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Health Related Quality of Life of Cancer Patients in Ethiopia

Health Related Quality of Life of Cancer Patients in Ethiopia Hindawi Journal of Oncology Volume 2018, Article ID 1467595, 8 pages https://doi.org/10.1155/2018/1467595 Research Article Tadesse Melaku Abegaz , Asnakew Achaw Ayele , and Begashaw Melaku Gebresillassie CollegeofMedicineandHealthSciences,Schoolof Pharmacy, Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia Correspondence should be addressed to Tadesse Melaku Abegaz; abegaztadesse981@gmail.com Received 22 December 2017; Accepted 8 March 2018; Published 15 April 2018 Academic Editor: James L. Mulshine Copyright © 2018 Tadesse Melaku Abegaz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Neoplasm,AKA cancer (Ca),isassociatedwithmajormorbidityandmortality. Aim. Measurement of health related quality of life (HRQoL) of Ca patients is uncommon in Ethiopia. The present study determined the HRQoL and its determinants among people living with Ca in north Ethiopia. Methods. A prospective hospital based study was conducted from 1 January 2017 to 30 August 2017 on Ca patients attending cancer treatment center of University of Gondar Teaching Hospital. eTh European Organization for Research and Treatment of Cancer Questionnaire version 3 was utilized to collect the data. eTh rate of QoL was presented using means with standard deviation (±SD). Binary logistic regression was employed to determine factors associated with HRQoL. Result. The present study is based on the findings from 150 subjects. The rate of QoL was 52.7 (20.1) (mean ± SD). The highest functional status was emotional functioning 61 (25.5). Patients with no disease metastasis, 92.1 (5.1), had high QoL as compared to metastasis, 22.1 (18.9)(𝑝 = 0.03). Patients with aeff cted physical functioning have a 20% reduction in QoL and Adjusted Odds Ratio (AOR) of 0.794 [0.299–891]. Patients with low satisfaction level with the provided care, 0.82 [0.76–0.93], and those with unmet needs, 0.85 [0.80–0.95], experienced reduced level of HRQoL. Conclusion. Health related quality of life of cancer patients was found to be low in Ethiopia. Patients with limited rate of disease metastasis had improved HRQoL. Further, the unmet needs of Ca patients and the level of satisfaction with the overall care were found to influence the extent of HRQoL. Therefore, early detection of neoplasm to arrest metastasis is warranted in order to achieve better QoL. In addition, addressing the unmet needs of these patients and ensuring higher satisfaction rate are recommended to maintain adequate HRQoL. 1. Introduction Cancer is emerging as a formidable challenge in low in- come countries that have limited logistic to protect the Neoplasm, AKA cancer (Ca), is associated with major mor- health of citizens. In developing countries, the burden of Ca bidity and mortality in the world. A twenty-five-year system- overlaps with the magnitude of infectious diseases including atic analysis of cancer registry from 195 countries demon- HIV/AIDS, tuberculosis, hepatitis virus, and human papil- strated that there were 17.5 million cancer cases and 8.7 loma virus which can contribute to the pathogenesis of million deaths in the year 2015 worldwide [1]. Over a ten-year Ca. eTh lack of early detection and timely treatment would period (2005–2015), cancer cases increased by one-third aggravate the situation in these nations [4]. In Ethiopia, can- (33%). The longevity of the general population (16%) and cer belongs to the second most common noncommunicable population density (13%) contributed to this magnitude. disease (NCD) only next to cardiovascular disorders [5]. In Breast cancer is the most commonly isolated cancer and Gondar University Hospital, the number of new cases seen the leading cause of mortality among women. Globally, it is has increased following the establishment of new cancer attributed to one-fourth of the total cancer diagnosis and 14% treatment center. Tefera et al. 2016 reported that the top three of cancer deaths. Lung cancer is the leading malignancy site cancer types were lymphoma (17.2%), cervical cancer (15.2%), inmalesandmakes17% ofthetotal newcancerincidenceand and breast cancer (14.1%), respectively [6]. While treating cancer patients, we usually set dieff rent 23% of the gross cancer deaths [2]. In Africa, cancer mortality was estimated to be 542,000 with a diagnosis of 715,000 new end points to measure the effectiveness of our intervention. cancer cases as of 2008 [3]. Some of the parameters are regarded as primary end points 2 Journal of Oncology and coprimary and surrogate (intermediate)endpoints. These 2.3. Study Design and Period. A prospective hospital based measurements include Overall Survival (OS), Progression- cross-sectional study was conducted from 1 January 2017 to Free Survival (PFS), Overall Radiographic Response (ORR), 30 August 2017. andhealthrelated qualityoflife(HRQoL).OSisanobjective primary endpoint which measures all causes of death. But, 2.4. Inclusion and Exclusion Criteria. Patients who were it does not determine the exact impact of treatment [7]. receivingtherapy andare above18yearsoldwereincluded. PFS is an intermediate end point which predicts OS rate Those who did not consent for the study and are unable to within short period of time and with reduced cost. However, respond for the questions were excluded. PFS does not imply the clinical advantage of the treatment for the patient since the PFS is achieved in the expense of 2.5. Sample Size Determination and Sampling Technique. All treatment toxicity and decline in HRqol. Like PFS, ORR cancer patients were consecutively included in the study directly measures the extent of the tumor through radiogra- basedoninclusion andexclusioncriteriaduringthestudy phy. Nonetheless, it lacks reproducibility due to observer bias. period. Moreover, the above measures do not incorporate the patient perspective. On the other hand, HRqol is self-perceived 2.6. Study Variables. Our dependent variable was the rate approach to evaluate patients’ view of their own health of HRQoL. Independent variables include sociodemographic status [7]. The definition of HRqol remains different among characteristics of the patient including age and gender, different literatures. HRQoL can be defined as “how well functional status, and symptom scales. individuals function on some predefined activities in their life and wellbeing in physical, mental, and social domains of 2.7. Data