P A P E R
Health ‐ related quality of life and psychological distress among cancer survivors in a middle ‐ income country
Shridevi Subramaniam
1 |Yek ‐ Ching Kong
1 |Karuthan Chinna
2,3 |Merel Kimman
4 |Yan ‐ Zheng Ho
5 |Nadiah Saat
1 |Rozita Abdul Malik
6 |Nur Aishah Taib
7 |Matin Mellor Abdullah
8 |Gerard Chin ‐ Chye Lim
9 |Nor ‐ Saleha Ibrahim Tamin
10 |Yin ‐ Ling Woo
11 |Kian ‐ Meng Chang
12 |Pik ‐ Pin Goh
1 |Cheng ‐ Har Yip
8 |Nirmala Bhoo ‐ Pathy
21National Clinical Research Centre, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur, Malaysia
2Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
3School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
4Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, AZ Maastricht, The Netherlands
5Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia
6Clinical Oncology Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
7Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
8Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
9Department of Radiotherapy & Oncology, National Cancer Institute, Putrajaya, Malaysia
10Disease Control Division, Ministry of Health Malaysia, Putrajaya, Malaysia
11Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
12Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia Correspondence
Nirmala Bhoo Pathy MD PhD, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
Email: ovenjjay@gmail.com
Funding information
Roche Malaysia, Grant/Award Number:
UPUM/SSC.172
Abstract
Objectives:
Quality of life and psychological well
‐being are important patient
‐cen- tered outcomes, which are useful in evaluation of cancer care delivery. However, evi- dence from low
‐income and middle
‐income countries remains scarce. We assessed health
‐related quality of life (HRQoL) and prevalence of psychological distress (anxi- ety or depression), as well as their predictors, among cancer survivors in a middle
‐income setting.
Methods:
Through the Association of Southeast Asian Nations Costs in Oncology study, 1490 newly diagnosed cancer patients were followed
‐up in Malaysia for 1 year.
Health
‐related quality of life was assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ
‐C30) and EuroQol
‐5 (EQ
‐5D) dimension questionnaires at baseline, 3 and 12 months. Psychological distress was assessed by using Hospital Anxiety and Depression Scale. Data were modeled by using general linear and logistic regressions analyses.
Results:
One year after diagnosis, the mean EORTC QLQ
‐C30 Global Health score of the cancer survivors remained low at 53.0 over 100 (SD 21.4). Fifty
‐four percent of survivors reported at least moderate levels of anxiety, while 27% had at least moder- ate levels of depression. Late stage at diagnosis was the strongest predictor of low HRQoL. Increasing age, being married, high
‐income status, hospital type, presence of comorbidities, and chemotherapy administration were also associated with worse HRQoL. The significant predictors of psychological distress were cancer stage and hospital type.
Conclusion:
Cancer survivors in this middle
‐income setting have persistently impaired HRQoL and high levels of psychological distress. Development of a holistic cancer survivorship program addressing wider aspects of well
‐being is urgently needed in our settings.
