Jpn J Clin Oncol 2014;44(2)141– 152 doi:10.1093/jjco/hyt184 Advance Access Publication 4 December 2013
Comparison of Health-related Quality of Life Between Cancer Survivors Treated in Designated Cancer Centers and the General Public in Korea Jung-A Lee1,2, So-Young Kim2, Yoon Kim1,3, Juhwan Oh4,5, Hyung-Jin Kim6, Deog-Yeon Jo7, Tae-Gyun Kwon8 and Jong-Hyock Park2,* 1
*For reprints and all correspondence: Jong-Hyock Park, Division of Cancer Policy and Management, National Cancer Control Research Institute, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410 – 769, Korea. E-mail: [email protected] Received May 29, 2013; accepted November 1, 2013
Objective: We assessed health-related quality of life in cancer survivors treated in designated cancer centers when compared with the general population in Korea. Methods: A multicenter survey was conducted from July through August 2008 using the quotasampling approach. A general population sample was drawn from the Fourth Korean National Health and Nutrition Examination Survey, second year. We compared the multivariate-adjusted least square means of cancer patients with those of the general population to examine relationships between EuroQol five-dimensional questionnaire components and cancer sites, cancer stage and time since diagnosis. The independent variables of responses to the EuroQol five-dimensional questionnaire were evaluated using logistic regression analysis. Results: Cancer patients scored significantly poorer on measures of self-care (means: stomach 1.25; lung 1.40; liver 1.27; colon 1.26; breast 1.27; cervical 1.29 vs. general 1.18), engagement in usual activities (means: stomach 1.47; lung 1.63; liver 1.45; colon 1.44; breast 1.46; cervical 1.47 vs. general 1.33) and anxiety/depression (means: stomach 1.41; lung 1.50; liver 1.41; colon 1.42; breast 1.50; cervical 1.47 vs. general 1.28). Those in the local stage scored significantly better on mobility (mean ¼ 1.35) than the general population (mean ¼ 1.40). Cancer patients, especially those with lung cancer, in the advanced stage and more than 5 years since diagnosis had poorer health-related quality of life than the general population. Some factors such as medical insurance and healthcare services were related to health-related quality of life among cancer patients. Conclusions: Health-related quality of life of cancer survivors with lung cancer at advanced stages, ,1 year earlier and more than 5 years since diagnosis was poorer than that for the noncancer control group, and these differences were statistically significant. Cancer survivors should be continuously observed and offered support. Key words: cancer – health-related quality of life – EQ5D – EQ-VAS
# The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
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Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, 2National Cancer Control Institute, National Cancer Center, Goyang, 3Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, 4Department of Medicine, Seoul National University College of Medicine, Seoul, 5Biomedical Research Institution, Seoul National University Hospital, Seoul, 6Jeonbuk Regional Cancer Center, Jeonju, 7Daejeon Regional Cancer Center, Daejeon and 8Daegu-Gyeongbuk Regional Cancer Center, Daegu, Korea
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PATIENTS AND METHODS
Quality of life is as important to patients with cancer as is their expected life span and other issues related to survival (1). Thus, as the quality of life of patients with cancer has come to be recognized as a robust indicator of their well-being, it has assumed new importance in studies (2). However, previous studies have shown that the quality of life of patients with cancer is worse than that of the general population in terms of physical, emotional and social functioning (3,4). Despite expectations of treatment effectiveness, an acceptable quality of life and a comfortable death, patients with cancer generally experience decreases in their quality of life as experiences of helplessness and despair emerge during prolonged medical treatment (e.g. surgery, chemotherapy or radiotherapy). Health-related quality of life (HRQoL) can be defined as the multidimensional influence of a disease and its treatment on the physical, psychological and social functioning and overall well-being of patients (5). A variety of tools are available to assess HRQoL. The EuroQol five-dimensional (EQ5D) questionnaire, developed by EuroQol Group, is a simple and generally applicable approach appropriate for large-scale evaluations of overall health status. The EQ5D is now widely accepted in many countries due to its availability in various languages as well as its appropriateness for use in diverse cultures and circumstances (6). Many previous studies have attempted to identify factors that affect the quality of life. For example, studies involving patients with cancer have evaluated factors such as age, ethnicity, income, education, alcohol use, smoking, comorbid conditions, treatment, stage of illness, time since diagnosis and recurrence as potential contributors to HRQoL (7 – 12). Examinations of the relationship between quality of life and demographic characteristics have indicated that the quality of life of those who are male, relatively young, earned more and were more highly educated is better than that of individuals without these characteristics (7 – 9,11,13 – 16). However, another study reported no significant differences in quality of life as a function of economic condition or level of education (17). Studies of clinical factors have reported that differences in the quality of life of patients undergoing chemotherapy and radiotherapy are related to cancer stage, especially among those in the early stage of the disease (8 – 10,18,19). However, most previous studies on HRQoL involved small numbers of patients with specific cancer types from single centers located in Western countries, and they therefore have limited generalizability in non-Western countries where social and cultural norms may be different. Thus, the independent influence of various cancers on HRQoL and comparisons between individuals with these cancers and the general population, as well as mixed results and the limitations mentioned above, preclude generalization of the findings. In this study, we investigated the difference in HRQoL between patients with cancer treated in designated cancer centers and the general population. Secondary objectives were to examine factors that contribute to HRQoL in patients with cancer.
STUDY POPULATION A nationwide multicenter survey involving one national and nine regional cancer centers (RCCs) was conducted from July to August 2008. The government designated three national university hospitals in provincial cities as RCCs in 2004. The other six national university hospitals were designated as RCCs in 2005 and 2006. The RCCs must perform their jobs responsibly to provide comprehensive clinical care for regional cancer patients and to facilitate the national cancer control programs. The National Cancer Center and the nine government-designated RCCs participated in the survey as representatives of all cancer centers in Korea. We used the following quota-sampling approach. Our aim was to recruit 200 – 300 Korean patients from each center; we attempted to build a sample in which 80% of participants had at least one of the six major types of cancer (stomach, lung, liver, colon and rectal, breast and cervical), and 20% had other types. In this survey, we set quotas with regard to sex, age, residential location and cancer type to make sure that our sample represented the demographic distribution of Korea as shown in the most recent adult population. Detailed procedures have been described in previous studies (20,21). In total, 2661 completed surveys were collected. The following inclusion criteria were used: older than 20 years of age, used the inpatient or outpatient facilities of at least one of these 10 cancer centers, at least 4 months since diagnosis and in current or follow-up treatment. After we reviewed the questionnaires for completeness and to identify individuals with the six most common cancers, 1608 patients who provided consent remained in the study. This study was approved by the Institutional Review Board of the National Cancer Center in Korea. Data on the general population were drawn from those collected during 2008, the second year of the Fourth Korean National Health and Nutrition Examination Survey, a crosssectional and nationally representative survey on the health and nutritional status of the non-institutionalized Korean population. The participants were chosen by proportional allocation-systematic sampling using multistage stratification (age, sex and region). Of the 9308 participants who finished the health examination and health questionnaire, data from 5443 cancer-free individuals (58.5%) aged 20 were included in the analyses. We excluded individuals who had been diagnosed with cancer by a physician and had been treated for cancer.
