Comparison of quality of life of Turkish breast cancer patients receiving breast conserving surgery or modified radical mastectomy.

PURPOSE
The aim of this study was to investigate the differences in quality of life in patients who received breast conserving surgery (BCS) or modified radical mastectomy (MRM) for breast cancer.


MATERIALS AND METHODS
A total of 100 women with breast cancer who underwent either BCS or MRM between September 2011 and April 2012 at a private health center and completed their chemotherapy and radiation therapy cycles were included in the study. To assess the quality of life, we used a demographic questionnaire, the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Quality of Life assessment in Breast Cancer (EORTC QLQ-BR23).


RESULTS
Using QLQ-C30, we found that patients who underwent BCS had better functional status and fewer symptoms than patients who underwent MRM. In QLQ-BR23, independent factors improving the functional scales were BCS, higher level of education and marital status (married); independent factors improving symptoms were BCS, higher level of education, younger age and low and normal body mass index (BMI). In QLQ-C30, independent factors affecting the functional and symptom scales were only BCS and higher level of education.


CONCLUSIONS
We determined that patients who received BCS had better functional status and less frequent symptoms than patients who underwent MRM.


Introduction
Breast cancer is an important global public health issue and is one of the most common cancer types in women (Zhang et al., 2013). It ranks the first among the ten most prevalent cancers in women in Turkey (Turkey's Statistical Yearbook, 2010) and it is reported as the second leading cause of death from cancer. Recent advances in the diagnosis and treatment of breast cancer allows for early detection and prolonged survival and thus brings up the issue of quality of life in patients with longer life expectancies. (Sert et al., 2013).
Five-year survival rates of patients with breast cancer regardless of stage are 73% in developed countries while it is only 53% in developing countries (Gencturk, 2013). Survival rates with BCS are similar to mastectomy (Ozmen, 2012;Abdullah et al., 2013). Survival rates of breast cancer have been increasing. However this affects the individuals in physical, psychological and social aspects in both positive and negative ways and the problems that the patients continue to experience become the most important factor determining the decrease in quality of life (Inan and Ustun, 2013).
Many studies have shown that women who are of 1 Hande Acil 1 , Ikbal Cavdar 2 * younger age and have poorer health status at the time of diagnosis experience worse symptoms and this has a negative impact on their quality of life. (Janz et al., 2007;Cleeland, 2007;Leak et al., 2008;Kim et al., 2009;Dodd et al., 2010). Quality of life depends on the functional health state of the individual, pain level, self-attribution, self-perception and quality of interaction with their surrounding environment (Mohammadi et al., 2013). Importance of breast cancer in quality of life studies is growing both because it is the most prevalent cancer among women and loss of breast has a major effect on patient's identity (Demirci, 2010).
In this study, we aim to investigate the differences in quality of life in patients who received breast conserving surgery (BCS) of modified radical mastectomy (MRM) for breast cancer.

Materials and Methods
Written permission of Istanbul University Istanbul Faculty of Medicine Clinical Studies Ethical Board was obtained prior to the beginning of the study (Date/ number 2011(Date/ number /1248. Written permission of the private health center, where the study was to be conducted at, was also obtained. 100 women with breast cancer who received either BCS or MRM by a single surgeon between September 2011 and April 2012 at a private health center and completed their chemotherapy and radiation therapy cycles were included in the study. A demographic questionnaire (including age, sex, marital status, education, occupation, age of menarche, alcohol use and smoking, family history of breast cancer and the type of surgery performed), the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Quality of Life assessments in Breast Cancer (EORTC QLQ-BR23) quality of life scales were used in the study.

EORTC QLQ-C30 and EORTC QLQ-BR23 Quality of Life Scale
Beser and Öz conducted the content validity and reliability studies of EORTC QLQ-C30 quality of life scale in Turkey and found the Cronbach alpha coefficient (r) to be 0,9014. EORTC QLQC30 Version 3.0 is a quality of life scale commonly used in patients with cancer worldwide (Beser and Oz, 2003;Ertem et al., 2009). Breast cancer-specific EORTC QLQ-BR23 consists of 23 items and two subgroups, which are function and symptom scales. The higher scores in function scale represent better health status while higher scores symptom scale indicate more symptoms (Demirci, 2010;Demirci et al., 2011). to determine whether the results of EORTC QLQ-C30 and EORTC QLQ-BR23 scales showed any difference depending on the type of surgical intervention. Multiple Linear Regression Model (method: stepwise) was used to determine the independent factors affecting the functional and symptom scales in both QLQ-C30 and QLQ-BR23. Results were evaluated with 95% confidence interval and p<0.05 significance level.

