Determinants of Health-related Quality of Life in Breast Cancer Patients: A Comprehensive Study in Marrakech, Morocco

1. INTRODUCTION

Breast cancer is the leading cause of death among women worldwide, with 685,000 deaths recorded in 2020. Most of these deaths occur in low- and middle-income countries [1]. Successful management of breast cancer relies on early diagnosis, which must be linked to effective treatment. Treatment usually involves a multimodal protocol combining systemic treatment (chemotherapy, hormone therapy, and targeted therapy) and surgery for operable tumors, sometimes followed by radiotherapy to control disease in the breast, lymph nodes, and surrounding areas [2, 3]. This type of treatment has adverse effects on the patient's state of health, physically, psychologically, and socially [4]. Indeed, it is considered a traumatic experience because of its impact on self-image, linked to surgery, radiotherapy, or chemotherapy complications, such as hair loss, as well as the change in lifestyle and social relationships [5]. In addition, the psychological aspect is influenced by fatigue, depression, and anxiety [6], aggravated by the prolongation of physical symptoms, such as pain, vomiting, risk of infection, and insomnia. Added to this is the fear of cancer recurrence and death [7], impacting the patient's well-being and health-related quality of life [8]. This concept is becoming an essential criterion in oncology care, providing a multidisciplinary perspective that goes beyond the medical and therapeutic aspects and enabling the detection of patients' needs to ensure a better quality of life [9]. The World Health Organization explains “QoL as a subjective evaluation of one's perception of their reality relative to their goals as observed through the lens of their culture and value system”. It is a very vast and broad concept that can be influenced in complex ways by the subject's physical health, psychological state, level of independence, social relationships, and relationships to the essential elements of their environment [8].

Quality of life (QoL) is a concept that aims to capture physical, mental, and spiritual well-being [8]. It is a subjective assessment of a population or individual regarding the positive and negative elements in their overall existence at a specific point in time, different from health-related quality of life, which explores the link between the two [8]. Several studies have attempted to assess it, especially in patients treated for breast cancer, on the one hand, its frequency and its improved prognosis over time, and on the other, the symbolic aspect of the organ affected [10]. The female breast is considered a noble organ, symbolizing beauty, femininity, and sovereignty [11]. However, damage to the breast leads to despair, low self-esteem [12], depression, anxiety, and dissatisfaction with body image [13]. The QoL of breast cancer patients has improved in recent years due to psychosocial interventions and better management of pathology-related symptoms [14]. As a result, improving women's mental and emotional state, as well as patients' acceptance of new health problems, can only be achieved through the assessment of quality of life [15], which must be an ongoing process throughout the care pathway.

Several tools have been developed to assess the quality of life of patients. The European Organization for Research and Treatment of Cancer (EORTC) has been able to develop valid, reliable, and commonly used question- naires [16] with items specific to each type of cancer, such as the EORTC QLQ-C30 and QLQ-BR23 version 3.0, which assess not only the symptoms of breast cancer but also the physical and emotional aspects of the disease. Numerous publications have provided psychometric validation of the EORTC QLQ-C30 and QLQ-BR23 measures [17] from different languages, including Arabic [18] and Arabic dialects [19, 20]. The choice of using a standard tool in the present study, such as the EORTC QLQ-C30, is based on its validation in dialectal Arabic, minimizing cost-saving time and facilitating cross-cultural comparisons [21]. Studies have reported the importance of quality of life assessment for optimizing survivorship care and have shown that there are factors that positively or negatively influence physical and emotional functioning after cancer treatment [22, 23], and they have suggested psychosocial follow-up to maximize the quality of life of patients, especially in those who have undergone mastectomy [24]. This is the background to our study, aiming to analyze the factors influencing health-related quality of life in breast cancer patients in the city of Marrakech, Morocco.

2. MATERIALS AND METHODS

This is a cross-sectional, analytical study conducted between January and June, 2023, at the Onco-Hematology Centre and Ibn Tofail Hospital of the Mohammed VI University Centre in Marrakech. As a tertiary care center, the facility cares for a variety of patients with different cancer stages, ages, and clinical manifestations. The management of breast cancer patients is based on a predefined protocol for each stage of their care.

