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Hindawi International Journal of Breast Cancer Volume 2020,Article ID 8460374, 6 pages https://doi.org/10.1155/2020/8460374 Research Article Female Breast Cancer Patients, Mastectomy-Related Quality of Life: Experience from Ethiopia Engida Abebe , Kassaw Demilie, Befekadu Lemmu, and Kirubel Abebe Department of Surgery, SPHMMC, Addis Ababa, Ethiopia Correspondence should be addressed to Kirubel Abebe; kirumel@yahoo.com Received 16 September 2019; Revised 10 March 2020; Accepted 24 March 2020; Published 9 April 2020 Academic Editor: Vladimir F. Semiglazov Copyright © 2020 Engida Abebe et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Mastectomy is the most common form of treatment for a developing-nation woman diagnosed with breast cancer. This can have huge effect on a women’s quality of life. Objective. To assess mastectomy-related quality of life in female breast cancer patients. Materials and Methods. A facility-based cross-sectional descriptive study was conducted from February 1 to July 30 , 2018. A pretested structured data collection format was used to interview patients. The European Organization for Research and Treatment for Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and Breast Cancer-Specific (EORTC QLQ-BR23) were used to evaluate quality of life, functional capacity, and symptom scales. Data was analyzed with SPSS version 23. Results. The mean age of the 86 patients was 43.2 years (SD ± 11:4) and ranged from 25 to 70 years. 54.7% (47) of patient’s mastectomy was done on the right side. Based on EORTC QLQ-C30 global health status/QOL scale, the mean score was 48.3. On the evaluation of EORTC QLQ-BR23, future perspective about their health was low with a mean of 40.3 and their sexual functioning and enjoyment were significantly affected with mean scores of 85.3 and 71.2, respectively. Symptom scales were low with mean from 19.1 to 24.5. Majority (49, 57%) of respondents do not want to have breast reconstruction after mastectomy. Conclusion. Our breast cancer patients who underwent mastectomy performed poor in terms of quality of life as compared to international findings which demands attention in incorporating psychosocial aspects in the treatment plan. 1. Background As Ethiopia is a developing nation, adjuvant treatment for BC do exists but not readily available. There is only Breast cancer (BC) is a potentially deadly disease affecting one radiotherapy machine for a population of 110 million one in eight women. It is the most frequent cause of cancer which makes adjuvant, neoadjuvant, or breast conserving death in less-developed regions, causing one in five deaths surgery inaccessible. Due to the above-mentioned reasons, in African women and 50–75% of women present with very the main stay of treatment modality for BC in Ethiopia is advanced disease [1, 2]. According to World Health Organi- modified radical mastectomy. Despite the current effort of zation Cancer Country Profile 2014, incidence of breast can- the Ethiopian government on the issue of noncommunic- cer in Ethiopia was reported to be 12,956, contributing to able diseases including cancer, there is no screening pro- 24.4% of the deaths [3]. Even if adequate data is lacking in gram for BC in the country [7]. the trends of BC in Ethiopia, some authors suggested that it In general, survival of women with BC in Sub-Saharan is increasing [4]. Africa tends to be poor due to a number of reasons such as Surgery is the primary modality in the management of late presentation and poor access to timely and standard resectable BC. In certain parts of the world including Africa, treatment [8]. According to a retrospective follow-up study mastectomy can be the only treatment option due to limited with survival analysis done by Areri et al. at a teaching hospi- resources for complimentary adjuvant therapies [5]. Reports tal, Adult Oncology Unit, Addis Ababa, Ethiopia, it showed from east Africa indicate that up to 99% of patients undergo that the overall estimated survival rate after diagnosis of BC mastectomy for a lack of other modalities of treatment [6]. was 26.42% at 72 months of follow-up [9].2 International Journal of Breast Cancer As breast is considered as an attribute of feminity, mater- obtained from SPHMMC