K E Y W O R D S
cancer, middle income, oncology, psychological distress, quality of life DOI: 10.1002/pon.4787
Psycho‐Oncology. 2018;1–8. wileyonlinelibrary.com/journal/pon © 2018 John Wiley & Sons, Ltd. 1
1
|B A C K G R O U N D
With more and more patients surviving cancer in recent times,1quality of life and psychological well‐being are increasingly being recognized as important patient‐centered outcomes, which are useful in evaluation of cancer care delivery. While many studies have assessed health‐related quality of life (HRQoL)2in cancer patients, much of the evidence to date has been generated from those living in high‐income settings, who are more likely to have access to cancer screening services, timely diagno- sis, optimal treatment, good survivorship care plan, and palliative care.3 Studies examining HRQoL and psychological distress among cancer patients living in low‐income and middle‐income settings are relatively scarce and often limited by small numbers, or focused on subsets of patients receiving a particular cancer therapy, hence limiting the gener- alizability and translation into policy and practice.4,5
Between 2012 and 2014, the Association of Southeast Asian Nations Costs in Oncology (ACTION) study was conducted across 8 low‐income and middle‐income Southeast Asian countries to examine the impact of cancer on household economic well‐being and patients' survival and quality of life.6We recently showed that 1 year after diagnosis, the mean EORTC QLQC30 global health score for cancer survivors in the Southeast Asian region was 66.2 out of 100, the mean index score on the EQ‐5D was 0.74 out of 1.00, with 37% and 46% of survivors reporting at least mild levels of anxiety and mild levels of depression, respectively.7
Moreover, a report on breast cancer by The Economist Intelli- gence Unit in 2016 had revealed that Malaysia scored poorly in the area of providing cancer survivorship care.8 This is corroborated by the findings of a recent survey in a tertiary academic hospital with established oncology services in the country, which revealed that the psychological needs of women with breast cancer were left unmet.9 Using data from the ACTION study, we undertook country‐specific analysis to assess the HRQoL and prevalence of psychological distress 1 year after diagnosis among cancer survivors in Malaysia, a multieth- nic middle‐income country with universal health coverage. In this study, an individual was considered a cancer survivor from the time of diagnosis through the balance of his or her life.10Apart from facil- itating development of national policies in cancer survivorship care and optimizing the use of limited resources in the country, the study findings may also be used for informed decision making pertaining to cancer care delivery in other middle‐income countries.
2
|M E T H O D S
2.1
|Ethics approval
The ACTION study has obtained ethics approval from the Medical Research and Ethics Committee Ministry of Health Malaysia (NMRR‐11‐800‐10093). Written informed consent was obtained from all participants prior to entry into the study.
2.2
|Study population
The current study used data from the ACTION study, a longitudinal study in which the impact of cancer on patients' finances and HRQoL
was assessed in 8 low‐income and middle‐income Southeast Asian countries. Further details of the study have been described else- where.6 In the present analysis, only the Malaysian patients were included. A total of 1662 patients were recruited from 9 Malaysian states comprising newly diagnosed cancer patients with solid and nonsolid tumors from 12 general government hospitals, 1 academic hospital, and 2 private centers (Appendix S1). One year after diagnosis, 9.5% (n = 158) of the initial study population had died and 1.0%
(n = 14) were lost to follow up and were subsequently excluded from this study. Thus, the remaining 1490 cancer patients who were alive and contactable at 1 year after cancer diagnosis were included.
2.3
|Data collection
Face‐to‐face interviews were conducted to collect baseline data on demographic characteristics (age, sex, marital status, and highest attained education) and socioeconomic status (employment status, annual household income, and health insurance status). Self‐reported household income was grouped into low (0%‐75% of mean national income), middle (75%‐125%), and high (>125%) categories. Data on clinical characteristics (cancer site, staging, and comorbidities) and treatment (surgery, chemotherapy, radiotherapy, and hormone therapy) were obtained from medical records at the third and twelfth month after diagnosis.
Study participants were interviewed by trained research staff to measure cancer‐specific and generic HRQoL and psychological dis- tress at baseline (within 12 weeks after clinical diagnosis) and at the third and twelfth month after diagnosis. All questionnaires were administered in local languages.6 Notably, the local language ver- sions of HADS, EORTC QLQ‐C30, and EQ‐5D have been previously validated.11-13 Cancer‐specific HRQoL was assessed by using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life Questionnaire Core 30 (QLQ‐C30) version 3.014; higher scores in the functional and global health domains indicate better HRQoL, whereas higher scores in symptom scales represent worse HRQoL.15 Generic HRQoL was assessed by the EuroQol‐5 dimension questionnaire (EQ‐5D).16The Malaysian Tariff for EQ‐5D was used to calculate index scores; full health is scored at 1 and death at 0.17 Psychological distress was determined by using the Hospital Anxiety and Depression Scale (HADS) with 2 subscales, anxiety (HADS‐A) and depression (HADS‐D).18 Cutoff of
≥11 was used for both scales to indicate cases of at least moder- ate anxiety and depression, respectively19 (see the supporting information).
