Qual Life Res DOI 10.1007/s11136-014-0831-4
Quality of life profile in Italian long-term cancer survivors Barbara Muzzatti • Cristiana Flaiban • Antonella Surbone • Maria Antonietta Annunziata
Accepted: 17 October 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Understanding the quality of life (QoL) of longterm cancer survivors is relevant to daily clinical practice as well as to healthcare policy. This study assessed QoL of Italian survivors and tested the association between QoL and the main clinical and socio-demographic sample’s characteristics. Methods Two hundred and sixty-five Italian adult longterm cancer survivors (people free from cancer and its treatments for at least 5 years) were administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the Impact of Cancer, and the Short Form 36 questionnaires obtaining three different QoL profiles—cancer-specific, survivorshipspecific, and generic. Results In both cancer-specific and generic QoL profiles, participants reported a lower general health and a higher social functioning than normative samples; in addition, they reported low emotional functioning and vitality, respectively, in the former and latter profile. In the survivorshipspecific profile, participants scored higher on personal growth and altruism (p \ 0.001) and lower on dissatisfaction and life interferences (p \ 0.001). Males reported less dissatisfaction and life interferences (p \ 0.001), and less pain (p \ 0.001) than females. Employed participants reported higher physical functioning (p = 0.001) and fewer role limitations (p \ 0.001) than unemployed participants. B. Muzzatti C. Flaiban M. A. Annunziata (&) Unit of Oncological Psychology, CRO Aviano National Cancer Institute, Via F. Gallini, 2, 33081 Aviano, PN, Italy e-mail: [email protected] A. Surbone Department of Medicine, New York University, New York, NY, USA
Differences according to cancer type were recorded only in survivorship-specific domains (p \ 0.004). No association between survivorship length and any of the three QoL profiles was found. Finally, the absence of other reported health issues was associated to higher functioning in the majority of cancer-specific and generic QoL domains. Conclusions Our data support the usefulness of multidisciplinary follow-ups for long-term cancer survivors and the need to pay particular attention to the psycho-emotional long-term and late-presenting sequels of cancer and its treatment. Keywords Adults Long-term cancer survivorship Oncology Quality of life Questionnaire
Introduction Long-term survivorship has increasingly become a reality for people with cancer. In Italy, the average rate of [5 years survival since cancer diagnosis is 57 %, corresponding to the 2.2 % of the entire Italian population [1], and from 1990 to 2007, 5-year standardized relative survival has increased by 15 % for all cancers except skin cancer [2]. Being a cancer survivor very often means having to face new (i.e., late-presenting) and/or known (i.e., long-term) effects, both psychosocial and physical, that can impact QoL years after treatment completion. Fatigue, pain, musculoskeletal problems, sexual dysfunction, anxiety, depression, and cognitive limitations are some of the effects which can be found during treatment, and which can also characterize long-term cancer survivorship [3–5]. More specific long-term effects such as relapses, iatrogenic tumors, fear of cancer recurrence, and limitations in restarting one’s work or one’s pre-illness
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functioning are frequently reported by survivors [3–6]. Long-term cancer survivorship may also be accompanied by positive changes such as improved self-esteem, greater life appreciation and sense of meaning, heightened spirituality, and greater feelings of peace and purposefulness, as summarized in the concept of post-traumatic growth [7]. Understanding long-term cancer survivors’, QoL can inform healthcare policy as well as offer help in supporting individual patients. In Italy, services aimed specifically at long-term cancer survivors are rare and generally only offered as part of research studies. Consequently, few data are available for Italian cancer survivors, defined as persons with a diagnosis of cancer who have been free from the disease and its treatments for at least 5 years [8]. A recent Italian survey [9] found that women diagnosed with breast cancer reported having a poor QoL (measured as physical and mental functioning) even many years after treatment completion. Similar differences in QoL in comparison to the general population were reported United Kingdom study [10]. Other studies, however, have not shown substantial differences in terms of QoL between survivors and general population [11, 12]. The chief aim of the present work was to investigate QoL in a sample of Italian long-term cancer survivors. Three questionnaires—for assessing QoL in cancer patients at different stages of their disease trajectory European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (the EORTC QLQC30), for assessing specificities in the condition of the cancer survivorship the Impact of Cancer (IOC), and a generic QoL measure (the SF-36) commonly used in different clinical settings as well as for general populations— were administered. A secondary study aim was to explore associations between the three obtained QoL profiles (cancer-specific, survivorship-specific, and generic) and the main socio-demographic and clinical characteristics of the sample. The hypotheses of the study were: (1) differences in QoL domains would point to the need for multidimensional assessment of QoL in long-term cancer survivors; in particular, we expected higher scores in domains related to physical functioning and spirituality than in those referring to psychological areas; and (2) QoL would be affected by socio-demographic and clinical variables of gender, age, education, marital status, occupational status, cancer type, length of survivorship, and other health issues. This study adds to our understanding of QoL in longterm cancer survivors, providing a composite picture of this multidimensional construct by means of three different (in target population and in covered domains) questionnaires. In particular, it contributes to enhance the knowledge of this specific population through enlightening the domains in which it is stronger and weaker. Secondly, since three QoL questionnaires were administered to the same sample,
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it allows considerations on the issue of choosing the more adequate QoL tool among the available ones. Finally, describing QoL in cancer survivors from Italy, it pertains a national context different from those generally represented in the literature.
Methods Participants Participants were consecutive long-term cancer survivors (i.e., people free from cancer and its treatments for at least 5 years) attending the Centro di Riferimento Oncologico in Aviano for follow-up visits. Inclusion criteria were age of 18 or older; proficiency in Italian; the absence of prior mental disorders; the absence of physical or sensory disabilities that would interfere with filling out questionnaires; and able to provide informed consent. Procedure All participants completed the EORTC QLQ-C30 [13]), the IOC [14], the Short Form 36 Health Survey Questionnaire (SF-36, [15]), and a form to collect socio-demographic and clinical data. Since these three questionnaires consider different QoL domains, we decided to administer them simultaneously to cover a large range of QoL domains consistent with the condition of long-term cancer survivorship. In addition, all have been published in the international scientific literature and their Italian versions have been validated. Eligible participants were approached by a psychologist during follow-up visits. After explaining the purposes and methods of the research and answering all questions, signed informed consent was obtained. Participants received a survey booklet with all questionnaires and a prepaid envelope to return them. They were instructed to fill out materials at home and to return them by mail within 3 weeks. A reminder phone call was made 4 weeks after the mailing date to participants who had not returned the survey questionnaires. Materials The EORTC QLQ-C30 is a thirty-item, cancer-specific questionnaire for assessing the QoL of cancer patients [13] validated for Italy by Apolone et al. [16]. It comprises five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, nausea, and vomiting), a general health and QoL scale, and six single items for assessing additional symptoms commonly reported by cancer patients, including dyspnea, appetite
