Breast cancer related physical, psychological, social and spiritual domains of quality of life among women in Bahrain

Introduction

The worldwide occurrence of breast cancer varies from region to region and country to country. Most developed nations have a higher rate of breast cancer among their populations than developing and less developed nations. In all types of cancer among females, breast cancer affects a large number of women throughout the world. In 2020, around 2.3 million women were diagnosed with the breast cancer and during the last five years women with breast cancer reached around 7.8 million (WHO, 2021). This makes breast cancer one of the most prevalent cancers among women. The survival rate for breast cancer patients has also improved when early detection is carried out. In developed countries the survival chances are 90%, while in Asian countries it’s 66% and in African countries it is a mere 40% (American Cancer Society, 2022).

Breast cancer is classified into different types based on tumor pathology, including DCIS, invasive ductal carcinoma, lobular carcinoma in situ, and invasive lobular carcinoma. Stages of breast cancer are determined by tumor size, lymph node involvement, and metastasis, using the TNM system (Tumor, Node, Metastasis). Stages range from 0 to IV, with stage 0 being non-invasive and stage IV indicating metastatic cancer. Understanding these classifications is essential for treatment decisions and prognosis prediction (Montazeri, 2008).

In populations of Arab women, breast cancer is the most widely occurring cancer. In six Gulf Cooperation Council (GCC) countries, the most abundant cancer in women is breast cancer. In Bahrain around 54.4% of cancer among female is breast cancer. Middle eastern countries, UAE (United Arab Emirates), and Saudi Arabia have low incidences of breast cancer while countries like Bahrain, Qatar and Kuwait have high incidence rate for these types of cancer. Compared to most developed European countries, the spread of breast cancer among Arab women is almost the same or less (Hamadeh et al., 2014).

Due to the difference in environmental and lifestyle related factors the incidence of breast cancer is highly variable among most advanced economies and growing economies. However, each region may also face the presence of breast cancer cases according to the fertility rate and health of the woman.

The alarming rate of increase of breast cancer in Bahrain suggests the requirement of multi-disciplinary approach in prevention and control of this disease. There are many factors responsible for the rapid spread of breast cancer in women and these may include hereditary oncogenes. The study on Bahrain women for awareness of Breast cancer suggest that there is lack of knowledge about prevention and control of breast cancer among Bahrain women (Brazee, Nugent, Sereika, & Rosenzweig, 2021).

In Bahrain, cancer is the second leading cause of death after cardiovascular diseases, with around 10% of deaths caused by cancer. In Bahrain, it is mandatory to document new cases of cancer into Bahrain Cancer Register (BCR) at the Ministry of Health (MOH). According to the published report for the incidence of cancers in Bahrain, breast cancer has the topmost incidence rate among all cancers in women. In 2020, around 244 cases were reported for breast cancer which is around 37.9% of the total cases of cancer in women in Bahrain. Breast cancer is the highest occurring cancer followed by colorectum cancer, ovarian, corpus uteri, lung, and others. The incidence and mortality rate for breast cancer is higher in Bahrain. Overall, Breast cancer is the leading cause of disrupting Quality of life (QOL) among women (Kefale, Alebachew, Tadesse, & Engidawork, 2019).

The Bahrain cancer society has been running an awareness campaign for breast cancer for 20 years in Bahrain and has educated many women on breast self-examination and detection through mammogram. According to guidelines, women aged 40 years or above should take a mammogram every two years to keep track of breast health and early diagnosis of cancer (Akpaniwo, Boynes, Danfulani, Chigozie, & Umar, 2016). Ministry of health, Bahrain in collaboration with BATELCO (Bahrain Telecommunication Company) started a mission for early detection of breast cancer in 2005. Often, women with breast cancer face many physical, medical and psychological challenges. The developments in treatments have consequently led to an increasing focus on quality of life issues among breast cancer patients and in research (Montazeri et al., 2008). There is a strong need to understand effects on Quality of Life (QOL) in breast cancer patients. Apart from physical challenges, women generally faced many other challenges during diagnosis, treatment and control of breast disease. The aim of this study is to understand on effect on quality of life (QOL) among breast cancer patients by specifically surveyed Bahrain women patients.

Methods

Results

The main purpose of this study was to measure quality of life of the patients with breast cancer in Bahrain. To investigate, the questionnaire was segmented in four parts representing four main domains. The QOL-CS is a 46-item visual analog scale composed of four multi-item sub-scales (physical well-being, psychological well-being, social well-being, spiritual well-being). Each question was evaluated on a scale of 0 to 10 and represented results on mean overall score for the question. A score range between 0 to 90 is considered very poor, 91 to 180 is poor, 181 to 270 is average, 271 to 360 is good and 361 to 460 is considered very good.

