Quality of life and hope in elderly people with cancer

doi:10.4236/ojn.2011.12004

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Open Journal of Nursing, 2011, 1, 26-32

doi:10.4236/ojn.2011.12004 Published Online September 2011 (http://www.SciRP.org/journal/ojn/ OJN

Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJN

Quality of life and hope in elderly people with cancer

Bente Appel Esbensen1, Thordis Thomsen2

1 Research Unit of Nursing and Health Science, Glostrup University Hospital, Nrd. Ringvej, Glostrup, Denmark;

2 Research Unit, Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej, Herlev, Denmark.

E-mail: [email protected]

Received 2 August 2011; revised 24 August 2011; accepted 7 September 2011.

ABSTRACT

The aim of this study was to describe the charac-

teristics in Quality of Life (QoL) and hope in eld-

erly people newly diagnosed with cancer, and to

compare the results for those who survived six

months after diagnosis with those who did not. The

design of the study was a quantitative study in-

cluding drop-out analysis. Data were collected pro-

spectively from a group of 101 older people with

cancer. The core questionnaire EORTC QLQ-C30

was used to measure QoL and Nowotny’s Hope

Scale (NHS) was employed to measure hope. Par-

ticipants who died within six months of diagnosis

had significantly lower QoL and had more com-

plaints about symptoms compared to those who

survived. However, hope did not differ significantly

between those who died and those who survived.

Despite lower QoL score among those who died they

were able to deal with their difficult situation and

maintain hope in late life. This capa city seems to be

an important component of hope in the elderly;

thus it is essential to strengthen hope.

Keywords: Hope; Quality of Life; Elderly People with

Cancer; Palliative Care; Survivors

1. BACKGROUND

The improvement and maintenance of QoL are a ma-

jor goal of cancer care for older people, especially

under conditions of limited improvement of survival

and at the price of significant complications [1]. From

a study comparing QoL in elderly people with and

without cancer it was found that the former group had

lower (poorer) scores in QoL and more symptom

complaints [2]. This issue is particularly relevant to

the elderly person with cancer, who may have a lim-

ited life expectancy compared to younger to younger

people and increased risk of complications from their

treatment [1].

People newly diagnosed with cancer are in an es-

pecially vulnerable and unknown situation in which

the diagnosis can threaten hope and make the future

uncertain. Hope may be particularly important for

people diagnosed with a life-threatening illness [3],

such as cancer. Few studies describe the concept of

hope in people who are elderly and have cancer [4-5].

A qualitative study identified loss of hope as threat-

ening for an elderly person with cancer, because it

represented the finiteness of life [6]. According to

Nowotny [7] the aspect of life expectancy may not

necessarily be important because seriously ill people

speculate less on cure or extra life span and more on

what is possible and realistic in the situation. This is

in line with Benzein [3] who identified hope in

healthy people as a process linked to meaning in life.

Therefore, hope is a notion that not only contains the

number of years left to live, but also the meaning of

life, which is in line with the findings of Nowotny [7].

This issue may be important for the elderly person

with cancer due to limited life expectancy, regardless

of the outcome of the disease trajectory.

Few studies re port on QoL and ho pe for cancer patient s

and for ol der people i n general. I n a follow- up study a lo w

level of hope was identified as a predictor for decreased

QoL in elderly people with cancer six months after di-

agnosis [8]. Rustoen an d Hanestad (199 8) ob serv ed in an

intervention study (age range 26 - 78; n = 96 newly di-

agnosed cancer patients) that hope scores in ‘the hope

group’ were significantly improved two weeks after the

intervention compared to the scores in the two control

groups. In another study hope was identified as an im-

portant resource for cancer patients having an impact on

their QoL [9]. According to Rustoen and Hanestad [10],

one signi ficant important issue in em ploying t he conce pts

of ‘hope’ and QoL is that they can be seen as two separate

ones. However, although they are dependent on one an-

other, the relationship is not simple [9]. Earlier interven-

tion studies have identified a strong positive relation

between hope and QoL, and suggest that both improve

B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 27

following intervention [10-12]. Thus, hope may buffer

against decreased QoL and so be regarded as a personal

resource. QoL is often assumed to be an important out-

come variable within health care in regard to disease

trajectory, treatment and the ability to manage daily liv-

ing with a diagnosis of cancer. Hope, however, appears

little investigated as an important outcome variable in

health care.

