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Quality of Life of Patients with Gynecological Cancers A

Introduction: The quality of a women’s life is very closely related to their health. Oncogynecological disease brings substantial changes into their life that women need to adapt to them. As determination of quality of life is in nurse competence, the quality of life in women with diagnosed oncogynecological illness and surgical treatment has been described in the paper. Aim: The aim of the paper was to examine cancer’s influence on the quality of life based on physical health, survival, social relationships, and the environmental domains. Methods: The sample consisted of 84 female respondents with surgical treatment of oncogynecological disease and the patients fulfilled the standardized WHOQOL-BREF questionnaire. Results: The results have shown that patients experienced significant reductions in the quality of life in regard to physical and mental health. Social and environmental domain were significantly less affected. Conclusions: The oncogynecoogical diseases significantly affect quality of life in all four investigated domains, but to a different extent. These findings emphasize an individual approach that takes into account not only the nursing aspect but also the ability to respond to a variety of other related factors that affect the quality of women with oncogynecological disease.


INTRODUCTION
The perception of the quality of life in women is highly individual, and satisfactions of each woman's bio-psycho-social needs are unique, particularly during the illness. Its evaluation is competence of the nurses. The number of oncologically ill women is steadily rising and, although the treatment can substantially prolong life, its quality may be significantly deteriorated [1]. Survivors had clinically significant problems with social functioning, constipation, diarrhea, severe lymphedema, menopausal symptoms, physical changes of the body, sexual or vaginal dysfunction, and difficulties with their finances compared with the general female population [2]. All this is devastating to their quality of life (QOL). Nowadays, when the survival has been substantially prolonging, the assessment of QOL of patients with cancer is essential for personalizing treatment and providing better care [3].
For this reason, our work aimed to analyze the QOL of women with gynecological cancer.

METHODS
The survey was carried out in January -June 2017 in the Slovak Republic. The target population was postoperative women with oncogynecological diagnoses and surgical treatment. The patients' recruitment started after obtaining the ethics committee's permissions of the College of health and social work of St Elizabeth, Bratislava, Slovak Republic.

The sample
The participants were women at least 18 years old, diagnosed with gynecological cancer by an oncologist and having and surgical treatment of the disease and willingness to participate in this study voluntarily. The questionnaire was distributed to the patients during their 3 months post-operation visit to the clinical center. A total of 105 questionnaires were distributed, while eighty-four women (80%) agreed to participate and fulfilled the questionnaire.

The questionnaire
The socio-demographic characteristics, age, gender, marital status, educational level, occupation, the time passed since the cancer diagnosis, and the type of treatment were analyzed by the questionnaire.
The validated WHOQOL-BREF was used to measure QOL. It consists of 24 items to assess perception of quality of life in four domains, including physical health, psychological, social relationships, and environmental domain, and two items on overall QOL and general health. The domain scores were transformed into a linear scale between 0 and 100 following the scoring guidelines. A higher score indicated a better QOL.
The WHOQOL-BREF questionnaire was designed by WHO (1996) and translated into the Czech language understandable to Slovak was used for evaluation the quality of life of the women with cancer [4]. It consists of 24 items in order to assess the perception of quality of life of participants of the study in four domains. The domain scores were transformed into a linear scale between 0 and 100 following the scoring guidelines. A higher score indicated a better QOL. Two additional items were separately added (QOL and satisfaction with health) ( Table 1).
All data were coded, entered, and analyzed using SPSS version 20 (SPSS Inc) and Microsoft Office Excel 2010 (Microsoft Corporation, Redmond, WA, USA).
The range of scores is between 15 to 105, with a higher score or number being indicative of a higher quality of life. An average total rating for a healthy person is usually around 90, whereas a low quality of life measures around 15.

RESULTS
The questionnaire was distributed to the patients during their 3 months post-operation visit to the clinical center. Altogether, 105 questionnaires were distributed to the patients who attended the oncology clinic in the Slovak Republic. Eighty-four women (80%) agreed to participate. They were all with oncogynecological disease, 3 months after the gynecological operation. the patients in the four domains and overall QOL. Also, for each domain, the question with a maximal and minimal score is presented.
The environmental health domain was the highest of all four domains with a mean raw score of 3.21 and a transformed score of 56/100, while the physical domain was the lowest with a mean raw score of 2.79/5 or a transforms score of 44/100. The physical domain's minimal score was obtained in answer to the item considering the amount of energy for everyday life and 38 (45%) women answered they have not or have little energy,35 (42%) average, while only 11 (13% had a lot of energy for everyday life. The maximal score was obtained to answer an item dealing with difficulty to go out of the house. Only 11 women found it difficult, 52 on average, while 21 women answered it is not difficult at all ( Table  2).
The oncogynecological impairment most affected quality of life of women in the physical domain (table 3). 58% of respondents needed medication for pain when performing usual daily activities. 41% of respondents used analgesics occasionally, and only 1% of respon-dents did not take this group of medicines. An important factor influencing the quality of life is sleeping. 52% of respondents reported a deterioration in sleep quality. Only 25% of respondents were satisfied with the quality of their sleeping. Also, only 21% of respondents were satisfied with performing daily activities. For 27% of respondents, carrying out daily activities was "very difficult. " Domain 2 (DOM2 -psychologicalsurvival) -Life was meaningful for 78% of respondents. Also, only 33% of respondents accepted their new physical appearance while 41% of respondents could not accept the physical changes of the body. Negative feelings, such as bad mood, anxiety, despair depression, were often or still felt by 89% of respondents.
Domain 3 (DOM3 -Social Relations) -50% of respondents were satisfied with their personal relationships; 30% were dissatisfied. There is general dissatisfaction with sexual life in up to 38% of respondents. Only 13% of respondets were satisfied with their sexual life.