2.4
|Statistical analysis
Descriptive statistics were used to report the distribution of demo- graphic, socioeconomic, and clinical characteristics of patients. The distribution of HRQoL scores and prevalence of anxiety and depres- sion at 12 months after diagnosis of cancer were determined. A general linear regression analysis (using backward method) with HRQoL as the endpoint was performed to determine the independent predictors of HRQoL. Beta coefficient was considered statistically sig- nificant if the 95% CI does not include 0. Logistic regression models
(backward method) were used to identify the predictors of anxiety and depression, respectively. In this analyses, odds ratios were considered statistically significant if the 95% CI did not include 1.
3
|R E S U L T S
Baseline characteristics of the 1490 cancer survivors with complete follow up at 12 months are shown in Table 1. More than half of the patients (52%) treated in Ministry of Health (MOH) hospitals were from the low‐income category, whereas the majority of patients in the private hospitals were from the high‐income category (59%).
Patients treated in public academic hospital were largely from mid- dle‐income (31%) and high‐income groups (25%).
The mean global health score based on QLQ‐C30 at baseline was 60.8. At 3 months, the mean global health score of the study partici- pants dipped to 56.8, and at 1 year after diagnosis, this score remained low at 53.0 (Table 2). Mean score on function scales at 1 year ranged from 63.3 for emotional function up to 88.1 for cognitive function. In symptoms scales, the cancer patients reported worst scores for fatigue and pain, while better scores were observed for diarrhea and constipa- tion. At baseline, 38.9% of patients reported moderate or severe anx- iety, whereas 21.3% of patients reported moderate or severe depression. The proportion of patients reporting psychological distress increased further at 3 months after diagnosis (Table 2). One year after cancer diagnosis, only 16.3% of patients reported no symptoms of anxiety, whereas 29.8% reported mild anxiety symptoms, 38.4% had moderate level of anxiety, while 15.5% reported severe anxiety. On the other hand, 21.2% of patients did not report any symptoms of depression at 1 year, whereas 51.6% reported mild depression, 15.5% reported moderate depression, and 11.7% had severe level of depression.
The HRQoL scores and psychological distress based on patients' demography at 1 year after diagnosis are shown in Table S1 (see the supporting information). Clinically meaningful differences in HRQoL scores were seen among patients above 65 years compared with age
<45 years for physical and emotional function. Older patients also reported worst scores for fatigue. Nevertheless, older participants reported lower prevalence of anxiety (40.9% vs 46.8%) and depression (18.5% vs 25.3%) compared with the younger patients. Compared with patients from the high‐income category, those with low income reported high physical function, emotional function, and global health as well as decreased pain and fatigue. Advanced cancer stages (stages III and IV) were associated with lower physical function, emotional func- tion, and global health scores compared with patients with stage I or stage II tumors. Analyses based on cancer sites showed that the mean QLQ‐C30 global health scores was lowest in patients with lymphoma but did not vary substantially among other sites (see the supporting information: Figure S1). Patients with preexisting comorbidity reported lower physical and emotional functions as well as high fatigue scores.
Institutional variations in HRQoL were also observed. Patients treated at the public academic hospital for instance reported lower HRQoL score compared with patients treated in MOH Hospitals (physical score: 68.2 vs 77.9, emotional score: 53.1 vs 74.7), and also showed high pain and fatigue score. However, the patients from
TABLE 1 Demographic, socioeconomic, and clinical characteristics of the 1490 study participants
Characteristic
Overall
n %
Age, mean (SD) 51.5 (14.69)
<45 466 (31.3)
45‐54 362 (24.3)
55‐64 376 (25.2)
≥65 286 (19.2)
Gender
Male 562 (37.7)
Female 928 (62.3)
Education level
Primary 450 (30.2)
Secondary 707 (47.5)
Tertiary 333 (22.3)
Marital status
Married 388 (26.0)
Unmarried 1102 (74.0)
Hospital type
Ministry of Health hospitals 723 (48.5)
Public academic hospital 665 (44.6)
Private hospitals 102 (06.9)
Income status
Low 609 (45.9)
Middle 435 (32.8)
High 282 (21.3)
Missing 164
Health insurance
Insured 412 (27.6)
Uninsured 1078 (72.4)
Cancer stage at diagnosis
Early stage 325 (28.9)
Late stage 448 (39.9)
Hematologic tumor 350 (31.2)
Missing 367
Cancer site
Mouth 118 (07.9)
Colorectal 181 (12.1)
Breast 466 (31.3)
Female reproductive 94 (06.3)
Lymphomas 350 (23.5)
Others 281 (18.9)
Radiotherapy
No 842 (56.9)
Yes 637 (43.1)
Missing 11
Surgery
No 967 (65.3)
Yes 513 (34.7)
Missing 10
Chemotherapy
No 397 (26.8)
(Continues)
MOH hospitals were more likely to report higher levels of anxiety and depression.
