THE EFFECTS OF CARE COORDINATION ON SYMPTOMS AND QUALITY OF LIFE ON CANCER PATIENTS UNDERGOING TREATMENTS a SYSTEMATIC REVIEW

THE EFFECTS OF CARE COORDINATION ON
SYMPTOMS AND QUALITY OF LIFE ON
CANCER PATIENTS UNDERGOING
TREATMENTS: A SYSTEMATIC REVIEW
Tran Thuy Duong
RN, BSN

Supervisor: Dr. Kimberly Alexander

Submitted in fulfilment of the requirements of the degree of
Masters of Nursing (Coursework)

School of Nursing and Midwifery
Faculty of Health
Queensland University of Technology
July 2015



Keywords

Care coordination, cancer patients, treatments, symptoms, systematic review, and
quality of life.

i


Abstract

Background: Patients living with cancer experience poor symptoms and quality of
life during and after treatments. As supplementary to usual care to improve

symptoms and QoL, nursing interventions such as care coordination or nurse
navigation are increasly used in cancer cares.
Objectives: The main objective of this systematic review was to evaluate the
effectiveness of care coordination on symptoms and QoL of cancer patients receiving
active treatments.
Methods: A systematic, computerized search in CINAHL, MEDLINE, PUBMED
and PsycINFO was conducted. Included studies in this review were measured
symptoms or QoL in patients cared for by care coordination as a primary outcome
measure. In total, 3626 published articles were identified and 16 studies were
reviewed that met the inclusion criteria and methological quality standards.
Results: The effect of care coordination in symptom improvement was documented
in pain, fluid intake, sleep and rest, mobility, sociability, physical safety, body image
and sexuality, while other symptoms were not improved. Also, few studies provide
evidence for better QoL scores and other subdomains. However, this review cannot
provide a qualified conclusion about the relationship between care coordination and
symptoms and QoL. The main reasons for this include: limited number of studies,
inconsistencies across the included studies, and the poor quality of the included
studies.
Conclusion: There was insufficient evidence to evaluate whether care coordination
is effective in cancer patients’ QoL while undergoing treatments. Future research

ii


needs to be conducted to understand the effect of care coordination on cancer patient
symptoms and QoL.

iii

Table of Contents

Keywords ............................................................................................................................. i
Abstract ............................................................................................................................... ii
Table of Contents ................................................................................................................ iv
List of Figures .................................................................................................................... vi
List of Tables ..................................................................................................................... vii
List of Abbreviations ........................................................................................................ viii
Statement of Original Authorship ........................................................................................ ix
Acknowledgements .............................................................................................................. x

Chapter 1: Introduction ......................................................................................... 1
1.1 Background.................................................................................................................... 1
1.2 Problems ........................................................................................................................ 3
1.3 Significance ................................................................................................................... 3
1.4 The purposes of the project ............................................................................................ 4
1.5 Summary ....................................................................................................................... 5

Chapter 2: Literature Review ................................................................................ 7
2.1 Cancer symptoms on patients undergoing treatments ...................................................... 7
2.1.1 Chemotherapy ............................................................................................................... 7
2.1.2 Radiotherapy ................................................................................................................. 8
2.1.3 Stem cell transplant and Bone marrow transplant ........................................................... 9
2.1.4 Immunotherapy ........................................................................................................... 10

2.2 Quality of life on patients undergoing cancer treatments ............................................... 12
2.2.1 Quality of life .............................................................................................................. 12
2.2.2 Quality of life on patients undergoing cancer treatments ............................................... 13

2.3 Outcome measure instruments ...................................................................................... 15

2.3.1 Symptom measurement................................................................................................ 15
2.3.2 Quality of life measurement ......................................................................................... 16
2.3.3 Factors associated with symptom burdens and QoL ...................................................... 18

2.4 Support interventions ................................................................................................... 20
2.4.1 The gaps of usual care nursing interventions ................................................................ 21
2.4.2 Care coordination ........................................................................................................ 23

2.5 Summary ..................................................................................................................... 26

Chapter 3: Methodology ...................................................................................... 29
3.1 Literature search .......................................................................................................... 29
3.2 Inclusion criteria .......................................................................................................... 30
3.2.1 Types of studies........................................................................................................... 30
3.2.2 Types of participants.................................................................................................... 30
3.2.3 Types of interventions/Phenomena of Interest .............................................................. 31

3.3 Assessment of methodological quality .......................................................................... 31
3.4 Data extraction ............................................................................................................. 31

iv


3.5 Data synthesis .............................................................................................................. 32
3.6 Methodological result ................................................................................................... 32