In palliative care, where patients have to live with un-

certainty due to their illness and due to the length of life

they may expect, hope is one of the most important is-

sues [13]. The concept of palliative care is above all

based on the idea of reinforcing factors that improve

QoL and decreasing the impact of factors that may re-

duce it [14]. However, there is a lack of knowledge a bout

elderly people with cancer, especially in relation to those

in the advanced stages. Nevertheless, it may be impor-

tant to explore QoL and hope in the elderly with cancer

to gain insights about how they may be better able to

manage their situation and to give them high quality care

at the end of life. Thus, the aim of this study was to de-

scribe the characteristics in QoL and hope in elderly

people newly diagnosed with cancer, and to compare the

results for those who survived six months after diagnosis

with those who d id not.

2. METHOD

2.1. Design

A prospective, follow-up study with the overall aim to

examine elderly persons newly diagnosed with cancer

was conducted [15]. A dropout analysis was performed

and results from this analysis will be presented in this

paper with focus on the difference in QoL and hope be-

tween those elderly people newly diagnosed with cancer

who survived for six months after the diagnosis and

those who did not.

2.2. Sample Selection

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tions.

Among 142 patients (aged 65 + years) referred to the

Department of Oncology in the Capital Region. Inclu-

sion criteria for the study were having a diagnosis of

breast cancer, lung cancer, gynecological cancer or colo-

rectal cancer, and undergoing treatment and / or receiv-

ing supportive hospital care for the cancer. Eligible pa-

tients were invited to participate by letter and subse-

quently contacted via telephone by the first author

(BAE), when their willingness to participate and full

understanding of their rights concerning participation

and non-participation were confirmed. In total, 101

newly diagnosed with cancer, met inclusion criteria for

the study and agreed to participate. In total, 41 refused to

participate for reasons of to general frailty (n = 13), cog-

nitive dysfunction (n = 3), next of kin not wanting the

patient to contribute (n = 10) or for unspecified reasons

(n = 15). The 101 people in the stud y group consisted of

74 women and 27 men. In total, 26 of the 101 partici-

pants (17 women, 9 men) died within six months of di-

agnosis (labeled ‘died’) while 75 survived (labeled ‘sur-

vivors’) at least six months.

2.3. Instruments

A questionnaire was developed for the follow - up study

addressing socio-demographic data, and QoL and hope

[15]. Quality of life (QoL) was used as a health-related

quality of life measurement and was measured using the

EORTC QLQ-C30 (version 3), referred to below as

QLQ-C30 [16]. The instrument is cancer specific, multi-

dimensional, applicable in different cultures [17-18], and

has been translated into several languages, including

Danish. The QLQ consists of three subscales: the global

health status/QoL, functional scale and symptoms scale

including 30 items. The response format for all subscales

consists of a 4-point Likert scale format ranging from

one to four “not at all”, “a little”, “quite a bit” and “very

much” [19]. QLQ-C30 was scored in accordance with

the methodology developed by QLQ-C30 ranging from

0 to 100 [19]. The internal consistencies of the instru-

ments were calculated using Cronbach’s Alpha (0.70 -

0.90). The reliability analysis for QLQ-C in this study

was α 0.76 - 0.97, except for emotional function α 0.61

and cognitive fun ction α 0.43.

Nowotny’s Hope Scale (NHS) was used to measure

hope. The instrument consists of 29 questions covering

six dimensions, and provides detailed information on

different aspects of hope. It is specifically developed to

measure hope in individuals suffering a crisis such as a

diagnosis of cancer. The response format scores consist

of a 4-point Likert format ranging from one to four

“strongly agree”, “agree”, “disagree” to “strongly dis-

agree” [20]. NHS was translated from English into Dan-

ish according to internationally accepted guidelines [21]

and was transformed to scores ranging from 29 to 116

according to Nowotny [20]. A score from 29 - 50 indi-

cates “hopelessness”, 51 - 72 “low hope”, 73 - 94 “mod-

erately hopeful” and 95 - 116 “hopeful” [22]. In this

study the reliability analysis ranged from α 0.74 - 0.88,

B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18

OJN

except for the item “comes from within” (α 0.20 ).

