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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 268-274

Physical, emotional, and social well-being and toxicity assessment in post-mastectomy female breast carcinoma patients undergoing adjuvant treatment


1 Department of Radiotherapy, Malda Medical College, West Bengal University of Health Sciences, Malda 732101, West Bengal, India
2 Department of Radiotherapy, Medical College Kolkata, West Bengal University of Health Sciences, Kolkata 700073, West Bengal, India

Date of Submission19-Apr-2022
Date of Acceptance18-Aug-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Dr. Swapan K Mallick
Department of Radiotherapy, Malda Medical College, West Bengal University of Health Sciences, Malda 732101, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_48_22

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  Abstract 

Objective: Breast carcinoma is one of the most common cancers in India. Breast cancer is usually associated with serious side effects due to the long-term treatment procedure. This study investigates how to improve the overall quality of life (QoL) of patients in physical, psychological, and social aspects. Materials and Methods: Records of patients attending the Radiotherapy Outpatient Department (OPD) from May 2019 to June 2021 were analyzed retrospectively. Records of several patients available in the department were reviewed by the census method, which is based on pre-decided inclusion and exclusion criteria. Results: Out of 105 patients included in the study, 38.1% (N=40) of the patients were graduates, and 30.5% (N=32) of the patients were illiterate; 54.3% (N=57) of the patients belong to rural areas. Only 24.8% (N=26) of the patients were employed and the remaining 75.2% (N=79) of the patients were unemployed. However, most of the patients (41.0%) developed grade 1 acute skin toxicity, among which a maximum number of patients (N=47) developed grade1 late skin toxicity. After radiotherapy among all included patients, almost 13.0% of the patients developed arm edema. According to the Hospital Anxiety and Depression Scale score, the maximum abnormal scores for depression were 60.0% (N=63) and for anxiety 59.0% (N= 62). Conclusion: This study emphasizes that older women and those from lower socio-economic strata tolerated chemotherapy and radiotherapy better. We can also conclude that improved QoL has been a major concern for breast cancer patients undergoing long-term treatment. In a post-treatment setting, serial evaluation of the QoL not only improves the treatment outcome but can also be a prognostic factor.

Keywords: Breast cancer, chemotherapy, post-mastectomy, quality of life, radiotherapy, toxicity


How to cite this article:
Mallick SK, Nahid GK, Deb AR. Physical, emotional, and social well-being and toxicity assessment in post-mastectomy female breast carcinoma patients undergoing adjuvant treatment. MGM J Med Sci 2022;9:268-74

How to cite this URL:
Mallick SK, Nahid GK, Deb AR. Physical, emotional, and social well-being and toxicity assessment in post-mastectomy female breast carcinoma patients undergoing adjuvant treatment. MGM J Med Sci [serial online] 2022 [cited 2022 Dec 6];9:268-74. Available from: http://www.mgmjms.com/text.asp?2022/9/3/268/357471




  Introduction Top


Breast cancer is the most common cancer in India. According to GLOBOCAN 2020, the number of new cases of breast cancer in India is 178,361 (13.5%) among all ages and sexes[1] [Figure 1].
Figure 1: Incidence of new cases of breast carcinoma in India

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Almost 80% of the Indian patient population is less than 60 years of age. In India, pre-menopausal patients constitute more than 50.0% of all patients. Several population-based studies conducted in different parts of the country reported that the average age of breast cancer patients ranges from 50 to 55 years. A significant proportion of Indian breast cancer patients are younger than 35 years of age. Young age has been associated with larger tumor size, a higher number of metastatic lymph nodes, low rates of hormone receptor-positive status, poorer tumor grade, earlier and more frequent locoregional recurrences, and poorer overall survival. Quality of life (QoL) of breast cancer patients is significantly affected from diagnosis to treatment. Breast cancer treatment causes serious side effects, affecting QoL, like physical, psychological, and social aspects.[2] Delay in detection and treatment of breast cancer leads to the presence in an advanced stage. Prolonged treatment and increased duration of hospital stay affect patient compliance and QoL.[3] Breast cancer patients are liable to complain of sleeping disorders, high levels of anxiety, and depression. Overcoming such emotional difficulties will result in better treatment outcomes.[4]