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loss, disturbed sleep, constipation, diarrhea, and financial impact of the disease and its treatment. Scores range from 0 to 100; in scoring interpretation, higher ratings correspond to better functioning in the functional scales, higher levels in symptom perceptions in the symptom scales, and better QoL in the general health and QoL scale [17]. Reliability has been reported as adequate in each multi-item scale excepting for Role Functioning [13]. In this research, the EORTC QLQ-C30 was administered excluding the nausea and vomiting symptom scales and six single symptom items because these dimensions have been considered less descriptive of the condition of long-term cancer survivorship. The IOC [14] is a questionnaire developed to measure specific and multidimensional aspects of long-term cancer survivorship. The answer scale is a five-point disagreement/agreement Likert scale. According to a previous published Italian validation [18], three different domains are provided by IOC: uncertainty/worry about health and future; personal growth and altruism; dissatisfaction and life interferences. In each factor, higher scores correspond to a higher level in that dimension. A linear transformation was used to standardize IOC raw scores to a 0–100 scale. IOC reliability was reported as adequate in each factor for both versions (i.e., the original one [14] and the version validated for Italy [18]). The SF-36 [15] is a generic QoL measure which has been widely used with different populations (both healthy and clinical). It consists of 36 items providing eight different QoL indices: physical functioning, role-physical limitation, bodily pain, general health, vitality, social functioning, role-emotional limitations, and mental health. Each QoL index is ranged 0–100 where higher scores correspond to better functioning in that domain. Reliability (internal consistency and temporal stability) of each SF-36 sub-scale was found adequate across different studies [15, 19]. Apolone et al. [19] provided both validation and norms for the Italian version. Socio-demographic and clinical data were obtained from a self-report questionnaire regarding gender, age, marital status, education, occupational status, cancer type, length of survivorship, and the presence of other health issues. Statistical analyses The cancer-specific QoL profile was obtained by administering the EORTC QLQ-C30, the survivorship-specific QoL profile was obtained by administering the IOC, and the generic QoL profile was obtained by administering the SF-36. For each profile, domain means and standard deviations were calculated. Three analyses of variance (ANOVA) for repeated measures (one for each profile) were performed to verify
differences in domains’ scores. To test the association between QoL domains and the socio-demographic and clinical characteristics—gender, age (\61 vs. 61 ? years); education (compulsory vs. post-compulsory); work (gainfully employed or not); relational status (partnered or not); cancer type (breast, lymphoma, and other cancers); survivorship (5–10 vs. 10 ? years) and other reported health issues (yes or no)—a series of multivariate analyses of variance (MANOVA) was performed separately for the cancer-specific, survivorship-specific, and generic QoL profiles. When a factor was statistically significant (principal effect), ANOVAS (one for each QoL domain) were performed. In all analyses, p \ 0.05 (2-tailed) was considered to be statistically significant. Bonferroni’s correction was used, where appropriate, to avoid errors due to multiple comparisons. Regarding clinical significance, on a scale of 0–100, a difference of 5–10 units was considered small, a difference of 10–20 units was considered moderate, a difference of 20 units (or more than 20) was considered large, and a difference of \5 units was considered not clinically significant [20]. The Statistical Package for the Social Sciences (SPSS) was used to perform the analyses.
Results Sample characteristics Three hundred and sixty-two potential participants were approached. Eight were not eligible, and three hundred forty-six agreed to participate. Eighty-four did not return the materials and five returned incomplete materials. Hence, full data were available for two hundred and sixtyfive participants (73.2 %), including 57 males (21.5 %) and 208 females (78.5 %). Median age was 60 years (range: 28–79). Out of 265 participants, 39.2 % had attended school for more than 8 years; 31.8 % were employed; and 56.2 % reported being in a stable emotional relationship (i.e., being married or cohabitating). The most commonly represented cancer diagnosis was breast cancer (60.4 %), followed by lymphoma (23.4 %), and other cancers (16.2 %). Median survivorship was 10 years (range: 5–33), with 52.9 % and 47.1 % of the sample having survived cancer for 5–10 and 11 ? years, respectively. Finally, 50.6 % of the sample reported having physical health issues unrelated to the past cancer. Cancer-specific QoL profile Table 1 displays the means and the standard deviations of the entire sample for the eight QoL domains investigated
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Qual Life Res Table 1 Cancer-specific, survivorship-specific, and generic QoL profiles Domain
Mean
Stand. Dev.
Physical functioning
85.9
15.4
Role functioning
86.9
20.8
Cognitive functioning
83.5
19.6
Emotional functioning
76.6
18.8
Social functioning
92.1
18.2
Fatigue Pain
24.5 16.7
21.4 22.4
General health and QoL
68.2
18.8
Uncertainty/worry about health and future
50.0
19.1
Personal growth and altruism
66.1
13.3
Dissatisfaction and life interferences
30.9
17.1
Physical functioning
77.6
23.4
Role-physical limitation
63.1
41.8
Bodily pain
67.4
27.7
General health
60.6
23.6
Vitality
56.8
19.3
Social functioning
73.1
23.1
Cancer-specific QoL profile (N = 241)
Survivorship-specific QoL profile (N = 262)
Generic QoL profile (N = 243)
Role-emotional limitation
67.6
39.0
Mental health
68.9
18.4
by means of the EORTC QLQ-C30. An ANOVA for repeated measures was performed using the five functional domains (physical, role, cognitive, emotional, and social) as dependent variables: at least one of the ten possible paired comparisons between the five functional domains was statistically significant (p \ 0.001). The subsequent qualitative inspection of the profile showed emotional functioning (M = 76.6) being lower than the others, whereas social functioning (M = 92.2) being the higher. Analogously, a paired samples t test was performed using the two administered symptom scales (fatigue and pain) as dependent variables, showing fatigue higher than pain (p \ 0.001). A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical variable on the cancer-specific QoL profile. In particular, gender (p = 0.028), education (p = 0.008), cancer type (p = 0.003), and the presence of other health issues (p \ 0.001) were found statistically associated, whereas age (p = 0.294), occupational status (p = 0.137), relational status (p = 0.494), and length of survivorship (p = 0.164) were found not associated. Table 2 summarizes profile scores according to the significantly associated factors. In particular, participants declaring having no other health issues reported a relatively higher physical (p \ 0.001; small
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difference), role (p \ 0.001; moderately large difference), emotional (p = 0.005; small difference), and social (p = 0.006; small difference) functioning, less fatigue (p \ 0.001; moderately large difference), less pain (p \ 0.001; moderately large difference), and a relatively higher general health and QoL (p = 0.001; small difference) than their counterparts. Survivorship-specific QoL profile Table 1 displays the means and the standard deviations of the entire sample for the three QoL domains investigated by the IOC. According to the performed ANOVA for repeated measures, at least one of the three possible paired comparisons between the three domains was statistically significant (p \ 0.001): I.E. participants reported more personal growth and altruism than both uncertainty/worry about health/ future, and dissatisfaction and life interferences (p \ 0.001); whereas they reported less dissatisfaction and life interferences than both personal growth and altruism, and uncertainty/worry about health/future (p \ 0.001). A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical characteristic on the survivorship-specific QoL profile. In particular, gender (p = 0.001) and cancer type (p = 0.002) were associated with it, whereas age (p = 0.761), education (p = 0.161), occupational status (p = 0.055), relational status (p = 0.189), the presence of other health issues (p = 0.075), and length of survivorship (p = 0.233) were not. Table 3 summarizes profile scores according to the significantly associated characteristics. In particular, males reported relatively less dissatisfaction and life interferences (p \ 0.001; small difference); furthermore, differences according to cancer type were recorded in uncertainty/worry about health and future (p = 0.001; small differences excepting the difference between participants with an history of lymphoma and other type of cancer which was moderately large) and in dissatisfaction and life interferences (p = 0.003; small differences), where participants with an history of lymphoma reported few of them in comparisons with the other two subgroups. Generic QoL profile Table 1 displays the means and the standard deviations of the entire sample for the eight QoL domains investigated by the SF-36. According to the performed ANOVA for repeated measures, at least one of the 28 possible paired comparisons between the eight domains was statistically significant (p \ 0.001): The subsequent qualitative inspection of the profile showed participants reporting vitality (M = 56.8) and general health (M = 60.6) as lower, and physical functioning (M = 77.6) and social functioning (M = 73.1) as higher than the other domains.