2.4. Data Collection

Data reported in this paper are all from the drop-out

analysis from the prospective follow-up study (baseline

measurement) after having identified those, who were

lost to follow-up six months after. Structured interviews,

based on the questionnaire developed for the follow-up

study, were conducted by the first author two to four

weeks after the diagnosis. All data were therefore self-

reported by participants, except for age, sex, and type of

cancer, which were collected from the referral list of the

oncology clinic.

2.5. Ethical Approval

The Danish Data Protection Agency was informed of the

database. The study protocol was sent to the Copenha-

gen County Ethical Committee which found formal ap-

proval unnecessary. Prior to enrolment, each participant

received oral and written information about the aim of

the study, and it was emphasized that participation was

voluntary and would not in any way affect their treat-

ment. All participants were informed about procedures

for ensuring conf identiality and anonymity.

2.6. Analysis

Descriptive statistical analyses were performed on all

variables. The measures are described using median and

Interquartile Range (IQR). Data were further analyzed

for differences between those who died and those who

survived. In addition, all variables were regarded as not-

normally distributed; hence non-parametric statistics

methods were applied. For differences between two in-

dependent groups (age groups and years at school)

Kruskal-Wallis one-way analysis of variance was used

for analyzing ordinal scale data (Ta ble 1). Analysis was

performed to explore differences between those who

died (n = 26) and tho se who surviv ed (n = 75) within the

six-month period. Mann Whitney U-test was used to

analyze differences in the nominal and categorical level

of data at baseline between the two groups. Tests with p-

values < 0.05 were regarded as statistically significant.

Statistical analyses were carried out with SPSS 11.5 for

Windows®.

3. RESULTS

3.1. Socio—Demographic Data

The median age of the study group was 74.74 (IQR 8.75)

(Table 1). Those who died (n = 26) had a median age of

73.90 (IQR 9.88). Sex distribution was 65.4% women

and 34.6% men. Those who survived (n = 75) had a me-

dian age of 75.49 (IQR 8.7). Sex distribution was 76%

women and 24% men. For further information, see Ta-

bles 1 and 2. There were no statistically significant dif-

ferences in the distribution by age, sex, type of accom-

modation, number of years at school, latest occupation,

no income other than retirement pension and financial

circumstances between those who survived and those

who died.

Table 1. Demographic characteristics %.

Variable (n = 26) S urvivors (n = 75)To ta l (n = 101) P-Value¹

Age, Median ( IQR) 73.90 (9.88) 75.49 (8.7) 74.74 (8.75) 0.2842 & 3

Sex % 0.294

Women 65.4 76 73.3

Men 34.6 24 26.7

Diagnosis (= n)

Breast cancer 1 23 24

Gynecological cancer 5 20 25

Lung Cancer 6 19 25

Colo-rectal cancer 14 13 27

Total 26 75 101

Marital Status % 0.193

Married 61.5 46.7 50.5

Not married (includes divorced, widowed, separated and single) 38.5 53.3 49.5

Type of accommodation (%) 0.321

Apartment 53.8 56 44.6

House / farm 42.3 41.3 52.5

Sheltered house 3.8 2.7 3.0

Years at school, Median (I QR) 8.00 (3.00) 9.00 (3.00) 8.00 (3.00) 0.091

Last profession/o ccupation % 0.641

Housewife or blue col l ar 53.8 27.3 46. 5

Employee or public servant 30.8 42.7 33.7

Self-employed 15.4 16 19.8

1Mann-Whitney test; 2 & 3 Kruskall Wallis test.