QUESTIONNAIRE The study also included the EQ5D, a measure of HRQoL, and questions regarding sociodemographic and medical variables, stress, depression and suicidal thoughts (22). The EQ5D questionnaire is a simple two-page measure of generic HRQoL. On the first page (the ‘self-classifier’ section), respondents
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INTRODUCTION
Jpn J Clin Oncol 2014;44(2)
report on the extent of their problems in each of five dimensions with higher scores reflecting more negative outcomes: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. On the second page, they record their perceptions of their overall health using a visual analogue scale (EQ-VAS). EQ-VAS scores range between 0 (worst imaginable health) and 100 (best imaginable health). The accuracy of the medical information about site and stage of cancer (SEER stage) was ascertained by checking this information with data from medical records. Comorbidity information was obtained from the patient survey. STATISTICAL ANALYSES
RESULTS CHARACTERISTICS OF CANCER PATIENTS AND THE GENERAL POPULATION Table 1 presents the distributions of participants in terms of demographic characteristics, health-related behaviors, clinical status and utilization of healthcare services in 2008. Among the patients with cancer, females were slightly more numerous (51.3%) than males. Most patients had attended middle school or less, were married, lived with more than two family members, earned less than $1779.00 (US dollars) per month, lived in the city or country, had national health insurance (NHI), did not smoke, did not drink, had no comorbid conditions, had undergone surgery/chemotherapy, had not received
radiotherapy, were satisfied with the healthcare services they received, participated in all treatments recommended by their doctor and trusted their doctor. More than three-quarters of the sample (76.4%) were diagnosed at 20 – 64 years of age, 49.6% had been diagnosed 1 – 5 years ago and 86.2% were in either the ‘in situ/local’ or a ‘regional’ stage of the disease. Of the 5443 members of the general population included in this study, 59.5% were female, and 76.1% were 20 – 64 years of age. The majority had more than a high school education, were married, lived with more than two family members, had monthly incomes of more than $1779.00, lived in the city or country, had NHI, did not smoke, did not drink and had no comorbid conditions. COMPARISON OF HRQOL OF PATIENTS WITH CANCER AND THE GENERAL POPULATION ACCORDING TO CANCER SITE, STAGE AND TIME SINCE DIAGNOSIS Compared with the general population, those with the six major forms of cancer (stomach, lung, liver, colon/rectum, breast and cervix) had significantly higher LS mean scores on the self-care, usual activities and anxiety/depression scales of the EQ5D, and those with lung or breast scored significantly higher on the EQ5D scales for pain/discomfort after adjusting for sex, age, education, marital status, household income, place of residence, insurance, smoking, drinking and comorbidity, which were associated with QOL in previous studies (12,16 – 18) (Fig. 1). Those with lung cancer scored significantly higher on the EQ5D scale for mobility compared with the general population after adjusting for the same variables. In terms of cancer stage, those in the regional and distant stages scored significantly higher than those in the general population on four of the EQ5D scales; the exception was the pain/discomfort scale (Fig. 2). Those in the local stage scored significantly lower on the EQ5D scales than the general population. Two groups (regional and distant) scored significantly higher on the EQ5D pain/discomfort scale than the general population after adjusting for the same variables. In general, patients in the advanced stages of illness scored higher on all dimensions of the EQ5D scale. With respect to time since diagnosis, a reflection of survival time, all three groups (,1, 1 – 5, .5 years) scored significantly higher than the general population on all EQ5D scales except that addressing mobility; however, those who had been diagnosed ,1 year or more than 5 years ago scored significantly higher on the EQ5D mobility scale, when compared with the general population after adjusting for the same variables (Fig. 3). Additionally, those diagnosed ,1 year or more than 5 years ago scored higher on all dimensions of the EQ5D scale compared with those who had been diagnosed 1 – 5 years ago. The distribution of cancer types showed little variation according to time since diagnosis. Because this study population had a broad age range, the subjects were stratified into categories of 20 – 64 and more than 65 years of age. The results showed little variation by age
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The original responses to the EQ5D self-classifier section (no problems, some or moderate problems and extreme problems or unable to function) were collapsed into two categories (no problem and any problem). The proportions of patients reporting any problem were compared with the cancer-free general population, which served as the reference group. We compared the multivariate-adjusted least square (LS) means of the patients with those of the general population to examine the relationships between EQ5D components and cancer sites, cancer stage and time since diagnosis. The independent influence of demographic information including gender, age, education, marital status, family members, income, residence, insurance, health behaviors (including smoking, drinking, comorbidity), age at diagnosis, time since diagnosis, cancer site and stage and healthcare services (including operation, chemotherapy, radiotherapy, satisfaction, treatment compliance, trust in doctor) on each dimension of the EQ5D scale was examined using multivariate logistic regression analysis. Patients who experienced any problems were part of the reference group. Additional multiple regression analyses explored relationships among demographic characteristics, health-related behaviors and clinical indicators, as well as the overall EQ-VAS (a continuous variable). P values ,0.05 indicated statistical significance, and all data analyses were performed using the SPSS statistical software (ver. 21.0; SPSS, Inc., Chicago, IL, USA).
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Table 1. Characteristics of the patients with cancer and the general population
Table 1. Continued
Variables
Variables
Patients with cancer (n ¼ 1608)
General population (n ¼ 5443)
Demographic factors
Patients with cancer (n ¼ 1608)
Cancer site
Gender
Stomach
379 (23.6)
Male
783 (48.7)
2205 (40.5)
Lung
261 (16.2)
Female
825 (51.3)
3238 (59.5)
Liver
167 (10.4)
Colon
282 (17.5)
Breast
345 (21.5)
Cervix
174 (10.8)
Age (years) 20–64
1091 (67.8)
4144 (76.1)
Mean + SD
51.5 + 8.3
45.3 + 10.2
65 Mean + SD
517 (32.2) 70.4 + 4.4
1299 (23.9) 72.3 + 5.6
Middle school or less
832 (51.7)
2431 (44.7)
More than high school
776 (48.3)
3012 (55.3)
Marital status
Cancer stage Local
994 (61.8)
Regional
393 (24.4)
Distant
221 (13.7)
Healthcare services Operation
Married
1360 (84.6)
4522 (83.1)
Yes
1283 (79.8)
Othersa
248 (15.4)
921 (16.9)
No
325 (20.2)
138 (8.6)
356 (6.5)
1470 (91.4)
5087 (93.5)
Family members (n) 2
Chemotherapy
Income ($)b 1075 (66.9)
2374 (43.6)
1779
533 (33.1)
3069 (56.4)
Residence
Metropolitan area
Medical Aid
1084 (67.4)
No
524 (32.6)
Yes
519 (32.3)
No
1089 (67.7)
Satisfaction 1117 (69.5)
3209 (59.0)
Yes
1109 (69.0)
491 (30.5)
2234 (41.0)
No
499 (31.0)
Insurance NHI
Yes
Radiotherapy
,1779
City or country
Follow treatment recommendations of doctor 1446 (89.9)
5255 (96.5)
162 (10.1)
188 (3.5)
Health behaviors and clinical factors
All Some
Yes
452 (28.1)
1136 (20.9)
No
1156 (71.9)
4307 (79.1)
Drinking
50 (3.1)
Yes
1396 (86.8)
No
212 (13.2)
EQ5D dimensions Mobility
Yes
692 (43.0)
2794 (51.3)
Extreme problems
No
916 (57.0)
2649 (48.7)
Some problems
Yes
483 (30.0)
2347 (43.1)
Self-care
No
1125 (70.0)
3096 (56.9)
Extreme problems
Comorbidity
No problems
Age at diagnosis (years) 65
1558 (96.9)
Trust in doctor
Smoking
20–64
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Education
1
General population (n ¼ 5443)
Some problems 1228 (76.4)
No problems
380 (23.6)
Usual activities
Time since diagnosis (years)
Extreme problems
,1
564 (35.1)
Some problems
1 –5
798 (49.6)
No problems
.5
246 (15.3)
28 (1.7)
43 (0.8)
403 (25.1)
1109 (20.4)
1177 (73.2)
4291 (78.8)
40 (2.5)
37 (0.7)
222 (13.8)
266 (4.9)
1346 (83.7)
5140 (94.4)
51 (3.2)
76 (1.4)
451 (28.0)
694 (12.8)
1106 (68.8)
4673 (85.9) Continued
Continued
Jpn J Clin Oncol 2014;44(2)
Table 1. Continued Variables
Patients with cancer (n ¼ 1608)
General population (n ¼ 5443)
Pain/discomfort Extreme problems
74 (4.6)
239 (4.4)
Some problems
609 (37.9)
1494 (27.4)
No problems
925 (57.5)
3710 (68.2)
Anxiety/depression Extreme problems Some problems No problems
47 (2.9)
81 (1.5)
498 (31.0)
810 (14.9)
1063 (66.1)
4552 (83.6)
chemotherapy (OR ¼ 2.07, 95% CI ¼ 1.53 – 2.82) and trusting the doctor (OR ¼ 1.65, 95% CI ¼ 1.14 – 2.39) were strongly associated with higher scores on the EQ5D scale measuring typical activities, when compared with other characteristics. Being female (OR ¼ 1.96, 95% CI ¼ 1.40 – 2.74), being in the distant stage (OR ¼ 1.75, 95% CI ¼ 1.23 – 2.48), undergoing chemotherapy or radiotherapy (OR ¼ 1.34, 95% CI ¼ 1.03– 1.75; OR ¼ 1.71, 95% CI ¼ 1.34– 2.19) and trusting the doctor (OR ¼ 1.61, 95% CI ¼ 1.16 – 2.23) were more strongly associated with higher scores on the EQ5D scale measuring pain and discomfort relative to other characteristics. Being female (OR ¼ 1.48, 95% CI ¼ 1.05 – 2.10), being in the regional or distant stage (OR ¼ 1.50, 95% CI ¼ 1.14 – 1.97; OR ¼ 2.10, 95% CI ¼ 1.48 – 2.99) and undergoing radiotherapy (OR ¼ 1.36, 95% CI ¼ 1.06 – 1.75) were more closely associated with higher scores on the EQ5D scale for anxiety/depression than the other characteristics. FACTORS OF OVERALL HRQOL ACCORDING TO THE MULTIPLE REGRESSION ANALYSIS
and were consistent with former studies showing that cancer patients and advanced cancer scored significantly higher on the EQ5D scale (data not shown). FACTORS OF HRQOL ACCORDING TO THE LOGISTIC ANALYSIS Table 2 presents the results of the multivariate logistic regression analysis examining the predictive power of demographic characteristics, health-related behaviors, clinical status and utilization of healthcare services on EQ5D dimensions. Having Medical Aid insurance [odds ratio (OR) ¼ 1.89, 95% confidence interval (CI) ¼ 1.29 – 2.78], suffering from a comorbid condition (OR ¼ 1.31, 95% CI ¼ 1.00 – 1.72), being over 65 years of age at diagnosis (OR ¼ 2.19, 95% CI ¼ 1.35 – 3.58), having been diagnosed more than 5 years ago (OR ¼ 1.83, 95% CI ¼ 1.24 – 2.71), having lung cancer (OR ¼ 1.67, 95% CI ¼ 1.10 – 2.53), being in the regional or distant stage (OR ¼ 1.41, 95% CI ¼ 1.04 – 1.91; OR ¼ 2.76, 95% CI ¼ 1.90 – 4.01) and undergoing chemotherapy and/or radiotherapy (OR ¼ 1.55, 95% CI ¼ 1.12 – 2.13; OR ¼ 1.37, 95% CI ¼ 1.03 – 1.83) were associated with higher mobility scores on the EQ5D scale compared with other characteristics. Having Medical Aid insurance (OR ¼ 1.60, 95% CI ¼ 1.03 – 2.48), having been diagnosed more than 5 years ago (OR ¼ 1.95, 95% CI ¼ 1.25 – 3.04), being in the regional or distant stage (OR ¼ 1.68, 95% CI ¼ 1.17 – 2.41; OR ¼ 3.86, 95% CI ¼ 2.56 – 5.82) and undergoing radiotherapy (OR ¼ 1.56, 95% CI ¼ 1.12 – 2.15) were more closely associated with higher EQ5D scores for self-care compared with other characteristics. Being female (OR ¼ 1.60, 95% CI ¼ 1.12 – 2.29), having Medical Aid insurance (OR ¼ 1.67, 95% CI ¼ 1.14 – 2.44), being in the regional or distant stage (OR ¼ 1.44, 95% CI ¼ 1.08 – 1.91; OR ¼ 2.89, 95% CI ¼ 2.02 – 4.13), undergoing
The multiple regression analysis identified the following independent variables of lower EQ-VAS scores: not being married (i.e. separated, widowed, divorced), having a lower monthly family income, having NHI, having a comorbid condition, being in the regional or distant cancer stage, not being satisfied with healthcare services and not trusting the doctor (Table 3).