Findings from the multivariable regression analysis showed that older age, being married, high‐income status, being treated in aca- demic hospital, presence of co‐morbidity, advanced cancer stage or hematological malignancies, and chemotherapy administration remained as significant and independent predictors of worse HRQoL (Table 3). Of these, cancer stage at diagnosis emerged as the strongest predictor of HRQoL. Patients with hematologic malignancies were
independently associated with less psychological distress compared with patients with late stage solid tumors (Table 4). Patients treated in the public academic hospital were also less likely to be associated with psychological distress compared with their counterparts in MOH hospitals.
4
|D I S C U S S I O N
A year after diagnosis, cancer survivors in this middle‐income setting with universal health coverage continued to report impaired HRQoL and high prevalence of anxiety and depression. Compared with results from the regional study involving 8 Southeast Asian countries,7we observed a substantially lower mean global health score (53.0 versus 66.2), and higher proportion of psychological distress at 1 year among the Malaysian cancer survivors. These differences may be explained by variations in participant characteristics between the countries, namely, in cancer sites and stage, as well as socioeconomic status.7 Nonetheless, a common observation was that advanced cancer stage at diagnosis was strongly associated with poorer HRQoL compared with presentation with stage I or stage II tumors. Stage and site of can- cer reflect disease severity and are main determinants of the inten- siveness of cancer therapy. In patients with advanced cancer stages, quality of life may commonly worsen due to fatigue and pain20,21as well as due to side effects from more aggressive treatments.22,23
A striking observation was that as opposed to the regional study, which found that low‐income status was associated with low HRQoL, in the current study, patients from high‐income groups were more likely to be associated with low HRQoL. Socioeconomic status has been well documented to be a significant predictor of HRQoL among cancer survivors, in which those from the lower education and income stratums have been associated with poorer outcomes.7Contrary to expectations, our study found that patients from the low‐income group reported better HRQoL compared with those from the high‐ income group. While this may appear to be explained by the fact that patients from low‐income groups may have been more likely to receive subsidized cancer care from the general government (MOH) hospitals, leading to lesser financial worries, multivariable adjustment showed that low‐income status remains independently associated with high HRQoL following adjustment for type of hospital. Alterna- tively, it is possible that in Malaysia, which enjoys a much higher GDP than its counterparts participating in ACTION study,24 the high‐income patients generally have higher expectations of their treat- ment outcomes and recovery. Furthermore, it is thought that patients from low‐income categories may have reported higher HRQoL as they are more likely to be religious and hence optimistic25and come from close‐knit communities with better social support, leading to better coping strategies.26This is also supported by findings from a previous study in Malaysia, whereby the presence of social support in the low‐ income group was associated with increased HRQoL.27
