Quality of life in patients with endometrial carcinoma: A Longitudinal Study

Abstract Aim To investigate the quality of life in patients with endometrial carcinoma and provide theoretical basis for nursing care. Design In this study, 69 patients diagnosed with endometrial carcinoma from 2016–2018 were included in the cohort. Methods Sixty‐nine patients from our hospital who underwent endometrial cancer surgeries were selected. The SF‐36 was used to investigate and analyse the patients’ quality of life in the first, second and third months after their operations. Questionnaires were administered to analyse the factors affecting postoperative quality of life. Results Quality of life for the second and third months was obviously better than that for the first month after the operation (p < .05). Based on multivariate regression analysis, we found that patients with higher family income had better quality of life after surgery(p < .05). These results can provide some guidance for daily nursing work after endometrial cancer operation.


| INTRODUC TI ON
Endometrial cancer (EC) is the sixth most common female tumour worldwide, and its incidence is increasing each year. It is currently the most common female pelvic malignant tumour in the United States now (Faria et al., 2019), and a retrospective study showed that the incidence rate of endometrial cancer in white Americans has reached 19/100,000 (Lortet-Tieulent et al., 2018). According to data from the World Health Organization in 2018, nearly 380,000 women were diagnosed with endometrial cancer worldwide, resulting in approximately 90,000 deaths; thus, this type of cancer should receive more attention . Quality of life refers to people's feelings about their position inside their culture and value system, including the concept of health, which consists of the living environment, psychological health and social support (Panzini et al., 2017;Skevington, 2002). Quality of life can reflect the health status of people from multiple dimensions. To date, studies on the quality of life in patients with endometrial cancer have mostly been limited to cross-sectional studies, and longitudinal studies in this field are extremely rare (Ferguson et al., 2018;Robertson et al., 2019;Salehi et al., 2018;Shisler et al., 2018). The 36-item Short Form Health Survey (SF-36) is a well-known quantitative tool for evaluating quality of life (Ware & Sherbourne, 1992). It systematically assesses eight dimensions of psychological and physiological health and provides powerful evidence on the effect of a disease on quality of life.
In our study, we used the SF-36 to dynamically assess the quality of life of patients with endometrial cancer at different times after their operations. Specifically, this study also used multivariate regression analysis and discovered the risk factors for low quality of life after surgery. Based on these findings, some targeted and individualized disposes can be applied in daily nursing work for different kinds of patients. This can help improve their quality of life after operations. The study adhered to the principles of the Declaration of Helsinki.

| Study design
Research Ethics Committee approval was obtained for this study.
The approval included the participant information sheet and informed consent form signed by all participants.

| Data collection
Questionnaires were uniformly distributed by trained investigators uniformly and collected by one-to-one interviews. Investigators described our research to those who met the inclusion criteria and obtained their informed consent. All participants completed the SF-36 the first, second and third months after the operation. Participants were excluded if they stopped chemotherapy without authorization or went to another hospital for treatment at any point of the study.

| Investigation tools
The questionnaire for basic information included patient age, marital status, work status, educational level, disease stages and complications. The Chinese version of the SF-36 was adopted. This scale includes 36 items across 8 dimensions, including physical function (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH). Scores for each item are counted and converted into standardized scores by (original score-lowest possible score)/ possible score range × 100, and the standardized scores of the eight dimensions are summed to obtain the SF-36 total score. The average score of the SF-36 ranges from 0-100 points, where 0 points and 100 points represent the worst and best health results, respectively.

| Statistical analysis
All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 23.0 software. One-way ANOVA was adopted for comparing the means of three groups, and the Bonferroni test was used for post hoc comparison. Univariate analysis was used to identify factors associated with quality of life, and those factors with a p-value of <.10 were included in multivariate regression analysis. A p-value of <.05 was considered statistically significant.

