Open Journal of Nursing, 2011, 1, 26-32
doi:10.4236/ojn.2011.12004 Published Online September 2011 ( OJN
Published Online September 2011 in SciRes.
Quality of life and hope in elderly people with cancer
Bente Appel Esbensen1, Thordis Thomsen2
1 Research Unit of Nursing and Health Science, Glostrup University Hospital, Nrd. Ringvej, Glostrup, Denmark;
2 Research Unit, Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej, Herlev, Denmark.
Received 2 August 2011; revised 24 August 2011; accepted 7 September 2011.
The aim of this study was to describe the charac-
teristics in Quality of Life (QoL) and hope in eld-
erly people newly diagnosed with cancer, and to
compare the results for those who survived six
months after diagnosis with those who did not. The
design of the study was a quantitative study in-
cluding drop-out analysis. Data were collected pro-
spectively from a group of 101 older people with
cancer. The core questionnaire EORTC QLQ-C30
was used to measure QoL and Nowotny’s Hope
Scale (NHS) was employed to measure hope. Par-
ticipants who died within six months of diagnosis
had significantly lower QoL and had more com-
plaints about symptoms compared to those who
survived. However, hope did not differ significantly
between those who died and those who survived.
Despite lower QoL score among those who died they
were able to deal with their difficult situation and
maintain hope in late life. This capa city seems to be
an important component of hope in the elderly;
thus it is essential to strengthen hope.
Keywords: Hope; Quality of Life; Elderly People with
Cancer; Palliative Care; Survivors
The improvement and maintenance of QoL are a ma-
jor goal of cancer care for older people, especially
under conditions of limited improvement of survival
and at the price of significant complications [1]. From
a study comparing QoL in elderly people with and
without cancer it was found that the former group had
lower (poorer) scores in QoL and more symptom
complaints [2]. This issue is particularly relevant to
the elderly person with cancer, who may have a lim-
ited life expectancy compared to younger to younger
people and increased risk of complications from their
treatment [1].
People newly diagnosed with cancer are in an es-
pecially vulnerable and unknown situation in which
the diagnosis can threaten hope and make the future
uncertain. Hope may be particularly important for
people diagnosed with a life-threatening illness [3],
such as cancer. Few studies describe the concept of
hope in people who are elderly and have cancer [4-5].
A qualitative study identified loss of hope as threat-
ening for an elderly person with cancer, because it
represented the finiteness of life [6]. According to
Nowotny [7] the aspect of life expectancy may not
necessarily be important because seriously ill people
speculate less on cure or extra life span and more on
what is possible and realistic in the situation. This is
in line with Benzein [3] who identified hope in
healthy people as a process linked to meaning in life.
Therefore, hope is a notion that not only contains the
number of years left to live, but also the meaning of
life, which is in line with the findings of Nowotny [7].
This issue may be important for the elderly person
with cancer due to limited life expectancy, regardless
of the outcome of the disease trajectory.
Few studies re port on QoL and ho pe for cancer patient s
and for ol der people i n general. I n a follow- up study a lo w
level of hope was identified as a predictor for decreased
QoL in elderly people with cancer six months after di-
agnosis [8]. Rustoen an d Hanestad (199 8) ob serv ed in an
intervention study (age range 26 - 78; n = 96 newly di-
agnosed cancer patients) that hope scores in ‘the hope
group’ were significantly improved two weeks after the
intervention compared to the scores in the two control
groups. In another study hope was identified as an im-
portant resource for cancer patients having an impact on
their QoL [9]. According to Rustoen and Hanestad [10],
one signi ficant important issue in em ploying t he conce pts
of ‘hope’ and QoL is that they can be seen as two separate
ones. However, although they are dependent on one an-
other, the relationship is not simple [9]. Earlier interven-
tion studies have identified a strong positive relation
between hope and QoL, and suggest that both improve
B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 27
following intervention [10-12]. Thus, hope may buffer
against decreased QoL and so be regarded as a personal
resource. QoL is often assumed to be an important out-
come variable within health care in regard to disease
trajectory, treatment and the ability to manage daily liv-
ing with a diagnosis of cancer. Hope, however, appears
little investigated as an important outcome variable in
health care.
