HR-QoL has been widely accepted as an important health indicator by both healthcare providers and patients, functioning as a comprehensive evaluation of disease and treatment effects on patient wellbeing. In this cross-sectional study, we compared the HR-QoL of patients with upper GI diseases in different groups in rural China and examined the influencing factors of major HR-QoL dimensions. The results of this study can provide useful evidence regarding aspects of HR-QoL that are impaired due to upper GI diseases or their treatment among rural Chinese patients, and thus, may lead to better supportive treatment.
Our major finding was that there was no significant difference in HR-QoL between precancerous and early stage groups. In contrast, patients with advanced upper GI cancers showed worse HR-QoL in all function scales and most symptom scales, consistent with earlier studies [32, 33]. This finding suggests that doctors should pay more attention to deterioration in the HR-QoL of patients with advanced cancer, as well as seek to prevent deterioration of the relatively high levels of HR-QoL in early stage upper GI patients. Patients with upper GI diseases suffered from social problems, fatigue and financial difficulties, and may require appropriate social support to improve HR-QoL after treatment. As for gastric cancer, the results showed that in the early stage, there was some significant impact on physical and social functions as well as in the symptom scales, such as fatigue and appetite loss. The results suggest that an assessment of physical and psychological issues is clinically important among those patients with gastric cancer so that patients can be referred for care to relieve problems of fatigue, appetite loss, diarrhea and financial difficulties.
As for patients with esophageal cancer, we found that the advanced group in general suffered from the most serious symptoms compared to the other groups. Dysphagia and trouble with coughing were two major early symptoms. Similarly, Seo-in Ha et al. found that dysphagia was one of the most common symptoms affecting the HR-QoL of patients with esophageal cancer . Unlike a previous study, we found that as the disease worsened, HR-QoL areas of dry mouth and trouble with taste remained constant (i.e., no significant difference) . We also found that the most severe symptom was reflux, which agrees with a previous study on HR-QoL in patients after esophageal cancer surgery . Since there is an association between reflux and sleep problems, which may further lead to a series of other problems, useful measures should be taken to relieve this symptom . It would be useful for health care providers to provide dietary guidance and counselling services for patients with esophageal disease to relieve their problems of reflux and insomnia.
As for patients with gastric cancer, the precancerous group and early stage group both reported better HR-QoL scores compared with the advanced stage group. This finding further confirms that people with advanced cancer had the worst HR-QoL. It is interesting to note that for most symptom scales, the HR-QoL began to get worse in the early stage of cancer. This is consistent with the work by Axon et al. who showed that early gastric cancer usually presented with long-standing dyspepsia . Therefore, doctors should pay attention to those signal symptoms and undertake meticulous examination of the stomach to relieve symptoms. Body image was also one of the most severe problems. This can be explained as the digestive symptoms related to inadequate food intake could cause weight loss and further lead to body image disturbance among gastric cancer patients . Health providers should therefore provide proper nutritional care to manage the symptoms better and improve patients’ perception of body image.
We also explored the influencing factors of HR-QoL in patients with upper GI diseases. It was not surprising that pathological stage was the most important influencing factor of HR-QoL in this study. As the disease progresses, the HR-QoL of patients gradually deteriorates. The significant effect of residence area on the HR-QoL scores in certain scales, such as physical functioning, cognitive functioning, financial difficulties etc., could be explained by the different living conditions and economic levels between the two counties. We also found that gender was an important factor associated with constipation. Similarly, Forootan et al. found that constipation as a disorder in the gastrointestinal tract was more common in women than in men, and severe constipation was discovered more often in elderly women as compared to male patients [40, 41]. Hu and Sellick reported that education level was a significant predictor of HR-QoL and a higher education level was related to a higher HR-QoL among patients with GI cancer . Similarly, our results showed that higher symptom scores were associated with a lower education level. Our results demonstrated a significant association between marital status and patients’ cognition and insomnia, because poor marital status was associated with a higher level of psychological distress, which is detrimental to one’s health . Overall, it is needed to provide more supports for those elderly patients with lower education levels and poorer health states.
Results from the EORTC QLQ-OES18 module revealed that the pathological stage had greater effects on symptom scales, and other factors had little effects on those scales. In this regard, Yu-Ling Chang showed that advanced tumor stage had significant deleterious effects on several aspects of HR-QoL, such as eating difficulties, and there were no associations between any factors (age, gender and body weight loss) and esophageal-specific aspects of HR-QoL . Therefore, it is important to carry out early diagnosis and treatment program and to conduct follow-up care since those patients with advanced cancer usually have worse HR-QoL.
Results from the EORTC QLQ-STO22 module showed that age, education level and pathological stage were major influencing factors of HR-QoL scores. A previous study has shown that stomach-specific symptoms (pain, eating restrictions, and anxiety) lessened with increasing age . We also found that the age of the patients significantly influenced body image and hair loss. In addition, education level had an impact on symptoms among patients with gastric diseases that mainly involved pain, eating difficulties, dry mouth and body image. Similarly, Lin Chenxi et al. found that educational background had a positive correlation with HR-QoL among patients with gastric cancer . Therefore, better health educations should be provided for those patients in rural areas to guide them to choose healthy lifestyles and thus improve their HR-QoL.
Although this study provides valuable information for improving the HR-QoL of patients with upper GI diseases, there are still several limitations. Firstly, in terms of the influencing factors, the effect of surgery-related factors (e.g. type of surgical technique, adjuvant therapy, postoperative complications etc.) on HR-QoL, which have been found to be main factors that influence HR-QoL in previous studies, were not included in the questionnaire. Limited by data availability, we didn’t include surgery-related factors, so our findings can not fully reflect the reasons affecting the HR-QoL of patients. Secondly, because the sample of this study involved only rural patients in two counties in Shandong province in China, the results could only reflect the HR-QoL of patients with upper GI diseases in high-risk rural areas. Based on this study, investigations with a larger sample size should be conducted to evaluate the HR-QoL for patients at different pathological stages of upper GI diseases in the future. Thirdly, as a cross-sectional study, it was impossible to make an analysis of repeated measurements of HR-QoL over time. However, this study still provides useful basic information for a further study. In addition, it was also a limitation that we didn’t analyze the relative importance of the significant factors against pathological stage due to the sample size. In the future, it is necessary to conduct a long-term follow-up investigation to test the above findings.