Chapter 4: Results ................................................................................................ 41
4.1 Demographic and sample group characteristics ............................................................. 41
4.1.1 Age…. ........................................................................................................................ 41
4.1.2 Marital status............................................................................................................... 42

4.1.3 Employment status ...................................................................................................... 43
4.1.4 Cancer stages .............................................................................................................. 43
4.1.5 Treatments .................................................................................................................. 44

4.2 Nursing Interventions ................................................................................................... 45
4.3 Outcome measure instruments ...................................................................................... 48
4.4 The effects of care coordination .................................................................................... 49
4.4.1 The effects of care coordination on symptoms .............................................................. 49
4.4.2 The effects of care coordination on QoL ...................................................................... 55

4.5 Summary...................................................................................................................... 62

Chapter 5: Discussion ........................................................................................... 63
5.1 Overall symptom evaluation ......................................................................................... 63
5.1.1 Pain… ......................................................................................................................... 64
5.1.2 Depression .................................................................................................................. 65
5.1.3 Distress ....................................................................................................................... 67
5.1.4 Anxiety ....................................................................................................................... 69
5.1.5 Other symptoms .......................................................................................................... 70

5.2 Overall QoL evaluation ................................................................................................ 71
5.2.1 QoL evaluation on five studies favoured care coordination ........................................... 73
5.2.2 QoL evaluation on nine studies which did not favour care coordination ........................ 81

5.3 Recommendations ........................................................................................................ 83
5.3.1 Indications in research ................................................................................................. 83
5.3.2 Indications in clinical practice...................................................................................... 85

5.4 Summary...................................................................................................................... 86

Chapter 6: Conclusions......................................................................................... 87
6.1 Summary of the systematic review findings .................................................................. 87
6.2 Limitations ................................................................................................................... 88

References… ......................................................................................................... 89
Appendices.. .......................................................................................................... 99
Appendix A: Detailed search strategy according to databases ............................................. 99
Appendix B: Critical appraisal checklists and data extraction forms from JBI MASTARI . 103

v


List of Figures

Figure 1: The process of study selection ............................................................... 33

vi


List of Tables

Table 1: Summary table of the included studies.................................................... 39

vii


List of Abbreviations

APN

Advanced Nurse Practice

BPI

Brief Pain Inventory

CES-D

Centre for Epidemiologic Studies Depression Scale

CPGS

Chronic Pain Grade Scale

EORTC QLQ-C30

European Organization for Research and Treatment of
Cancer Core Quality of Life Questionnaire

FACT-G

Functional Assessment of Cancer Therapy-General

HRQoL

Health Related Quality of Life

MPQ

McGill Pain Questionnaire

NRS

Numeric Rating Scale

PHQ-9

Patient Health Questionaire-9 score

QLACS

Quality of Life in Adult Cancer Survivors Scale

QoL

Quality of Life

RCT

Randomized Controlled Trial

SF-36

Medical Outcomes Study 36-Item Short-Form Health
Survey

VAS

Visual Analogue Scale

WHO

World Health Organization

viii


Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.

Signature:

_________________________

Date:

_________________________

ix


Acknowledgements

I am so proud and happy to give my special thanks to all the people who
supported me to achieve my goals.
First and foremost, my sincere thanks must go to my supervisor, Dr. Kimberly

Alexander. Your enthusiastic support throughout my last semester kept me on the
right track to achieve the difficult requirements of my course.
A special thanks to Ms. Rena Frohman, who supported me in language
development. My writing has improved a lot; actually it would not be smooth
without your help. Many students said that I was so lucky when I could work with
you, and I totally agree with them.
My most important thanks is to my family, especially my Mom, who always
encouraged me when I felt tired. I would also like to thank my housemates: Tuyen,
Huyen, Nguyen and little boy Tony. They seem to be my second family in Australia.
I cannot forget to thank my dear friends Trang and Thuy. Although we live far
from each other, we always share happiness and troubles in our lives.
Finally, I acknowledge that I would not have learned here without the support
of Australia Awards Scholarships (AAS). Thus, I would like to give many thanks to
AAS, especially to Ms. Zia, Youngnam and Mr. Lay who provided the most
convenient learning for me in QUT.