In palliative care, where patients have to live with un-
certainty due to their illness and due to the length of life
they may expect, hope is one of the most important is-
sues [13]. The concept of palliative care is above all
based on the idea of reinforcing factors that improve
QoL and decreasing the impact of factors that may re-
duce it [14]. However, there is a lack of knowledge a bout
elderly people with cancer, especially in relation to those
in the advanced stages. Nevertheless, it may be impor-
tant to explore QoL and hope in the elderly with cancer
to gain insights about how they may be better able to
manage their situation and to give them high quality care
at the end of life. Thus, the aim of this study was to de-
scribe the characteristics in QoL and hope in elderly
people newly diagnosed with cancer, and to compare the
results for those who survived six months after diagnosis
with those who d id not.
2.1. Design
A prospective, follow-up study with the overall aim to
examine elderly persons newly diagnosed with cancer
was conducted [15]. A dropout analysis was performed
and results from this analysis will be presented in this
paper with focus on the difference in QoL and hope be-
tween those elderly people newly diagnosed with cancer
who survived for six months after the diagnosis and
those who did not.
2.2. Sample Selection
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Among 142 patients (aged 65 + years) referred to the
Department of Oncology in the Capital Region. Inclu-
sion criteria for the study were having a diagnosis of
breast cancer, lung cancer, gynecological cancer or colo-
rectal cancer, and undergoing treatment and / or receiv-
ing supportive hospital care for the cancer. Eligible pa-
tients were invited to participate by letter and subse-
quently contacted via telephone by the first author
(BAE), when their willingness to participate and full
understanding of their rights concerning participation
and non-participation were confirmed. In total, 101
newly diagnosed with cancer, met inclusion criteria for
the study and agreed to participate. In total, 41 refused to
participate for reasons of to general frailty (n = 13), cog-
nitive dysfunction (n = 3), next of kin not wanting the
patient to contribute (n = 10) or for unspecified reasons
(n = 15). The 101 people in the stud y group consisted of
74 women and 27 men. In total, 26 of the 101 partici-
pants (17 women, 9 men) died within six months of di-
agnosis (labeled ‘died’) while 75 survived (labeled ‘sur-
vivors’) at least six months.
2.3. Instruments
A questionnaire was developed for the follow - up study
addressing socio-demographic data, and QoL and hope
[15]. Quality of life (QoL) was used as a health-related
quality of life measurement and was measured using the
EORTC QLQ-C30 (version 3), referred to below as
QLQ-C30 [16]. The instrument is cancer specific, multi-
dimensional, applicable in different cultures [17-18], and
has been translated into several languages, including
Danish. The QLQ consists of three subscales: the global
health status/QoL, functional scale and symptoms scale
including 30 items. The response format for all subscales
consists of a 4-point Likert scale format ranging from
one to four “not at all”, “a little”, “quite a bit” and “very
much” [19]. QLQ-C30 was scored in accordance with
the methodology developed by QLQ-C30 ranging from
0 to 100 [19]. The internal consistencies of the instru-
ments were calculated using Cronbach’s Alpha (0.70 -
0.90). The reliability analysis for QLQ-C in this study
was α 0.76 - 0.97, except for emotional function α 0.61
and cognitive fun ction α 0.43.
Nowotny’s Hope Scale (NHS) was used to measure
hope. The instrument consists of 29 questions covering
six dimensions, and provides detailed information on
different aspects of hope. It is specifically developed to
measure hope in individuals suffering a crisis such as a
diagnosis of cancer. The response format scores consist
of a 4-point Likert format ranging from one to four
“strongly agree”, “agree”, “disagree” to “strongly dis-
agree” [20]. NHS was translated from English into Dan-
ish according to internationally accepted guidelines [21]
and was transformed to scores ranging from 29 to 116
according to Nowotny [20]. A score from 29 - 50 indi-
cates “hopelessness”, 51 - 72 “low hope”, 73 - 94 “mod-
erately hopeful” and 95 - 116 “hopeful” [22]. In this
study the reliability analysis ranged from α 0.74 - 0.88,
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B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18
Copyright © 2011 SciRes.
except for the item “comes from within” (α 0.20 ).