Qual Life Res Table 2 Cancer-specific QoL profile (as displayed by the EORTC QLQ-C30) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 51)
Female (N = 190)
–
p
Physical functioning
89.2 (15.1)
85.0 (15.5)
–
0.091
Role functioning
87.9 (22.4)
86.7 (20.4)
–
0.705
Cognitive functioning
83.3 (19.1)
83.5 (19.8)
–
0.955
Emotional functioning
77.5 (18.1)
76.3 (19.1)
–
0.707
Social functioning
91.2 (18.7)
92.4 (18.1)
–
0.579
Fatigue
26.5 (24.2)
23.9 (20.6)
–
0.451
Pain General health and QoL
9.8 (19.2) 70.8 (20.5)
18.6 (22.9) 67.5 (18.3)
– –
0.013 0.274
Education
Compulsory (N = 147)
Post-compulsory (N = 92)
–
p
Physical functioning
84.3 (15.6)
88.3 (15.0)
–
0.051
Role functioning
84.9 (21.8)
89.9 (19.0)
–
0.075
Cognitive functioning
83.4 (19.9)
83.5 (19.2)
–
0.979
Emotional functioning
77.2 (18.3)
75.5 (19.9)
–
0.481
Social functioning
92.6 (15.9)
91.1 (21.6)
–
0.536
Fatigue
24.5 (19.7)
24.5 (24.2)
–
0.997
Pain General health and QoL
19.4 (21.5) 65.7 (19.0)
12.7 (23.5) 71.8 (18.1)
– –
0.015 0.024
Cancer type
Breast (N = 147)
Lymphoma (N = 56)
Others (N = 38)
p
Physical functioning
85.6 (14.9)
87.9 (15.6)
84.2 (17.5)
0.496
Role functioning
87.4 (19.3)
90.8 (21.3)
79.4 (24.0)
0.029
Cognitive functioning
84.8 (17.4)
81.3 (21.3)
81.6 (24.4)
0.417
Emotional functioning
77.9 (17.5)
76.6 (17.5)
71.5 (24.5)
0.179
Social functioning
94.0 (14.3)
92.6 (20.3)
84.2 (25.4)
0.012
Fatigue
21.8 (18.7)
26.8 (20.8)
31.4 (29.4)
0.029
Pain General health and QoL
18.0 (22.0) 67.3 (17.7)
11.0 (20.4) 72.9 (18.2)
20.2 (25.7) 64.7 (22.8)
0.081 0.074
Presence of other health issues
No (N = 121)
Yes (N = 120)
–
p
Physical functioning
90.3 (12.3)
81.4 (17.0)
–
0.000*
Role functioning
92.3 (15.2)
81.5 (24.0)
–
0.000*
Cognitive functioning
85.1 (18.7)
81.8 (20.4)
–
0.189
Emotional functioning
79.9 (16.5)
73.2 (20.5)
–
0.005*
Social functioning
95.3 (12.4)
88.9 (22.2)
–
0.006*
Fatigue
19.1 (16.8)
29.9 (24.1)
–
0.000*
Pain General health and QoL
9.1 (14.8) 72.1 (17.0)
24.4 (26.0) 64.2 (19.8)
– –
0.000* 0.001*
* p value was statistically significant according to Bonferroni’s correction
A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical characteristic on the generic QoL profile. In particular, gender (p = 0.040), education (p = 0.001), occupational status (p \ 0.001), and the presence of other health issues (p \ 0.001) were found statistically associated, whereas age (p = 0.070), relational status (p = 0.436), cancer type (p = 0.244), and length of survivorship
(p = 0.182) were found not associated. Table 4 summarizes profile scores according to the significantly associated factors. In particular, males reported less pain than females (p \ 0.001; moderately large difference); more educated participants reported less role-physical limitations than counterparts (p = 0.001; moderately large difference); employed participants reported a higher physical functioning (p = 0.001; moderately large difference) and less role-
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Qual Life Res Table 3 Survivorship-specific QoL profile (as displayed by IOC) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 57)
Female (N = 205)
–
p
Uncertainty/worry about health and future
47.6 (20.5)
50.7 (18.7)
–
0.280
Personal growth and altruism
66.5 (14.4)
66.0 (13.1)
–
0.807
Dissatisfaction and life interferences
23.5 (13.7)
33.0 (17.5)
–
0.000*
Cancer type
Breast (N = 157)
Lymphoma (N = 62)
Others (N = 43)
p
Uncertainty/worry about health and future
50.8 (18.7)
43.1 (17.7)
56.8 (19.9)
0.001*
Personal growth and altruism
65.1 (13.2)
67.2 (13.2)
68.2 (14.0)
0.303
Dissatisfaction and life interferences
32.9 (16.5)
24.6 (17.7)
32.8 (16.6)
0.003*
* p value was statistically significant according to Bonferroni’s correction
physical (p \ 0.001; large difference) and emotional-role (p \ 0.001; large difference) limitations than non-employed participants; and participants declaring no other health issues reported a higher physical (p \ 0.001; moderately large difference) and social (p \ 0.001; moderately large difference) functioning, less physical-role limitations (p = 0.001; moderately large difference) and less pain (p \ 0.001; large difference), a higher general health (p \ 0.001; moderately large difference) and more vitality (p \ 0.001; moderately large difference) than their counterparts.
Discussion Understanding the QoL of long-term cancer survivors, a growing population only recently considered as a specific target by clinicians and researchers, is relevant to daily clinical practice, as it helps support individual patients, and to healthcare policy, as it provides important information for the organization of services tailored on user needs. This study was aimed at assessing the QoL of people with a diagnosis of cancer who had been free from the disease and its treatments for at least 5 years, and at testing the association between QoL and the main clinical and sociodemographic sample’s characteristics. The first key finding of the study consists of identifying both the strongest and weakest QoL domains. In this Italian sample of long-term cancer survivors, general health, emotional functioning, and vitality were the weakest domains whereas social and physical areas were the ones of better functioning. Our findings on Italian survivors’ emotional functioning are consistent with earlier findings numerous prior studies showing that psychological distress including anxiety and depression, along with fear of relapse, persist long after cancer treatment [9, 21–25]. Better functioning in physical than mental domains has also been already described in the research literature [26]. The high social functioning of the present sample may be a
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function of the particular features of Italian family structure and dynamics, as well as of public healthcare/social care system in Italy. However, other surveys using EORTC QLQ-C30 and/or SF-36 in samples of long-term cancer survivors provided data quite different from ours. For instance, Klein et al. [27] reported that breast cancer longterm survivors had poorer scores than healthy controls for all functional and symptom scales of the EORTC QLQC30 except for emotional functioning and pain. They also found differences in all SF-36 scales with the exception of mental health. Long-term survivors (5–10 years postdiagnosis) had significantly reduced global QoL, physical function, social function, and fatigue (assessed by EORTC QLQ-C30) compared with controls in a Swedish population-based survey [28]. Poorer SF-36 scores excepting pain in a sample of cancer survivors (heterogeneous in cancer diagnosis and time since diagnosis) than in controls from general population were reported also by Santin et al. [10]. Conversely, Helgeson and Tomich [12] compared SF-36 scores of 5-year disease-free breast cancer survivors with those of age-and neighborhood-matched controls and found statistically significant differences only in physical functioning (lower in survivors than controls). Since differences exist in data analyses between these studies and ours (i.e., comparisons in QoL scores between survivors and controls versus comparisons in QoL domains within subjects), no conclusive sentences can be drawn. Regarding cancer survivors’ specific features assessed by the IOC, personal growth and altruism was the most frequently reported dimension by the present sample, whereas dissatisfaction and life interference was the least frequently reported. Post-traumatic growth is described in the literature as an unexpected positive outcome of different traumatic experiences, including cancer [29–32]. In our sample, this spiritual/existential aspect was present and appeared stronger than worry, uncertainty and dissatisfaction, which are some of the potentially negative specific outcomes of cancer survivorship.
