Quality of life in women with breast cancer treated at a radiotherapy centre in Caruaru, Pernambuco, Brazil

Abstract

Objective

To evaluate the quality of life (QOL) of patients with breast cancer undergoing radiotherapy treatment.

Methods

The current study is a descriptive quantitative approach that seeks to identify the QOL of breast cancer patients during their radiotherapy treatment. A convenience sample of 30 women undergoing radiotherapy for breast cancer completed the EORTC QLQC30 questionnaire on Day 1 and Day 28.

Results

Results showed significant differences in QOL between the two sessions. Decreases in overall health (88.33 to 61.67) and functional health (76.45 to 67.77) were noted in parallel to an increase in the scale of symptoms (13.85 for 24.62).

Conclusions

The radiotherapeutic treatment impacts the QOL of patients with breast cancer. It is crucial for the nursing team to work together with a multi-professional team to adequately manage the treatment of these patients adequately.

INTRODUCTION

According to Araújo and Galvão (2010), cancer is one of the most feared pathologies in the world and, depending on the type, treatment is not always 100% effective. In Brazil, cancer is the second cause of death, losing only to deaths due to cardiovascular diseases (Malta et al., 2017). It is estimated that worldwide cancer will kill a total of 9.6 million people annually and be responsible for 53% of deaths (Bray et al., 2018).

According to the Ministry of Health Ordinance No. 741/2005 (Brazil, 2005), the Brazilian Unified Health System (Sistema Único de Saúde - SUS) must guarantee the following services for all diagnoses and treatment of cancer: Oncologic Surgery Services, Clinical Oncology, Radiotherapy, Hematology, and Pediatric Oncology in High Complexity Oncology Unit.

Radiation therapy uses high-energy ionizing rays or particles that eliminate malignant cells in the irradiated regions (Linard, Silva, & Silva, 2002). With the technical evolution of radiotherapy, it is possible to administer a higher concentration of radiation in the area to be treated and, at the same time, show a decrease in the concentrations of doses in the surrounding healthy tissues. This promotes the possibility to a greater potentiation in the control of the disease, while reducing the complications that could appear during the treatment (BMA, 2014).

QOL is defined as the individual’s perception of their position in life, in the context of the culture and value systems in which they live, and their goals, expectations, standards, and concerns (Group, 1995). A better understanding of the elements that compose this perception can help the health professional to define interventions that contemplate the integrality of the patient and not be restricted to the approach of disease and treatment. The advantages and disadvantages of treatment can be recognized through the assessment of the QOL of patients undergoing radiotherapy treatment, which is done by specific instruments. An example of such an instrument is the European Organization for Research and Treatment of Cancer Quality Life Questionnaire (EORTC QLQ) developed by the European Organization (Fayers et al., 2001).

The EORTC QLQ-C30 is a questionnaire for assessing the QOL of cancer patients, structured with 30 questions. It was designed to be supplemented by additional modules assessing QOL aspects specific to particular patient groups. The EORTC QLQ BR -23 is a specific questionnaire for patients with breast cancer (Fayers et al., 2001).

With the type of complications that might arise from breast cancer and the complexity of its treatment, radiotherapy may interfere directly and negatively on the QOL of women with breast cancer. Given the large number of women who may be diagnosed with cancer and the possibility of some patients evolving to therapeutically uncontrollable stages, this research attempted to identify factors that may be associated with the improvement or worsening of the QOL of breast cancer patients undergoing radiotherapy.

METHODS AND MATERIALS

The current study used a descriptive quantitative approach that seeks to identify the QOL of patients with breast cancer during their radiotherapy treatment. The study was performed in a hospital specialized in the breast cancer treatment using radiotherapy, agreed to by the Sistema Único de Saúde (SUS), and located in the city of Caruaru in the state of Pernambuco, Brazil.

The study was carried out with women diagnosed with breast cancer who underwent treatment at the cancer specialist hospital. Sampling was non-probabilistic and convenience, which, according to Fontelles et al. (2010), is used when the researcher does not know what the probability is of an element of the population belonging to the sample. Therefore, the sample results cannot be statistically generalized for the population because the sampling error cannot be estimated. If the characteristics of the accessible population are similar to those of the target population, the results may be equivalent to those of a probabilistic sampling, but we cannot guarantee their reliability.