2.4. Data Collection
Data reported in this paper are all from the drop-out
analysis from the prospective follow-up study (baseline
measurement) after having identified those, who were
lost to follow-up six months after. Structured interviews,
based on the questionnaire developed for the follow-up
study, were conducted by the first author two to four
weeks after the diagnosis. All data were therefore self-
reported by participants, except for age, sex, and type of
cancer, which were collected from the referral list of the
oncology clinic.
2.5. Ethical Approval
The Danish Data Protection Agency was informed of the
database. The study protocol was sent to the Copenha-
gen County Ethical Committee which found formal ap-
proval unnecessary. Prior to enrolment, each participant
received oral and written information about the aim of
the study, and it was emphasized that participation was
voluntary and would not in any way affect their treat-
ment. All participants were informed about procedures
for ensuring conf identiality and anonymity.
2.6. Analysis
Descriptive statistical analyses were performed on all
variables. The measures are described using median and
Interquartile Range (IQR). Data were further analyzed
for differences between those who died and those who
survived. In addition, all variables were regarded as not-
normally distributed; hence non-parametric statistics
methods were applied. For differences between two in-
dependent groups (age groups and years at school)
Kruskal-Wallis one-way analysis of variance was used
for analyzing ordinal scale data (Ta ble 1). Analysis was
performed to explore differences between those who
died (n = 26) and tho se who surviv ed (n = 75) within the
six-month period. Mann Whitney U-test was used to
analyze differences in the nominal and categorical level
of data at baseline between the two groups. Tests with p-
values < 0.05 were regarded as statistically significant.
Statistical analyses were carried out with SPSS 11.5 for
3.1. Socio—Demographic Data
The median age of the study group was 74.74 (IQR 8.75)
(Table 1). Those who died (n = 26) had a median age of
73.90 (IQR 9.88). Sex distribution was 65.4% women
and 34.6% men. Those who survived (n = 75) had a me-
dian age of 75.49 (IQR 8.7). Sex distribution was 76%
women and 24% men. For further information, see Ta-
bles 1 and 2. There were no statistically significant dif-
ferences in the distribution by age, sex, type of accom-
modation, number of years at school, latest occupation,
no income other than retirement pension and financial
circumstances between those who survived and those
who died.
Table 1. Demographic characteristics %.
Variable (n = 26) S urvivors (n = 75)To ta l (n = 101) P-Value¹
Age, Median ( IQR) 73.90 (9.88) 75.49 (8.7) 74.74 (8.75) 0.2842 & 3
Sex % 0.294
Women 65.4 76 73.3
Men 34.6 24 26.7
Diagnosis (= n)
Breast cancer 1 23 24
Gynecological cancer 5 20 25
Lung Cancer 6 19 25
Colo-rectal cancer 14 13 27
Total 26 75 101
Marital Status % 0.193
Married 61.5 46.7 50.5
Not married (includes divorced, widowed, separated and single) 38.5 53.3 49.5
Type of accommodation (%) 0.321
Apartment 53.8 56 44.6
House / farm 42.3 41.3 52.5
Sheltered house 3.8 2.7 3.0
Years at school, Median (I QR) 8.00 (3.00) 9.00 (3.00) 8.00 (3.00) 0.091
Last profession/o ccupation % 0.641
Housewife or blue col l ar 53.8 27.3 46. 5
Employee or public servant 30.8 42.7 33.7
Self-employed 15.4 16 19.8
1Mann-Whitney test; 2 & 3 Kruskall Wallis test.