B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 29

3.2. Quality of Life

Participants who d ied had an overall lower QoL than those

who survived (P = 0.018). They had lower scores in func-

tional scale (P = 0.006), lower physical function (P = 0.003)

and lower role function measured on the subscale role func-

tion (P = 0.003). Moreover, in the symptom scale (P =

0.026), they had a higher score, indicating more problems

and complaints. Those who died reported significantly

more frequent fatigue than those who survived (P = 0.007)

as well as more dyspnea (P = 0.025) ( Table 3).

3.3. Hope

No significant difference was found in the level of hope

between those who died and those who survived.

However, in the subscale ‘comes from within’ a total

score was median 11.00 and a significant difference

was identified between the two groups (P = 0.005)

(Table 4). Those who died and those who survived.

However, in the subscale ‘comes from within’ a total

score was median 11.00 and a significant difference was

identified between the two groups (P = 0.005) (Table 4).

Table 2. Economic situation, Receiving help and in contact with health care system.

Variable Died

(n = 26) Survivors

(n = 75) Total

(n = 101) P-value¹

Economical situation

Other income than retirement pension 25.7 24.0 27.7 0.581

Reduced economic ability activity due to cancer 7.7 14.7 12.9 0.360

In contact with health care system

Hospitalized within the l ast six months 88.5 94.7 93.1 0.285

In contact with general practitioner (GP) 80.8 84 83.2 0.706

In contact with home help service 38.5 26.7 29.7 0.259

In contact with home nu rse 26.9 22.7 23.8 0.662

Receiving help

Need more help 75.9 73.0 75.8 0.268

Having children 96.2 88 90.1 0.233

Getting help from children 65.4 59.1 61.5 0.428

Having grandchildren 88.5 84 85.1 0.583

Getting help from grandchildren 34.6 19 24.4 0.056

¹Mann-Whitne y Test.

Table 3. Quality of life-comparison for those who died within the first six months and those who survived.

Variable Died

(n = 26) Survivors

(n = 75) In total

(n = 101) P-value¹

Global health status / QOL (QL)² 50.00 (50.00) 75.00 (33.33) 66.67 (33.3 3) 0.018

Functional scales³ 63.33 (37.78) 77.78 (22.22) 77.78 (25.5 6) 0.006

Physical function (PF) 46.67 (50.00) 73.68 (33.33) 73.33 (40.00) 0.003

Role function (RF) 66.67 (87.50) 100.00 (33.33) 66.67 (66.67) 0.003

Emotional function (EF) 66.67 ( 43.75) 75.00 (41.67) 75.00 (41.67) 0.345

Cognitive function (CF) 83.33 (16.67) 83.33 (33.33) 83.33 (16.67) 0.789

Social function (SF) 100.00 (33.33) 100.00 (0.00) 100.00 (00.00) 0.069

Symptom scales4 28.21 (17.95) 20.51 (26.51) 23.08 (20.51) 0.026

Fatigue (FA) 66.67 (44.44) 33.33 (38.89) 44.44 (44.44) 0.007

Nausea & vomiting (NV) 0.00 (33.33) 0.00 (16.67) 0.00 (16.67) 0.903

Pain (PA) 33.33 (50.00) 16.67 (33.33) 16.67 (33.33) 0.086

Single items 5

Dyspnoea (DY) 33.33 (66.67) 0.00 (33.33) 0.00 (66.67) 0. 02 5

Insomnia (SL) 33.33 (41.67) 0.00 (66.67) 0.00 (66. 67) 0.626

Appetite loss (AP) 33.33 (66.67) 0.00 (33.33) 0.00 (33.33) 0.086

Constipation (CO) 0.00 (33.33) 0.0 0 (33.33) 0.00 (33.33) 0.844

Diarrhoea (DI) 0.00 (0.00) 0.00 (33.33) 0.00 (33.33) 0.293

Financial difficulties (FI) 0.00 (0.00) 0.00 (0.00) 0.00 (00.00) 0.108

1Man n-Whitney test; 2Higher scores indicate higher health related quality of life.; 3Higher score indicate higher function; 4Lower scores indicate fewer prob-

lems5 Lower scores indicate fewer problems.