The inclusion criteria included women with a diagnosis of breast cancer, older than 18, who could read, who were undergoing exclusive radiotherapy, and who agreed to participate in the research. At Time 1, patients were in their first session of radiation treatment, and at Time 2 they were in the 28th session of treatment. Exclusion criteria included patients receiving palliative radiotherapy, who were undergoing chemotherapy treatment concomitantly with radiotherapy, who could not understand or articulate answers related to the study implementation (i.e., neurological deficit, coma, or impossibility of associating questions with coherent answers), and men with a breast cancer diagnosis.

The data were collected between August and December 2017 using three research instruments in two stages. Data collection was performed during the treatment day, previously scheduled with professionals from the radiotherapy sector. First, a review of patients who would receive radiotherapy on the day and who met the research inclusion criteria was carried out. After this step, the patients were approached during the nursing consultation about the objective of the research. The risks for the patient in participating in the study were explained, and the Informed Consent Form was signed. After signing the consent form, the patient was interviewed. In the first stage, a semi-structured questionnaire was used, which had been adapted from a questionnaire applied by Marques (2006) from the inclusion of questions focused on radiotherapy (Table 1). This instrument included socio-demographic, clinical, and therapeutic variables, as well as data related to the characterization of the research participant (i.e., gender, age, race, level of education, type of housing, wage income, etc.). Two other instruments were used to analyze the QOL of cancer patients: 1) the European Organization for Research and Treatment of Cancer Quality Life Questionnaire C30 (EORTC QLQ-C30) version 3.0 in Portuguese, and 2) the EORTC QLQ BR-23, which is specific for patients with breast cancer. These instruments were applied by the main researcher during an interview on the 1st and 28th sessions of radiotherapy.

Table 1.

Questions addressed in the sociodemographic questionnaire

Variables	Options
Gender	(1) Male (2) Female
Age	(1) Up to 45 (2) 46–55 (3) 56–65 (4) 66–75 (5) 76–81
Race	(1) White (2) Black (3) Yellow (4) Brown (5) Indigenous
Marital Status	(1) Married (2) Single (3) Widowed (4) Separated
Education	(1) Illiterate (2) Incomplete Primary Education (3) Complete Primary Education (4) Incomplete High School (5) Complete High School (6) Incomplete Higher Education (7) Complete Higher Education (8) Post-Graduate
Current occupation	(1) Retired (2) Unemployed (3) Worker with employment relationship (4) Self-employed (5) Household (6) Other
Monthly Salary Income	(1) Less than 1 minimum wage (2) From 1 to 3 minimum wages (3) From 3 to 5 minimum wages (4) From 5 to 10 minimum wages (5) More than 10 minimum wages
Religion	(1) Catholic (2) Protestant/Evangelical (3) Spiritist (4) Afro-Brazilian (5) Buddhist/Oriental (6) Other (7) None
Type of residence	(1) Own (2) Rented (3) Provided (4) Other
Lives with	(1) Alone (2) Only with spouse (3) Only with child(ren) (4) With spouse and child(ren) (5) Friend(s) (6) Father and/or mother (7) Another family member(s)
How did you discover the disease?	(1) Felt unwell (2) Routine medical examination (3) Selfexamination (4) Other
Do you use any oral medication?	(1) Yes (2) No
Did you miss any appointments/radiotherapy sessions?	(1) Yes (2) No
What kind of complementary treatment to radiotherapy did you do?	(1) Chemotherapy (2) Surgery (3) Hormone therapy (4) Immunotherapy
Do you use any substance in the place that is receiving the radiation?	(1) Yes (2) No
According to the previous question, if you answered yes, which substance?	(1) Ointment (2) Home remedies, teas (3) Cold water (4) Hot water (5) Sunscreen (6) Prescribed by a health care professional (7) Other

Source: Adapted from Marques (2006)

The EORTC QLQ-C30 questionnaire aims to evaluate the QOL of cancer patients. It presents 30 questions, which are divided into three scales: Overall health (focus on aspects of general health and QOL); Functional (focus on physical, emotional, cognitive, functional, and social aspects); Symptoms (focus on issues about fatigue, pain, insomnia, motion sickness, and other symptoms). The responses are presented as a Likert scale with the following score: 1 – not at all, 2 – a little, 3 – quite a bit, and 4 – very much. The overall health scale is composed of two questions related to general health and QOL in the last week, indicating a score from 1 to 7, in which 1 is bad, and 7 is optimal.