Qual Life Res Table 4 Generic QoL profile (as displayed by SF-36) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 54)
Female (N = 189)
p
Physical functioning
83.0 (22.0)
76.1 (23.6)
0.055
Role-physical limitation
73.6 (37.4)
60.1 (42.6)
0.035
Bodily pain
79.2 (26.2)
64.0 (27.2)
0.000*
General health
64.7 (24.0)
59.4 (23.5)
0.147
Vitality
62.0 (19.9)
55.3 (18.9)
0.023
Social functioning
75.9 (22.5)
72.3 (23.3)
0.313
Role-emotional limitation Mental health
76.4 (34.7) 73.1 (15.2)
65.1 (39.8) 67.6 (19.0)
0.060 0.053
Education
Compulsory (N = 144)
Post-compulsory (N = 97)
p
Physical functioning
75.0 (23.6)
81.2 (22.8)
0.044
Role-physical limitation
55.7 (42.3)
74.0 (38.9)
0.001*
Bodily pain
64.3 (27.8)
71.5 (27.1)
0.047
General health
57.5 (23.8)
64.8 (22.8)
0.019
Vitality
57.2 (18.7)
56.3 (20.4)
0.735
Social functioning
73.4 (21.7)
72.5 (25.4)
0.773
Role-emotional limitation Mental health
65.6 (39.1) 70.3 (17.2)
70.7 (38.9) 66.6 (20.1)
0.323 0.133
Occupational status
Non-employed (N = 160)
Employed (N = 79)
p
Physical functioning
74.0 (23.8)
84.6 (21.0)
0.001*
Role-physical limitation
53.1 (43.0)
82.6 (32.4)
0.000*
Bodily pain
64.2 (28.4)
74.2 (25.7)
0.009
General health
57.4 (23.3)
65.8 (23.5)
0.010
Vitality
55.9 (18.4)
58.4 (21.4)
0.341
Social functioning
71.2 (22.6)
76.6 (24.3)
0.088
Role-emotional limitation Mental health
60.1 (40.7) 68.5 (18.9)
81.7 (31.1) 69.6 (17.9)
0.000* 0.675
Presence of other health issues
No (N = 119)
Yes (N = 124)
p
Physical functioning
83.0 (20.8)
72.4 (24.6)
0.000*
Role-physical limitation
72.5 (38.7)
54.0 (42.8)
0.001*
Bodily pain
78.0 (24.1)
57.2 (27.1)
0.000*
General health
67.0 (21.8)
54.4 (23.8)
0.000*
Vitality
62.7 (17.1)
51.1 (19.6)
0.000*
Social functioning
79.7 (17.6)
66.8 (26.0)
0.000*
Role-emotional limitation Mental health
72.7 (37.6) 71.8 (16.5)
62.7 (39.7) 66.0 (19.7)
0.046 0.014
* p value was statistically significant according to Bonferroni’s correction
Other key findings of our study relate to the associations of the tested QoL domains and the socio-demographic and clinical characteristics of the sample. Males reported less dissatisfaction and life interference due to cancer and less pain than females. Since females usually display more depression and anxiety than males [33], exploring the association between these symptoms and life interference could be highly informative. We hypothesize that also
testing the association between life interferences and body image issues, generally more deeply experienced by females [34], could provide an explanation for these data. Analysis of generic QoL questionnaire responses reveals several associations between both education and occupational status and their domains. In particular, more educated participants showed fewer role-physical limitations, while participants who were gainfully employed reported
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fewer less role limitations (physical and emotional) and better physical functioning. These results are not surprising by themselves, but they support the usefulness of administering heterogeneous tools since, in this study, the cancerspecific QoL questionnaire (the EORTC QLQ-C30) did not capture such differences in physical or role functioning. Regarding the clinical characteristics of our participants, cancer type was found to be associated only with survivorship-specific issues and duration of survivorship was associated with neither of the assessed QoL domains, while the presence of other health issues was the sample’s characteristic having more associations with QoL in this research. Participants with a history of lymphoma reported less uncertainty and worry for the future, and less dissatisfaction and life interference than other participants. The lack of association between survivorship length and cancer-specific, survivorship-specific, or generic QoL is consistent with previous findings [9, 28]. Finally, in line with previous surveys [9, 26, 35], participants with no other health issues reported better functioning in all assessed domains except for three survivorship-specific ones, including less pain and fatigue, more vitality and a better general health and QoL, compared with participants who reported poor general health. Our data on the association between QoL and clinical characteristics suggest the need to further investigate the variability based on the specific cancer diagnosis, and the importance of performing multidisciplinary assessments during oncological follow-up visits for years following treatment completion. Our study has several limitations including small sample size and lack heterogeneity among participants, which did not allow to test simultaneously the association of QoL with two or more sample’s characteristics, thus precluding a deeper analysis of the association between QoL and diagnosis. In addition, different potential effects of specific treatments of each participant, including type and duration, on QoL could not be accounted for. Moreover, due to the number of comparisons, the study is underpowered [19]. However, to reduce this problem, we corrected all p values by means of Bonferroni method. Our results offer a composite QoL profile in a consecutive sample of Italian long-term cancer survivors obtained through validated tools and support the usefulness of assessing QoL through a multi-tool battery. Ferrell [36, 37] summarized the QoL domains in four areas: physical, psychological, social, and spiritual/existential. The three tools administered in this study covered all of these domains and suggest that the psychological domain is one of the more problematic in this sample of Italian cancer survivors. In conclusion, our data support the usefulness of both medical and psychosocial follow-up visits for long-term cancer survivors and suggest that we should pay particular attention to the psycho-emotional long-term and/or late effects of cancer.
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Acknowledgments The Authors wish to thank Dr. Lorena Giovannini for her help in collecting data. This work was supported by the Italian Ministry of Health: RF Ordinary ‘‘Cancer survivorship: a new paradigm of care’’ 2012–2014 and by CCM ‘‘Valutazione della Qualita` di Vita e degli aspetti psicosociali della Cancer Survivorship e ottimizzazione dei programmi di sorveglianza’’ 2012–2014. Conflict of interest interests.
The authors declare no potential conflict of
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26. Le Borgne, G., Mercier, M., Woronoff, A. S., Guizard, A. V., Abeilard, E., Klein, D., et al. (2013). Quality of life in long-term cervical cancer survivors: A population-based study. Gynecological Oncology, 129, 222–228. 27. Klein, D., Mercier, M., Abeilard, E., Puyraveau, M., Danzon, A., Dalstein, V., et al. (2011). Long-term quality of life after breast cancer: A French registry-based controlled study. Breast Cancer Research and Treatment, 129, 125–134. 28. Wikman, A., Dja¨rv, T., Johar, A., & Lagergren, P. (2013). Health-related quality of life does not differ between short-term, long-term and very long-term cancer survivors in the Swedish general population. Psycho-Oncology, 22, 1369–1374. 29. Calhoun, L. G., & Tedeschi, R. G. (2006). Handbook of posttraumatic growth. Mahwah, NJ: Erlbaum. 30. Park, C. L., Lechner, S. C., Antoni, M. H., & Stanton, A. L. (2009). Medical illness and positive life change: Can crisis lead to personal transformation?. Washington, DC: American Psychological Association. 31. Mols, F., Vingerhoets, A. J., Coebergh, J. W., & van de PollFranse, L. V. (2009). Well-being, posttraumatic growth and benefit finding in long-term breast cancer survivors. Psychology & Health, 24, 583–595. 32. Jansen, L., Hoffmeister, M., Chang-Claude, J., Brenner, H., & Arndt, V. (2011). Benefit finding and posttraumatic growth in long-term colorectal cancer survivors: Prevalence, determinants, and associations with quality of life. British Journal of Cancer, 105, 1158–1165. 33. ESEMeD, MHEDEA 2000 Investigators. (2004). Disability and quality of life impact of mental disorders in Europe: results from the European study of the epidemiology of mental disorders (ESEMeD) project. Acta Psychiatrica Scandinavica, 109(Suppl. 420), 21–27. 34. Annunziata, M. A., Giovannini, L., & Muzzatti, B. (2012). Assessing the body image: relevance, application and instruments for oncological settings. Supportive Care in Cancer, 20, 901–907. (IF = 2.649). 35. Smith, S. K., Crespi, C. M., Petersen, L., Zimmerman, S., & Ganz, P. A. (2010). The impact of cancer and quality of life for posttreatment non-Hodgkin lymphoma survivors. PsychoOncology, 19, 1259–1267. 36. Ferrell, B. R. (1993). Overview of breast cancer: Quality of life. Oncological Patient Care, 15, 7–8. 37. Ferrell, B. R., & Dow, K. H. (1997). Quality of life among longterm cancer survivors. Oncology, 11, 565–571.
