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Anne Lanham, Lillian Mwanri

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Factors Affecting Health Related Quality of Life among Women with Breast Cancer Receiving Chemotherapy

Salehah Hamid Al Shaikh*, Samah Mahmoud Sofar

Master of Nursing Medical Surgical Department, KAAU, JED, SA

Abstract: Introduction: Chemotherapy is the most common therapeutic modality used in the treatment of breast cancer. It has different side effects, with associated degrees of disruption in quality of life. Health-related quality of life (HRQOL) is a multidimensional concept, considered as a subjective assessment of physical, social, psychological, and spiritual factors. The study aim: To assess factors affecting health related quality of life among women with breast cancer receiving chemotherapy. Design: Quantitative, descriptive correlational design was used. Setting: Chemotherapy Department, King Abdullah Medical City (KAMC) in Makkah. Sample: A convenient sample of 122 women was selected. Tools: Three tools were used for data collection. First, demographic and clinical data. Second, 36-Short Form version 1, and third, Factors affecting health related quality of life among women with breast cancer receiving chemotherapy questionnaire. Results: More than half 51.6% of the studied women were moderately affected regarding overall factors affecting health related quality of life. There was a significant negative relationship between psychological factors and quality of life (P < 0.001). Conclusion: The majority of studied women had moderately affected by overall social factors and nearly two third had moderately affected by overall psychological factors. While more than half were moderately affected by overall physical and spiritual factors. Moreover, women had moderate level of overall QOL. Recommendation: The study recommended for further research to develop self-care practices educational program for women with breast cancer receiving chemotherapy.

Keywords: factors affecting health, health related quality of life, breast cancer, chemotherapy

Received October 03, 2018; Revised November 22, 2018; Accepted December 27, 2018

Citation: Salehah Hamid Al Shaikh, Samah Mahmoud Sofar, Factors Affecting Health Related Quality of Life among Women with Breast Cancer Receiving Chemotherapy. American Journal of Nursing Research, 7 (1). 37-50. January 2019. doi:10.12691/ajnr-7-1-6

1. Introduction

Breast cancer is the second most common type of cancer affecting women worldwide [1]. The Saudi Cancer Registry [2] asserted that the estimated incidences of breast cancer are 29.1% and increasing annually. In addition, breast cancer represents the most common cancer affecting Saudi Arabian women, with 1853 new cases reported in 2015. The lifetime risk of breast cancer for Saudi Arabia women is one in every nine women, while the mean age of diagnosis of breast cancer is 50 years old [2]. Despite breast cancer screening services in Saudi Arabia being provided free, there has been an extremely low turn-up for the screening [3]. In Saudi Arabia (2013) according to the Sheikh Mohammed Al-Amoudi Center of Excellence in Breast Cancer, about 70% of cancer cases are detected at advanced stages rather than early detection in comparison to western countries. However, there seems to be an even geographical distribution of women with breast cancer in Saudi Arabia, as majority of women diagnosed from different regions in Saudi Arabia [3].

Breast cancer is a complex and multifactorial disease that results in abnormal cell growth, leading to malignant tumor formation [4]. Breast cancer has many types of treatment modalities, such as surgical, chemotherapy, radiation, hormonal and biotherapy [5]. Chemotherapy is the most common therapeutic modality used in the treatment of breast cancer [6,7]. Chemotherapy is cytotoxic agents designed to stop cancer cells by either destroying them or inhibit their growth to prevent cancer cells from metastases. Treatment with chemotherapy depends on woman’s age, menopausal status, cancer stage, tumor size, location and molecular subtype [8]. Chemotherapy can be used as a single agent or in-combination with other modality therapy [9]. On the other hand, chemotherapy is associated with numerous side effects such as fatigue, pain, stomatitis, loss of appetite nausea, vomiting, dyspnea, diarrhea, constipation, and lymphedema [10,11]. Women with breast cancer will be affected physically, socially, psychologically, and spiritually by chemotherapy side effects which in turn affect women health-related quality of life.

Health-related quality of life (HRQOL) is a multidimensional concept, considered as a subjective assessment of physical, social, psychological, and spiritual factors [12,13]. The main focus of health-related quality of life is the effects of illnesses on women and their treatment [13]. Measuring HRQOL is a challenge due to the experiences of women with breast cancer are different and may vary over time. Furthermore, women with breast cancer have fears and worries about their health and need support when receiving chemotherapy in order to empower women to cope the chemotherapy side effects [14].

The World Health Organization [15] reported that breast cancer is the predominant type of cancer in women. Actually, it is a considerable factor affecting women in Saudi Arabia as it contributes to the highest number of deaths around the world [16]. In this light, chemotherapy is the treatment procedure undertaken to curb the re-occurrence of breast [17]. This treatment approach is facing dynamic changes that aim at bettering its treatment efficiency. Among the notable changes is the ability to interfere with the rapidly dividing cells and molecules that accelerate tumor growth and eventually the spread of cancer [18]. The squeals of breast cancer and its treatment have considerable impact on Health-related quality of life, which in turn affects the ability of these women with breast cancer to perform many of usual roles in their lives [19,20]. Some study have noted declines in health-related quality of life during chemotherapy followed by returns to baseline after treatment is completed [21]. For these reasons, sustaining and improving the quality of life after undergoing chemotherapy has become one of the most significant areas of interest in clinical research and practice [22].

