Introduction

Ovarian cancer accounts for most of the deaths from gynecologic cancers. Unfortunately, 60% or more of ovarian cancers are diagnosed in advanced stages. Only 15% diagnosed at an early stage, while the 5-year survival rate, in general, is only 46% (Bhoola & Hoskins, 2006). Most women are usually diagnosed in an advanced stage which can recur and the chance of cure with each recurrence is reduced. The women often present in advanced stages with compromised physical and emotional well being (Jelovac & Armstrong, 2011).

Ovarian cancer management normally includes radical pelvic surgery and multiple aggressive courses of chemotherapy. The trauma of being diagnosed with a life threatening illness, which is typically unexpected for many women, may be associated with insecurity and anxiety about the future resulting in an immediate threat to a woman's life and associated fear of death (Su, Graybill, & Zhu, 2013). Women also suffer disease-related symptoms and face difficulty in coping with them. Although advances in Medicine powered the development of new treatments for ovarian cancer, treatments have associated side effects and toxicities that may impact the quality of life of the women (Coleman, Monk, Sood, & Herzog, 2013). Undoubtedly, quality of life is an ultimate consideration for patients with ovarian cancer. Risks and benefits must be balanced while designing a treatment plan to achieve an optimal quality of life (Chie & Greimel, 2012).

A study reported that the women who underwent surgery had poor physical functioning, role limitations, pain, social and sexual functioning after the first month. However, most deficits resolved by 6 months, but the RRSO group still reported persistent menopausal complaints (Butt et al., 2008). Moreover, cancer related fatigue (CRF) has been identified in the ovarian cancer population. It is a symptom that appears to affect women across all stages and influences other factors involved in general quality of life, including social or functional well being (Holzner, 2003).

Ovarian Cancer is one of the major present public health dilemma faced by Pakistan. Highest rates of breast and ovarian cancer have been reported in Pakistan among Asian countries, with the former being the most common and ovarian the third most common malignancy among Pakistani women (Rashid, 2006). Ovarian cancer is the most common cancer of gynecological origin in Pakistan. Its incidence is increasing at an alarming rate, with nearly 13.6 percent of the women suffering from this cancer, while 70 percent of the cases are diagnosed at later stages, making it highly difficult for the healthcare providers to treat the deadly disease (Kulhánová et al., 2020).

Effective screening programs and/or individual tests have yet to be clearly defined. Although ovarian cancer is most often fatal, it is relatively rare compared with other cancers in women, such as breast or lung, which feasibly makes ovarian cancer screening trials expensive and less effective.

Although quality of life measurement in clinical trials evaluating therapeutic options for ovarian cancer is common, but its use in the screening literature is limited, especially in developing countries, including Pakistan (Au et al., 2010). Quality of life evaluation is a valuable measure in optimizing care of patients with ovarian cancer, but more research is required to make such evaluations suitably inexpensive and easy to perform so that they can be more fully incorporated into general oncologic practice. Thus, the present study was designed to assess the quality of life among ovarian cancer patients in Pakistan.

Methodology

A descriptive cross-sectional study design was used to assess health-related quality of life among ovarian cancer patients in twin cities (Islamabad and Rawalpindi) of Pakistan. Study approval was taken from the Ethical Committee of Hamdard University (BASR-82-5.8). All health care facilities, both from the public and private sector treating ovarian cancer patients located in twin cities, were included in the study. Study respondents included patients diagnosed with ovarian cancer aged between 18-65, having any comorbidity and patients receiving chemotherapy, radiotherapy and/or surgery.

All cancer patients other than ovarian cancer and those below or above the age range of 18-65 were excluded. Approval was also taken from Medical superintendents of different healthcare facilities of Rawalpindi and Islamabad. Patients were briefed regarding the nature and objectives of the study. Verbal and written consent was obtained before data collection. Respondents were ensured of the confidentiality of their responses along with full right to withdraw from the study at any time.

The sample size was calculated using Rao soft at a 95% confidence interval and 5% margin of error, which came to be 383. The convenience sampling technique was used to select respondents available and willing to participate at the time of data collection. Prospective data were collected from primary sources by self-administering a pre validated questionnaire, i.e. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-Ov-28). The questionnaire was filled by the patients on the spot and collected back on the same day to avoid biasness.

The EORTC QLQ-OV28 was originated to supplement the EORTC QLQ-C30 for the precise assessment quality of life of ovarian cancer patients. The questionnaire comprises 28 items which have been divided into seven domains, which include assessing symptoms related to the abdomen and gastrointestinal, peripheral neuropathy, side effects related to chemotherapy, 19 symptoms related to menopause and hormonal issues, body image, disease and treatment attitude and sexual function. Pilot testing was performed on 10% of the sample size for assessing the reliability of the tool. The value of Cronbach's alpha for EORTC QLQ-OV28 was 0.72. After data collection, data was cleaned, coded and entered in SPSS. Descriptive statistics comprising of frequency and percentages were calculated. Univariate analysis was performed to find out the differences among different variables.