Collection Methods. Data was collected by two health.” Wellbeing refers to an individual’s subjective feelings trained clinical nurses. A structured questionnaire which [7, 8]. It is assessed by a standard structured questionnaire contained of 30 items was adopted from the Quality of Life called Quality of Life Questionnaire (QLQ) prepared by the Questionnaire (QLQ-30) version 3 which is the standard ver- European organization for research and treatment of cancer. sion currently. It was released in 1993 [9]. eTh questionnaire It has been used for clinical trials. But, recently it is introduced contains vfi e multi-item functional status scales (physical, in nontrial studies [9, 10]. role, social, emotional, and cognitive) and 9 symptoms scales eTh significant number of people living with cancer (pain, fatigue, financial impact, appetite loss, and nausea/) (PLWCa) rarely achieves reemission with chemotherapy, and two global health status items. surgery, or radiotherapy. In these patients, our goal is to im- eTh scoring of the n fi dings was based on EORTC QLQ- prove their quality of life and to promote their functioning. 30 scoring manual [10, 11]. eTh scales are rated in terms of HERqol is an important tool used to evaluate the functioning percentage. A high score in functional scale and global health of our patients. Assessment of HERqol is also helpful to pass status denotes high health status, respectively. But, for a shared decision between the patient and the clinician regard- symptom scale high score represents sever symptomatology. ing the treatment. But, it has not been implemented in our setup so far. er Th efore, the present study aimed to investigate 2.8. Data Quality Control Technique. Data collectors were cancer patients’ health related quality of life at Gondar trained intensively on contents of the questionnaire, data University Hospital Cancer Center. collection methods, and ethical concerns. eTh questions were translated into Amharic so as to maintain unbiased response. The filled questionnaire was checked daily for completeness 2. Methods by the principal investigator. eTh reliability (psychometric property) of the tool was evaluated and demonstrated a Cron- 2.1. Study Setting and Area. University of Gondar Referral bach alpha value of 0.871. eTh content of the questionnaire Hospital (UoGRH) is a teaching hospital located in Gondar was reviewed by senior experts. Town, northwest Ethiopia. Gondar is 748 kms away from the capital, Addis Ababa. eTh Gondar Cancer Center was 2.9. Data Analysis. All the statistical data were carried out established in January 2015 with few dedicated individuals. using Statistical Package for Social Sciences (SPSS), version It is regarded as the second treatment center in the country. 20 (SPSS Inc., Cary, NC, USA). Descriptive statistics was More than 600 patients visit the center for chemotherapy presented using means with standard deviation (±SD) and and screening. It is run by few physicians and nurses who percentages (%).𝑝 values were kept<0.05 with 95% confi- have gained adequate training on the discipline. The inpatient dence interval. Bivariate analysis was applied to investigate ward contains ten beds in which chemotherapy is adminis- the correlation of independent variables. Binary logistic tered in each cycle. eTh cytotoxic admixture and administra- regression was employed to determine associated factors. tion arecarriedoutbynurses. However, thereisnoradiother- One-way analysis of variance has been employed to assess the apy service in the hospital so far. mean difference in quality of life. 2.2. Population. All cancer patients who were admitted to 3. Results oncology ward of UoGRH during the study period were our source populations, whereas patients above the age of 18 years 3.1. Sociodemographic and Clinical Characteristics of Patients. were the study population. The present study was based on the ndin fi gs from 150 Journal of Oncology 3 subjects. All of the patients who attended the cancer treat- Table 1: Sociodemographic and clinical characteristics of cancer patients attending UoGRH. ment center responded to the questionnaire. The mean age of the respondents was 46.8 (14.5). More than half of the Variables 𝑁 (%) patients werefemales83(52.9%).Abovefortypercentof Age 46.8 (14.5) them did not have formal education 69 (43.9%). eTh average Females 83 (52.9) monthly income was 1336.1± 240.3 Ethiopian birr ($49.48 Occupation ± 8.9, $ = 27.175 ETB). Nearly forty percent of cases were metastasis 65 (41.4). eTh mean duration of the disease was Nongovernmental 14 (8.9) 13.4 ± 12.1 months. The most common Ca include breast Private employee 36 (22.9) Ca37(24.7) followedbybloodrelatedCa36(24). eTh Government employee 20 (2.7) frequently prescribed medications include leucovorin (79), 5- Agriculture 56 (37.33) u fl orouracil (68), and cisplatin (47), respectively (Table 1). Retire 24 (16) Education 3.2. Global Health Status, Functional Scales, and Symptom No education 69 (43.9) Scales. eTh rate of quality of life based on global health Elementary 32 (20.4) status (GHS) was 52.7 (20.1). eTh highest FS was emotional High school 25 (16.7) functioning (EF) 61 (25.5) followed by cognitive functioning College 12 (8) 59.31 (43.6%). eTh physical functioning state of the patients University 12 (8) was 53.27 (22.9) whereas social functioning (SF) and role Marital status functioning (RF) accounted to 46.31 (25.5) and 43.32 (26.7), Single 33 (21) respectively. Nausea and vomiting were the most annoying Married 83 (52.9) symptom, 43.3 (23.1) followed by 42.1 (33.3), and fatigue, 41.47 (24.5) (Table 2). Divorced 14 (8.9) Widowed 20 (12.7) 3.3. The Mean Difference in QoL Scales versus Sociodemo- Monthly income 1336.1± 240.3 graphic Characteristics. RF was found to be different based Residence on marital status(𝑝=0.02).Accordingtoposthoc analysis, Rural 78 (49.7) the difference was found to be between single marital status, Surgery (yes) 72 (45.5) 43 (31.6), and divorced, 1.2 (2.3)(𝑝 = 0.01), and married, Duration of the disease (months) 13.4± 12.1 36.7 (29.8), and divorced(𝑝 = 0.03). eTh mean difference Metastasis (yes) 65 (41.4) of GHS was significant for disease metastasis. Accordingly, Diagnosis patients with no disease metastasis, 92.1 (5.1), had high GHS Colorectal Ca 30 (20) as compared to metastasis, 22.1 (18.9)(𝑝=0.03).Themean Cervical Ca 32 (21.33) difference of EF was also significant in terms of disease Lung Ca 15 (10) metastasis, 34.1 (25.5) versus 53.2 (25.3)(𝑝=0.04).GHSwas