الفهرس 
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Abstract
SUMMARY
Breast cancer is a significant health problem worldwide and a complex disease both
physically and psychologically .Not only breast cancer cause negative impact on women
quality of life but also used treatment such as mastectomy, chemotherapy, radiation
therapy and hormonal therapy cause physical, mental stress and leading to changes in
every day women life.
Researchers suggested that breast cancer treatments can have long-term physical,
psychological, sexual and cognitive effects that may influence quality of life. There are
many reasons for measuring QoL as to justify or refuse the different forms of medical
treatment, to identify the squeal of disease or treatment which may be resolved by other
therapeutic interventions including nursing and to provide a basis for allocating resources
to carry those treatments which are judged to be cost effective. Post mastectomies
women’s’ quality of life can be recognized and derived from in-depth analysis of many
aspects of quality of life including: Physical health, Psychological health, level of
independence, social relationship, environment and spirituality. The present study aimed
to identify factors associated with quality of life among women undergoing hormonal
therapy post mastectomy.
A descriptive cross sectional research design was used to carry out this study. It had
been carried out in one setting: hormonal therapy outpatient clinics in oncology center in
Damanhour city at EL-Beheira governorate. The present study subjects was 200 women
with mastectomy received hormonal therapy with specific inclusion criteria , were in
reproductive age period , married and live with her husband, no history of chronic disease,
absence from mental and physical disability and conducted mastectomy surgery at least
from one month.
Two tools were used to collect data in this study .Tool I - Women structured
interview schedule: it was developed by the researcher after reviewing recent literature in
order to collect required data about the post mastectomies women’s’ socio-demographic
and socioeconomic characteristics , women’s health profile that covered family history of
breast cancer or any type of cancer ,menstrual history, obstetric history and history of
current cancer .Tool II Quality of Life Assessment scale Sheet (WHOQOL-100): This
sheet was derived from WHO quality of life -100. It included: six domains namely:
physical functioning, psychological, level of independence, social relationships,
environment and spirituality.
Process of data collection:
-
Official letters from the faculty of Nursing, Damanhour University was
directed to the director of oncology center to inform him about the study aim
and to take their permission for conducting the study.
-
Non probability sampling method was utilized to draw a convenient sample of
200 women participated in study. The study sample of women who were at the
time of study attending breast cancer follow up appointment or receiving
hormonal therapy after mastectomy operation.
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301
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The tools were tested for face and content validity by Jury composed of (five)
experts in the field of Community Health Nursing, Medical Surgical Nursing
and Obstetric Nursing.
-
Approvals were obtained for conducting the study from post mastectomies
women.
-
A pilot study was carried out on (20) post mastectomies women to assure the
clarity, applicability and comprehension of the tool and identify obstacles and
problems that might be encountered during data collection.
-
The study was conducted in a period of 6 months (from February 2020 to
November 2020) . (from April 2020 to June 2020) 3 months ban due to wave
of corona virus.
-
Data was collected by the researcher then appropriate descriptive and
analytical statistics were carried out such as arithmetic mean, standard
deviation, Chi square, Monte Carlo tests of significance and logistic regression
analysis.
The main results obtained from the study were as follows:-
Section
I:
Post
mastectomies
women
socio
demographic
and
socioeconomic data:
- Post mastectomies women age ranged from (18 to ≤ 45) years, with a mean of 36.64 ±
5.33 years. Nearly less than half (48.5%) of them aged 30 years to less than 40 years.
- The majority (91.0%) of the studied women were muslim and only (9%) were christian .
- More than one third (37%) of patients had obtained secondary education while about
one quarter (24.5%) had university education, while more than one tenth of them (10.5
% & 14.0%) had preparatory education and illiterate respectively.
- More than two thirds (69.5%) of the studied women were house wife and less than one
third(30.5%) were work .
- More than half (55.5%) were living in rural areas and less than half (44.5%) were living
in urban areas.
- The majority (82.5%) of the studied women hadn’t insured related to health and only
(17.5%) had health insurance.
- More than half (60.5%) of the studied women belonged to nuclear families ,almost two
fifths (39.5%) belonged to extended family ,less than two thirds (62.5%) of them their
families consisted of 5 and more members while the same percentage (15.5%) of them
consisted of 3 and 4 members respectively.
