Quality of life (QOL) or specifically health-related quality of life is defined as breast cancer patients’ perception of their own physical, mental and social health that is influenced by diagnosis, treatment, post-treatment, and survivorship as assessed by using well validated instruments. Health-related quality of life is now considered an important endpoint in cancer clinical trials. Among the QOL studies in cancer patients, breast cancer has received most attention for several reasons. First, it is the most common cancer in women. As per GLOBOCAN 2018, almost two million cancer cases have been diagnosed worldwide. Secondly, in the past years, breast cancer prognosis has improved significantly over time, so increasing proportion of cured patients require dedicated strategies to manage long term sequelae with particular attention to quality of life.Thirdly, breast cancer affects women’s identity and therefore studying QOL for those who loose their breasts is vital.
The first paper on QOL in breast cancer patients was published in 1974 where advanced breast cancer patients receiving adrenalectomy with chemotherapy were assessed for their response and quality of life. The results showed that 64% of the patients returned to essentially normal living with the treatment . However, the publications related to QOL gained momentum two to three decades later. There are a number of review papers about QOL in breast cancer patients, concerning the symptoms related to cancer, psycho-social issues, treatment related factors etc. which we will be discussed in the following sections.
- Symptoms
Most common symptoms related to breast cancer and its treatment are fatigue, lymphedema, pain, and menopausal symptoms. A recent publication studying 1,588 breast cancer patients showed that fatigue (as measured by the EORTC QLQ-C30 fatigue subscale) was the most significant factor influencing quality of life and independently predicted longer recurrence-free survival.
- Psychological distress
Psychological distress is seen very commonly in women with breast cancer. The diagnosis of the disease, impairment of body image, alopecia, alteration of femininity, sexuality and attractiveness are factors that can cause unexpected psychological distress even years after diagnosis and treatment. It leads to depression, anxiety, and overall decline in QOL especially emotional functioning, social functioning and mental health. In some cases, overall survival is also affected and timely treatment of depression is helpful.
- Local treatment-surgery and radiation
Quality of life in breast cancer depends significantly on the type of surgery. The results of a 5-year prospective study indicated that patients undergoing mastectomy had a significantly worse body image, role and sexual functioning, and their lives were more disrupted as compared to patients who underwent breast preservation. However, both short-term and long-term distress levels may depend on patient’s age and type of adjuvant treatment given. The negative impact of breast cancer and its treatment was greater for younger women regardless of treatment type. Patients receiving either immediate vs delayed breast reconstruction experienced similar satisfaction and QOL after reconstruction. Only few studies have studied impact of QOL in breast cancer receiving radiation and it can be interpreted that improved local outcomes can have positive effect on overall quality of life.
- Systemic therapy
Adjuvant chemotherapy can have acute detrimental effects on many physical and psychosocial aspects of health related QOL with longer and more aggressive therapies causing worse and persistent effects. Nevertheless, most aspects of QOL recover rapidly after the end of chemotherapy, without long-term effects for the majority of patients. The studies also indicated that the current medical condition, amount of social support, and current income level were strong positive predictors of quality of life. Recent studies focusing on adjuvant hormonal therapies and QOL in postmenopausal breast cancer patients reported that overall QOL was improved in patients receiving hormonal therapy. Adverse events such as hot flushes were the most common, other side effects were vaginal dryness and discharge, dyspareunia, and arthralgia which vary in prevalence with the hormonal therapy.
5.Sexual Functioning
Sexual functioning is an important issue, especially in younger patients. About 60% of women usually report disruption in their sexual quality of life which is related to diagnosis at younger age, treatment with chemotherapy, emotional distress and psychosocial issues. It is argued that younger survivors may need interventions that specifically target their needs related to relationships, sexual functioning and body image
Conclusions
Overall QOL in terms of global health status in breast cancer patients has improved in recent years due to effective treatments and psychosocial counselling. However management of symptoms such as fatigue, pain , lymphedema, alopecia and sexual functioning in younger patients deserve further considerations. Long term sequalae of treatment and its related QOL need further attention in view of improved survival rates.
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