Introduction
Cervical cancer is a significant public health challenge globally, particularly in low- and middle-income countries due to late diagnosis, advanced stages of diagnosis, lack or inaccessibility of treatment, lack of treatment facilities and logistic and cultural obstacles to treatment resulting in poor prognosis. Reference Hull1 It is the fourth most frequently diagnosed cancer among women worldwide, with 661,021 new cases and 348,189 deaths recorded in 2022 alone. Reference Bray2 The burden of cervical cancer is disproportionately higher in sub-Saharan Africa, where it accounts for the highest incidence and mortality rates due to limited access to preventive and therapeutic cancer care services. Reference Bhatla3 The management of cervical cancer has psychological implications for patients’ self-identity, their ability to satisfy their partners and the overall self-perception as a female, which often affect their quality of life (QoL) negatively. Reference Bhatla3,Reference Ferrandina4 A study found that the emotional functioning of patients with cervical cancer worsened after treatment compared to their emotional functioning before treatment. Reference Pasek, Suchocka and Urbanski5 Important components of emotional functioning include feelings of fear, hopelessness, anger, shock and self-blame as a result of the outcomes of physical changes associated with treatment. Reference Perrin6 The physical functioning of patients with cervical cancer can also be impaired by acute adverse effects of radiation treatment such as diarrhoea, making it difficult for patients to attend social functions. Reference Pasek, Suchocka and Urbanski5
Assessment of the QoL of patients with cervical cancer has become necessary due to significant improvements in long-term survival, Reference Xie7 attributable to modern therapeutic modalities. The impact of cancer treatment on patients’ well-being and overall QoL is of growing interest in cancer research. Reference Safaee8 Some psychological factors also contribute to the toxicity experienced by patients with cervical cancer undergoing treatment such as depression, somatization and anxiety. Reference Helen, Jolanda and Guus9,Reference Lee10 High anxiety levels at the start of treatment are associated with decreased QoL. Reference Schreier and Williams11
QoL focuses on four concepts, comprising physical, social, emotional and functional well-being—to provide a holistic outcome per patients’ own perspective. Reference Araya12 Multiple questionnaires have been developed and validated for the assessment of the QoL of patients diagnosed with cancer, such as the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) Reference Torkzahrani13,Reference Bjelic-Radisic14 and the Functional Assessment of Cancer Therapy—General (FACT-G) questionnaires. Reference Webster, Cella and Yost15
Although some studies have been carried out in other jurisdictions to assess the QoL of patients with cervical cancer undergoing treatment, Reference Bjelic-Radisic14,Reference Schaller16 only a few have been conducted in the sub-Saharan African setting. Reference Abegaz, Ayele and Gebresillassie17 The aim of the study was to evaluate the impact of radiotherapy on the overall QoL of patients with cervical cancer using a validated assessment tool.
Methods
This research was a quantitative cross-sectional study conducted between February and May, 2023 at the National Radiotherapy, Oncology and Nuclear Medicine Centre, Korle-Bu Teaching Hospital (KBTH) in Accra in Ghana. The study involved adult female patients (≥ 18 years) with a histopathologically confirmed diagnosis of cervical cancer who were treated with definitive chemoradiotherapy. Patients with metastatic cervical cancer and those with locally advanced disease treated with palliative intent were excluded from the study. Likewise, patients with cervical cancer who received only radiotherapy, without concurrent chemotherapy were not included in the study. Based on the Taro Yamane formula Reference Chaokromthong and Sintao18 [N/(K+N(E)2) where K(constant)=1, N(Population of study) =140 and E(degree of error expected) = 0.05], a sample size of 103 patients was determined to be appropriate for this study. Out of 140 eligible patients, a purposive sampling technique was used to recruit 120 consenting participants for the study. Data were collected using the FACT-Cx questionnaire. Reference Cella19 The first section of the questionnaire elicited information regarding patients’ age, marital and employment status. The second section elicited information pertaining to the physical, social, emotional and functional well-being of the participants as well as their additional concerns. The questionnaire was offered to patients after they had received radiotherapy for at least two weeks, to allow enough time for patients to experience the acute effects of radiotherapy prior to completing the research questionnaire. For participants who faced challenges in fully comprehending certain questionnaire items, verbal clarifications were provided in English by trained research personnel, ensuring that participants understood the intent and meaning of the questions without altering their original phrasing. Statistical analysis for the study was conducted using the Statistical Package for Social Sciences (version 22), employing both descriptive and inferential statistical methods to analyse data. Categorical variables, such as demographic and clinical characteristics, were summarized with frequency distributions and percentages, while continuous variables, including FACT-CX scores, were described using means and standard deviations. Correlations between groups were performed using Spearman Rho correlational analysis. p-values < 0·05 were considered to be statistically significant.