Blood related Ca 36 (24) also dieff rent for patients who underwent surgical procedure, 82.8 (4.9) and 24.5 (19.5)(𝑝=0.01) (Table 3). Breast Ca 37 (24.7) Medications 5-Fluorouracil 68 3.4. Multinomial Regression Indicating Factors Affecting Qual- ity of Life. Binary logistic regression indicated that patients Cisplatin 47 with aeff cted physical functioning have a 20% reduction in Leucovorin 79 quality of life of AOR of 0.794 [0.299–891]. Patients with Cyclophosphamide 41 no history of vomiting were 2.5 more likely to have good Doxorubicin 39 QoL as compared to patients with vomiting history of AOR Methotrexate 45 of 2.655 [1.839–8.397]. Patients whose social functioning is Irinotecan 27 not affected more than three times are more likely to have Others 31 good QoL of 3.637 [1.838–8.300]. Patients with unaeff cted EF had 4.5 times good HRQoL as compared to aeff cted HRQoL of 4.426 [2.890–6.613]. Patients with low satisfaction level with the provided care of 0.82 [0.76–0.93] and those with living with Ca helps to evaluate the eeff ctiveness of our unmet needs of 0.85 [0.80–0.95] experienced reduced level interventions. In developing countries including Ethiopia, of HRQoL (Table 4). HRQoL measurement is not performed routinely. This study aimed to determine the rate of HRQoL among Ca patients attending a teaching referral hospital in north Ethiopia. Based 4. Discussion on GHS data, the rate of quality of life was found to be 52.7 Ca and its treatment strategies substantially aeff ct HRQoL (SD: 20.1) which was comparable from a result obtained in of patients. HRQoL is viewed as one of treatment end AddisAbaba,52.5(SD:26.0)[11],butlowerfromthereference points in these individuals. Estimation of HRQoL of patients value [12]. In addition, QoL was quite small when compared 4 Journal of Oncology Table2:Themeanglobalhealthstatus,functionalscales,andsymp- symptoms couldaggravate theprevalenceand severityof tom scales of cancer patients at UoGRH. fatigue. Researches revealed that malignancy by itself could induce malaise and weakness [19]. Scales mean± SD The rate of role functioning was found to be different with Global health status 52.7 (20.1) respecttomarital status.Singleand married individualshad Functional scales good role functioning as compared to divorced individuals Physical functioning 53.27 (22.9) (𝑝 < 0.05). Married persons tend to present early before Role functioning 43.32 (26.7) metastasis and receive advanced care unlike other individu- als. Other study also estimated that cancer survival rate was Social functioning 46.31 (25.5) also aeff cted by marital status. A comparative study indicated emotional functioning 61 (25.5) that widowed patients were found to be at greater risk of death Cognitive functioning 59.31 (43.6) relative to other groups [20]. With regard to GHS, the mean Symptoms scale difference of GHS was significant based on the level of disease Fatigue 41.47 (24.5) metastasis.Advanceddiseaseswerefound toreducethe Nausea and vomiting 43.3 (23.1) GHS and emotional functioning of Ca patients. Accordingly, Pain 34.8 (24.4) patients with no disease metastasis had high GHS as com- Dyspnea 34.8 (29.2) pared to metastasis(𝑝=0.03). Another finding on this study Insomnia 42.1 (33.3) indicatedthatsurgery showed apositiveimpactontheglobal Appetite 38.4 (31.2) health status of patients since it could bring a radical cure Constipation 40.6 (31.2) ofthediseasesifitisfollowedbyadequateadjuvanttherapy. But, it is difficult to generalize this finding for all forms of Diarrhea 44.2 (34.1) Ca as some cases favor improved quality of life when surgery Financial difficulties 69.6 (31.2) preserves organs such as breast cancer and lung cancer so as to spare aesthetic values [21–23]. In the current study, multiple factors have been correlated with QoL of cancer patients. It was found that patients with with other studies from India, Melbourne, Nepal, and Brazil aeff cted physical functioning have a reduced quality of life. [13–15]. Low level of QoL in our study might be due to quality The global health QoL and functional status of cancer patients of care provided in the setup. eTh cancer center has been usually go parallel. For instance, a study measured the oro- established only recently, as of 2015, and advanced treatments pharyngeal neoplasia and its function and the global health including radiotherapy, adequate surgical procedure, and status demonstrated that patients with limited or compro- palliative care are yet to be started. In addition, patients mised oropharyngeal function were having poor QoL [24]. are usually admitted once they are terminally ill. One study Patients with no history of vomiting were 2.5 more likely reiterated that level of care affects QoL [12]. Surgery has been to have good QoL as compared to patients with vomiting linked with the improvement in QoL of patients in our study history. Vomiting was found to aeff ct routine activities of which is demonstrated by mean difference in QoL among patients including household activities, feeding style, time individuals who underwent surgery. allocation for social activities, and daily function and recre- The present study discovered that emotional and cog- ation [25]. In addition, patients with preserved social func- nitive functions were among the highest functional status tioning are nearly four times more likely to have good QoL. scores. eTh y remain relatively unaffected. Emotions contain Furthermore, patients with unaeff cted EF had 4.5 times good depression, worries, tension, and irritability whereas cogni- HRQoL as compared to aeff cted HRQoL. A comparative tion evaluated the patients’ level of concentration on things study reported that emotional disturbance among cancer pa- and their ability to remember. Patients report “not at all or tients couldleadtolowlevelofglobalQoL[26,27]. a little” disturbance of emotion. Binary regression indicated In general, the present study provided baseline informa- that individuals with intact emotion were considered to have tion on the quality of life of Ca patients in developing country. good QoL. In addition, a retrospective study in USA reported However, it is limited to single institution as well as few high cognitive functioning but low role functioning among sample size. In light of this, large studies are recommended hepatic Ca patients [16]. Rather, role functioning aspects such to increase the generalizability of findings. as doing daily activities and leisure were highly affected. The most common compliance on