IRB. Individual patient written nity, and sexuality, its loss as a remedy for breast cancer can consent to participate in the study was obtained. Confidenti- affect quality of life of women. When evaluating holistically ality was kept throughout the study. the life of woman after mastectomy, all spheres of everyday NB: The QLQ-C30 is composed of both multi-item scales functioning should be taken into account including physical, and single-item measures. These include five functional cognitive, emotional, and social wellbeing [10]. scales, three symptom scales, a global health status/QOL Traditionally, the primary end points in evaluations of scale, and six single items. All of the scales and single-item medical therapies were improvement in clinical outcomes, measures rangeinscorefrom0to100.Rangeisthedifference cure, and survival. However, the concept of the medical between the maximum possible value of raw scores (RS) and outcome’s movement and the worldwide effort to contain the minimum possible value. The QLQ-C30 has been the rising costs of care has underscored the importance of designed so that all items in any scale take the same range patient-centered outcomes. There are different parameters of values. Therefore, the range of RS equals the range of the which were used to assess quality of life (QOL) of patients item values. Most items are scored 1 to 4, giving range =3. with chronic illness including health-related quality of life The exceptions are the items contributing tothe global health (HRQOL). HRQOL is one of several variables commonly status/QOL, which are 7-point questions with range= 6. A studied in the field of medical outcomes research. It encom- high scale score represents a higher response level. Thus, a passes a wide range of human experience, including function- high score for a functional scale represents a high/healthy ing and subjective responses to illness. HRQOL instruments level of functioning except in sexual functioning and enjoy- may be general or disease-specific. General HRQOL domains ment. High score for the global health status/QOL represents address the components of overall wellbeing, whereas a high QOL, but a high score for a symptom scale/item rep- disease-specific domains focus on the impact of particular resents a high level of symptomatology/problems. organic dysfunctions that affect HRQOL [11]. Examples of cancer-specific instruments include the European Organiza- tion for the Research and Treatment of Cancer Quality of Life 3. Results Questionnaire (EORTC QLQ-C30) [12]. 3.1. Sociodemographic Characteristics. A total of 86 patients Even though significant numbers of mastectomies are with breast cancer were included. The mean and median done in Ethiopia, to the best of the authors’ knowledge, there age of patients was 43.23 years (SD ±11:35) and 42 years are no data which assessed the quality of life of patients afterand ranged from 25 to 70 years. The majority of the patients mastectomy at a national level. Hence, this study was con- were Amhara (34, 39.5%) and Oromo (31, 36%) in ethnicity. ducted to assess the quality of life in female breast cancer Nearly one-third of the patients (28, 32.6%) did not attend patients who underwent mastectomy. any formal education while 20 (23.3%) attended college/uni- versity. More than half (44, 51.2%) of the patients were 2. Materials and Methods housewives. Forty-seven (54.7%) participants are married st and 71 (82.6%) had children, with majority (58, 81.7%) hav- A cross-sectional study was conducted from February 1 to ing two or more children. Urban residents accounted for July 30 , 2018, at St. Paul’s Hospital Millennium Medical 73.3% (63) of the patients (Table 1). Majority (70, 81.8%) of College (SPHMMC), a teaching-tertiary referral hospital them were diagnosed with stage III disease, and all of them in Addis Ababa. Patients are followed postoperatively by have mastectomy. More than half (47, 54.7%) of the patients consultant surgeons, oncologists, and surgery residents. had the cancer on the right side (Figures 1 and 2). All female breast cancer patients who underwent mastec- tomy at SPHMMC were included while male breast cancer 3.2. Quality of Life Assessment. Based on EORTC QLQ-C30, patients, female patients operated elsewhere, and patients the global health status/QOL