DISCUSSION This study measured the HRQoL of patients with the six most common types of cancer, compared these data with those from a sample of the general population, and tried to identify the factors that contribute to the HRQoL of patients with cancer. Reeve et al. (23) compared older patients with nine different types of cancer to individuals without cancer. Their study found that all cancer patients, except those with melanoma and endometrial cancer, had significantly worse physical health than patients without cancer, and that colorectal, prostate and lung cancer patients reported worse mental health scores than the control group. Our study comparing Korean patients with cancer to the general population found that all patients with cancer scored significantly poorer on scales measuring self-care, usual activities and anxiety/depression. With regard to pain/discomfort, those with lung or breast cancer scored worse than did those in the general population. These results are similar to those of Reeve et al., who used different measurement tools. However, their study did not include stomach and cervical cancer. Those with lung cancer emerged as especially compromised compared with members of the general public with regard to all dimensions of the HRQoL; this group seems to have a particularly strong need for continuous management and support.
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SD, standard deviation; NHI, national health insurance; EQ5D, EuroQol five-dimensional. Includes single, living separately, divorced and separation by death. b Income: monthly household income ($1 ¼ 1124.1 KRW, based on the mean 2008 exchange rate). a
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Figure 1. Adjusted least square (LS) mean values of EuroQol five-dimensional (EQ5D) dimensions according to cancer type. **P , 0.001; P value for each cancer type was compared with data for the general population (reference group). The samples included 379 stomach, 261 lung, 167 liver, 282 colon, 345 breast and 174 cervical cancer patients, and 5443 reference individuals.
Additionally, comparisons between cancer patients and the general population based on the stage of cancer revealed that all of those in the local, regional and distant stages scored worse on measures of mobility, self-care, usual activities and anxiety/depression, and those in the regional and distant stage had poorer scores on all dimensions of the HRQoL. In a prospective study of head and neck cancer, patients with more
advanced disease (Stages III – IV) scored worse than patients with Stages I – II (24). This may be because patients with advanced cancer were more often bothered by problems with their physical and mental functioning. Similarly, the patients who were diagnosed ,1 year earlier had poorer mobility, self-care, usual activities and pain/discomfort scores, but these variables showed relative recovery
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Downloaded from http://jjco.oxfordjournals.org/ at University of Manitoba on June 7, 2015 Figure 2. Adjusted LS mean values of EQ5D dimensions according to cancer stage. **P , 0.001, *P , 0.05; P value for each cancer stage was compared with data for the general population (reference group). There were 994 local, 393 regional and 221 distant cancer patients, and 5443 reference individuals.
or stable tendencies in patients 1 – 5 years after diagnosis. However, they deteriorated again in patients more than 5 years since diagnosis. Additionally, the anxiety and depression scores were consistently worse in cancer patients than in the general population. Therefore, cancer patients should be continuously observed and offered support for physical and psychosocial functioning. HRQoL and related factors were analyzed using each of the five dimensions of the EQ5D questionnaire as a dependent variable. First, patients with at least a high school education scored better on mobility and usual activities, and higher family income was also related to better HRQoL with regard
to mobility and self-care. These findings are consistent with those of prior studies showing that higher income and more education have positive effects on the HRQoL (14,15,25). Secondly, patients with Medical Aid insurance had lower scores for mobility, self-care and usual activities, indicating that economic status affects the quality of life, probably because basic needs cannot be met and general satisfaction with life is reduced by comparing oneself with others. Additionally, patients in the regional or distant cancer stage scored worse on all dimensions of the HRQoL scale than the reference group. This finding is consistent with the results of other studies (3). Thus, the degree to which cancer has
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Comparing HRQoL of patients with cancer
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Figure 3. Adjusted LS mean values of EQ5D dimensions according to time since cancer diagnosis. **P , 0.001, *P, 0.05; P value for each period since cancer diagnosis was compared with data for the general population (reference group). There were 564 individuals with ,1 year, 798 individuals with 1 –5 years and 246 with .5 years since diagnosis, and 5443 reference individuals.
progressed affects the quality of life owing to its impact on physical pain, fear of the disease and the emotional burden associated with the condition. Thirdly, patients receiving chemotherapy had lower scores on measures of mobility, usual activities and pain/discomfort, and patients receiving radiotherapy scored worse on measures of mobility, self-care, pain/discomfort and anxiety/depression. Contrary to earlier reports that chemotherapy and radiotherapy increase overall HRQoL 1 year after surgery, these data suggest that the HRQoL decreases as a function of increasing limitations in some areas of physical functioning (26).
Radiotherapy is generally more strongly associated with decreased HRQoL than surgery or chemotherapy (27,28). Also, the previous studies were longitudinal studies based on randomized controlled trials, in which patients who had received surgery were included in the surgery-only group, but the same patients may have also been included in the combined treatment group at a later point in time. Our study indicates that chemotherapy, surgery and radiation reduce patients’ HRQoL because they are difficult processes for the patients. Patients who were satisfied with healthcare services demonstrated better HRQoL in all dimensions, and patients
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Table 2. Logistic model for EQ5D dimensions of patients with cancer Variables
Mobilitya
Self-carea
Usual activitiesa
Pain/discomforta
Anxiety/depressiona
Demographic factors Gender (female)
1.41 (0.97– 2.05)
1.18 (0.76–1.82)
1.60 (1.12–2.29)
1.96 (1.40– 2.74)
1.48 (1.05–2.10)
Age (65 years)
1.09 (0.68– 1.72)
0.85 (0.49–1.48)
1.25 (0.81–1.94)
0.82 (0.54– 1.24)
0.93 (0.61–1.43)
Education (more than high school)
0.75 (0.57– 0.99)
0.88 (0.64–1.21)
0.76 (0.59–0.99)
0.97 (0.76– 1.23)
1.20 (0.94–1.53)
Marital status (other)
1.34 (0.90– 1.99)
1.02 (0.64–1.64)
1.17 (0.80–1.72)
1.31 (0.91– 1.88)
0.94 (0.65–1.36)
Family members (2)
1.19 (0.72– 1.96)
0.73 (0.41–1.29)
0.92 (0.57–1.48)
0.82 (0.52– 1.30)
0.70 (0.44–1.11)
Income ($1779)b
0.53 (0.39– 0.73)
0.57 (0.39–0.84)
0.78 (0.59–1.04)
0.80 (0.62– 1.03)
0.86 (0.66–1.12)
0.82 (0.62– 1.08)
0.94 (0.68–1.29)
0.76 (0.58–0.98)
1.17 (0.93– 1.48)
1.00 (0.79–1.27)
Insurance (Medical Aid)
1.89 (1.29– 2.78)
1.60 (1.03–2.48)
1.67 (1.14–2.44)
1.02 (0.70– 1.47)
1.36 (0.94–1.97)
Smoking (yes)
1.04 (0.75– 1.45)
0.98 (0.67–1.44)
0.89 (0.65–1.21)
1.10 (0.82– 1.47)
1.22 (0.91–1.66)
Drinking (yes)
0.90 (0.68– 1.20)
0.83 (0.60–1.16)
1.06 (0.81–1.38)
1.07 (0.84– 1.36)
0.96 (0.75–1.23)
Comorbidity (yes)
1.31 (1.00– 1.72)
1.30 (0.95–1.78)
1.22 (0.94–1.58)
1.02 (0.80– 1.29)
1.05 (0.82–1.35)
Age at diagnosis (65 years)
2.19 (1.35– 3.58)
1.68 (0.94–3.03)
1.31 (0.82–2.09)
1.42 (0.90– 2.22)
1.00 (0.63–1.59)
Health behaviors and clinical factors
Time since diagnosis 1–5 years
1.01 (0.77– 1.34)
0.88 (0.63–1.22)
0.90 (0.69–1.17)
0.93 (0.73– 1.18)
1.11 (0.87–1.41)
.5 years
1.83 (1.24– 2.71)
1.95 (1.25–3.04)
1.28 (0.88–1.85)
0.93 (0.66– 1.31)
0.96 (0.67–1.36)
Lung
1.67 (1.10– 2.53)
1.38 (0.85–2.26)
1.17 (0.78–1.75)
1.28 (0.87– 1.88)
1.04 (0.70–1.55)
Liver
1.41 (0.87– 2.28)
1.33 (0.75–2.36)
1.31 (0.83–2.06)
1.12 (0.74– 1.71)
1.21 (0.78–1.87)
Colon
0.98 (0.66– 1.45)
0.85 (0.52–1.38)
0.72 (0.50–1.05)
0.83 (0.59– 1.17)
0.95 (0.66–1.36)
Breast
0.77 (0.48– 1.26)
0.88 (0.50–1.55)
0.55 (0.35–0.87)
0.85 (0.57– 1.28)
1.18 (0.77–1.79)
Cervix
0.88 (0.52– 1.48)
0.78 (0.42–1.47)
0.67 (0.41–1.09)
0.73 (0.47– 1.14)
1.28 (0.81–2.01)
Regional
1.41 (1.04– 1.91)
1.68 (1.17–2.41)
1.44 (1.08–1.91)
1.16 (0.89– 1.52)
1.50 (1.14–1.97)
Distant
2.76 (1.90– 4.01)
3.86 (2.56–5.82)
2.89 (2.02–4.13)
1.75 (1.23– 2.48)
2.10 (1.48–2.99)
Operation (yes)
0.82 (0.58– 1.16)
0.96 (0.64–1.43)
0.88 (0.63–1.24)
0.85 (0.62– 1.18)
1.15 (0.83–1.61)
Chemotherapy (yes)
1.55 (1.12– 2.13)
1.33 (0.90–1.97)
2.07 (1.53–2.82)
1.34 (1.03– 1.75)
1.27 (0.96–1.68)
Radiotherapy (yes)
1.37 (1.03– 1.83)
1.56 (1.12–2.15)
