Journal of Cancer Therapy, 2013, 4, 1256-1261
http://dx.doi.org/10.4236/jct.2013.47148 Published Online September 2013 (http://www.scirp.org/journal/jct)
Quality of Life in Egyptian Children with Cancer
Mohamed Fawzy1*, Mai Saleh2, Mohamed El-Wakil3, Zeinab Monir4, Eman Eltahlawy2
1Department of Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt; 2Department of Environmental and
Occupational Medicine, National Research Center, Cairo, Egypt; 3Department of Clinical Oncology, Faculty of Medicine, Beni-Suef
University, Beni-Suef, Egypt, 4Department of Child Health, National Research Center, Cairo, Egypt.
Email: *mohammed.fawzy@57357.com
Received August 9th, 2013; revised August 25th, 2013; accepted August 31st, 2013
Copyright © 2013 Mohamed Fawzy et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background and Objectives: Cancer treatments leading to increased survival rates are reported to participate in the
creation of debilitating physical and psychosocial deficits for cancer survivors. Measures of health-related quality of life
(HRQOL) are designed to tap such consequences of cancer treatment together with the impact of the disease itself.
Methods: Parents of 67 included patients aged 8 - 12 years, were asked to complete the parent proxy report of
PedsQL™ 3.0 Cancer Module (Arabic version), as well as a separate sheet for socio-demographic data. Results: The
ratio of Males to females was 1.8:1 among study patients with a median age of 8 years at diagnosis. Hematological ma-
lignancies represented 70.1% of the sample, with the highest proportion for ALL (52.2%). Total QOL showed to be
relatively low with mean value of 62.29 for the whole group. Subscales with least scores were for; worry (44.11), per-
ceived physical appearance (50.6), and procedural anxiety (55.34). On the other hand, the best score was 75.98 for
communication, followed by 72.63 for cognitive problems. The impacts of some medical and socio-demographic vari-
ables on QOL and its subscales were elicited in our results. Conclusion: Increased treatment intensity, long duration of
hospital admission, higher frequency of hospital visits, female sex, younger age at diagnosis, and large family size were
all associated with a poorer total QOL and/or its subscales among Egyptian pediatric cancer patients.
Keywords: Quality of Life; Children Cancer Patients; PedsQL™ 3.0 Cancer Module
1. Introduction
Childhood cancer patients are now long term survivors
with current survival rates approaching 90% [1]. Con-
temporary therapies for pediatric malignancies represent
the main contributor for such advancement [2]. However,
same treatments leading to increased survival rates are
reported to participate in the creation of debilitating phy-
sical and psychosocial deficits for cancer survivors [3].
Health-related morbidity among childhood cancer survi-
vors is mainly attributed to late effects including chro-
nic health conditions and life-threatening complications
during adulthood [4-6]. Measures of health-related qual-
ity of life (HRQOL) are designed to tap such conse-
quences of cancer treatment together with the impact of
the disease itself [3]. HRQOL targets a variety of dimen-
sions including physical, mental and social domains [7].
For childhood cancer patients, assessment of HRQOL at
relevant points throughout the treatment process can help
in the identification of acute dysfunction associated with
both illness and treatment, as well as figuring out ex-
pected residual dysfunction in long-term survivors [8-
11].
The present study was designed to identify the HR-
QOL profile in Egyptian pediatric cancer patients. The
impact of underlying disease, treatment and sociodemo-
graphic variables on the total QOL and its domains was
also evaluated.
2. Patients and Methods
Patients: a convenient sample of 67 pediatric cancer pa-
tients aged from 8 to 12 years with established diagnosis
at the pediatric inpatient as well as outpatient clinic of
the National Cancer Institute of Egypt were included
onto study. Parents of every included patient were asked
to complete the PedsQL™ 3.0 Cancer Module [3] (Ara-
bic version), as well as a separate sheet for sociodemo-
graphic data.
Instrument: the PedsQL™ 3.0 Cancer Module—de-
signed to measure HRQOL dimensions specifically tai-
lored for pediatric cancer—was the instrument in use. It
*Corresponding author.
Copyright © 2013 SciRes. JCT
Quality of Life in Egyptian Children with Cancer 1257
investigated 8 domains with the total of 27 items for the
whole module; 2 items for pain and hurt, 3 for each of
procedural anxiety, treatment anxiety, worry, perceived
physical appearance, and communication, whereas 5 items
for each of nausea and cognitive problems.
