Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 3 Issue: 5

Health-Related Quality of Life and its Influencing Factors among Breast Cancer Patients in Palestine

Ashraf Eljedi1* and Mohammed Nofal2
1Faculty of Nursing, Islamic University of Gaza, Palestine
2MPH Public Health, Head of In-service Training Department, General Directorate of Human Resources Development, Ministry of Health, Gaza strip, Palestine
Corresponding author : Ashraf Eljedi
(BSN, MSN, DrPH), Assistant Professor in Public Health, Faculty of Nursing, Islamic University of Gaza, P.O Box 108, Al Rimal- Gaza - Gaza strip, Palestine
Tel: 00970 599 527 415; Fax: + 970 (8) 286 0700
E-mail: [email protected]
Received: April 14, 2014 Accepted: August 21, 2014 Published: August 26, 2014
Citation: Eljedi A and Nofal M (2014) Health-Related Quality of Life and its Influencing Factors among Breast Cancer Patients in Palestine. J Womens Health, Issues Care 3:5. doi:10.4172/2325-9795.1000162


Health-Related Quality of Life and its Influencing Factors among Breast Cancer Patients in Palestine

Increasing incidence rates of breast cancer in Palestine emphasize the importance of increased knowledge about the health-related quality of life (HRQOL) and its influencing factors in this patient group. The purpose of this study was to assess the healthrelated quality of life among breast cancer patients in Palestine based on socio-demographic and clinical characteristics by using the World Health Organization Quality of Life – Short Version Questionnaire.

Keywords: Health-related quality of life; Breast cancer; Palestine


Health-related quality of life; Breast cancer; Palestine


HRQOL: Health-related Quality of Life; WHOQOL-BREF: World Health Organization Quality of Life Questionnaire – Short Version


Breast cancer is the leading cancer killer among women aged 20–59 years globally and in the Middle East [1]. It is estimated that worldwide over 508 000 women died in 2011 due to breast cancer. Although breast cancer is thought to be a disease of the developed world, almost 50% of breast cancer cases and 58% of deaths occur in less developed countries [2]. It negatively affects not only the woman diagnosed with the disease but also the family as a whole [3]. In Palestine, significant demographic, socioeconomic, and behavioral changes have taken place over the past decades. Life expectancy has progressively increased, and there has been steady shift from traditional and rural ways of life to more urbanized and modern lifestyle. With modernization, life styles linked with physical inactivity, smoking, and new eating habits have emerged which promote non communicable diseases, including cancer [4].
In Palestine, cancer was the second-leading cause of death in 2013, after heart disease while breast cancer is now the leading cause of cancer-related death [5,6]. Political instability, military conflicts, and poor planning have kept the majority of the Palestinian people away from enjoying the medical advances of the second half of the twentieth century. Therefore, huge differences exist between survival rates for Palestinian women and other women diagnosed with breast cancer worldwide. In Australia, for example, the survival rate at 5 years was 80% compared with only 40% in Palestine. Most of women with breast cancer in Palestine are diagnosed in late stages. Social, cultural and psychological factors can be responsible for reluctance for women to discuss breast cancer openly or agree to have a clinic breast examination [6].
Quality of life is a common concept in the health status and health promotion literature. Improving quality of life is the most important outcome of health services [7]. Hence, the World Health Organization raised the notion: "Adding years to life" is an empty victory without "adding life to years" [8]. Based on published literature, a number of socio-demographic and clinical factors may be associated with the HRQOL of breast cancer patients. Aging, low income, level of education and treatment modalities have been known to be significant high risk factors for poor quality of life [9,10]. Previous studies suggested that younger women had greater psychological morbidity and poorer QOL after breast cancer than older women [11,12]. The main reasons might be the worrying about body image and sexuality, psychological stress, anxiety, fear of recurrence, sleep dysfunction, fear of loss of fertility, pain, fatigue, and impaired physical functioning [10,13,14].
While many published data on the quality of life of many chronic diseases in Palestine are available, no previous studies were conducted to assess the health related quality of life for breast cancer patients. Therefore, this study was carried out to evaluate the HRQOL and its influencing factors among Palestinian breast cancer patients.