- The majority (94.5%) of the studied women families’ income were 500 pounds / month
or above while only (5.5%) of them their income were less than 500 LE / month.
- More than half (53%) of studied women didn’t use computer and less than half (47%) of
them used computer.
- The same percent of studied women (45%) belonged to medium and high class while
the rest of them (10%) belonged to low class.
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301
Section II: Post mastectomies women family history of breast cancer or
any type of cancer & menstrual and obstetric history:
- Highest percent of the studied women (28.5%) had family history of different type of
cancer as colon ,liver , lung ,bone , stomach . while exactly one fifth (20%) of them
had family history of cancer in reproductive organs and one tenth (10%)of them had
family history of breast cancer. On the other hand less than half (45%) of them had a
first degree family history of breast cancer and more than half (55%) of studied women
had second degree of relatives of family history of breast cancer.
- Two fifths (38%) of the studied women, their menstruation started at age of twelve to
less than fourteen years while more than one quarter (26%) of them started menstruation
at the age below twelve years. It is also observed from the table that the majority
(77.5%) of the studied women had irregular menstruation.
- Less than two thirds (62%) of the studied women, menstruation frequently every 30
days or more while more than one fifth (21.5%) of them, their menstruation came every
25 to less than 30 days.
- The majority (83.7%) of the studied women had small amount of menstruation.
- The majority (90%) of studied women had previous pregnancies and only (10%) no
previous pregnancy.
- More than half (56.7%) didn’t use any family planning method and less than half
(43.3%) used family planning methods. About half (52.8%) of studied women didn’t
use oral hormonal contraceptive pills .
- The majority (81%) of studied women had previously breast fed their children but about
one fifth (19%) of them didn’t breast fed their children.
Section III: History of current cancer:
- More than half (55%) of studied women had stage (II)in which tumor spread beyond the
breast tissue and reach to the lymph node and more than one third of them (35%) had
stage (I) in which tumor spread beyond the breast .
- More than half (60.5%) of the studied women didn’t have problems in the lymph nodes
under the armpit of a resurrected breast .
- More than half (56.5%) of them took tamoxifen and almost two fifths (38.5%) of them
took aramedix (1mg). More than one third (34%) of them took zoladex 30 days and
only (9.5%) took aromsin.
- About one third(32%) of studied women spent five years and more than one quarter
(28.5%,29.5% )of them spent seven years and lifelong in hormonal treatment
respectively.
- Highest percent (51%) of women in the study reported that breast mass, presence of
twitch, breast shrinkage and skin rash were the most presenting manifestation.
- Less than three quarters (73.5%) of the studied women had hormonal therapy side
effect.
- The majority (96.5%) of studied women comply regularly with the follow up visits.
- No women reported recurrence of cancer to other breast.
- The majority (86.5%) of studied women wouldn’t use breast prosthesis, performed
breast cancer nuclear scan and had knowledge regarding breast cancer.
- Regarding physical problems associated with the illness, less than two thirds(61.5%) of
the studied women had difficulty of arm movement , more than three quarters(77.5%)
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301
had numbness in the arm of operation, less than two thirds (63%) had weakness in the
arm of operation and the majority of them (83.5%) had edematous of the arm.
- Regarding psychological problems associated with the illness ,low self - esteem after
operations reported by less than two thirds (62%) of women, less than two thirds
(63.5%) had sadness feeling, Less than two thirds (64.5% ) had stress feeling and Less
than two thirds (61.5%) had shy feeling and less than two thirds(60%) continuous
depression after operation
- Social problems associated with the illness, more than half (56%) not limit visit to
relatives, less than half (46.5%) avoid appearing in social events and less than half
(45.5%) reported lack on going out to public place.
Section Iv: Quality of life assessment of post mastectomy women:
- More than half of the studied women (57.5%) had fair quality of life while more than
two fifths (42%) of them had poor quality of life with a mean of 51.27 ± 10.75.