The EORTC QLQ-BR23 is a specific questionnaire for patients with breast cancer. It contains 23 questions assessing functional QOL, (body image, sexual function, sexual satisfaction, and future perspectives) and symptoms (side effects of systemic therapy, breast symptoms, arm symptoms, and hair loss). All 23 questions are in the Likert style, in which responses follow the same pattern as the EORTC QLQ-C30 questionnaire.

The data were tabulated in a Microsoft® Excel spreadsheet program. Sociodemographic data were evaluated through descriptive analysis of the variables, where percentage frequencies were calculated, and the respective frequency distributions determined.

The EORTC QLQ-C30 and EORTC QLQ BR-23 questionnaires were analyzed according to the guidance of the European Organization for Research and Treatment of Cancer (Fontelles et al., 2010), in which the scores for each scale ranged from 0 to 100. In the Overall Health and Functional scales, the higher total scores showed the patient is closer to healthy levels of QOL. Regarding the scale for symptoms, the higher scores indicated the patient’s impairment was greater. Data were treated statistically in Excel and after analysis were presented descriptively, through tables with percentages.

Ethics approval and consent to participate

All procedures involving human participants were conducted under an approved protocol and in accordance with the ethical standards of the institutional research committee of the Caruaruense Association of Higher Education and Technical (Approval No. 70232217.0.0000.5203).

RESULTS

Demographic characteristics and clinical variables

We identified 37 eligible patients during the study period, but five refused to participate in the research because of being in pain and unable to answer the questionnaires. Another two patients participated in the interview in the first radiotherapy session, but did not attend the interview during the 28th session. As a result, 30 women with breast cancer who underwent radiotherapy during the period of data collection were included in our study. Table 2 shows the sociodemographic data collected from the study patients.

Table 2.

Sociodemographic profile of study patients (N=30)

Variables (options)	%
Age group (years)
Up to 45	10
46–55	20
56–65	20
66–75	40
76–81	10
Race
White	20
Non-white	80
Marital status
Single	10
Married	40
Widow	40
Education
Illiterate	30
Incomplete primary education	70
Occupation
Retired	20
Freelancer	20
Farmer	20
From home	20
Pensioner	10
Unemployed	10
Monthly salary income (U$ 283)
Less than 1 minimum wage	20
1 to 3 minimum salaries	80
How did you discover the disease?
Routine medical examination	20
Self-examination	80
Did you miss any appointments/radiotherapy sessions?
Yes	0
No	100
What kind of complementary treatment to radiotherapy did you do?
Chemotherapy	70
Surgery	30
Do you use any substance in the place that is receiving the radiation?
Yes	0
No	100

Eighty percent of the patients were between the ages of 43 and 81 years. Forty percent of the women were married, 40% were widows, 10% were single, and 10% did not report their marital status. Regarding education, there is a predominance of patients with incomplete primary education (80%). The distribution of occupation was homogeneous, with 90% having a job that was their main source of financing to support the family. Concerning monthly income, 80% of the women received from one to three minimum wages. Minimum wage in Brazil refers to the lowest monetary payment, defined by law, that a worker must receive for their services (ILO, 2017). At the time of the survey, this amount was R$ 937.00 (US$ 283) per month.

Regarding clinical variables, 80% of the patients reported they discovered breast cancer through breast self-examination, while 20% discovered it when a routine clinical examination was performed. All patients reported following radiotherapy treatment regularly without missing any of the scheduled sessions. As for other treatments, 70% reported having undergone chemotherapy before starting radiotherapy, while 30% had undergone a surgical procedure. We also questioned patients about the use of topical medications on the place where the radiation was given. A hundred percent of the patients reported not using any topical substance in the area of the skin where the radiation was performed (Table 2).

According to the data on the QOL questionnaire, 80% of the patients scored 6 and above on the overall health scale in their first session of radiotherapy. When questioned in the 28th session, a drop was observed with only 50% scoring 6 and above (Table 3).