Materials and Methods

Participants and procedures
This study was designed as a cross-sectional and hospital-based study. It was performed in two governmental hospitals which are the only sites that provide medical services for breast cancer patients in Gaza governorates. The first hospital was Al-Shifa Medical Complex in Gaza city and the other was The European Hospital in Khanyounes city. The eligibility criteria for our study were women with confirmed pathological breast cancer report, able to communicate in Arabic language, older than 18 years old, living in Gaza strip, and having regular follow up records in one of the two hospitals. Excluded from this study were those women with evidence of systemic metastasis, who were terminally ill and who had severe physical or mental illnesses. A total of 107 patients were invited to participate in the study and 96 agreed to participate (94%). Questionnaires were distributed to the patients during their visit to the outpatient clinics in the two hospitals. The study was approved by the Helsinki Ethical Committee of Ministry of Health, Gaza governorates. All participants signed informed consents before participation. Anonymity and confidentiality were maintained all over the study period.
Health-related quality of life
The instrument of this study consists of two parts: Part one is sociodemographic such as age, educational level, marital status, and residence place; occupation, income, duration of cancer, type of treatment: surgical, chemotherapy, radiotherapy and hormonal therapy. The second part is: The World Health Organization Quality of Life Questionnaire – Short Version (WHOQOL-BREF). It is used in this study to capture patients’ perspective on the impact of breast cancer treatment on their quality of life. It consists of 26 facets, first two questions rate general value, which reflect QOL and satisfaction with health. The other 24 facets provide a profile of scores on four domains of QOL: physical health, psychological, social relationships, and the environment. These four domains of QOL (Table 1) contain several components distributing as items to meet the questions of study instrument [15]. Subjects rated all items on a 5 point Likert-type scale.
Table 1: Domains of WHOQOL-BREF
Statistical analysis
Data analyses were conducted by using the SPSS version 20.0 software. To compute the QOL scores, the four domain scores of the QOL denote an individual's perception of QOL in each particular domain. Domain scores are scaled in a positive direction (i.e. higher scores denote higher quality of life). The mean score of items within each domain is used to calculate the domain score. Mean scores are then multiplied by 4 in order to converts domain scores to a 0-100 scale, where 100 is the highest and 0 the lowest QOL. Means and SDs of subscales were evaluated for descriptive data. Proportion was evaluated for categorical data. T-test and analysis of variance (ANOVA) were performed to compare means between groups regarding QOL subscales. P value < 0.05 was determined as statistically significant.
To identify factors associated with HRQOL, logistic regressions stratified by low or high HRQOL were used to model the odds of poor HRQOL. Variables included in the models were age, educational level, marital status, employment, income and type of treatment. For logistic modeling, all independent variables were dichotomized. Odds ratios (ORs) and confidence intervals (CIs) were used to determine significance. If the CI did not include 1, the associated OR was considered significant.


Characteristics of the sample
The baseline characteristics of the 96 participants were presented in Table 2.
Table 2: Socio-demographic characteristics of breast cancer patients
The mean age of patients was 52.4 ±11.4. About 53.1% were (46 – 60) years old. 79.2% of women were illiterate or had only basic education. The majority of the participants were married (70.8%), unemployed (86.5%) and with low monthly income (66.7%). Only 2% of breast cancer patients had only surgical intervention. About 21.9% of the participants were treated by surgical intervention, followed by chemotherapy and radiation, while 40.6% of the participants underwent all treatment modalities: surgical intervention, chemotherapy, radiotherapy and hormonal therapy.
Evaluation of the HRQOL
The analysis of WHOQOL-BREF questionnaire revealed that 42.7% of the subjects rated their quality of life as good and very good, while 15.6 % considered their quality of life poor and very poor. About 39.7% were not satisfied with their health (Table 3).
Table 3: Rating general HRQOL and satisfaction with health (n=96)
For the differential quality of life domains, the physical domain score was strongly reduced (61.3 points of the 0–100 score), followed by the environmental and psychological domains (64.6; 65.8 respectively) while the social was the least (66.9) (Table 4).
Table 4: Mean Scores of HRQOL domains of WHOQOL-BREF (n=96)
We found patients aged below 45 years old had higher mean scores in terms of physical domain, psychological domain, environmental domain as well as total QOL domains (63.5±19.2; 66.5±13.8; 65.1±17.5; 69.6±13.4 respectively) (Table 5).
Table 5: Effect of socio-demographic characteristics and treatment modalities
Patients with better socioeconomics (Employed with higher monthly income) had significant higher mean scores in terms of physical domain, psychological domain, environmental domain as well as total QOL domains (P=0.001 and P=0.003). Moreover, we found patients with higher education had better scores in all domains of QOL (P=0.033). Single women had higher scores in terms of physical domain, psychological domain and total QOL domains, while married women had better scores in social domain. Patients who received hormonal therapy had the lowest mean scores in all QOL domains compared with other types of treatment. Those who underwent combination of surgery, chemotherapy and radiotherapy achieved the highest score in the social domain. However, receiving all treatment modalities did not influence the QOL of breast cancer patients (P=0.204).
By multiple regression analysis (table 6), we found patients who were employed, with high education and high income were more likely to have high score of QOL, with ORs (95% CI) of 4.60 (1.51-13.98), 4.57 (1.17-17.84) and 9.95 (2.10-47.07) respectively, while patients who underwent surgical intervention only and receiving hormonal therapy were more likely to have poorer QOL with ORs (95% CI) of 2.18 (1.75-2.72) and 3.15 (1.00-10.61) respectively.
However, age, marital status, chemotherapy, radiotherapy and combination of all types of treatment did not significantly influence QOL, with ORs (95% CI) of 0.84 (0.34-2.07), 0.68 (0.17-2.71), 2.73 (0.89-8.41), 0.75 (0.28-1.98) and 0.47 (0.21-1.09), respectively.