- The four domains that women had better quality of life included: environment, level of
independence, social support and Psychological health domains. Environment and level
of independence domains, received the highest score with mean score ranging from
(53.82 ± 12.39) and (53.23 ± 8.34) respectively. This was followed by Social
relationships and Psychological health domains with mean scores ranging from :( 52.09
± 12.65) and (50.0 ± 14.46) respectively.
- In addition, the three domains where patients had lower quality of life included:. The
physical domain received the lowest mean Quality of Life scores (45.24 ± 16.07). This
was followed by general quality of life and the spirituality domains were associated
with lower QoL mean scores as well (48.88 ± 18.47 and 47.28 ± 18.70)respectively.
Section V: Impact of post mastectomy and hormonal therapy on quality
of life:
- There is statistically significant difference between the women’s QoL and their age
.Younger age of studied women 30-<40 years (52.2%) had fair quality of life and more
than one third (34.8%) of those in those aged equal or less than 45 years had fair quality
of life.
- Statistically significant difference was observed between the women’s QoL and their
secondary education (MCp = <0.001). Nearly one quarter (26.2%) of illiterates reported
poor quality of life.
- There is statistically significant difference between the women’s QoL and their
occupation .The majority (72.6%) house wife women had poor quality of life and
about one third (32.2%) of them who work had fair quality of life.
- More than half (59.5%) of the studied women who belonged to nuclear families and
(40.5%)who belonged to extended families had poor quality of life .
- Statistically significant difference between the women’s QoL and their socioeconomic
status (MCp =<0.001). Less than half (48.8%) of them with medium class and less than
one third (32.1%) with high class had poor quality of life.
- About one tenth (9.5%) of studied women had family history of breast cancer had poor
quality of life.
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301
- No statistically significant difference between the women’s QoL and their previous and
number of pregnancy (MCp =0.317 ,MCp =0.155 respectively). More than half (56.2%)
of studied women who had three or more pregnancy had poor quality of life.
- No statistically significant difference between the women’s QoL and their number of
labor and type of labor(MCp =0.115 ,MCp =0.522 respectively). Poor quality of life
among women reported in less than half (47.9%) with three labor or more and more
than half (60.3%) of them who had normal delivery.
- Statistically significant difference between the women’s QoL and using family planning
methods (MCp =0.011).More than two third (68.5%) of the studied women who didn’t
use family planning methods had poor quality of life.
- No statistically significant difference between the women’s QoL and using oral
hormonal pills (MCp =0.200).More than half (58.9%) of the studied women who didn’t
use oral hormonal pills had poor quality of life.
- More than one third (33.3% ,36.7%) who used oral hormonal pills for duration one to
two years and two to three years respectively had poor quality of life.
- No statistically significant difference between the women’s QoL and breast feeding
(MCp =0.488).More than three quarters (77.4%) of studied women who breastfed her
children had poor quality of life and more than half (53.8%) of them who breastfed
during maternity cycle for duration more than or equal eighty month respectively had
poor quality of life.
Most common predictors of quality of life among women
undergoing hormonal therapy post mastectomy:
The most independent risk factors associated with poor QoL were women’s
education( OR═4.545, P=0.017) in which lower educated is more risk for poor
QoL (4) fold than higher educated, monthly income (OR═4.936, p =0.002) in
which not enough income is more risk for poor QoL (4) fold than who have
enough income, using of family planning methods ( OR═6.431, P=0.001) in
which non user is more risk for poor QoL (5) fold than user , Stage (III) in
which tumor spread beyond the breast tissue , reach to the lymph node near to
chest bone (OR═16.010 , p =0.004) is more risk for poor QoL (16) fold than
other locations and the presence of sores in the breast skin(OR═1.192, p
=0.006) in which women who had this signs are risk for poor QoL (1) fold than
other signs.
The most independent protective factors associated with good QoL were
women’s age( OR═0.837, P=0.015) in which old age are (80%) protective for
good QoL than young age , occupation (OR═0.201, p =0.017) in which worker
women are (20%) protective factors associated with good QoL than non worker
and number of children (OR═0.709 , p =0.011) in which women who have
higher number of children are (70%) protective for good QoL than women have
lower number of children
The factors which showed the same effect on Qol .Concerning factors related
to socio-demographic characteristic were women’s residence (OR═1.150
P=0.790) followed by use of computer (OR ═2.240 , p ═0.238), age of husband
(OR ═1.087 p ═0.075), husband’s occupation especially administrative
functions (OR ═0.929, p ═0.891) and no work(OR ═1.324, p ═0.771) .
