EuroQoL-Visual Analog Scale as a Tool for Assessing Health Status in Breast Cancer Patients: A Cross-sectional Study

ABSTRACT

Introduction:

Breast cancer significantly influences women’s health and overall well-being, necessitating comprehensive assessments to guide effective supportive care during cancer treatment. This study utilizes the EuroQoL-Visual Analog Scale (EQ-VAS) to systematically evaluate the health status and quality of life in women undergoing treatment for breast cancer.

Materials and Methods:

A study was conducted on a sample of 100 patients with breast cancer who were treated at a tertiary care hospital in New Delhi. The EQ-VAS, a part of the EuroQoL five-dimension instrument, was used to evaluate the participants. It measures the participants’ self-rated health on a vertical visual analog scale, with 0 representing the worst possible health and 100 representing the best health.

Results:

The participants’ mean EQ-VAS score was 46.95 (standard deviation = 9.4), which denotes low self-perceived health. There were notable differences in EQ-VAS ratings between the various stages of breast cancer, with advanced stages exhibiting lower scores. Patients who underwent surgery for breast cancer were reported with high EQ-VAS scores (52.00 ± 16.71).

Conclusion:

The results emphasize the different health experiences of women suffering from breast cancer and the value of individualized care programs during cancer care. The EQ-VAS has shown to be a valuable instrument for gathering patient self-perceived health status, providing important information for healthcare professionals to improve supportive care and the overall health of women struggling with breast cancer.

INTRODUCTION

Breast cancer is the most common type of cancer among women globally, posing significant challenges not only in terms of mortality but also significantly impacting their physical, emotional, and social well-being. Breast cancer incidence is rising in India. With an anticipated 162,500 new cases and 87,000 deaths from breast cancer observed in India in 2018 and 90,408 deaths in 2020, India ranked highest in the number of estimated breast cancer deaths, 98,337 for the year 2022. The country urgently needs comprehensive cancer treatment plans.[1,2,3]

The complexity of breast cancer treatment, which includes surgery, chemotherapy, radiation, and hormonal therapies, often leads to substantial physical and psychological distress for patients. Therefore, assessing the quality of life (QoL) and overall health status of women undergoing treatment is essential to provide individualized care interventions.

Assessing the Health-related QoL (HRQoL) has become a crucial part of cancer therapy because it provides valuable insights into the impact of the disease and its treatment from the patient’s perspective.[4] We have used the EuroQoL-Visual Analog Scale (EQ-VAS) to assess the health status of breast cancer women in our study. EQ-VAS, a component of the EuroQoL five dimension (EQ-5D) instrument, is extensively used to measure patients’ self-perceived health status on a scale from 0 to 100 (EuroQoL Group, 1990) with higher scores indicating better health.[5]

This simple yet effective tool facilitates assessing patients’ overall health and directs clinical decision-making and supportive care interventions.[6] Although there is a growing recognition of the importance of HRQoL assessments in breast cancer management, limited research has focused on this aspect within the Indian context.

The objective of this research is to evaluate HRQoL in breast cancer patients by employing the EQ-VAS scale. Conducted in a tertiary care hospital in New Delhi with 100 participants, it evaluates how age, stage of breast cancer, and treatment type influence self-perceived health status. The findings of this study provide insights into the physical and mental well-being of Indian women with breast cancer which will help in developing personalized patient care, support strategies and ultimately improving treatment outcomes.

MATERIALS AND METHODS

A cross-sectional study using the EQ-VAS scale was carried out to evaluate the health and well-being of women battling breast cancer. One hundred patients were interviewed at a tertiary care hospital in New Delhi from January to March 2024.

Our study included women diagnosed with breast cancer, aged 18 and above, who were undergoing treatment at the tertiary care hospital. Written informed consent was collected from every participant. All females over 18 years of age coming to the hospital with invasive breast cancer were included in the study. Patients who had (i) a recurrence of breast cancer, (ii) a history of mental illness before cancer diagnosis, or (iii) those who had other cancers in addition to breast cancers were excluded from the study.