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Quality of life profile in Italian long-term cancer survivors Barbara Muzzatti • Cristiana Flaiban • Antonella Surbone • Maria Antonietta Annunziata
Accepted: 17 October 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Understanding the quality of life (QoL) of longterm cancer survivors is relevant to daily clinical practice as well as to healthcare policy. This study assessed QoL of Italian survivors and tested the association between QoL and the main clinical and socio-demographic sample’s characteristics. Methods Two hundred and sixty-five Italian adult longterm cancer survivors (people free from cancer and its treatments for at least 5 years) were administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the Impact of Cancer, and the Short Form 36 questionnaires obtaining three different QoL profiles—cancer-specific, survivorshipspecific, and generic. Results In both cancer-specific and generic QoL profiles, participants reported a lower general health and a higher social functioning than normative samples; in addition, they reported low emotional functioning and vitality, respectively, in the former and latter profile. In the survivorshipspecific profile, participants scored higher on personal growth and altruism (p \ 0.001) and lower on dissatisfaction and life interferences (p \ 0.001). Males reported less dissatisfaction and life interferences (p \ 0.001), and less pain (p \ 0.001) than females. Employed participants reported higher physical functioning (p = 0.001) and fewer role limitations (p \ 0.001) than unemployed participants. B. Muzzatti C. Flaiban M. A. Annunziata (&) Unit of Oncological Psychology, CRO Aviano National Cancer Institute, Via F. Gallini, 2, 33081 Aviano, PN, Italy e-mail: [email protected] A. Surbone Department of Medicine, New York University, New York, NY, USA
Differences according to cancer type were recorded only in survivorship-specific domains (p \ 0.004). No association between survivorship length and any of the three QoL profiles was found. Finally, the absence of other reported health issues was associated to higher functioning in the majority of cancer-specific and generic QoL domains. Conclusions Our data support the usefulness of multidisciplinary follow-ups for long-term cancer survivors and the need to pay particular attention to the psycho-emotional long-term and late-presenting sequels of cancer and its treatment. Keywords Adults Long-term cancer survivorship Oncology Quality of life Questionnaire
Introduction Long-term survivorship has increasingly become a reality for people with cancer. In Italy, the average rate of [5 years survival since cancer diagnosis is 57 %, corresponding to the 2.2 % of the entire Italian population [1], and from 1990 to 2007, 5-year standardized relative survival has increased by 15 % for all cancers except skin cancer [2]. Being a cancer survivor very often means having to face new (i.e., late-presenting) and/or known (i.e., long-term) effects, both psychosocial and physical, that can impact QoL years after treatment completion. Fatigue, pain, musculoskeletal problems, sexual dysfunction, anxiety, depression, and cognitive limitations are some of the effects which can be found during treatment, and which can also characterize long-term cancer survivorship [3–5]. More specific long-term effects such as relapses, iatrogenic tumors, fear of cancer recurrence, and limitations in restarting one’s work or one’s pre-illness
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functioning are frequently reported by survivors [3–6]. Long-term cancer survivorship may also be accompanied by positive changes such as improved self-esteem, greater life appreciation and sense of meaning, heightened spirituality, and greater feelings of peace and purposefulness, as summarized in the concept of post-traumatic growth [7]. Understanding long-term cancer survivors’, QoL can inform healthcare policy as well as offer help in supporting individual patients. In Italy, services aimed specifically at long-term cancer survivors are rare and generally only offered as part of research studies. Consequently, few data are available for Italian cancer survivors, defined as persons with a diagnosis of cancer who have been free from the disease and its treatments for at least 5 years [8]. A recent Italian survey [9] found that women diagnosed with breast cancer reported having a poor QoL (measured as physical and mental functioning) even many years after treatment completion. Similar differences in QoL in comparison to the general population were reported United Kingdom study [10]. Other studies, however, have not shown substantial differences in terms of QoL between survivors and general population [11, 12]. The chief aim of the present work was to investigate QoL in a sample of Italian long-term cancer survivors. Three questionnaires—for assessing QoL in cancer patients at different stages of their disease trajectory European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (the EORTC QLQC30), for assessing specificities in the condition of the cancer survivorship the Impact of Cancer (IOC), and a generic QoL measure (the SF-36) commonly used in different clinical settings as well as for general populations— were administered. A secondary study aim was to explore associations between the three obtained QoL profiles (cancer-specific, survivorship-specific, and generic) and the main socio-demographic and clinical characteristics of the sample. The hypotheses of the study were: (1) differences in QoL domains would point to the need for multidimensional assessment of QoL in long-term cancer survivors; in particular, we expected higher scores in domains related to physical functioning and spirituality than in those referring to psychological areas; and (2) QoL would be affected by socio-demographic and clinical variables of gender, age, education, marital status, occupational status, cancer type, length of survivorship, and other health issues. This study adds to our understanding of QoL in longterm cancer survivors, providing a composite picture of this multidimensional construct by means of three different (in target population and in covered domains) questionnaires. In particular, it contributes to enhance the knowledge of this specific population through enlightening the domains in which it is stronger and weaker. Secondly, since three QoL questionnaires were administered to the same sample,
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it allows considerations on the issue of choosing the more adequate QoL tool among the available ones. Finally, describing QoL in cancer survivors from Italy, it pertains a national context different from those generally represented in the literature.