There is a growing body of nursing literature on the physical, social, psychological, and spiritual domains of health-related quality of life. Although Cheng et al. [23] addressed that the majority of studies regarding quality of life among women with breast cancer aimed to examining the women’s QOL after completing aggressive treatment. Essentially, limited studies have explored factors related to QOL during the acute chemotherapy treatment phase. Therefore, nurses should emphasized on the assessment of chemotherapy side effects during the acute phase to improve the patient’s quality of care.

2. Research Aim

To assess factors affecting health related quality of life among women with breast cancer receiving chemotherapy.

3. Research Question

1. What are the factors affecting health related quality of life among women with breast cancer receiving chemotherapy?

2. What are the levels of quality of life in women with breast cancer receiving chemotherapy?

3. What is the relationship between the factors affecting health and women’ quality of life?

4. What is the relationship between sociodemographic and clinical data with factors affecting health related quality of life?

4. Materials and Method

4.1. Materials

4.1.1. Design

Quantitative, descriptive correlational design was used in carrying out this study.

4.1.2. Setting

This study was conducted at King Abdullah Medical City (KAMC) in the Holy Capital Oncology Center, in Chemotherapy Unit. The oncology inpatient services consist of: Medical Oncology Ward with beds capacity 40 beds and current active beds 35 beds, Hematology Oncology Ward with beds capacity 50 beds and current active beds 15 beds, Chemotherapy Unit with capacity 17 beds, and Palliative Care Unit with bed capacity 10 beds (KAMC annual report, 1434 H).

4.1.3. Sample

The total number of women diagnosed with breast cancer at King Abdullah Medical City in 2015 was 178. A convenience sample of 122 women was selected by using Robert Mason equation with 95% confidence interval, 5% margins of error and 50% prevalence of women with breast cancer.

M: Population size = 178.

S = z/E, z: coefficient level at 95% (standard value of 1.96), E: error proportion = 0.05.

P: the probability (30%-60%) or = 50% the best.

q: 1-p = 0.25.

n: sample size = 122 women.

Inclusion Criteria

Women with breast cancer receiving chemotherapy under surgical protocol or not; stage I, II, and III breast cancer; aged from 20 years to 60 years; after received third cycle; able to speak Arabic or English Language; willingly agree to participate in the study.

Exclusion Criteria

Women with history of mental illness; metastasis and cognitive impairment.

4.1.4. Tool of the Study

Three tools were used in the study to collect the necessary data.

Tool 1: Socio-Demographic and Clinical data sheet:

It was developed by the researcher according to review of relevant literatures, it aimed to collect patient's personal and clinical data. It divided into two parts:

Part 1: Sosio-Demographic data:

It was included: age; nationality; marital status; level of education; occupation; income; financial support from government; area of residence; living with family members and data of being involved in the study.

Part II: Clinical data:

It was included: weight; height; body mass index; family history of breast cancer; co-morbidity; hemoglobin level; red blood cells level; white blood cells level; have any benign tumors before; kind of breast cancer; treatment methods; type of surgery; diameter of the tumor; stages of breast cancer; recent chemotherapy cycle; chemotherapy delayed or discontinued for any reason; and chemotherapeutic protocol.

Tool II: 36-Item Short form survey, version 1 (SF-36).

This tool was developed by research and development Corporation (RAND), which is a nonprofit institution [24]. It aimed to assess health related quality of life (HRQOL). The SF-36 multiple-choice questions consisted of eight scales as the following: physical functioning 10 items, role limitations caused by physical health role 4 items, role limitations caused by emotional role 3 items, body pain 2 items, vitality energy/fatigue 4 items, social functioning 2 items, mental health 5 items and general health perceptions 5 items.

Items are measured using binary responses (yes/no); categorical responses (not at all, somewhat, a lot); and 5-point Likert scales, ranging from 1 all of the time to 5 none of the time. Higher scores defines a more favorable Quality of life. The score was calculated according the scoring rules of the RAND Health Survey version I [25].

Tool III: Factors affecting quality of life among women with breast cancer receiving chemotherapy questionnaire:

This tool was developed by the researcher based on review of relevant literatures to assess factors affecting health related quality of life among women with breast cancer receiving chemotherapy [26,27,28,29,30]. The questionnaire is composed of 83 items describing the four factors as following:

Ÿ Physical factors was included 49 items about: General manifestations (5 items), CNS manifestations (3 items), cardiopulmonary manifestations (2 items), GIT manifestations (6 items), Skin & hair (3 items), activities of daily living (7 items), Indoor activities (10 items), outdoor activities (3 items), sexuality (3 items), arm edema (2 items), extravasations (4 items).

