Health Related Quality of Life and Depression among Blood Cancer Patients in Pakistan: The Missing Public Health Link

Introduction: Limited access to health care facilities, less number of qualified oncologists, lack of technical equipment for diagnosis are the major factors effecting adequate control and prevention of blood cancer in Pakistan. Objective: The objective of the study was to assess health related quality of life and depression among blood cancer patients in Pakistan. Methodology: A descriptive cross-sectional study design was used. Two pre validated questionnaires i.e. SF 36 and HADS were self-administered to a sample of 400 blood cancer patients’ selected using convenience sampling technique for measuring HRQoL and depression, respectively. After data collection, data was cleaned, coded and entered in SPSS. Results: The results highlighted that lowest scores for HRQoL among blood cancer patients were observed in the domain of role emotional (33.55, ± 27.528) followed by bodily pain (42.93, ± 30.838) whereas highest scores were observed in the domain of mental health (73.7, ± 18.488). Original Research Article Malik et al.; JPRI, 33(9): 51-62, 2021; Article no.JPRI .65783 52 Significant difference (p ≥ 0.05) was observed in HRQoL of cancer patients with different marital status, stages of blood cancer and receiving different types of therapies. Conclusion:The present study concluded that blood cancer patients had poor HRQoL and moderate depression in spite of advanced therapeutic strategies.


INTRODUCTION
Cancer and its treatment often produce significant morbidities that undermine the health of cancer survivors [1]. Cancer patients experience many persistent symptoms including pain, nausea, vomiting, lack of appetite, physical discomfort, psychological distress which affects the treatment outcomes of the cancer patients [2]. Better quality of life is associated with increased level of optimism, lower level of psychological distress and by social support. Quality of life among cancer patients can improve treatment outcomes as well as survival of an individual [3]. Health related quality of life (HRQoL) is a multidimensional construct of physical, psychological and social well-being, evaluating individuals own assessment of his / her health and capacity to perform daily activities of life [4,5]. It is a significant measure in hematological malignancies and is a major concern while treating the cancer patients due to severity of symptoms and duration of treatment [6]. Cancer patients often experience multiple concurrent symptoms which are the predictors of changes in patient normal functioning, treatment failures and therapeutic outcomes. Most of the blood cancer patients were reported with worst health-related quality of life with varying symptom including fatigue, pain, psychological distress and impairing treatment outcomes in USA [7]. Similarly, patients of blood cancer showed substantial symptom burden in disease trajectory affecting overall wellbeing in Germany and Canada [8,9]. Symptoms like nausea, vomiting, anxiety, depression, dyspnea, fatigue, pain and insomnia affected prognosis, quality of life and working status of cancer patients in Spain [10,11].Physical and psychological symptoms along with socioeconomic factors were also reported to contribute towards good health of cancer patient in Brazil [12]. A study from Iran highlighted that physical symptoms like fatigue, pain can effect quality of life but these symptoms can be improved by proper counseling resulting in improved quality of life of cancer patients [13]. Similarly, another study from Iran reported that patients with cancer had lower quality of life during chemotherapy and off treatment [14].
Depression is an independent predictor of morbidity and mortality in cancer patients [15]. Depression and hopelessness is common among cancer patients associated with high morbidity and mortality rates [16]. Hematological cancer patients suffers from anxiety and depression which effect their daily life activities, body image and self-esteem. The compliance of the patient towards treatment decreases with increased depression [17]. Higher level of anxiety, depression, fatigue, pain, insomnia influencing health outcomes among blood cancer patients were reported in Malaysia [18].
Blood cancer has been considered as an emerging non-communicable public health threat in Pakistan. Lower educational background, poor socio-economic status, socially stigmatized situation and paucity of early detection programs also add to the burden of cancer disease in Pakistan.Limited access to health care facilities, less number of qualified oncologists, lack of technical equipment for diagnosis are the major factors effecting adequate control and prevention of blood cancer in Pakistan. A study conducted in Multan reported high level of depression and anxiety especially among the younger population suffering from blood cancer [19]. Similarly, elderly cancer patients were identified as more vulnerable group to psychological problems including anxiety, sadness, depression, isolation, insomnia and dementia in Pakistan [20,21]. The importance of health related quality of life and its determinants including physical, emotional and functional domains along with depression among blood cancer patients has long been recognized in developed world but in developing countries this concept is in infancy, although its rate has been increasing at an alarming rate in Pakistan. Therefore, this study was designed to assess health related quality of life and depression among blood cancer patients in Pakistan.