Data was collected for the demographic profile of each breast cancer patient included age, location, education level, marital status, occupation, religion, family income and type of family. The full dataset can be found under Underlying data (Narayanan et al., 2022).

The demographic information of breast cancer participants in the “Breast cancer and quality of life among Bahraini women” study is presented in Table 1. As stated in Table 1, around 46% of women with breast cancer fall within the age group of 41 to 50 years old. A total of 18% of Bahraini women under the age of 40 are diagnosed with breast cancer, indicating that breast cancer incidence increases after middle age. 21 cases for breast cancer in women were reported from the North region of Bahrain and 13, 7 and 9 cases were reported from the Capital, South and Muharraq respectively. The highest number of cancer cases reported in women with at least bachelors level of education which is 40% of all reported cases in this study. Interestingly, around half of the women with breast cancer were homemakers. This may be due to lack of active lifestyle among Bahrainian homemakers (Tanner & Cheung, 2020). Religion and family income were neutral parameters, and they were not evaluated in this study and act as supporting data for any other future analysis. As most of the cases of breast cancer were from nuclear families, it may affect quality of life after diagnosis of the patient due to lack of support from the nuclear family, which can be reversed if the patient gets support from joint or extended family. For a patient to deal with cancer it is very important to have psychological and mental support from family.

Table 2 provides demographic variables related to the study. It includes the number of women and the percentage distribution based on different factors such as age, governorates, educational level, marital status, occupation, religion, family income per month (optional), and type of family. This table gives a comprehensive overview of the demographic characteristics of the participants involved in the study.

Clinical variables were studied in breast cancer patients such as duration of the illness, stage of cancer, and type of treatment (Table 3). Out of 50 participants in this study, around 32 (64%) were diagnosed with cancer within the last year and 18 (36%) cases had breast cancer for over a year. Participants were selected so that approximately all stages of cancer were covered and thus 18 (36%), 14 (28%), 12 (24%) and 6 (12%) cases were examined for Stage I, Stage II, Stage III and Stage IV, respectively. The breast cancer patients were given different types of treatment such as surgery, chemotherapy, anti-retroviral therapy, and radiation. Sixty-four percent (32 women) received either chemotherapy with surgery or chemotherapy with surgery and antiretroviral therapy. 64% (32 women) received either chemotherapy in conjugation with surgery or chemotherapy in conjugation with surgery and anti-retroviral therapy.

Table 3 also represents the evaluation of physical wellbeing questions related to quality of life. Breast cancer patients struggle through various physical challenges such as fatigue, pain, appetite changes, sleep disorders, vaginal discharge, menstrual changes and other physical problems. The findings on 50 breast cancer patients suggest that fatigue, pain and sleep changes have a higher than median score for quality of life while problems such as vaginal distress, menopausal symptoms and menstrual changes are more significant in women with breast cancer. In terms of physical health, the overall score for patients is 31.76 out of 80 and 39.70% of the mean score. The psychological state is most affected in breast cancer patients because cancer is known as an untreatable disease. People have a general perception that cancer is a terminal disease and non-treatable. These cause more psychological stress for patients.

Table 4 represents psychological challenges faced by breast cancer patients. Among 22 questions for psychological wellbeing, three questions were found to have lower than 40% QOL. This represents the difficulty faced by patients after the diagnosis of the disease and during the treatment phase. The overall quality of life for breast cancer patients is above average and represented by the mean QOL score of 73%. Positive parameters such as happiness, satisfaction, memory power, usefulness, and self-awareness were found to be above average in terms of quality of life. The negative impact parameters such as anxiety and depression were not very problematic in breast cancer patients.

Table 5 represents to the psycholiogical well being and the availability of resources for treatment and medical facilities in Bahrain hospitals. In most cases, patients did not experience major distress during the initial diagnosis, chemotherapy or surgery for cancer, while radiation therapy received a lower QOL score (4.72) which represents that it might be painful or not patient friendly. Most patients were skeptical about the future after their initial diagnosis and due to these there is constant fear among the patient of the reoccurrence, future diagnosis, metastatic cancer and loss of time. The social life of cancer patients is most affected due to diagnosis and treatment of disease. The mean score percentage for two questions were higher than 70%, which represents that the patients felt more concern about their family members after they tested positive. A mother with breast cancer may start worrying about her daughter due to heredity threat. Most participants received a good amount of support from their family members. All other factors including personal relationship, workplace situation, sexuality, and financial burden were found to be lower in terms of impact on a patient’s life after breast cancer.