Methods Participants Participants were consecutive long-term cancer survivors (i.e., people free from cancer and its treatments for at least 5 years) attending the Centro di Riferimento Oncologico in Aviano for follow-up visits. Inclusion criteria were age of 18 or older; proficiency in Italian; the absence of prior mental disorders; the absence of physical or sensory disabilities that would interfere with filling out questionnaires; and able to provide informed consent. Procedure All participants completed the EORTC QLQ-C30 [13]), the IOC [14], the Short Form 36 Health Survey Questionnaire (SF-36, [15]), and a form to collect socio-demographic and clinical data. Since these three questionnaires consider different QoL domains, we decided to administer them simultaneously to cover a large range of QoL domains consistent with the condition of long-term cancer survivorship. In addition, all have been published in the international scientific literature and their Italian versions have been validated. Eligible participants were approached by a psychologist during follow-up visits. After explaining the purposes and methods of the research and answering all questions, signed informed consent was obtained. Participants received a survey booklet with all questionnaires and a prepaid envelope to return them. They were instructed to fill out materials at home and to return them by mail within 3 weeks. A reminder phone call was made 4 weeks after the mailing date to participants who had not returned the survey questionnaires. Materials The EORTC QLQ-C30 is a thirty-item, cancer-specific questionnaire for assessing the QoL of cancer patients [13] validated for Italy by Apolone et al. [16]. It comprises five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, nausea, and vomiting), a general health and QoL scale, and six single items for assessing additional symptoms commonly reported by cancer patients, including dyspnea, appetite
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loss, disturbed sleep, constipation, diarrhea, and financial impact of the disease and its treatment. Scores range from 0 to 100; in scoring interpretation, higher ratings correspond to better functioning in the functional scales, higher levels in symptom perceptions in the symptom scales, and better QoL in the general health and QoL scale [17]. Reliability has been reported as adequate in each multi-item scale excepting for Role Functioning [13]. In this research, the EORTC QLQ-C30 was administered excluding the nausea and vomiting symptom scales and six single symptom items because these dimensions have been considered less descriptive of the condition of long-term cancer survivorship. The IOC [14] is a questionnaire developed to measure specific and multidimensional aspects of long-term cancer survivorship. The answer scale is a five-point disagreement/agreement Likert scale. According to a previous published Italian validation [18], three different domains are provided by IOC: uncertainty/worry about health and future; personal growth and altruism; dissatisfaction and life interferences. In each factor, higher scores correspond to a higher level in that dimension. A linear transformation was used to standardize IOC raw scores to a 0–100 scale. IOC reliability was reported as adequate in each factor for both versions (i.e., the original one [14] and the version validated for Italy [18]). The SF-36 [15] is a generic QoL measure which has been widely used with different populations (both healthy and clinical). It consists of 36 items providing eight different QoL indices: physical functioning, role-physical limitation, bodily pain, general health, vitality, social functioning, role-emotional limitations, and mental health. Each QoL index is ranged 0–100 where higher scores correspond to better functioning in that domain. Reliability (internal consistency and temporal stability) of each SF-36 sub-scale was found adequate across different studies [15, 19]. Apolone et al. [19] provided both validation and norms for the Italian version. Socio-demographic and clinical data were obtained from a self-report questionnaire regarding gender, age, marital status, education, occupational status, cancer type, length of survivorship, and the presence of other health issues. Statistical analyses The cancer-specific QoL profile was obtained by administering the EORTC QLQ-C30, the survivorship-specific QoL profile was obtained by administering the IOC, and the generic QoL profile was obtained by administering the SF-36. For each profile, domain means and standard deviations were calculated. Three analyses of variance (ANOVA) for repeated measures (one for each profile) were performed to verify
differences in domains’ scores. To test the association between QoL domains and the socio-demographic and clinical characteristics—gender, age (\61 vs. 61 ? years); education (compulsory vs. post-compulsory); work (gainfully employed or not); relational status (partnered or not); cancer type (breast, lymphoma, and other cancers); survivorship (5–10 vs. 10 ? years) and other reported health issues (yes or no)—a series of multivariate analyses of variance (MANOVA) was performed separately for the cancer-specific, survivorship-specific, and generic QoL profiles. When a factor was statistically significant (principal effect), ANOVAS (one for each QoL domain) were performed. In all analyses, p \ 0.05 (2-tailed) was considered to be statistically significant. Bonferroni’s correction was used, where appropriate, to avoid errors due to multiple comparisons. Regarding clinical significance, on a scale of 0–100, a difference of 5–10 units was considered small, a difference of 10–20 units was considered moderate, a difference of 20 units (or more than 20) was considered large, and a difference of \5 units was considered not clinically significant [20]. The Statistical Package for the Social Sciences (SPSS) was used to perform the analyses.
Results Sample characteristics Three hundred and sixty-two potential participants were approached. Eight were not eligible, and three hundred forty-six agreed to participate. Eighty-four did not return the materials and five returned incomplete materials. Hence, full data were available for two hundred and sixtyfive participants (73.2 %), including 57 males (21.5 %) and 208 females (78.5 %). Median age was 60 years (range: 28–79). Out of 265 participants, 39.2 % had attended school for more than 8 years; 31.8 % were employed; and 56.2 % reported being in a stable emotional relationship (i.e., being married or cohabitating). The most commonly represented cancer diagnosis was breast cancer (60.4 %), followed by lymphoma (23.4 %), and other cancers (16.2 %). Median survivorship was 10 years (range: 5–33), with 52.9 % and 47.1 % of the sample having survived cancer for 5–10 and 11 ? years, respectively. Finally, 50.6 % of the sample reported having physical health issues unrelated to the past cancer. Cancer-specific QoL profile Table 1 displays the means and the standard deviations of the entire sample for the eight QoL domains investigated
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Qual Life Res Table 1 Cancer-specific, survivorship-specific, and generic QoL profiles Domain
Mean
Stand. Dev.
Physical functioning
85.9
15.4
Role functioning
86.9
20.8
Cognitive functioning
83.5
19.6
Emotional functioning
76.6
18.8
Social functioning
92.1
18.2
Fatigue Pain
24.5 16.7
21.4 22.4
General health and QoL
68.2
18.8
Uncertainty/worry about health and future
50.0
19.1
Personal growth and altruism
66.1
13.3
Dissatisfaction and life interferences
30.9
17.1
Physical functioning
77.6
23.4
Role-physical limitation
63.1
41.8
Bodily pain
67.4
27.7
General health
60.6
23.6
Vitality
56.8
19.3
Social functioning
73.1
23.1
Cancer-specific QoL profile (N = 241)
Survivorship-specific QoL profile (N = 262)
Generic QoL profile (N = 243)
Role-emotional limitation
67.6
39.0
Mental health
68.9
18.4
by means of the EORTC QLQ-C30. An ANOVA for repeated measures was performed using the five functional domains (physical, role, cognitive, emotional, and social) as dependent variables: at least one of the ten possible paired comparisons between the five functional domains was statistically significant (p \ 0.001). The subsequent qualitative inspection of the profile showed emotional functioning (M = 76.6) being lower than the others, whereas social functioning (M = 92.2) being the higher. Analogously, a paired samples t test was performed using the two administered symptom scales (fatigue and pain) as dependent variables, showing fatigue higher than pain (p \ 0.001). A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical variable on the cancer-specific QoL profile. In particular, gender (p = 0.028), education (p = 0.008), cancer type (p = 0.003), and the presence of other health issues (p \ 0.001) were found statistically associated, whereas age (p = 0.294), occupational status (p = 0.137), relational status (p = 0.494), and length of survivorship (p = 0.164) were found not associated. Table 2 summarizes profile scores according to the significantly associated factors. In particular, participants declaring having no other health issues reported a relatively higher physical (p \ 0.001; small
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difference), role (p \ 0.001; moderately large difference), emotional (p = 0.005; small difference), and social (p = 0.006; small difference) functioning, less fatigue (p \ 0.001; moderately large difference), less pain (p \ 0.001; moderately large difference), and a relatively higher general health and QoL (p = 0.001; small difference) than their counterparts. Survivorship-specific QoL profile Table 1 displays the means and the standard deviations of the entire sample for the three QoL domains investigated by the IOC. According to the performed ANOVA for repeated measures, at least one of the three possible paired comparisons between the three domains was statistically significant (p \ 0.001): I.E. participants reported more personal growth and altruism than both uncertainty/worry about health/ future, and dissatisfaction and life interferences (p \ 0.001); whereas they reported less dissatisfaction and life interferences than both personal growth and altruism, and uncertainty/worry about health/future (p \ 0.001). A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical characteristic on the survivorship-specific QoL profile. In particular, gender (p = 0.001) and cancer type (p = 0.002) were associated with it, whereas age (p = 0.761), education (p = 0.161), occupational status (p = 0.055), relational status (p = 0.189), the presence of other health issues (p = 0.075), and length of survivorship (p = 0.233) were not. Table 3 summarizes profile scores according to the significantly associated characteristics. In particular, males reported relatively less dissatisfaction and life interferences (p \ 0.001; small difference); furthermore, differences according to cancer type were recorded in uncertainty/worry about health and future (p = 0.001; small differences excepting the difference between participants with an history of lymphoma and other type of cancer which was moderately large) and in dissatisfaction and life interferences (p = 0.003; small differences), where participants with an history of lymphoma reported few of them in comparisons with the other two subgroups. Generic QoL profile Table 1 displays the means and the standard deviations of the entire sample for the eight QoL domains investigated by the SF-36. According to the performed ANOVA for repeated measures, at least one of the 28 possible paired comparisons between the eight domains was statistically significant (p \ 0.001): The subsequent qualitative inspection of the profile showed participants reporting vitality (M = 56.8) and general health (M = 60.6) as lower, and physical functioning (M = 77.6) and social functioning (M = 73.1) as higher than the other domains.