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301
Factors related to age of menarche (OR═ 1.879,p = 0.194) , stress feeling and
depression after operation as psychological problem (OR═0.471, p =0.692)
,(OR═1.222, p =0.911) respectively , having information about breast
cancer(OR═ 0.493, p =0.326) and isolation from social relations as a social
problem(OR═1.647, P= 0.414).
Factors related to women’s stage of breast cancer , Stage (II) in which tumor
spread beyond the breast and tumor spread beyond the breast tissue and reach to
the lymph node ( OR═ 0.995 , P=0.992).
Regarding factors related to duration of disease , if disease duration (1- < 2 yrs)
(OR=2.961, P=0.206) , (2 - <3 yrs) (OR=4.123, P=0.078) and (3 yrs or more)
(OR=1.847, P=0.410).Factors related to duration of hormonal treatment ,if
duration 5 yrs (OR=3.526, P=0.142) ,7 yrs (OR=1.355, P=0.703) and if lifelong
of hormonal treatment (OR=4.141, P=0.090).
Based upon the findings of the present study, it could be concluded that more
than half of the studied women (57.5%) had fair quality of life while more than
two fifths (42%) of them had poor quality of life. women’s education, monthly
income, using of family planning methods , tumor spread beyond the breast
tissue , reach to the lymph node near to chest bone and the presence of sores in
the breast skin were the most independent risk factors associated with poor
QoL. women’s age , occupation, number of children were the most independent
protective factors associated with good QoL.
According to the previous conclusion, this study recommends
the following:
I- Recommendations directed to the Ministry of Health& Population
(MOHP):
1-Ministry of Health and Population (MOH) should continue their efforts in establishing
and upgrade the national cancer screening program in which breast cancer prevention and
early detection is receiving highest priority.
2-MOH should continue their efforts to update clinical guidelines and monitor its
adherence. The importance of taking patient history during premarital examination which
will help in detecting high risk women for breast cancer especially those with first degree
cancer relative. Accordingly these women should do screening at more frequent intervals
in order to help in early detection of breast cancer and carrying clinical breast examination
should be stressed during routine checkup visits and during premarital care.
3-Community health screening campaigns should be carried out for high risk women
both in urban and rural areas. Appropriate referral should be done based on the screening
results.
4-MOH should establish cancer centers, or provide access to mobile screening units, in
the different governorates in Egypt .These centers should offer comprehensive health
services for screening, diagnosis and treatment for breast cancer patients.
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301
5-MOH should continue their efforts toward improving the quality of health services
offered to breast cancer patients and post surgery. This includes prevention /early
detection, diagnostic services, cancer management and palliative services as well as
support women use of such services.
6-Establish and support breast cancer hot line. In order to respond to all the inquiries of
breast cancer patients’ and answer their questions, queries and concerns.
7-Increase the budgetary allowance for breast cancer treatment and stresses the
importance of early initiation of breast cancer treatment.
8-MOH should establish hospice care services mainly or providing end of life care to
promote the awareness in both the health care community and the general public of the
“human right to a peaceful death”.
9-Strengthen outreach programs to women in rural and squatter areas through home
visiting schedule .This will help raise women awareness concerning breast cancer through
providing them with the needed information especially with respect to screening services.
10-MOH should conduct structured training program by enforcing Psychiatric Liaison
Nursing Consultation in these hospitals to perform a periodical workshops for all nurses
especially nurses dealing with cancer patients focusing on knowledge regarding body mind
interrelationship, psychological disorders; symptoms, diagnosis, management, stress,
depression and anxiety management.
11- MOH should provide different type of external breast prosthesis to all women after
mastectomy for free as a line of treatment or by low price.
12-MOH should provide a highly trained, motivated breast cancer and post mastectomy
survivors to be a part of the breast cancer care team in order to motivate and support other
breast cancer patients especially newly diagnosed ones and help in acceptance of body
image.