3. RESULTS

4. DISCUSSION

The assessment of the quality of life of breast cancer patients is gaining increasing importance in medical research. It allows for a more holistic approach to breast cancer management. Indeed, this measurement takes into account the physical, emotional, and psychosocial impact of the disease and its treatment on the daily lives of patients. It is in this context that the aim of this study was set.

The results demonstrated that the general health and quality of life score was 60.4%, similar to studies carried out in Morocco (68.5%) [22] and Ethiopia (65.6%) [28]. A higher score was described for Emirati women (74.73%) [29]. This rate found in these studies is higher than the mean score described in the EORTC QL-C30 reference, which averages 61.8% (SD = 24.6) [30].

In terms of functional scales, Moroccan women showed strong results in all five functional scales, with mean scores ranging from 70.4% in emotional functioning to 85.8% in social functioning. This generally indicates a satisfactory level of functional health. It should be noted that the results of the present study are consistent with those of a study by Fakir et al. conducted nationwide in Morocco.

Our study revealed an average score of 76.6% for patients' cognitive functioning, suggesting that they have a good ability to understand and manage information related to their medical condition. This cognitive ability can have a significant impact on their willingness and confidence, as patients with better cognitive functioning are more likely to understand the details of their treatment, follow medical recommendations, and actively participate in decisions concerning their health.

The social function presented the best-performing scale in this study, identical to a study carried out among 250 women in the United Arab Emirates [29], in contrast to the study carried out in Ethiopia, reflecting insufficient social support for the patients [28], perhaps due to the strength of family, friendship and community ties among the Arab population and especially among Moroccans.

Emotional functioning is the most affected in this study, which is consistent with a study done in Bahrain [31] and Iran [32]. Indeed, the diagnosis of cancer causes a number of emotions, such as fear, anxiety, distress [33], uncertainty in the face of a stressful process of treatment follow-up, imprecise prognosis, management of adverse effects, and possible relapse [34]. Therefore, it seems important to consider psychotherapeutic approaches and effective support to relieve these women emotionally, as reported in a study that beauty care interventions can reduce psychological distress and enable a higher quality of life and self-esteem [35].

As for the symptom scale of the EORTC questionnaire, QLQ C30, the highest score was financial difficulties, demonstrating that women have financial problems linked to cancer. This is due, of course, to the high cost of treatment for this pathology as well as medical coverage, which does not cover all benefits. Morocco is generally classified as a middle-income country by the World Bank [36]. In their responses, patients expressed the greatest complaints about fatigue (31%), pain (29.2%), and loss of appetite (27.1%). This is in line with studies carried out in Morocco, Iran, Ethiopia, and Saudi Arabia. Indeed, the literature supports these findings [22, 28, 32, 37]. The appearance of these symptoms may be justified by the adverse effects of chemotherapy [38]. Despite the perception of cancer as a serious, life-threatening disease, the majority of patients rated their cancer-related functions as good on the BR23 scale, and despite the state of their health, 74.7% were optimistic about their future, which is concordant with the study done in Saudi Arabia [39]. However, only 40.5% expressed the opposite in the study done in Morocco [22]. This must be taken into consideration while raising awareness among women with cancer in order to maintain these satisfactory results. The body image score was affected in Moroccan patients, a result similar to a qualitative study carried out on eighteen women who had breast cancer in Italy, which deduced that the experience of breast cancer is a pathology, with therapy that damages the body through scarring and weight gain, had a negative impact on their relationship with their body, emotions, and thoughts [5]. In addition, it has been shown that distress linked to body image perception is closely related to mental disorders, principally anxiety-depression syndrome [40]. Another study on 354 breast cancer survivors in China reported that body image plays a more important role in mental well-being [41].

In the present study, body image was significantly more influential in married women (p = 0.033) than in unmarried women, which may be explained by the fact that married women may feel additional pressure to maintain a physical appearance that corresponds to the cultural and social expectations associated with marriage. With this in mind, the American Society of Clinical Oncology has developed guidelines to guide clinicians in supporting the restoration of self-esteem in their breast cancer patients. These guidelines address various physical enhancement options, such as breast prostheses and specialized bras, and highlight the help available to women in finding wigs, scarves, and other products to mitigate treatment-related body changes [42]. As far as sexual function is concerned, it is impaired in the population studied. This is in line with other studies, which suggest that the sexual quality of life of women with breast cancer is considerably altered, with a decrease in the frequency of sexual activity, the appearance of depressive symptoms, and a loss of sexual desire [43, 44].