Qual Life Res Table 2 Cancer-specific QoL profile (as displayed by the EORTC QLQ-C30) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 51)
Female (N = 190)
–
p
Physical functioning
89.2 (15.1)
85.0 (15.5)
–
0.091
Role functioning
87.9 (22.4)
86.7 (20.4)
–
0.705
Cognitive functioning
83.3 (19.1)
83.5 (19.8)
–
0.955
Emotional functioning
77.5 (18.1)
76.3 (19.1)
–
0.707
Social functioning
91.2 (18.7)
92.4 (18.1)
–
0.579
Fatigue
26.5 (24.2)
23.9 (20.6)
–
0.451
Pain General health and QoL
9.8 (19.2) 70.8 (20.5)
18.6 (22.9) 67.5 (18.3)
– –
0.013 0.274
Education
Compulsory (N = 147)
Post-compulsory (N = 92)
–
p
Physical functioning
84.3 (15.6)
88.3 (15.0)
–
0.051
Role functioning
84.9 (21.8)
89.9 (19.0)
–
0.075
Cognitive functioning
83.4 (19.9)
83.5 (19.2)
–
0.979
Emotional functioning
77.2 (18.3)
75.5 (19.9)
–
0.481
Social functioning
92.6 (15.9)
91.1 (21.6)
–
0.536
Fatigue
24.5 (19.7)
24.5 (24.2)
–
0.997
Pain General health and QoL
19.4 (21.5) 65.7 (19.0)
12.7 (23.5) 71.8 (18.1)
– –
0.015 0.024
Cancer type
Breast (N = 147)
Lymphoma (N = 56)
Others (N = 38)
p
Physical functioning
85.6 (14.9)
87.9 (15.6)
84.2 (17.5)
0.496
Role functioning
87.4 (19.3)
90.8 (21.3)
79.4 (24.0)
0.029
Cognitive functioning
84.8 (17.4)
81.3 (21.3)
81.6 (24.4)
0.417
Emotional functioning
77.9 (17.5)
76.6 (17.5)
71.5 (24.5)
0.179
Social functioning
94.0 (14.3)
92.6 (20.3)
84.2 (25.4)
0.012
Fatigue
21.8 (18.7)
26.8 (20.8)
31.4 (29.4)
0.029
Pain General health and QoL
18.0 (22.0) 67.3 (17.7)
11.0 (20.4) 72.9 (18.2)
20.2 (25.7) 64.7 (22.8)
0.081 0.074
Presence of other health issues
No (N = 121)
Yes (N = 120)
–
p
Physical functioning
90.3 (12.3)
81.4 (17.0)
–
0.000*
Role functioning
92.3 (15.2)
81.5 (24.0)
–
0.000*
Cognitive functioning
85.1 (18.7)
81.8 (20.4)
–
0.189
Emotional functioning
79.9 (16.5)
73.2 (20.5)
–
0.005*
Social functioning
95.3 (12.4)
88.9 (22.2)
–
0.006*
Fatigue
19.1 (16.8)
29.9 (24.1)
–
0.000*
Pain General health and QoL
9.1 (14.8) 72.1 (17.0)
24.4 (26.0) 64.2 (19.8)
– –
0.000* 0.001*
* p value was statistically significant according to Bonferroni’s correction
A series of eight MANOVAs have been conducted to verify the effects of each registered socio-demographic and clinical characteristic on the generic QoL profile. In particular, gender (p = 0.040), education (p = 0.001), occupational status (p \ 0.001), and the presence of other health issues (p \ 0.001) were found statistically associated, whereas age (p = 0.070), relational status (p = 0.436), cancer type (p = 0.244), and length of survivorship
(p = 0.182) were found not associated. Table 4 summarizes profile scores according to the significantly associated factors. In particular, males reported less pain than females (p \ 0.001; moderately large difference); more educated participants reported less role-physical limitations than counterparts (p = 0.001; moderately large difference); employed participants reported a higher physical functioning (p = 0.001; moderately large difference) and less role-
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Qual Life Res Table 3 Survivorship-specific QoL profile (as displayed by IOC) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 57)
Female (N = 205)
–
p
Uncertainty/worry about health and future
47.6 (20.5)
50.7 (18.7)
–
0.280
Personal growth and altruism
66.5 (14.4)
66.0 (13.1)
–
0.807
Dissatisfaction and life interferences
23.5 (13.7)
33.0 (17.5)
–
0.000*
Cancer type
Breast (N = 157)
Lymphoma (N = 62)
Others (N = 43)
p
Uncertainty/worry about health and future
50.8 (18.7)
43.1 (17.7)
56.8 (19.9)
0.001*
Personal growth and altruism
65.1 (13.2)
67.2 (13.2)
68.2 (14.0)
0.303
Dissatisfaction and life interferences
32.9 (16.5)
24.6 (17.7)
32.8 (16.6)
0.003*
* p value was statistically significant according to Bonferroni’s correction
physical (p \ 0.001; large difference) and emotional-role (p \ 0.001; large difference) limitations than non-employed participants; and participants declaring no other health issues reported a higher physical (p \ 0.001; moderately large difference) and social (p \ 0.001; moderately large difference) functioning, less physical-role limitations (p = 0.001; moderately large difference) and less pain (p \ 0.001; large difference), a higher general health (p \ 0.001; moderately large difference) and more vitality (p \ 0.001; moderately large difference) than their counterparts.
