{'fraction_non_alphanumeric': 0.03788794840790004, 'fraction_numerical': 0.026141532792076927, 'mean_word_length': 4.968384879725086, 'pattern_counts': {'":': 0, '<': 6, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 2, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Health-Related Quality of Life among Breast Cancer Patients and Influencing Factors in Morocco

Background: Breast cancer is the most common cancer among women in most countries of the world. It is ranked first in females in Morocco (accounting for 33.4% of the total cancer burden) and more than 60% of cases are diagnosed at stage III or IV. During the last decade, health-related quality of life (HRQOL) has become an important aspect of breast cancer treatment. The objective of this study was to describe self-reported HRQOL in patients with breast cancer and to investigate its associations with sociodemographic and clinical variables. Methods: A prospective study was carried out in the main oncology centers in Morocco. Quality of life was measured using the Moroccan Arabic versions of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C 30 (EORTC QLQ C30) and the Breast Cancer-Specific Quality of Life Questionnaire (EORTC QLQ-BR23). Statistical analyses were performed using descriptive statistics and multivariate analyses. Results: A total of 1463 subjects were included in the study, with a mean age of 55.6 (SD. 11.2) years, 70% being married. The majority had stage II (45.9%) and a few cases stage IV (12.9%) lesions. The participants’ global health mean score was 68.5 and in “functional scales”, social functioning scored the highest (Mean 86.2 (SD=22.7)). The most distressing symptom on the symptom scale was financial difficulties (Mean 63.2 (SD=38.2)). Using the disease specific tool, it was found that future perspective scored the lowest (Mean 40.5 (SD=37.3)). On the symptom scale, arm symptoms scored the highest (Mean 23.6 (SD=21.6)). Significant mean differences were noted for many functional and symptom scales. Conclusion: Our results emphasized that the general HRQOL for our study population is lower than for corresponding populations in other countries. This study provided baseline information on the quality of life for a large sample of Moroccan women diagnosed with breast cancer.

Health-related quality of life (HRQOL) assessment is now considered as a key component of clinical oncology trials (Mandelblattet al, 1995). HRQOL issues are especially important when trying to weigh the clinical benefits of a possible treatment for breast cancer. Previous studies of patients with advanced or metastatic breast cancer have shown HRQOL data to be predictors of primary clinical outcomes Montazeri et al, 2003;Montazeri et al ,2001;Coates et al, 1992).
Breast cancer is one of these prevailing chronic conditions which adversely affects the HRQOL in the patients and has been the subject of many studies (Perry et al, 2007). Patients with breast cancer can have physical and emotional troubles as well as problems affecting their families, social activities and work by the disease itself, or can be related to the cancer treatment like surgery, radiotherapy, chemotherapy and hormone therapy.In addition studies have shown that uncontrolled nausea, vomiting and weightgain have a negative effect on the quality of life of women with breast cancer who are receiving chemotherapy (Lev et al, 1997;Lev et al, 2000;Spagnola et al , 2003). To our knowledge no studies on HRQOL of Moroccan cancer patients has been reported.
The aim of the present study was to describe selfreported HRQOL in patients with breast cancer and to investigate its associations with sociodemographic and clinical variables.

Study population and data collection
This was a prospective study of quality of life in breast cancer patients. The study was conducted during 2009-2011; cancer patients were recruited from the main oncology centers in the country (National institute of oncology in Rabat, oncology center of IbnRochd hospital in Casablanca, oncology center of Mohamed VI hospital in Marrakech, oncology center of Hassan II hospital in Fez, oncology center in Oujda, oncology center in Agadir). Data collection was made by investigators doctors administering standardized questionnaires at the inclusion before treatment (week 0), through treatment (Week 12) and after treatment (Week 24,38 and 52).In this study we presented only baseline HRQOL data.
Patients responding to following criteria were included in our study: • Patients with histological diagnosis of breast cancer confirmed, since less than 3 months, • Patients adults (≥ 18 years) The exclusion criteria were as follows: • Patients who have previously received treatment for more than 3 months for their breast cancer.
• Patients with severe neuropsychiatric disorders. Weincluded patients with all types of treatment, as determined by their doctors. Hence, patients received a wide variety of chemotherapy.Ethical approval was obtained from the ethics committees in the University Hospital Hassan II in Fez-Morocco and all the subjects were informed of the conditions related to the study; and gave their written-informed consent.

Measures Patient Information Form
The form included questions about personal information: gender, educational level,age was reported in these categories: 18-34; 35-54 and ≥55 years,marital status was defined in these categories: single, married and Divorced/separated/widowed,employment status and health insurance, illness related (stage of disease, familyhistory of a malignant disease), and treatment-related (chemotherapy, history of surgical intervention and radiationrelated to the breast) characteristics.