| RE SULTS
In our study, 69 participants completed the SF-36 at the first, second and third months after their operations. All data were divided into three groups depending on the time since the operation. In addition, personal information from participants was collected from the first questionnaire. The general information of 69 patients is shown in Table 1.
For total SF-36 scores, we found a statistically significant difference between the three groups. Specifically, the total scores were significantly higher in the second month and the third month than in the first month after the operation(p < .05), but no significant difference was found between the second and the third months (p > .05). (Table 2).
Next, univariate analysis was used to identify factors that influenced the difference between the total scores of the third and first months after the operation. (Table 3) Those factors with a p-value of<.05 were included in multivariate regression analysis, including educational experience, monthly income and physical discomfort.
After excluding the confounding factor, we noticed that monthly income had a considerable impact on the quality of life after operation (both p < .05), while higher monthly income led to better postoperative quality of life. (Table 4). surgery. During this period, the postoperative follow-up by interacting and communicating with doctors and nurses for appropriate intervention and guidance was beneficial to patients. In this study, we found that the quality of life in endometrial carcinoma patients within the first month postoperatively was significantly lower than that in the second and third months, and the monthly income was positively correlated with their postoperative quality of life.

| D ISCUSS I ON
Nowadays, the treatment of endometrial cancer is developing.
Staging operation followed by adjuvant treatments including but not limited to chemotherapy and radiotherapy have been widely applied (Amant et al., 2018;Lu & Broaddus, 2020). Within the first month postoperatively, endometrial cancer patients not only experienced physiological pain caused by the operation itself, but also the powerlessness owing to the inability to self-care and unknown pathological results. In some situations, adjuvant treatments especially chemotherapy are performed right after operation, usually within 1 month (Lu & Broaddus, 2020). For most of endometrial cancer patients, the sequential burden of operation and chemotherapy in a short period of time can lead to a significant decrease in quality of life, including but not limited to pain, postoperative weakness, nausea, vomiting, fatigue, myelosuppression and alopecia caused by chemotherapeutic drugs (Lorusso et al., 2017;Shiozawa et al., 2013). As a result, health education and psychological counselling are highlighted for their importance to improve quality of life. Previously, studies have thoroughly demonstrated the importance of pre-operative education (Kruzik, 2009;O'Brien et al., 2013). Besides, the management of physical and psychological problems during the immediate postoperative phase might improve satisfaction with the surgery experience, and decrease complications and length of hospital stay (Ramesh et al., 2017). Learn from previous experiences, disease-related knowledge and comprehensive pre-operative education should be propagated by nurses to help patients better prepare for postoperative challenges. Additionally, nurses can encourage them to communicate with other patients and build up their confidence by telling some success stories. Moreover, comfortable physical and psychological postoperative care need to be provided by nurses to help patients recover quickly. As previously described (Knols et al., 2005;Spence et al., 2010), nurses can also schedule postoperative reha- Age (mean ± standard deviation) 53.9 ± 8.45 members can also satisfy their physical and mental needs, contribute to a quick postoperative recovery and improve their quality of life . Eventually, patients would gradually embrace the pain caused by their condition and take the resolution to start their new life, which is conductive to an immense boost in their quality of life.
We also noticed that the monthly income of patients Similarly, univariate analysis also revealed that physical discomfort may reduce patients' quality of life. As mentioned before, patients undergoing chemotherapy may suffer from different kinds of physical discomfort such as nausea, vomiting, choking sensation TA B L E 2 Scores of each dimension and total scores after operation in the chest, dyspnoea and palpitation, which significantly influ- the creation of non-nausea and vomiting wards may alleviate patients' anxiety and relieve their discomfort. In order to distract patients and enable them to have some fun, nurses can also utilize some individual nursing methodologies such as music therapy (Bradt et al., 2016), relaxation therapy (Sun et al., 2017) and psychological guidance.
In daily clinical work, most nurses bear a heavy working pressure. The California government signed a legislation and stipulated that in oncology wards, one nurse should be responsible for no more than four patients at the same time (Coffman et al., 2002;Spetz, 2004). However, an observation study showed that in highlevel general hospitals of China, a nurse usually takes care of eight patients during the day and even twenty-three patients at night on average (Shen et al., 2020). Busy daily work will inevitably lead to the lack of care for every patient. In our study, we systematically analysed the postoperative quality of life of endometrial cancer pa-

| CON CLUS ION
In summary, doctors and nurses should pay more attention to patients' quality of life in the first month after endometrial cancer operation, especially patients with lower income, lower educational level and physical discomfort. We can fully utilize psychological counselling and humanistic care, help patients fully understand the disease and coordinate to treatment positively, relax patients and increase their confidence again. In addition, the important role of family members should also be taken seriously.

ACK N OWLED G EM ENTS
The authors would like to thank all patients who participated in this study. We also express the deepest appreciation to all colleagues giving help for data collection and proofreading the article.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on reasonable request from the corresponding author. The data are not publicly available due to patient privacy reasons.