Quality of life and factors affecting it in adult cancer patients undergoing cancer chemotherapy in a tertiary care hospital

Abstract Background Cancer is the second most common cause of deaths worldwide. Likewise, in India, it is a major health problem, and disease burden is escalating every year. Cancer chemotherapy produces unfavorable effects on the well‐being of an individual. Since the past few years, quality of life (QoL) is considered as the main goal of cancer treatment in the survival of a patient. Aim This current study aimed to assess the QoL and factors affecting it in adult cancer patients undergoing chemotherapy treatment. Methods and Results An analytical, cross‐sectional study was conducted to achieve the objectives, employing the consecutive sampling method. A total of 120 adult (>19 years) patients were recruited from daycare chemotherapy unit of a tertiary care hospital. The data were collected using patient record form and Functional Assessment of Cancer Therapy‐General (FACT‐G), a quality of life (QoL) questionnaire. The overall mean score of quality of life (QoL) was 61.933 ± 5.85502. The domains of functional well‐being and emotional well‐being were most negatively affected after cancer chemotherapy. Education (illiteracy) and occupation (unemployment) were negatively associated with overall quality of life (QoL) of cancer patients on chemotherapy. Adverse drug reactions due to cancer chemotherapy negatively affect the quality of life (QoL) of cancer patients. Education (illiteracy) affects social well‐being domain of cancer patients. Working in the government/private sector has a positive impact on functional well‐being domain of quality of life (QoL). Conclusion The study findings suggest an overall low quality of life (QoL) among adult cancer patients undergoing chemotherapy at our setup. It has been identified as a stressful therapy, also affecting both psychological and physical well‐being. Poor infrastructure, illiteracy, poverty, and lack of proper treatment facilities at most centres often lead to poor survival outcomes and hence focus has always been on achieving quantity of life rather than quality of life (QoL). This is further complicated due to nonavailability of validated tools in local vernacular, apathy of the treating physicians in the context of QoL aspects and social and cultural factors that are unique to this society. Psycho‐oncology needs to become an integral entity of comprehensive cancer care.


