This study was conducted in Oman. It included 275 participants diagnosed with breast, thyroid, colorectal, stomach, or prostate cancer. The main aim of the study was to examine the determinants of HRQoL in hospitalized patients with cancer in Oman and to investigate if HRQoL varied by patients' demographical and clinical variables, cancer-related fatigue, and sleep quality. Findings of the study showed that HRQoL differed significantly by patients’ demographical and clinical characteristics, sleep quality, and cancer-related fatigue. Furthermore, results showed that age, poor sleep quality, severe cancer-related fatigue, and being diagnosed with thyroid or prostate cancer were significant determinants of HRQoL.
Our findings showed that 64% of Omani patients with cancer reported poor sleep quality, which is similar to a Lebanon study that showed poor sleep quality was high among patients who had non-metastatic breast cancer during active treatment [17]. It is also consistent with findings of a systematic review that reported about 30-70% of newly diagnosed patients with breast, thyroid, colorectal, stomach, and prostate cancer had poor sleep quality [23]. Various factors suggested the growth of poor sleep quality among patients with cancer, of which, cancer treatments modalities, the frequent awakening of patients in midnight and early morning for a nursing procedure or therapy administration, breath discomfort, hospital environmental noise, pain, and worries about illness and treatment are some examples influencing sleeping patterns [17]. In Oman, these factors could also explain why the majority of patients reported poor sleep quality taking into consideration that about 82% of patients were receiving chemotherapy. This study established baseline data about sleep quality in patients with cancer in Oman. Our finding highlights that health care professionals should pay attention to patients’ sleep patterns and quality and identify specific factors that can be managed to improve patients’ sleep quality and, subsequently, improve their health-related quality of life.
The mean total score of HRQoL was 73.0 (SD=16.2), which was above the midpoint of 54. Physical well-being, which involves issues related to pain, nausea, low energy, feeling ill, treatment's side effects, and trouble meeting family's needs, showed the lowest score among HRQoL domains, and physical well-being seemed to pose the most significant challenge for patients with cancer in Oman. A similar result was found in Saudi Arabia, a middle eastern Arabic country, for patients with solid cancer [24]. A Low physical well-being score could be related to the fact that the majority of the Omani patients included in this study were in stage III and IV, were anemic, and had poor sleep quality, all of which have been found to influence the overall HRQoL in current study significantly. Additionally, in this study, social and family well-being domains (feeling like being close to friends, family and friend's support, family cancer acceptance, feeling close and getting enough support and love from the partner) were reported the highest score compared to the other three domains. This finding is parallel to a previous Omani study among oncology population that found Omani patients said that their relationships with husbands and family members became more substantial and more supportive after diagnosis with cancer [25], which could explain our findings considering that 73.8% of patients were married. This finding also supports the notion that social support can improve distress and alleviate coping skills among Omani women challenged with cancer and its management [26]. This finding denotes that healthcare providers should improve patients' physical well-being and correlate this domain to patients’ sleep quality.
In this study, we found that poor sleep quality, severe cancer-related fatigue, age, and type of cancer (prostate and thyroid) significantly determine HRQoL and explained about 33% of the variance in HRQoL. This study had found that those participants with poor sleep quality had decreased HRQoL in general. This finding is in line with the literature that showed sleep quality as one of the main predictors of HRQoL; for instance, Ha and colleague (2019) reported that sleep quality was an important determinant of HRQoL in patients with lung cancer; and that poor sleep quality, dyspnea, fatigue and depression were related to lower HRQoL, and together accounted for 85% of variances in HRQoL [27]. Likewise, a Nigerian study among women with breast cancer with lower sleep quality showed a significant reduction in HRQoL [28]. In the Arab world, a study in Palestine reported that sleep quality was one of the HRQoL determinants and, together with the pain, were responsible for 42% of the variance in HRQoL [29]. The positive and significant relationship between poor sleep quality and low HRQoL could be related to the negative impact of poor sleep on the patients' immune systems, making them more susceptible to infection and illness [30]. Another explanation could be linked to the fact that poor sleep tempts changes in the cognitive performance of the patients with cancer, which, as a result, influence their HRQoL [31]. Besides, Poor sleep quality is connected with poor physical well-being, such as gastrointestinal dysfunction that aggravates sickness [32]. The current study extends the observations of the relationship between sleep quality and HRQoL from Western societies to the developing world, specifically the Arabs Omani population, and enlightens future focus to promote screening for and improving sleep quality to enhance HRQoL community with cancer.