1.20 (0.92–1.58)
1.71 (1.34– 2.19)
1.36 (1.06–1.75)
Satisfaction (yes)
0.69 (0.53– 0.89)
0.57 (0.42–0.77)
0.67 (0.52–0.86)
0.61 (0.48– 0.76)
0.70 (0.55–0.88)
Cancer site
Cancer stage
Healthcare services
Follow treatment recommendations of doctor (all)
0.79 (0.41– 1.51)
0.69 (0.35–1.39)
0.55 (0.30–1.03)
0.76 (0.41– 1.39)
0.61 (0.34–1.11)
Trust in doctor (yes)
1.32 (0.90– 1.95)
1.16 (0.74–1.81)
1.65 (1.14–2.39)
1.61 (1.16– 2.23)
1.16 (0.84–1.61)
Sex, male (reference), female; age, 20– 64 years (reference), 65 years; education, middle school or less (reference), more than high school; marital status, married (reference), other; number of family members, 1 person (reference), 2 persons; income¼ ,$1779 (reference), $1779; place of residence, city or country (reference), metropolitan area; insurance status, NHI (reference), Medical Aid; smoking, non-smoker (reference), smoker; drinking, non-drinker (reference), drinker; comorbidity, no comorbidity (reference), comorbidity; age at diagnosis, 20– 64 years (reference), 65 years; time since diagnosis ,1 year (reference), 1 –5 years, .5 years; cancer site, stomach (reference), lung, liver, colon, breast, cervix; cancer stage, local (reference), regional, distant; operation, not received (reference), received; chemotherapy, not received (reference), received; radiotherapy, not received (reference), received; satisfaction, not satisfied (reference), satisfied; treatment compliance, some of the recommendations (reference), all of the recommendations; trust in doctor, no trust (reference), trust. a Each dimension of the EQ5D scale was a dependent variable; responses were grouped into two categories: no problem and problem. Data were adjusted for gender, age, education, marital status, family members, income, residence, insurance, smoking, drinking, comorbidity, age at diagnosis, time since diagnosis, cancer site and stage, operation, chemotherapy, radiotherapy, satisfaction, treatment compliance, trust in doctor. b Income: monthly household income ($1 ¼ 1124.1 KRW, mean in 2008).
who trusted their doctor scored significantly worse on usual activities and pain/discomfort. We had initially predicted that trust in doctors would be correlated with a better HRQoL, but
the results of this study showed the reverse association. This correlation seems to occur because patients who had difficulty with usual activities and who had pain/discomfort were more
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Residence (metropolitan)
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Comparing HRQoL of patients with cancer
Table 3. Multiple regression analysis using EQ5D visual analogue scale (VAS) scores of patients with cancer Variables
EQ5D VAS
b
T
P value
Demographic factors Sex (female)
0.014
Age (65 years)
0.372
0.710
0.027
0.611
0.541
Education (more than high school)
20.019
20.714
0.475
Marital status (othersa)
20.082
22.709
0.024
0.818
Family members (2 persons) b
Income ($1779)
Insurance (Medical Aid)
0.085
3.091
20.018
20.720
0.055
2.156
0.413 ,0.01 0.472 ,0.05
Health behaviors and clinical factors Smoking (no)
0.011
0.375
0.708
Drinking (no)
20.028
21.046
0.296
Comorbidity (no)
,0.01
0.072
2.837
20.028
20.641
0.521
1 –5 years
20.014
20.499
0.618
.5 years
20.048
21.682
0.093
Age at diagnosis (65 years) Time since diagnosis
Cancer site Lung
20.026
20.795
0.427
Liver
20.013
20.442
0.658
Colon
0.050
1.677
0.094
Breast
0.017
0.430
0.667
Cervix
0.020
0.632
0.527
Caner stage Regional
20.083
23.090
,0.01
Distant
20.139
24.960
,0.001
20.028
20.946
0.344
Healthcare services Operation (no) Chemotherapy (no)
0.031
1.075
0.282
Radiotherapy (no)
0.046
1.713
0.087
Satisfaction (no)
20.158
26.423
,0.001
Follow treatment recommendations of doctor (some)
20.015
20.624
0.533
Trust in doctor (no)
20.082
23.309
F
6.579
Adj. R 2
0.086
,0.01 ,0.001
Sex, male (reference), female; age, 20–64 years (reference), 65 years; education, middle school or less (reference), more than high school; marital status, married (reference), other; number of family members, 1 person (reference), 2 persons; income, ,$1779 (reference), $1779; place of residence, city or country (reference), metropolitan area; insurance status, NHI (reference), Medical Aid; smoking, smoker (reference), non-smoker; drinking, drinker (reference), non-drinker; comorbidity, comorbidity (reference), no comorbidity; age at diagnosis, 20– 64 years (reference), 65 years; time since diagnosis, ,1 year (reference), 1 –5 years, .5 years; cancer site, stomach (reference), lung, liver, colon, breast, cervix; cancer stage, local (reference), regional, distant; operation, received (reference), not received; chemotherapy, received (reference), not received; radiotherapy, received (reference), not received; satisfaction, satisfied (reference), not satisfied; treatment compliance, followed all treatment recommendations (reference), followed some treatment recommendations; trust in doctor, trust (reference), no trust. a Includes single, living separately, divorced and separated by death. b Income: monthly household income ($1 ¼ 1124.1 KRW, mean in 2008).
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Residence (metropolitan area)
,0.01
Jpn J Clin Oncol 2014;44(2)
Authors’ contributions Data access and responsibility: J.-H.P. and S.-Y.K. had full access to all data in the study and takes responsibility for the integrity of the data. Data collection: The following 1 National Cancer Center and 9 Regional Cancer Centers participated in this study and data collection (in alphabetical order): National Cancer Center (Goyang), Busan Regional Cancer Center, Chungbuk Regional Cancer Center, DaeguGyeongbuk Regional Cancer Center, Daejeon Regional Cancer Center, Gangwon Regional Cancer Center, Gyeongnam Regional Cancer Center, Jeju Regional Cancer Center, Jeonbuk Regional Cancer Center, and Jeonnam Regional Cancer Center.
Acknowledgements The work has not been presented in oral form previously. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, see: http://www.textcheck.com/certificate/yppTw6.
Funding The study was supported by a grant from the National Cancer Center, Korea (grant number 1210150).
Conflict of interest statement None declared.
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dependent on their doctor than were those with a better HRQoL related to mobility, self-care and anxiety/depression, leading to a deepening of the empathic and therapeutic alliance. On the other hand, contradictory results also showed that distrust in their physicians was not associated with physical HRQoL. Patients may have distrusted their physicians because health management activities were sometimes burdensome or painful or because they experienced a substantial reduction in support from their physician/organization over time after diagnosis (29 – 31). However, it is not possible to infer causality or directionality in this study because the data were cross-sectional. Our findings should be interpreted in light of their limitations. Our sampling method was not optimal, as we could not randomly sample or statistically assess the representativeness of our sample. In the original survey, with respect to cancer types we used quota sampling to obtain a similar distribution to the general Korean cancer population. However, in survey data, breast and cervical cancer showed relatively high proportional distribution. Considering the high incidence of these women’s cancers in younger ages and given that, in our study, younger ages and female participants numbered more than the entire distribution of cancer survivors in Korea, we believe that gender and age could be somewhat skewed for these types of cancers in our study. Additionally, due to the crosssectional design of our study, we were unable to determine causal relationships. Nevertheless, our study compared the HRQoL of patients who had the six most common cancers with that of the general population and examined the patients’ quality of life. Thus, findings from this study could provide a generalized comparison of the HRQoL between cancer survivors and the general public.
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21. Choi KH, Park JH, Park SM. Cancer patients’ information needs on health promotion and related factors: a multi-institutional, cross-sectional study in Korea. Support Care Cancer 2011;19:1495 –504. 22. Kim MH, Cho YS, Uhm WS, Kim S, Bae SC. Cross-cultural adaptation and validation of the Korean version of the EQ-5D in patients with rheumatic diseases. Qual Life Res 2005;14:1401–6. 23. Reeve BB, Potosky AL, Smith AW, et al. Impact of cancer on health-related quality of life of older Americans. J Natl Cancer Inst 2009;101:860–8. 24. Hammerlid E, Bjordal K, Ahlner-Elmqvist M, et al. A prospective study of quality of life in head and neck cancer patients. Part I: at diagnosis. Laryngoscope 2009;111:669– 80. 25. Vahdaninia M, Omidvari S, Montazeri A. What do predict anxiety and depression in breast cancer patients? A follow-up study. Soc Psychiatry Psychiatr Epidemiol 2010;45:355– 61. 26. Lidgren M, Wilking N, Jo¨nsson B, Rehnberg C. Health related quality of life in different states of breast cancer. Qual Life Res 2007;16:1073–81.