Table 3.

Percentage of patients (N=30) responding to the questions that composed the Overall Health scale of the EORTC questionnaire QLQ-C30

	% Answering / Radiotherapy Section Rating of 1 = poor/7 = optimal
	1st								28th
Question	1	2	3	4	5	6	7	Total	1	2	3	4	5	6	7	Total
29-How would you rate your overall health during the past week?	0	0	0	10	10	20	60	100	0	10	10	20	10	30	20	100
30-How would you rate your overall quality of life during the past week?	0	0	0	10	10	20	60	100	10	0	30	10	10	30	10	100

Regarding the physical aspects, patients presented better conditions in the first session of radiotherapy for several questions. In the first session, 80% reported they did not have difficulty with #5 (Do you need help with eating, dressing, washing yourself or using the toilet?), and #26 (Has your physical condition or medical treatment interfered with your family life?); 70% did not have difficulty with #7 (Were you limited in pursuing your hobbies or other leisure time activities?). This was contrary to the 28th session where the percentages of people reporting no difficulties for questions #26 and #7 were reduced to 50% and 60% of patients as shown in Table 4.

Table 4.

Percentage of patients (N=30) responding to the functional scale questions of the EORTC questionnaire QLQ-C30

	% Answering “yes” / Radiotherapy Section
	1st				28th
Question	Not at all	A little	Quite a bit	Very much	Not at all	A little	Quite a bit	Very much
1-Do you have any trouble doing strenuous activities, like carrying heavy shopping bag or a suitcase?	50	40	0	10	40	30	20	10
2-Do you have any trouble taking a long walk?	50	30	20	0	30	40	30	0
3-Do you have any trouble taking a short walk outside of the house?	50	30	20	0	30	40	20	10
4-Do you need to stay in bed or a chair during the day?	40	40	20	0	40	20	30	10
5-Do you need help with eating, dressing, washing yourself or using the toilet?	80	20	0	0	80	20	0	0
6-Were you limited in doing either your work or other daily activities?	60	30	0	10	50	30	10	10
7-Were you limited in pursuing your hobbies or other leisure time activities?	70	20	0	10	60	30	0	10
20-Have you had difficulty in concentrating on things, like reading a newspaper or watching television?	40	50	0	10	60	40	0	0
21-Did you feel tense?	40	30	10	20	10	40	20	30
22-Did you worry?	50	30	0	20	0	60	20	20
23-Did you feel irritable?	50	10	0	40	30	40	0	30
24-Did you feel depressed?	60	20	20	0	10	20	50	20
25-Have you had difficulty remembering things?	40	40	10	10	60	40	0	0
26-Has your physical condition or medical treatment interfered with your family life?	80	20	0	0	50	30	10	10
27-Has your physical condition or medical treatment interfered with your social activities?	60	30	0	10	60	20	10	10

As for the scale of symptoms, the most frequently reported ones during the first radiotherapy session were: pain (Question 9) where 40% answered “a little” and 10% “very much”; constipation (Question 16) where 20% answered “a little”, 10% “quite a bit” and 10% “very much”; diarrhea (Question 17) where 40% answered “a little”; and nausea (Question 14) where 20% answered “very much” and 10% “a little”. When the same questionnaire was applied in the 28th radiotherapy session, the most reported symptoms were: weakness (Question 12) where 50% answered “a little”, 20% “quite a bit” and 20% “very much”; tiredness (Question 18) where 50% answered “a little”, 30% “quite a bit” and 10% “very much”; need to rest (Question 10) where 40% answered “a little”, 10% “quite a bit” and 20% “very much”; and pain (Question 9) where 40% answered “a little”, 10% “quite a bit” and 10% “very much”. Table 5 shows the percentage of responses on the symptom scale of the QOL questionnaire, in which we can observe an increase in symptoms when comparing the 1st with the 28th radiotherapy session, especially with regard to tiredness.

Table 5.

