We found a low mean FACT G-7 HRQOL score in our study population, with the large majority of patients reporting a low score of ≤ 16. Our baseline evaluation indicates that our cancer survivors who are accessing community-based rehabilitation still have persistently low HRQOL, which likely reflects persistent impairments even after the acute cancer treatment phase. Our results also confirm that lack of energy, pain and sleep issues are persistent and bothersome symptoms in cancer survivorship . The majority of the FACT-G7 items are also derived from the FACT-G physical and functional well-being scales, which highlights areas of impairment in these domains. Similarly, a study on Singaporean breast cancer survivors also reported low composite HRQOL scores with high levels on multiple symptom domains, even at in patients up to 5 years after breast cancer .
We also found tumor stage and ethnicity to have significant associations with HRQOL. Malay patients may be likely to have a better HRQOL than Chinese patients , with a study at an outpatient oncology clinic in a tertiary hospital in Malaysia reporting that Chinese patients were more likely to have unmet supportive care needs . Additionally, a prospective longitudinal observational study done at a regional hospital in Singapore found that ethnicity was a significant determinant of HQOL in the domains of role limitations due to emotional problems and social functioning on the Short Form-36 health survey scale . Being a multi-ethnic country, further study is required to understand the relationship between ethnicity and HRQOL in cancer patients, and if this influences patients’ response to disease and treatment sequelae.
Advanced stage disease was associated with poorer HRQOL. These patients usually require a more complicated course of treatment, resulting in greater physical and psychological sequelae [32–34]. Patients with bone metastases have a higher incidence of pain, while those with visceral metastases require multiple lines of treatment . The presence of metastases is also associated with depression and overall HRQOL, which may be due to the fear additional disease spread and burden of additional treatments . Despite the presence of metastases, selected patients can still benefit from careful mobility and strength-based interventions, to maintain existing function and HRQOL .
We also report a mean distress level of 3.51, which is similar to an earlier study in Singapore, which reported a mean distress level of 3.3 . Nearly 2/3 of our study population experiencing significant distress, which is in line with a reported worldwide prevalence rate of 20–52% of cancer patients [38, 39]. Several physical symptoms including breathing, getting around and indigestion, were associated with significant distress. These may be reflective of limited mobility and activities and daily living, leading to unmet supportive care needs and high dependence on others [39, 40]. The results in our study also indicated that psychosocial and physical problems were important factors in determining if a patient experienced significant distress. In many of these patients, depression, worry, and family health issues were significantly associated with distress, with nearly half of the study population expressing worry. Unsurprisingly, distress has been shown to be strongly associated with mood disturbances including stress, anxiety and depression which may not reach criterial for clinical diagnosis, but still interfere with HRQOL [41, 42]. Our findings emphasize the need to consistently screen for social and emotional issues in cancer survivors, even while many of these patients are undergoing physical therapy-based rehabilitation .
This study has several limitations. Firstly, this was a cross-sectional study, which limits evaluation of a causal relationship between clinical factors and HRQOL or distress. Second, these findings may only be generalizable to patients presenting at a community rehabilitation center, and hence physical disability and HRQOL may be more severe in patients who do not have access to such services. Third, we chose the FACT G7 due to its brevity and ease of administration. We did not use other more complex scales such as the FACT-G or European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30). The FACT G7 may not reflect social and emotional aspects of HRQOL as much as symptom-related concerns , although this is attenuated to a certain extent by the use of the DT in our study. We also did not collect information such as comorbidities, socio-economic status, social support or on self-efficacy in symptom management, which have previously been reported to affect overall well-being .