Quality of Life Assessment after Breast Cancer Treatment using EORTC QLQ-C30 and BR-23 Questionnaire: A Prospective Study

INTRODUCTION

Breast cancer (BC) is the most frequent cancer in women and the leading cause of mortality in both developing and developed countries.^[1,2] The GLOBOCAN report estimated that 2.3 million people were diagnosed with BC in 2020, and 684,996 people died from BC.^[3] The incidence rates of BC have been increasing globally during the past 30 years. According to the Indian Council of Medical Research (2020), the incidence rate of BC is 14.8% in India.^[4] It is estimated that the number of BC cases in India will increase from 153,297 cases annually in 2011 to 235,490 cases in 2026.^[5]

In India, the majority of the population lives in rural areas and because of a lack of awareness about BC and also a lack of access to health care majority of patients present with advanced-stage disease. The treatment for BC includes surgery, chemotherapy and radiotherapy. In the majority of patients who underwent mastectomy for a large tumour or locally advanced disease, there is considerable psychological trauma to patients. This is also one of the reasons the patient denies treatment. Furthermore, chemotherapy and radiation treatment have inherent side effects associated that can also impair quality of life (QoL) in these patients.^[6,7] Studies in India have shown that QoL among BC patients after treatment is good, but the arm symptoms and sexual disturbances were persistent even after completion of treatment.^[8-10]

Measurements of QoL in patients with BC have recently become a focus of clinical practice and research, and they are critical in determining treatment success.^[11] According to the World Health Organization, QoL is defined as “the individual’s perception of their position in life in the context of the culture and value systems in which they live and about their goals.”^[12] Women who underwent surgery experienced a variety of physical and emotional issues, such as depression and anxiety, which have a significant impact on the mental health of the patients. Some studies have shown that the prevalence of depression among BC patients ranges from 1.5% to 50%.^[13,14]

Previous studies have assessed the QoL at diagnosis, treatment and rehabilitation and found that patients were more likely to experience physical problems (fatigue, sleep disturbances and pain) as well as psychological distress (depression, anxiety, negative thoughts, fear of recurrence and death, feelings of isolation, sexual problems and poor self-image), all of which have a negative impact on QoL and survival.^[15,16] The long-term follow-up studies in the Indian context are lacking to assess the QoL of BC patients. The present study was planned to understand the perspective of BC patients regarding their post-treatment QoL. The information obtained from this research will be useful in planning care to improve QoL during the rehabilitation phase.

MATERIALS AND METHODS

RESULTS

Median score of QoL and functioning

Changes in QoL were assessed at the 3, 12 and 24 months after completion of their BC treatment using the EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires. For the EORTC QLQ-C30, the median global health status score demonstrated a significant improvement over time, increasing from 58 (interquartile range [IQR]: 50–67) at 3 months to 75 (IQR: 66–75) at 12 months, and further to 83 (IQR: 75–83) at 24 months (P = 0.001). Most functional dimension scores also showed significant improvements across the follow-up periods. However, social functioning did not show a statistically significant change, with scores of 75 (IQR: 0–23) at 3 months, 66 (IQR: 50–100) at 12 months and 75 (IQR: 67–92) at 24 months (P = 0.16) [Figure 1].

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Figure 1:

Median score of the quality of life (QOL) and functioning as per EORTC C-30.

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Median symptom score

The median fatigue scores at 3, 12 and 24 months were 22 (IQR: 44–56), 22 (IQR: 11–56) and 55 (IQR: 44–67), respectively. A statistically significant increase in fatigue was observed from 3 to 24 months (P < 0.05). In contrast, all six symptom scales – nausea/vomiting, dyspnoea, sleep disturbances, appetite loss, constipation and diarrhoea – demonstrated a median score of 0 at all time points, with the upper limit of the IQR also being 0, indicating minimal symptom burden. Financial difficulties were notably higher at 24 months, with a median score of 67, compared to 33 at both 3 and 12 months [Figure 2].

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Figure 2:

Median symptoms score as per EORTC C-30.

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Breast functioning scores

For the EORTC QLQ-BR23 questionnaire, improvements were observed in sexual functioning, sexual enjoyment and future prospects over the study period. In contrast, body image, which had high median scores at 3 and 12 months, showed a decline at 24 months with median scores of 75 (IQR: 67–92), 91 (IQR: 75–100) and 50 (IQR: 33–83), respectively (P = 0.001). Regarding the symptom dimensions, improvements were noted in hair loss and systemic side effects, whereas arm and breast symptoms demonstrated deterioration in QoL [Figure 3].

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Figure 3:

Median breast functioning and symptoms score as per EORTC B23.

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DISCUSSION

BC and its treatment strategies substantially affect the QoL of patients. One of the treatment goals for these patients is to maintain the QoL. The estimation of QoL of patients with BC aids in assessing the efficacy of treatment. This study allowed us to analyse the evolution of the post-treatment QoL in patients with BC. The assessment of QoL was done at 3, 12 and 24 months with English and Hindi versions EORTC QLQ-C30 and EORTC QLQ-BR23 validated and standardised questionnaires.