B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18

Table 4. Nowotny’s Hope scale-those who died within the first six months and those who survived.

Variable Died (n = 26) Survivors (n = 75) To t al (n = 101) P-value¹

Nowotny’s Hope scale² 85.00 (16.25) 86.00 (14.00) 85.00 (14.50) 0.929

Confidence 14.50 (6.00) 25.00 (5.00) 25.00 (5.00) 0.861

Related to others 1 8.00 (4.50) 17.00 (5.00) 18.00 (5.00) 0.810

Future is possible 14.50 (5.00) 13.00 (5.00) 14.00 (5.00) 0.800

Spiritual beliefs 7.00 (6.00) 5.00 (5.00) 5.00 (5.00) 0.224

Active involvement 14.00 (4.00) 14.00 (4.00) 14.00 (4.00) 0.901

Comes from within 10.00 (1.25) 11.00 (1.00) 11.00 (1.00) 0.005

1Mann-Whitne y Test; 2Higher scores indicate more hope.

4. METHODOLOGICAL CONSIDERATIONS

Collecting data through personal, structured interviews

may have strengthened the result of the study in more

than one respect. Such interviews ensured that all ques-

tions in the schedu le were answered, with no gaps in the

data. Another advantage was that emotive and sensitive

questions could be asked and misunderstandings checked

immediately. The interviewers were also able to sense if

some questions were particularly difficult for partici-

pants to handle. Nowotny’s Hope Scale questions were

posed towards the end of the interview. It could be ar-

gued that, during the interview, participants were taken

through all aspects of a difficult life situation, and, from

a rational point of view, this may have negatively influ-

enced hope-scores. Equally, the participants may have

experienced the interview situation as valuable and

meaningful, which may have influenced hope-scores

positively.

No study like this one has been carried out before so it

can be regarded as a valuable pilot. It should be stressed

that 26 patients in the sample died within the first six

months from the follow-up study. Although statistically

taken into account this small number suggests the need

to conduct a similar but larger study focusing on hope

and QoL in elderly patients with advanced cancer. The

relationship between hope and QoL should be the key

especially when each group is studied independently

with focus on survival and palliative care.

5. DISCUSSION

The 75 elderly cancer patients who survived the first six

months after diagnosis were in good condition according

to QoL, physical functioning and incidence of symptoms

at the time of diagnosis as opposed to those who did not.

Those who died had, as expected, significantly lower

QoL and more complaints. However, the level of hope

did not differ significantly between the two groups (ex-

cept from the subscale ‘comes from within’). As ex-

pected, those who died were at a significantly lower

level of functioning capability than those who survived.

Though, it is noteworthy that th e same level of hope was

reported by bo th gro ups. D ifferent aspects of this f inding

will be discussed below.

Despite a lower QoL score among those who died

(and despite the seriousness of their situation ), they were

equally able to deal with their difficult situation and to

maintain hope in late life as newly diagnosed with can-

cer. The theoretical approach to hope in this study was

not only related to the future but also to new goals and

strategies in life, and / or feelings of safety and comfort

[22]. The importance of hope and meaning, and how to

maintain and measure hope, has been of interest within

cancer care [10,20,23-25]. However, consensus on a

common definition has not been reached [9]. Hope has

been defined as a catalyst that assists individuals to cope

successfully with life’s challenges and transitions, and

which facilitates continued functioning during chronic

illness and other significant losses [26-28]. This is espe-

cially important for elderly people who are challenged

with the task of maintaining hope in the face of loss [12].

Defining hope in relation to achievement, success, and

control is problematic for the elderly who may perhaps

already have experienced loss of their spouse and friends,

moving away from the family home, and / or reduction

in physical capacity [27-29]. In clinical practice, it is

often stated that health care professionals should not take

away hope from people suffering from cancer; especially

those with advanced cancer. Assuming that hope is a

catalyst that assists people to handle successfully

changes in life, and th at it is an inner power or resource,

it should be independent of experienced losses and may

be based in a person’s ability to maintain hope perse,

despite losses and difficulties.