Ÿ Social factors was included 10 items about: feel safe in family; feel independent; have enough time to do the things want to do; able to get an appointment when need referral to clinic/physician; meet friends; need to have strong connections with people; maintaining relationships is important to you; get support from family; physical condition or medical treatment caused financial difficulties; participate in social groups work.

Ÿ Psychological factors was included 13 items about: Ability to enjoy life; sit at ease and feel relaxed; fear; sad; anxious; losing interest in thing; accepting illness; less physically attractive as a result of disease or treatment; worry that condition will get worse; worry about die; bother by hair loss; dissatisfaction with appearance; avoid being with people.

Ÿ Spiritual factors was included 15 items about: Self-awareness 5 items, spiritual practices 6 items, spiritual needs 4 items.

4.1.5. Scoring System

Each item was weighted on a scale of 3 points 1= rarely affected, 2= moderately affected, 3= highly affected. Total score classified as the following:

1. Mean from 2.34 to less than 3.00 of the total health related quality of life scores were considered highly affected.

2. Mean from 1.67 to less than 2.34 of total health related quality of life scores were considered moderate affected.

3. Mean from one to less than 1.67 of total health related quality of life scores were considered rarely affected.

4.2. Method

4.2.1. Ethical Consideration

Written approval was obtained from the faculty of nursing, King Abdul Aziz University and King Abdullah Medical City in the Holy capital, Institutional Review Board. Written consent was obtained from participants after explained the purpose of the study. Confidentiality and privacy were assured.

4.2.2. Validity

The content of the tools were revised by 7 experts in the field of Medical Surgical Department Faculty of Nursing at King Abdul Aziz University to test content validity, completeness, and clarity of items, comments and suggestion of experts was considered and the tool was modified accordingly.

4.2.3. Reliability

The reliability of tool II: 36-Item Short form survey, version 1 has good reliability, Cronbach's alpha ranged from 0.68 to 0.94 [31,32]. In the current study, Cronbach's alpha reliability ranged from 0.71 to 0.85. The reliability of tool III has good reliability, Cronbach's alpha ranged from 0.77 to 0.82.

4.2.4. Pilot Study

A pilot study was conducted on 10% of sample size equivalent to 12 women to test clarity, feasibility, and applicability of the study and tools, modifications were done based on the results. Participants excluded from the main study sample.

4.2.5. Data Collection Process

After ethical approval was obtained, the data collection was started and continued for a period from March to November 2016.

Ÿ The researcher reviewed the women’ medical file for compliance with study clinical data.

Ÿ The women who agree to participate were interviewed individually once by the researcher, each interview was about 30-40 minutes.

Ÿ The researcher was filled the socio-demographic questionnaire using tool I parts I from the women and clinical data questionnaire using tool I parts II from the patients' medical file.

Ÿ Then, the researcher assess women quality of life by using tool II 36-Item short form survey, version 1 (SF-36).

Ÿ After that, the researcher assess the factors affecting quality of life among women with breast cancer receiving chemotherapy using tool III factors affecting quality of life among women with breast cancer receiving chemotherapy questionnaire.

Ÿ Finally, the collected data was analysed.

4.2.6. Statistical Analysis

Data ware coded, organized, fed to the computer and analyzed using IBM Statistical Package for Social Sciences analysis (SPSS) software version 24.0. Quantitative data were described using frequency and percentages, means and standard deviations. Relationship between variables were tested using T-test or ANOVA. Moreover, Pearson correlation coefficient was used.

5. Results

Table 1 shows frequency distribution of the studied women with breast cancer in relation to sociodemographic characteristics.

Table 1. Frequency distribution of the studied women with breast cancer in relation to socio-demographic characteristics

Nearly half of the sample (45.0%) were in the age group of (40 < 50) years, while only (4.1%) were in the age group of (20 < 30) years. The majority (81.1%) were Saudi. More than half (58.2) were married. About (35.2%) had basic education, while only (12.3%) had university education. The majority (88.5%) were housewife. About (16.4%) had insufficient monthly income to fulfill the daily requirements.

Table 2 Shows frequency distribution of the studied women with breast cancer in relation to the clinical characteristics.

The majority (79%) of the studied women had no family history, while (20.5%) had close family member with breast cancer. More than half (59.8%) had no chronic diseases, while only (8.2%) and (18%) had diabetes mellitus and hypertension. The majority (80.3%) had amenorrhea. The majority (92.6%) had no previous history, while (7.4%) of had suffered from past history of benign tumors.

Table 3 Shows frequency distribution of the studied women in relation to their breast cancer types and chemotherapy.