Data were collected using EQ-VAS, part of the EQ-5D instrument developed by the EuroQol Group.[5] The EQ-VAS is a self-reported measure of health status, in which patients rate their health on a scale from 0 (the worst imaginable health) to 100 (the best imaginable health). In addition, demographic and clinical data, including age, cancer stage, type of treatment, and duration of illness, were collected through questionnaires, patient interviews, and medical records. The treatment given to the patients was divided into four groups: Group A (Chemotherapy), Group B (Surgery), Group C (Surgery, Chemotherapy and Radiotherapy), and Group D (Surgery and Chemotherapy).

Patients were approached during their routine hospital visits. EQ-VAS Integrated with the questionnaire was handed over to participants, and data was collected from them. The researcher read and explained the questions to patients who had difficulty comprehending them and recorded their responses. The procedure ensured minimal disruption to patients’ treatment schedules.

Statistical analysis

Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were employed to summarize demographic and clinical traits. Average EQ-VAS scores were determined to explore how these scores varied based on demographic and clinical characteristics. A multiple regression analysis was carried out to identify factors influencing the health status of the patients. P < 0.05 was considered statistically significant.

RESULTS

The study included 100 women with breast cancer, with a mean age of 53.05 years (standard deviation [SD] =9.71). Thirty-seven percent of participants were in the < 50 years age group, 33% in the 50–59 age group, and 30% in the 60–69 age group. No patient in our study was above 70 years of age. Most (42%) patients who were diagnosed to have breast cancer had Stage II breast cancer. The percentage of patients diagnosed as Stage I, III, and IV were 10%, 34%, and 14%, respectively. The majority (54%) were undergoing treatment that combines surgery, chemotherapy, and radiotherapy (Group C), followed by patients (34%) who were given a combination treatment of surgery and chemotherapy (Group D), patients (10%) who underwent treatment Group A (chemotherapy only), and finally, patients who underwent only surgery (Group B) were 4%. The demographic and clinical characteristics of patients have been depicted in Table 1.

Table 1.

Demographic and clinical characteristics of patients

Characteristics	Frequency (n=100)
Age group (years), mean age	53.05±9.71
<50	37
50–59	33
60–69	30
70 and above	0
Stages of cancer
Stage I	10
Stage II	42
Stage III	34
Stage IV	14
Type of treatment
Chemotherapy (Group A)	10
Surgery (Group B)	4
Surgery, chemotherapy, and radiotherapy (Group C)	54
Surgery and chemotherapy (Group D)	32

The mean EQ-VAS score for the sample was 46.95 (SD ± 9.4), indicating a low level of self-perceived health. Scores ranged from 42 to 55 during analysis, with higher scores observed in younger patients and patients with Stage II and III breast cancer. Patients of Stage IV had lowest self-perceived health status whereas patients of Stage III had highest self-perceived health status closely followed by Stage II patients. Patients undergoing treatment in Group A and Group C reported low mean scores (45.36 and 45.83 respectively) compared to Group D (47.17) and Group B (52.00), with significant differences (P < 0.05). Patients undergoing treatment Group B had highest self-perceived health status followed by treatment Group D. EQ VAS scores for different age groups, stages, and treatment groups have been enumerated in Table 2.

Table 2.

EuroQoL-Visual Analog Scale scores by demographic and clinical variables

Variable	Mean EQ-VAS score ± SD	P
Overall	46.95±9.4
Age group (years)
<50	50.8±8.3	<0.05
50–59	45.8±9.8
60–69	42.2±10.1
Stages of cancer
Stage I	42.20±6.37	<0.01
Stage II	46.36±6.69
Stage III	47.32±11.31
Stage IV	41.36±6.18
Type of treatment
Chemotherapy (Group A)	45.36±2.76	<0.01
Surgery (Group B)	52.00±16.71
Surgery, chemotherapy, and radiotherapy (Group C)	45.83±1.47
Surgery and chemotherapy (Group D)	47.17±10.62

SD: Standard deviation, EQ-VAS: EuroQoL-Visual Analog Scale

Multiple regression analysis [enumerated in Table 3] was conducted to evaluate the effect of age, cancer stages, and types of treatment on the health status of breast cancer patients. Age was found to be a significant predictor of patient health status across all age groups. Patients under 50 years demonstrated the highest regression coefficient, 23.92 (standard error [SE] =1.01, P < 0.01), indicating a stronger positive association with better health status than older age groups. The coefficient for patients aged 50–59 years was slightly lower at 21.48 (SE = 0.98, P < 0.01), while patients aged 60–69 years had the lowest coefficient, 16.34 (SE = 0.83, P < 0.01). All age groups were significantly associated with EQ-VAS scores, suggesting that younger patients experienced more favorable health status.