  Materials and methods Top


The Institutional Ethical Committee approved this study. About 105 patients with invasive, previously untreated, non-metastatic carcinoma of the breast were treated with surgery, chemotherapy, and adjuvant radiation therapy (RT). Records of patients given during follow-up, and attending Radiotherapy Outpatient Department (OPD) from May 2019 to June 2021, were considered. Several patient records available in the department were reviewed by the census method based on pre-decided inclusion and exclusion criteria. An assessment of QoL was conducted and interpreted accordingly.

Study design

This is a single institutional, observational, record-based study.

Study population

A total of 214 post-mastectomy patients were registered in our OPD register for adjuvant treatment. All patients gave their informed consent and they were finally selected for this study.

Sample size

Out of 214 breast cancer patients, 105 patients were selected for the study.

Inclusion criteria

  1. The age group of patients was 20 to > 60 years;


  2. Histopathologically diagnosed with non-metastatic upfront operable breast carcinoma;


  3. Patients who are the candidates for adjuvant chemotherapy and RT after modified radical mastectomy (MRM);


  4. No pre-existing uncontrolled comorbidity or psychiatric illness;


  5. Patients who are not interested currently sexually function.


Exclusion criteria

  1. Individuals who cannot comprehend the questionnaires or refuse to answer due to personal or medical reasons;


  2. Post-hysterectomy with or without salpingo-oophorectomy patients;


  3. Patients with a history of diagnosis of another primary cancer (other than breast cancer);


  4. Patients who have had any oncological treatment including surgery, chemotherapy, or radiotherapy for their current disease before enrollment;


  5. Uncontrolled major comorbidities preclude normal daily functioning;


  6. Obvious genital and/or urinary infection;


  7. Pregnancy/lactation;


  8. Patients receive only endocrine therapy as a part of adjuvant treatment.


Laboratory investigations, parameters, and procedures

Complete blood count, fasting sugar, urea, creatinine, liver function test, X-ray chest posteroanterior view, ECG 12 leads, and 2-D echocardiography for CT fitness are to be done before starting the first cycle of adjuvant chemotherapy.

Routine blood/liver function test/kidney function test is to be checked before starting of every cycle of CT.

During RT, complete blood count/urea/creatinine is to be checked every week.

A maximum number of patients was treated with a conventional fractionation course of RT with Telecobalt 60 machine. The fractionation regime was either 50 Gy in 25 fractions at 2 Gy/fraction or 42.5 Gy in 16 fractions at 2.6 Gy/fraction. The overall treatment time ranged from 21 to 24 (mean 22.5) days for hypofractionated radiotherapy, whereas it was from 34 to 39 (mean 36.42) days in the conventionally fractionated radiotherapy (P-value = 0.0001).

Questionnaire

Immediately after the neoadjuvant chemotherapy followed by surgery and radiotherapy, the patients were surveyed using the Hospital Anxiety and Depression Scale (HADS). The HADS comprises 14 items developed to measure the levels of anxiety and depression in patients.[5] The questions were verbally explained to patients in their respective local languages.


  Results Top


After treatment completion, patients were followed according to our study protocol. Demographic characteristics along with medical history data regarding breast cancer were gathered from the medical records of the corresponding patients. Out of 105 patients, 42.0% were post-menopausal and 58.1% were pre-menopausal patients. About 69.5% of the study population was educated and 38.1% which was graduate, and around 30.5% were illiterate. The rural study population was 54.3% and the urban study population was 45.7% [Table 1]. Left-sided breast cancer was a little more than right-sided disease.
Table 1: Demographic profile of patients

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Age distribution of patients: The maximum number of patients falls in the age category of 41–60 years. In our study, the maximum number of patients are found with 2–5 cm (T2) tumor size [Table 2].
Table 2: Age and tumor stage distribution

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Estrogen receptor, progesterone receptor, and HER 2/neu receptor status

Hormonal receptor-positive patients were found to be 76.8%, whereas HER2-positive patients were found to be 16.7%.

