Knowledge on the concerns of cancer survivors and their effects on QOL is an important step in developing appropriate interventions to enhance coping skills and improve their QOL. In this study, we found that the top concerns of the cancer survivors were cancer treatment and the risk of recurrence, long-term treatment effects and FOR. Cancer treatment related acute and late side effects have been well reported in the literature [3,5,8-12,14,15]. It has also been reported that even 20 years after stopping cancer treatment, the risks of recurrence (distant or contralateral breast) was present [34]. In our study, FOR was the top emotional concern among the cancer survivors and also throughout the cancer trajectory. This finding has also been reported by other studies [14,25,35-40]. Evidence in literature reveals the negative impacts associated with FOR, including emotional distress [41], functional status [42] and QOL [42-44]. Unlike other studies, we find that higher FOR is not associated with poorer QOL of survivors. A recent study by Cho and Park [45] on 292 adolescent and young adult cancer survivors found that the negative association between FOR and mental health-related quality of life (HRQOL) was moderated by perceived growth (such as relating to others, personal growth, new possibilities, appreciation of life and spiritual life). In view of the moderating effects of perceived growth on the FOR-HRQOL links, enhancing on the growth perception may also be an strategy worth considering. As our study only measured the respondents’ overall QOL and we did not measure the perceived growth, this finding warrants further study.
Financial concerns were amongst the top concerns for patients who were either undergoing or about to undergo treatment in this study. We also found that those with lower economic status including those staying in public Housing Development Board (HDB) flats are at higher risk of poorer QOL. As demonstrated in other studies, financial burden of cancer treatment is high and respondents expressed a great deal of worry about financial matters [40,47,48]. Evidence [48] also indicates that increased financial burden as a result of cancer care costs is the strongest independent predictor of poor QOL and adverse psychological issues such as depression, anxiety, and distress [48,49] among cancer survivors. As QOL is negatively affected by financial burden, early identification of at risk patients and referrals to financial support services may help lessen this concern. At the state level, efforts to manage the escalating cost of cancer treatment, provision of better financial coverage and support and addressing the aspect of unemployment of cancer patients would be needed.
Fatigue was the most prevalent physical concern and one of the predictors for QOL in this study. Cancer-related fatigue is a well-established concern for cancer survivors [8,36,39,40,50]. Fatigue reduces QOL by affecting a patient’s self-concept, appetite, activities of daily living, employment, social relationships and compliance with medical treatment [8,18,39,50], and may lead to treatment discontinuation and reduced survival [51]. Our study also found that fatigue was a major concern of the longer term cancer survivors which suggested that fatigue might have some lingering effect after cancer treatment. Bower’s [51] review suggests that approximately slightly more than a quarter cancer survivors experienced persistent fatigue through 10 years after cancer diagnosis and that is underreported by patients and undertreated by clinicians. Besides fatigue, our study also found that patients who had physical concerns of pain had poorer QOL. In addition, one of the risk factors for having ≥ 1 physical concern was whether patient had chemotherapy. Our findings are consistent with other studies. For instance, Heydarnejad et al. [18] found that QOL of patients undergoing chemotherapy was lower in patients with pain than to those who had no pain and pain was found to be the strongest predictor of fatigue, Fatigue can be caused by pain [50]. This may potentially revealed a symptom cluster (i.e., two or more concurrent symptoms that are related and may or may not have a common cause) [52] that warrants more in-depth study to closely examine if there is any relationship between these symptoms. Knowledge of whether these symptoms are interrelated within a cluster might therefore help manage these symptoms more effectively and thus lessen the total symptom burden.
Significant difference in QOL was also found between patients who were concerned with the most prevalent issue and those who were not for the NT and RS patients, but not the CT patients (Additional Table 2). It is not surprising that NT and RS patients’ QOL is more significantly affected as these are vulnerable times in the survivorship trajectory and the psychological distress confronting them is well reported in the literature [4,53,54].
Based on current evidence, cancer treatment with its inherent side effects and whether it is efficacious, FOR, financial concerns and fatigue are the most distressing concerns with some of these concerns affecting their QOL in cancer patients throughout their cancer trajectory warrant the monitoring of these acute and long-term effects across the entire cancer trajectory for clinical identification of patients who might benefit from enhanced medical attention resulting in an improved QOL. They also underscore the importance of creating an information and supportive care environment that addresses survivors’ information needs and emotional support over time. This could also include assessments for symptoms and distress, and the adoption of the use of survivorship care plans (SCPs) [55,56]. SCPs have been recommended by the IOM [57] as a tool to assist cancer survivors transit from cancer treatment to follow-up care through educating survivors and providers with comprehensive health information and resources [56]. This would also potentially address their concern about the integration of survivorship care between oncology and primary care settings. This is critical as well informed and supported patients have been associated with many positive outcomes, including, increased patient involvement in decision making, increased satisfaction with treatment decisions, enhanced coping during the diagnostic, treatment and post treatment phases of illness, decreased anxiety and mood disturbances, and less emotional distress [22,23,27,58,59].