Table 6 represents the social wellbeing and Table 7 represents the spiritual wellbeing and the data on this variable is quite interesting.

Table 6 presents the social well-being assessment based on various questions related to the impact of illness on family, sufficiency of support, interference with personal relationships, impact on sexuality, interference with employment, interference with daily activities, extent of isolation, concern about breast cancer in relatives, and financial burden incurred during the illness and treatment. The table includes the maximum score for each question, the mean score, standard deviation (SD), and the percentage of the mean score. This assessment provides insights into the social and emotional impact of the illness and treatment on the participants.

The spiritual wellbeing is mostly unaffected by the disease and women felt more spiritual after diagnosis of the disease and during treatment. The mean percentage for spiritual wellbeing is highest (82.09%) among all variables and spiritual life may increase the patients’ positivity of. The association between the level of quality of life and demographic variables proves two inferences and two variables found significant through a chi square test. Elders and those with higher levels of education have a higher QOL score than others. This may be due to the subsidence of symptoms after some age. Those with higher levels of education were more aware about self-examination, self-care and treatment procedures and the way of dealing with critical situations. This could prove beneficial to them compared to less educated individuals. All other demographic variables were found non-significant as per Table 7.

The association between quality of life and clinical variables can be seen in Table 8. Less duration of illness and lower stage of cancer resulted in a higher QOL score than others. The type of cancer treatment and complimentary medicine have no relation with the quality-of-life score. When observing the association between level of physical wellbeing through quality of life and demographic variables, elders who were ill for less time and who were at an earlier stage of cancer had a highger QOL score than others (Table 9). The One-way ANOVA test is used to determine whether psychological wellbeing quality of life is associated with demographic characteristics. Elder and more educated women have a higher QOL score than others at a psychological level. All other demographic and clinical variables were non-significant (as shown in Table 10). An analysis of one-way ANOVA data shows that women with more education and fewer stages of cancer have a greater quality of life score than women without education or cancer. All other variables were found to be non-significant with respect to social wellbeing (Tables 11, 12). The association between spiritual wellbeing quality of life score and demographic variables shows less duration of illness and less cancer stage results in a significantly higher QOL score than others.

Finally, while comparing the association between overall quality of life and demographic variables, it was found that elders who were more educated, were ill for less time and had less cancer stages women had a higher QOL score than others. The obtained results were in-line with the individual QOL score with respect to each variable.

In the study, the four variables were analyzed in relation to the sample size (N=60) and Pearson’s Coefficient (r) (Table 13). The residence variable was divided into highly polluted (25), moderately polluted (25), and low polluted (10) categories, with corresponding Pearson’s Coefficient values of 0.845, 0.845, and 0.432, respectively. For occupation, the categories were Government Sector (20, r=0.678), Private Sector (15, r=0.498), and Others (25, r=0.876). The historical types of breast cancer were classified as Classical (15, r=0.498), Alveolar (8, r=0.2976), Solid (22, r=0.798), and Tubulo-lobular (15, r=0.498). Lastly, the types of treatment included Surgery (10, r=0.3102), Radiation therapy (14, r=0.4690), Chemotherapy (16, r=0.5012), and Immunotherapy (20, r=0.678). These findings provide insights into the relationships between demographic variables and breast cancer outcomes.

Discussion

Abnormal growth of cells results in the formation of cancer. Breast cancer develops when cells out regulate their normal growth and start aggregating at the breast area. Around 50 to 60% of breast cancers develop in the milk ducts, around 5-20% develop in lobules and the remaining begin in other areas of breast tissues. The more profound treatment for breast cancer is surgery and most cases can be treated easily. The surgery can be followed up by additional treatments such as chemotherapy, anti-retro viral therapy, radiotherapy and hormonal replacement therapy (NBCC, 2022).