Ethical approval for the study was obtained from the Ethical and Protocol Review Committee of the School of Biomedical and Allied Health Sciences, University of Ghana, Legon (SBAHS/AA/RAD/10573772/2023). Participants’ privacy and the confidentiality of their data were safeguarded throughout the study. Data were anonymized to remove all patient-identifying information prior to analysis. The study involved only participants who provided written informed consent. All standard ethical considerations were rigorously adhered to, ensuring that the study was conducted with respect for the rights, dignity and welfare of all the participants.
Results
Baseline characteristics
Overall, there were 120 participants, with a mean age of 53·5 years (SD 15·6), ranging from 29 to 83 years. In all, 16·6% were younger than 40 years and 23·3% were ≥ 70 years. Half of the participants (50%) were married whiles 30% were widowed. The majority of the participants (77%) were employed whereas 17% were unemployed and 6% retired as summarized in Table 1.
Baseline characteristics of the study participants (N = 120)
QoL of patients with cervical cancer
1. Physical well-being
Table 2 summarizes participants’ responses to questionnaire items regarding the impact of cervical cancer and its treatment on their physical well-being. Half of the respondents (50·0%) reported a significant lack of energy (“very much”) and 20·0% did not experience any lack in energy. Also, 56·7% experienced no nausea compared with 30% who experienced significant nausea.
Physical well-being of patients with cervical cancer (N = 120)
2. Social well-being
All participants concurred that their family had accepted their illness. In all, 90% received overwhelming emotional support from their family and 80% were satisfied with their family’s communication about their illness (Table 3). However, 6·7% did not feel close to their partners during the treatment period. Additionally, 30% were very satisfied with their sex life, however, a considerable majority (46·7%) were not satisfied at all.
Social well-being of the study participants (N = 120)
3. Emotional well-being
A considerable majority (60%) were very sad, 46·7% felt very nervous about their condition and more than half of the participants (73·3%) had hope in the fight against their illness. Also, 66·7% were not worried at all, that their condition would get worse (Table 4).
Emotional well-being of the study participants (N = 120)
4. Functional well-being
A considerable majority (56·7%) were not at all content with their QoL and 23·3% were unable to enjoy the things they usually did for fun (Table 5). All of the participants (100%) had accepted their illness whereas only 33·3% were very much able to enjoy their life.
Functional well-being of the study participants (N = 120)
5. Additional concerns
In all, 50% were not bothered at all by the experience of vaginal discharge and/or bleeding and 46·7% were not bothered by vaginal odour. However, 70% were afraid to have sex even though 20% and 33·3% felt “somewhat” and “very much” sexually attractive, respectively (Table 6). Majority (80%) were able to eat the food they liked as most participants (63·3%) had a very good appetite.
Additional concerns of patients (N = 120)
The mean scores obtained in Table 7 show that the scores of the various QoL domains were above half of the total scores which is satisfactory. Proportionally, the lowest mean scores were obtained for functional well-being (12·3/24·0), physical well-being (15·4/28·0) and additional concerns (33·0/560). The highest scores were obtained in social well-being (17.3/24.0) and emotional well-being (16·8/24·0).
Descriptive analysis of total scores
The majority of participants (66·7%) reported having a good QoL, indicating a favourable outcome for the majority in the population whereas 6·7% reported poor QoL (Figure 1).
Distribution of the QoL of participants.
