Cancer is one of the five leading causes of death in all age groups in both males and females in the USA. Moreover, it is the main cause of death among women of ages 40 to 79 years and among men of ages 60 to 79 years. Since there has been a notable improvement in the relative 5-year survival rates for many cancer types and for all cancers combined [
Moreover, cancer is a major disorder which affects not only the patients themselves, but their family and relatives as well. Previous research has demonstrated that caring for patients with cancer has a considerable impact on the caregiver [
In order to assess the health-related quality of life (HRQoL) of cancer patients, both generic and disease-specific questionnaires have been applied [
The EQ-5D has been increasingly used recently in cancer patients, and the growing body of literature provides evidence to support its validity and reliability [
The purpose of our survey was to investigate the HRQoL of cancer patients and their caregivers during the period of chemotherapy and to assess the impact of various demographic parameters on the quality of life of the dyad, using the EQ-5D.
From October 2008 to March 2009, two hundred twenty-two cancer patients attending the oncology day clinic of our hospital and their accompanying person (hereinafter designated as the “caregiver”) were enrolled in the study. Two dedicated investigators conducted the interview-based cross-sectional survey of the target population.
Eligibility criteria for the patients and their caregivers included being more than 18 years old and being physically and mentally well to communicate with the interviewers. Moreover, eligible patients were those with an Eastern Cooperative Oncology Group (ECOG) performance status between 0 and 2 [
Patients’ demographic and social characteristics (gender, age, marital status, and educational level), disease primary site, and comorbidities (hypertension, coronary heart disease, diabetes mellitus, and other) were also recorded by the interviewers. Data relating to the specific patient-caregiver relationship were also recorded (i.e., spouse, parent, or offspring, if he/she was the main caregiver and if they lived together).
The study was approved by the ethical and scientific committee of Attikon University Hospital, Athens, Greece.
The EQ-5D [
The EQ-5D was found to be applicable and adaptable to the Greek environment [
Nonparametric tests (Mann-Whitney and Kruskal-Wallis) were used to assess the socioeconomic and clinical differences in EQ-5D VAS and Index Scores in both patient and caregivers subgroups. The chi-square test was applied to evaluate the differences in response frequencies between the five dimensions of EQ-5D in patients and their caregivers as well as to assess the gender differences in the five EQ-5D dimensions. Spearman test was used to find out relationships between patients and caregivers HRQoL dimensions of EQ-5D. Results were considered statistically significant when
Of the 222 eligible patient-caregiver dyads, 212 finally participated in the study (response rate 96.5%). From the rest of the cases, six relatives and four patients were reluctant to participate. Patients’ and caregivers’ sociodemographic and clinical characteristics, as well as the mean EQ-5D VAS and Index Scores, are presented in Tables
Patients’ sociodemographic and clinical characteristics and EQ-5D VAS and Index Scores.
VAS ± 1SD | EQ-5Dindex ± 1SD | ||
---|---|---|---|
Gender | |||
Females | 119 (56.1) | ||
Males | 93 (43.9) | ||
| 0.268 | 0.017 | |
Age | |||
Mean | 57.4 | ||
Range | 18–81 | ||
Marital status | |||
Married | 170 (80.2) | ||
Unmarried | 19 (9.0) | ||
Divorced | 5 (2.6) | ||
Widowed | 14 (6.6) | ||
| 0.686 | 0.936 | |
Education | |||
Primary | 77 (36.3) | ||
Secondary | 74 (34.9) | ||
Technological education institution | 18 (9.1) | ||
University | 28 (14.2) | ||
| 0.664 | 0.579 | |
Comorbidity | |||
Hypertension | |||
Yes | 63 (29.7) | ||
No | 149 (69.3) | ||
| 0.443 | 0.468 | |
Coronary Heart disease | |||
Yes | 27 (12.7) | ||
No | 185 (86.3) | ||
| 0.151 | 0.775 | |
Diabetes mellitus | |||
Yes | 22 (10.4) | ||
No | 190 (89.6) | ||
| 0.088 | 0.145 | |
Cancer site | |||
Gastrointestinal | 57 (26.9) | ||
Urogenital | 46 (21.7) | ||
Breast | 39 (18.4) | ||
Respiratory | 33 (15.6) | ||
Head and neck | 12 (5.7) | ||
Other | 25 (11.8) | ||
| 0.861 | 0.166 |
Caregivers’ sociodemographic and clinical characteristics, EQ-5D VAS, and Index Scores.