27. Vistad I, Fossa˚ SD, Dahl AA. A critical review of patient-rated quality of life studies of long-term survivors of cervical cancer. Gynecol Oncol 2006;102:563– 72. 28. Landoni F, Maneo A, Colombo A, et al. Randomised study of radical surgery versus radiotherapy for stage Ib – IIa cervical cancer. Lancet 1997;350:535 –40. 29. Waters EA, Arora NK, Klein WMP, Han PKJ. Perceived risk, trust and health-related quality of life among cancer survivors. Ann Behav Med 2010;39:91– 7. 30. Karnell LH, Christensen AJ, Rosenthal EL, Magnuson JS, Funk GF. Influence of social support on health-related quality of life outcomes in head and neck cancer. Head Neck 2006;29:143–6. 31. Arora NK, Finney Rutten LJ, Gustafson DH, Moser R, Hawkins RP. Perceived helpfulness and impact of social support provided by family, friends, and health care providers to women newly diagnosed with breast cancer. Psychooncology 2007;16:474– 86.
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Comparison of Health-related Quality of Life Between Cancer Survivors Treated in Designated Cancer Centers and the General Public in Korea Jung-A Lee1,2, So-Young Kim2, Yoon Kim1,3, Juhwan Oh4,5, Hyung-Jin Kim6, Deog-Yeon Jo7, Tae-Gyun Kwon8 and Jong-Hyock Park2,* 1
*For reprints and all correspondence: Jong-Hyock Park, Division of Cancer Policy and Management, National Cancer Control Research Institute, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410 – 769, Korea. E-mail: [email protected] Received May 29, 2013; accepted November 1, 2013
Objective: We assessed health-related quality of life in cancer survivors treated in designated cancer centers when compared with the general population in Korea. Methods: A multicenter survey was conducted from July through August 2008 using the quotasampling approach. A general population sample was drawn from the Fourth Korean National Health and Nutrition Examination Survey, second year. We compared the multivariate-adjusted least square means of cancer patients with those of the general population to examine relationships between EuroQol five-dimensional questionnaire components and cancer sites, cancer stage and time since diagnosis. The independent variables of responses to the EuroQol five-dimensional questionnaire were evaluated using logistic regression analysis. Results: Cancer patients scored significantly poorer on measures of self-care (means: stomach 1.25; lung 1.40; liver 1.27; colon 1.26; breast 1.27; cervical 1.29 vs. general 1.18), engagement in usual activities (means: stomach 1.47; lung 1.63; liver 1.45; colon 1.44; breast 1.46; cervical 1.47 vs. general 1.33) and anxiety/depression (means: stomach 1.41; lung 1.50; liver 1.41; colon 1.42; breast 1.50; cervical 1.47 vs. general 1.28). Those in the local stage scored significantly better on mobility (mean ¼ 1.35) than the general population (mean ¼ 1.40). Cancer patients, especially those with lung cancer, in the advanced stage and more than 5 years since diagnosis had poorer health-related quality of life than the general population. Some factors such as medical insurance and healthcare services were related to health-related quality of life among cancer patients. Conclusions: Health-related quality of life of cancer survivors with lung cancer at advanced stages, ,1 year earlier and more than 5 years since diagnosis was poorer than that for the noncancer control group, and these differences were statistically significant. Cancer survivors should be continuously observed and offered support. Key words: cancer – health-related quality of life – EQ5D – EQ-VAS
# The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
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Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, 2National Cancer Control Institute, National Cancer Center, Goyang, 3Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, 4Department of Medicine, Seoul National University College of Medicine, Seoul, 5Biomedical Research Institution, Seoul National University Hospital, Seoul, 6Jeonbuk Regional Cancer Center, Jeonju, 7Daejeon Regional Cancer Center, Daejeon and 8Daegu-Gyeongbuk Regional Cancer Center, Daegu, Korea
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PATIENTS AND METHODS
Quality of life is as important to patients with cancer as is their expected life span and other issues related to survival (1). Thus, as the quality of life of patients with cancer has come to be recognized as a robust indicator of their well-being, it has assumed new importance in studies (2). However, previous studies have shown that the quality of life of patients with cancer is worse than that of the general population in terms of physical, emotional and social functioning (3,4). Despite expectations of treatment effectiveness, an acceptable quality of life and a comfortable death, patients with cancer generally experience decreases in their quality of life as experiences of helplessness and despair emerge during prolonged medical treatment (e.g. surgery, chemotherapy or radiotherapy). Health-related quality of life (HRQoL) can be defined as the multidimensional influence of a disease and its treatment on the physical, psychological and social functioning and overall well-being of patients (5). A variety of tools are available to assess HRQoL. The EuroQol five-dimensional (EQ5D) questionnaire, developed by EuroQol Group, is a simple and generally applicable approach appropriate for large-scale evaluations of overall health status. The EQ5D is now widely accepted in many countries due to its availability in various languages as well as its appropriateness for use in diverse cultures and circumstances (6). Many previous studies have attempted to identify factors that affect the quality of life. For example, studies involving patients with cancer have evaluated factors such as age, ethnicity, income, education, alcohol use, smoking, comorbid conditions, treatment, stage of illness, time since diagnosis and recurrence as potential contributors to HRQoL (7 – 12). Examinations of the relationship between quality of life and demographic characteristics have indicated that the quality of life of those who are male, relatively young, earned more and were more highly educated is better than that of individuals without these characteristics (7 – 9,11,13 – 16). However, another study reported no significant differences in quality of life as a function of economic condition or level of education (17). Studies of clinical factors have reported that differences in the quality of life of patients undergoing chemotherapy and radiotherapy are related to cancer stage, especially among those in the early stage of the disease (8 – 10,18,19). However, most previous studies on HRQoL involved small numbers of patients with specific cancer types from single centers located in Western countries, and they therefore have limited generalizability in non-Western countries where social and cultural norms may be different. Thus, the independent influence of various cancers on HRQoL and comparisons between individuals with these cancers and the general population, as well as mixed results and the limitations mentioned above, preclude generalization of the findings. In this study, we investigated the difference in HRQoL between patients with cancer treated in designated cancer centers and the general population. Secondary objectives were to examine factors that contribute to HRQoL in patients with cancer.
STUDY POPULATION A nationwide multicenter survey involving one national and nine regional cancer centers (RCCs) was conducted from July to August 2008. The government designated three national university hospitals in provincial cities as RCCs in 2004. The other six national university hospitals were designated as RCCs in 2005 and 2006. The RCCs must perform their jobs responsibly to provide comprehensive clinical care for regional cancer patients and to facilitate the national cancer control programs. The National Cancer Center and the nine government-designated RCCs participated in the survey as representatives of all cancer centers in Korea. We used the following quota-sampling approach. Our aim was to recruit 200 – 300 Korean patients from each center; we attempted to build a sample in which 80% of participants had at least one of the six major types of cancer (stomach, lung, liver, colon and rectal, breast and cervical), and 20% had other types. In this survey, we set quotas with regard to sex, age, residential location and cancer type to make sure that our sample represented the demographic distribution of Korea as shown in the most recent adult population. Detailed procedures have been described in previous studies (20,21). In total, 2661 completed surveys were collected. The following inclusion criteria were used: older than 20 years of age, used the inpatient or outpatient facilities of at least one of these 10 cancer centers, at least 4 months since diagnosis and in current or follow-up treatment. After we reviewed the questionnaires for completeness and to identify individuals with the six most common cancers, 1608 patients who provided consent remained in the study. This study was approved by the Institutional Review Board of the National Cancer Center in Korea. Data on the general population were drawn from those collected during 2008, the second year of the Fourth Korean National Health and Nutrition Examination Survey, a crosssectional and nationally representative survey on the health and nutritional status of the non-institutionalized Korean population. The participants were chosen by proportional allocation-systematic sampling using multistage stratification (age, sex and region). Of the 9308 participants who finished the health examination and health questionnaire, data from 5443 cancer-free individuals (58.5%) aged 20 were included in the analyses. We excluded individuals who had been diagnosed with cancer by a physician and had been treated for cancer.