DISCUSSION
WHO defines quality of life as "individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns". QOL refers to how the individual's well-being may be impacted over time by a disease and is thereby a measure of the person's own perception of the disease's impact [5].
In our study, the diagnosis of malignancy, followed by surgical therapy that changes the body, had the most significant impact on the physical and mental spheres' of quality of life. The patients did not have enough energy for daily activities, they were not satisfied with the volume of work they had done, and with the possibility to perform daily activities, and they had to take the medication to cope with the problems that they have. As many as 89% patients often or always had negative feelings such as blue mood, despair, anxiety, depression. The findings are consistent with study published by Wong et al [6], which showed that the four domains of QOL and perceived general health are interrelated. People with positive emotions or better QOL in the psychological domain evidence better physical health outcomes, such as fewer physical complaints, more exercise, longer sleeping hours and better sleep quality. Negative results like, long lasting diagnosis as well as the treatment, conservative or operative, were related to negative influence on QOL, as found in other studies [7].
The treatment significantly affect intensity of psychosomatic problems in patients with cancer [8,9]. Hnilicova and Benco draws attention to the fact that fatique most affects patients' quality of life with oncological deseases [8]. In our survey, the pain, psychological tension and nausea had negative impact on the quality of life of women with oncogynecological disease. This is in agreement with Trachtová et al [10], who stated that pain is the most complex human experience because it affects the physical, mental and social spheres. Pain significantly affects the daily regimen, including mobility, autonomy, and the need for sleep. According to Maslow [10], sleep is a basic human need that affects the quality of life. Sleep and sleep need is an individual need that is determined by the daily activities of man, the physiology of the organism, and the age. In our survey, up to 52% of respondents reported deteriorating sleep quality. Fatigue, loss of energy is the most common symptom and side effect of survival of women with oncogynecological disease and markedly affect quality of life of patients with oncological disease. Subjectively, it was confirmed that oncogynecological disease has a negative effect on survival. 89% of respondents reported anxiety, bad mood, and depression. A similar view is expressed by Raudenska [11], who claims that an bad psychic attitude harms the health status. She also describes depression, anxiety, and mania as the most commonly diagnosed disorders found in oncological diseases. The author also claims that psychiatric disorders in oncological patients in exceptional cases can result in suicide. Therefore, the author believes that the treatment of oncological diseases is not just in drugs prescription. An important is also psychological and social encouragement and rewarding patients in treatment.
After diagnosing oncogynecological disease, we have found that 2% of respondents subjectively experience a loss of life meaning. Bačová [12] states that the values and norms of life's meaning are different in each period of life. They depends on the value system, the relationship to its goals, expectations, standards and interests.
In the social area, the oncological illness can have serious consequences. Longterm treatment often leads to loss of employment, income loss, social contacts, family well-being, and total isolation. It usually takes some time for a woman to find enough energy to think about sexual intercourse.More than three-quarters of oncological patients have problems with sexual life [13]. In our study, the patients were dissatisfied mostly with sexual life -only 11 women (13%) were satisfied with the sexual life. This is understandable, having in mind that they have many physical and mental difficulties and an uncertain future in terms of health. Satisfaction with sexual life ranked fourth among the worst values of all. Valsangkar et al [5] in patients with reproductive tract infections and sexually transmitted diseases have found, impairment in all domains of QOL with the largest impact on the social and sexual domain. That indicates that sexual life is the item which in social domain, regardless of the cause, significantly affects life quality.

CONCLUSION
The most significant negative impact on quality of life was observed in domains 1, physical halth. The average raw score in physical health was 44%, while it was 50% or above 50% in other domains. Patients mostly burdened with physical problems. In the psychological domain, negative emotions such as despair, anxiety, depression, feelings that life has no meaning have significantly contributed to the reduction of quality of life. In the social domain, dissatisfaction with sexual life was most prominent.But, by contrast, 37% of women said they very muh enjoy life, 70% are satisfied with their health, 83% and that their quality of life is good. These findings call for an individual approach that takes into account not only the nursing aspect but also the ability to respond to a variety of other related factors that affect the quality of women with oncogynecological disease.