Linguistic translation: the parent proxy-report for chil-
dren aged 8 - 12 years of the “PedsQL™ 3.0 Cancer Mo-
dule” was translated into Arabic (native language of the
study sample) using the PedsQL™ Measurement Model
Translation Methodology. Linguistic validation process
included forward translation from the source language
(English) to the target language (Arabic), backward trans-
lation to the source language, and finally cognitive de-
briefing step according to PedsQL Cognitive Inter-
viewing MethodologySM [12,13]. Detailed reports for
every step throughout the whole process were sent to
Mapi research Institute in Lyon, France, on behalf of Dr.
James W. Varni, the copyright owner of the PedsQL™
for approval. A 5 point likert scale ranging from 0 for
“never a problem” till 4 for “almost always a problem”
was used for each item. The scale is converted to a cor-
responding score from 0 to 100, where 0 represented the
worst quality of life and 100 represented the best one.
The total QOL is the average of the scores for all do-
mains, while QOL for each domain is the average of
scores of its items.
Treatment related measures: a) intensity of cancer
therapy: scored from 1 to 3: low intensity such that sur-
gery only and/or six months chemotherapy with a favor-
able prognosis had a score 1, medium intensity took the
score of 2 for cases with chemotherapy longer than 6
months according to the treatment protocol in addition to
an intermediate prognosis, 3 was the score for high in-
tensity of therapy that represented treatment according to
high risk protocols, bone marrow transplantation, and/or
diseases with less favorable prognosis [14,15]. b) Phase
of treatment: the on-treatment group was defined as any
patient actively receiving anticancer therapy at any phase
of the treatment protocol, whereas the follow-up group
indicated patients ended their treatment and scheduled
for timed interval follow up. c) Frequency of hospital
visits: classified into either 3 or >3 visits per month. d)
Length of hospital admission: had 3 levels: low for ad-
mission periods within one third of the total duration of
therapy, medium if admission period was about 1 - 2
thirds the total duration, and high if it exceeded 2 thirds
the total treatment duration. e) Therapy duration: 6
month was considered to be low, between 6 month and 1
year was medium, and 1 year represented high duration
of therapy. Indirect method for measuring treatment
compliance (compliant or non-compliant) [16] was used
through a single screening question “Is your child used to
strictly follow instructions and take medications as the
doctor prescribed?” with a parent report of “yes” or “no”.
Other sociodemographic data included; residence (urban
or rural), family size, and gender.
Statistical analysis: scores for total QOL and the 8
subscales for each participant were calculated after the
guidelines of the PedsQL™ 3.0 Cancer Module deve-
loper. Descriptive statistics were expressed as mean and
standard deviation. Data analysis was performed using
the student t-test with SPSS version 18. p value < 0.05
was considered to be significant.
3. Results
Descriptive demographic and medical data for the study
sample are shown in Table 1. Study patients were 43
males and 24 females (1.8:1) with a median age of 8
years at diagnosis and 5.25 as mean value for family size.
Patients with hematological malignancies represented
70.1% versus 29.9% with solid tumors, with the highest
proportion for ALL (52.2%). The on-treatment and fol-
low-up cancer groups had very close percentages of
53.7% and 46.3% respectively, together with 50.7% had
treatment duration of 1 year or above at time of evalua-
tion. The urban and rural distribution for residence was
also 50.7% and 49.3%, respectively. Medium and high
intensity of therapy (59.7% & 31.3% respectively) were
much more represented than low intensity (9.0%). While
hospital visits for 70.1% of the sample exceeded 3 times/
month, 43.3% had hospital admissions for more than two
thirds of their treatment duration with a compliance rate
of 89.6% of the whole sample.
Total QOL showed to be relatively low with mean
value of 62.29. Subscales with least scores were for;
worry (44.11), perceived physical appearance (50.6), and
procedural anxiety (55.34). On the other hand, the best
score was 75.98 for communication, followed by 72.63
for cognitive problems, (Table 2).