QUESTIONNAIRE The study also included the EQ5D, a measure of HRQoL, and questions regarding sociodemographic and medical variables, stress, depression and suicidal thoughts (22). The EQ5D questionnaire is a simple two-page measure of generic HRQoL. On the first page (the ‘self-classifier’ section), respondents
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INTRODUCTION
Jpn J Clin Oncol 2014;44(2)
report on the extent of their problems in each of five dimensions with higher scores reflecting more negative outcomes: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. On the second page, they record their perceptions of their overall health using a visual analogue scale (EQ-VAS). EQ-VAS scores range between 0 (worst imaginable health) and 100 (best imaginable health). The accuracy of the medical information about site and stage of cancer (SEER stage) was ascertained by checking this information with data from medical records. Comorbidity information was obtained from the patient survey. STATISTICAL ANALYSES
RESULTS CHARACTERISTICS OF CANCER PATIENTS AND THE GENERAL POPULATION Table 1 presents the distributions of participants in terms of demographic characteristics, health-related behaviors, clinical status and utilization of healthcare services in 2008. Among the patients with cancer, females were slightly more numerous (51.3%) than males. Most patients had attended middle school or less, were married, lived with more than two family members, earned less than $1779.00 (US dollars) per month, lived in the city or country, had national health insurance (NHI), did not smoke, did not drink, had no comorbid conditions, had undergone surgery/chemotherapy, had not received
radiotherapy, were satisfied with the healthcare services they received, participated in all treatments recommended by their doctor and trusted their doctor. More than three-quarters of the sample (76.4%) were diagnosed at 20 – 64 years of age, 49.6% had been diagnosed 1 – 5 years ago and 86.2% were in either the ‘in situ/local’ or a ‘regional’ stage of the disease. Of the 5443 members of the general population included in this study, 59.5% were female, and 76.1% were 20 – 64 years of age. The majority had more than a high school education, were married, lived with more than two family members, had monthly incomes of more than $1779.00, lived in the city or country, had NHI, did not smoke, did not drink and had no comorbid conditions. COMPARISON OF HRQOL OF PATIENTS WITH CANCER AND THE GENERAL POPULATION ACCORDING TO CANCER SITE, STAGE AND TIME SINCE DIAGNOSIS Compared with the general population, those with the six major forms of cancer (stomach, lung, liver, colon/rectum, breast and cervix) had significantly higher LS mean scores on the self-care, usual activities and anxiety/depression scales of the EQ5D, and those with lung or breast scored significantly higher on the EQ5D scales for pain/discomfort after adjusting for sex, age, education, marital status, household income, place of residence, insurance, smoking, drinking and comorbidity, which were associated with QOL in previous studies (12,16 – 18) (Fig. 1). Those with lung cancer scored significantly higher on the EQ5D scale for mobility compared with the general population after adjusting for the same variables. In terms of cancer stage, those in the regional and distant stages scored significantly higher than those in the general population on four of the EQ5D scales; the exception was the pain/discomfort scale (Fig. 2). Those in the local stage scored significantly lower on the EQ5D scales than the general population. Two groups (regional and distant) scored significantly higher on the EQ5D pain/discomfort scale than the general population after adjusting for the same variables. In general, patients in the advanced stages of illness scored higher on all dimensions of the EQ5D scale. With respect to time since diagnosis, a reflection of survival time, all three groups (,1, 1 – 5, .5 years) scored significantly higher than the general population on all EQ5D scales except that addressing mobility; however, those who had been diagnosed ,1 year or more than 5 years ago scored significantly higher on the EQ5D mobility scale, when compared with the general population after adjusting for the same variables (Fig. 3). Additionally, those diagnosed ,1 year or more than 5 years ago scored higher on all dimensions of the EQ5D scale compared with those who had been diagnosed 1 – 5 years ago. The distribution of cancer types showed little variation according to time since diagnosis. Because this study population had a broad age range, the subjects were stratified into categories of 20 – 64 and more than 65 years of age. The results showed little variation by age
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The original responses to the EQ5D self-classifier section (no problems, some or moderate problems and extreme problems or unable to function) were collapsed into two categories (no problem and any problem). The proportions of patients reporting any problem were compared with the cancer-free general population, which served as the reference group. We compared the multivariate-adjusted least square (LS) means of the patients with those of the general population to examine the relationships between EQ5D components and cancer sites, cancer stage and time since diagnosis. The independent influence of demographic information including gender, age, education, marital status, family members, income, residence, insurance, health behaviors (including smoking, drinking, comorbidity), age at diagnosis, time since diagnosis, cancer site and stage and healthcare services (including operation, chemotherapy, radiotherapy, satisfaction, treatment compliance, trust in doctor) on each dimension of the EQ5D scale was examined using multivariate logistic regression analysis. Patients who experienced any problems were part of the reference group. Additional multiple regression analyses explored relationships among demographic characteristics, health-related behaviors and clinical indicators, as well as the overall EQ-VAS (a continuous variable). P values ,0.05 indicated statistical significance, and all data analyses were performed using the SPSS statistical software (ver. 21.0; SPSS, Inc., Chicago, IL, USA).
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Table 1. Characteristics of the patients with cancer and the general population
Table 1. Continued
Variables
Variables
Patients with cancer (n ¼ 1608)
General population (n ¼ 5443)
Demographic factors
Patients with cancer (n ¼ 1608)
Cancer site
Gender
Stomach
379 (23.6)
Male
783 (48.7)
2205 (40.5)
Lung
261 (16.2)
Female
825 (51.3)
3238 (59.5)
Liver
167 (10.4)
Colon
282 (17.5)
Breast
345 (21.5)
Cervix
174 (10.8)
Age (years) 20–64
1091 (67.8)
4144 (76.1)
Mean + SD
51.5 + 8.3
45.3 + 10.2
65 Mean + SD
517 (32.2) 70.4 + 4.4
1299 (23.9) 72.3 + 5.6
Middle school or less
832 (51.7)
2431 (44.7)
More than high school
776 (48.3)
3012 (55.3)
Marital status
Cancer stage Local
994 (61.8)
Regional
393 (24.4)
Distant
221 (13.7)
Healthcare services Operation
Married
1360 (84.6)
4522 (83.1)
Yes
1283 (79.8)
Othersa
248 (15.4)
921 (16.9)
No
325 (20.2)
138 (8.6)
356 (6.5)
1470 (91.4)
5087 (93.5)
Family members (n) 2
Chemotherapy
Income ($)b 1075 (66.9)
2374 (43.6)
1779
533 (33.1)
3069 (56.4)
Residence
Metropolitan area
Medical Aid
1084 (67.4)
No
524 (32.6)
Yes
519 (32.3)
No
1089 (67.7)
Satisfaction 1117 (69.5)
3209 (59.0)
Yes
1109 (69.0)
491 (30.5)
2234 (41.0)
No
499 (31.0)
Insurance NHI
Yes
Radiotherapy
,1779
City or country
Follow treatment recommendations of doctor 1446 (89.9)
5255 (96.5)
162 (10.1)
188 (3.5)
Health behaviors and clinical factors
All Some
Yes
452 (28.1)
1136 (20.9)
No
1156 (71.9)
4307 (79.1)
Drinking
50 (3.1)
Yes
1396 (86.8)
No
212 (13.2)
EQ5D dimensions Mobility
Yes
692 (43.0)
2794 (51.3)
Extreme problems
No
916 (57.0)
2649 (48.7)
Some problems
Yes
483 (30.0)
2347 (43.1)
Self-care
No
1125 (70.0)
3096 (56.9)
Extreme problems
Comorbidity
No problems
Age at diagnosis (years) 65
1558 (96.9)
Trust in doctor
Smoking
20–64
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Education
1
General population (n ¼ 5443)
Some problems 1228 (76.4)
No problems
380 (23.6)
Usual activities
Time since diagnosis (years)
Extreme problems
,1
564 (35.1)
Some problems
1 –5
798 (49.6)
No problems
.5
246 (15.3)
28 (1.7)
43 (0.8)
403 (25.1)
1109 (20.4)
1177 (73.2)
4291 (78.8)
40 (2.5)
37 (0.7)
222 (13.8)
266 (4.9)
1346 (83.7)
5140 (94.4)
51 (3.2)
76 (1.4)
451 (28.0)
694 (12.8)
1106 (68.8)
4673 (85.9) Continued
Continued
Jpn J Clin Oncol 2014;44(2)
Table 1. Continued Variables
Patients with cancer (n ¼ 1608)
General population (n ¼ 5443)
Pain/discomfort Extreme problems
74 (4.6)
239 (4.4)
Some problems
609 (37.9)
1494 (27.4)
No problems
925 (57.5)
3710 (68.2)
Anxiety/depression Extreme problems Some problems No problems
47 (2.9)
81 (1.5)
498 (31.0)
810 (14.9)
1063 (66.1)
4552 (83.6)
chemotherapy (OR ¼ 2.07, 95% CI ¼ 1.53 – 2.82) and trusting the doctor (OR ¼ 1.65, 95% CI ¼ 1.14 – 2.39) were strongly associated with higher scores on the EQ5D scale measuring typical activities, when compared with other characteristics. Being female (OR ¼ 1.96, 95% CI ¼ 1.40 – 2.74), being in the distant stage (OR ¼ 1.75, 95% CI ¼ 1.23 – 2.48), undergoing chemotherapy or radiotherapy (OR ¼ 1.34, 95% CI ¼ 1.03– 1.75; OR ¼ 1.71, 95% CI ¼ 1.34– 2.19) and trusting the doctor (OR ¼ 1.61, 95% CI ¼ 1.16 – 2.23) were more strongly associated with higher scores on the EQ5D scale measuring pain and discomfort relative to other characteristics. Being female (OR ¼ 1.48, 95% CI ¼ 1.05 – 2.10), being in the regional or distant stage (OR ¼ 1.50, 95% CI ¼ 1.14 – 1.97; OR ¼ 2.10, 95% CI ¼ 1.48 – 2.99) and undergoing radiotherapy (OR ¼ 1.36, 95% CI ¼ 1.06 – 1.75) were more closely associated with higher scores on the EQ5D scale for anxiety/depression than the other characteristics. FACTORS OF OVERALL HRQOL ACCORDING TO THE MULTIPLE REGRESSION ANALYSIS
and were consistent with former studies showing that cancer patients and advanced cancer scored significantly higher on the EQ5D scale (data not shown). FACTORS OF HRQOL ACCORDING TO THE LOGISTIC ANALYSIS Table 2 presents the results of the multivariate logistic regression analysis examining the predictive power of demographic characteristics, health-related behaviors, clinical status and utilization of healthcare services on EQ5D dimensions. Having Medical Aid insurance [odds ratio (OR) ¼ 1.89, 95% confidence interval (CI) ¼ 1.29 – 2.78], suffering from a comorbid condition (OR ¼ 1.31, 95% CI ¼ 1.00 – 1.72), being over 65 years of age at diagnosis (OR ¼ 2.19, 95% CI ¼ 1.35 – 3.58), having been diagnosed more than 5 years ago (OR ¼ 1.83, 95% CI ¼ 1.24 – 2.71), having lung cancer (OR ¼ 1.67, 95% CI ¼ 1.10 – 2.53), being in the regional or distant stage (OR ¼ 1.41, 95% CI ¼ 1.04 – 1.91; OR ¼ 2.76, 95% CI ¼ 1.90 – 4.01) and undergoing chemotherapy and/or radiotherapy (OR ¼ 1.55, 95% CI ¼ 1.12 – 2.13; OR ¼ 1.37, 95% CI ¼ 1.03 – 1.83) were associated with higher mobility scores on the EQ5D scale compared with other characteristics. Having Medical Aid insurance (OR ¼ 1.60, 95% CI ¼ 1.03 – 2.48), having been diagnosed more than 5 years ago (OR ¼ 1.95, 95% CI ¼ 1.25 – 3.04), being in the regional or distant stage (OR ¼ 1.68, 95% CI ¼ 1.17 – 2.41; OR ¼ 3.86, 95% CI ¼ 2.56 – 5.82) and undergoing radiotherapy (OR ¼ 1.56, 95% CI ¼ 1.12 – 2.15) were more closely associated with higher EQ5D scores for self-care compared with other characteristics. Being female (OR ¼ 1.60, 95% CI ¼ 1.12 – 2.29), having Medical Aid insurance (OR ¼ 1.67, 95% CI ¼ 1.14 – 2.44), being in the regional or distant stage (OR ¼ 1.44, 95% CI ¼ 1.08 – 1.91; OR ¼ 2.89, 95% CI ¼ 2.02 – 4.13), undergoing
The multiple regression analysis identified the following independent variables of lower EQ-VAS scores: not being married (i.e. separated, widowed, divorced), having a lower monthly family income, having NHI, having a comorbid condition, being in the regional or distant cancer stage, not being satisfied with healthcare services and not trusting the doctor (Table 3).
