Quality of Life in Egyptian Children with Cancer

doi:10.4236/jct.2013.47148

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Journal of Cancer Therapy, 2013, 4, 1256-1261

http://dx.doi.org/10.4236/jct.2013.47148 Published Online September 2013 (http://www.scirp.org/journal/jct)

Quality of Life in Egyptian Children with Cancer

Mohamed Fawzy1*, Mai Saleh2, Mohamed El-Wakil3, Zeinab Monir4, Eman Eltahlawy2

1Department of Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt; 2Department of Environmental and

Occupational Medicine, National Research Center, Cairo, Egypt; 3Department of Clinical Oncology, Faculty of Medicine, Beni-Suef

University, Beni-Suef, Egypt, 4Department of Child Health, National Research Center, Cairo, Egypt.

Email: *[email protected]

Received August 9th, 2013; revised August 25th, 2013; accepted August 31st, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background and Objectives: Cancer treatments leading to increased survival rates are reported to participate in the

creation of debilitating physical and psychosocial deficits for cancer survivors. Measures of health-related quality of life

(HRQOL) are designed to tap such consequences of cancer treatment together with the impact of the disease itself.

Methods: Parents of 67 included patients aged 8 - 12 years, were asked to complete the parent proxy report of

PedsQL™ 3.0 Cancer Module (Arabic version), as well as a separate sheet for socio-demographic data. Results: The

ratio of Males to females was 1.8:1 among study patients with a median age of 8 years at diagnosis. Hematological ma-

lignancies represented 70.1% of the sample, with the highest proportion for ALL (52.2%). Total QOL showed to be

relatively low with mean value of 62.29 for the whole group. Subscales with least scores were for; worry (44.11), per-

ceived physical appearance (50.6), and procedural anxiety (55.34). On the other hand, the best score was 75.98 for

communication, followed by 72.63 for cognitive problems. The impacts of some medical and socio-demographic vari-

ables on QOL and its subscales were elicited in our results. Conclusion: Increased treatment intensity, long duration of

hospital admission, higher frequency of hospital visits, female sex, younger age at diagnosis, and large family size were

all associated with a poorer total QOL and/or its subscales among Egyptian pediatric cancer patients.

Keywords: Quality of Life; Children Cancer Patients; PedsQL™ 3.0 Cancer Module

1. Introduction

Childhood cancer patients are now long term survivors

with current survival rates approaching 90% [1]. Con-

temporary therapies for pediatric malignancies represent

the main contributor for such advancement [2]. However,

same treatments leading to increased survival rates are

reported to participate in the creation of debilitating phy-

sical and psychosocial deficits for cancer survivors [3].

Health-related morbidity among childhood cancer survi-

vors is mainly attributed to late effects including chro-

nic health conditions and life-threatening complications

during adulthood [4-6]. Measures of health-related qual-

ity of life (HRQOL) are designed to tap such conse-

quences of cancer treatment together with the impact of

the disease itself [3]. HRQOL targets a variety of dimen-

sions including physical, mental and social domains [7].

For childhood cancer patients, assessment of HRQOL at

relevant points throughout the treatment process can help

in the identification of acute dysfunction associated with

both illness and treatment, as well as figuring out ex-

pected residual dysfunction in long-term survivors [8-

11].

The present study was designed to identify the HR-

QOL profile in Egyptian pediatric cancer patients. The

impact of underlying disease, treatment and sociodemo-

graphic variables on the total QOL and its domains was

also evaluated.

2. Patients and Methods

Patients: a convenient sample of 67 pediatric cancer pa-

tients aged from 8 to 12 years with established diagnosis

at the pediatric inpatient as well as outpatient clinic of

the National Cancer Institute of Egypt were included

onto study. Parents of every included patient were asked

to complete the PedsQL™ 3.0 Cancer Module [3] (Ara-

bic version), as well as a separate sheet for sociodemo-

graphic data.

Instrument: the PedsQL™ 3.0 Cancer Module—de-

signed to measure HRQOL dimensions specifically tai-

lored for pediatric cancer—was the instrument in use. It

*Corresponding author.