x


Chapter 1: Introduction

This chapter will present the background to this Master of Nursing project,
which reviews cancer patients’ symptom burden and quality of life (QoL) and
current nursing care interventions for cancer patients. Firstly, cancer symptoms and
quality of life will be discussed in relation to current treatments. This will be
followed by an overview of usual care and supplemental care in relation to symptom
management and QoL. Lastly, the gaps in current knowledge related to the current
model of care for symptom and QoL management, as well as the significance and the
purposes of this project will be presented.
1.1 Background

Patients with cancer usually experience negative effects, which can increase
symptom burden and decrease quality of life, as a result of the disease process itself
and required medical treatments. Across different cancer types, disease stages, or
treatment methods, cancer symptoms are both prevalent and tenacious. Pain and
fatigue are the two most common symptoms of cancer (Laird et al., 2011; LuctkarFlud, Groll, Tranmer & Woodend, 2007; Stark, Tofthagen, Visovsky & McMillan,
2012). Nausea or vomiting, difficulty sleeping, weight loss, losing hair or skin
reactions are also frequently presented in patients undergoing cancer treatments
(Cheng & Yeung, 2013; Dikken & Wildman, 2013; McQuestion, 2011). Cancer and
treatment related symptoms can interfere with patients’ daily activities and their
social functions, and consequently may impair their QoL. To demonstrate, some
studies (Andresen et al., 2012; Brandt et al., 2010; Malihi et al., 2013) were
conducted to measure the QoL in cancer patients undergoing treatments. Despite the

Chapter 1: Introduction

1


heterogeneity in cancer or treatment types, the results of these studies indicated that
patients, after receiving treatments, reported poorer QoL in comparison with before
receiving treatments. Consequently, the medical interventions or the occurrence of
treatment-related symptoms may compromise the symptoms and QoL or the social
and functional well-being of patients living with cancer. Hence, nursing interventions
are becoming an important aspect of care to improve patient outcomes.
Symptom experience and QoL of cancer patients undergoing treatments require
comprehensive cancer care services. To address this, many kinds of nonpharmacological nursing interventions have been applied such as educating patients
about physical activities, symptom self-management or mindfulness-based therapy
(Baumann, Zopf & Bloch, 2012; McCorkle et al., 2011; Piet, Würtzen & Zachariae,
2012). As the range of possible interventions increases, the choices and decisions can
become more complicated for nurses, patients and their families. One response to

this situation has been the introduction of care coordination models. Indeed, the
fundamental purpose of care coordination is to provide a supplement to the usual
biomedical and nursing interventions in order to increase patient satisfaction with
health care services and positively impact QoL. An example of care coordination is
the Patient Navigators model, which is provided throughout the cancer care
continuum (The National Cancer Institute, 2015). Patients and their families are
supported in symptom management, the scheduling of appointments with healthcare
providers, and in arranging follow-up services. The implementation of care
coordination seems to be a reasonable response to providing better support to
patients and the health system; however the impact of care coordination has not been
systematically evaluated in relation to patients’ symptom experience and QoL.

2

Chapter 1: Introduction


Hence, his project was initiated to develop a better understanding of patient problems
and care coordination.
1.2 Problems
Although care coordination is commonly implemented in clinical practices, the
research on the effects of care coordination has not been extensively reviewed and
the studies which have concentrated on outcomes of care coordination have not
concentrated on symptom management and QoL. In a report on the development and
principles of care coordination, Freeman and Rodriguez (2011) stated that the effects
of care coordination have not been evaluated extensively due to the limited number
of studies. For example, Chumbler et al. (2007) and Ozcelik, Fadiloglu, Karabulut
and Uyar (2014) when assessing the relationship between care coordination and
patient outcomes, only focused on hospitalization and satisfaction with care or cost.
Similarly, Fiscella et al. (2012) only documented that care coordination could

actually improve patients’ satisfaction and the quality of cancer care services without
mentioning symptom management or QoL. Moreover, studies, which have examined
the relationship between care coordination and symptoms and QoL, commonly have
assessed symptoms and QoL as secondary outcomes (Jahn et al., 2008; O'Sullivan et
al., 2011). Hence, because these studies have not measured a range of confounders,
the results may be not evaluated in terms of care coordination’s efficacy. Therefore,
the evidence for the value of care coordination on symptoms and QoL on cancer
patients undergoing treatment needs to be considered more comprehensively.
1.3 Significance
The findings of this project and systematic review may significantly contribute
to evaluating the role of care coordination in relation to management of cancer and