Table 8 depicts the correlation between age and the subdomains of QoL. There was statistically insignificant positive correlation between age and the emotional (Rho =0·069, p = 0·709) as well as functional well-being domains (Rho =0·147, p = 0·440). Also, there was a statistically insignificant negative correlation between age and the physical (Rho =−0.240, p = 0·201) as well as social well-being domains (Rho =−0·119, p = 0·587) (Table 8).
Correlation between patients’ age and QoL domains
Discussion
QoL during and after treatment has become the focus for treatment aside from survival statistics as was the norm in the recent past, in Ghana and other sub-Saharan African countries. Reference Amo-Antwi20 Among young survivors of cancer, loss of reproductive organs due to radiation and or surgery can have a negative impact on psychophysical identity Reference Amo-Antwi20 and even more significantly affect QoL than in an older population of cancer survivors. Reference Pfaendler21 This could be a source of distress among nulliparous married women after undergoing radical treatment for cervical cancer. The impact of radiation therapy on sexual relationships between survivors and their partners cannot be overlooked. Reference Amo-Antwi20 A 5–10-year post-treatment survey found that survivors of cervical cancer still experience more sexual discomfort, pain with penetration and vaginal dryness than controls even though sexual pleasure was similar compared with control group. Reference Wenzel22 Le Borgne et al. (2013) noted that overall sexual and vaginal functioning improved over time, with 15-year survivors reporting improved sexual function among 173 study participants. Reference Le Borgne23 Aside from the reproductive changes, treatment for cervical cancer also disrupts the working lifestyle of patients. Reference Amo-Antwi20 Treatment with radiation and systemic therapies concurrently requires daily visits to the facility. Patients who must travel and relocate for care due to sparsely distributed treatment facilities (as seen in Ghana) will therefore have to be absent from work for long periods for their care as well as recovery from adverse effects of care. This has severe financial implications for patients and their families.
The mean age of 53·3 years (SD 15·6) in this study is comparable with the results of a previous study at KBTH that reported a mean age of 56·8 years Reference Kyei24 and another study in the Ashanti region that reported a mean age of 56·9 years. Reference Nartey25 Furthermore, a retrospective study in Lagos, Nigeria reported a mean age of 55·3 years (SD 12·5). Reference Ola26 This highlights the younger age population of patients with cervical cancer in Africa and this may correlate with the amount of man-hours lost to contribute to the economy but rather used for treatment. Reference Ngcamphalala, Östensson and Ginindza27 To further highlight this, over seventy percent (77%) of the participants had gainful employment, 17% were unemployed and 6% were retired. Nartey et al. (2017) reported that 68·5% of patients with cervical cancer in the Ashanti region of Ghana were gainfully employed. Reference Nartey25 A similar finding in a related study conducted in Thailand corroborated this with 72·7% employed participants and 25·6% unemployed. Reference Taechaboonsermsak28 On the other hand, a study conducted in Zambia observed the opposite trend with 84% of the participants unemployed whereas 16% were employed. Reference Chitashi29 In a low-middle income country where patients have to pay out of pocket for healthcare, affordability is key if patient is to report early. Therefore, employed patients are more likely to report for care but this may not be true as social factors such as the number of family members depending on patient for their living can influence this health-seeking behaviour. A further study will be needed to analyse this specifically for cervical cancer.
A considerable percentage (50%) of the participants were married, which is consistent with a Thailand study which also revealed that majority (60·1%) of patients with cervical cancer were married. Reference Wilailak30 Taechaboonsermsak et al. (2005), on the other hand, recorded a higher 73·1% percentage of married and low percentage 2·2% of single patients as compared to this study. Reference Taechaboonsermsak28 The significance of marriage in cancer care is the social support advantage that it provides. It is a predictive factor indicating that the presence of a partner creates greater comfort and emotional support for patients diagnosed with cervical cancer. Reference Fernandes and Kimura31 On the contrary, it may also contribute to a poor psychological QoL as patients are worried about decreased sexual performance contributing to emotional stress. Reference Wilailak32
Seventy percent of patients were very much afraid to have sex, 46% were interested in sex and only 33·3% felt sexually attractive despite 63·3% not experiencing narrow or short vaginal canal. This finding translates into majority (60%) of patients losing interest in sex and they explained that they were afraid to have sex due to the intensity of pain felt during sexual intercourse as documented in other studies. Reference Amo-Antwi20,Reference Fernandes and Kimura31,Reference Frumovitz33 This can have a detrimental effect on patients’ relationships with their partners.
