems 3/2% 4/3% 14/3%
Unable to wash or dress
myself 2/1% 1/1% 24/5%
Usual Activities
No problems 138/75% 87/64% 293/61%
Slight problems 30/16% 31/23% 100/21%
Moderate problems 8/4% 10/7% 29/6%
Severe problems 5/3% 4/3% 24/5%
Unable to do 3/2% 4/3% 34/7%
Pain/Discomfort
No problems 103/56% 50/37% 202/42%
Slight problems 60/33% 63/47% 182/38%
Moderate problems 8/4% 14/10% 48/10%
Severe problems 10/5% 6/4% 24/5%
Extreme pain 3/2% 3/2% 24/5%
Anxiety/Depression47
Not anxious or depressed 70/38% 31/23% 139/29%
Slightly 71/39% 60/44% 197/41%
Moderately 25/14% 25/19% 72/15%
Slightly 10/5% 14/10% 38/8%
Extremely 8/4% 6/4% 34/7%
A strong correlation was found between quality of life and number of chemotherapy cycles.
Nevertheless, a significant di erence was found between the levels of quality of life in patients with
2 cycles and/or with 3–5 cycles (p < 0.001). It was also the case for the level of quality of life in patients
with 6 cycles (p < 0.001) (Table 6).
Int. J. Environ. Res. Public Health 2020, 17, 6938 10 of 16
Table 6. Impact of the number of chemotherapy cycles on the quality of life.
Number of
Chemotherapy Cycles
Quality of Life
Non-Favourable Fairly Favourable Favourable p
Characteristics N/%
2 36/16% 150/67% 38/17% 0.001
3–5 34/10% 265/77% 45/13% 0.001
6 19/8% 116/50% 97/42% 0.001
4. Discussion
TheWorld Health Organization defines quality of life as an individual’s perception of their position
in life, in the context of their value systems and culture and concerning their goals, expectations and
interests [14–16]. According to Siegrist and Jung, quality of life includes three closely related elements:
physical indicators, mental determinants and social indicators. The quality of life of a specific person is
always related to aspects that are significantly important to them [17,18]. Assessment of the quality
of life of cancer patients takes up more and more space in the literature or discussions of specialists;
moreover, it is becoming a standard. It is related to an individual, subjective approach to the patient
and allows for the assessment of the impact of disease and treatment on functioning of the patient and
their relatives in terms of physical, mental and social well-being. The purposefulness of measuring the
quality of life in cancer patients was demonstrated by Montazieri, who stated that the global quality
of life of patients before starting oncological treatment is an important predictor of survival [19–21].
Similarly, Li et al., based on a sample of over 400 cancer patients, presented results proving that
health-related quality of life is a strong and independent predictor of overall survival [22]. As reported
by Smyth EN and Jacob J., patients with advanced cancer often experience low quality of life caused by
their illness and side e ects of treatment. Health-related quality of life is a multifaceted well-being
concept and is considered a priority area by oncologists [23,24].