It was exhibited that global health status improved at 12 and 24 months after the completion of treatment and was generally consistent with other studies^[21,22] and was also equal to the reference value for BC patients.^[23] Improved QoL in our study might be due to the quality of care provided in the setup. This institute has a regional cancer care centre with advanced treatment modalities, including radiotherapy, adequate surgical procedures and chemotherapy with palliative care. This result was in line with the earlier findings showing that living with BC and its treatment is a different experience that often affects many aspects of the patient’s QoL and these patients are usually satisfied with the treatment decision over time and experience minimal decisional regret.^[24-26]

The present study discovered that the functional score i.e. physical, role, emotional and cognitive functions, improved with time, and their score remained relatively unaffected during the follow-up, as patients recovered from treatment effects, and they are generally able to return to their previous functioning. These findings are congruent with the earlier studies,^[22,27] as they found considerable improvement in the different domains over time. However, in the present study, social well-being was most commonly affected. The social well-being scale involves those terms that reflect whether the medical condition or physical condition interfered with the patient’s family and social life. Out of the five domains, the participants opined that the social domain greatly impacted the QoL. These findings are congruent with the previous study^[28] experienced social life as one of the crucial indicators of QoL. Different treatment modalities can impair social life, such as surgery and chemotherapy can disturb the body image which leading to disturbed family and social life.

As for the symptom scale of EORTC QLQ-C30, the current study revealed a significant decrease in the severity of symptoms for pain, nausea and vomiting, insomnia, constipation, diarrhoea and loss of appetite. The improvement of these symptoms could probably be associated with the completion of treatment, as these symptoms are usually observed with chemotherapy and radiotherapy. The observed increase in fatigue scores over time, from 22 at 3 months to 55 at 24 months, contrasts with improvements in other functional and symptom domains. Several potential factors may explain this trend. Long-term treatment-related side effects, including persistent inflammation or hormonal changes, may contribute to sustained fatigue. Psychological stress, such as anxiety, depression or fear of recurrence, may also exacerbate fatigue over time. In addition, socioeconomic factors, including financial difficulties – especially as noted at 24 months – may further compound physical and emotional exhaustion. Consequently, the QoL of patients is reduced as fatigue becomes severe. Our results differ from those of Moro-Valdezate et al.^[27] who reported an improvement in all symptom scales, and Hartl et al.^[22] reported dyspnoea and diarrhoea among patients. In the current study, it has been seen that patients had difficulty managing their expenses during the 2 years of follow-up. This is because the majority of women belong to the lower- income class and do not have any financial security. Similar results have also been reported by Moro-Valdezate et al.^[27] which showed that lower-income group patients without any financial support reported poor QoL.

It is usual for BC survivors to suffer from persistent arm morbidity (i.e. pain, limited range of motion, reduced strength) with decreased upper limb function after surgery and/or adjuvant treatment.^[29] This study also found strength) with decreased upper limb function after surgery and/or adjuvant treatment.^[29] This study also found restriction in arm and shoulder movement at 2-year follow-up, which in turn affects QoL. These results were generally observed among patients who underwent surgery or adjuvant therapy, which may contribute to restrictions in arm and shoulder mobility. Such reduced functionality can lead to physical inactivity and contribute to the worsening of the health status in BC survivors.^[30]

The financial burden observed in this study, with a notable increase at 24 months, is an important aspect of long-term survivorship. Financial difficulties can adversely affect patients’ overall QoL, treatment adherence and psychological well-being. In the context of India, where out-of-pocket expenses remain a significant challenge for many cancer survivors, these findings highlight the urgent need for comprehensive survivorship care policies. Existing initiatives, such as government-supported health insurance schemes and non-governmental support programmes, are steps in the right direction; however, more structured and accessible financial assistance programmes are required to address the sustained economic impact faced by survivors. Integrating financial counselling and support services into survivorship care models could help mitigate this burden and improve long-term outcomes for BC survivors.^[31]

Breasts are important for female beauty and sexuality, which constitute the female body image. In BC patients, body image may suffer due to the changes related to the oncological treatment (alterations in the skin texture, breast asymmetry and size).^[32] The present study showed that women have lower body image scores (felt less attractive, did not like their appearance, were unhappy with their breasts and scars) even 1 year after the treatment. A similar finding was obtained by Esmaili et al. in a BC patient after mastectomy, depicting the fear of negative body image.^[33] In our study, sexual functioning improved over a period after the treatment. In addition, scores of sexual functioning and sexual enjoyment were pretty high compared with similar researches.^[34,35] However, the findings were not consistent with the previous studies that reported disturbed sexual functioning or unsatisfactory sexual life.^[36,37] This might be due to the unique cultural background. In India, sexuality is considered a private topic and is not openly discussed. Thus, women are more conservative about sex-related topics; older or lower-educated patients are more likely to avoid answering these questions or choose a random answer. Shankar et al.^[38] also mentioned that in Indian scenarios with cultural and ethical boundaries, sex and related dysfunctions are still taboo. This highlights the need for culturally sensitive approaches in addressing sexual health concerns among cancer survivors. The National Cancer Grid’s Survivorship Care Policy in India emphasises holistic post-treatment care, including psychosocial and sexual health support tailored to patient preferences and sociocultural sensitivities. Incorporating structured counselling, patient education and culturally appropriate communication strategies can help mitigate these biases and ensure comprehensive survivorship care.^[39] To help patients manage their symptoms while undergoing cancer treatment, psychological and support groups are essential. This support may come from a health professional who offers emotional and supportive counselling to the patients or from other patients, as hearing about other patient’s symptoms and their management strategies may help the patients to find different ways to deal with their symptoms. Healthcare professionals should also have a separate counselling room for discussing problems related to their body image and sexual life.

CONCLUSION

After a 2-year follow-up, we were able to demonstrate a significant overall improvement in the QoL of patients with BC using the EORTC QLQ-C30 questionnaire’s functional and symptom scales. For the EORTC QLQ-BR23 BC questionnaire, there was a decline in QoL in terms of body image on the functional scale, as well as arm and breast symptoms on the symptom scales. In addition, the findings are observational in nature, and therefore, causal relationships cannot be established. The results should be interpreted with caution, as unmeasured confounding variables may have influenced the outcomes. This study would help the clinician to understand how QoL and symptoms vary over time so that they can modify their care plan during follow-up of the patients.