B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 29
3.2. Quality of Life
Participants who d ied had an overall lower QoL than those
who survived (P = 0.018). They had lower scores in func-
tional scale (P = 0.006), lower physical function (P = 0.003)
and lower role function measured on the subscale role func-
tion (P = 0.003). Moreover, in the symptom scale (P =
0.026), they had a higher score, indicating more problems
and complaints. Those who died reported significantly
more frequent fatigue than those who survived (P = 0.007)
as well as more dyspnea (P = 0.025) ( Table 3).
3.3. Hope
No significant difference was found in the level of hope
between those who died and those who survived.
However, in the subscale ‘comes from within’ a total
score was median 11.00 and a significant difference
was identified between the two groups (P = 0.005)
(Table 4). Those who died and those who survived.
However, in the subscale ‘comes from within’ a total
score was median 11.00 and a significant difference was
identified between the two groups (P = 0.005) (Table 4).
Table 2. Economic situation, Receiving help and in contact with health care system.
Variable Died
(n = 26) Survivors
(n = 75) Total
(n = 101) P-value¹
Economical situation
Other income than retirement pension 25.7 24.0 27.7 0.581
Reduced economic ability activity due to cancer 7.7 14.7 12.9 0.360
In contact with health care system
Hospitalized within the l ast six months 88.5 94.7 93.1 0.285
In contact with general practitioner (GP) 80.8 84 83.2 0.706
In contact with home help service 38.5 26.7 29.7 0.259
In contact with home nu rse 26.9 22.7 23.8 0.662
Receiving help
Need more help 75.9 73.0 75.8 0.268
Having children 96.2 88 90.1 0.233
Getting help from children 65.4 59.1 61.5 0.428
Having grandchildren 88.5 84 85.1 0.583
Getting help from grandchildren 34.6 19 24.4 0.056
¹Mann-Whitne y Test.
Table 3. Quality of life-comparison for those who died within the first six months and those who survived.
Variable Died
(n = 26) Survivors
(n = 75) In total
(n = 101) P-value¹
Global health status / QOL (QL)² 50.00 (50.00) 75.00 (33.33) 66.67 (33.3 3) 0.018
Functional scales³ 63.33 (37.78) 77.78 (22.22) 77.78 (25.5 6) 0.006
Physical function (PF) 46.67 (50.00) 73.68 (33.33) 73.33 (40.00) 0.003
Role function (RF) 66.67 (87.50) 100.00 (33.33) 66.67 (66.67) 0.003
Emotional function (EF) 66.67 ( 43.75) 75.00 (41.67) 75.00 (41.67) 0.345
Cognitive function (CF) 83.33 (16.67) 83.33 (33.33) 83.33 (16.67) 0.789
Social function (SF) 100.00 (33.33) 100.00 (0.00) 100.00 (00.00) 0.069
Symptom scales4 28.21 (17.95) 20.51 (26.51) 23.08 (20.51) 0.026
Fatigue (FA) 66.67 (44.44) 33.33 (38.89) 44.44 (44.44) 0.007
Nausea & vomiting (NV) 0.00 (33.33) 0.00 (16.67) 0.00 (16.67) 0.903
Pain (PA) 33.33 (50.00) 16.67 (33.33) 16.67 (33.33) 0.086
Single items 5
Dyspnoea (DY) 33.33 (66.67) 0.00 (33.33) 0.00 (66.67) 0. 02 5
Insomnia (SL) 33.33 (41.67) 0.00 (66.67) 0.00 (66. 67) 0.626
Appetite loss (AP) 33.33 (66.67) 0.00 (33.33) 0.00 (33.33) 0.086
Constipation (CO) 0.00 (33.33) 0.0 0 (33.33) 0.00 (33.33) 0.844
Diarrhoea (DI) 0.00 (0.00) 0.00 (33.33) 0.00 (33.33) 0.293
Financial difficulties (FI) 0.00 (0.00) 0.00 (0.00) 0.00 (00.00) 0.108
1Man n-Whitney test; 2Higher scores indicate higher health related quality of life.; 3Higher score indicate higher function; 4Lower scores indicate fewer prob-
lems5 Lower scores indicate fewer problems.