Specific recommendations geared toward improving health services offered to
patients throughout the different health outlets dealing with breast cancer patients
and their treatment (including hospitals, inpatient wards and outpatient clinics)
1. Breast cancer diagnosis and treatment should be offered in a pleasant , privacy
and non stressful physical environment.
2. Cancer out patients’ clinics and inpatient wards should be set up in such a way that
early breast cancer patients are separated from women with advanced disease
,women with simple mastectomy are separated from women with bilateral
mastectomy or modified radical mastectomy in order to lessen the anxiety of new
diagnosed or new post operative patients .
3. All cancer diagnosis and treatment units should be equipped to follow standard
protocols in accordance to international criteria. This will insure that diagnosis and
treatment at all stages of breast cancer will be done in accordance to standards and
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330
accordingly will improve breast cancer patients’ quality of life and survival
chances.
4. All post mastectomy patients should be treated by multidisciplinary teams who are
able to provide the best chances of cure, palliation, psycho-social and spiritual
support.
5. Health services affiliated to different organizations should continue in establishing
and implementing standard screening and management protocols. These will help
to improve the quality of life and survival of breast cancer patients.
6. At every stage, patients should be offered clear, objective, full and prompt
information in both verbal and written form. Each patient should receive
information relevant to her case about the disease, diagnostic procedures, and
treatment options. This will facilitate patient choice about treatment decisions and
foster their cooperation.
7. Breast cancer patients should have prompt re-referral, follow up and access to
support services. They should be encouraged to report new, persistent symptoms
promptly without waiting for the next scheduled appointment.
8. Evidence based modules/lectures about breast cancer screening and management
modalities should be added to the curriculum in all medical and nursing schools.
These should be done in accordance to national protocols which should include an
important component on enhancing the patients’ quality of life.
II- Recommendations directed to Ministry of Social Solidarity:
1-Provide financial support for underprivileged, breast cancer survivors and patients
with low socioeconomic status in order to help them in continuing treatment
according to protocol.
2-Provide family strengthening services, such as parenting sessions, the promotion of
positive husband-wife relationships, and conflict resolution skills.
3-Develop and support campaigns to raise awareness about the rights of these women
so as to prevent discrimination and stigma and to ensure respect for their identity post
mastectomy.
III- Recommendations directed to the Ministry of Communication and
Information Technology:
1-Raise community’s awareness especially women about breast cancer including :
risk factors, signs& symptoms, preventive measures, breast self examination , early
detection methods of breast cancer , type of mastectomy and hormonal therapy
category and its side effect , how to avoid post mastectomy complications, how to
use external breast prosthesis and available community resources that offer health
services to breast cancer patients.
2-Address informational needs about breast cancer through developing well designed
health messages to be used in the media, in community mobilization campaigns , in
Primary Health Care Units, family health centers, or schools , universities , clubs or
by using mobile application and web sites.
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333
IV - Recommendations directed to Nongovernmental Organization.
1. Ensure collaboration of all governmental as well as Non Governmental
Organizations in order to: raise community awareness, conduct early
detection/screening campaigns, and provide medical services, emotional support,
and research. Other forms of collaboration could include offering financial
assistance especially during the treatment phase of receiving hormonal therapy and
assistance in ensuring legal rights of breast cancer patients.
V - Recommendations for further researches:
1. Future researches should focus on collecting data that encompasses not only how
quality of life is negatively affected but also on protective factors.
2. Conduct qualitative studies which will help to gain more understanding of
women’s’ views on their needs.
3. Testing the development of new herbal drugs for treatment of cancer (either for
mainline therapy or as an adjunct), which could help in providing better and
cheaper management of breast cancer cases.
4. An experimental study should be carried out to find out the effectiveness of a
liaison psychiatric nursing program in reducing the stress levels, improving QoL,
and enhancing coping strategies among the patients with cancer especially those
undergoing mastectomy.
5. Comprehensive health educational programs for all women following breast cancer
treatment in outpatients’ clinics of oncology department units include
psychological, social, rehabilitation, and follow up.
6. Study the impact of different type of mastectomy and its stigma on the life of
women after operations.