In a pooled analysis of 25 EORTC randomized controlled trials that included data from 6024 cancer patients, age was found to be a significant predictor of HRQoL.28Besides managing the side effects from their cancer and treatment, older cancer patients also face addi- tional challenges in dealing with age‐related health problems. A TABLE 1 (Continued)
Characteristic
Overall
n %
Yes 1084 (73.2)
Missing 9
Hormonal therapy
No 1304 (88.2)
Yes 174 (11.8)
Missing 12
Comorbidity
Absent 1077 (72.3)
Present 413 (27.7)
TABLE 2 Health‐related quality of life and psychological distress following diagnosis with cancer in 1490 participants
Baseline 3 Months 12 Months Health‐Related Quality
of Life Mean SD Mean SD Mean SD
Cancer‐specific HRQoL (EORTC QLQ‐C30)
Global health 60.8 22.2 56.8 21.0 53.0 21.4 Physical function 72.3 25.4 70.0 19.6 72.7 18.8 Emotional function 66.6 28.7 60.1 28.1 63.3 26.0 Role function 62.8 33.6 60.7 27.9 64.1 28.3 Cognitive function 80.6 22.8 84.8 20.6 88.1 19.1 Social function 65.9 31.5 62.3 26.6 68.5 21.6
Fatigue 38.3 29.0 36.6 23.7 32.1 24.2
Nausea/vomiting 14.4 23.6 24.9 22.9 21.6 18.0
Pain 32.6 27.6 31.3 22.6 26.7 23.7
Dyspnea 16.0 25.9 20.8 23.7 21.4 21.8
Insomnia 30.0 34.1 24.2 26.4 24.0 27.9
Appetite loss 23.6 31.2 24.0 28.3 23.7 27.7
Constipation 13.8 26.1 18.5 25.3 17.8 22.9
Diarrhea 9.1 21.0 13.4 21.5 15.8 20.2
Generic HRQoL (EQ‐5D)
Index score 0.74 0.20 0.69 0.19 0.71 0.18
Psychological distressa N % N % N %
Anxiety (HADS‐A) 579 38.9 721 51.0 668 53.9 Depression
(HADS‐D)
316 21.3 400 28.3 336 27.1
Abbreviations: EORTC QLQ‐C30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; EQ‐5D, EuroQol‐5; HADS, Hospital Anxiety and Depression Scale; HRQoL, health‐related quality of life.
aAnxiety (moderate or severe anxiety; HADS‐A score > =11); depression (moderate or severe depression; HADS‐D score > =11).
TABLE3Standardizedbetasfrommultivariablelinearregressionanalyses(backwardmethod)aevaluatingtheassociationbetweenindependentvariablesandHRQOLacrossallcancers,at1yearafter diagnosis(N=1490) VariablesPhysicalFunctionEmotionalFunctionGlobalHealthPainFatigue Age−0.14(−0.23,−0.06)c−0.12(−0.22,−0.03)b0.17(0.05,0.28)b0.21(0.10,0.32)c Maritalstatus Married3.98(0.70,7.26)b UnmarriedRef Hospitaltype MOHRefRefRefRefRef Publicacademichospital−11.81(−14.63,−8.99)c−19.26(−22.94,−15.57)c−5.35(−8.42,−2.28)c9.88(6.15,13.61)c15.30(11.76,18.85)c Private−5.25(−11.73,1.23)−7.38(−15.95,1.19)−5.95(−13.01,1.11)2.72(−5.86,11.30)6.21(−1.89,14.31) Incomestatus Low5.19(2.24,8.13)c9.45(5.55,13.34)c3.78(0.58,6.98)b−6.18(−10.07,−2.30)b−10.41(−14.08,−6.73)c Middle0.84(−2.26,3.94)6.92(2.82,11.02)c1.31(−2.07,4.70)−1.42(−5.52,2.69)−7.42(−11.30,−3.55)c HighRefRefRefRefRef Cancerstageatdiagnosis EarlystageRefRefRefRefRef Latestage−7.46(−10.13,−4.80)c−13.45(−16.98,−9.92)c−7.94(−10.85,−5.03)c12.57(9.03,16.10)c12.08(8.75,15.41)c Hematologictumor−10.34(−13.82,−6.85)c−1.42(−5.94,3.09)−33.52(−37.31,−29.72)c10.07(5.47,14.68)c5.92(1.57,10.28)b Chemotherapy No2.89(0.12,5.65)b YesRef Comorbidity Absent3.61(1.11,6.11)b4.34(1.07,7.62)b−5.41(−8.54,−2.28)c PresentRefRefRef Abbreviations:β,beta‐coefficient;CI,confidenceinterval. aInitialmodelincludedage,sex,maritalstatus,hospitaltype,incomestatus,healthinsurance,cancerstageatdiagnosis,surgery,chemotherapy,radiotherapy,andcomorbidity. bP‐value≤.05. cP‐value≤.001.