Table 3 shows the impact of different variables on
QOL and its subscales. High and medium treatment in-
tensities as well as long duration of hospital admission
were associated with a poorer total QOL (p < 0.05). Per-
ceived physical appearance was also affected by treat-
ment intensity (p < 0.01) with more negative impact on
female patients who also suffered more than males from
treatment anxiety and worry (p < 0.05). Pain & hurt was
increased among patients with; lower age (5 years) at
time of diagnosis (p < 0.05), longer hospital admission (p
< 0.01), and non-compliance to treatment (p < 0.01). The
latter also affected the procedural anxiety domain sig-
nificantly (p < 0.05), while long periods of hospital ad-
mission deteriorated treatment anxiety subscale (p <
0.05).
Larger family size (>5 members) was associated with
a negative effect on communication subscale (p < 0.01).
None of diagnosis subtypes (hematological/solid ma-
lignancies), phase of treatment (on-treatment/follow-up),
Copyright © 2013 SciRes. JCT
Quality of Life in Egyptian Children with Cancer
1258
Table 1. Descriptive demographic and medical characteris-
tics.
Variable n (%)
Gender
Female
Male
24 (35.8%)
43 (64.2%)
Type of malignancy
Hematological:
ALL
NHL
AML
HD
LCH
Solid:
Brain
ES
STS
RMS
OS
Ca Colon
NB
47 (70.1%)
35 (52.2%)
5 (7.5%)
1 (1.5%)
4 (6.0%)
2 (3.0%)
20 (29.9%)
8 (12.0%)
5 (7.5%)
1 (1.5%)
1 (1.5%)
2 (3.0%)
1 (1.5%)
2 (6.0%)
Phase of treatment
On treatment
Follow up
36 (53.7%)
31 (46.3%)
Intensity of therapy
Low
Medium
High
6 (9.0%)
40 (59.7%)
21 (31.3%)
Therapy duration
6 month
> 6 month
1 year
12 (17.9%)
21 (31.3%)
34 (50.7%)
Hospital admission
Low
Medium
High
18 (26.9%)
20 (29.9%)
29 (43.3%)
Hospital visits
3/month
>3/month
47 (70.1%)
20 (29.9%)
Compliance
Compliant
Non-compliant
60 (89.6%)
7 (10.5%)
Residence
Rural
Urban
33 (49.3%)
34 (50.7%)
ALL = Acute Lymphoblastic Leukemia; NHL = Non Hodgkin Lymphoma;
AML = Acute Myeloid Leukemia; HD = Hodgkin Lymphoma; LCH =
Langerhan’s Cell Histiocytosis; ES = Ewing’s sarcoma; STS = Soft-Tissue
Sarcoma; RMS = Rhabdomyosarcoma; OS = Osteosarcoma; Ca Colon =
Cancer Colon; NB = Neuroblastoma.
or residence (urban/rural) appeared to have a statistically
significant effect on either total QOL or its subscales in
our study.
4. Discussion
The parent-proxy report for pediatric cancer patient
showed a total QOL of 73.6 for the US, 72.2 for the
Indonesian and 71.02 for the Chinese mandarin child-
Table 2. Scores of total QOL and its subscales among study
group.
Scale/Subscale MeanMedian Std. D Min.Max.
Total QOL 62.2966.50 18.85 19.492.5
Pain & Hurt 66.9875.00 33.89 0.0100.0
Nausea 68.3280.00 29.39 0.0100.0
Procedural anxiety 55.3475.00 36.17 0.0100.0
Treatment anxiety 63.6475.00 32.24 0.0100.0
Worry 44.1150.00 30.70 0.0100.0
Cognitive problems72.6380.00 26.99 5.0100.0
Perceived physical
appearance 50.6058.30 28.09 0.0100.0
Communication 75.9891.70 31.80 0.0100.0
hood cancer patients [3,17,18]. Although the total QOL
for Egyptian pediatric cancer patients showed to be re-
latively poorer than aforementioned studies with a score
of 62.3, yet it showed to be better than results of the
Pakistani data which showed much lower total QOL
score of 42.07 [10]. Relatively poor QOL was attributed
according to our results to intensity of therapy which was
reported to represent an independent predictor of poor
QOL [9]. As shown by the illustrated data, high and me-
dium intensities of treatment showed significant lower
total QOL (p < 0.05) compared to low intensity therapy,
with mean values of 60.4, 60.4 and 81.0 respectively.