scale of study participants had who had mastectomy for nonmalignant conditions were mean and median scores of 48.25 and 48.1, respectively. excluded. When it comes to breast cancer QOL assessment (based on Data was collected by trained OPD nurses using a pre- EORTC QLQ-BR23), the mean and median scores for body tested questionnaire. Data on sociodemographic characteris- image were 69.3 and 74.6. The mean score of future perspec- tics (age, marital status, parity, ethnicity, educational tive about their health was 40.3 and the median was 42. The background, and residency) and side of mastectomy were mean and median scores for sexual functioning were 85.3 collected in as shown in Background. In addition, selected and 89.6, while that of sexual enjoyment were 71.2 and items of EORTC QLQ-C30 and EORTC QLQ-BR23 were 73.2, respectively. adopted and used to asses HRQOL, psychosocial and func- Postoperative breast symptoms scale had mean and tional scales, and postmastectomy symptoms. During data median scores of 19.1 and 15.3 while arm symptoms had collection, the principal investigator checked data for com- mean and median scores of 24.5 and 20.3, respectively pleteness, any ambiguity, and suspicions on the spot. Col- (Table 2). lected data was cleaned, checked for completeness, entered Patients who are >50 years (p =0:044), unemployed to EpiData 3.1, and exported and analyzed with SPSS version (p =0:013), no formal education (p =0:044), married 23. Mean scores of EORTC QLQ-C30 and EORTC QLQ- (p =0:005), and living in urban area (p = 0:013) had signifi- BR23 were calculated. Then QOL, functional scales, and cantly higher body image response level than their respective symptom scales were calculated. Ethical clearance was groups. Regarding GHS/QOL and symptom scores, there is aInternational Journal of Breast Cancer 3 Table 1: Sociodemographic characteristics of female breast cancer Side affected patients, mastectomy-related quality of life (SPHMMC, Addis Ababa, Ethiopia, 2018). 2.30% Item Age range Number Percent ≤30 17 19.8% 31-40 24 27.9% Age distribution 41-50 24 27.9% 43% 51-60 14 16.3% 54.70% >60 7 8.1% Amhara 34 39.5% Oromo 31 36% Ethnicity Tigre 6 7.0% Gurage 5 5.8% Right Others 10 11.6% Left Both Housewife 44 51.2% Government employee 15 15.1% Figure 2: Site of affected breast (mastectomy done) (SPHMMC, Occupation 2018). Merchant 9 10.5% Others 20 23.3% Married 47 54.7% Table 2: QOL, functional capacity, and symptom scales of female Single 9 10.5% breast cancer patients, mastectomy-related quality of life Marital status (SPHMMC, Addis Ababa, Ethiopia, 2018). Divorced 18 14.0% Widowed 12 20.9% Scale Scale Mean Median 1 2 Illiterate 28 32.6% EORTC QLQ-C30 GHS/QOL 48.25 48.1 Functional scales Read and write 10 11.6% Educational status Elementary school 10 11.6% Body image 69.3 74.6 High school 18 20.9% Future perspective 40.3 42 ∗ College/university 20 23.3% 3 Sexual functioning 85.3 89.6 EORTC QLQ-BR23 Sexual enjoyment∗ 71.2 73.2 Urban 63 73.3% Residency Rural 23 26.7% Symptom scales/items Breast symptoms 19.1 15.3 Yes 71 82.6% Parity Arm symptoms 24.5 20.3 No 15 17.4% 1 European Organizatio2 for the Research and Treatment of Cancer Quality 3f Life Questionnaire. GHS/QOL: global health status/quality of life. EORTC QLQ-BR23: European Organization for Research and Treatment Stage at diagnosis Center Quality ∗f Life Questionnaire Breast Cancer-Specific. NB: Items for the scales markedare scored positively (i.e., “very much” is best) and therefore use the same algebraic equation as for symptom scales; however, 10% 8% the body image scale uses the algebraic equation for functioning scales. significant response level difference among the different demographic variables (Table 3). Majority (49, 57%) of the respondents do not want to have breast reconstruction after mastectomy. 4. Discussions 82% In agreement with other studies, breast cancer affected youn- gerpatients inurbansetting[2,5,6].Andtherightbreastwas Stage II more commonly involved than the left. Though it is a cross- Stage III Stage IV sectional study which assessed patients’ QOL at one point, overall, patients’ quality of life was low compared to that in literatures. For example, the mean score for QOL according Figure 1: Stages of breast cancer at diagnosis (SPHMMC, 2018). to EORTC QLQ-C30 for the study patients was 48.25, which4 International Journal of Breast Cancer , C u 7 6 4 1 9 M v . . . . . . M L p 0 0 0 0 0 0 P Q e l . 