Discussion Understanding the QoL of long-term cancer survivors, a growing population only recently considered as a specific target by clinicians and researchers, is relevant to daily clinical practice, as it helps support individual patients, and to healthcare policy, as it provides important information for the organization of services tailored on user needs. This study was aimed at assessing the QoL of people with a diagnosis of cancer who had been free from the disease and its treatments for at least 5 years, and at testing the association between QoL and the main clinical and sociodemographic sample’s characteristics. The first key finding of the study consists of identifying both the strongest and weakest QoL domains. In this Italian sample of long-term cancer survivors, general health, emotional functioning, and vitality were the weakest domains whereas social and physical areas were the ones of better functioning. Our findings on Italian survivors’ emotional functioning are consistent with earlier findings numerous prior studies showing that psychological distress including anxiety and depression, along with fear of relapse, persist long after cancer treatment [9, 21–25]. Better functioning in physical than mental domains has also been already described in the research literature [26]. The high social functioning of the present sample may be a
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function of the particular features of Italian family structure and dynamics, as well as of public healthcare/social care system in Italy. However, other surveys using EORTC QLQ-C30 and/or SF-36 in samples of long-term cancer survivors provided data quite different from ours. For instance, Klein et al. [27] reported that breast cancer longterm survivors had poorer scores than healthy controls for all functional and symptom scales of the EORTC QLQC30 except for emotional functioning and pain. They also found differences in all SF-36 scales with the exception of mental health. Long-term survivors (5–10 years postdiagnosis) had significantly reduced global QoL, physical function, social function, and fatigue (assessed by EORTC QLQ-C30) compared with controls in a Swedish population-based survey [28]. Poorer SF-36 scores excepting pain in a sample of cancer survivors (heterogeneous in cancer diagnosis and time since diagnosis) than in controls from general population were reported also by Santin et al. [10]. Conversely, Helgeson and Tomich [12] compared SF-36 scores of 5-year disease-free breast cancer survivors with those of age-and neighborhood-matched controls and found statistically significant differences only in physical functioning (lower in survivors than controls). Since differences exist in data analyses between these studies and ours (i.e., comparisons in QoL scores between survivors and controls versus comparisons in QoL domains within subjects), no conclusive sentences can be drawn. Regarding cancer survivors’ specific features assessed by the IOC, personal growth and altruism was the most frequently reported dimension by the present sample, whereas dissatisfaction and life interference was the least frequently reported. Post-traumatic growth is described in the literature as an unexpected positive outcome of different traumatic experiences, including cancer [29–32]. In our sample, this spiritual/existential aspect was present and appeared stronger than worry, uncertainty and dissatisfaction, which are some of the potentially negative specific outcomes of cancer survivorship.
Qual Life Res Table 4 Generic QoL profile (as displayed by SF-36) according to the associated socio-demographic/clinical characteristics [means and (standard deviations)] Gender
Male (N = 54)
Female (N = 189)
p
Physical functioning
83.0 (22.0)
76.1 (23.6)
0.055
Role-physical limitation
73.6 (37.4)
60.1 (42.6)
0.035
Bodily pain
79.2 (26.2)
64.0 (27.2)
0.000*
General health
64.7 (24.0)
59.4 (23.5)
0.147
Vitality
62.0 (19.9)
55.3 (18.9)
0.023
Social functioning
75.9 (22.5)
72.3 (23.3)
0.313
Role-emotional limitation Mental health
76.4 (34.7) 73.1 (15.2)
65.1 (39.8) 67.6 (19.0)
0.060 0.053
Education
Compulsory (N = 144)
Post-compulsory (N = 97)
p
Physical functioning
75.0 (23.6)
81.2 (22.8)
0.044
Role-physical limitation
55.7 (42.3)
74.0 (38.9)
0.001*
Bodily pain
64.3 (27.8)
71.5 (27.1)
0.047
General health
57.5 (23.8)
64.8 (22.8)
0.019
Vitality
57.2 (18.7)
56.3 (20.4)
0.735
Social functioning
73.4 (21.7)
72.5 (25.4)
0.773
Role-emotional limitation Mental health
65.6 (39.1) 70.3 (17.2)
70.7 (38.9) 66.6 (20.1)
0.323 0.133
Occupational status
Non-employed (N = 160)
Employed (N = 79)
p
Physical functioning
74.0 (23.8)
84.6 (21.0)
0.001*
Role-physical limitation
53.1 (43.0)
82.6 (32.4)
0.000*
Bodily pain
64.2 (28.4)
74.2 (25.7)
0.009
General health
57.4 (23.3)
65.8 (23.5)
0.010
Vitality
55.9 (18.4)
58.4 (21.4)
0.341
Social functioning
71.2 (22.6)
76.6 (24.3)
0.088
Role-emotional limitation Mental health
60.1 (40.7) 68.5 (18.9)
81.7 (31.1) 69.6 (17.9)
0.000* 0.675
Presence of other health issues
No (N = 119)
Yes (N = 124)
p
Physical functioning
83.0 (20.8)
72.4 (24.6)
0.000*
Role-physical limitation
72.5 (38.7)
54.0 (42.8)
0.001*
Bodily pain
78.0 (24.1)
57.2 (27.1)
0.000*
General health
67.0 (21.8)
54.4 (23.8)
0.000*
Vitality
62.7 (17.1)
51.1 (19.6)
0.000*
Social functioning
79.7 (17.6)
66.8 (26.0)
0.000*
Role-emotional limitation Mental health
72.7 (37.6) 71.8 (16.5)
62.7 (39.7) 66.0 (19.7)
0.046 0.014
* p value was statistically significant according to Bonferroni’s correction
Other key findings of our study relate to the associations of the tested QoL domains and the socio-demographic and clinical characteristics of the sample. Males reported less dissatisfaction and life interference due to cancer and less pain than females. Since females usually display more depression and anxiety than males [33], exploring the association between these symptoms and life interference could be highly informative. We hypothesize that also
testing the association between life interferences and body image issues, generally more deeply experienced by females [34], could provide an explanation for these data. Analysis of generic QoL questionnaire responses reveals several associations between both education and occupational status and their domains. In particular, more educated participants showed fewer role-physical limitations, while participants who were gainfully employed reported
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Qual Life Res
fewer less role limitations (physical and emotional) and better physical functioning. These results are not surprising by themselves, but they support the usefulness of administering heterogeneous tools since, in this study, the cancerspecific QoL questionnaire (the EORTC QLQ-C30) did not capture such differences in physical or role functioning. Regarding the clinical characteristics of our participants, cancer type was found to be associated only with survivorship-specific issues and duration of survivorship was associated with neither of the assessed QoL domains, while the presence of other health issues was the sample’s characteristic having more associations with QoL in this research. Participants with a history of lymphoma reported less uncertainty and worry for the future, and less dissatisfaction and life interference than other participants. The lack of association between survivorship length and cancer-specific, survivorship-specific, or generic QoL is consistent with previous findings [9, 28]. Finally, in line with previous surveys [9, 26, 35], participants with no other health issues reported better functioning in all assessed domains except for three survivorship-specific ones, including less pain and fatigue, more vitality and a better general health and QoL, compared with participants who reported poor general health. Our data on the association between QoL and clinical characteristics suggest the need to further investigate the variability based on the specific cancer diagnosis, and the importance of performing multidisciplinary assessments during oncological follow-up visits for years following treatment completion. Our study has several limitations including small sample size and lack heterogeneity among participants, which did not allow to test simultaneously the association of QoL with two or more sample’s characteristics, thus precluding a deeper analysis of the association between QoL and diagnosis. In addition, different potential effects of specific treatments of each participant, including type and duration, on QoL could not be accounted for. Moreover, due to the number of comparisons, the study is underpowered [19]. However, to reduce this problem, we corrected all p values by means of Bonferroni method. Our results offer a composite QoL profile in a consecutive sample of Italian long-term cancer survivors obtained through validated tools and support the usefulness of assessing QoL through a multi-tool battery. Ferrell [36, 37] summarized the QoL domains in four areas: physical, psychological, social, and spiritual/existential. The three tools administered in this study covered all of these domains and suggest that the psychological domain is one of the more problematic in this sample of Italian cancer survivors. In conclusion, our data support the usefulness of both medical and psychosocial follow-up visits for long-term cancer survivors and suggest that we should pay particular attention to the psycho-emotional long-term and/or late effects of cancer.
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Acknowledgments The Authors wish to thank Dr. Lorena Giovannini for her help in collecting data. This work was supported by the Italian Ministry of Health: RF Ordinary ‘‘Cancer survivorship: a new paradigm of care’’ 2012–2014 and by CCM ‘‘Valutazione della Qualita` di Vita e degli aspetti psicosociali della Cancer Survivorship e ottimizzazione dei programmi di sorveglianza’’ 2012–2014. Conflict of interest interests.
The authors declare no potential conflict of
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