Quality of Life in Egyptian Children with Cancer 1257

investigated 8 domains with the total of 27 items for the

whole module; 2 items for pain and hurt, 3 for each of

procedural anxiety, treatment anxiety, worry, perceived

physical appearance, and communication, whereas 5 items

for each of nausea and cognitive problems.

Linguistic translation: the parent proxy-report for chil-

dren aged 8 - 12 years of the “PedsQL™ 3.0 Cancer Mo-

dule” was translated into Arabic (native language of the

study sample) using the PedsQL™ Measurement Model

Translation Methodology. Linguistic validation process

included forward translation from the source language

(English) to the target language (Arabic), backward trans-

lation to the source language, and finally cognitive de-

briefing step according to PedsQL Cognitive Inter-

viewing MethodologySM [12,13]. Detailed reports for

every step throughout the whole process were sent to

Mapi research Institute in Lyon, France, on behalf of Dr.

James W. Varni, the copyright owner of the PedsQL™

for approval. A 5 point likert scale ranging from 0 for

“never a problem” till 4 for “almost always a problem”

was used for each item. The scale is converted to a cor-

responding score from 0 to 100, where 0 represented the

worst quality of life and 100 represented the best one.

The total QOL is the average of the scores for all do-

mains, while QOL for each domain is the average of

scores of its items.

Treatment related measures: a) intensity of cancer

therapy: scored from 1 to 3: low intensity such that sur-

gery only and/or six months chemotherapy with a favor-

able prognosis had a score 1, medium intensity took the

score of 2 for cases with chemotherapy longer than 6

months according to the treatment protocol in addition to

an intermediate prognosis, 3 was the score for high in-

tensity of therapy that represented treatment according to

high risk protocols, bone marrow transplantation, and/or

diseases with less favorable prognosis [14,15]. b) Phase

of treatment: the on-treatment group was defined as any

patient actively receiving anticancer therapy at any phase

of the treatment protocol, whereas the follow-up group

indicated patients ended their treatment and scheduled

for timed interval follow up. c) Frequency of hospital

visits: classified into either ≤3 or >3 visits per month. d)

Length of hospital admission: had 3 levels: low for ad-

mission periods within one third of the total duration of

therapy, medium if admission period was about 1 - 2

thirds the total duration, and high if it exceeded 2 thirds

the total treatment duration. e) Therapy duration: ≤6

month was considered to be low, between 6 month and 1

year was medium, and ≥1 year represented high duration

of therapy. Indirect method for measuring treatment

compliance (compliant or non-compliant) [16] was used

through a single screening question “Is your child used to

strictly follow instructions and take medications as the

doctor prescribed?” with a parent report of “yes” or “no”.

Other sociodemographic data included; residence (urban

or rural), family size, and gender.

Statistical analysis: scores for total QOL and the 8

subscales for each participant were calculated after the

guidelines of the PedsQL™ 3.0 Cancer Module deve-

loper. Descriptive statistics were expressed as mean and

standard deviation. Data analysis was performed using

the student t-test with SPSS version 18. p value < 0.05

was considered to be significant.

3. Results

Descriptive demographic and medical data for the study

sample are shown in Table 1. Study patients were 43

males and 24 females (1.8:1) with a median age of 8

years at diagnosis and 5.25 as mean value for family size.

Patients with hematological malignancies represented

70.1% versus 29.9% with solid tumors, with the highest

proportion for ALL (52.2%). The on-treatment and fol-

low-up cancer groups had very close percentages of

53.7% and 46.3% respectively, together with 50.7% had

treatment duration of 1 year or above at time of evalua-

tion. The urban and rural distribution for residence was

also 50.7% and 49.3%, respectively. Medium and high

intensity of therapy (59.7% & 31.3% respectively) were

much more represented than low intensity (9.0%). While

hospital visits for 70.1% of the sample exceeded 3 times/

month, 43.3% had hospital admissions for more than two

thirds of their treatment duration with a compliance rate

of 89.6% of the whole sample.

Total QOL showed to be relatively low with mean

value of 62.29. Subscales with least scores were for;

worry (44.11), perceived physical appearance (50.6), and

procedural anxiety (55.34). On the other hand, the best

score was 75.98 for communication, followed by 72.63

for cognitive problems, (Table 2).