Response after neoadjuvant chemotherapy (NACT)

These patients underwent an average of three cycles of neoadjuvant chemotherapy (FAC, FEC, AC→T, or TAC based) followed by surgery. Partial response is found in 66 patients (62.9%), 26 patients (24.5%) have complete response, and 13 patients (12.4%) have stable disease [Table 3].
Table 3: Response after neoadjuvant chemotherapy (NACT)

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Side effects after neoadjuvant chemotherapy

At baseline, none of the patients complained of nausea, vomiting, fatigue, pain, insomnia, loss of appetite, constipation, diarrhea, change of body image, loss of sexual function, hair loss, or diarrhea, but after the third cycle of CT, many patients experienced diarrhea. The mean score further increased after the 6th cycle of CT.

Side effects after radiotherapy

After neoadjuvant chemotherapy, radiotherapy was started. A systemic side effect was reduced significantly immediately after RT. After 6 months of completion of external beam radiation therapy, radiation-related side-effects reached again to baseline.


  Acute toxicity assessment Top


After radiotherapy, the area of the breast which was irradiated became itchy, dry, flaky, and oversensitive [Figure 2].
Figure 2: Acute skin toxicity

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Acute esophagitis

Maximum number of patients (N=51) suffered from grade 2 acute esophagitis but grade 3 toxicity was not seen in any patients.

Acute laryngitis/pharyngitis

The patients had difficulty swallowing due to acute pharyngitis. Maximum number of patients (N=55) were found with no toxicity.

Late toxicity assessment

A maximum number of patients were presented with grade 1 (G1) late skin toxicity [Figure 3]. Majority of the patients were presented with grade 1 (G1) followed by grade 2 (G2) subcutaneous skin toxicity [Figure 4].
Figure 3: Skin toxicity

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Figure 4: Subcutaneous skin toxicity

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Chronic toxicities including late skin toxicity and subcutaneous tissue toxicity, like fibrosis and arm edema, were observed significantly [Figure 5]. In the case of arm edema, patients had pain and swelling in their arms. They also had difficulty raising their arm and moving it sideways. The late reaction was assessed by RTOG/EORTC Late Radiation Morbidity Scoring Scheme.
Figure 5: Arm edema

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There were no cases of brachial plexopathy, pneumonitis, or rib fracture found. The degree of depression and anxiety was measured using the HADS questionnaire. Of these 105 patients, the majority showed abnormal 60.0% (N=63) or borderline 17.1% (N=18) scores for depression, whereas only 24 patients (22.9%) displayed normal ranges. Regarding anxiety, 59.0% (N= 62), 25.7% (N= 27), and 15.2% (N=16) of the patients showed abnormal, borderline, and normal HADS scores,[4] respectively [Table 4].
Table 4: Patients’ emotional status

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  Discussion Top


In our data analysis, patients with a median age of 55 years and tumor sizes T2 and T3 (< 5 cm) of the entire sample size were included. The patients included in this study were mostly graduates coming from urban areas and mostly unemployed. Maximum patients were also found to be pre-menopausal and hormonal receptor-positive. Breast cancer is more prevalent in the developed world, and the mortality rates in the developing world are comparatively higher.[6]

Breast cancer is mainly a pre-menopausal disease in developing countries; older women and those from lower socio-economic strata tolerated chemotherapy better. Analysis of QoL at baseline revealed better functional scores for women who were older, less educated, and economically backward. Working women had better scores. Cognitive impairment was also higher in post-menopausal and aged women (age > 50 years).