Likewise, cancer-related fatigue was found as another determinant of HRQoL in Oman, in which those with severe fatigue had a significant reduction in their overall HRQoL. Our finding is similar to studies from Nigeria, Greek, and France that were conducted in patients with breast and colorectal cancer and found that cancer-related fatigue was a significant determinant of HRQoL [28, 33, 34]. In the Arab population, we couldn’t identify literature examining the relationship between fatigue and HRQoL. Many reasons could explain the relationship between fatigue and HRQoL; one reason could be attributed to chemotherapy management and its side-effects [35], and this could explain our finding as about 43% of our participants were on chemotherapy. Other reasons could be due to the effect of cancer-related fatigue on patients’ self-care behavior as they demonstrated less involvement in taking care of themselves, which as a result, affect their HRQoL [36]. Although cancer-related fatigue experienced by the participants in the current study was as low as 18.5%, nevertheless, cancer-related fatigue remains a disabling symptom, a common determinant of patients' HRQoL, and it may prolong to two years after diagnosis [33, 34]. These findings could inform the future direction to establish strategies to understand cancer-related fatigue and its attributing factors to enhance HRQoL of patients with cancer.
In this study, age was also found to determine HRQoL in the Omani oncology population, indicating that HRQoL is better among younger age. Our findings were similar to results among cancer population from Sweden and Turkey [37, 38], but inconsistent with a study in Yemen, an Arab Country, that reported no relationship [39]. This finding could be because as people get older, they demonstrated lower performance in activities of daily living, lower functional abilities, and more risk of depression, which in consequence, reduce the HRQoL and supporting our finding [37, 40]. Our finding underlines the mounting need to focus HRQoL at a younger age and pay specific attention toward senior patients. In the Omani context of Oman and based on our findings related to the mean age of our participants (52 years), special attention toward improving HRQoL among older patients with cancer should be accentuated.
Thyroid and prostate cancer found to determine HRQoL in hospitalized Omani, and that those with thyroid and prostate cancer reported better HRQoL compared to other types of cancer. Our findings were similar to a study from Iran [41] but inconsistent with studies from Turkey and France who reported no association [42, 43]. The high survival rate of prostate and thyroid cancer compared to another type of cancer could explain the link between these types of cancer and HRQoL compared to other cancer such as stomach (70%) and colorectal (80%) [44].
This study should be considered within the following limitation; first, use of a cross-sectional design limits the ability to establish causal relationships. Second, we use a convenient nonprobability sample, which could impede the generalizability of the findings. However, a heterogeneous sample from the largest two tertiary health settings in Oman could minimize this threat. Third, Pittsburgh Sleep Quality Index (PSQI) instrument had below the satisfactory level of internal reliability (Cronbach's alpha = .67), which is similar to another recent Omani study that used PSQI among myocardial infarction patients that reported a Cronbach's α of 0.64 [45]. However, having an adequate sample size could provide robust statistical power and confidence in the results.
Sleep quality, cancer-related fatigue, and HRQoL deserve adequate medical attention regarding supportive care and routine assessment. Prompt recognition, observation, and documentation of these variables will guide the clinical teams to develop interventions to improve fatigue and sleep quality and their impact on the health-related quality of life. Holistic multidisciplinary cancer care is necessary to implement by clinicians inside the hospital and out of the hospital to improve all aspects of HRQoL of oncology population. On the other hand, an individualized approach should be maintained considering unique patients’ characteristics such as age, cancer type, stage, and treatment modalities. Policymakers should design the oncology centers to empower patients’ physical, functional, social, and emotional well-being. Sleep quality, cancer-related fatigue, and HRQoL can be regarded as quality indicators for patients with cancer. Finally, future studies should examine 1) strategies to improve sleep quality and cancer-related fatigue across the cancer population in general and the Arab community in specific, 2) the same variables among patients with non-solid cancer like leukemia and 3) determinants of each subscale as this was not the scope of the current study.