Emotional well-being has been documented in previous studies to be associated and improved by age, marital status, modality of treatment and stage. Reference Kyei24,Reference Azmawati34,Reference Zhao35 Poor emotional well-being scores have been recorded in patients with advanced disease. Reference Pasek, Suchocka and Urbanski5,Reference Baze, Monk and Herzog36 In terms of association between treatment modality and emotional well-being, there is divided evidence in literature with respect to an association. Reference Perrin6,Reference Frumovitz33,Reference Krikeli37 The emotional well-being of patients with cervical cancer recorded a mean score of 16·8/24. Almost all (90%) the participants were satisfied with their ability to cope with the ailment. Over seventy percent (73·3%) had hope in their fight against the illness and 66·7% were not worried that their condition would get worse. This explains the good total above average emotional well-being score recorded.
Functional well-being recorded the lowest scores (12·3/24) among all the sub-sections of QoL in this study. Other studies have documented higher functional well-being scores. Reference Taechaboonsermsak28,Reference Fernandes and Kimura31,Reference Wilailak32 This is associated with the type of treatment modality and age with scores of concurrent radiotherapy and chemotherapy is lower than that of patients with surgery and postoperative adjuvant treatment. Reference Zhao35 More than half (56·7%) were not able to enjoy life and were not content with the QoL even though all the participants had accepted their illness. This might explain the lowest average score in the functional well-being domain compared with the other domains in this study. Half of the study population lacked energy, 45·6% had pain and 50% trouble meeting the needs of their family. These contribute to the average mean score in the domain of physical well-being. Although there is documented influence of age and education on physical well-being, Reference Kyei24,Reference Ashing-Giwa, Lim and Gonzalez38 it is difficult to interpret. For instance, a Ghanaian study showed that the majority of the study population had no formal education and therefore might not comprehend the impact of their diagnosis or the educated population and younger population worry about the side effects of the treatment. Reference Kyei24
In general, the total FACT-Cx mean score was higher than 50% of the maximum. This picture is seen to occur in all subdomains (table 7). The lowest mean score is seen in the functional well-being subdomain and this has been corroborated in previous studies. Reference Kyei24,Reference Wilailak30,Reference Fernandes and Kimura31,Reference Zhao35 Similar to other studies the data revealed that the items of the additional concerns domain: interest in sex, fear of having sex, feeling less sexually attractive and feeling the vagina is narrow or short were the negative evaluations observed. Reference Fernandes and Kimura31 However, there was no association between age and any of the subdomains or the total FACT-Cx scores. The study population included patients sampled during treatment, within a specific period of time and did not reflect the entire population of patients with cervical cancer seen at the centre and in the country. Furthermore, aside from age, the effect of other confounding factors such as the stage, marital status, educational level and employment status were not studied.
Conclusions
This study highlights that most participants with cervical cancer at a tertiary facility in sub-Saharan Africa reported a good QoL despite challenges in specific domains. The highest scores were recorded in social and emotional well-being, reflecting strong family support and emotional resilience. However, physical and functional well-being, as well as additional concerns such as fear of treatment impact and sexual health issues, showed lower mean scores, indicating areas requiring targeted interventions. No significant correlation was observed between age and QoL domains, suggesting that other factors may play a more critical role in influencing QoL outcomes.
Limitations
One major limitation of the study is the lack of baseline data on participants’ QoL prior to the initiation of treatment which limits the ability to assess changes directly attributable to the treatment. Second, the study relied on self-reported data, which is subjected to recall bias and social desirability bias, potentially influencing participants’ responses. Also, the cross-sectional design of the study does not allow for the assessment of long-term trends or causal relationships between treatment and QoL outcomes. Future studies addressing these limitations, particularly using longitudinal designs with baseline data collection, are recommended.
Open access