The highest majority (94.3%) had invasive ductal carcinoma, while only (3.3%) had ductal carcinoma in situ, and (2.5%) had invasive lobular carcinoma. About (32.79%) were treated by chemotherapy, and (22.13%) treated surgically, while only (1.64%) by chemotherapy and biotherapy. Nearly two third (70.5%) had T3 (> 5 cm), while only (1.6%) had T1 (<2 cm). The majority (86.9%) had stage III, while the minority (1.6%) had stage I. About (26.2%) had 3th cycle of chemotherapy, while (6.6%) had 7th cycle of chemotherapy. Nearly three quarters (74.6%) had no delayed or discontinued chemotherapy cycle. About (21.3 %) had neutropenia. About (38.5%) of the were received docetaxel, while only (9.8%) were received FEC.

Table 2. Frequency distribution of the studied women with breast cancer in relation to the clinical characteristics

Table 3. Frequency distribution of the studied women in relation to their breast cancer types and chemotherapy

Table 4 shows the frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to physical factors.

The majority (87.7%) of the studied women were highly affected by fatigue and more than half (60.7%) of the studied women were highly affected by general pain. Moreover, nearly half (42.6%) of studied women were moderately affected by insomnia. Regarding central nervous system, nearly two third (67.2%) of studied women were moderately affected by numbness of the extremities. Regarding gastrointestinal tract, around half (50.8%), (57.4%) of studied women were highly affected by dry mouth and anorexia. In addition more than two third of studied women (76.2%) were rarely affected by vomiting. Moreover more than half (59%) of studied women were moderately affected by nausea. Regarding skin and hair, almost all studied women (95.9%) were highly affected by alopecia.

Considering activities of daily living, more than half (59%) of studied women were highly affected by taking frequent bed rest. Moreover, more than half (55.7%) of studied women were moderately affected by division of each task done. Regarding assessing indoor activities for women undergoing surgery about third of studied women (35.52%) were highly affected by closure blouse from the back, while near half (47.37%) of studied women were highly affected by sleeping on the affected side. Concerning assessing outdoor activities, nearly half (43.4%), (45.9 %), (49.2%) of studied women were highly affected by carrying a shopping bag, pushing a heavy door, and lifting heavy objects respectively.

Table 5 shows the frequency distribution of the studied women with breast cancer in relation to social factors.

The majority (90.2%) of the studied women were rarely affected by feeling safe in family. Moreover nearly half (45.9%) of the studied women were highly affected by inability to meeting friends. In addition, the majority (87.7%) of the studied women were highly affected by maintaining relationships with others. Furthermore, near one-third (32%) of the studied women were moderately affected by get support from family, while (13.9%) of the studied women were highly affected by financial difficulties due to treatment cost treatment. Moreover, more than two-third (76.2%) and (74.6%) of the studied women were highly affected by participation in social work group and need to have strong connections with people respectively.

Table 6 shows the frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to psychological factors.

Regarding psychological factors, Regarding psychological factors, it was found that about two-third (71.3%) and (79.5%) of the studied women were moderately affected by ability to enjoy their life and feeling relaxed, while only (37.7%) of the studied women were highly affected by feeling sad. On the other hand, more than half (50.8%), (58.2%) of the studied women were moderately affected by fear and worry about her condition. In addition, it was found that more than half of studied women (69.7%) were highly affected by feel less physically attractive and (43.4%) of studied women were highly affected by hair loss. Moreover, it was found that near two third (70.5%) of the studied women were rarely affected by avoid being with people because their appearance.

Table 7 shows the frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to spiritual factors.

Regarding self-awareness, the majority (94.3%), (85.2%) of the studied women were highly affected by feeling trust in God and empathy with others, as well as near two-third (66.4%) of the studied women were highly affected by found meaning in difficult situation. In addition, near two-third (62.3%) of the studied women were rarely affected by loneliness. Considering spiritual practices, the majority (85.2%), (82.8%) of the studied women were moderately affected by thinking to achieve inner peace and finding any opportunity to enhance spirituality condition. Regarding spiritual needs, the majority (83.6%) of studied women were highly affected by listening to holy Qur'an, while only (5.7%) were rarely affected by seek beauty.

Table 8 the level of the eight health concepts for QOL of the studied women with breast cancer receiving chemotherapy.

Regarding all eight concepts for QOL level, the majority (81.4%) of the studied women had moderate level of QOL. In addition, the majority (94.3%), (89.4%), and (77.9%) of the studied women were had poor level in role limitations due to physical health and emotional problems, as well as vitality (energy/fatigue) respectively. Furthermore, (75.4%) (56.6%) (33.6%) (53.3%) of the studied women had moderate level in physical functioning, emotional well-being, social functioning, and pain, while near two-third (73 %) of the studied women had good level regarding general health.

Table 4. Frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to physical factors

Table 5. Frequency distribution of the studied women with breast cancer in relation to social factors

Table 6. Frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to psychological factors

Table 7. Frequency distribution of the studied women with breast cancer receiving chemotherapy in relation to spiritual factors

Table 8. The level of the eight health concepts for QOL of the studied women with breast cancer receiving chemotherapy

Table 9 reveals Pearson Correlation between the mean of the total level of QOL and the overall factor affecting health of the studied women.