METHODOLOGY
All health care facilities both from public and private sector treating blood cancer patients located in twin cities were included in study. Study respondents included patients diagnosed with blood cancer. Inclusion criteria for this study were blood cancer patients aged between 18-65 years, both genders, having any comorbidity and patients receiving chemotherapy, radiotherapy and Imatinib. All cancer patients other than blood cancer and those below or above the age range of 18-65 years were excluded. Blood cancer patients with any disease effecting HRQoL in similar manner or any other surgery leading towards depression were also excluded. Approval was also taken from Medical superintendents of different healthcare facilities of Rawalpindi and Islamabad. Patients were briefed regarding nature and objectives of the study. Verbal and written consent were obtained prior to data collection. Respondents were ensured of the confidentiality of their responses along with full right to withdraw from the study at any time. The sample size was calculated by using Rao soft at 95% confidence interval and 5% margin of error which came to be 400. Convenience sampling technique was used for selection of respondents available and willing to participate at the time of data collection. Prospective data was collected from primary sources by self-administering two pre validated questionnaires i.e. SF 36 and HADS for assessment of HRQoL and Depression, respectively. The questionnaires were filled by the patients on spot and collected back to avoid biasness. SF-36 consist of eight subscales including: perceived mental health (5 items), physical functioning (10 items), general health perceptions (5 items), role limitations due to physical problems (4 items), role limitation due to emotional problems (3 items), social functioning (2 items), vitality (4 items) and bodily pain (2 items) [22] while Hospital Anxiety and Depression Scale (HADS) consists of 7 items each for anxiety and depression [23]. Pilot testing was performed on 10% of the sample size for assessing reliability of the tool. The value of Cronbach's alpha for SF 36 was 0.73 and 0.69 for Hospital Anxiety and Depression Scale (HADS). After data collection, data was cleaned, coded and entered in SPSS. Descriptive statistics comprising of frequency and percentages were calculated. Non-parametric tests Kruskal Wallis and Mann Whitney tests (p ≥ 0.05) were performed to find out the differences among different variables.

Health Related Quality of Life among Blood Cancer Patients
The results highlighted that lowest scores for HRQoL among blood cancer patients were observed in the domain of role emotional (33.55, ± 27.528) followed by bodily pain (42.93, ± 30.838) whereas highest scores were observed in the domain of mental health (73.7, ± 18.488). A detailed description is given in (Table 2).

Depression among Blood Cancer Patients
Comparison of severity of depression among blood cancer patients having different demographic characteristics revealed that blood cancer patients of all age groups, gender, marital A detailed description is given in (Table 4).

Comparison of Severity of Depression among Blood Cancer Patients According to Different Demographic Characteristics
Significant difference (p ≥ 0.05) was observed in level of depression among blood cancer patients having comorbidities. However, no significant difference (p ≤ 0.05) was observed for depression among different age groups, marital status, qualification level, children, stages of blood cancer, type of therapy, cancer patients treated in different sectors, provinces, setting, and gender. A detailed description is given in (Table 5).

DISCUSSION
Blood cancer has become one of the most prevailing cancer worldwide affecting overall standards of living of an individual. Due to prolonged therapy and recurrence of blood cancer, patients suffer from physical, emotional and social discomfort leading towards poor disease outcomes. Estimation of HRQoL is important in blood cancer, as it helps both patients and physicians in choosing better treatment options which in return can improve health outcomes. The results of this study reported a consequential impact on several domains of HRQoL of blood cancer patients in Pakistan. Minimal scores for HRQoL were observed in the domain of role emotional followed by bodily pain whereas maximum scores were observed in the domain of mental health. These findings were supported by study conducted in Brazil which also reported highest mental health score among blood cancer patients [24]. However, in blood cancer specific domains; the present study results showed lowest score in the domain of symptom scale that is constipation followed by cognitive function whereas highest  [30].
The results of the present study highlighted that patients social activities, support were limited which are in concordance with findings of study conducted in Turkey which showed a positive correlation between social support and quality of life [31]. Most of the cancer patients enrolled in the present study revealed that their activities were affected due to their emotional problems. These finding are in consistent with the study from USA which reported that cancer patients accomplished less work, missed working days than usual due to fatigue and emotional problems [32].
The results of the current study reported that blood cancer patients who were unmarried or those in acute stage or receiving radiotherapy had comparatively better HRQoL which might be due to their positive attitude or hope for the future to cope up with this disease, support from the family, friends or community and might be due to the known treatment side effects. These findings are consistent with studies from USA and Sweden in which patients receiving radiotherapy and in acute stage had relatively better quality of life [33,34].
Blood cancer patients are usually at high risk of experiencing depression and anxiety during and after course of illness. The results of this study revealed that some of the blood cancer patients had definitely lost interest in their appearance and felt frightened very frequently and enjoyed a book or radio or TV program very seldom while most of them felt tensed from time to time occasionally and got sudden feeling of panic and had worrying thoughts occasionally. These findings are in line with the findings from a study of Germany which reported moderate to high level of depression among blood cancer patients [35].

LIMITATIONS OF THE STUDY
The main issues faced during the study were time and financial constraints and cross sectional study design which does not show cause and effect relationship. Furthermore, the results of this study are limited to twin cities of Pakistan and may not be generalized to other parts of country.

CONCLUSION
The present study concluded that blood cancer patients had poor health related quality of life and moderate depression in spite of advanced therapeutic strategies. The results highlighted that lowest scores for health related quality of life were observed in the domain of role emotional, followed by bodily pain. Unmarried patients, those in acute stage and receiving radiotherapy had comparatively better health related quality of life. Moreover,blood cancer patients of all age groups, gender, marital status, having different qualification and job status were found severely depressed. Health care providers should regularly assess health related quality of life to improve treatment outcomes. Appropriate health educational and psychological interventional programs specifically targeting patients with lower educational programs should be initiated to improve awareness regarding cancer and its coping strategies and to reduce depression among blood cancer patients. Future research should be conducted to explore the relationship between blood cancer and depression in termsof different patients' sociodemographic characteristics.

CONSENT
Verbal and written consent were obtained prior to data collection.

ETHICAL APPROVAL
A descriptive cross-sectional study design was used to assess health related quality of life and depression among blood cancer patients in twin cities (Islamabad and Rawalpindi) of Pakistan.Study approval was taken from the Ethical Committee of Hamdard University (BASR-81-5.2).