Table 3.

Predictors of EuroQoL-Visual Analog Scale scores (multiple regression analysis)

Predictor	Regression coefficient	SE	P
Age (years)
<50	23.92	1.01	<0.01
50–59	21.48	0.98	<0.01
60–69	16.34	0.83	<0.01
Stages of cancer
I	30.14	1.71	<0.05
II	17.92	0.89	<0.01
III	10.69	0.45	<0.01
IV	7.47	3.42	>0.05
Type of treatment
Chemotherapy (Group A)	6.08	0.27	<0.01
Surgery (Group B)	32.13	1.67	>0.05
Surgery, chemotherapy, and radiotherapy (Group C)	3.21	0.14	<0.01
Surgery and chemotherapy (Group D)	22.53	1.06	<0.01

SE: Standard error

The stage of cancer was another significant predictor of QoL. Patients in Stage I exhibited the highest positive impact on health status, with a regression coefficient of 30.14 (SE = 1.71, P < 0.05). Stage II patients showed a moderate effect, with a coefficient of 17.92 (SE = 0.89, P < 0.01). Stage III patients demonstrated a further reduction in EQ-VAS scores, with a coefficient of 10.69 (SE = 0.45, P < 0.01). However, for Stage IV patients, the impact was much lower and not statistically significant, with a coefficient of 7.47 (SE = 3.42, P > 0.05), indicating a diminished or negligible influence on health status.

Different treatment modalities also affect patient health status. Chemotherapy alone was associated with a regression coefficient of 6.08 (SE = 0.27, P < 0.01), indicating a modest but statistically significant effect. In contrast, surgery alone had the highest regression coefficient of 32.13 (SE = 1.67), though it was not statistically significant (P > 0.05). The combination of surgery, chemotherapy, and radiotherapy yielded an important but smaller effect, with a coefficient of 3.21 (SE = 0.14, P < 0.01). Patients who underwent surgery and chemotherapy together showed a stronger association with EQ-VAS scores, with a regression coefficient of 22.53 (SE = 1.06, P < 0.01), suggesting this combination had a more favorable impact on patient health status outcomes compared to other treatments.

DISCUSSION

This cross-sectional study evaluated the health condition of 100 patients with breast cancer using the EQ-VAS, examining how different factors such as age, cancer stage, and treatment type influenced their scores. The results offer insightful information about how these variables relate to patients’ perceptions of their health and can guide tailored therapies to enhance their QoL.

The EQ-VAS scores showed considerable age-group variation. Compared to older age groups, patients under 50 had the highest mean EQ-VAS score (50.8 ± 8.3), indicating higher subjective health status. As age increased, the scores declined, with the group aged 60–69 having the lowest mean score (42.2 ± 10.1). Age appears to significantly impact EQ-VAS ratings, as indicated by the (P < 0.05). This result is consistent with research conducted by Torres et al., which found that younger breast cancer patients had higher EQ-VAS scores.[7] A study by Zrubka et al. found that EQ-VAS scores decline linearly with age. For ages 30, 40, 50, 60, 70, and 80 years, the mean EQ-VAS scores observed in the studies were 93, 87, 80, 73, 65, and 57, respectively.[8] These results are corroborated by two different studies that emphasize the effect of age on the health status of breast cancer patients.[9,10] This pattern of younger patients reporting better-perceived health aligns with findings in other studies, such as Kimman et al., where breast cancer survivors under 50 years similarly reported higher health status.[11]

In addition, our study found notable variations in EQ-VAS ratings amongst cancer stages. Patients in Stages II and III had higher EQ-VAS scores (46.36 and 47.32, respectively) compared to Stage I (42.0), while Stage IV had lower EQ-VAS scores (P < 0.01).