| INTRODUCTION
Worldwide, deaths due to malignancy are the second common leading cause of mortality. Globally, about one in six deaths is due to malignancy. Roughly, 70% of fatality from cancers occur in low-and middle-income countries. 1 Cancer mortality in India has increased twofold from 1990 to 2016. 2  This signifies, on the one hand, that prospectively only by large-scale multicentre trials and retrospectively only by meta-analyses of commensurate trials can adequate numbers of patients be reached to allow a detection of treatment benefits of a pragmatic size. On the other hand, if treatments do not differ much with respect to survival, it is a reasonable step forward to stretch out the classical criteria of assessing treatment efficacy.
It is undisputed that the disease and its treatment have a bearing on all aspects of a cancer patient's life. Although physicians had previously recorded the occurrence of toxic reactions possibly induced by cancer treatment, it was not until the 1940s that with their pioneering work, Karnofsky et al (1948) 4 made a first attempt to quantify the performance status of patients with advanced cancer. In the ensuing decades, there has been increasing recognition of the need to achieve a more comprehensive evaluation of treatment efficacy over and above the objective facets of achieving optimal survival, maximal tumor response, and minimal toxicity (Maguire & Selby, 1989). 5 In attempting to reach this target, additional end points in cancer clinical trials were initiated that embrace the subjective response of the patients to their illness and its treatment. The sum of aspects of the patients' subjective well-being is most often called "quality of life"(QoL) (eg, Tchekmedyian & Cella, 1990). 6 Although each individual usually has an instinctive comprehension of what quality of life implies for him or her, no general and unique definition of QoL is deemed as conceivable or even sensible. Cella and Tulsky (in Tchekmedyian & Cella, 1990) 6 honestly confess that "QoL cannot be validly measured because it means so many different things to so many different people." This is particularly valid for the remarkable life situation of persons who have faced the often lifethreatening detection of cancer.
Instead of trying to garnish an analytical definition, QoL is initiated into clinical research by means of a so-called operational construct, recognizing that an individual's life and its matching quality cannot be quantified in an objective way. Instead, and rather pragmatically, a patient's QoL is quantified using measurements obtained from a set of sensibly defined, quantifiable dimensions. The major points of settlement among QoL researchers on this construct can be epitomized by the statements that QoL is: 1. Multidimensional: encompassing important elements of a patient's emotional, social, and physical well-being; 2. Subjective: depending on primarily on the patient's own judgments; and 3. Nonstatic: and subject to transitions over a patient's lifetime.
Point 1 leads to the requirement that QoL has to be dissected into its major aspects, each of which can be sufficiently concretized for an evaluation in patients. A suitable measuring instrument should account for the multidimensionality of QoL by satisfactorily embracing all the major dimensions. The second point of the QoL construct seems rather obvious, but it has taken some time to become established that, whenever possible, the individual patient is the principal authority to be asked about his/her QoL. Physician's assessment of the patients' QoL, which was widely resorted to when QoL methodology was introduced, has proved to be less trustworthy when used exclusively (Slevin et al, 1988;Regan et al, 1991). 7,8 It is irrefutable that a detailed interview is the most suited approach to inclusively evaluate an individual's well-being. However, the most workable form of a measuring instrument in the background of multicenter trials is the self-administered questionnaire. A good questionnaire is distinguished by having in it certain so-called "psychometric" standards like validity (measuring what is intended to be measured), reliability (measuring with sufficient precision), and sensitivity (ability to detect changes). The last is important especially in the light of point 3 of the QoL construct. A person's QoL is subject to transitions over time, evincing, for example, the patient's competency to cope with the disease or the experiences with varied treatment modalities. Therefore, a requisite evaluation of QoL is imperative at more than two points in time to be able to evaluate both short-and long-term effects of treatments.
Because of the need to setup and use valid and reliable measuring instruments, the endorsement of any preexisting validated questionnaires should be selected over the development of new ad hoc questionnaires.
If one feels that important specific aspects are absent in a specific questionnaire, it is in most cases possible to append ancillary components to the existing measuring instrument without altering its original structure. 9 The term quality of life (QoL) is used to assess the general well- illness-related factors exist that can affect QoL. The extent of distress symptoms experienced by a person has been related to QoL in many people with cancer. QoL is more and more being utilized as essential outcome measures in studies to decide the efficacy of treatment. 10,11 All domains of an individual's QoL can be affected by malignancy.
The deterioration in the QoL kicks off following diagnosis of the malignancy and lingers due to the vigorous nature of the treatment.
Cancer patients receive chemotherapy to fight against the affliction.
Out of 65% of the cancer population, chemotherapy is being used as the first line of management in 25% of patients. 12  QoL. 16 In a study by Elsaie et al (2012), it was found that there was a significant decrease in functional well-being of colorectal cancer patients after chemotherapy. 17 D'souza et al (2013) conducted a study on head and neck cancer patients and concluded that physical, psychological, and functional domains are affected. 18 In a crosssectional study conducted by Jacob et al (2019) in India, lower-income status had a positive association with decreased physical, social, and psychological well-being. 19 A cross-sectional study on breast cancer patients in India showed overall QoL to be good except for sexual function. 20 Most of the QoL studies have been conducted only in the southern and eastern region of India. There are very few notable studies about QoL research in North India. A study by Sharma et al(2017) in Delhi concluded that there is association between clinical, sociodemographic characteristics, and QoL of breast cancer patients. 21 Another study by Barwal et al (2016) in North India concluded that there is a decline in the global QoL and social functioning in lung cancer patients following treatment. 22 Uttarakhand is now recognized as India's "cancer bowl" with rising cancer burden leading to additional noncommunicable disease load. This is one of the states which has high crude cancer incidence rates (91.0 per 1,00000) in 2016 according to India State-Level Disease Burden Initiative. 23 There are various cultural, ethnic diversities existing among different regions of India. Uttarakhand and its associated hilly areas have a varied diverse heterogeneous population. A study by Mason et al (2019) showed that 39% of cancer patients had psychological distress, and prevalence was higher in female patients and old-age patients. 24 Another study by Pruthi et al (2018) showed that emotional well-being was affected negatively after chemotherapy in surgically resected gastric cancer patients. QoL is the least explored dimension in this part of the country which has a high disease burden. 25 Hence, this study was conducted to explore the QoL of adult cancer patients on chemotherapy in the hilly Himalayan region of the northern part of India.

| Purpose
To determine the overall QoL and factors affecting it in adult cancer patients undergoing cancer chemotherapy in Uttarakhand region.

| Research design
This was a cross-sectional, analytical study.

