Assessment of quality of life (QOL) in cancer patients attending oncology unit of a Teaching Hospital in Bangladesh

Abstract Background The quality of life (QoL) of a cancer patient is their perception of their physical, functional, psychological, and social well‐being. QoL is one of the most important factors to consider when treating someone with cancer and during follow‐up. The aim of this study was to understand the state of QoL among cancer patients in Bangladesh and to determine the factors that affect it. Methods This cross‐sectional study was conducted on 210 cancer patients who attended the oncology unit of Delta Medical College & Hospital, Dhaka during the period between 1 May 2022 and 31 August 2022. Data were collected using the Bengali version of the European Organization for Research and Treatment of Cancer (EORTC) questionnaire. Results The study reported a high number of female cancer patients (67.6%), who were married, Muslims by religion, and non‐residents of Dhaka. Breast cancer was more common among women (31.43%), while lung and upper respiratory tract cancer was more prevalent among men (19.05%). The majority of the patients (86.19%) were diagnosed with cancer in the past year. The overall mean score for functional scales was higher for physical functioning (54.92) whereas it was lower for social functioning (38.89). The highest score on the symptom scale was for financial problems (63.02), while the lowest was for diarrhea (33.01). The overall QoL score of cancer patients in the study was 47.98 and it was lower for males (45.71) compared to females (49.10). Conclusions The overall QoL was poor among Bangladeshi cancer patients compared to those in developed countries. A low QoL score was observed for social and emotional functions. Financial difficulty was the main reason behind the lower QoL score on the symptom scale.


| INTRODUCTION
Bangladesh is a low-income country in South Asia with a population of 165 158 616. 1 Among the population, 20.5% live in poverty and 10.5% live in extreme poverty. 1 In 2020, there were 156 775 new cases of cancer and 108 990 cancer-related deaths reported in the country. 2 Lung, prostate, and esophageal cancers were the eighth, tenth, and fourteenth leading causes of total mortality in men, while breast, cervical, leukemia/ lymphoma, and other cancers were the eleventh, twelfth, thirteenth, and fifteenth leading causes of total mortality in women. 3 Quality of life (QoL) is a critical parameter for follow-up in cancer patients undergoing treatment and reflects their physical, functional, psychological, and social wellbeing. 4 Considering QoL is essential when making a therapeutic decision as there are various treatment regimens for cancer. 4 In 2022, the government planned to establish 18 000 community clinics and add 1400 additional beds to provide cancer care as there were fewer than 500 beds available in 2013. 2,5 This demonstrates the government's commitment to cancer care. However, providing cancer care is challenging and time-consuming as it requires collaboration with various health care services, including pathology, radiology, surgical oncology, medical oncology, gynecology, and palliative care.
Cancer and its treatment result in excruciating misery for patients, both those who survive and those who succumb to the disease. Several studies have shown that cancer and its treatment can result in significant physical, emotional, and social distress in patients, negatively affecting their QoL. Moreover, the effectiveness of cancer treatment depends not only on increasing survival rates but also on how well it improves patients' overall well-being. 4 Therefore, assessing QoL is crucial in making treatment decisions, particularly in advanced stages of cancer, where the primary goal of therapy is to improve patients' feelings. 4 However, the value of QoL measurement depends on their accuracy in capturing the key facets of patients' QoL, their reliability, responsiveness, and clinical relevance in terms of benefits and associated costs. 6 Various QoL assessment tools are available, and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire is a reliable and valid method for assessing the QoL of cancer patients participating in trials and research where patientreported outcomes are collected. 7 The EORTC QLQ-C30 questionnaire has met all necessary criteria for validity, reliability, and sensitivity, making it a suitable method for assessing the QoL of cancer patients in various studies. 7 This study aims to use this tool to assess the QoL of cancer patients in Bangladesh and to identify the factors affecting it. The information generated from this study will be essential for making informed therapeutic decisions, improving cancer patients' overall wellbeing, and strengthening cancer care delivery in Bangladesh and other low-income countries facing similar challenges.

| METHODS
The study proposal and the consent form were approved by the

| Data collection
Data were collected 2 days a week, on Monday and Wednesday. This was due to the roster duty of the authors involved in data collection.
The objective of the study was explained to the patients and informed consent was obtained from those who participated. All adult patients who visited to the outpatient clinic and all patients newly admitted to the inpatient clinic on those days were included in the study and were administered the questionnaire by the authors (NI, KJU and MRK) in person. Literate patients filled out the questionnaire by themselves.
For illetrate patients, authors dictated the items in the questionnaire and recorded their responses. Patients who were interviewed for this study previously, those who could not provide consent (unconscious), patients with suspected cancer but without a confirmed report, and patients less than 18 years of age were excluded. Sociodemographic characteristics such as age at treatment, gender, marital status, religion, economic status, and education were obtained from the patients. Information on clinical status, such as the site of the primary tumor, the stage of the tumor, and the type of treatment, was recorded from the clinical documentation.