The mastectomy is the most common breast cancer treatment in which a portion of cancer-affected cells can be removed through surgery, and it removes a few normal cells from the rim of the cancerous cells. This type of surgery is widely used in removing breast cancer. There are various surgical procedures, but mastectomy and breast-conserving surgery are the most popular (De Siqueira et al., 2022). Any surgery’s primary goal is to remove a tumor in its early stages to prevent it from spreading to other healthy tissue. Some people require extra (adjuvant) therapies, including chemotherapy, radiation, and hormones depending on the stage of the disease, the patient’s age, and the hormonal/condition of the tumor (Adamowicz & Baczkowska-Waliszewska, 2020). Adjuvant therapies have been demonstrated to lower the chance of recurrence, improving survival in breast cancer patients (Ghanei Gheshlagh, Mohammadnejad, Dalvand, & Dehkordi, 2022). Chemotherapy lowers the mortality rate by 38% for people under 50 and 20% for those over 50. When determining if systemic adjuvant therapy is necessary, factors such as the patient’s age, hormonal state, risk of recurrence, side effects, and actability must be considered. The patient’s body surface is used to calculate the dosage of chemotherapy, which can be administered every week or every three weeks. The most common side effects of chemotherapy are hair loss, fatigue, decreased appetite, changes in taste, nausea and vomiting, dry mouth and constipation. A patient is usually scheduled for radiotherapy three to eight weeks after surgery, depending on whether chemotherapy will follow.

Several adverse effects, including those impacting quality of life, exhaustion, and discomfort, are linked to breast cancer treatment (Montazeri, 2008). Fatigue is the adverse effect that patients with breast cancer report experiencing the most. The effects of fatigue, which include weakness, exhaustion, and lack of energy, can frequently persist for years after the completion of treatment (Choi & Henneghan, 2022). Few studies concentrate on the epidemiology and treatment of major depression, although there is evidence that depression considerably impacts the quality of life in breast cancer patients. Distress and mixed depressive states have been the main topics of the therapy investigations (El Mokhallalati et al., 2022).

Body image distorted from mastectomy and sexuality problems after treatment are likely to produce more mood related disorders (Montazeri, 2008). The link between higher risk of breast cancer and depression is a very complicated and complex problem among the literature. Some studies suggested a protective factor, while others find a relation between stress, immunity and cancer occurrences or even mortality. The study on breast cancer survivors reported a higher prevalence of mild to moderate depression with a lower QOL in all areas except for family functioning and treatment of depression in breast cancer women improved their QOL and might increase longevity (Setyowibowo et al., 2022). Anti-depressant medications remained the cornerstone of depression treatment. The hypothetical link between their prescription and increased breast cancer risk was not supported by the literature.

Breast cancer is widespread among Bahraini females; around 37.1% of all cancers are breast-related (Martin et al., 2021). Annually around 54.4 per 100,000 people are diagnosed with breast cancer worldwide. Generally, research shows increased chances of breast cancer over 20 years old. The less ASR (34.9 in 100,000) was reported in 1998, and the highest (63.2 in 100,000) was reported in 2001. There is a tendency for increased ASR trend; however, it was not statistically significant (p-value = 0.3188) (10 years cancer incidence among Nationals of the GCC states (1998-2007). Most people can still clearly recall their feelings after learning they had breast cancer. Whatever the patient’s first feelings are, they may later go through a wide range of emotions. When someone is dealing with a potentially fatal condition, anxiety is only natural. They may become irritated, experience appetite and sleep changes, become hyperactive, and experience heart palpitations due to stress. Anxiety can occasionally become so severe that it triggers panic episodes, which increases anxiety and worry (Podvorica, Kraja, Rrustemi, Dugolli, & Hyseni, 2022).

Quality of life is now considered an important tool to measure patient wellbeing in cancer clinical trials. It has been shown that assessing QOL in cancer patients could contribute to improving treatment and be prognostic as several medical factors. Above all, studies of QOL can further indicate the directions needed for more efficient treatment of cancer patients. Among the QOL studies in cancer patients, breast cancer has received the maximum attention for several reasons (Osoba, 2021). When women develop breast cancer, all members of the family might develop some sort of illnesses. Further research is needed for improvements in medicine and medical practice and studying the quality of life for breast cancer can increase QOL among patients (Kimura, Kamada, Guilhem, & Monteiro, 2013).

It is crucial to assess the quality of life of women who lose their breasts since breast cancer impacts their personality and sense of self. Women usually have a significant role in the family, and when one woman is diagnosed with breast cancer, all the family members may be affected. As a result, research into the long-term implications of breast cancer detection and therapy is now necessary because the prevention and treatment of the disease have become essential issues. The time during initial treatment and months following it are very hard for the patients, poor QOL can be observed in this phase, and by recognizing proper QOL parameters, treatment can be modified without affecting QOL (Jiang, Torgerson, & Ayars, 2015).