Percentage of patients (N=30) responding to the symptom scale of the EORTC questionnaire QLQ-C30

	% Answering “yes” / Radiotherapy Section
	1st				28th
Question	Not at all	A little	Quite a bit	Very much	Not at all	A little	Quite a bit	Very much
8-Were you short of breath?	80	20	0	0	60	30	0	10
9-Have you had pain?	50	40	0	10	40	40	10	10
10-Did you need to rest?	90	0	10	0	30	40	10	20
11-Have you had trouble sleeping?	80	20	0	0	50	30	10	10
12-Have you felt weak?	80	10	0	10	10	50	20	20
13-Have you lacked appetite?	80	10	0	10	90	0	0	10
14-Have you felt nauseated?	70	10	0	20	90	0	0	10
15-Have you vomited?	90	0	10	0	90	0	10	0
16-Have you been constipated?	60	20	10	10	90	10	0	0
17-Have you had diarrhea?	60	40	0	0	70	10	10	10
18-Were you tired?	90	0	0	10	10	50	30	10
19-Did pain interfere with your daily activities?	90	0	0	10	60	20	10	10
28-Has your physical condition or medical treatment interfered with your social activities?	60	20	10	10	50	10	30	10

The higher scores on the overall health and functional health scales indicate better QOL while the higher scores on the symptom scale indicate a greater number of symptoms and worse QOL (Lima & Silva, 2020). The results in Table 6 regarding global health information showed that during the first radiotherapy session patients had an average global health score of 88.33. When compared with the average score in the 28th session, a reduction was seen, with an average of 61.67. We can also observe this reduction in the functional scale, with an initial average of 76.45 reduced to 67.77 at the 28^th day. On the other hand, the rate of symptoms increased. During the first session, the mean symptom score was 13.85, but increased to 24.62 by the 28th session. These results show that radiotherapy impacted the QOL of patients, with an increase in symptoms and a reduction in the global and functional health scales.

Table 6.

Analysis of the scales of the quality-of-life questionnaire EORTC QLQ-C30

Session of Radiotherapy	Scales	Mean (sd)	Median	Min-max	α Cronbach
1st session	Overall Health	88.33(17.65)	100	50–100	1
	Functional	76.45(19.21)	82.22	33.33–95.56	0.875
	Symptoms	13.85(19.97)	7.69	2.56–69.23	0.909
28th session	Overall Health	61.67(28.65)	61.66	8.33–100	0.902
	Functional	67.77(21.60)	78.89	24.45–91.11	0.922
	Symptoms	24.62(20.62)	15.38	5.12–69.23	0.887

The EORTC QLQ-BR23 specific QOL questionnaire for breast cancer was divided into the functional scale and symptom scale. For the functional scale analysis, the data were subdivided into body image, sexual function, sexual satisfaction, and future perspective. The scale for symptoms was subdivided into adverse events of systemic therapy, breast symptoms, arm symptoms, and hair loss. In the first radiotherapy session, the patients presented a low sexual satisfaction (mean 13) compared to the other functional subscales. When they were questioned in the 28th session of radiotherapy, a higher average was observed for the sexual satisfaction subscale (mean 30) and a decrease in body image (mean 63) and future outlook (mean 37) was seen as shown in Table 7. A little more than half of the patients reported hair loss (mean 53) in the first session of radiotherapy. However, by the 28th session of radiotherapy, we observed that in addition to reporting more hair loss (mean 63), the women also reported more symptoms in the breast (mean 45) and in the arms (mean 25).

Table 7.

Analysis of the subscales of the quality-of-life questionnaire EORTC QLQ BR23

Session of Radiotherapy	Scales	Mean (sd)	Median	Min–max
1st session	Functional Scale
	Body image	75(32.86)	87.5	0–100
	Sexual function	92(14.16)	100	66.67–100
	Sexual satisfaction	13(28.11)	0	0–66.67
	Future Perspective	60(51.64)	100	0–100
	Symptoms Scale
	Adverse Events of Systemic Therapy	31(20.36)	21.43	9.52–76.19
	Symptoms of Breast	12(13.72)	4.16	0–33.33
	Symptoms of Arm	14(21.62)	0	0–55.55
	Hair Loss	53(50.18)	66.66	0–100
28th session	Functional Scale
	Body Image	63(37.92)	62.5	0–100
	Sexual Function	97(7.02)	100	83.33–100
	Sexual Satisfaction	30(48.30)	0	0–100
	Future Perspective	37(45.68)	16.67	0–100
	Symptoms Scale
	Adverse Events of Systemic Therapy	38(25.83)	30.95	14.28–76.19
	Symptoms of Breast	45(18.92)	50	8.33–75
	Symptoms of Arm	25(20.32)	22.22	0–66.67
	Hair Loss	63(45.68)	83.33	0–100