symptom scale was 5. Conclusion nausea andvomitingfollowedbyfatigue.Nauseas andvomit- ing are common in Ca patients due to the disease and therapy. Health related quality of life of cancer patients was found The underutilization of antiemetics due to cost and nonad- to be low in Ethiopia. Patients with limited rate of disease herence to guidelines might contribute to the prevalence of metastasis had improved HRQoL. Further, the unmet needs nauseas and vomiting [17]. Furthermore, fatigue was found of Ca patients and the level of satisfaction with the overall to be the second most disabling symptom among Ca patients. care were found to inu fl ence the extent of HRQoL. eTh refore, It is resulted from the therapy including radiotherapy and early detection of neoplasm to arrest metastasis is warranted chemotherapy as well as the disease state. Consequently, the in order to achieve better QoL. In addition, addressing the QoL of patients is reduced as fatigue becomes sever [18]. unmet needs of these patients and ensuring higher satisfac- Advanced disease states and the occurrence of psychosocial tion rate are recommended to maintain adequate HRQoL. Journal of Oncology 5 Table 3: eTh mean difference QLQ scales versus sociodemographic characteristics. QoL PF RF EF CF SF Marital status Single 26.9 (22.7) 52.6 (23.7) 43 (31.6) 47.1 (28.2) 56.5 (20) 44.9 (24.1) Married 73.7 (4.6) 53.8 (24.4) 36.7 (29.8) 36.7 (25.1) 61.3 (54.8) 48.3 (25.9) Divorced 26.3 (16.7) 53 (18.8) 1.2 (2.3) 38.9 (23.1) 63 (31.4) 36.9 (23.7) Widowed 25 (20.5) 52.3 (18.1) 20 (29.1) 37.3 (22.9) 53.3 (22.1) 46.7 (27.4) 𝑝 value 0.871 0.989 0.02 0.25 0.85 0.475 Sex Female 74.7 (4.6) 50.3 (23.4) 48.2 (29.9) 37.6 (24.4) 56 (24.1) 71.5 (29.1) Male 25 (20.2) 56.9 (21.8) 37.3 (27.8) 41.3 (26.8) 63.4 (59.5) 67.2 (33.7) 𝑝 value 0.377 0.673 0.265 0.436 0.124 0.397 Education No education 80.8 (4.9) 51.7 (24.9) 50.7 (10.8) 36.1 (23.1) 57.2 (25.2) 44.9 (25.3) Elementary 33.1 (19.3) 48.4 (21.5) 38.1 (31.1) 37.2 (26.1) 48.5 (24.8) 47.4 (19.3) High school 25.9 (18.9) 59.4 (20.9) 37.3 (35.3) 48.7 (30.8) 74.9 (65.3) 41.6 (30.1) College and above 22.9 (14.7) 57.6 (19.1) 35.4 (23.1) 23.8 (49.7) 63 (19.4) 55.7 (24.4) 𝑝 value 0.361 0.152 0.57 0.175 0.128 0.214 Residence Urban 24.1 (17.5) 54.9 (23.5) 50.4 (10.3) 40.3 (24.7) 60 (25.2) 47 (25.7) Rural 84.1 (3.4) 51.4 (22.1) 35.6 (28.3) 38.1 (26.4) 58.5 (57.4) 45.6 (25.5) 𝑝 value 0.283 0.341 0.239 0.608 0.836 0.73 Duration of the disease 0–12 months 65.5 (4.1) 52.4 (22.6) 45.7 (19.1) 40.6 (26.2) 57.5 (25.1) 44.1 (25.71) 13-24 29.6 (22.2) 54.2 (22.9) 39.4 (35.9) 31.7 (21.7) 65.1 (81.3) 48.9 (26.0) ≥25 16.7 (13.7) 57.5 (25.3) 35.5 (30) 46.4 (25.8) 58.8 (21.8) 55.5 (21.50) 𝑝 value 0.412 0.531 0.162 0.11 0.689 0.217 Metastasis Yes 22.1 (18.9) 49.9 (19.5) 34.1 (27.1) 34.1 (25.5) 54.6 (22.7) 45.1 (27.7) No 92.1 (5.1) 55.8 (24.9) 50.34 (29.8) 53.2 (25.3) 62.9 (54.3) 47.2 (23.8) 𝑝 value 0.03 0.11 0.20 0.04 0.246 0.625 Surgery Yes 82.8 (4.9) 53.4 (20.7) 36.4 (30.8) 37.4 (25.6) 61.6 (57.2) 48.1 (25.1) No 24.5 (19.5) 53.2 (24.8) 49.7 (10.2) 40.95 (25.4) 57.2 (25.6) 44.6 (25.9) 𝑝 value 0.01 0.96 0.289 0.39 0.545 0.41 PF: physical functioning, RF: role functioning, EF: emotional functioning, CF: cognitive functioning, and SF: social functioning. Abbreviations Data Availability AOR: Adjusted Odds Ratio All data generated or analyzed during this study are included AKA: Also Known As in this article. Ca: Cancer CF: Cognitive functioning Ethical Approval COR: Crude Odds Ratio Ethical approval was sought from University of Gondar EF: Emotional functioning Hospital’s clinical director. GHS: Global health status HRQoL: Health related quality of life Conflicts of Interest QoL: Quality of life OS: Overall Survival eTh authors declare that they have no conflicts of interest. ORR: Overall Radiographic Response PF: Physical functioning Authors’ Contributions PFS: Progression-Free Survival SF: Social functioning Tadesse Melaku Abegaz conceived the study, prepared the studyprotocol, analyzed thedata,andwrote upthefinal UoGRH: University of Gondar Referral Hospital. 6 Journal of Oncology Table 4: Association between functional and symptom scales and quality of life. QoL Variables COR 95% CI AOR 95% Aect ff ed Not aect ff ed Sex Male 21 (14) 22 (14.7) 1 1 Females 61 (40.7) 46 (30.7) 1.34 [0.648–2.713] 1.419 [0.596–3.378] Age 47.3 (13.6) 45.7 (14.9) 1.11 [0.98–1.21] 1.002 [0.971–1.034] Residence Rural 57 (38) 21 (14) 0.877 [0.429–1.79] 1.482 [0.630–3.484] Urban 50 (33.33) 22 (14.7) 1 1 Duration of the Dz (month) 11.91 13.27 0.11 [0.97–1.1] 1.001 [0.959–1.045] Surgery No 58 (38.7) 20 (13.33) 1.433 [0.7–2.95] 1.084 [0.447–2.633] Yes 49 (32.7) 23 (15.33) 1 1 Metastasis Yes 49 (32.7) 24 (16) 0.728 [0.351–1.511] 0.590 [0.235–1.479] No 16 (10.7) 26 (17.33) 1 1 Physical functioning No 61 (40.7) 27 (18) 1 1 Yes 46 (30.7) 16 (10.7) 1.357 [0.649–2.84] 0.794 [0.299–891] Role functioning Yes 42 (28) 21 (14) 0.646 [0.315–1.33] 0.655 [0.220–1.949] No 65 (43.3) 21 (14) 1 1 Emotional functioning Yes 46 (30.7) 14 (9.33) 1 1 No 61 (40.7) 29 (19.3) 1.682 [0.788–3.59] 4.426 [2.890–6.613] Cognitive functioning Yes 36 (24) 9 (6) 1 1 No 71 (47.3) 34 (22.7) 2.56 [0.91–5.14] 2.286 [0.684–7.637] Social functioning Yes 36 (24) 7 (4.7) 1 1 No 71 (47.3) 36 (24) 3.04 [1.173–7.89] 3.637 [1.838–8.300] Fatigue Yes 57 (38) 14 (9.3) 2.45 [1.15–5.25] 1.999 [0.488–8.188] No 50 (33.3) 28 (18.7) 1 1 Vomiting Yes 55 (36.7) 18 (12) 1 1 ∗∗ No 52 (34.7) 25 (16.7) 1.55 [0.756–3.21] 2.655 [1.839–8.397] Pain Yes 54 (36) 28 (18.7) 1 1 No 53 (35.33) 15 (10) 0.529 [0.251–1.14] 0.639 [0.217–1.881] Dyspnea Yes 36 (24) 20 (13.33) 0.614 [0.296–1.271] 0.867 [0.308–2.438] No 71 (47.33) 23 (15.33) 1 1 Appetite Yes 38 (25.33) 11 (7.33) 1 1 No 69 (46) 32 ( 21.33) 1.762 [0.782–3.973] 1.784 [0.487–6.532] Constipation Yes 36 (24) 14 (9.33) 1.14 [0.476–2.161] 0.600 [0.165–2.180] No 71 (47.33) 29 (19.33) 1 1 Diarrhea Yes 60 (40) 24 (16) 1 1 No 47 (31.33) 19 (12.7) 0.957 [0.467–1.97] 1.253 [0.447–3.514] Journal of Oncology 7 Table 4: Continued. QoL Variables COR95% CI AOR95% Aect ff ed Not aect ff ed Financial problem Yes 35 (23.33) 11 (7.33) 1 1 No 71 (47.33) 33 (22) 1.81 [0.787–4.191] 2.240 [0.711–7.064] Need required Yes 59 (39.33) 30 (20) 0.67 [0.54–0.79] 0.85 [0.80–0.95] No 26 (17.33) 35 (23.34 1 1 Level of satisfaction Low 72 (48) 25 (16.67) 0.73 [0.62–0.89] 0.82 [0.76–0.93] High 34 (22.67) 19 (12.67) 1 1 ∗ ∗∗ Significant at 0.05 levels; significant at 0.01 levels. assessment in neuro-oncology working group,” Journal of Clin- manuscript. Begashaw Melaku Gebresillassie and Asnakew ical Oncology,vol.28,no.11, pp.1963–1972,2010. Achaw Ayele interpreted and analyzed the data and wrote the initial draft of manuscript. All the authors read and approved [9] K. Mystakidou, E. Tsilika, E. Parpa, O. Kalaidopoulou, V. Smyr- niotis, and L. 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Health Related Quality of Life of Cancer Patients in Ethiopia