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B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18
Table 4. Nowotny’s Hope scale-those who died within the first six months and those who survived.
Variable Died (n = 26) Survivors (n = 75) To t al (n = 101) P-value¹
Nowotny’s Hope scale² 85.00 (16.25) 86.00 (14.00) 85.00 (14.50) 0.929
Confidence 14.50 (6.00) 25.00 (5.00) 25.00 (5.00) 0.861
Related to others 1 8.00 (4.50) 17.00 (5.00) 18.00 (5.00) 0.810
Future is possible 14.50 (5.00) 13.00 (5.00) 14.00 (5.00) 0.800
Spiritual beliefs 7.00 (6.00) 5.00 (5.00) 5.00 (5.00) 0.224
Active involvement 14.00 (4.00) 14.00 (4.00) 14.00 (4.00) 0.901
Comes from within 10.00 (1.25) 11.00 (1.00) 11.00 (1.00) 0.005
1Mann-Whitne y Test; 2Higher scores indicate more hope.
Collecting data through personal, structured interviews
may have strengthened the result of the study in more
than one respect. Such interviews ensured that all ques-
tions in the schedu le were answered, with no gaps in the
data. Another advantage was that emotive and sensitive
questions could be asked and misunderstandings checked
immediately. The interviewers were also able to sense if
some questions were particularly difficult for partici-
pants to handle. Nowotny’s Hope Scale questions were
posed towards the end of the interview. It could be ar-
gued that, during the interview, participants were taken
through all aspects of a difficult life situation, and, from
a rational point of view, this may have negatively influ-
enced hope-scores. Equally, the participants may have
experienced the interview situation as valuable and
meaningful, which may have influenced hope-scores
No study like this one has been carried out before so it
can be regarded as a valuable pilot. It should be stressed
that 26 patients in the sample died within the first six
months from the follow-up study. Although statistically
taken into account this small number suggests the need
to conduct a similar but larger study focusing on hope
and QoL in elderly patients with advanced cancer. The
relationship between hope and QoL should be the key
especially when each group is studied independently
with focus on survival and palliative care.
The 75 elderly cancer patients who survived the first six
months after diagnosis were in good condition according
to QoL, physical functioning and incidence of symptoms
at the time of diagnosis as opposed to those who did not.
Those who died had, as expected, significantly lower
QoL and more complaints. However, the level of hope
did not differ significantly between the two groups (ex-
cept from the subscale ‘comes from within’). As ex-
pected, those who died were at a significantly lower
level of functioning capability than those who survived.
Though, it is noteworthy that th e same level of hope was
reported by bo th gro ups. D ifferent aspects of this f inding
will be discussed below.
Despite a lower QoL score among those who died
(and despite the seriousness of their situation ), they were
equally able to deal with their difficult situation and to
maintain hope in late life as newly diagnosed with can-
cer. The theoretical approach to hope in this study was
not only related to the future but also to new goals and
strategies in life, and / or feelings of safety and comfort
[22]. The importance of hope and meaning, and how to
maintain and measure hope, has been of interest within
cancer care [10,20,23-25]. However, consensus on a
common definition has not been reached [9]. Hope has
been defined as a catalyst that assists individuals to cope
successfully with life’s challenges and transitions, and
which facilitates continued functioning during chronic
illness and other significant losses [26-28]. This is espe-
cially important for elderly people who are challenged
with the task of maintaining hope in the face of loss [12].
Defining hope in relation to achievement, success, and
control is problematic for the elderly who may perhaps
already have experienced loss of their spouse and friends,
moving away from the family home, and / or reduction
in physical capacity [27-29]. In clinical practice, it is
often stated that health care professionals should not take
away hope from people suffering from cancer; especially
those with advanced cancer. Assuming that hope is a
catalyst that assists people to handle successfully
changes in life, and th at it is an inner power or resource,
it should be independent of experienced losses and may
be based in a person’s ability to maintain hope perse,
despite losses and difficulties.