Methods of HRQOL evaluation
Quality of life was measured using the Moroccan Arabic version of EORTC QLQ-C30 and its supplementary breast cancer questionnaire (QLQBR23) (El Fakir et al, 2014).
The EORTC QLQ-C30 is a well-known instrument for measuring quality of life in cancer patients. It is composed of nine multi-item scales: 5 functional scales, a global QOL scale (GQOL), and three symptom scales (fatigue, pain, nausea / vomiting). In addition, there are five single item symptom scales (dyspnea, sleep disturbance, appetite loss, constipation and diarrhea); and a final item evaluates the perceived financial impact of the disease. The QLQ-BR23 is a specific questionnaire containing 23 items measuring functioning and symptoms related to breast cancer.

Statistical analysis
Scores on the items and scales were linearly transformed to a scale from 0 to 100. A high score for a functional scale represents a healthy level of functioning. A high score for the global health status represents a high quality of life, but a high score for a symptom scale/ item represents a high level of symptomatology (Fayers et al, 2001).
The descriptive statistics technique was used for the description of clinical, socioeconomic, and demographic variables such as age, place of residence, date of the diagnosis of breast cancer, stage of the disease, marital status, education level and profession.
We analyzed the association of scale scores with socio-demographic and clinical variables, by t-tests and one-way ANOVA. Variables with P ≤ 0.20 on univariate analysis were taken in account in the multivariate linear regression model to assess the predictors of the scales of the EORTC QLQ -C30 and EORTC BR 23. Results of the multivariate analyses are presented as β with a P value.
The P value of equal or less than 0.05 was considered significant. Data analysis was performed using the statistical software package SPSS 17.0.

Results
A total of 1,463 subjects were included in the study. The subjects' mean age was 55.6 (SD. 11.2) years. The majority (970 or 66.3%) of the subjects indicated that they lived in the urban area. The distribution of the patients according to the diagnosed stages of breast cancer showed that the majority of the subjects had stage II breast cancer (606 or 45.9%). and the few cases had stage IV (12.9%) breast cancer. A greater part of the subjects were married (70%). The majority of them were illiterate (61.7%) and 26.9% of them had health insurance. Table 1 displays the demographic and clinical characteristics of participants.

Health-related quality of life EORTC QLQ C30
Of the QLQ -C30 scales, Table 2 presents the mean scores of the functional and the symptom scales. The mean score for the global health status for breast cancer patients was 68.5 (SD=18.5). The best functional outcomes were found for the social, cognitive and physical functioning subscales (the respective mean scores were 86.2(SD=22.7), 83.2(SD=23.2) and 78.1(SD=21.5)), while the evaluation of the emotional function scored the lowest, the mean score was 68.5. Almost 69% of all women with breast cancer reported that they felt depressed, irritable, 58.1% reported being sexually inactive. Of 612 sexually active patients, 19.4 % reported that sex was not enjoyable, whereas enjoyment was described as 'a little', 'quite a bit' or 'very much' by 40.5%, 25.0% and 10.3% women, respectively.

Factors associated with HRQOL scale scores EORTC QLQ C30
In the functional scale we found that younger patients (aged less than 55 years old) demonstrated better physical functions than older patients (79.9 versus 77.2 ; P=0.03). In the symptom scale, mean scores showed that patients aged between 35-54 years experienced greater financial troubles than older patients (63 versus 57; P=0.03). We showed no statistically significant differences between the three groups and other functional and symptom scale (Table 3 and Table 4).
The analysis of the mean scores of the parameters of the quality of life showed that women who were married demonstrated better Global health status, Physical, Role and Cognitive than women whowereDivorced/separated tense, or worried. In the symptom scale, fatigue and Pain were the most pronounced symptoms (the respective mean scores were 29.2(SD=24.5), 23.8(SD=26.8)), and the mean evaluation of the financial trouble aspect was 63.2(SD=38.2).
Scores on symptoms scales ranged from 18.7 to 23.6. "Systemic therapy side effects" scale had the lower score 18.7. More than half of patients reported pain in the breast area, 35% had swelling in the breast area, over half reported over-sensitivity and 25.4% had skin problems. 27.6% reported having no interest in sex and  or widowed. Mean scores of all scales in these women reflected better well-being. Women who were married had significantly fewer problems than women whowereDivorced/separated or widowedwith Nausea and vomiting(P = 0.005), Pain (P = 0.04), Constipation (P = 0.01), and Financial difficulties (P<0.001) ( Table 4).
We compared mean values of the characteristics between different stages of the disease. In the functional scale we found that women with early-stage of breast cancer demonstrated better general health status and better physical, emotional, cognitive, and social functions than those with breast cancer in its later stages. In the symptom scale, more pronounced symptoms in all categories were found in women with later-stage breast cancer.
After adjusting for confounding factors, Global health status and physical functioning were better in women who were married than women who were Divorced/    (Table 3).