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Hindawi Publishing Corporation
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Copyright © 2018 Tadesse Melaku Abegaz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Oncology Volume 2018, Article ID 1467595, 8 pages https://doi.org/10.1155/2018/1467595 Research Article Tadesse Melaku Abegaz , Asnakew Achaw Ayele , and Begashaw Melaku Gebresillassie CollegeofMedicineandHealthSciences,Schoolof Pharmacy, Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia Correspondence should be addressed to Tadesse Melaku Abegaz; abegaztadesse981@gmail.com Received 22 December 2017; Accepted 8 March 2018; Published 15 April 2018 Academic Editor: James L. Mulshine Copyright © 2018 Tadesse Melaku Abegaz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Neoplasm,AKA cancer (Ca),isassociatedwithmajormorbidityandmortality. Aim. Measurement of health related quality of life (HRQoL) of Ca patients is uncommon in Ethiopia. The present study determined the HRQoL and its determinants among people living with Ca in north Ethiopia. Methods. A prospective hospital based study was conducted from 1 January 2017 to 30 August 2017 on Ca patients attending cancer treatment center of University of Gondar Teaching Hospital. eTh European Organization for Research and Treatment of Cancer Questionnaire version 3 was utilized to collect the data. eTh rate of QoL was presented using means with standard deviation (±SD). Binary logistic regression was employed to determine factors associated with HRQoL. Result. The present study is based on the findings from 150 subjects. The rate of QoL was 52.7 (20.1) (mean ± SD). The highest functional status was emotional functioning 61 (25.5). Patients with no disease metastasis, 92.1 (5.1), had high QoL as compared to metastasis, 22.1 (18.9)(𝑝 = 0.03). Patients with aeff cted physical functioning have a 20% reduction in QoL and Adjusted Odds Ratio (AOR) of 0.794 [0.299–891]. Patients with low satisfaction level with the provided care, 0.82 [0.76–0.93], and those with unmet needs, 0.85 [0.80–0.95], experienced reduced level of HRQoL. Conclusion. Health related quality of life of cancer patients was found to be low in Ethiopia. Patients with limited rate of disease metastasis had improved HRQoL. Further, the unmet needs of Ca patients and the level of satisfaction with the overall care were found to influence the extent of HRQoL. Therefore, early detection of neoplasm to arrest metastasis is warranted in order to achieve better QoL. In addition, addressing the unmet needs of these patients and ensuring higher satisfaction rate are recommended to maintain adequate HRQoL. 1. Introduction Cancer is emerging as a formidable challenge in low in- come countries that have limited logistic to protect the Neoplasm, AKA cancer (Ca), is associated with major mor- health of citizens. In developing countries, the burden of Ca bidity and mortality in the world. A twenty-five-year system- overlaps with the magnitude of infectious diseases including atic analysis of cancer registry from 195 countries demon- HIV/AIDS, tuberculosis, hepatitis virus, and human papil- strated that there were 17.5 million cancer cases and 8.7 loma virus which can contribute to the pathogenesis of million deaths in the year 2015 worldwide [1]. Over a ten-year Ca. eTh lack of early detection and timely treatment would period (2005–2015), cancer cases increased by one-third aggravate the situation in these nations [4]. In Ethiopia, can- (33%). The longevity of the general population (16%) and cer belongs to the second most common noncommunicable population density (13%) contributed to this magnitude. disease (NCD) only next to cardiovascular disorders [5]. In Breast cancer is the most commonly isolated cancer and Gondar University Hospital, the number of new cases seen the leading cause of mortality among women. Globally, it is has increased following the establishment of new cancer attributed to one-fourth of the total cancer diagnosis and 14% treatment center. Tefera et al. 2016 reported that the top three of cancer deaths. Lung cancer is the leading malignancy site cancer types were lymphoma (17.2%), cervical cancer (15.2%), inmalesandmakes17% ofthetotal newcancerincidenceand and breast cancer (14.1%), respectively [6]. While treating cancer patients, we usually set dieff rent 23% of the gross cancer deaths [2]. In Africa, cancer mortality was estimated to be 542,000 with a diagnosis of 715,000 new end points to measure the effectiveness of our intervention. cancer cases as of 2008 [3]. Some of the parameters are regarded as primary end points 2 Journal of Oncology and coprimary and surrogate (intermediate)endpoints. These 2.3. Study Design and Period. A prospective hospital based measurements include Overall Survival (OS), Progression- cross-sectional study was conducted from 1 January 2017 to Free Survival (PFS), Overall Radiographic Response (ORR), 30 August 2017. andhealthrelated qualityoflife(HRQoL).OSisanobjective primary endpoint which measures all causes of death. But, 2.4. Inclusion and Exclusion Criteria. Patients who were it does not determine the exact impact of treatment [7]. receivingtherapy andare above18yearsoldwereincluded. PFS is an intermediate end point which predicts OS rate Those who did not consent for the study and are unable to within short period of time and with reduced cost. However, respond for the questions were excluded. PFS does not imply the clinical advantage of the treatment for the patient since the PFS is achieved in the expense of 2.5. Sample Size Determination and Sampling Technique. All treatment toxicity and decline in HRqol. Like PFS, ORR cancer patients were consecutively included in the study directly measures the extent of the tumor through radiogra- basedoninclusion andexclusioncriteriaduringthestudy phy. Nonetheless, it lacks reproducibility due to observer bias. period. Moreover, the above measures do not incorporate the patient perspective. On the other hand, HRqol is self-perceived 2.6. Study Variables. Our dependent variable was the rate