DISCUSSION

QOL assesses the physical, psychological, and psychosocial impacts of a disease. Also, it identifies sources of family and social support, and measures the effectiveness and costs of treatment. In this study, it was observed that treatment with radiotherapy in patients with breast cancer had a notable impact on patients’ QOL. Results showed a decrease in overall and functional health scores from the first session of radiotherapy to the 28th, with an increase in the symptom score on the QOL questionnaires (e.g., EORTC QLQ-C30 and the EORTC QLQ-BR23). Further, we noticed an impact on arm and breast symptoms and perception of the body itself, factors that may contribute to the development of secondary problems of cancer and compromising the treatment of these studied patients.

The sample ages in our study are similar to those in other studies of breast cancer patients. Heunis et al., (2018) reported the age of patients with breast cancer undergoing radiotherapy was between 20 and 84 years and Rahman et al., (2014) reported the peak of incidence to be between 40 to 69 years.

Sociodemographic data are important because they allow us to know the profile of patients in a given region and understand factors such as social inequality and access to clinical examinations, as well as the treatment they need (Kim et al., 2013; Rosa et al., 2020). Rosa et al. (2020) evaluated the impact of sociodemographic factors on the diagnosis and clinical-pathological characteristics of breast cancer in Brazil and reported that 58.5% of the patients evaluated were white, 27.6% had not completed primary education, and 58.8% were married. These results corroborate the data obtained in our study (Table 2). Furthermore, the results of marital status, allows us to understand if these patients may have support from their partner during treatment. According to Su et al. (2017), family support for breast cancer patients can reduce cases of major depressive disorder and consequently help patients’ QOL.

Impact on overall QOL

QOL refers to the appreciation patients hold, and their satisfaction, with the level of functioning, compared to what is perceived to be possible or ideal. The evaluation of the overall QOL includes the physical, psychological, social, sexual, and spiritual functioning, although there is variation among authors regarding the nomenclature or division of these areas of functioning and their contents (Barbosa et al., 2017). Barbosa et al. (2017) reported that there is an impact on the QOL of patients undergoing radiotherapy compared to other modalities of breast cancer treatment. Xiao et al. (2016) also evaluated the quality of life in breast cancer patients who underwent radiotherapy, but only included early-stage women who had undergone mastectomy before receiving radiotherapy. These authors observed that radiotherapy did not influence the QOL of those patients. In our study, 70% of the patients evaluated had already received chemotherapy before radiotherapy (Table 2), which may have contributed to the reduction in QOL. Antineoplastic agents, according to Binotto et al. (2020), can decrease QOL in these patients.

When assessing patients with breast cancer in chemotherapy, Lôbo et al. (2014) observed a global QOL score with a mean of 76.14. In our work, in the 1st radiotherapy session the QOL score was higher than the study by Lôbo et al., (2014). However, data from the 28th radiotherapy session showed a decrease in the overall health score to 61.67 (Table 6) and demonstrated that with radiotherapy the QOL of patients in our study decreased. This was also seen with the study of Sharma and Purkayastha (2017), which observed a reduction in the overall QOL score at the end of radiotherapy treatment.

Impact on various domains of QOL

Various studies have reported an impact of radiotherapy on different domains of quality of life for women with breast cancer. In their study using the EORCT QLQ-C30 questionnaire, Zhang et al. (2018) showed significant changes in physical, social, painful and financial impact over time for patients after radiotherapy. We also observed an increase in the number of patients who reported some physical discomfort as radiotherapy progressed. For example, when asked if they felt any trouble taking a long walk (Question 2) and short walking outside of the house (Question 3), there was an increase of 20% when comparing the 1st session with the results of the 28th session. We also observed a 30% increase in patients who reported that pain interfered with their daily activities and a 10% increase in patients who felt pain. Zhang et al. (2018) reported similar results. According to Mikulandra et al. (2016), one of the effects of radiotherapy is breast pain.