Table 3 shows the impact of different variables on

QOL and its subscales. High and medium treatment in-

tensities as well as long duration of hospital admission

were associated with a poorer total QOL (p < 0.05). Per-

ceived physical appearance was also affected by treat-

ment intensity (p < 0.01) with more negative impact on

female patients who also suffered more than males from

treatment anxiety and worry (p < 0.05). Pain & hurt was

increased among patients with; lower age (≤5 years) at

time of diagnosis (p < 0.05), longer hospital admission (p

< 0.01), and non-compliance to treatment (p < 0.01). The

latter also affected the procedural anxiety domain sig-

nificantly (p < 0.05), while long periods of hospital ad-

mission deteriorated treatment anxiety subscale (p <

0.05).

Larger family size (>5 members) was associated with

a negative effect on communication subscale (p < 0.01).

None of diagnosis subtypes (hematological/solid ma-

lignancies), phase of treatment (on-treatment/follow-up),

Quality of Life in Egyptian Children with Cancer

1258

Table 1. Descriptive demographic and medical characteris-

tics.

Variable n (%)

Gender

Female

Male

24 (35.8%)

43 (64.2%)

Type of malignancy

Hematological:

ALL

NHL

AML

LCH

Solid:

Brain

STS

RMS

Ca Colon

47 (70.1%)

35 (52.2%)

5 (7.5%)

1 (1.5%)

4 (6.0%)

2 (3.0%)

20 (29.9%)

8 (12.0%)

5 (7.5%)

1 (1.5%)

2 (3.0%)

1 (1.5%)

2 (6.0%)

Phase of treatment

On treatment

Follow up

36 (53.7%)

31 (46.3%)

Intensity of therapy

Low

Medium

High

6 (9.0%)

40 (59.7%)

21 (31.3%)

Therapy duration

≤ 6 month

> 6 month

≥ 1 year

12 (17.9%)

21 (31.3%)

34 (50.7%)

Hospital admission

Low

Medium

High

18 (26.9%)

20 (29.9%)

29 (43.3%)

Hospital visits

≤3/month

>3/month

47 (70.1%)

20 (29.9%)

Compliance

Compliant

Non-compliant

60 (89.6%)

7 (10.5%)

Residence

Rural

Urban

33 (49.3%)

34 (50.7%)

ALL = Acute Lymphoblastic Leukemia; NHL = Non Hodgkin Lymphoma;

AML = Acute Myeloid Leukemia; HD = Hodgkin Lymphoma; LCH =

Langerhan’s Cell Histiocytosis; ES = Ewing’s sarcoma; STS = Soft-Tissue

Sarcoma; RMS = Rhabdomyosarcoma; OS = Osteosarcoma; Ca Colon =

Cancer Colon; NB = Neuroblastoma.

or residence (urban/rural) appeared to have a statistically

significant effect on either total QOL or its subscales in

our study.

4. Discussion

The parent-proxy report for pediatric cancer patient

showed a total QOL of 73.6 for the US, 72.2 for the

Indonesian and 71.02 for the Chinese mandarin child-

Table 2. Scores of total QOL and its subscales among study

group.

Scale/Subscale MeanMedian Std. D Min.Max.

Total QOL 62.2966.50 18.85 19.492.5

Pain & Hurt 66.9875.00 33.89 0.0100.0

Nausea 68.3280.00 29.39 0.0100.0

Procedural anxiety 55.3475.00 36.17 0.0100.0

Treatment anxiety 63.6475.00 32.24 0.0100.0

Worry 44.1150.00 30.70 0.0100.0

Cognitive problems72.6380.00 26.99 5.0100.0

Perceived physical

appearance 50.6058.30 28.09 0.0100.0

Communication 75.9891.70 31.80 0.0100.0

hood cancer patients [3,17,18]. Although the total QOL

for Egyptian pediatric cancer patients showed to be re-

latively poorer than aforementioned studies with a score

of 62.3, yet it showed to be better than results of the

Pakistani data which showed much lower total QOL

score of 42.07 [10]. Relatively poor QOL was attributed

according to our results to intensity of therapy which was

reported to represent an independent predictor of poor

QOL [9]. As shown by the illustrated data, high and me-

dium intensities of treatment showed significant lower

total QOL (p < 0.05) compared to low intensity therapy,

with mean values of 60.4, 60.4 and 81.0 respectively.