This study investigated the effect of breast cancer on the healthrelated quality of life of patients in Palestine and correlated their sociodemographic and clinical characteristics to the changes in HRQOL scores.
The analysis of the question of satisfaction with health showed that most of Palestinian breast cancer women were satisfied with their health in spite of the presence of the disease. This could be referred to the religious values and social support they receive. Many studies supported these findings; Hebert et al. indicated that positive religious coping methods predict better mental health and life satisfaction in women with breast cancer [16]. Others found that breast cancer survivors had similar health status and psychological well-being and a better satisfaction with life compared of the same age of controls [13,17,18].
The social domain had the highest scores among HRQOL subscales. This may be referred to effective social support system in the Palestinian community. Such findings were constant with Hong-Li et al. who found that social well-being was the best QOL subscale for one of the study groups [19]. De Aguiar, et al. [20] and Cheng, et al. [21] indicated that social support is a significant factor positively influencing quality of life in breast cancer survivors. Ogce, et al. showed that the breast cancer patients with increased social support had more physical wellness besides overall quality of life [22]. In contrast, Sert, et al. reported that having breast cancer is an independent factor that affects social well-being and social life in a negative way [23].
Most of our participants were older than 46 years, which indicated that the risk of getting breast cancer increases with age. According to CDC research center, the chance will double to get breast cancer after 40 years old every 10 years [20,24]. However, the differences in QOL domain scores between different age groups in our study did not reach statistical significance. This is consistent with two studies conducted in Iran and Yemen which showed the absence of any significant relationship between quality of life with age [10,25]. Other studies revealed contradicting findings; some correlated poorer QOL with increasing age [26,27], while others found that younger age patients had more physical wellness and better overall quality of life [22]. The inconsistency of these studies may be explained by differences in population background, source of subjects and sample size.
Based on the logistic regression analysis, low education level, unemployment and lower income in this study were associated with poorer QOL. This is supported by many studies which indicated that increased QOL scores were significantly correlated with increased education and better socioeconomics [10,25,28-32]. The possible rationale for this is the ability of the educated women to understand the nature of the disease and to comply with the therapeutic regime more than the uneducated. Moreover, illiterate women with low income are less likely to be screened for breast cancer, would delay seeking care in the presence of symptoms, and were diagnosed in later stages of the disease [10].
We found marital status was not a significant factor for predicting HRQOL scores. This is constant with a previous studies conducted by Sert, et al. [23] and Musarezaie, et al. [25], who reported that marital status had no significant effect on HRQOL domains, while others [29,33,34] reported that it had a significant association with overall HRQOL and differential domains of HRQOL.
The logistic regression also indicated that surgical intervention and hormonal therapy were indicators for poorer QOL while chemotherapy, radiotherapy and combination of all types of treatment did not significantly influence QOL.
The findings of other studies revealed differential results: positive effect, negative effect or no effect of treatment modalities on HRQOL. In constant with our results, some studies indicated that QOL did not show any association with chemotherapy and radiotherapy [23,26,29,34]. In contrast, Groenvold reported that chemotherapy was associated with more negative impact on QOL during the treatment period [35]. DiSipioalso found that receiving multiple forms of adjuvant treatment was associated with declines in QOL among women with breast cancer [36]. This is reinforced by Musarezaie, et al. [25] and Bayram, et al. [37] who reported a negative correlation between the number of chemotherapy sessions and patients' quality of life.
On the other side, other studies have showed positive effects of different treatment modalities on HRQOL of breast cancer patients. In a selective literature search in the PubMed database from January 2000 to May 2010 to investigate the impact of various local or systemic treatments on QOL scores, it is found that most studies reported that overall QOL was maintained or improved in breast cancer patients receiving hormonal and chemotherapy [18]. Adjuvant intravenous chemotherapy was significant factor predicting FACT-G scores at 6 months, 1, and 2 years after surgery [38]. Sert, et al. emphasized that all QOL scores for all dimensions had statistically significant changes in terms of hormonal regimes [23]. A study conducted in Yemen reported that there was a significant association between the type of surgery and radiotherapy and QOL in terms of functional well-being and emotional well-being [10]. The discrepancies of these results may be explained by differences in population background, sample size, stages of the disease and presence of other comorbidities.
In conclusion, all quality of life domains of the breast cancer women in Palestine were negatively affected. Unemployment, low educational status, low family income, surgical intervention and hormonal therapy were associated with lower score of QOL by WHOQOL-BREF subscale assessment. In contrast, age, marital status, chemotherapy, radiotherapy and combination of all types of treatment did not significantly influence QOL. Larger sample studies from Palestinian population are still needed. Further qualitative studies are also recommended at different life stages to explore deeply the experiences and concerns of the breast cancer patients in Palestine.


Authors acknowledge the school of public health, Alquds University for their guidance and support. Special thanks for the staff of oncology departments in El-Shifa and the European Hospitals and for the participants who gave their time willingly and shared their stressful experiences.

Competing Interests

The authors declare that they have no competing interests. The study received ethical clearance from Helsinki Ethical Committee of Ministry of Health, Gaza governorates.


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