VAS ± 1SD | EQ-5Dindex ± 1SD | ||
---|---|---|---|
Gender | |||
Females | 133 (62.7) | ||
Males | 79 (37.3) | ||
| 0.023 | <0.001 | |
Age | |||
Mean | 48.9 | ||
Range | 20–80 | ||
Marital status | |||
Married | 160 (75.5) | ||
Unmarried | 36 (17.0) | ||
Divorced | 8 (3.8) | ||
Widowed | 6 (2.8) | ||
| 0.018 | 0.177 | |
Education | |||
Primary | 30 (14.2) | ||
Secondary | 91 (42.9) | ||
Technological educational institution | 33 (16.7) | ||
University | 44 (22.3) | ||
| 0.009 | 0.493 | |
Comorbidity | |||
Hypertension | |||
Yes | 37 (17.5) | ||
No | 175 (82.5) | ||
| 0.206 | 0.588 | |
Coronary Heart disease | |||
Yes | 14 (6.6) | ||
No | 198 (93.4) | ||
| 0.141 | 0.481 | |
Diabetes mellitus | |||
Yes | 11 (5.2) | ||
No | 201 (94.8) | ||
| 0.048 | 0.570 | |
Relationship | |||
Spouse | 98 (46.2) | ||
Parent | 40 (18.9) | ||
Offspring | 47 (22.2) | ||
Other | 27 (12.7) | ||
0.183 | 0.367 | ||
Main caregiver | |||
Yes | 155 (73.1) | ||
No | 57 (26.9) | ||
| 0.009 | 0.686 | |
Living in the same house | |||
Yes | 155 (73.1) | ||
No | 57 (26.9) | ||
| 0.113 | 0.800 |
Distribution of EQ-5D dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) of the patients and the caregivers are summarized in Table
Patients’ and caregivers’ EQ-5D dimension scores.
Patients | Caregivers | |
Mobility | ||
No difficulties | 137 (64.6) | 201 (94.8) |
Some difficulties | 68 (32.1) | 11 (5.2) |
Extreme difficulties | 7 (3.3) | 0 (0) |
| ||
Self-care | ||
No difficulties | 171 (80.7) | 210 (99.1) |
Some difficulties | 34 (16.0) | 2 (0.9) |
Extreme difficulties | 7 (3.3) | 0 (0) |
| ||
Usual activities | ||
No difficulties | 105 (49.5) | 196 (92.5) |
Some difficulties | 89 (42.0) | 16 (7.5) |
Extreme difficulties | 18 (8.5) | 0 (0) |
| ||
Pain/discomfort | ||
No difficulties | 99 (46.7) | 173 (81.6) |
Some difficulties | 88 (41.5) | 38 (17.9) |
Extreme difficulties | 25 (11.8) | 1 (0.5) |
| ||
Anxiety/depression | ||
No difficulties | 55 (25.9) | 42 (19.8) |
Some difficulties | 122 (57.5) | 127 (59.9) |
Extreme difficulties | 35 (16.5) | 43 (20.3) |
|
df: degrees of freedom.
Intragender differences in patients’ and caregivers’ EQ-5D dimensions.
Patients | Caregivers | |||||
Males | Females | Males | Females | |||
Mobility | ||||||
No difficulties | 63 (67.7) | 74 (62.2) | 78 (98.7) | 123 (92.5) | ||
Some difficulties | 29 (31.2) | 39 (32.8) | 1 (1.3) | 10 (7.5) | ||
Extreme difficulties | 1 (1.1) | 6 (5.0) | 0 (0) | 0 (0) | ||
Self-care | ||||||
No difficulties | 77 (82.8) | 94 (79.0) | 79 (100) | 131 (98.5) | ||
Some difficulties | 12 (12.9) | 22 (16.5) | 0 (0) | 2 (1.5) | ||
Extreme difficulties | 4 (4.3) | 3 (2.5) | 0 (0) | 0 (0) | ||
Usual activities | ||||||
No difficulties | 47 (50.5) | 58 (48.7) | 76 (96.2) | 120 (90.2) | ||
Some difficulties | 41 (44.1) | 48 (40.3) | 3 (3.8) | 13 (9.8) | ||
Extreme difficulties | 5 (5.4) | 13 (10.9) | 0 (0) | 0 (0) | ||
Pain/discomfort | ||||||
No difficulties | 45 (48.4) | 54 (45.8) | 75 (94.9) | 98 (73.7) | ||
Some difficulties | 35 (37.6) | 53 (44.5) | 4 (5.1) | 34 (25.6) | ||
Extreme difficulties | 13 (14.0) | 12 (10.1) | 0 (0) | 1 (0.8) | ||
Anxiety/depression | ||||||
No difficulties | 34 (36.6) | 21 (17.6) | 20 (25.3) | 22 (16.5) | ||
Some difficulties | 53 (57.0) | 69 (58.0) | 51 (64.6) | 76 (57.1) | ||
Extreme difficulties | 6 (6.5) | 29 (24.4) | 8 (10.1) | 35 (26.3) | ||
df: degrees of freedom.