During treatment, there was a global deterioration of functional scores during chemotherapy and improvement during and after radiotherapy. This is similar to findings of other studies in breast cancer patients which showed a decrease in the physical, emotional role, and social function after completion of chemotherapy[7],[8] and good QoL scoring during radiotherapy indicating that it was well tolerated.[9] Studies have shown that fatigue, sleep disturbances, and pain were moderately intense during adjuvant treatments and decreased significantly over time.[9],[10],[11] Our patients had similar complaints with loss of appetite and nausea–vomiting ranking as one of the other major symptoms. Our study revealed that the systemic side effects or symptoms after administering chemotherapy were progressively increased during the period of six consecutive cycles; findings of which are quite different from the study conducted by Parmar et al.,[12] who observed that the symptoms were at the peak after the first cycle of chemotherapy and then decreased gradually after successive cycles of CT. Radiotherapy did not worsen physical QoL, and scores improve in patients during radiation. Radiotherapy-induced acute side effects are skin reactions, pharyngitis, laryngitis, and so on. Late complications such as subcutaneous skin thickening and arm edema are manageable. Arm edema is due to axillary lymph node dissection and also due to supra-clavicular and axillary radiotherapy. Arm edema can be managed with the arm raised, exercise, compression elastic bandage, and so on. Acute skin reactions such as erythema can alone be treated with antifungal hydrocortisone cream. Dry desquamation is usually managed with moisturizing cream along with vitamin A and D cream. In the case of wet desquamation area, zinc oxide and Bacitracin topical ointment are applied locally. Indian breast cancer patients have similar QoL issues concerning women elsewhere. Social, mental well-being, and sexual function were marginally worse in the breast conservation (BCS) group when compared with the mastectomy group.[13] In the BCS group, a post-lumpectomy mammogram should be routinely obtained to rule out residual microcalcification. Systemic therapy side effects were seen more in urban women than in rural women, possibly due to better education in urban women resulting in more self-esteem and self-care.[14]

The findings of the study showed that women, who were in the younger age group of 35–45 years old, experienced more nausea and vomiting worries, than the older age group. They also had more concerns in the aspects of body image and future health function than women who were 45 years old and above. Many younger women often have major concerns about getting married and having children in the future after going through various cancer interventions such as chemotherapy that may cause premature menopause and fertility loss. They are also worried about the possibility of cancer recurrence that may affect their health, families, work, and career. Hair loss was a major problem and accounted for worse socio-emotional scores in all women but more so in the young. We deliberately chose only those patients who had undergone upfront MRM. We have seen that mastectomy had a bad impact on patients’ body image perspective. Hence, decreased QoL due to depression of having a distorted feminine outlook is also having findings similar to other international studies.[15],[16] Our study has shown that the interest in sexual activity was greatly diminished after the third cycle of chemotherapy and all patients became sexually inactive after the sixth cycle of CT. However, at 6 months post-RT follow up, most of the pre-menopausal women regained their sexual activity, but post-menopausal women showed no interest in sexual activity even after the completion of treatment. After completion of chemotherapy, post-menopausal women were given aromatic inhibitors (1 mg of Anastrazole and 2.5 mg of Letrozole) and pre-menopausal survivors have given Tamoxifen tablets of 20 mg daily for 5 years based on their hormone-positive status. They reported symptoms such as hot flushes, amenorrhea, oligomenorrhea, or uterine bleeding. In our study, trastuzumab was used for patients with HER2/neu overexpression for 1 year in post-chemotherapy. Concurrent administration of trastuzumab with left-sided radiotherapy does not appear to increase cardiac toxicities. These symptoms did not have any significant impact on their socio-mental status and sexual function. The maximum number of patients taken in our study is from rural backgrounds. Mostly, they are unconcerned about their well-being and betterment of life in the future. Their life expectancy gets reduced due to this carelessness. On the contrary, Kuwaiti female breast cancer patients are more concerned about their body image and future perspective.[17] A study from Iran showed a statistically significant correlation between HADS scores with emotional functioning and global health scores.[18] Our study also corporates with impaired QoL in patients with worse psychological well-being (higher HADS scores).


  Conclusion Top


The QoL of the Indian women population differs from their western counterparts. So, it is necessary to study various factors affecting the QoL of Indian women. Based on different aspects of life, i.e., social, cultural, ethnic, economic, and so on, they vary widely among the Indian population. These patients greatly need proper awareness and support. Moreover, psychological counseling and adequate patient education are vital for patients newly diagnosed with breast cancer.