Results

Demographic Characteristics

Of the total respondents, 72.8 % (n = 280) of the women were having a family history of breast or ovarian cancer. The most common age groups prevalent with ovarian cancer were: 40-49 years (n = 143, 35 %) and 29-39 years (n = 129, 33.7 %). More than half of the women, 56.6 % (n = 216), were obese and 60.6 % (n = 232) were having hormonal issues along with the irregular menstrual cycle. Out of 383 respondents, 71.5% (n=274) were married and 23.2% (n=89) were single. Regarding the type of treatment patients treating through medications, More than half of the patients (66.1%, n=253) were on medications while 19.6% (n=75) received surgery (Table 1).

Quality of Life among Ovarian Cancer Patients in Pakistan

The results highlighted that the lowest scores for EORTC-QLQ-OV 28 were observed in the domain of hormonal problems (15.21, ± 21.983) followed by peripheral neuropathy (17.07, ± 19.287), whereas the highest scores were observed in the domain of attitude to disease or treatment (6.06, ± 26.873). A detailed description is given in (Table 2).

Comparison of Quality of Life among Ovarian Cancer Patients by Demographic Characteristics

Univariate analysis was conducted comparing the symptom and functioning scales with clinical factors such as age, obesity, setting, hormonal issue, family history, and marital status. The results of the current study highlighted a significant difference (p ≥ 0.05) in the quality of life of women with respect to all of the indicators. Abdominal symptoms were relatively less among non-obese and women from a rural setting. On the other hand, young women had better peripheral neuropathy, hormonal problems and side effects while unmarried patients had relatively poor quality of life in terms of body image, peripheral neuropathy and attitude towards the disease. Moreover, patients from rural settings had a relatively better quality of life in peripheral neuropathy, body image and abdominal GI. Furthermore, patients with a history of hormonal issues had a relatively poor quality of life (Table 3).

Discussion

Women diagnosed with ovarian cancer may be met with significant and often sudden disruption to their everyday wellbeing. Unfortunately, it is common to experience multiple recurrences throughout the progression of the disease. It is important to recognize that diagnosis of ovarian cancer and subsequent treatment may adversely influence a woman's life, both as a sole individual as well in terms of the multiple roles she may play in the lives of others. Quality of life is an important factor leading towards patients overall satisfaction with their health and life (Sun, Ramirez, & Bodurka, 2007).

The present study reported poor quality of life among ovarian cancer women. Lowest quality of life score was observed in hormonal problems followed by peripheral neuropathy, whereas the attitude to disease or treatment was found positive. The overall quality of life was found poor among unmarried single, which might be due to decreased support and increased societal pressure. These findings are consistent with studies conducted in Korea which reported that unmarried women had low quality of life as compared to married women who received more support women (Özaras & Özyurda, 2010).

The results of the current study revealed that overall quality of life was relatively better among women from rural areas, which might be due to increased physical activity and healthy diet patterns. However, sexual functioning and fertility were affected among them, which might be due to unawareness regarding reproductive health and access to better healthcare facilities. These findings are in concordance with findings from Turkey, which reported gynaecological problems had a negative impact on sexual functioning and fertility (Pinheiro et al., 2010). The results of the present study reported low quality of life among women in the age group of 50 years and above, which might be due to unhealthy dietary pattern and decreased physical activity. Similar findings were supported by a study conducted in the UK (Teng, Kalloger, Brotto, & McAlpine, 2014). The results of the present study reported that married women with no children had poor quality of life in terms of sexuality. Similar findings were reported from a study conducted in Iran which stated that infertile women had a comparatively low quality of life (Bazarganipour, Ziaei, Montazeri, Foroozanfard, & Faghihzadeh, 2013).

Moreover, the results of the present study reported low quality of life among obese, those having no family history of cancer and women with a history of hormonal issues along with the irregular menstrual cycle. This might be due to poor health promoting lifestyle behavior among patients. This might be due to a lack of awareness regarding women reproductive health, as discussion regarding the gynecological problem is considered a social taboo due to cultural and religious beliefs in Pakistan. Similar findings were reported from a study that identified obesity, family history and hormonal issues as important predictors of quality of life among women with ovarian cancer (Salehi, Dunfield, Phillips, Krewski, & Vanderhyden, 2008).

Conclusions

The results of the present study concluded poor quality of life among women with ovarian cancer in Pakistan. Lowest quality of life score was observed in hormonal problems followed by peripheral neuropathy, whereas the attitude to disease or treatment was found positive. Cancer care should be extended beyond primary treatment to include long-term care that addresses physical, psychosocial, and emotional factors that influence survivor’s quality of life throughout their lifetime. Support and appropriate interventions can not only improve the perspectives of patients and their families but may also affect an individual's overall survival. Therefore, quality of life must be focused as the main indicator for developing appropriate policy and interventions addressing the poor health of women in Pakistan.

Funding Support

The authors declare that they have no funding support for this study.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.