approach to evaluate patients’ view of their own health of HRQoL. Independent variables include sociodemographic status [7]. The definition of HRqol remains different among characteristics of the patient including age and gender, different literatures. HRQoL can be defined as “how well functional status, and symptom scales. individuals function on some predefined activities in their life and wellbeing in physical, mental, and social domains of 2.7. Data Collection Methods. Data was collected by two health.” Wellbeing refers to an individual’s subjective feelings trained clinical nurses. A structured questionnaire which [7, 8]. It is assessed by a standard structured questionnaire contained of 30 items was adopted from the Quality of Life called Quality of Life Questionnaire (QLQ) prepared by the Questionnaire (QLQ-30) version 3 which is the standard ver- European organization for research and treatment of cancer. sion currently. It was released in 1993 [9]. eTh questionnaire It has been used for clinical trials. But, recently it is introduced contains vfi e multi-item functional status scales (physical, in nontrial studies [9, 10]. role, social, emotional, and cognitive) and 9 symptoms scales eTh significant number of people living with cancer (pain, fatigue, financial impact, appetite loss, and nausea/) (PLWCa) rarely achieves reemission with chemotherapy, and two global health status items. surgery, or radiotherapy. In these patients, our goal is to im- eTh scoring of the n fi dings was based on EORTC QLQ- prove their quality of life and to promote their functioning. 30 scoring manual [10, 11]. eTh scales are rated in terms of HERqol is an important tool used to evaluate the functioning percentage. A high score in functional scale and global health of our patients. Assessment of HERqol is also helpful to pass status denotes high health status, respectively. But, for a shared decision between the patient and the clinician regard- symptom scale high score represents sever symptomatology. ing the treatment. But, it has not been implemented in our setup so far. er Th efore, the present study aimed to investigate 2.8. Data Quality Control Technique. Data collectors were cancer patients’ health related quality of life at Gondar trained intensively on contents of the questionnaire, data University Hospital Cancer Center. collection methods, and ethical concerns. eTh questions were translated into Amharic so as to maintain unbiased response. The filled questionnaire was checked daily for completeness 2. Methods by the principal investigator. eTh reliability (psychometric property) of the tool was evaluated and demonstrated a Cron- 2.1. Study Setting and Area. University of Gondar Referral bach alpha value of 0.871. eTh content of the questionnaire Hospital (UoGRH) is a teaching hospital located in Gondar was reviewed by senior experts. Town, northwest Ethiopia. Gondar is 748 kms away from the capital, Addis Ababa. eTh Gondar Cancer Center was 2.9. Data Analysis. All the statistical data were carried out established in January 2015 with few dedicated individuals. using Statistical Package for Social Sciences (SPSS), version It is regarded as the second treatment center in the country. 20 (SPSS Inc., Cary, NC, USA). Descriptive statistics was More than 600 patients visit the center for chemotherapy presented using means with standard deviation (±SD) and and screening. It is run by few physicians and nurses who percentages (%).𝑝 values were kept<0.05 with 95% confi- have gained adequate training on the discipline. The inpatient dence interval. Bivariate analysis was applied to investigate ward contains ten beds in which chemotherapy is adminis- the correlation of independent variables. Binary logistic tered in each cycle. eTh cytotoxic admixture and administra- regression was employed to determine associated factors. tion arecarriedoutbynurses. However, thereisnoradiother- One-way analysis of variance has been employed to assess the apy service in the hospital so far. mean difference in quality of life. 2.2. Population. All cancer patients who were admitted to 3. Results oncology ward of UoGRH during the study period were our source populations, whereas patients above the age of 18 years 3.1. Sociodemographic and Clinical Characteristics of Patients. were the study population. The present study was based on the ndin fi gs from 150 Journal of Oncology 3 subjects. All of the patients who attended the cancer treat- Table 1: Sociodemographic and clinical characteristics of cancer patients attending UoGRH. ment center responded to the questionnaire. The mean age of the respondents was 46.8 (14.5). More than half of the Variables 𝑁 (%) patients werefemales83(52.9%).Abovefortypercentof Age 46.8 (14.5) them did not have formal education 69 (43.9%). eTh average Females 83 (52.9) monthly income was 1336.1± 240.3 Ethiopian birr ($49.48 Occupation ± 8.9, $ = 27.175 ETB). Nearly forty percent of cases were metastasis 65 (41.4). eTh mean duration of the disease was Nongovernmental 14 (8.9) 13.4 ± 12.1 months. The most common Ca include breast Private employee 36 (22.9) Ca37(24.7) followedbybloodrelatedCa36(24). eTh Government employee 20 (2.7) frequently prescribed medications include leucovorin (79), 5- Agriculture 56 (37.33) u fl orouracil (68), and cisplatin (47), respectively (Table 1). Retire 24 (16) Education 3.2. Global Health Status, Functional Scales, and Symptom No education 69 (43.9) Scales. eTh rate of quality of life based on global health Elementary 32 (20.4) status (GHS) was 52.7 (20.1). eTh highest FS was emotional High school 25 (16.7) functioning (EF) 61 (25.5) followed by cognitive functioning College 12 (8) 59.31 (43.6%). eTh physical functioning state of the patients University 12 (8) was 53.27 (22.9) whereas social functioning (SF) and role Marital status functioning (RF) accounted to 46.31 (25.5) and 43.32 (26.7), Single 33 (21) respectively. Nausea and vomiting were the most annoying Married 83 (52.9) symptom, 43.3 (23.1) followed by 42.1 (33.3), and fatigue, 41.47 (24.5) (Table 2). Divorced 14 (8.9) Widowed 20 (12.7) 3.3. The Mean Difference in QoL Scales versus Sociodemo- Monthly income 1336.1± 240.3 graphic Characteristics. RF was found to be different based Residence on marital status(𝑝=0.02).Accordingtoposthoc analysis, Rural 78 (49.7) the difference was found to be between single marital status, Surgery (yes) 72 (45.5) 43 (31.6), and divorced, 1.2 (2.3)(𝑝 = 0.01), and married, Duration of the disease (months) 13.4± 12.1 