possible explanation for our observation that married cancer patients were experiencing higher fatigue level compared with unmarried can- cer patients is that there were more likely to be burdened by their social responsibilities. A previous study had further showed that mar- ried cancer patients lacked confidence in performing stress reduction strategies and had low efficacy for self‐care.29
Findings from the current study highlighted that patients treated in the general public (MOH) hospitals were independently associated with better quality of life compared with patients in the public aca- demic hospital. This may be explained to a substantial extent by the underlying differences in ethnic composition of cancer patients seen in the general public, academic, and private hospitals in Malaysia.
Notably, previous studies have shown that ethnicity is an independent determinant of HRQoL as it tends to serve as a proxy of cultural health beliefs, social support, spirituality, and socioeconomic status.27,30 Unfortunately, we were unable to adjust for the ethnic differences among participants as the data were not collected within the main framework of the ACTION study. Furthermore, cancer care subsidy in MOH hospitals are higher than in the public academic hospitals, making it possible for patients in MOH to experience less financial concerns than their counterparts seeking care in the academic and pri- vate hospitals, ultimately leading to a better sense of well‐being.
Residual confounding from economic status may also explain the var- iations in HRQoL between the different hospitals given that patients managed in the academic hospital in this study largely comprise mid- dle‐and high‐income urban residents,31who might have higher expec- tations from health services compared with low‐income patients.
As found in previous studies, patients who did not receive chemo- therapy reported better global health scores compared with patients who underwent chemotherapy.32 This is conceivable given that the adverse effects of adjuvant chemotherapy may persist up to 1 year after treatment and only resolve later on.33,34It has to be noted that the short‐term and long‐term side effects of chemotherapy may be alleviated by high‐quality supportive care35 including symptom
management. Apart from the focus on provision of optimal cancer treatment, effective management of the side effects of cancer therapy such as pain and nausea must therefore be prioritized in low‐income and middle‐income settings. Furthermore, we would like to echo the view that supportive care in cancer management should also include addressing the emotional, social, spiritual, and practical needs of cancer patients.36
The persistently high prevalence of psychological distress found in this study is particularly alarming, whereby a substantial proportion of our cancer survivors continued to report moderate to severe levels of anxiety and depression at 1 year following diagnosis. This may be explained by the fact that a considerable proportion of Malaysian can- cer patients tend to avoid discussing about their physical and mental health or seek help because of the social and cultural stigma attached to a cancer diagnosis. It was also noted that the prevalence of anxiety appeared to be higher, compared with depression in the present study.
A previous Malaysian study, which had demonstrated similar findings among breast cancer survivors, had postulated that the feeling of uncertainty on disease progression and cancer recurrence among the cancer survivors may serve as a major driver of anxiety.37 While involvement of psychiatrists or psychologists in the provision of men- tal health services to cancer survivors may be out of reach in most low‐income and middle‐income settings, international guidelines have recommended some pragmatic alternatives for resource limited set- tings. At basic levels of resource allocation, health professionals are for instance encouraged to refer affected patients for peer support by trained volunteers.38This further implies that provision of effective cancer survivorship services in low‐income and middle‐income coun- tries may require active engagement of civil societies including patient support groups, nongovernmental organizations, philanthropic foun- dations, faith‐based organizations, and professional associations to reduce the burden on health systems. Albeit reporting lower HRQoL, patients from academic hospitals were less likely to experience psy- chological distress than their counterparts in MOH hospitals. Access TABLE 4 Multivariable logistic regression (backward method) analysisaevaluating the association between independent variables and psycho- logical distress across all cancers at 1 year after diagnosis (N = 1490)
Variables
Anxietyb Depressionc Distressd
OR (95% CI) OR (95% CI) OR (95% CI)
Cancer stage at diagnosis
Early stage 1.05 (0.74, 1.48) 1.40 (0.95, 2.05) 1.11 (0.78, 1.59)
Late stage Ref Ref Ref
Hematologic malignancies 0.47 (0.31, 0.71)f 0.88 (0.56, 1.37) 0.52 (0.34, 0.80)e
Hospital type
MOH Ref Ref Ref
Public academic hospital 0.33 (0.23, 0.47)f 0.52 (0.36, 0.77)f 0.31 (0.21, 0.45)f
Private 0.63 (0.27, 1.46) 1.12 (0.43, 2.93) 0.73 (0.31, 1.74)
Abbreviations: CI, confidence interval; OR, odd ratio.