Adverse effect of therapy intensity on QOL could be ex-
plained in terms of more intensive chemotherapy and
poor disease prognosis [9,19]. The participation of inten-
sive chemotherapy on the deteriorated QOL could be em-
phasized again by the highly significant decrease in per-
ceived physical appearance subscale among medium and
high intensity of treatment in comparison to low therapy
intensity patients (p < 0.01). Hair loss and other distress-
ing adverse effects on physical appearance as a result of
using anit-neoplastic agents in childhood cancer proto-
cols could perfectly explain the low QOL for this domain
[20,21]. In the same context, high frequency of hospital
visits was significantly correlated to reduced QOL score
in nausea subscale (60.0) compared to higher value in
case of less frequent visits (80.0) (p < 0.05). Such find-
ings indicated more that frequent exposure to hospital at-
mosphere and consequently more therapy administration
could be a leading factor.
Hospitalization, was another therapy related factor
which showed significant impact on the total QOL (p <
0.05). Patients with hospital admissions exceeding two
thirds of their treatment duration showed a more deterio-
rated QOL (55.6) compared to others with lower duration
in consistence to others’ data [22]. Similarly, a signifi-
cant decrease in QOL was also shown in the pain and
hurt (p < 0.01) and treatment anxiety (p < 0.05) domains
in relation to duration of hospital admission resulting in
Copyright © 2013 SciRes. JCT
Quality of Life in Egyptian Children with Cancer
Copyright © 2013 SciRes. JCT
1259
Table 3. Total QOL and its 8 subscales in relation to study variables.
Variable Total QOL Pain & Hurt Nausea Procedural
anxiety
Treatment
anxiety Worry Cognitive
problems
Perceived
physical
appearance
Communication
Age at
diagnosis
<5 yrs
5 yrs
p value
59.2 (19.0)
63.4 (18.9)
*
51.0 (41.0)
73.0 (30.0)
0.02
65.0 (31.0)
69.0 (29.0)
*
58.3 (37.2)
54.3 (36.2)
*
59.6 (38.1)
65.0 (30.3)
*
45.0 (23.0)
44.0 (33.0)
*
69.0 (24.0)
74.0 (28.0)
*
53.0 (26.0)
50.0 (29.0)
*
2.1 (34.4)
77.3 (31.1)
*
Gender
Female
Male
p value
57.9 (20.3)
64.7 (17.8)
*
64.0 (35.0)
69.0 (34.0)
*
65.0 (28.0)
70.0 (30.0)
*
48.3 (38.5)
59.3 (34.4)
*
52.0 (30.4)
70.1 (31.7)
0.02
34.0 (30.0)
50.0 (30.0)
0.04
79.0 (26.0)
69.0 (27.0)
*
41.0 (28.0)
56.0 (27.0)
0.03
71.9 (36.3)
78.3 (29.2)
*
Intensity of
treatment
Low
Medium
High
p value
81.7 (5.3)
60.4 (19.8)
60.4 (16.7)
0.02
90.0 (9.0)
61.0 (36.0)
72.0 (32.0)
*
79.0 (15.0)
71.0 (29.0)
60.0 (32.0)
*
73.6 (26.0)
52.3 (38.0)
56.0 (34.9)
*
81.9 (8.2)
63.1 (32.8)
59.5 (34.6)
*
62.0 (10.0)
45.0 (33.0)
36.0 (28.0)
*
92.0 (14.0)
70.0 (26.0)
71.0 (30.0)
*
79.0 (18.0)
45.0 (28.0)
53.0 (26.0)
0.01
95.8 (10.2)
73.9 (32.6)
74.2 (33.2)
*
Family size
5
>5
p value
61.8 (18.9)
63.1 (19.2)
*
64.0 (35.0)
72.0 (32.0)
*
69.0 (30.0)
68.0 (29.0)
*
47.1 (36.1)
70.1 (31.9)
*
61.0 (32.9)
68.4 (31.2)
*
42.0 (32.0)
48.0 (28.0)
*
76.0 (26.0)
67.0 (29.0)
*
52.0 (28.0)
49.0 (29.0)
*
83.3 (26.6)
62.8 (36.4)
0.01
Hospital
admission
Low
Medium
High
p value
65.9 (20.0)
68.8 (11.3)
55.6 (20.5)
0.03
69.0 (37.0)
83.0 (26.0)
54.0 (32.0)
0.01
68.0 (25.0)
74.0 (28.0)
65.0 (33.0)
*
51.8 (40.6)
63.4 (27.9)
52.0 (38.6)
*
69.8 (28.3)
74.1 (24.0)
52.6 (36.7)
0.04
55.0 (30.0)
47.0 (33.0)
35.0 (28.0)
*
71.0 (26.0)
79.0 (19.0)
69.0 (32.0)
*
58.0 (27.0)
51.0 (25.0)
45.0 (31.0)
*
81.9 (27.8)
77.5 (33.6)
71.2 (33.2)
*
Hospital
visits
3/month
>3/month
p value
67.4 (16.0)
60.1 (19.7)
*
78.0 (24.0)
62.0 (37.0)
*
80.0 (19.0)
63.0 (32.0)
0.02
60.8 (39.7)
53.0 (34.7)
*
56.1 (32.1)
66.9 (32.1)
*
49.0 (26.0)
42.0 (33.0)
*
75.0 (25.0)
72.0 (28.0)
*
58.0 (25.0)
47.0 (29.0)
*
82.1 (32.8)
73.4 (31.4)
*
Compliance
Compliant
Non-compl.