As demonstrated by numerous studies, quality of life parameters deteriorate as a result of cancer
diagnosis. Diagnosis of neoplastic disease usually causes severe anxiety, a sense of danger and
insecurity, and often depression. These reactions stem from the social perception of cancer as a painful
disease that is inevitably fatal [16,20]. The research carried out for this study shows that shock was a
reaction to news about the disease in 38% of patients while 22% experienced a breakdown. The disease
caused anger in 35% of patients, shame in 12% and depression in 30%. As many as 48% of respondents
felt fear for their future. Similar results were obtained by Dehkordi et al., who showed that the
most common problems among cancer patients treated with chemotherapy were fear of the future
(29%), thinking about the disease and its consequences (26.5%), impatience (24%) and depression
(17.5%) [25]. A study by NayakMGet al., including a number of participants very similar to the number
of subjects in our own research, showed that the mental well-being of the respondents influenced
feelings of significant depression among 54.4% of participants and that the majority (98.3%) did not
feel comfortable taking part in social life. Most of the patients feared disease recurrence (76.2%) and
disability (62.1%) [26]. A comprehensive study of a US oncology centre involving nearly 4500 patients
aged 19 years and older showed high rates of psychological symptoms that met the criteria for clinical
diagnoses such as depression, adaptive disorders and anxiety, which was confirmed by subsequent
studies by other scientists [27–29]. According to Charmaz and Stanton et al., chronic illness can cause
guilt, loss of control, anger, sadness and confusion. Patients may also experience more general worries,
such as fear of the future, inability to plan, and fear of changing sexual functions and changing role in
the family [30,31]. In the studies by Mziray and Z˙ uralska, all oncological patients experienced anxiety
and the largest group of patients (45.8%) had moderate anxiety, all patients studied by the author and
her team showed symptoms of depression and 45.8% had moderate depression [32]. The research of
K˛edra and Wi´sniewski also showed that almost half (45.71%) of the respondents felt more anxious,
sad and depressed [33]. Modli´nska et al. showed that the anxiety response to cancer significantly
Int. J. Environ. Res. Public Health 2020, 17, 6938 11 of 16
a ects the quality of life of terminally ill patients under 65 years of age, and it is known that, in older
patients, problems related to everyday existence play the most important role [34]. Mood disorders are
associated with a reduction in the quality of life of cancer patients, which has been demonstrated in
numerous studies on these issues [35,36]. It is assumed that the prevalence of these abnormalities in
the population of oncological patients is around 40% [20].
An extremely important aspect of the quality of life of cancer patients is the impact of the disease
on their marital, family and social relations as well as on received support. The authors’ own research
showed that, for the vast majority of respondents (37%), relations with their families and friends were
not changed by the disease and remained satisfying while relations with their partners changed for the
better in 28% of patients. During their illness, patients received support mostly from their spouses
(62%). Gangane N. et al. obtained a very similar result using the same research tool and demonstrated
that the lack of a partner was negatively related to quality of life, mental health and social relations [37].
Completely di erent results were obtained by Jacob J. et al.—in this research, unmarried patients
reported higher social/family well-being compared to married patients and married women reported
lower social/family well-being than unmarried women [24]. Unfortunately, as shown by the results of
studies by Nayak MG et al., as many as 92.7% of oncological patients undergoing chemotherapy did
not receive any support from friends and relatives [26].
Quality of life largely depends on the state of health, i.e., the impact of disease and treatment
on the patient’s physical functioning. Cancer has a versatile impact on the lives of those a ected,
especially during chemotherapy treatment. It causes a decrease in the patient’s physical activity and
influences a change in the appearance and a loss of the sense of attractiveness, which in turn reduces
patient’s self-esteem [33]. Many authors emphasize the dependence of the quality of life of cancer
patients on the applied anticancer therapy. In the study by Słowik-Gabryelska [38], in more than half
of patients with primary lung cancer, it was observed that the side e ects of chemotherapy decreased
overall performance and had a negative impact on quality of life. A significant relation between quality
of life and line of treatment is also reported. Along with the next line of chemotherapy, the quality of
life of the studied patients deteriorated significantly [39]. The conclusions of Zieli ´nska-Wi˛eczkowska B.
from the study conducted using the EORTC QLQ-C30 questionnaire are very interesting, showing
that treatment with cytostatics reduces the quality of life of patients but to an extent that is not
statistically significant [40]. In the author’s own research, the vast majority of patients assessed
their self-esteem and quality of life as average. The assessment of the profile, quality of life and
psychometric properties of EQ-5D-5L showed that the patients had the most severe problems in terms
of self-care and feeling anxious and depressed. The result is comparable to the study conducted
by Adamowicz K. and Waliszewska Z., and the similarity may result from the study design and
the tool used. After 6 months of therapy, the majority of respondents (66%) stated that they did
not feel tired and 23% of respondents felt a clear lack of energy. Patients most often complained
of weakness (80%). Many patients reported nausea and vomiting (60%). Among the limitations in
everyday life resulting from treatment, the majority of patients (58%) indicated inability to continue
working. The vast majority of respondents (88%) described their health condition as bad, and the
disease limited the social activity of 70% of patients. In the study population, the mean general
quality of life before treatment was 60.92 and, after treatment, was 58.20 [41]. The results of this study
are supported by Gandhi et al. [42], who conducted a cohort study of 100 patients su ering from
multiple symptoms such as pain, insomnia, loss of appetite and fatigue. These symptoms adversely
a ected the normal functioning of the patients. Emotional functioning deteriorated in 50% of patients,
and physical functioning deteriorated in nearly 23% of the remaining 50% of the population. A study
by Kannan et al. also showed that the overall mean Quality of Life (QoL) result of the study population
was 122.38 13.86, and the mean of approximately 80% of the population was below the mean QoL [37].