Chapter 1: Introduction

3


treatments related to symptoms and QoL. It is important to clearly understand how
well care coordination is currently supplementing usual care. Due to the complex
disease processes, cancer patients receive multiple types of care including biomedical
approaches and nursing interventions for symptom management. In addition,
supplemental care such as care coordination is also being delivered to enhance
treatment results. However, the recent development of care coordination indicates
gaps which can better inform patient management and identify the demands for
future studies. Hence, this study will provide health providers with knowledge about
care coordination and the benefits of care coordination in terms of symptom
management and QoL.
Furthermore, it is also important to evaluate the current evidence regarding the
impact of care coordination on symptom management and QoL. This is important
because before recommending interventions to clinical practice, each intervention

needs to have demonstrated effectiveness. Therefore, this review will evaluate and
synthesize the findings of previous studies to indicate future directions for care
coordination in relation to patients’ symptom experience and QoL.
1.4 The purposes of the project
For this project, the first purpose is to provide an overview of care coordination
and secondly report on a systematic review of care coordination as a nursing
intervention aiming to increase patients’ symptom management and QoL for patients
undergoing treatments. This project will identify the benefits regarding current
knowledge related to care coordination in relation to patients’ symptom experience
and QoL for both patients and health providers, and provide recommendations for
clinical practice and future research.

4

Chapter 1: Introduction


1.5 Summary
Cancer

patients

experience

complicated

treatments

which

require

comprehensive care services. Nursing interventions include many strategies which
are designed and delivered to patients to manage symptom experience and improve
QoL. In order to improve the effectiveness of treatments and nursing care,
supplemental care such as care coordination is provided; however, the effects of this
intervention are not well understood. This project aims to provide a comprehensive
description of cancer patients’ symptoms and QoL, and care coordination, so as to
provide appropriate conclusions and recommendations about the application of this
supplemental care in clinical practice.

Chapter 1: Introduction

5



Chapter 2: Literature Review

The following literature review has three sections: cancer treatment choices,
quality of life, and supportive care. In section one, the state of symptoms for cancer
patients receiving treatments will be discussed, followed by the side-effects of four
common cancer treatments including chemotherapy, radiotherapy, stem cells or bone
marrow transplants and immunotherapy. To better understand the management of
symptom burden caused by both the cancer processes and the treatment effects,
section two will define QoL, which is a common consideration, used to evaluate
intervention impacts on cancer care. In addition, this section will discuss how QoL is
reduced by cancer treatments, and common factors associated with QoL. Section
three briefly introduces limitations of current nursing interventions used in usual
cancer care, which consequently has led to the presence of care coordination to

improve patient outcomes, in particular to decrease symptom burden and increase
QoL.
2.1 Cancer symptoms on patients undergoing treatments
Cancer and cancer treatments can cause a range of symptoms including pain,
fatigue, vomiting and loss of appetite and weight. The following sections will discuss
how cancer treatments negatively impact on patients’ symptoms and Qol.
2.1.1 Chemotherapy
Chemotherapy is one of the most common treatments in cancer, and can
negatively impact physical health, emotional health and lead to other health issues.
Chemotherapy is used to kill cancer cells or delay cancer cell growth, and thus
improve cancer symptoms (Cancer Australia, 2015). It can be used alone or with

Chapter 2: Literature Review

7


other treatment methods, depending on type, stage of cancer or size of malignant
tumors (Sugerman et al., 2013). When managing cancer burden, both patients and
health providers need to acknowledge that although chemotherapy kills cancer cells,
it is associated with negative symptoms as well. Patients undergoing chemotherapy
may experience problems with physical health such as nausea and vomiting, hair
loss, weight gain or weight loss, mouth ulcers and infections, diarrhea or
constipation, menopausal symptoms, skin or nail changes or reactions, nerve and
muscle problems and swelling in the arms and legs (DeHaven, 2014; Goedendorp et
al., 2012; Gozzo et al., 2014; Trüeb, 2010).
Chemotherapy may also affect a patient’s emotional health by causing fatigue
and anxiety or depression (Scialdone, 2012; Sugerman et al., 2013). These side
effects may impact clinical outcomes. For example, nausea and vomiting, which are
two distressing symptoms for patients, may result in nutritional depletion, poor

performance, and poor mental status (Dikken & Wildman, 2013; Scialdone, 2012).
In addition, chemotherapy can lead to other health issues including cardiac
conditions, anemia or neutropenia (Monsuez et al., 2010; Scialdone, 2012).
Furthermore, long-term side effects of chemotherapy include infertility. Reinmuth et
al. (2013), who examined the fertility in adults who received chemotherapy and
radiation in childhood, found 14.1% and 24.4 % of female and male participants,
respectively, were classified as “possible infertile”. Thus, chemotherapy is a common
cancer treatment; however its side effects are diverse in terms of physical, emotional
and health impacts.
2.1.2 Radiotherapy
Radiotherapy is used in cancer treatment to kill cancer cells or reduce cancer
symptoms, but it also negatively influences patient’s health. Radiation therapy