In the current study QoL was measured by EORTC, a

health related QoL instrument where a person’s percep-

tions of health status and aspects of life are considered in

relation to expectations of normal living [30]. EORTC

cover aspects such as general health, physical function-

ing, physical symptoms, emotional functioning and cog-

nitive function [31 ]. Although the global QoL seemed to

B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 31

be equal and without significant difference in the two

groups we investigated, the result und erlines the need for

recognition of QoL by health care professionals immedi-

ately on diagnosis in order to counteract the serious re-

duction in QoL that could occur in the early stages of

cancer in the elderly.

The entire sample scored “moderately hopeful” in ac-

cordance with the methodology developed by Nowotny

(1989). Accor ding to Rustoen [2 4] , ho pe ca n be re garded

as a component in the individual’s ability to cope with

stress in a life-threatening situation. In terpretation of the

results of this study, however, requires caution for at

least two reasons. Firstly, the relation between QoL and

hope is uncertain [24]. Secondly, the reliability of the

subscale ‘comes from within’ was low (α = 0.30). Find-

ings from a qualitative study, however, confirm that the

existential dimension of hope in elderly people newly

diagnosed with cancer is essential (Esbensen, 2004). In

the current study, such people had suddenly to face the

possibility that they might die within a short time-frame.

Despite the diagnosis of cancer in old age, advanced can-

cer and a need for palliative care, those who died obvi-

ously managed to maintain hope at the same level as those

who survived the first six months after diagnosis. This

may be interpreted in the light of the core of the SOC

model (The model of Selective Optimization with Com-

pensation) according to which, to some extent, the elderly

were able to strengthen their belief in handling difficulties

and to set up new goals despite an uncertain future [32].

However, it has been suggested that the meaning of hope

for palliative patients is the hope for others, not suffering

and a peaceful death. This reflects a discourse of hope that

is framed by QoL, not li fe or death [5,29] .

Based on this study we suggest that patients adapt to

their situation and appreciate every day in the face of a

potentially limited life expectancy. We also suggest that

other issues normally neglected in life become important

when one is diagnosed with a life-threatening disease.

Morse and Doberneck [33] pointed out from a qualita-

tive study of four participant groups (patients undergo-

ing heart transplant, spinal cord-injured patients, breast

cancer survivors, and breastfeeding mothers intending to

continue nursing while employed) that the degree of

threat experienced by a person as opposed to feeling safe

can motivate and strengthen hope. This may also have

been the situation for the 26 people in the sample who

died within the first six months; their ability to mobilize

their own resources despite the cancer may have helped

to maintain hope.

6. RELEVANCE T O CLINICAL PRACTICE

This study has implications for care and support in the

field of cancer care in the elderly. A group of elderly

people had suddenly to face the possibility that they

might die within a short time-Despite the diagnosis of

cancer and the need for palliative care, those who died

obviously managed to maintain hope at the same level as

those who survived the first six months after diagnosis.

Assuming that hope is a catalyst that assists people to

cope successfully with changes in life, and that it is an

inner power or resource, it should be independent of

experienced losses. Instead, hope may be based in a

person’s ability to maintain it perse, despite losses and

difficulties, and the clinical implications are therefore to

support hope in the individual patient.

Despite limited life expectation some patients were

able to adapt to their changed situation. It might be that

other matters become more important with a potentially

life-threatening disease. Health-care professionals may

play a significant role in identifying elderly people with

cancer who are unable to mobilise their own resources to

maintain a moderate level of QoL. In addition, those

patients who have difficulty in adapting to the new situa-

tion, and therefore at risk of experiencing reduced QoL

and hope need specific intervention.

7. CONCLUSIONS

Those who died within the first six months had lower

QoL and more complaints than those who survived. A

significant difference was identified in Global QoL, in

physical and role function. However, no significant dif-

ference was identified in the total level of hope between

the two groups. Hope may be based in a person’s ability

to maintain hope per se which underlines the necessity

for health care professionals continuously to recognize

the situation of the elderly individual with cancer in or-

der to counteract the reduction in QoL that may occur

and to support their hope.

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