DISCUSSION This study measured the HRQoL of patients with the six most common types of cancer, compared these data with those from a sample of the general population, and tried to identify the factors that contribute to the HRQoL of patients with cancer. Reeve et al. (23) compared older patients with nine different types of cancer to individuals without cancer. Their study found that all cancer patients, except those with melanoma and endometrial cancer, had significantly worse physical health than patients without cancer, and that colorectal, prostate and lung cancer patients reported worse mental health scores than the control group. Our study comparing Korean patients with cancer to the general population found that all patients with cancer scored significantly poorer on scales measuring self-care, usual activities and anxiety/depression. With regard to pain/discomfort, those with lung or breast cancer scored worse than did those in the general population. These results are similar to those of Reeve et al., who used different measurement tools. However, their study did not include stomach and cervical cancer. Those with lung cancer emerged as especially compromised compared with members of the general public with regard to all dimensions of the HRQoL; this group seems to have a particularly strong need for continuous management and support.
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SD, standard deviation; NHI, national health insurance; EQ5D, EuroQol five-dimensional. Includes single, living separately, divorced and separation by death. b Income: monthly household income ($1 ¼ 1124.1 KRW, based on the mean 2008 exchange rate). a
145
146
Comparing HRQoL of patients with cancer
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Figure 1. Adjusted least square (LS) mean values of EuroQol five-dimensional (EQ5D) dimensions according to cancer type. **P , 0.001; P value for each cancer type was compared with data for the general population (reference group). The samples included 379 stomach, 261 lung, 167 liver, 282 colon, 345 breast and 174 cervical cancer patients, and 5443 reference individuals.
Additionally, comparisons between cancer patients and the general population based on the stage of cancer revealed that all of those in the local, regional and distant stages scored worse on measures of mobility, self-care, usual activities and anxiety/depression, and those in the regional and distant stage had poorer scores on all dimensions of the HRQoL. In a prospective study of head and neck cancer, patients with more
advanced disease (Stages III – IV) scored worse than patients with Stages I – II (24). This may be because patients with advanced cancer were more often bothered by problems with their physical and mental functioning. Similarly, the patients who were diagnosed ,1 year earlier had poorer mobility, self-care, usual activities and pain/discomfort scores, but these variables showed relative recovery
Jpn J Clin Oncol 2014;44(2)
147
Downloaded from http://jjco.oxfordjournals.org/ at University of Manitoba on June 7, 2015 Figure 2. Adjusted LS mean values of EQ5D dimensions according to cancer stage. **P , 0.001, *P , 0.05; P value for each cancer stage was compared with data for the general population (reference group). There were 994 local, 393 regional and 221 distant cancer patients, and 5443 reference individuals.
or stable tendencies in patients 1 – 5 years after diagnosis. However, they deteriorated again in patients more than 5 years since diagnosis. Additionally, the anxiety and depression scores were consistently worse in cancer patients than in the general population. Therefore, cancer patients should be continuously observed and offered support for physical and psychosocial functioning. HRQoL and related factors were analyzed using each of the five dimensions of the EQ5D questionnaire as a dependent variable. First, patients with at least a high school education scored better on mobility and usual activities, and higher family income was also related to better HRQoL with regard
to mobility and self-care. These findings are consistent with those of prior studies showing that higher income and more education have positive effects on the HRQoL (14,15,25). Secondly, patients with Medical Aid insurance had lower scores for mobility, self-care and usual activities, indicating that economic status affects the quality of life, probably because basic needs cannot be met and general satisfaction with life is reduced by comparing oneself with others. Additionally, patients in the regional or distant cancer stage scored worse on all dimensions of the HRQoL scale than the reference group. This finding is consistent with the results of other studies (3). Thus, the degree to which cancer has
148
Comparing HRQoL of patients with cancer
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Figure 3. Adjusted LS mean values of EQ5D dimensions according to time since cancer diagnosis. **P , 0.001, *P, 0.05; P value for each period since cancer diagnosis was compared with data for the general population (reference group). There were 564 individuals with ,1 year, 798 individuals with 1 –5 years and 246 with .5 years since diagnosis, and 5443 reference individuals.
progressed affects the quality of life owing to its impact on physical pain, fear of the disease and the emotional burden associated with the condition. Thirdly, patients receiving chemotherapy had lower scores on measures of mobility, usual activities and pain/discomfort, and patients receiving radiotherapy scored worse on measures of mobility, self-care, pain/discomfort and anxiety/depression. Contrary to earlier reports that chemotherapy and radiotherapy increase overall HRQoL 1 year after surgery, these data suggest that the HRQoL decreases as a function of increasing limitations in some areas of physical functioning (26).
Radiotherapy is generally more strongly associated with decreased HRQoL than surgery or chemotherapy (27,28). Also, the previous studies were longitudinal studies based on randomized controlled trials, in which patients who had received surgery were included in the surgery-only group, but the same patients may have also been included in the combined treatment group at a later point in time. Our study indicates that chemotherapy, surgery and radiation reduce patients’ HRQoL because they are difficult processes for the patients. Patients who were satisfied with healthcare services demonstrated better HRQoL in all dimensions, and patients
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Table 2. Logistic model for EQ5D dimensions of patients with cancer Variables
Mobilitya
Self-carea
Usual activitiesa
Pain/discomforta
Anxiety/depressiona
Demographic factors Gender (female)
1.41 (0.97– 2.05)
1.18 (0.76–1.82)
1.60 (1.12–2.29)
1.96 (1.40– 2.74)
1.48 (1.05–2.10)
Age (65 years)
1.09 (0.68– 1.72)
0.85 (0.49–1.48)
1.25 (0.81–1.94)
0.82 (0.54– 1.24)
0.93 (0.61–1.43)
Education (more than high school)
0.75 (0.57– 0.99)
0.88 (0.64–1.21)
0.76 (0.59–0.99)
0.97 (0.76– 1.23)
1.20 (0.94–1.53)
Marital status (other)
1.34 (0.90– 1.99)
1.02 (0.64–1.64)
1.17 (0.80–1.72)
1.31 (0.91– 1.88)
0.94 (0.65–1.36)
Family members (2)
1.19 (0.72– 1.96)
0.73 (0.41–1.29)
0.92 (0.57–1.48)
0.82 (0.52– 1.30)
0.70 (0.44–1.11)
Income ($1779)b
0.53 (0.39– 0.73)
0.57 (0.39–0.84)
0.78 (0.59–1.04)
0.80 (0.62– 1.03)
0.86 (0.66–1.12)
0.82 (0.62– 1.08)
0.94 (0.68–1.29)
0.76 (0.58–0.98)
1.17 (0.93– 1.48)
1.00 (0.79–1.27)
Insurance (Medical Aid)
1.89 (1.29– 2.78)
1.60 (1.03–2.48)
1.67 (1.14–2.44)
1.02 (0.70– 1.47)
1.36 (0.94–1.97)
Smoking (yes)
1.04 (0.75– 1.45)
0.98 (0.67–1.44)
0.89 (0.65–1.21)
1.10 (0.82– 1.47)
1.22 (0.91–1.66)
Drinking (yes)
0.90 (0.68– 1.20)
0.83 (0.60–1.16)
1.06 (0.81–1.38)
1.07 (0.84– 1.36)
0.96 (0.75–1.23)
Comorbidity (yes)
1.31 (1.00– 1.72)
1.30 (0.95–1.78)
1.22 (0.94–1.58)
1.02 (0.80– 1.29)
1.05 (0.82–1.35)
Age at diagnosis (65 years)
2.19 (1.35– 3.58)
1.68 (0.94–3.03)
1.31 (0.82–2.09)
1.42 (0.90– 2.22)
1.00 (0.63–1.59)
Health behaviors and clinical factors
Time since diagnosis 1–5 years
1.01 (0.77– 1.34)
0.88 (0.63–1.22)
0.90 (0.69–1.17)
0.93 (0.73– 1.18)
1.11 (0.87–1.41)
.5 years
1.83 (1.24– 2.71)
1.95 (1.25–3.04)
1.28 (0.88–1.85)
0.93 (0.66– 1.31)
0.96 (0.67–1.36)
Lung
1.67 (1.10– 2.53)
1.38 (0.85–2.26)
1.17 (0.78–1.75)
1.28 (0.87– 1.88)
1.04 (0.70–1.55)
Liver
1.41 (0.87– 2.28)
1.33 (0.75–2.36)
1.31 (0.83–2.06)
1.12 (0.74– 1.71)
1.21 (0.78–1.87)
Colon
0.98 (0.66– 1.45)
0.85 (0.52–1.38)
0.72 (0.50–1.05)
0.83 (0.59– 1.17)
0.95 (0.66–1.36)
Breast
0.77 (0.48– 1.26)
0.88 (0.50–1.55)
0.55 (0.35–0.87)
0.85 (0.57– 1.28)
1.18 (0.77–1.79)
Cervix
0.88 (0.52– 1.48)