A study on decreased health-related QOL due to chemotherapy side effects may predict early treatment discontinuation in patients with breast cancer. The studies on post-treatment adjustment of breast cancer survivors demonstrated that breast cancer patients might enjoy a good QOL (Ghanei Gheshlagh, Mohammadnejad, Dalvand, & Dehkordi, 2022). When Casso, Buist, and Taplin examined the QOL of women who had been diagnosed with breast cancer between the ages of 40 and 49 and had survived for five to ten years, they found that these younger women had an excellent quality of life (Casso, Buist, & Taplin, 2004). However, when trying to comprehend and improve long-term QOL, it may be crucial for doctors and breast cancer patients to consider the long-term effects of adjuvant therapy and the management of long-term breast-related symptoms (Moshina, Falk, & Hofvind, 2021). Throughout their lives, body image fluctuates frequently, and disease can impact how they feel and cause low levels of self-confidence. After diagnosis and therapy, they could have a radically different perspective of their body than they did previously. Treatment for breast cancer may serve as a permanent or recurring visual reminder. Patients can have scars and skin changes following radiotherapy, hair loss or regrowth following chemotherapy, and lymphedema (Lin et al., 2022).

Additionally, the course of treatment may induce weight increase or loss. All of these cause people to feel less satisfied with their bodies and less confident about their appearance. Changes in a person’s body image and self-esteem may impact their feelings about their sexuality and interpersonal interactions. Around the time of diagnosis, sleep patterns frequently change, and this disruption may last during therapy and even after. Sleep patterns typically eventually revert to normal. The main reasons for sleep disruption are stress and worry brought on by the cancer diagnosis and its side effects. According to Bower, behavioral symptoms, such as energy, sleep, mood, and cognition disruptions, are a frequent adverse impact of breast cancer diagnosis and therapy (Bower, 2008). These symptoms cause severe disruption in patients’ quality of life and can be seen for years after the treatment. To circumvent and alleviate Total Mood Disturbance (TMD), patients should be educated on how relaxation, meditation and yoga can be helpful. The scores represented a 13% reduction in overall mood disturbance for the participants after practicing meditation (Martin, Loomis, & Dean, 2021).

In our study, after the questionnaire was developed for “Breast cancer and Quality of life among Bahraini women”, it was analyzed for its validity and reliability. A content validity assessment was conducted to determine the tool’s validity by a panel of nurses with experience in oncology and QOL researchers.

The QOL-CS is a 46-item visual analog scale composed of four multi-item sub-scales (physical well-being, psychological well-being, social well-being, spiritual well-being). The overall quality of life (QOL) among breast cancer women is higher in the spiritual category and lower in the physical category, with the psychological and social categories falling in between. This indicates maximum adverse effects on quality of life starting from first physical, second psychological, third social and lastly spiritual well-being. Within psychological variable most adverse effect observed among breast cancer patient is fear for present and future, while distress was second major parameter affecting psychological health. General psychological parameters were moderately affected due to disease condition.

None of the women have a very poor or poor quality-of-life score. This indicates that breast cancer is a manageable disease, and around 90% of patients can get back to their daily life and have a considerably good quality of life through some changes in lifestyle and extra care for their health. The current study provides important information about Bahraini women’s breast cancer related physical, psychological, social, and spiritual quality of life domains. Our study is population-based, and the characterization of this population concerning risk factors for breast cancer is incomplete, being only able to analyze the association between levels of physical, psychological, social, and spiritual domains of quality of life. A disease-free control group should be included in future research, as well as complete clinical information regarding cancer in the Cancer Registry, including grade, stage, and location of the disease. One limitation of this study is the small sample size, which consisted of only 10 women in the preliminary pilot study. Future research should aim to include a larger sample size, preferably more than 100 women, to increase the generalizability of the results.

Conclusion

Breast cancer has affected many women in Bahrain, and it is essential to know about the quality of life of Bahrain women with breast cancer. The current study was carried out on the patient population to determine women’s difficulties after a cancer diagnosis. It was found that over half of women had a good quality of life and faced some difficulty after diagnosis. The quality of life of women was affected due to four parameters: physical, psychological, social, and spiritual. Spiritual life was least affected, while social and psychological parameters were moderately affected due to breast cancer. Quality of life as a physical parameter, has a minimum quality of life score, and they are worst affected due to breast cancer. The Pearson’s Coefficient results indicated strong correlations between residence and quality of life (QOL) among women with breast cancer, with highly polluted and moderately polluted areas showing high positive correlations (r=0.845). Additionally, occupation, historical types of breast cancer, and types of treatment also exhibited varying degrees of correlation with QOL, as indicated by their respective Pearson’s Coefficient. These findings highlight the need to consider demographic factors when addressing QOL in women with breast cancer, informing targeted interventions and support strategies for improved well-being.