8

Chapter 2: Literature Review


destroys or injures cancer cells so they cannot multiply. This anti-cancer method is
also used to reduce malignances’ size, pain and other symptoms (Cancer Australia,
2015). Radiotherapy is administered on its own or as a part of combined modality
treatment (Sammut & Arumainathan, 2013). Similar to chemotherapy, radiotherapy
can have negative effects, which challenge patients and health workers as they
attempt to manage physical health impacts including: fatigue, nausea, loss of
appetite, dry, red or itchy skin, digestive problems, cough or shortness of breath. One
of the most common side effects is an acute skin reaction for around 80% of cancer
patients treated with radiotherapy (McQuestion, 2011). Acute radiation-induced skin
reactions can lead to itching, pain or diminished aesthetic appearance and subsequent
decrease in quality of life (Salvo et al., 2012). Furthermore, radiotherapy may impact
on fertility in both men and women (Balcerek et al., 2012; Reinmuth et al., 2013).

Also, cancer patients may be at risk of radiation-induced secondary cancer after
treating by radiation therapy (Lee, Lee, Sung & Yoon, 2014; Paganetti et al., 2012;
Stokkevåg et al., 2015). In two articles, Elumelu-Kupoluyi, Adenipekun and Ntekim
(2013) and Watts (2014) stated that secondary cancer was associated with an
increase of symptom burdens, especially pain, distress symptoms and cancer-related
fatigue. In summary, radiotherapy has side-effects which can impact on symptom
burden and may be associated with on-going cancer cell growth. Therefore, a
comprehensive care service including supplemental care is necessary to better
manage complicated patient conditions.
2.1.3 Stem cell transplant and Bone marrow transplant
Stem cell or bone marrow transplant is considered another effective cancer
treatment; however, its side effects are similar to chemotherapy or radiotherapy.
Transplantation is a procedure that replaces a person's cancer stem cells with healthy

Chapter 2: Literature Review

9


ones (The National Heart, Lung and Blood Institute, 2011). There are two kinds of
transplantation, which are allogeneic and autologous transplant (Leukemia
Foundation, 2015). Allogeneic transplants replace patients’ cells with haemopoietic
stem cells which come from the bone marrow, peripheral blood or umbilical cord
blood of a donor who may be the patients’ family member or a volunteer.
Autologous transplants replace patients’ cells with their own peripheral blood or
bone marrow (Lennard & Jackson, 2000).
The complications of stem cell and bone marrow transplant have been studied
for many years. For example, in a research of the side effects of bone marrow
transplant (Bellm, Epstein, Rose-ped, Martin & Fuchs, 2000), the authors reported
that mouth pain, nausea and vomiting, diarrhoea, and fatigue are the most debilitating

side effects of their transplants. Although their study was conducted 15 years ago, the
results have been replicated more recently (Bos-den, Potting, Bronkhorst, Huysmans
& Blijleven, 2014; Cohen et al., 2012).
In addition, it is also well documented that transplants have long-term side
effects including increasing the incidence of diabetes and hypertension and
secondary malignancies or late relapse of the primary disease (Andersson, Ahlberg,
Stockelberg, Persson, 2011; Cohen et al., 2012; Mohty & Mohty, 2011). Thus,
although this therapy is an effective treatment, some unexpected short-term and longterm symptoms can occur including mouth sores, nausea and vomiting and fatigue,
which require diverse nursing interventions.
2.1.4 Immunotherapy
Immunotherapy is a new method which is promising in cancer treatment but
negative effects have also been documented. Cancer immunotherapy uses the body's
own immune system to treat cancer, stopping or slowing the growth of cancer cells

10

Chapter 2: Literature Review


(McNutt, 2013). There are two common types of immunotherapy, including
monoclonal antibodies, non-specific immunotherapies, and cancer vaccines. First,
monoclonal antibodies destroy proteins, which support the growth of the cancer cells,
on the surface of cancer cells. It can also directly deliver radiation or powerful drugs
to cancer cells to prevent these cells from growing rapidly (Scott, Wolchok & Old,
2012). However, health providers should consider its use because according to
Hansel, Kropshofer, Singer, Mitchell & George (2010), this treatment can lead to
serious severe side effects including: immune reactions, infections, platelet and
thrombotic disorders, skin reactions, rashes, low blood pressure, and flu-like
symptoms, such as fever, chills, headache, weakness, extreme tiredness, loss of
appetite, upset stomach, or vomiting.