0.78 (0.42–1.47)
0.67 (0.41–1.09)
0.73 (0.47– 1.14)
1.28 (0.81–2.01)
Regional
1.41 (1.04– 1.91)
1.68 (1.17–2.41)
1.44 (1.08–1.91)
1.16 (0.89– 1.52)
1.50 (1.14–1.97)
Distant
2.76 (1.90– 4.01)
3.86 (2.56–5.82)
2.89 (2.02–4.13)
1.75 (1.23– 2.48)
2.10 (1.48–2.99)
Operation (yes)
0.82 (0.58– 1.16)
0.96 (0.64–1.43)
0.88 (0.63–1.24)
0.85 (0.62– 1.18)
1.15 (0.83–1.61)
Chemotherapy (yes)
1.55 (1.12– 2.13)
1.33 (0.90–1.97)
2.07 (1.53–2.82)
1.34 (1.03– 1.75)
1.27 (0.96–1.68)
Radiotherapy (yes)
1.37 (1.03– 1.83)
1.56 (1.12–2.15)
1.20 (0.92–1.58)
1.71 (1.34– 2.19)
1.36 (1.06–1.75)
Satisfaction (yes)
0.69 (0.53– 0.89)
0.57 (0.42–0.77)
0.67 (0.52–0.86)
0.61 (0.48– 0.76)
0.70 (0.55–0.88)
Cancer site
Cancer stage
Healthcare services
Follow treatment recommendations of doctor (all)
0.79 (0.41– 1.51)
0.69 (0.35–1.39)
0.55 (0.30–1.03)
0.76 (0.41– 1.39)
0.61 (0.34–1.11)
Trust in doctor (yes)
1.32 (0.90– 1.95)
1.16 (0.74–1.81)
1.65 (1.14–2.39)
1.61 (1.16– 2.23)
1.16 (0.84–1.61)
Sex, male (reference), female; age, 20– 64 years (reference), 65 years; education, middle school or less (reference), more than high school; marital status, married (reference), other; number of family members, 1 person (reference), 2 persons; income¼ ,$1779 (reference), $1779; place of residence, city or country (reference), metropolitan area; insurance status, NHI (reference), Medical Aid; smoking, non-smoker (reference), smoker; drinking, non-drinker (reference), drinker; comorbidity, no comorbidity (reference), comorbidity; age at diagnosis, 20– 64 years (reference), 65 years; time since diagnosis ,1 year (reference), 1 –5 years, .5 years; cancer site, stomach (reference), lung, liver, colon, breast, cervix; cancer stage, local (reference), regional, distant; operation, not received (reference), received; chemotherapy, not received (reference), received; radiotherapy, not received (reference), received; satisfaction, not satisfied (reference), satisfied; treatment compliance, some of the recommendations (reference), all of the recommendations; trust in doctor, no trust (reference), trust. a Each dimension of the EQ5D scale was a dependent variable; responses were grouped into two categories: no problem and problem. Data were adjusted for gender, age, education, marital status, family members, income, residence, insurance, smoking, drinking, comorbidity, age at diagnosis, time since diagnosis, cancer site and stage, operation, chemotherapy, radiotherapy, satisfaction, treatment compliance, trust in doctor. b Income: monthly household income ($1 ¼ 1124.1 KRW, mean in 2008).
who trusted their doctor scored significantly worse on usual activities and pain/discomfort. We had initially predicted that trust in doctors would be correlated with a better HRQoL, but
the results of this study showed the reverse association. This correlation seems to occur because patients who had difficulty with usual activities and who had pain/discomfort were more
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Residence (metropolitan)
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Comparing HRQoL of patients with cancer
Table 3. Multiple regression analysis using EQ5D visual analogue scale (VAS) scores of patients with cancer Variables
EQ5D VAS
b
T
P value
Demographic factors Sex (female)
0.014
Age (65 years)
0.372
0.710
0.027
0.611
0.541
Education (more than high school)
20.019
20.714
0.475
Marital status (othersa)
20.082
22.709
0.024
0.818
Family members (2 persons) b
Income ($1779)
Insurance (Medical Aid)
0.085
3.091
20.018
20.720
0.055
2.156
0.413 ,0.01 0.472 ,0.05
Health behaviors and clinical factors Smoking (no)
0.011
0.375
0.708
Drinking (no)
20.028
21.046
0.296
Comorbidity (no)
,0.01
0.072
2.837
20.028
20.641
0.521
1 –5 years
20.014
20.499
0.618
.5 years
20.048
21.682
0.093
Age at diagnosis (65 years) Time since diagnosis
Cancer site Lung
20.026
20.795
0.427
Liver
20.013
20.442
0.658
Colon
0.050
1.677
0.094
Breast
0.017
0.430
0.667
Cervix
0.020
0.632
0.527
Caner stage Regional
20.083
23.090
,0.01
Distant
20.139
24.960
,0.001
20.028
20.946
0.344
Healthcare services Operation (no) Chemotherapy (no)
0.031
1.075
0.282
Radiotherapy (no)
0.046
1.713
0.087
Satisfaction (no)
20.158
26.423
,0.001
Follow treatment recommendations of doctor (some)
20.015
20.624
0.533
Trust in doctor (no)
20.082
23.309
F
6.579
Adj. R 2
0.086
,0.01 ,0.001
Sex, male (reference), female; age, 20–64 years (reference), 65 years; education, middle school or less (reference), more than high school; marital status, married (reference), other; number of family members, 1 person (reference), 2 persons; income, ,$1779 (reference), $1779; place of residence, city or country (reference), metropolitan area; insurance status, NHI (reference), Medical Aid; smoking, smoker (reference), non-smoker; drinking, drinker (reference), non-drinker; comorbidity, comorbidity (reference), no comorbidity; age at diagnosis, 20– 64 years (reference), 65 years; time since diagnosis, ,1 year (reference), 1 –5 years, .5 years; cancer site, stomach (reference), lung, liver, colon, breast, cervix; cancer stage, local (reference), regional, distant; operation, received (reference), not received; chemotherapy, received (reference), not received; radiotherapy, received (reference), not received; satisfaction, satisfied (reference), not satisfied; treatment compliance, followed all treatment recommendations (reference), followed some treatment recommendations; trust in doctor, trust (reference), no trust. a Includes single, living separately, divorced and separated by death. b Income: monthly household income ($1 ¼ 1124.1 KRW, mean in 2008).
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Residence (metropolitan area)
,0.01
Jpn J Clin Oncol 2014;44(2)
Authors’ contributions Data access and responsibility: J.-H.P. and S.-Y.K. had full access to all data in the study and takes responsibility for the integrity of the data. Data collection: The following 1 National Cancer Center and 9 Regional Cancer Centers participated in this study and data collection (in alphabetical order): National Cancer Center (Goyang), Busan Regional Cancer Center, Chungbuk Regional Cancer Center, DaeguGyeongbuk Regional Cancer Center, Daejeon Regional Cancer Center, Gangwon Regional Cancer Center, Gyeongnam Regional Cancer Center, Jeju Regional Cancer Center, Jeonbuk Regional Cancer Center, and Jeonnam Regional Cancer Center.
Acknowledgements The work has not been presented in oral form previously. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, see: http://www.textcheck.com/certificate/yppTw6.
Funding The study was supported by a grant from the National Cancer Center, Korea (grant number 1210150).
Conflict of interest statement None declared.
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dependent on their doctor than were those with a better HRQoL related to mobility, self-care and anxiety/depression, leading to a deepening of the empathic and therapeutic alliance. On the other hand, contradictory results also showed that distrust in their physicians was not associated with physical HRQoL. Patients may have distrusted their physicians because health management activities were sometimes burdensome or painful or because they experienced a substantial reduction in support from their physician/organization over time after diagnosis (29 – 31). However, it is not possible to infer causality or directionality in this study because the data were cross-sectional. Our findings should be interpreted in light of their limitations. Our sampling method was not optimal, as we could not randomly sample or statistically assess the representativeness of our sample. In the original survey, with respect to cancer types we used quota sampling to obtain a similar distribution to the general Korean cancer population. However, in survey data, breast and cervical cancer showed relatively high proportional distribution. Considering the high incidence of these women’s cancers in younger ages and given that, in our study, younger ages and female participants numbered more than the entire distribution of cancer survivors in Korea, we believe that gender and age could be somewhat skewed for these types of cancers in our study. Additionally, due to the crosssectional design of our study, we were unable to determine causal relationships. Nevertheless, our study compared the HRQoL of patients who had the six most common cancers with that of the general population and examined the patients’ quality of life. Thus, findings from this study could provide a generalized comparison of the HRQoL between cancer survivors and the general public.
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