p value
63.5 (18.9)
52.1 (16.7)
*
72.0 (29.0)
25.0 (43.0)
0.00
69.0 (30.0)
66.0 (28.0)
*
58.7 (35.6)
26.2 (29.0)
0.02
63.8 (32.8)
61.9 (29.6)
*
46.0 (30.0)
29.0 (31.0)
*
73.0 (28.0)
72.0 (20.0)
*
51.0 (29.0)
49.0 (17.0)
*
75.4 (33.4)
80.9 (12.5)
*
Therapy
duration
6 month
>6 month
1 year
p value
64.9 (21.6)
65.2 (21.6)
59.6 (18.0)
*
72.0 (37.0)
74.0 (33.0)
61.0 (33.0)
*
63.0 (39.0)
70.0 (24.0)
65.0 (25.0)
*
54.2 (41.7)
43.6 (35.5)
63.0 (33.5)
*
74.3 (24.7)
64.7 (33.2)
59.2 (33.8)
*
47.0 (42.0)
43.0 (31.0)
44.0 (27.0)
*
77.0 (28.0)
83.0 (19.0)
65.0 (29.0)
0.04
54.0 (25.0)
57.0 (33.0)
46.0 (26.0)
*
80.6 (29.8)
78.2 (31.9)
73.0 (33.0)
*
*no significant difference.
increased physical and psychological distress [23,24].
Moreover, pain and hurt and procedural anxiety do-
mains; regarded as treatment related variables were shown
to be correlated to patients’ compliance to treatment pro-
tocols in agreement to related studies [23,25]. Decreased
compliance; in form of missing appointments and sche-
dule non adherence showed to be associated with de-
teriorated scores for both subscales at p values <0.01 and
<0.05 respectively.
While an association between phase of treatment and
QOL was reported by some investigators [15,26], our
results did not show any significant difference between
patients under current therapy and those at follow-up.
Similarly, Speechley and colleagues [27], found that type
of cancer can affect QOL which was on the contrary to
our data.
Some socio-demographic factors such as family size
and gender also showed a crucial role in determining
QOL [28]. Risk factors for poor QOL included family
size [29]. According to our results, patients related to
small families with 5 or less members had a significantly
better scores in the communication subscale with a mean
Quality of Life in Egyptian Children with Cancer
1260
value of 83.3 compared to 68.2 in larger sized families (p
< 0.05). This could be explained by difficult interper-
sonal relationships and less parental care offered to their
children with the increased number. The poorer QOL
among female versus male patients (p < 0.05) in more
than one domain was also matched with similar studies
[30,31]. Such domains included treatment anxiety, worry
and perceived physical appearance. For residence, on the
other hand, on showing no significant differences in
QOL and its subscales between the urban and rural resi-
dences, our results agreed with literature reporting the
weak influence of such a parameter on QOL [32].
In summary: increased treatment intensity, long dura-
tion of hospital admission, high frequency of hospital
visits, female sex and younger age were all associated
with a poorer total QOL and/or its subscales among
Egyptian pediatric cancer patients.
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