There was a negative significant correlation between overall psychological factors with overall level QOL (r=-.465**, P-value < 0.000). There was a negative significant correlation between overall factors affecting health with overall level QOL (r=-.289-**, P-value < 0.001).

Table 10 illustrates the relationship of socio-demographic and clinical characteristics on factors affecting HRQOL of the studied women.

There was statistically significance difference between age group and physical factors P ≤ 0.024*. There was no statistically significance difference of marital status on factors affecting HRQOL of the studied women with breast cancer receiving chemotherapy.

Regarding clinical characteristics, there was statistically significance difference between stages of breast cancer and psychological factors P ≤ 0.039*. Finally, there was statistically significance difference between body mass index and spiritual factors P ≤ 0.006**.

Table 9. Pearson Correlation between the mean of the total level of QOL and the overall factor affecting health of the studied women

Table 10. The relationship of socio-demographic and clinical characteristics on factors affecting HRQOL of the studied women

6. Discussion

Breast cancer is an important health issues influencing women quality of life. Assessment Quality of life (QOL) among women with breast cancer has been shown contribution to improve treatment and it an important prognostic factor [33]. Women diagnosed with breast cancer in Saudi Arabia often face many challenges associated with cancer itself and its treatment. Breast cancer and chemotherapy side effects are destructive to the physical, social, psychological, and spiritual factors which affecting health-related quality of life (HRQOL).

The present study was carried out in order to assess the factors that can affecting health related quality of life among women with breast cancer receiving chemotherapy.

Regarding demographic characteristics, the results of present study revealed that nearly half the sample of studied women were in the age group of (40 < 50) years. This finding matched with Saudi Cancer Registry (2013) which reported that the mean age of breast cancer cases in Saudi Arabia was 50 years and it occurs at an earlier age.

Concerning clinical data, the current study found that more than two third of studied women had no family history with breast cancer. This result is in line with Howlader et al. [8] and Pecorino [34] who emphasized that only 15% of all the breast cancers women are inherited. In addition, the present study revealed that more than half of the studied women had no chronic diseases and only nearly quarter (8.2%), (18%) had diabetes mellitus and hypertension respectively. This result is consistent with Shin et al. [35] who reported that 71.2% of women with breast cancer had no chronic diseases.

The results of present study illustrated that the majority of the studied women had amenorrhea. This result may be due to side effect of chemotherapy, which induce ovarian follicles damage, decreased ovarian volume and finally ovarian fibrosis [36]. In the same line Yoo et al. [37] demonstrated that chemotherapy induce amenorrhea and disrupted menopause-specific quality of life in premenopausal women with breast cancer.

Regarding physical factors, the results of the present study revealed that women with breast cancer receiving chemotherapy were moderately affected by all over physical factors. This result is in agreement with Alzabaidey [38] who reported that women with breast cancer receiving chemotherapy had moderate affected of quality of life in regarding physical factors.

Regarding the most disturbing physical factors reported by women with breast cancer in the present study almost all studied women were highly affected by alopecia. This finding confirms the previous research that chemotherapy induced alopecia [39,40,41,42]. In addition, the current study revealed that the majority of the studied women were highly affected by feeling fatigue. This finding matched with Kim et al. [43], So et al. [44] and Devi [45], whom mentioned that fatigue, has been reported as one of the most commonly reported factor experienced by women with breast cancer receiving chemotherapy.

The present study revealed that more than half of the studied women were highly affected by general pain. This finding matched with Everdingen et al. [46] who reported that the prevalence of pain in women with breast cancer receiving chemotherapy was (59%) and emphasized that chemotherapy related pain were regarded as the worst outcomes on HRQOL.

The current study revealed that nearly half of studied women were moderately affected by insomnia. This finding is consistent with Devi [45] and Savard et al. [47] who indicated that the prevalence of insomnia was 46% to 51.3% in women with breast cancer receiving chemotherapy. Moreover, this result comes in line with Traeger et al. [48] who reported that sleep quality remained poor condition after chemotherapy, among women with breast cancer under chemotherapy.

Regarding central nervous system, the present study revealed that nearly two third of studied women were moderately affected by numbness of the extremities. This finding matches with Sucala et al. [49] who reported that more than half of the studied patients complain of numbness in the extremities. In addition, the current study revealed that less than quarter of studied women were highly affected by loss of balance. This result is in the same line with Tofthagen [50] who showed that chemotherapy induced peripheral neuropathy and it lead to loss of balance.

Concerning cardiopulmonary, the current study revealed that nearly half of the studied women were moderately affected by palpitation. This result supported by Polovich et al. [36] who explained that chemotherapy induce cardiovascular toxicity which include dysrhythmias and in some cases cardiac dysfunction cannot be linked to a specific chemotherapy but reflects the effects of a combination of chemotherapy. Furthermore, the present study revealed that more than half of the studied women were rarely affected by dyspnea. This result comes in line with Sucala et al. [49] who stated that 10.3% of the studied women were rarely affected by dyspnea.