This increase is linked to several factors, including the spouse's negative reaction to the disease, altered body image, as well as depression and anxiety [45]. This altered sex life is largely attributed to the effects of the disease itself and its treatments, which can negatively impact the symbolism of femininity and motherhood. Consequently, it is essential that healthcare professionals openly address the issue of sexuality with breast cancer patients and their partners, as this can have a significant impact on their overall quality of life [46].

As for factors influencing health-related quality of life in breast cancer patients, age was found to be significant for overall quality of life and sexual pleasure, a result similar to a study finding that younger women had less involvement in social and sexual functions, as well as decreased sexual pleasure and more modest future expectations [47]. This observation contrasts with a previous study conducted in Morocco, where age was associated with aspects, such as body image, sexual pleasure, side effects of systemic therapy, and hair loss [22]. This variation in results could be partly due to the higher proportion of younger women in our study sample, but it also highlights the complexity of the relationship between age and quality of life in breast cancer patients. According to the linear regression model, there is a significant positive relationship between quality of life and duration of pathology, which is consistent with the study carried out in Morocco on 1463 patients, which demonstrated a significant improvement in quality of life in breast cancer survivors after one year's follow-up [10]. Indeed, as time goes by and treatments are completed, side effects may lessen, which may contribute to improved quality of life [48]. Furthermore, adaptation to the disease and return to normal life may also contribute to this improvement. It appears that married women have a slightly better quality of life than unmarried women, and this statistically significant difference is also confirmed in several studies carried out in Morocco [10, 22, 49]. This can be explained by the fact that married women may have good emotional and financial support, as well as more comprehensive medical care, which could contribute to better outcomes [50]. Furthermore, it is important to emphasize that women occupy a central place within the family, and their quality of life has a significant impact not only on their own survival but also on the stability and cohesion of the family structure [16]. Thus, the influence of marriage on the quality of life of women with breast cancer extends beyond their individual well-being, also affecting family dynamics and unity, underlining the importance of family support in the care of breast cancer patients.

In addition, a study on 324 women with breast cancer in Poland revealed that quality of life decreased with age and that age was significantly related to physical, social, and sexual functioning, body image, occurrence of pain, and lack of appetite [15]. Quality of life is positively influenced by age, as most of the scientific literature has shown that older age implies a higher quality of life. This can be explained by the fact that older survivors are less concerned about their physical appearance, less stressed, have fewer financial problems, fewer side effects, and less possible infertility [47]. Studies have reported that women under 50 have a better quality of life because they have a greater social role and general support [37]. However, other researchers, such as Scotté et al., have a different perspective, suggesting that older cancer patients face unique age-related challenges, including comorbidities and special circumstances that may influence their quality of life in distinct ways compared with younger patients [51].

Yet, there was no significant relationship between the type of surgery and treatment and overall quality of life. However, in Mexico, a study on 183 women with breast cancer demonstrated that the type of surgery was positively correlated with the overall quality of life [47]. In thirty Brazilian women with breast cancer treated with radiotherapy, radiotherapy treatment adversely affected the HRQ of breast cancer patients [52]. This may be justified by patients' poor understanding of these issues. Therefore, this aspect needs to be considered in our population, and the use of breast-conserving therapy should be encouraged, which has several advantages, such as improved body image, good quality of life, and psychosocial well-being [53].

CONCLUSION

The findings of this study have revealed that patients express concerns related to financial difficulties while also coping with symptoms associated with their condition, such as fatigue, loss of appetite, and pain. It has also been observed that age, duration of illness, and monthly income are factors influencing the quality of life. Furthermore, the body image of patients is affected, along with their emotional well-being, thus underscoring the importance of addressing psychological aspects in their healthcare by healthcare professionals.

AUTHORS’ CONTRIBUTION

It is hereby acknowledged that all authors have accepted responsibility for the manuscript's content and consented to its submission. They have meticulously reviewed all results and unanimously approved the final version of the manuscript.

REFERENCES