Results
In this study, we evaluated 100 patients with breast cancer. Mean age was 51.83±9.26 (Range: 34-76). 80% of the subjects were married and the ratio of married subjects in the MRM group was significantly higher than the BCS group. Subjects whose level of education was primary school constituted 36% in the BCS group while this ratio was as high as 78% in the MRM group and the difference was statistically significant. 75% were housewives, 70% had middle income level, 98% had social security from Social Insurances Institution, 95% lived with their families, age of menarche of 20% was equal to and below 12 years. 38% were in menopause, 42% were overweight, 92% were non-smokers and 87% did not consume alcohol (Table 1).
Data of the patients who did not receive any treatment and were only followed-up by their physician while the study was being conducted are given in Table 2. The analysis of the results of QLQ-C30 based on the type of surgical intervention revealed that when compared to MRM, patients who received BCS had better functional status and fewer symptoms. The results were statistically significant (p<0.05).
The analysis of the results of QLQ-BR23 based on the type of surgery showed that body image, future   (Table 3). According to the Multiple Linear Regression Model (stepwise method) analysis, in QLQ-BR23 scale, independent factors improving the functional scales were BCS, higher level of education and marital status (married) (p<0.001); independent factors improving symptoms were BCS, higher level of education, younger age and low and normal body mass index (BMI) (p<0.05) ( Table  4). In QLQ-C30 scale, independent factors affecting the functional and symptom scales were only BCS and higher level of education (p<0.05) ( Table 5).

Discussion
Loss of breast, which is of great importance for female sexuality, body image and reproductivity, disrupts the bio-psycho-social balance, causes related problems and therefore affects the quality of life of the patients with breast cancer (Akyolcu, 2008). Patients who receive surgical intervention for breast cancer encounter many physical, psychological and social problems which in turn affect their quality of life negatively (Demir, 2008).
Surgical intervention, which has an important role in the treatment of breast cancer, affects the body image, self-confidence, psychological status, sexual life and interpersonal relationships of the patient negatively (Ozkan and Alcalar, 2009). Mastectomy may result in pain, depression, anxiety, fear, rage and other affective disorders, fatigue, loss of sexual desire, low self-esteem, social withdrawal, fear of losing femininity, worrying about disease recurrence, trouble finding appropriate clothing, and problems related to breast implants as well as a distorted body image and cause problems in the marriage and intimate relationships of the patients (Okanli and Ekinci, 2008;Karamanoglu and Ozer, 2008). Zanapalioglu et al. (2009) found better body image, sexual function, sexual satisfaction, future perspective, and arm and breast symptoms in patients who received BCS than patients who received MRM. In a similar study, body image, future perspective, arm symptoms and hair loss was worse in patients who received MRM while there was no difference in systemic therapy side effects and breast symptoms between BCS and MRM groups (Akca, 2011). Kement et al. (2011) reported better quality of life both physically and mentally in patients who received BCS. In similar studies comparing BCS and MRM, Han et al. (2010) showed higher physical and mental status in BCS patients while Arndt et al. (2008) reported better physical and social functioning and general quality of life. Bulotiene et al. (2005) found higher role functioning in young women and higher social functioning in retired women in post-BCS period when compared to MRM. Zanapalioglu et al. (2009) found general well-being, physical symptoms, role performance, emotional state, cognitive state, social state, fatigue, nausea, dyspnea, sleep disorders, anorexia, constipation, diarrhea and financial problem points to be better in subjects receiving BCS. Hadi et al. (2012) found better global health and role functioning in subjects receiving BCS and more fatigue, nausea, vomiting, pain, dyspnea, lack of sleep and arm symptoms in patients who underwent MRM. Akca. (2011) reported that patients who receive BCS or simple mastectomy for breast cancer have higher quality of life in terms of social function, fatigue, constipation and general quality of life in comparison to MRM. On the other hand, He and his colleagues reported significantly higher social functioning in patients who received BCS while there was no difference in physical, functional and emotional functioning between two groups (He et al., 2012).
In this study, we found quality of life to be better in patients who received BCS when comparing types of surgical intervention with both QLQ-C30 and QLQ-BR23. Similar to the results of other studies, BCS was found to be a positive factor affecting the functional and symptom scales in both scales and patients who received BCS had better functional state and less symptoms. Kizilci (1999) and Ertem et al. (2009) reported that level of education affects the quality of life and subjects with higher education have better quality of life (Kizilci, 1999;Ertem et al., 2009). Similarly, in this study we found higher level of education to be a factor positively influencing the functional state and symptoms in both QLQ-BR23 and QLQ-C30 scales.
There are various opinions regarding the effect of marital status on quality of life. Kizilci (1999) DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5377 Quality of Life in Breast Cancer Patients Undergoing Breast Conserving or Radical Surgery by Ertem and his colleagues being married was found to be a positive factor affecting the quality of life in QLQ-BR23 scale.
Overweight and obese women have a higher risk of experiencing treatment-related symptoms. High BMI in patients with breast cancer has been showed to be related to worse quality of life before, during and after radiation therapy and BMI was significantly correlated to symptoms (Fang et al., 2013). Similarly, we found low and normal BMI to be a factor decreasing symptoms according to QLQ-BR23 scale.
In conclusion, we determined that patients who receive BCS have better quality of life than patients who receive MRM.