Regarding gastrointestinal manifestations, this study showed that more than two third of studied women were rarely affected by vomiting and more than half of studied women were moderately affected by nausea. This was confirmed in a prior study by Farrell et al. [51] who mentioned that nausea is a troublesome and distressing factor after receiving chemotherapy and it is a more difficult factor to manage, while vomiting is well controlled with current antiemetic drugs. Furthermore, Vidal et al. [52] and Molassiotis et al. [53] reported that nausea more frequently than vomiting and its management has consequently improved significantly in recent years.

The current study revealed that around half of studied women with breast cancer were highly affected by dry mouth. This finding matches with Sucala et al. [49] who reported that more than half of women with breast cancer receiving chemotherapy complain of dry mouth. In addition, the present study revealed that around half of studied women were highly affected by anorexia. This finding supported by Almutairi et al. [54] who reported that the majority of studied women with breast cancer receiving chemotherapy had anorexia.

Regarding sexuality, the present study revealed that more than half of married studied women were highly affected by lack of sexual desire. This finding is in harmony with Devi [45] who reported that 66% of women with breast cancer receiving chemotherapy had alteration in sexual functioning and mentioned lack of sexual desire. Furthermore, Kedde et al. [55] reported that 64 % had a sexual dysfunction. Moreover, Farthmann et al. [56] analyzed the effect of chemotherapy on sexual quality of life and stated that the reasons for sexual inactivity were variable, including both physical and psychological factors. Additionally, the current study revealed that nearly third of married studied women were highly affected by dyspareunia and vaginal dryness. This result supported by Rosenberg et al. [57] who illustrated that almost women with breast cancer receiving chemotherapy suffered from strong association between sexual dysfunction and both vaginal dryness and dyspareunia.

Concerning activities of daily living, the present study showed that more than half of the studied women with breast cancer receiving chemotherapy were highly affected by frequent bed rest. Moreover, the current study revealed that half of the studied women were moderately affected by task not completed and divided each task done of activity. This result may be due to the side effect of chemotherapy treatment induce fatigue and change level of activity of women. This finding supported by Wyatt et al. [58] who reported that the majority of the women with breast cancer face difficulties in performing activities of daily living associated with treatment interruptions.

Regarding assessing activities in arm on surgery side, the present study showed that nearly half of the studied women were moderately affected by washing back, closed blouse from the back, and sleeping on the affected side. In addition, the current study revealed that more than two third of the studied women were highly affected by carrying a shopping bag, pushing a heavy door, and lifting heavy objects. This is because pre-operative education for exercise and postoperative surveillance with physiotherapy intervention exercise return upper limb function and improved range of motion.

In this context, Smoot et al. [59] who explained that activity avoidance recommended may be a difficulty, as upper extremity strength may deteriorate over time with reduced use, with elbow flexion and grip strength in women with lymphedema. This result is in line with Tiezzi et al. [60] considered that the lower scores in physical factors among women with breast cancer receiving chemotherapy reflects their limitations in daily activities such as running, lifting heavy objects, walking several blocks, climbing stairs, kneeling and bathing. In addition, the author explained these limitations might be associated with changes in the muscles and nerves, which is common in women who are treated with chemotherapy.

On the other hand, the present study revealed that nearly half of the studied women with breast cancer receiving chemotherapy were moderately affected by decreased range of motion (ROM) in arm on breast surgery side. In this respect, Letellier [61] emphasized that mainly with mastectomy, the women’s ability to move their limb easily in its complete ROM can be affected if damage to the nerve and muscle followed the surgery and scar tissues limit arm movement, as well as radiotherapy may lead to more scar and fibrotic tissues. This finding the same line with Springer et al. [62] who pointed that, most women undergoing breast cancer surgery who receive physiotherapy intervention may expect a return to baseline ROM and strength by three months.

Considering lymphedema, the present study revealed that only (10.7%) had lymphedema sign. In this line, Yarbro et al. [63] illustrated that lymphedema is a chronic condition that occurs when the ﬂow of lymph ﬂuid through lymphatic vessels is impaired and the ﬂuid accumulates in surrounding dependent tissue. This finding is congruent with Ashikaga et al. [64] who reported that lymphedema increased in breast cancer after six months, one year, and two years, at 9.4%, 11.1%, and 14% respectively.

The present study revealed that there was statistical significance difference related to age group with physical factors. This finding supported by Paskett et al. [65] who mentioned that there was statistically significant difference between the age group on Quality of life and classically was associated wi1th lower HRQOL. Moreover, this result is in line with Ahmed et al. [66] who reported that elderly women with breast cancer reported poorer physical factors than women of ages <60 years.