| Data analysis
Data collected were entered into an Excel worksheet and exported to the Statistical Package for the Social Sciences (SPSS) v.21.0 (IBM Corp., Armonk, NY, USA) for analysis. Descriptive statistics (mean, standard deviation (SD), frequency and percentage) were used to describe the distribution of the type, stage, and treatment of the cancer. Categorical variables were expressed as percentage and compared using the Chi-square test, with a p-value of less than .05 considered statistically significant. All the underlying data for the present study is available without restriction. 9

| RESULTS
In the study 210 cancer patients were included, of whom 68 were men and 142 women with a male-female ratio of 1:2.09. The age of the patients ranged from 18 to 85 years with a mean age of 51.09 (13.22) years. Majority of the patients were Muslim by religion, unemployed and had an average family income (Table 1).
Almost 4/5th of the patients were diagnosed with cancer in the last year, and breast cancer was the most common type of cancer diagnosed in patients, followed by oropharyngeal cancer. Cancerrelated characteristics including the stage and treatment is depicted in Table 2.
Most of the patients were taken care of by their first-degree relatives in the past 30 days, while 10% of the patients did not have a caregiver at home and had to manage their own care ( Table 3). None of the patients received professional home health care services.
The overall mean score for functional scales was higher for physical functioning (54.92) and lower for social functioning (38.89) ( Table 4). The highest score on the symptom scale was for financial problems (63.02), while the lowest was for diarrhea (33. When the QoL was evaluated with EORTC-QLQ-C30 score it was observed that scores for the functional scales decreased with advancing cancer stage. When symptoms were evaluated, fatigue, nausea and vomiting and pain worsened during the initial stage of the cancer but were less intense during later stages. Dyspnea and insomnia worsened with the advancing cancer stage (Table 5).

| DISCUSSION
The present study has reported a high number of women cancer patients in Bangladesh and revealed that the majority were married T A B L E 1 Sociodemographic characteristics of the participants.

Characteristics
Frequency, n (%)  5 There are 20 million individuals who use tobacco in some way, among which 1 in every 5 tobacco user is a woman. 5 Every year, diseases linked to tobacco use claim the lives of 57 000 people. 5 In contrast breast and cervical cancer are more prevalent in T A B L E 2 Cancer-related characteristics of the patient. subscale score and lower burden of symptoms than women. [17][18][19][20][21][22][23][24] The function scale scores decreased as the cancer stage advanced, except for social function, which increased from stage 1 to stage 2 and then decreased. General health improved as the cancer advanced.
When we evaluated symptoms and single-item scales, we found that financial difficulties were the main problems, followed by appetite loss, nausea and vomiting, and pain. This differs from the experience of Tanzanian cancer patients, who suffered more from pain and insomnia, and Iranian cancer patients, who presented with gastrointestinal symptom burden like nausea/vomiting and diarrhea. 25,26 The overall QoL of cancer patients in the present study was affected or unaffected status. 27 In contrast, an Indian study utilized a cutoff score of 50 to assess the QoL. 28 Selecting a cutoff point by the researcher is debatable and not without bias. 29 Based on the cutoff score of 75, the QoL in our population is severely affected. Cancer patients in Bangladesh report lower QoL, more symptoms, and a greater need for financial assistance and pain management like cancer patients in Ethiopia. 27,30 Global health and QoL were higher in developed European countries such as Austria (75.65), Germany (67.0) and Italy (64.87) when compared to our study (47.98). 17,31,32 In our study, the vast majority of cancer patients were cared for by first-degree relatives or close friends. A Japanese study found that family members and caregivers had a pessimistic view of QoL of their patients, reflecting their own emotional discomfort and the stress of providing care. 33 To minimize this bias, we encouraged patients to fill out the questionnaire by themselves if they were able to read and write. For illiterate patients, we dictated the items in the questionnaire and recorded their responses ourselves. This was a time-consuming process, but it allowed patients to express concerns about their QoL that they might not have otherwise acknowledged, and they could feel as though their concerns are legitimate and warrant further discussion. 34 T A B L E 5 EORTC-QLQ-C30 scores according to cancer stage.  The QoL also depends on the stage of the cancer and the treatment modality. There were 14 cases in the present study who were on palliative care. The main palliative care in cancer patients is pain management. The financial burden of cancer, which includes both direct and indirect costs such as missed wages, income, and savings, is a priority concern. 35 A crucial part of cancer care should involve discussing the expense and benefit of cancer therapy, as well as the accessibility and availability of resources, to determine the financial strain. 36

| CONCLUSION
The EORTC QLQ C-30 questionnaire was found to be easy to administer and helped patients feel their symptoms were being attended to. In general, the QoL of the female cancer patients in the study was better than that of the males. The financial burden was identified as a major factor that deteriorated the QoL in

ACKNOWLEDGMENTS
We are grateful for the support and guidance of Prof. Dr. Kazi Manzur Kader, Head of the Department of Oncology Unit, Delta Hospital Limited.

CONFLICT OF INTEREST STATEMENT
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are openly available in "Dryad" at doi: https://doi.org/10.5061/dryad.pnvx0k6s4. 9

ETHICS STATEMENT
The study proposal and consent form were approved by the Ethics Committee of the Delta Medical College Hospital, Dhaka (DLMCH/ IEC/2022/1).