1 . . . . . . . . . . . l c 4 4 4 4 4 4 4 4 4 4 4 4 o S i e a o a 0 5 5 8 1 2 q p v 0 0 0 0 0 0 e y p l s e - r a 7 0 . 5 3. 4 3. 5 4. 3 5 4 4 y A S 2 2 2 2 2 2 2 2 2 2 2 2 t e u 0 6 9 5 7 8 a t s v . . . . . . m a t p 0 0 0 0 0 0 t r p i B s l . 0 . . 6. . 3. . 4. . . . . a S 1 2 1 2 1 1 1 1 1 2 2 1 r c e c t a 3 2 0 5 5 5 s a e v 0 0 0 0 0 0 r x y p b S j e a e c 3 9 . 7 4. 4 8. 7 4. 7 4 3 . e S 8 5 5 8 9 4 8 5 8 5 5 8 f s l 8 8 4 7 1 7 a l i v . . . . . . s u o p 0 0 0 0 0 0 m e c p S u el . 6 . . 6. . 0. . 6. . . . . m f S 8 8 8 8 9 7 8 8 8 8 8 8 s n e , e a 2 1 6 1 1 7 i r c v 0 0 0 0 0 0 a t p p c F r e a p c 8 2 . 9 1. 0 0. 1 9. 0 0 4 6 o S 3 4 3 4 5 3 4 3 4 4 3 4 c u e l 3 5 3 3 , a v . . . . . . O i p 0 0 0 0 0 0 Q y n o l . . . . . 1. . 3. . . . . s B S 6 7 6 7 7 6 7 6 7 6 6 7 t r 6 c = 5 2 4 4 2 5 7 9 6 2 1 7 r n c i n p t i r d e c a y o 0 0 y l e u i l a a r t e ≤ > p p a e a i r u p a d ) m e m a M S U R o P e 1 E U f r N t 2 o F b i N o o a t t c E s s s b n a t : b s t o s c 3 A b p a a e l d r e u u r s r a d V A O E M R P T AInternational Journal of Breast Cancer 5 is low compared to a study in Poland which showed a mean sionals, and have a lack of psychological support. The mean score of 68.33 and 84.23, one month and one year after mas- score of postoperative breast and arm symptoms were low, which means our patients were not suffering from complica- tectomy, respectively [13]. It is also lower compared to the finding of Costa et al. in tions related to mastectomy site and ipsilateral arm. This Brazil who analyzed GHS patients for different stages. The finding is comparable to a study found in Poland but higher mean score of GHS of patients without metastasis was 62 than a study found in India which showed mean scores of (SD= 24) points, while those with locoregional metastases 8.98 and 15.52 for breast and arm symptoms [13, 18]. was 63 (SD =21:4), and the distant metastasis was 51.3 Overall, our breast cancer patients who underwent (SD= 24) points [14]. This finding makes the mean scores mastectomy performed poor in terms of quality of life as of our patients’ (all stages combined) QOL even worse than compared to international findings which demands atten- those of patients with advanced breast cancers. tion in incorporating psychosocial aspects in the treatment The lower mean score of our patients may be related plan. In addition, this probably could have been improved partly to the study design which assessed the QOL observed if patients presented early and breast conserving surgery at single point. But it is likely to be due to the lack/absence was available. Designing and implementing screening pro- of formal psychological and social support by a trained per- grams at all levels can help improve overall outcome and quality of life of patients who underwent modified radical sonnel. The economic impact of the cancer care in a setting where treatment is out of pocket can also be huge in patient’s mastectomy. Adjuvant treatment including radiotherapy postoperative psychosocial performance. The strong family availability at least at referral hospitals can make a differ- attachments among Ethiopians can be a good opportunity ence in the way breast cancer patients are managed and to train families on how to support cancer patients socially can improve their quality of life after the care. As this and psychologically. study has a relatively small subject studied in a cross-sec- On assessment of the scales/items of EORTC QLQ-BR23 tion, the true picture needs to be assessed with a further functional scale, our patients had higher mean score of body study which assesses quality of life of cancer patients in image compared to studies in Turkey, Sudan, and England. general and breast cancer patients in particular which The Turkey study showed that mastectomy negatively includes multiple centers including a bigger study subject. affected a woman’s body image and her self-image [15]. A study conducted in Khartoum showed that patients after Data Availability mastectomy were unsatisfied with their body images initially but improved over time [16]. 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