  Limitations Top


  1. OPD attendance was hindered by the COVID-19 pandemic and related complete lockdown during this period.


  2. Lack of dedicated surgical oncology unit unwillingly obscured patient’s outcome being a single institutional study; results derived cannot be extrapolated in the entire study.


  3. Detailed subgroup analysis was required for identifying risk factors in individual cancers.


Authors’ contributions

SKM: Concepts, design, literature search, data analysis, manuscript preparation. GKN: Design, literature search, data analysis, manuscript preparation. ARD: Design, literature search, manuscript preparation, data analysis, statistical analysis.

Acknowledgement

The authors were eternally grateful to (Prof) Dr. Partha Pratim Mukhopadhyay for guiding in ethical issues and logistic support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical consideration

Clearance/approval from the Institutional Ethics Committee of Malda Medical College, West Bengal University of Health Sciences, Malda, West Bengal, India was taken for the research protocol letter no. P/MLD-MC/-IEC22/12 dated 14.03.2022.



 
  References Top

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International Agency for Research on Cancer. GLOBOCAN 2020: The Global Cancer Observatory. Geneva: World Health Organization; 2021. Available from: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. [Last accessed on 10 July 2022].  Back to cited text no. 1
    
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Bahreinian A, Radmehr H, Mohammadi H, Mousavi MR The effectiveness of the spiritual treatment group in improving the quality of life and mental health in women with breast cancer. J Res Relig Health 2017;3:64-78.  Back to cited text no. 2
    
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Ibbotson T, Maguire P, Selby P, Priestman T, Wallace L Screening for anxiety and depression in cancer patients: The effects of disease and treatment. Eur J Cancer 1994;30A:37-40.  Back to cited text no. 3
    
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Kayser K, Scott JL Helping Couples Cope with Women’s Cancers: An Evidence-Based Approach for Practitioners. 1st ed. New York: Springer Science & Business Media; 2008.  Back to cited text no. 4
    
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Zigmond AS, Snaith RP The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 5
    
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Mackey J, Burford A, Sajun S, Pithers A Clinical implications of gene expression profiling in cancer. Asia Pac J Oncol Hematol 2009;1:13-23.  Back to cited text no. 6
    
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Chen Q, Li S, Wang M, Liu L, Chen G Health-related quality of life among women breast cancer patients in Eastern China. BioMed Res Int 2018;2018:1452635.  Back to cited text no. 7
    
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Gao F, Ng GY, Cheung YB, Thumboo J, Pang G, Koo WH, et al. The Singaporean English and Chinese versions of the Eq-5d achieved measurement equivalence in cancer patients. J Clin Epidemiol 2009;62:206-13.  Back to cited text no. 8
    
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Tan ML, Idris DB, Teo LW, Loh SY, Seow GC, Chia YY, et al. Validation of EORTC QLQ-C30 and QLQ-BR23 questionnaires in the measurement of quality of life of breast cancer patients in Singapore. Asia Pac J Oncol Nurs 2014;1:22-32.  Back to cited text no. 9
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Juan IA, Ana M, Miguel AD, Fernando A, Elena V, Pilar R, et al. Impact of radiotherapy on the quality of life of elderly patients with localized breast cancer. A prospective study. Clin Trans Oncol 2008;10:498-504.  Back to cited text no. 10
    
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Parmar V, Badwe RA, Hawaldar R, Rayabhattanavar S, Varghese A, Sharma R, et al. Validation of EORTC quality-of-life questionnaire in Indian women with operable breast cancer. Natl Med J India 2005;18:172-7.  Back to cited text no. 12
    
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Nasrin F, Farhad P, Hossein Ali-Mohammadi AM, Masumeh A, Effat M. Process of coping with mastectomy: A qualitative study in Iran. Asian Pac J Cancer Prev 2013;14:2079-84.  Back to cited text no. 15
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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