Similar results were observed in the study by Nayak MG et al. [26]. The results of other scientific
studies also show a significant reduction in QoL due to typical symptoms resulting from cancer [43–45].
Int. J. Environ. Res. Public Health 2020, 17, 6938 12 of 16
Many authors have reported that treatment side e ects a ect a patient’s QoL depending on individual
circumstances, type of cancer and its treatment [26].
Out of the somatic ailments that significantly modify the quality of life of oncological patients,
fatigue is the most emphasized in literature. Many researchers analysing the quality of life of cancer
patients undergoing anticancer therapy emphasize the prevalence of this symptom in the studied
patients. Currently, it is believed that fatigue is the most frequently reported symptom of cancer and
the therapy used; it a ects approximately 80% of cancer patients and 70% of those treated. It appears
often before diagnosis, very often as an initial symptom of the disease, and its severity does not
decrease even after rest. Chronic cancer fatigue may persist for months or even years after the end of
cancer treatment [16]. In the studies by Kieszkowska-Grudny A. et al., symptoms of chronic fatigue
were reported by the vast majority of respondents (72%) [46], according to Kapela et al., by 51%
of patients [16]. Similarly, studies by Smets EMA et al. showed that, among half of the patients
treated, oncological fatigue lasted up to 3 months after the end of therapy and, in 20%, it was of high
intensity [47]. The results of this study also indicate that fatigue is the most troublesome symptom of
cancer, which is declared by more than half of the surveyed patients (76%). The other most burdensome
symptoms mentioned by the patients were lack of appetite (71%), diculty sleeping (38%) and
constipation (65%). This is confirmed by the studies by Kapela et al., which showed that other ailments
reported by the respondents were nausea (20.7%), pain (20.7%) and lack of appetite (16.3%) [16].
Sleep disorders are confirmed by the studies by Kaczmarek-Borowska B. [48], Zieli ´nska-Wi˛eczkowska
B. [40] and Nowicki A. [49]. A significant modifier of quality of life is pain experienced by patients,
which is confirmed by our own research and by Thielking PD [50] andWool MS, Mor V. [51]. According
to the research of Kroenke K, et al., of 405 participants, 24% experienced only pain and 44% experienced
both depression and pain [52]. Research by Nayak MG et al., conducted with the use of similar tools
and a similar sample, showed that the low physical well-being of the respondents was influenced
by pain (72.9%), sleep problems (71.7%) and fatigue (91.8%) [26]. Data from the National Health
Interview Survey (NHIS) show that cancer at least doubles the probability of ill health and disability [1].
Physical impairments and disabilities as well as the fatigue and pain experienced by cancer patients
often lead to an inability to perform routine activities of everyday life. According to the research of
Yabro et al. in the United States, adults with an early diagnosis of cancer report the need for help
with daily activities more often than people of similar age, sex and level of education without such
diagnosis [53]. The data of the National Health Interview Survey show that people who survived cancer
without any other chronic disease reported twice as often a reduced ability to perform daily activities
than people without a history of cancer or another chronic disease [54]. In the author’s research,
the subjective assessment of fitness showed that 32% requires periodic help and 10% requires care
and assistance. Moreover, during the last month, 59% of patients had to reduce their regular activity
and 41% reported that they were unable to work for medical reasons. As shown by numerous studies,
in addition to deterioration in the quality of life and functional status, physical discomfort, especially
pain, is the most common cause of decreased work performance and causes a significant degree of
total disability [55]. In the studies by Kroenke K. et al., patients reported more than 60% of days in
bed or a significant reduction in activity and a health-related unemployment rate of 43% [52]. Also,
the meta-analysis by de Boer A. et al. showed that the unemployment rate in cancer patients is more
than twice as high as in the control group (34% vs. 15%) [56]. Very interesting results were obtained
by Jacob J. et al., who used very similar research tools and showed that patients with higher results
of financial diculties reported worse functional well-being, worse emotional well-being, a lower
subscale of spiritual well-being and higher symptoms of anxiety and depression [24]. A review of the
study results clearly shows that, with time, the quality of life of patients gradually deteriorates [57,58].