EORTC QLQ BR 23
In the functional scale we found that Body image and Sexual enjoyment were negatively affected by younger age (P<0.01). The mean score of the Body image scale for women undergoing mastectomy were significantly worse than those treated by wide local excision (the respective mean scores were 78.7, 85.5, p<0.001). Patients with metastasis had significantly more problems with Body image (P<0.001), Future perspective (P=0.002), Systemic therapy side effects (P<0.001), Breast symptoms (P<0.001) and Arm symptoms (P=0.001).
As shown in Table 5, the multivariate regression models included age, marital status, employment, metastasis and treatment received. The analysis revealed that body imageand sexual enjoyment were worse in younger patientsthan older patients (aged > 55 years old). For body image, patients aged between 18 and 34 years old had on average of 8.5 points lower compared to patients aged over 55 years old.Body image, Future perspective Breast symptoms, Arm symptoms and Upset by hair loss were negatively affected by the presence ofmetastasis. For upset by hair loss, patients without metastasis had on average of 11.1 points lower compared to patients with metastasis.

Discussion
From a survey of a large sample, the present study examined the Quality of Life (Qol) in patients with breast cancer and the association between socio-demographic, clinical variables and QoL in the Moroccan population.
Our findings showed that Global health status in patients with breast cancer in Morocco was fairly good (mean score, 68.5; SD, 18.5). Comparison of our findings with similar studies on the QoL performed in other countries showed that Global health status/QoL scores evaluated using the same instrument were comparable to those of Morocco. A study performed in Germany (Arndt et al, 2006) showed that the mean quality-of-life score was 65.3 (SD, 22.0) and the score in South Korea was 66.4 (Ahn et al., 2007). Moroccan women with breast cancer scored much better on almost all functional and symptoms scales of the EORTC-QLQ-C30 compared to Kuwaiti women and Lebanese women with BC (Alawadiet al, 2009;Abu-SaadHuijer et al., 2012). With regard to the pattern of functional scale scores of the EORTC QLQ -C30, our findings was similar to the results reported by King et al., (1996), the lowest scores were noted for physical functioning and role functioning; while the highest scores were for cognitive and social functioning. It may be that Moroccan women receive psychological support through othermeans such as the family social support and institutional (Waldman et al, 2007). It couldalso be that participants in this study had greater difficulty understanding the meaning of quality of life and consequently responded to questions more positively.
The worst scores among the QLQ-C30 symptoms were for financial trouble (mean score= 63.2 (SD=38.2). This was followed by fatigue(mean scores were  29.2(SD=24.5)). Participants in our study might had other worries than fatigue, such as fear from death or financial worries, that could had affected their psychological well-being more than fatigue. On the EORTC-QLQ-Br23, scores on functioning scales (Body image, sexual enjoyment) are similar to other study conducted in the United Kingdom (Hopwood et al, 2007). Scores of symptoms scales (Breast symptoms, arm symptoms) were worse than those reported previously (Hopwood et al, 2007;Jayasekara et al, 2008).
In agreement with previous studies (Høyer et al, 2011), that younger age was associated with poor functioning or high symptom burden included Body image, Sexual enjoyment, Systemic therapy side effects and Upset by hair loss.
It seems that for this sample of Moroccan patients with BC, the impact of clinical characteristics on QoL is far more significant than demographic characteristics, which was again supported by the negative correlation seen between symptoms and the global health status/QoL and functional dimensions.
Disease stage is an important variable in planning treatment andin giving care and support. We also found that functional scale scores were lower in patients with metastasis as compared to those without metastasis. This finding is similar to the studies that have reported that the stageof cancer has a negative effect on quality of life and its dimensions (Lidgren et al, 2007;Ivanauskiene et al, 2010). In a study conducted with a population of Turkish breast cancer patients (Ogce et al, 2007), it was determined that as the cancer stage increased, general quality of life, psychological wellness, perceived social support and performance status were more negatively affected.
Fatigue, sleeping disorders, pain, and arm symptoms were the most frequently reported symptoms. Our results also corroborated these findings.
Few limitations warrant careful interpretation of the results. Selection bias is related to the fact that all participants were recruited from outpatient clinics; our study sample may not have been representative of the general population of women with breast cancer.Because of the high frequency of illiteracy among participants, an interviewer had administered the questionnaire for all patients. Unlike northern countries, the questionnaire could not be used as an auto-administered questionnaire except for a minority of Moroccan population.Moreover, short duration of follow-up avoided to capture long-term benefits of treatments, as these are more interested in chronic diseases.
This study has a number of clinical implications. More attention targeted toward improving QoL should be given to patients who are suffering from metastasis and financial difficulties.
In conclusion, the quality of life among women with breast cancer in Morocco was found to be fair. Women with later-stage of breast cancer demonstrated poorer condition and were less socially active as compared to women diagnosed with early-stage of breast cancer.
This study provided baseline information on the quality of life of a large sample of Moroccan women diagnosed with breast cancer. The results of this study can set the ground work to address major concerns related to symptoms and financial difficulties.

Competing interests
The author(s) declare that they have no competing interests.