Regarding social factors, the present study revealed that quality of life of women with breast cancer receiving chemotherapy were moderately affected by all over social factors. This result could be due to the nature of Saudi culture and the strong social and emotional support that the patients received from family and friends during the period of illness. This finding is consistent with Tiezzi et al. [60] who reported that social factors in women with breast cancer receiving chemotherapy were moderately affected.

The current study showed that the majority of the studied women with breast cancer receiving chemotherapy feeling safe in family and about half of them get support from their family. This may be attributed to the fact that social support principally from family and friends plays a very important role in creating substantial relationships with all factors affecting women’s quality of life as well as the majority of studied women with breast cancer receiving chemotherapy in this study were living with their family which support them with overcome the symptoms. This finding matched with Salonen et al. [67] who stated that family support is important and the familial relationship between the patients and their family members is close. In the same line, Almutairi et al. [54] explained that most families surrounded their women with breast cancer during chemotherapy. Additionally, Gavric and Vukovic-Kostic [68] clarified that breast cancer or chemotherapy had considerably more impact on family and social life of women with breast cancer.

The current study showed that nearly half of the studied women were highly affected by their inability to meet their friends. In the same line, Al-Azri et al. [69] mentioned that many women with breast cancer prefer to share their illness with only close family members and reluctant to inform their friends. Moreover, the present study revealed that more than two third of the studied women were highly affected participating in social groups work. This finding is in the same direction with, Zhao et al. [70] and Harcourt & Frith, [71] who reported that women with breast cancer receiving chemotherapy had impaired participation in society and avoid social activities that requires interaction with people.

The current study revealed that nearly one-third were moderately affected by financial difficulties due to the cost of treatment. This may be due to most of women did not aware government subsidy during illness. In the same line, Almutairi et al. [54] and Rohani et al. [72] reported that financial difficulties were highly prominent that both high income and low income countries.

Regarding psychological factors, the current study revealed that women with breast cancer receiving chemotherapy were moderately affected by all over psychological factors. These findings are in harmony with Høyer.et al. [73] and Tiezzi et al. [60] who reported that breast cancer and chemotherapy have significant impact on the psychological factors of women. Moreover, this study showed that about two-third of the studied women were moderately affected by ability to enjoy their life and feeling relax. This result may be related to most of women with breast cancer under chemotherapy feeling sad about their prognosis so always not enjoy with others. This is in line with Jafari et al. [74] who mentioned that cancer patient with a higher degree of peace in their lives were able to enjoy their life. This result supported by, Pinar [75] reported that more than third women with breast cancer feeling relax. Furthermore, Shams & Al-Azri [69] stated that counsellors for women with breast receiving chemotherapy use techniques as psychotherapy, relaxation, coping skills training and education, alone or in combination to improved women’s psychological factors.

The present study found that more than one third of the studied women were highly affected by feeling sad. This finding comes in line with Sucala et al. [49] who mentioned that nearly third of the studied women were highly affected by feeling sad. In same line, Elsheshtawy et al. [76] reported that there was high prevalence of sadness among Arab women with breast cancer receiving chemotherapy, as they face two major threats. The first one concerns women’s life and breast cancer being the most common cause of death among women. The second threat concerns psychological image as a competent woman, particularly in relation to sexuality, femininity, body image, and maternal issues.

The current study illustrated that more than half of the studied women were moderately affected by fear and worry about their condition. This result comes in line with Alzabaidey [38] and Waters et al. [77] who reported that most women with breast cancer were fear and worry about their breast cancer progressing. Moreover this finding supported by Butow et al. [78] who explained that when women are confronted with a health threat, an illness representation is activated, consisting of cognition and emotions about illness.

The current study revealed that about nearly half of studied women were highly affected by their appearance as well as near two third of studied women were highly affected by feeling less physically attractive. This finding supported by Rugo et al. [79] and Choi et al. [80] who reported that half of studied women had chemotherapy-induced alopecia distress and it was negatively associated with body image and physically attractiveness.

The present study found that near two third of the studied women were rarely affected by avoid being with people because their appearance. There was noticed that during data collection women emphasized that they had affected by change in their appearance but they still had self-confidence and not hesitate to engage with other people because their appearance. This finding is congruent with Assaf [81] and Williams & Jeanetta [82] who reported that women with breast cancer had to cope with changes in their aberrance.

Regarding spiritual factors, the present study revealed that women with breast cancer receiving chemotherapy were moderately affected by all over spiritual factors. This result is in agreement with Aghakhani et al. [83] who emphasized that spiritual factors were moderately affected women’ QOL and suggested that religious and spiritual factors could effectively promote the optimism of women with breast cancer.

Regarding self-awareness, the present study revealed that the majority of the studied women were highly affected by trusting in God and empathy with others. In Saudi culture, where pure religion of Islam, people believe fate and God’s will, this belief conveys more acceptance of challenges a combined with breast cancer disease. This result in the same line with Yanez et al. [84] who described that faith was uniquely related to perceived positive life changes following a cancer diagnosis. Moreover, regarding this finding is matched with Carr et al. [85] who reported that some women with breast cancer remain connected to their faith in God which give them strength and comfort.