Adverse effect of therapy intensity on QOL could be ex-

plained in terms of more intensive chemotherapy and

poor disease prognosis [9,19]. The participation of inten-

sive chemotherapy on the deteriorated QOL could be em-

phasized again by the highly significant decrease in per-

ceived physical appearance subscale among medium and

high intensity of treatment in comparison to low therapy

intensity patients (p < 0.01). Hair loss and other distress-

ing adverse effects on physical appearance as a result of

using anit-neoplastic agents in childhood cancer proto-

cols could perfectly explain the low QOL for this domain

[20,21]. In the same context, high frequency of hospital

visits was significantly correlated to reduced QOL score

in nausea subscale (60.0) compared to higher value in

case of less frequent visits (80.0) (p < 0.05). Such find-

ings indicated more that frequent exposure to hospital at-

mosphere and consequently more therapy administration

could be a leading factor.

Hospitalization, was another therapy related factor

which showed significant impact on the total QOL (p <

0.05). Patients with hospital admissions exceeding two

thirds of their treatment duration showed a more deterio-

rated QOL (55.6) compared to others with lower duration

in consistence to others’ data [22]. Similarly, a signifi-

cant decrease in QOL was also shown in the pain and

hurt (p < 0.01) and treatment anxiety (p < 0.05) domains

in relation to duration of hospital admission resulting in

Quality of Life in Egyptian Children with Cancer

1259

Table 3. Total QOL and its 8 subscales in relation to study variables.

Variable Total QOL Pain & Hurt Nausea Procedural

anxiety

Treatment

anxiety Worry Cognitive

problems

Perceived

physical

appearance

Communication

Age at

diagnosis

<5 yrs

≥5 yrs

p value

59.2 (19.0)

63.4 (18.9)

51.0 (41.0)

73.0 (30.0)

0.02

65.0 (31.0)

69.0 (29.0)

58.3 (37.2)

54.3 (36.2)

59.6 (38.1)

65.0 (30.3)

45.0 (23.0)

44.0 (33.0)

69.0 (24.0)

74.0 (28.0)

53.0 (26.0)

50.0 (29.0)

2.1 (34.4)

77.3 (31.1)

Gender

Female

Male

p value

57.9 (20.3)

64.7 (17.8)

64.0 (35.0)

69.0 (34.0)

65.0 (28.0)

70.0 (30.0)

48.3 (38.5)

59.3 (34.4)

52.0 (30.4)

70.1 (31.7)

0.02

34.0 (30.0)

50.0 (30.0)

0.04

79.0 (26.0)

69.0 (27.0)

41.0 (28.0)

56.0 (27.0)

0.03

71.9 (36.3)

78.3 (29.2)

Intensity of

treatment

Low

Medium

High

p value

81.7 (5.3)

60.4 (19.8)

60.4 (16.7)

0.02

90.0 (9.0)

61.0 (36.0)

72.0 (32.0)

79.0 (15.0)

71.0 (29.0)

60.0 (32.0)

73.6 (26.0)

52.3 (38.0)

56.0 (34.9)

81.9 (8.2)

63.1 (32.8)

59.5 (34.6)

62.0 (10.0)

45.0 (33.0)

36.0 (28.0)

92.0 (14.0)

70.0 (26.0)

71.0 (30.0)

79.0 (18.0)

45.0 (28.0)

53.0 (26.0)

0.01

95.8 (10.2)

73.9 (32.6)

74.2 (33.2)

Family size

≤5

p value

61.8 (18.9)

63.1 (19.2)

64.0 (35.0)

72.0 (32.0)

69.0 (30.0)

68.0 (29.0)

47.1 (36.1)

70.1 (31.9)

61.0 (32.9)

68.4 (31.2)

42.0 (32.0)

48.0 (28.0)

76.0 (26.0)

67.0 (29.0)

52.0 (28.0)

49.0 (29.0)

83.3 (26.6)

62.8 (36.4)

0.01

Hospital

admission

Low

Medium

High

p value

65.9 (20.0)

68.8 (11.3)