aInitial model included age, sex, marital status, hospital type, income status, health insurance, cancer stage at diagnosis, surgery, radiotherapy, chemother- apy, and comorbidity.
bAnxiety (moderate or severe anxiety; HADS‐A score > =11).
cDepression (moderate or severe depression; HADS‐D score > =11).
dInclude anxiety or depression (HADS‐A score > =11, or HADS‐D score > =11).
eP‐value≤.05.
fP‐value≤.001.
to mental health services in MOH hospitals may be limited because of the overwhelming volume of patients. While it is conceivable that there is a stronger presence of mental health professionals in manage- ment of cancer patients within the academic setting, we remain cau- tious with our interpretation.
A major strength of this study includes the recruitment of a rela- tively large study population diagnosed with various types of cancers from different geographical regions, and economic status representa- tive of the cancer survivors in Malaysia. The present study therefore provides the best available evidence on HRQoL and psychological dis- tress in a large population of cancer survivors in a middle‐income Asian.
5
|C L I N I C A L I M P L I C A T I O N S
The present findings highlight the need for routine screening for psy- chological distress among cancer survivors in low‐income and middle‐ income settings. Establishment of cancer survivorship services within hospital and community settings should therefore be considered as high priority, and it is important that these services comprise supportive interventions addressing wider aspects of well‐being including the emotional, social, spiritual, and practical needs of cancer survivors.
There is a lack of psycho‐oncologists in limited resource settings, where the delivery of cancer care seems to be focused on treatment alone rather than the after‐care of cancer patients. Hence, the development of psycho‐oncology services within the health services is imperative.
Ultimately, the above requires multisectoral collaborations, task sharing of existing services, eg, rehabilitation services, community support, and most importantly, the political will to put in place policies leading to development of a holistic national cancer survivorship care plan that can lead to improvement in the quality of life of cancer survivors.
6
|S T U D Y L I M I T A T I O N S
Although widely endorsed as one of the best available measures of anxiety and depression, the use of the HADS across languages and cultures had been criticized due to concerns of unknown influence of linguistic and cultural factors on cut‐points for anxiety and depres- sion.39We also acknowledge that data on ethnicity, social support, religiosity, and information on understanding and knowledge of cancer among survivors were not available, which may impact self‐reported QOL and psychological well‐being.
7
|C O N C L U S I O N
This study points toward a high cancer burden in impaired HRQoL and psychological distress, among cancer survivors living in a middle‐ income country with universal health coverage. Development of a holistic cancer survivorship program addressing wider aspects of well‐being is urgently needed in our settings.
A C K N O W L E D G E M E N T S
This study was supported by an unrestricted educational grant from Roche Malaysia. We would like express our sincere gratitude to all
the patients and their family members who participated in ACTION study. We also acknowledge the support from all the physicians and health personnel (see the supporting information) who assisted with patient recruitment and study management at participating sites.
C O N F L I C T S O F I N T E R E S T
M. K., C. H. Y., and N. B. P. have received speaker fees and funding for travel and conference participation from Roche. All other authors declare no potential conflicts of interest.
E T H I C S S T A T E M E N T
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
O R C I D
Nirmala Bhoo‐Pathy http://orcid.org/0000-0003-0568-8863
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S U P P O R T I N G I N F O R M A T I O N
Additional supporting information may be found online in the Supporting Information section at the end of the article.
How to cite this article: Subramaniam S, Kong Y‐C, Chinna K, et al. Health‐related quality of life and psychological distress among cancer survivors in a middle‐income country.Psycho‐ Oncology. 2018;1–8.https://doi.org/10.1002/pon.4787