36.7 (29.8), and divorced(𝑝 = 0.03). eTh mean difference Metastasis (yes) 65 (41.4) of GHS was significant for disease metastasis. Accordingly, Diagnosis patients with no disease metastasis, 92.1 (5.1), had high GHS Colorectal Ca 30 (20) as compared to metastasis, 22.1 (18.9)(𝑝=0.03).Themean Cervical Ca 32 (21.33) difference of EF was also significant in terms of disease Lung Ca 15 (10) metastasis, 34.1 (25.5) versus 53.2 (25.3)(𝑝=0.04).GHSwas Blood related Ca 36 (24) also dieff rent for patients who underwent surgical procedure, 82.8 (4.9) and 24.5 (19.5)(𝑝=0.01) (Table 3). Breast Ca 37 (24.7) Medications 5-Fluorouracil 68 3.4. Multinomial Regression Indicating Factors Affecting Qual- ity of Life. Binary logistic regression indicated that patients Cisplatin 47 with aeff cted physical functioning have a 20% reduction in Leucovorin 79 quality of life of AOR of 0.794 [0.299–891]. Patients with Cyclophosphamide 41 no history of vomiting were 2.5 more likely to have good Doxorubicin 39 QoL as compared to patients with vomiting history of AOR Methotrexate 45 of 2.655 [1.839–8.397]. Patients whose social functioning is Irinotecan 27 not affected more than three times are more likely to have Others 31 good QoL of 3.637 [1.838–8.300]. Patients with unaeff cted EF had 4.5 times good HRQoL as compared to aeff cted HRQoL of 4.426 [2.890–6.613]. Patients with low satisfaction level with the provided care of 0.82 [0.76–0.93] and those with living with Ca helps to evaluate the eeff ctiveness of our unmet needs of 0.85 [0.80–0.95] experienced reduced level interventions. In developing countries including Ethiopia, of HRQoL (Table 4). HRQoL measurement is not performed routinely. This study aimed to determine the rate of HRQoL among Ca patients attending a teaching referral hospital in north Ethiopia. Based 4. Discussion on GHS data, the rate of quality of life was found to be 52.7 Ca and its treatment strategies substantially aeff ct HRQoL (SD: 20.1) which was comparable from a result obtained in of patients. HRQoL is viewed as one of treatment end AddisAbaba,52.5(SD:26.0)[11],butlowerfromthereference points in these individuals. Estimation of HRQoL of patients value [12]. In addition, QoL was quite small when compared 4 Journal of Oncology Table2:Themeanglobalhealthstatus,functionalscales,andsymp- symptoms couldaggravate theprevalenceand severityof tom scales of cancer patients at UoGRH. fatigue. Researches revealed that malignancy by itself could induce malaise and weakness [19]. Scales mean± SD The rate of role functioning was found to be different with Global health status 52.7 (20.1) respecttomarital status.Singleand married individualshad Functional scales good role functioning as compared to divorced individuals Physical functioning 53.27 (22.9) (𝑝 < 0.05). Married persons tend to present early before Role functioning 43.32 (26.7) metastasis and receive advanced care unlike other individu- als. Other study also estimated that cancer survival rate was Social functioning 46.31 (25.5) also aeff cted by marital status. A comparative study indicated emotional functioning 61 (25.5) that widowed patients were found to be at greater risk of death Cognitive functioning 59.31 (43.6) relative to other groups [20]. With regard to GHS, the mean Symptoms scale difference of GHS was significant based on the level of disease Fatigue 41.47 (24.5) metastasis.Advanceddiseaseswerefound toreducethe Nausea and vomiting 43.3 (23.1) GHS and emotional functioning of Ca patients. Accordingly, Pain 34.8 (24.4) patients with no disease metastasis had high GHS as com- Dyspnea 34.8 (29.2) pared to metastasis(𝑝=0.03). Another finding on this study Insomnia 42.1 (33.3) indicatedthatsurgery showed apositiveimpactontheglobal Appetite 38.4 (31.2) health status of patients since it could bring a radical cure Constipation 40.6 (31.2) ofthediseasesifitisfollowedbyadequateadjuvanttherapy. But, it is difficult to generalize this finding for all forms of Diarrhea 44.2 (34.1) Ca as some cases favor improved quality of life when surgery Financial difficulties 69.6 (31.2) preserves organs such as breast cancer and lung cancer so as to spare aesthetic values [21–23]. In the current study, multiple factors have been correlated with QoL of cancer patients. It was found that patients with with other studies from India, Melbourne, Nepal, and Brazil aeff cted physical functioning have a reduced quality of life. [13–15]. Low level of QoL in our study might be due to quality The global health QoL and functional status of cancer patients of care provided in the setup. eTh cancer center has been usually go parallel. For instance, a study measured the oro- established only recently, as of 2015, and advanced treatments pharyngeal neoplasia and its function and the global health including radiotherapy, adequate surgical procedure, and status demonstrated that patients with limited or compro- palliative care are yet to be started. In addition, patients mised oropharyngeal function were having poor QoL [24]. are usually admitted once they are terminally ill. One study Patients with no history of vomiting were 2.5 more likely reiterated that level of care affects QoL [12]. Surgery has been to have good QoL as compared to patients with vomiting linked with the improvement in QoL of patients in our study history. Vomiting was found to aeff ct routine activities of which is demonstrated by mean difference in QoL among patients including household activities, feeding style, time individuals who underwent surgery. allocation for social activities, and daily function and recre- The present study discovered that emotional and cog- ation [25]. In addition, patients with preserved social func- nitive functions were among the highest functional status tioning are nearly four times more likely to have good QoL. scores. eTh y remain relatively unaffected. Emotions contain Furthermore, patients with unaeff cted EF had 4.5 times good depression, worries, tension, and irritability whereas cogni- HRQoL as compared to aeff cted HRQoL. A comparative tion evaluated the patients’ level of concentration on things study reported that emotional disturbance among cancer pa- and their ability to remember. Patients report “not at all or tients couldleadtolowlevelofglobalQoL[26,27]. a little” disturbance of emotion. Binary regression indicated In general, the present study provided baseline informa- that individuals with intact emotion were considered to have tion on the quality of life of Ca patients in developing