55.6 (20.5)

0.03

69.0 (37.0)

83.0 (26.0)

54.0 (32.0)

0.01

68.0 (25.0)

74.0 (28.0)

65.0 (33.0)

51.8 (40.6)

63.4 (27.9)

52.0 (38.6)

69.8 (28.3)

74.1 (24.0)

52.6 (36.7)

0.04

55.0 (30.0)

47.0 (33.0)

35.0 (28.0)

71.0 (26.0)

79.0 (19.0)

69.0 (32.0)

58.0 (27.0)

51.0 (25.0)

45.0 (31.0)

81.9 (27.8)

77.5 (33.6)

71.2 (33.2)

Hospital

visits

≤3/month

>3/month

p value

67.4 (16.0)

60.1 (19.7)

78.0 (24.0)

62.0 (37.0)

80.0 (19.0)

63.0 (32.0)

0.02

60.8 (39.7)

53.0 (34.7)

56.1 (32.1)

66.9 (32.1)

49.0 (26.0)

42.0 (33.0)

75.0 (25.0)

72.0 (28.0)

58.0 (25.0)

47.0 (29.0)

82.1 (32.8)

73.4 (31.4)

Compliance

Compliant

Non-compl.

p value

63.5 (18.9)

52.1 (16.7)

72.0 (29.0)

25.0 (43.0)

0.00

69.0 (30.0)

66.0 (28.0)

58.7 (35.6)

26.2 (29.0)

0.02

63.8 (32.8)

61.9 (29.6)

46.0 (30.0)

29.0 (31.0)

73.0 (28.0)

72.0 (20.0)

51.0 (29.0)

49.0 (17.0)

75.4 (33.4)

80.9 (12.5)

Therapy

duration

≤6 month

>6 month

≥1 year

p value

64.9 (21.6)

65.2 (21.6)

59.6 (18.0)

72.0 (37.0)

74.0 (33.0)

61.0 (33.0)

63.0 (39.0)

70.0 (24.0)

65.0 (25.0)

54.2 (41.7)

43.6 (35.5)

63.0 (33.5)

74.3 (24.7)

64.7 (33.2)

59.2 (33.8)

47.0 (42.0)

43.0 (31.0)

44.0 (27.0)

77.0 (28.0)

83.0 (19.0)

65.0 (29.0)

0.04

54.0 (25.0)

57.0 (33.0)

46.0 (26.0)

80.6 (29.8)

78.2 (31.9)

73.0 (33.0)

*no significant difference.

increased physical and psychological distress [23,24].

Moreover, pain and hurt and procedural anxiety do-

mains; regarded as treatment related variables were shown

to be correlated to patients’ compliance to treatment pro-

tocols in agreement to related studies [23,25]. Decreased

compliance; in form of missing appointments and sche-

dule non adherence showed to be associated with de-

teriorated scores for both subscales at p values <0.01 and

<0.05 respectively.

While an association between phase of treatment and

QOL was reported by some investigators [15,26], our

results did not show any significant difference between

patients under current therapy and those at follow-up.

Similarly, Speechley and colleagues [27], found that type

of cancer can affect QOL which was on the contrary to

our data.

Some socio-demographic factors such as family size

and gender also showed a crucial role in determining

QOL [28]. Risk factors for poor QOL included family

size [29]. According to our results, patients related to

small families with 5 or less members had a significantly

better scores in the communication subscale with a mean

Quality of Life in Egyptian Children with Cancer

1260

value of 83.3 compared to 68.2 in larger sized families (p

< 0.05). This could be explained by difficult interper-

sonal relationships and less parental care offered to their

children with the increased number. The poorer QOL

among female versus male patients (p < 0.05) in more

than one domain was also matched with similar studies

[30,31]. Such domains included treatment anxiety, worry

and perceived physical appearance. For residence, on the

other hand, on showing no significant differences in

QOL and its subscales between the urban and rural resi-

dences, our results agreed with literature reporting the

weak influence of such a parameter on QOL [32].

In summary: increased treatment intensity, long dura-

tion of hospital admission, high frequency of hospital

visits, female sex and younger age were all associated

with a poorer total QOL and/or its subscales among

Egyptian pediatric cancer patients.

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