An impact on social relationships was observed in our study with a 30% reduction between responses from the first to the 28th session, when patients were asked if their physical condition or medical treatment did not interfere with family life (Question 26). Data were similar to those presented in the studies by Zhang et al. (2018) and Silveira et al. (2016). The social impact may be related to the fact that the radiotherapy treatment is long-term in an outpatient setting, leading to the daily displacement of patients, causing them to remain outside the home and, thereby, disrupting their family life. This social impact was also observed by the study of Sharma and Purkayastha (2017).

Regarding the financial impact, we observed a 10% reduction from the first to the 28th session, showing that the radiotherapy treatment can influence financial difficulties. This could also be because women can miss work and have to travel to appointments or receive treatments.

Our study showed significant differences in body image, sexual satisfaction, future perspective, breast symptoms, arm symptoms and hair loss scores. Patients had increases in sexual satisfaction scores (from means 13 to 30), breast symptoms (from means 12 to 45), and arm symptoms (from means 14 to 25), and decreases in body image scores (from means 75 to 63) and future perspective (from means 60 to 37) between the first and the 28th radiotherapy sessions. Zhang et al. (2018) also observed statistically significant changes in body image, sexual function, sexual satisfaction, future perspective, and breast symptoms when analyzing data from the breast cancer-specific QOL questionnaire (EORTC QLQ-BR23). He observed that body image and sexual function decreased over time after completion of radiotherapy. Previously Rim et al. (2017) had reported there were no statistically significant differences in body image scores, arm symptoms, and side effects of systematic therapy over time, while all other scores were significantly different from each other. Sharma and Purkayastha (2017) reported sexual activity decreased during radiation treatment.

The body image of breast cancer survivors has been related to depression. When women are depressed, they tend to have a negative image of their bodies and, in this case, to be more sexually dissatisfied. On the other hand, women with a better body image are more sexually satisfied (Archangelo et al., 2019; Paterson et al., 2016; Rezaei et al., 2016). Finally, when women are removed from work or their usual activities due to treatment for breast cancer, they are at increased risk of impaired QOL and contribute to the development of depression (Sclowitz et al., 2005).

Impact on QOL over time

The results obtained in our study indicate that the time and the number of sessions directly affected the QOL of women undergoing radiotherapy. The reduction in QOL after the larger number of sessions can also be related to the economic impact with so many trips to the hospital and absences from work to go to the doctor, especially for patients who live in other cities (Hunter et al., 2018; Lievens, 2010; Swanson et al., 2021). Therefore, a hypofractionation scheme has been adopted, with a reduction in radiotherapy sessions to five or 15 fractions becoming the standard for adjuvant radiotherapy treatment for breast cancer (Brunt, Haviland, Sydenham, et al., 2020; Brunt, Haviland, Wheatley, et al., 2020; Marta et al., 2020). The reduction in the total duration of radiotherapy sessions can improve patients’ QOL, in addition to reducing workloads and optimizing the use of radiation oncology services. In addition, hypofractionation appears to have less acute toxicity and better QOL according to the studies by Arsenault et al. (2020) and Hulle et al. (2020), when compared with the conventional radiotherapy scheme.

These results of this survey of QOL in women receiving radiotherapy for breast cancer reinforces the importance of professional monitoring of patients for adverse radiotherapy reactions. It also implies the needs for nurses to propose interventions to reduce these side effects and increase the QOL of patients with breast cancer (Abreu et al., 2021; Censabella et al., 2014; Kole et al., 2017).

CONCLUSION

Our study revealed that radiotherapy treatment influences the QOL of patients with breast cancer in our setting, inducing symptoms such as pain and fatigue, compromising daily activities, and generating a financial impact, probably due to the long duration of the treatment. Radiotherapy hypofractionation can be an alternative to provide a better QOL for these patients. The study also emphasizes the importance of nurses being involved in monitoring patients, in parallel with a multidisciplinary team, in order to better understand the needs and difficulties of cancer patients undergoing radiotherapy. It is also important that future research be conducted with a larger number of patients, to evaluate the QOL before and after interventions by nurses who are caring for radiotherapy patients.