In the current study QoL was measured by EORTC, a
health related QoL instrument where a person’s percep-
tions of health status and aspects of life are considered in
relation to expectations of normal living [30]. EORTC
cover aspects such as general health, physical function-
ing, physical symptoms, emotional functioning and cog-
nitive function [31 ]. Although the global QoL seemed to
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B. A. Esbensen et al. / Open Journal of Nursing 1 (2011) 12-18 31
be equal and without significant difference in the two
groups we investigated, the result und erlines the need for
recognition of QoL by health care professionals immedi-
ately on diagnosis in order to counteract the serious re-
duction in QoL that could occur in the early stages of
cancer in the elderly.
The entire sample scored “moderately hopeful” in ac-
cordance with the methodology developed by Nowotny
(1989). Accor ding to Rustoen [2 4] , ho pe ca n be re garded
as a component in the individual’s ability to cope with
stress in a life-threatening situation. In terpretation of the
results of this study, however, requires caution for at
least two reasons. Firstly, the relation between QoL and
hope is uncertain [24]. Secondly, the reliability of the
subscale ‘comes from within’ was low (α = 0.30). Find-
ings from a qualitative study, however, confirm that the
existential dimension of hope in elderly people newly
diagnosed with cancer is essential (Esbensen, 2004). In
the current study, such people had suddenly to face the
possibility that they might die within a short time-frame.
Despite the diagnosis of cancer in old age, advanced can-
cer and a need for palliative care, those who died obvi-
ously managed to maintain hope at the same level as those
who survived the first six months after diagnosis. This
may be interpreted in the light of the core of the SOC
model (The model of Selective Optimization with Com-
pensation) according to which, to some extent, the elderly
were able to strengthen their belief in handling difficulties
and to set up new goals despite an uncertain future [32].
However, it has been suggested that the meaning of hope
for palliative patients is the hope for others, not suffering
and a peaceful death. This reflects a discourse of hope that
is framed by QoL, not li fe or death [5,29] .
Based on this study we suggest that patients adapt to
their situation and appreciate every day in the face of a
potentially limited life expectancy. We also suggest that
other issues normally neglected in life become important
when one is diagnosed with a life-threatening disease.
Morse and Doberneck [33] pointed out from a qualita-
tive study of four participant groups (patients undergo-
ing heart transplant, spinal cord-injured patients, breast
cancer survivors, and breastfeeding mothers intending to
continue nursing while employed) that the degree of
threat experienced by a person as opposed to feeling safe
can motivate and strengthen hope. This may also have
been the situation for the 26 people in the sample who
died within the first six months; their ability to mobilize
their own resources despite the cancer may have helped
to maintain hope.
This study has implications for care and support in the
field of cancer care in the elderly. A group of elderly
people had suddenly to face the possibility that they
might die within a short time-Despite the diagnosis of
cancer and the need for palliative care, those who died
obviously managed to maintain hope at the same level as
those who survived the first six months after diagnosis.
Assuming that hope is a catalyst that assists people to
cope successfully with changes in life, and that it is an
inner power or resource, it should be independent of
experienced losses. Instead, hope may be based in a
person’s ability to maintain it perse, despite losses and
difficulties, and the clinical implications are therefore to
support hope in the individual patient.
Despite limited life expectation some patients were
able to adapt to their changed situation. It might be that
other matters become more important with a potentially
life-threatening disease. Health-care professionals may
play a significant role in identifying elderly people with
cancer who are unable to mobilise their own resources to
maintain a moderate level of QoL. In addition, those
patients who have difficulty in adapting to the new situa-
tion, and therefore at risk of experiencing reduced QoL
and hope need specific intervention.
Those who died within the first six months had lower
QoL and more complaints than those who survived. A
significant difference was identified in Global QoL, in
physical and role function. However, no significant dif-
ference was identified in the total level of hope between
the two groups. Hope may be based in a person’s ability
to maintain hope per se which underlines the necessity
for health care professionals continuously to recognize
the situation of the elderly individual with cancer in or-
der to counteract the reduction in QoL that may occur
and to support their hope.
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