The correlation between patients’ and caregivers’ HRQL indicated that problems in patients’ dimensions of self-care and usual activities had a negative influence in the dimension of anxiety/depression of the caregivers (
The most prevalent health profiles, out of a total of 243 possible health states for the patients and their caregivers, are described in Table
The most prevalent health profiles of the patients and their caregivers.
Patients’ health state | Frequency (%) | Caregivers’ health state | Frequency (%) |
---|---|---|---|
11112 | 31 (14.6) | 11112 | 102 (48.1) |
11111 | 21 (9.9) | 11111 | 35 (16.5) |
11122 | 21 (9.9) | 11113 | 29 (13.7) |
11212 | 11 (5.2) | 11122 | 12 (5.7) |
21222 | 10 (4.7) | 11121 | 6 (2.8) |
11113 | 8 (3.8) | 11123 | 6 (2.8) |
11121 | 8 (3.8) | 11212 | 4 (1.9) |
21212 | 8 (3.8) | 21223 | 3 (1.4) |
It is well documented [
In our study, according to the subjective state of health recorded on the visual analogue scale, male and higher-education caregivers had higher VAS scores. Interestingly, married caregivers had lower VAS scores than single ones in contrast with the general population’s observations. This can be explained by the fact that the higher proportion of caregivers in the current study was spouses of the patients with whom they were living with in the same house and caring for. According to Nijboer et al. [
On the contrary, these monitored factors (gender, marital status, and educational level) had no influence on the subjective health condition of the patients, as recorded by the EQ-VAS scores in the present study. Similarly, Slovacek et al. [
The EQ-5D item responses indicate that female patients experience more frequently anxiety or depression than male patients. Previous studies have demonstrated high levels of depression and anxiety in cancer patients. No gender differences for anxiety [
Cancer patients and their caregivers had statistically significant differences in all but one EQ-5D dimension (Table
As expected, caregivers’ anxiety and depression were highly correlated with patients’ problems in self-care and usual activities. These findings support previous study findings that caregivers’ depression and patients’ disability to perform their daily activities are highly related. Emanuel et al. have found that caregivers of terminally ill patients who needed a high amount of assistance (transportation, nursing care, homemaking, and personal care) were significantly more likely to have depressive symptoms than caregivers of patients with low care needs [
The difference observed between EQ-5D index and VAS, especially in marital status, education, comorbidity, and the type of caregiver (Table
We are aware of the fact that our study can be limited by some factors. First, there is a limitation associated with the EQ-5D itself. Health-related quality of life measurement in cancer patients is usually assessed using cancer-specific instruments that are likely to be more responsive than generic instruments [
Despite the limitations, the present study represents an attempt to understand the complicated interaction between cancer patients undergoing chemotherapy and their relatives, in terms of their health-related quality of life. In modern medicine, the evaluation of a patient’s health problem is based not only on clinical or laboratory markers but also on a holistic approach of the patient that includes the evaluation of the consequences of diagnosis or therapy of the health condition. Interventions that can improve HRQoL, especially in the domain of mental health, of both cancer patients and their caregivers need to be implemented.
Both cancer patients and caregivers were highly affected psychologically of the disease.
Demographic characteristics that influence the subjective health status of caregivers did not appear to influence the subjective health status of the patients.
Female patients appear to be more anxious or depressed than males.
Anxiety and depression of caregivers were correlated with patients’ problems in self-care and usual activities.