The present study showed that women with BC have a satisfactory level of QoL, as they scored high in functionality sub-scales. Regarding the symptoms of the disease, fatigue, insomnia, financial problems and hair loss emerged as the most important problems. Age, educational level and type of hospitalization are statistically related to the QoL.
The emotional function was the least favorable; hair loss appeared to be the least desirable side-effect of the treatment. Hair is an integral part of female identity and has a negative impact on different aspects of QoL. According to the literature, hair loss is one of the most important side effects of chemotherapy.[23] Monfared et al.,[24] in their study, found that QoL was lower in the emotional area compared to other areas. However, in our study, sample sub-scales GHS and emotional appeared to be improved in patients undergoing chemotherapy, giving a different perspective for the chemotherapy’s negative effects. This can probably be explained by the sense of security that patients have when there is a strong social support network (more common in non-urban communities), as we found a statistical correlation between rural patients and higher scores in emotional. This sense of security can also be enhanced by a specialist’s support. This is consistent with a study that showed that participation in social support groups can mitigate the adverse psychological effects of BC treatment. [25]
The most common type of social support and education for BC patients is support groups.[26] Professional support and training are provided by oncology nurses and other health workers such as psychologists, psychiatrists, psychotherapists, social workers, physiotherapists.[26] Phone support is a viable option for those who cannot attend support groups or live in rural areas with limited access to cancer support services.[27] Besides, symptoms such as fatigue and nausea from BC treatment can prevent women from participating in support groups and educational meetings. Grunfeld and colleagues[28] concluded that the average cost per patient was lower in telephone than in hospital follow-up. According to previous studies, face to face interventions could be a realistic alternative to conventional cancer care. These programs through individual psychosocial support and psychological intervention are beneficial for BC patients and have a positive effect on their QoL.[29]
Regarding the QLQ-BR23 questionnaire, all investigated symptoms were at fairly favorable levels in our study. The highest-scoring (worse) symptoms/items were fatigue, followed by insomnia and financial problems. Our results strengthen findings from previous studies that also report significant problems including fatigue, pain in the joints and sleeping disturbances.[30, 12] Patients living in a rural areas faced more financial difficulties, compared to women in urban cities and the AMA. Economic difficulties are negatively correlated with QoL and as the functional status of the BC women impairs, more adverse economic situations appear.[31] Further research is needed to investigate the associations between urban/rural residence and QoL aspects in different environments where the concepts of urbanization and rural life may have different meanings and impacts. Such studies would help to identify whether there are disparities in survivors’ support and, if so, to enable appropriate and effective development and provision of health care and supportive care in all areas of the BC survivors.
Regarding the age, studies showed that older women with BC have significantly fewer symptoms than younger women, which is consistent with our findings.[32-34] However, contrary to our findings, an older Greek study showed that younger patients exhibited better overall QoL, fewer symptoms, and better functionality than older.[18] The difference in the results could be interpreted in the light that women who suffer the consequences of a serious illness at a relatively young age have even greater scope to redefine their priorities by addressing their lives and disease as a challenge to overcome.[18] The problems that younger women face are often very different from those encountered by older ones, such as concerns about early menopause leading to fertility loss, negative body image,[33, 35, 36] sexuality, career, work and financial security.[32, 36, 37]
Women with no education or basic education (≤ 12 years at school) reported lower levels in QoL sub-scales, experiencing more systemic therapy side-effects, more arm morbidity and reduced physical, cognitive, and emotional function, body image and sexual functioning. This result is in line with another Greek study that revealed a statistically significant difference between high education level and QoL.[18] Similarly, another study states that women with low education may have jobs that require more physically demanding work, which leads to delayed work return, more physical, role, cognitive function, and financial problems and suggests exercise programs for faster recovery.[12]
On the other hand, a statistically significant finding revealed that patients with tertiary education reported better GHS. This can be interpreted by the different perspectives these patients adopt for their disease management, as the access to information can help them dispel prejudices.[33] Since young women are frequent users of social media and often highly educated, maybe the development of a multifunction online support hub can help them find credible and useful information.[38] In any case, if more concerns arises, they can always express it to their attending physicians.[33]
Besides, the presence of fewer symptoms highlighted in our study, such as pain and breast/arm morbidity in older women may be due to their choice of surgical treatment. A study with results consistent with ours concluded that younger BC women with reconstruction and more aggressive adjuvant therapies report a more negative body image than those receiving breast-conserving surgery.[39] The latter can be seen as a paradox; it can be explained, however, by the fact that young women who opt for reconstruction are more conscious of their body and have high, and often unrealistic, expectations from the breast reconstructive process.[40] The increased expectations of presumably younger women undergoing reconstruction may not be fully met regarding body image. However, they indeed restore their sexual self-confidence, which may be related to the image that the social environment shapes for them. This finding can be positively utilized by BC survivors to regain their confidence and thus their QoL after treatment.
It is also known that sexuality affects the QoL of women with BC, as those with an active sexual life report fewer QoL problems.[41] Our study suggests that women who had undergone breast reconstruction may maintain a good overall QoL in sexual function, as we found lower scores in sexual function and sexual enjoyment in those with mastectomy without reconstruction. This finding is consistent with the literature, where reconstruction had positive effects in this area of QoL.[42]
Irrespective of age and the type of surgery for BC survivors, body image awareness is often associated with other issues such as social. Therefore, breast loss due to mastectomy will be perceived by many people as a serious negative factor in the recognition and sense of self as a woman. The woman feels something is missing and may feel sick and disabled. The prevailing social perception shows the female breasts as a symbol of femininity and fertility. Women characterize breast loss as a deprivation of their identity and dignity to the extent that it even affects the performance of daily activities.[43] This process is a vicious circle, as harming feminine identity can affect their overall sense of self, which can, in turn, negatively affect their body image. However, the current study showed a positive correlation between breast reconstruction and future perspective. Many BC women can accept the fact that they live in a changed body and maintain a sexual activity and pleasure with their partners, regardless of the treatments they receive, even if they had undergone a mastectomy.[44]
For those who chose university hospital for their treatment, the GHS and social function were better and fewer diarrheas were reported, but they lacked body image, compared to those hospitalized in general hospitals. The comparison between the university and general hospitals has also been studied in the literature. Studies focusing on patients hospitalized in university hospitals record better quality health services, with lower mortality rates.[45, 46] Hospitals’ affiliation with a university provides access to new scientific data on diagnosis, treatment and rehabilitation. Also, the existence of more specialized structures in university hospitals increases the patient’s chance of receiving better health care services.
There is scarce evidence in the literature regarding the impact of complications on QoL. In their study, Browne and colleagues found no association between BC complications and QoL after mastectomy and reconstruction.[47] In our study, women who reported complications had better social function, fewer breast symptoms and a lower score in body image. In their study, Belmonte et al.,[48] found that sentinel lymph node biopsy outperforms axillary node clearance in terms of QoL, due to fewer complications from the arm, which is in accordance with the finding of the present study. However, because of the small sample size (3.5% of the sample had complications), further studies are needed to confirm and explain these findings.