A study by Mokhtari-Hessari and Montazeri observed that Stage II patients had a mean EQ-VAS score of 58.12 ± 11.03, while Stage III patients reported a score of 60.25 ± 13.78, both significantly higher than Stage I patients (51.45 ± 9.67, P < 0.05). However, in their study, Stage IV patients had a lower score (48.65 ± 15.12, P < 0.05), which is similar to our findings where Stage IV patients were also observed to have lower EQ VAS scores.[12] Another study by Kimman et al. was done on 765 breast cancer patients in which they observed that EQ-VAS scores for Stage II and III patients were significantly higher than for Stage I patients (P < 0.01), with a mean score of 56.34 ± 10.92 for Stage II and 59.10 ± 11.55 for Stage III. However, Stage IV patients reported an average score of 41.72 ± 8.64, markedly lower than earlier stages and with a significant difference (P < 0.01).[11] This contrast may suggest that the QoL in Stage IV is worse among all stages in breast cancer patients.

The types of treatment received by the patient may affect the QoL and health status of the patient. In our study, patients undergoing surgery alone had the highest mean EQ-VAS score (52.00 ± 16.71) as compared to all other treatment groups. Patients receiving combination therapies and chemotherapy alone had significantly lower EQ-VAS scores. A study done by Kim et al. showed that patients undergoing chemotherapy reported significantly lower EQ-VAS scores (45.3 ± 8.7) compared to those undergoing surgery alone (52.1 ± 7.9).[13] Another study by Torres et al. on 562 breast cancer patients found that those receiving combination therapies reported significantly lower EQ-VAS scores (44.95 ± 9.38) than those who had surgery alone (53.18 ± 10.27). In their study, patients undergoing chemotherapy alone had a mean score of 47.63 ± 12.09, highlighting the significant negative impact of chemotherapy on perceived health and QoL.[7] Similar findings were observed by Kimman et al. in their study. They also reported significantly higher EQ-VAS scores for patients receiving surgery alone (54.28 ± 11.06) than those undergoing combination treatments (43.91 ± 10.99) and chemotherapy alone (46.52 ± 9.63).[11]

One significant limitation of our study is the relatively small sample size of 100 patients and being a single-center study. This may have introduced selection bias and limited the generalizability of our findings. Future research should aim to include larger, more diverse populations to explore the relationship between age and health status in breast cancer patients more comprehensively.

The significant variation in EQ-VAS scores across age groups underscores the need for age-sensitive therapeutic interventions, especially for older patients who may perceive their health status worse than the younger patients, more so in the advanced stages of cancer. The observed higher EQ-VAS scores in patients with Stage II and III breast cancer invites further investigation into the psychological factors and coping mechanisms that may influence lower QoL in Stage I and IV patients.

The impact of treatment modalities on EQ-VAS scores stresses the profound effect of chemotherapy on patient’s QoL, particularly in comparison to patients undergoing only surgery. Our findings confirm that combined treatments, especially the ones including chemotherapy, tend to result in lower perceived health status. These results highlight the importance of integrating supportive care interventions to mitigate the adverse effects of intensive treatments on patients’ overall well-being.

CONCLUSION

This study underscores the importance of age, stage, and type of treatment when assessing the health status of breast cancer patients. It also highlights the significance of incorporating HRQoL assessments in routine cancer care in India in addition to the routine treatment protocols in all the stages of cancer. EQ-VAS is a valuable tool in assessing HRQoL and can guide tailored patient care. This study found that younger patients perceive their health more positively, possibly due to better resilience and faster recovery. Older patients may require additional psychological and physical support during treatment. Notably, the higher EQ-VAS scores observed in advanced and early cancer stages and the differential impact of treatment modalities call for further investigations to understand the underlying mechanisms of ill-perceived QoL. Exploring these patterns in greater depth could guide the development of targeted, evidence-based interventions aimed at improving patient-reported health perceptions and QoL for holistic cancer care. Supportive measures such as mental health counseling, nutritional support, and pain management should be integrated into breast cancer treatment programs. Future research should focus on these critical areas to refine personalized treatment strategies and improve patient outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.