country. good QoL. In addition, a retrospective study in USA reported However, it is limited to single institution as well as few high cognitive functioning but low role functioning among sample size. In light of this, large studies are recommended hepatic Ca patients [16]. Rather, role functioning aspects such to increase the generalizability of findings. as doing daily activities and leisure were highly affected. The most common compliance on symptom scale was 5. Conclusion nausea andvomitingfollowedbyfatigue.Nauseas andvomit- ing are common in Ca patients due to the disease and therapy. Health related quality of life of cancer patients was found The underutilization of antiemetics due to cost and nonad- to be low in Ethiopia. Patients with limited rate of disease herence to guidelines might contribute to the prevalence of metastasis had improved HRQoL. Further, the unmet needs nauseas and vomiting [17]. Furthermore, fatigue was found of Ca patients and the level of satisfaction with the overall to be the second most disabling symptom among Ca patients. care were found to inu fl ence the extent of HRQoL. eTh refore, It is resulted from the therapy including radiotherapy and early detection of neoplasm to arrest metastasis is warranted chemotherapy as well as the disease state. Consequently, the in order to achieve better QoL. In addition, addressing the QoL of patients is reduced as fatigue becomes sever [18]. unmet needs of these patients and ensuring higher satisfac- Advanced disease states and the occurrence of psychosocial tion rate are recommended to maintain adequate HRQoL. Journal of Oncology 5 Table 3: eTh mean difference QLQ scales versus sociodemographic characteristics. QoL PF RF EF CF SF Marital status Single 26.9 (22.7) 52.6 (23.7) 43 (31.6) 47.1 (28.2) 56.5 (20) 44.9 (24.1) Married 73.7 (4.6) 53.8 (24.4) 36.7 (29.8) 36.7 (25.1) 61.3 (54.8) 48.3 (25.9) Divorced 26.3 (16.7) 53 (18.8) 1.2 (2.3) 38.9 (23.1) 63 (31.4) 36.9 (23.7) Widowed 25 (20.5) 52.3 (18.1) 20 (29.1) 37.3 (22.9) 53.3 (22.1) 46.7 (27.4) 𝑝 value 0.871 0.989 0.02 0.25 0.85 0.475 Sex Female 74.7 (4.6) 50.3 (23.4) 48.2 (29.9) 37.6 (24.4) 56 (24.1) 71.5 (29.1) Male 25 (20.2) 56.9 (21.8) 37.3 (27.8) 41.3 (26.8) 63.4 (59.5) 67.2 (33.7) 𝑝 value 0.377 0.673 0.265 0.436 0.124 0.397 Education No education 80.8 (4.9) 51.7 (24.9) 50.7 (10.8) 36.1 (23.1) 57.2 (25.2) 44.9 (25.3) Elementary 33.1 (19.3) 48.4 (21.5) 38.1 (31.1) 37.2 (26.1) 48.5 (24.8) 47.4 (19.3) High school 25.9 (18.9) 59.4 (20.9) 37.3 (35.3) 48.7 (30.8) 74.9 (65.3) 41.6 (30.1) College and above 22.9 (14.7) 57.6 (19.1) 35.4 (23.1) 23.8 (49.7) 63 (19.4) 55.7 (24.4) 𝑝 value 0.361 0.152 0.57 0.175 0.128 0.214 Residence Urban 24.1 (17.5) 54.9 (23.5) 50.4 (10.3) 40.3 (24.7) 60 (25.2) 47 (25.7) Rural 84.1 (3.4) 51.4 (22.1) 35.6 (28.3) 38.1 (26.4) 58.5 (57.4) 45.6 (25.5) 𝑝 value 0.283 0.341 0.239 0.608 0.836 0.73 Duration of the disease 0–12 months 65.5 (4.1) 52.4 (22.6) 45.7 (19.1) 40.6 (26.2) 57.5 (25.1) 44.1 (25.71) 13-24 29.6 (22.2) 54.2 (22.9) 39.4 (35.9) 31.7 (21.7) 65.1 (81.3) 48.9 (26.0) ≥25 16.7 (13.7) 57.5 (25.3) 35.5 (30) 46.4 (25.8) 58.8 (21.8) 55.5 (21.50) 𝑝 value 0.412 0.531 0.162 0.11 0.689 0.217 Metastasis Yes 22.1 (18.9) 49.9 (19.5) 34.1 (27.1) 34.1 (25.5) 54.6 (22.7) 45.1 (27.7) No 92.1 (5.1) 55.8 (24.9) 50.34 (29.8) 53.2 (25.3) 62.9 (54.3) 47.2 (23.8) 𝑝 value 0.03 0.11 0.20 0.04 0.246 0.625 Surgery Yes 82.8 (4.9) 53.4 (20.7) 36.4 (30.8) 37.4 (25.6) 61.6 (57.2) 48.1 (25.1) No 24.5 (19.5) 53.2 (24.8) 49.7 (10.2) 40.95 (25.4) 57.2 (25.6) 44.6 (25.9) 𝑝 value 0.01 0.96 0.289 0.39 0.545 0.41 PF: physical functioning, RF: role functioning, EF: emotional functioning, CF: cognitive functioning, and SF: social functioning. Abbreviations Data Availability AOR: Adjusted Odds Ratio All data generated or analyzed during this study are included AKA: Also Known As in this article. Ca: Cancer CF: Cognitive functioning Ethical Approval COR: Crude Odds Ratio Ethical approval was sought from University of Gondar EF: Emotional functioning Hospital’s clinical director. GHS: Global health status HRQoL: Health related quality of life Conflicts of Interest QoL: Quality of life OS: Overall Survival eTh authors declare that they have no conflicts of interest. ORR: Overall Radiographic Response PF: Physical functioning Authors’ Contributions PFS: Progression-Free Survival SF: Social functioning Tadesse Melaku Abegaz conceived the study, prepared the studyprotocol, analyzed thedata,andwrote upthefinal UoGRH: University of Gondar Referral Hospital. 6 Journal of Oncology Table 4: Association between functional and symptom scales and quality of life. QoL Variables COR 95% CI AOR 95% Aect ff ed Not aect ff ed Sex Male 21 (14) 22 (14.7) 1 1 Females 61 (40.7) 46 (30.7) 1.34 [0.648–2.713] 1.419 [0.596–3.378] Age 47.3 (13.6) 45.7 (14.9) 1.11 [0.98–1.21] 1.002 [0.971–1.034] Residence Rural 57 (38) 21 (14) 0.877 [0.429–1.79] 1.482 [0.630–3.484] Urban 50 (33.33) 22 (14.7) 1 1 Duration of the Dz (month) 11.91 13.27 0.11 [0.97–1.1] 1.001 [0.959–1.045] Surgery No 58 (38.7) 20 (13.33) 1.433 [0.7–2.95] 1.084 [0.447–2.633] Yes 49 (32.7) 23 (15.33) 1 1 Metastasis Yes 49 (32.7) 24 (16) 0.728 [0.351–1.511] 0.590 [0.235–1.479] No 16 (10.7) 26 (17.33) 1 1 Physical functioning No 61 (40.7) 27 (18) 1 1 Yes 46 (30.7) 16 (10.7) 1.357 [0.649–2.84] 0.794 [0.299–891] Role functioning Yes 42 (28) 21 (14) 0.646 [0.315–1.33] 0.655 [0.220–1.949] No 65 (43.3) 21 (14) 1 1 Emotional functioning Yes 46 (30.7) 14 (9.33) 1 1 No 61 (40.7) 29 (19.3) 1.682 [0.788–3.59] 4.426 [2.890–6.613] Cognitive functioning Yes 36 (24) 9 (6) 1 1 No 71 (47.3) 34 (22.7) 2.56 [0.91–5.14] 2.286 [0.684–7.637] Social functioning Yes 36 (24) 7 (4.7) 1 1 No 71 (47.3) 36 (24) 3.04 [1.173–7.89] 3.637 [1.838–8.300] Fatigue Yes 57 (38) 14 (9.3) 2.45 [1.15–5.25] 1.999 [0.488–8.188] No 50 (33.3) 28 (18.7) 1 1 Vomiting Yes 55 (36.7) 18 (12) 1 1 ∗∗ No 52 (34.7) 25 (16.7) 1.55 [0.756–3.21] 2.655 [1.839–8.397] Pain Yes 54 (36) 28 (18.7) 1 1 No 53 (35.33) 15 (10) 0.529 [0.251–1.14] 0.639 [0.217–1.881] Dyspnea Yes 36 (24) 20 (13.33) 0.614 [0.296–1.271] 0.867 [0.308–2.438] No 71 (47.33) 23 (15.33) 1 1 Appetite Yes 38 (25.33) 11 (7.33) 1 1 No 69 (46) 32 ( 21.33) 1.762 [0.782–3.973] 1.784 [0.487–6.532] Constipation Yes 36 (24) 14 (9.33) 1.14 [0.476–2.161] 0.600 [0.165–2.180] No 71 (47.33) 29 (19.33) 1 1 Diarrhea Yes 60 (40) 24 (16) 1 1 No 47 (31.33) 19 (12.7) 0.957 [0.467–1.97] 1.253 [0.447–3.514] Journal of Oncology 7 Table 4: Continued. 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