The second type of immunotherapy, which is referred to as non-specific
immunotherapies, includes two common protein functions: interferons and
interleukins. Interferons support the immune system in fighting or slowing the
growth of cancer cells, while interleukins help the immune system produce cells that
destroy cancer. Both types of non-specific immunotherapies have the same sideeffects of increasing symptom burden such as: flu-like symptoms, an increased risk
of infection, rashes, thinning hair, weight gain and low blood pressure (Yoshomoto
& Morishima, 2009). Consequently, although immunotherapy shows promise in
theory as a cancer treatment, all types of immunotherapy are well documented as
providing negative effects on patient symptoms and future requiring comprehensive
care management.
In summary, the treatments including chemotherapy, radiotherapy, stem cells
or bone marrow transplants and immunotherapy are well recognised as being front
line treatments in preventing cancer progress. However, despite the advantages of

Chapter 2: Literature Review

11


these treatments, it is recognised that they also lead to worse symptoms for patients.
These treatments may result in common symptoms such as pain, nausea and
vomiting, fatigue, loss of appetite, weight loss, poor performance and mental status;
or specific symptoms such as hair loss, skin reactions and infertility. The complexity
of patient symptoms causes significant management challenges for both patients and
health providers, requiring an evidence-based nursing care approach.
2.2 Quality of life on patients undergoing cancer treatments
QoL is commonly recognised as a key criterion in both research and clinical
settings. Cancer patients undergoing treatment are impacted by both the disease itself
and the treatments. It can be seen that the complicated progress of the cancer and
patient symptoms presents problems for patients in terms of QoL. In particular it is

well documented that cancer patients experience reduced QoL. Hence it is important
to consider QoL factors including physical, functional, emotional and social wellbeing to ensure they are considered when managing care for cancer patients.
2.2.1 Quality of life
In order to evaluate the efficacy of any supportive care intervention, health
professionals need to have a deep understanding of multidimensional concepts
associated with QoL. For over 20 years, many authors have provided different
definitions of QoL. For example, the World Health Organization Quality of Life
Group (1995) expressed QoL as an individual’s awareness of their position in life,
relative to their expectation, standards, goals and concerns; while other authors
commented that QoL should be associated with life conditions and personal
satisfaction (Borthwick-Duffy, 1992). Most authors agree that QoL is a
multidimensional construct consisting of many domains: physical health,

12

Chapter 2: Literature Review


psychological condition, spiritual concern, social relationships, environmental
features and level of independence and development (Felce & Perry, 1995;
WHOQOL, 1997; Norkin, Hsu & Wingard, 2012). QoL is essential to cancer patients
and has emerged as a significant area of research alongside survival endpoints.
Addressing QoL can result in better communication between patients and clinicians,
better patient satisfaction, improved treatment adherence, and less stress to the health
worker teams (Norkin, Hsu & Wingard, 2012). Hence, comprehensive QoL
assessment is an important aspect in caring for cancer patients.
2.2.2 Quality of life on patients undergoing cancer treatments
QoL can be reduced by cancer symptom burdens and treatment side-effects.
During the intense period of treatment, cancer patients will experience a range of
possible complications, which are caused by disease, treatment methods or both,

including pain, fatigue, nausea, sleep disorder, spiritual uncertainty, distress, mood
disturbance, or relationship challenges (Manitta, Zordan, Cole-Sinclair, Nandurkar &
Philip, 2011). First, the reduction of QoL is well documented in patients receiving
chemotherapy. For example, Malihi et al. (2013) measured the QoL in a total of 63
acute leukaemia patients before and after chemotherapy. The results showed that the
mean score for global QoL decreased significantly from 60.31 (SD=20.65) to 50.39
(SD=17.5) after the introduction of chemotherapy (p<0.001) (greater mean score
indicates better QoL). In addition, the dose of chemotherapy can remarkably
influence QoL. For instance, Andresen et al. (2012) and Brandt et al. (2010) found
that patients receiving high-dose chemotherapy experienced a significant decrease in
more QoL subdomains including physical, role, emotional, cognitive, and social
functioning than those who received conventional chemotherapy. Although Oeyen et
al. (2013) indicated in their research that QoL improved after one year of receiving

Chapter 2: Literature Review

13