A regression in occupational functioning was observed, and it persisted even after the end of treatment.
Restriction in taking up professional activity in cancer patients lowered their quality of life [59].
In summary, the quality of life of patients treated with chemotherapy deteriorates, especially
due to su ering, sadness, anxiety, lack of vital energy, fear of treatment and accompanying physical
Int. J. Environ. Res. Public Health 2020, 17, 6938 13 of 16
ailments. Patients struggle with emotional, social and personal problems and very often have to accept
changes in their appearance. The results of this study showed that there was no correlation between
the quality of life and age, gender, social status, marriage and work. Similar results have been reported
by Vedat et al. and Rustøen. Moreover, a correlation was found between the degree of disease and
quality of life. Also, Rustøen and Holzner in two separate studies found that quality of life was related
to time, noting a decrease in the quality of life of cancer patients with an increase in the extent of the
disease [16,60].
Our qualitative study included patients with di erent types of cancer. These points make our
results transferable to other cancer contexts. However, there are some limitations to consider. Firstly,
the study was conducted in Poland and our results need to be cautiously transferred elsewhere,
as oncological care in Poland is highly dependent on the organization of the medical system and the
economy of the country. Secondly, we recruited patients diagnosed during the past 5 years. We took
sucient time to assist the patients and patient advocates in recalling their long-term memory and to
minimize the e ect of recall bias. The sample was too small for subgroup analysis. Our study should
be interpreted as exploratory because there are no reliable data available.
5. Conclusions
1. Cancer undoubtedly has a negative impact on the quality of life of patients, which is related to
the disease process itself, the treatment used and the duration of the disease. The necessity of
frequent hospitalizations, negative emotions and numerous somatic ailments that change over
time significantly reduce the quality of life of cancer patients.
2. Somatic symptoms accompany patients at every stage of the disease and are associated with
increased disability and reduced quality of life. The factors that significantly influence the
occurrence of symptoms depend on the phase of the disease, the cycles of chemotherapy and the
duration of the disease.
3. To achieve the best possible quality of life despite disease, it is important to regularly assess
the quality of life of patients to quickly assess the problems of each sphere of life, which will
enable the identification of high-risk patients and allow for early intervention depending on the
identified needs or deficits. Undetected and untreated disorders threaten the results of cancer
therapies, reduce the quality of life of patients and increase healthcare costs.
Author Contributions: Conceptualization, S.R., M.P. and J.B.; data curation, A.L., S.R., B.L. and J.B.; formal
analysis, G.R. and T.L.; funding acquisition, S.R.; investigation, B.L.; methodology, A.L., G.R., M.P. and T.L.;
project administration, A.L., G.R., T.L. and J.B.; resources, B.L.; software, G.R. and T.L.; supervision, G.R. and T.L.;
validation, S.R.; visualization, G.R. and T.L.; writing—original draft, A.L.; writing—review and editing, A.L. and
S.R. All authors have read and agreed to the published version of the manuscript.
Funding: This study was supported by our own resources.
Acknowledgments: We are thankful to all the participants in this study. The authors also thank the regional
authorities and hospital managements for permission, cooperation, contributions and logistic support during
data collection.
Conflicts of Interest: There are no aliations that may result in a conflict of interest. Implementation of this
research was from our own funds; no organization’s subsidy was used.
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