The present study showed that near two-third of the studied women were highly affected by found meaning in difficult situation. In Islam, struggling and calamities consider a sign of God love. Therefore, Muslims believe that acceptance is the beginning of the journey against breast cancer. This result supported by, Yanez et al. [84] who described that spirituality is an inner peace subjective experience that makes people feel a strong interest in understanding the meaning of things in life. Therefore, they may not have had much time to think about meaning in difficult situation after breast cancer and chemotherapy treatment.

The current study found that near two-third of the studied women were rarely affected by loneliness. Because as mentioned before, women insist to engage with other people, however their illness. Moreover, this may be due to religious participation stimulated a positive emotion in women with breast cancer and this contributed to their body relaxation, spiritual and mental well-being. Thus, women can cope with the disease actively and optimistically. This result is in line with, Tsai et al. (2016) who reported that religion helps patients compensate with the feeling of helplessness and promotes health recovery with hope, confidence, and optimism.

Considering spiritual practices, the present study found that the majority of the studied women were moderately affected by thinking to achieve inner peace and any opportunity to enhance spirituality condition. People practicing Islam have acceptance of their illness and coping effectively. This result in line with Jafari et al. [86] and Yanez et al. [87] who emphasized that the capability to find meaning and achieved inner peace in life is more powerful contributor to favorable adjustment during chemotherapy.

Regarding spiritual needs, the current study found that the majority of studied women with breast cancer receiving chemotherapy were highly affected by listening to Holy Qur’an. This finding may be attributed to the fact of the Muslim Holy Qur’an involves all parts of life and sources of strength. This result is in line with Mirghafourvand spiritual music, which enhance the secretion of endorphins via the brain and stimulating alpha waves which interns, alleviates women’s anxiety, improve a sense of relaxation and enhances immune system. In this context, El-Shatby et al. [88] maintained listening Qur’an reproduce strong faith that spiritual support can relieving of the problem were highly satisfied with their faith in Allah and supposed that illness is not a punishment but rather exam of their religious commitment.

Concerning the overall QOL level, the current study revealed that women with breast cancer receiving chemotherapy had moderate level regarding overall QOL. This finding is reasonable considering the women in the study have moved from a state of health to confronting the reality of a health problem with ongoing chemotherapy treatment. This result is in line with Musarezaie, et al. [87] who showed that level of QOL in women with breast cancer under chemotherapy was moderate.

Regarding relation between factors affecting health and the QOL level, the current study illustrated that there was statistically significant negative relationship between overall factors affecting health and overall QOL of women with breast cancer receiving chemotherapy. This is in line with Begum et al. [89] who showed that there were a statistically significant negative relationship among factors affecting health and QOL.

Moreover, the present study revealed that there was statistically significant negative relationship between psychological factors and overall QOL level of women with breast cancer. This finding is consistent with Sharif [90] who mentioned that there was a significant negative association between QOL and psychological factors. In contrast, [91] mentioned that there was a positive association between QOL for women with breast cancer and psychological distress is well recognized.

Concerning relationship between demographic and clinical characteristics with factors affecting health related quality of life, the present study revealed that there was statistically significance difference regarding age group with physical factors, in which elderly women above 60 years old had affected by physical factors than under 60 years old. This finding supported by Paskett et al. [65] who mentioned that there was statistically significant difference between the age group on QOL.

Considering grade of breast cancer the current study showed that there was statistically significance difference between stages of breast cancer and psychological factors in which women in grade III affected by psychological factors more than grade I & II. This finding supported by Al-Naggar et al. [92] who mentioned that there was statistically significant association histological grade of breast cancer with psychological factors.

Finally, nurses play an important role in the assessment of physical, social, psychological and spiritual factors for women with breast cancer receiving chemotherapy. Therefore, nurses should integrate assessment into their routine general practice activity. Furthermore, the nurse must provide information to women with breast cancer and educating them about these side effects.

7. Conclusions

In conclusion, the majority of studied women with breast cancer receiving chemotherapy had moderately affected by overall social factors and nearly two third had moderately affected by overall psychological factors. While more than half were moderately affected by overall physical and spiritual factors. Moreover, women with breast cancer receiving chemotherapy had moderate level of overall QOL. There was statistically significant negative relationship between overall factors affecting health and overall women’ QOL. In addition, there was negative relationship between psychological factors and overall quality of life level. There was statistically significance difference between age group and physical factors.

8. Recommendations

Ÿ Developing assessment guidelines and management booklet about the side effects of chemotherapy.

Ÿ Establishing self-care practices educational program about the side effects of chemotherapy and how to manage it.

Ÿ Further researches are needed to get a better understanding of women perception, attitude and practice regarding chemotherapy side effects.

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