| Research questions
What was the general level of QoL in physical, social, emotional, and functional domains in adult cancer patients?
What were the factors that affect QoL in adult cancer patients?  The original FACT-G tool is in English, and a translated version in Hindi is also available. The Hindi translation of the questionnaire has been validated in Indian cancer patients by Singh. 28 Prior permission was obtained from FACIT organization, and the validated Hindi translated tool was administered to the cancer patients. Descriptive statistics, frequencies, percentages, and means were used to represent the data in connection with the sociodemographic profile, clinical characteristics of patients, and FACT-G QoL scores. Oneway analysis of variance (comparison of means of three or more groups) was used to compare the mean QoL scores for several demographic and cancer treatment-related variables. P < .05 was considered to be statistically significant.

| Factors affecting the quality of life
A comparison of FACT-G overall QoL score and its subscale mean scores for some variables about demographic features and cancer treatment was done. The overall FACT-G mean QoL score for illiterate patients was significantly low (P = .009) and also for those who were engaged in agriculture/business (P = .04). No significant differences were found when FACT-G overall mean QoL scores were compared in terms of age, income status, type of cancer, number of ADRs, and stage of the disease ( Table 5).
The physical well-being score of patients who have more number of ADRs was found to be significantly low (P = .018) ( Table 5). The social well-being mean scores of patients who never went to school (illiterate) were found to be significantly low (P = .033) ( Table 5). The emotional well-being mean scores of the patients who have more ADRs were significantly low (P = .000) ( Table 5). The functional wellbeing subscale mean scores for patients who were engaged in agriculture/business were significantly low (P = .04) ( Table 5).

| DISCUSSION
The present study reveals a mean score of QoL as 61.93 which represents low QoL among adult patients undergoing cancer chemotherapy.
Upon comparison with US patient sample, patients in our sample reported lower functional, physical, emotional, and social well-being. This disparity in wellness scores may be explained by the availability of wellresourced allied health facilities in high-income countries and the relative lack of these facilities in our study setting and Indian public health context in India. The mean QoL score on our study is lesser when compared to other studies conducted in India. 19,30 The low QoL is attributed to the patient population who presented to the hospital with advanced stage of the disease. 31 Forty seven patients were diagnosed with stage 2 of the disease and 56 patients with stage 3 and 4 of the disease. Eighty two percentage of population in Uttarakhand belongs to Hindu religion, and they have spiritual concerns which are linked to poor psychosocial health and poorer QoL. 32 The accessability to healthcare system in Uttarkhand is also a reason for low QoL because of the shortage of physicians in remote and farflung hilly areas. 33 T A B L E 1 Distribution of demographic, disease, and treatment variables (n = 120) The second most affected QoL domain in our study was emotional well-being with a mean score of 14.50. Our findings are consistent with a study conducted on Indian cancer patients. 19   In North India, very few studies have been undertaken to focus on QoL concerns of cancer subjects. Poor infrastructure, illiteracy, poverty, and lack of proper treatment facilities at most centres often lead to poor survival outcomes, and hence focus has always been on achieving quantity of life rather than quality of life (QoL). This is further complicated due to nonavailability of validated tools in local vernacular, apathy of the treating physicians in the context of QoL aspects and social and cultural factors that are unique to this society. Psycho-oncology needs to become an integral entity of comprehensive cancer care. 54,55 Therefore, the results of our study are intended to inform and motivate healthcare workers and investigators for undertaking further analysis and outlining effective patient care plans to enhance QoL.

| LIMITATIONS
The modest sample size is a limitation of this study. The modest sample size might have caused some uncertainty during subgroup analysis.
Longitudinal studies are underway to provide a clearer picture of QoL in patients undergoing anticancer therapy in North India.

| CONCLUSIONS
The findings of the present study indicate low QoL among cancer patients on anticancer therapy. Functional well-being was most affected in cancer patients followed by emotional well-being among cancer patients on anticancer therapy. From our study, it was found that the overall QoL of patients was influenced by education and occupational status of the patient. Unemployed and illiterate patients have worser QoL than employed and educated patients.
Chemotherapy-induced ADRs affect the physical well-being as well as the emotional well-being of patients. It is imperative to initiate assuasive programs for patients on cancer chemotherapy in order to mollify their physical and emotional sufferings and consequently improving the QoL. p<0.01, *** p<0.001, 'D' indicates the group(s) that significantly differ.