Quality of life of cancer patients at palliative care units in developing countries: systematic review of the published literature

The patients age ranged from 18 [19] to 94 years [20]. Studies from Africa [19] and Asia [18, 20‐24] showed that older patients (> 65 years) had better QOL/QOL domains (psychological, existential, and support) compared to other age groups, which was related to positive coping mechanisms and social support from family and friends [20‐22]. The reported gender proportions varied among the studies. While six studies showed that the proportion of male patients was higher than of female patients [9, 20, 22, 25‐27], two studies demonstrated the opposite [23, 24]. Six Asian studies [9, 20, 23‐26] reported that female cancer patients had better QOL/QOL domains (constipation or dyspnea in symptom function, physical functioning, sexual functioning, support, or spirituality clusters) than male patients, while one study in India [27] and one in South Korea [22] found the opposite results. Gielen et al. stated that in Indian tradition, women acted as the central providers of care in the families [27]. Having a life-threatening illness often results in the loss of the care role in the family, and contributes to a more distressing situation for Indian women [27]. In contrast, Taiwanese culture considered men as breadwinners and decision-makers in the family [25]. Therefore, family members often try to prolong a male patient’s life by sending them to the hospital for additional treatments, despite their terminal condition. Female cancer patients in Taiwan tended to receive PC at home and experienced a better QOL compared to male cancer patients [25]. Personality differences between male and female cancer patients were considered a key factor for the observed discrepancy [24]. Women were more expressive in their needs, more willing to seek and receive help from others compared to men. Consequently, they often received more support, which contributed to a better QOL [24].

Our review indicated that sociodemographic factors e.g. marital status (married/ever been married), number of children (> 4 children) [26], education (high level) [19, 26, 27], occupation (formal employment) [19], and income (high) [19] were linked to better scores in QOL/QOL domains. Evidence showed that patients who lived with family/spouse/children/parents were more likely to have better QOL/low score of depression and anxiety compared to those who lived alone [20, 22, 28]. Patients, who lived with a spouse, often received psychological and financial supports during their illness, which positively influenced their QOL [20, 22]. Moreover, patients with unsupported family members had a high score on anxiety and depression and subsequently poor QOL [28]. Only one study that assessed the association between the number of children and QOL reported that patients having > 4 children tended to have better QOL [26]. Children were considered as one of the key caregivers in developing countries’ culture, since taking care of sick parents is seen as a responsibility and not a burden [26]. A low proportion of cancer patients had a high level of education (range from 10 to 15.7%) [19, 27]. Low educational level was associated with decreased disease awareness, late screening, and late-stage diagnosis which leads to poor prognosis and low score of QOL [19]. Moreover, Gielen et al. reported that less-educated cancer patients often had low socioeconomic status (SES) in society [27]. As a consequence, they were more likely to have limited understanding of their disease, to show symptoms of depression, and have poor QOL [27]. Better education of patients is often linked to better job opportunities. For example, 17% of cancer patients who had formal employment tended to have higher social, psychological, spiritual, and QOL scores compared to those who were farmers and casual worker [19]. While formal employment was associated with adequate social support based on high-income earnings, low income was linked to poverty, low SES, and limited access to health care [19].

Patients who underwent medical treatment e.g. chemotherapy cycles [17], palliative radiotherapy [29‐31], and symptoms management therapy particularly for pain and fatigue [8, 18, 22, 24, 32‐40], had positive association between these factors and QOL/QOL domains. For example, an Indian cohort study reported that short-course palliative radiotherapy schedule for inoperable head and neck cancer patients, which tended to improve social well-being, was seen favorably compared to the single conventional course of radiation [29]. Moreover, a Brazilian study, which assessed QOL change in four chemotherapy cycles showed that QOL/physical functioning was improved in advanced lung cancer patients [17]. Furthermore, Avelino et al. stated that chemotherapy at baseline assessment might improve QOL (small changes), physical and cognitive functioning [17]. Similarly, Mehta et al. emphasized that despite limited sample size which made the comparison between schedules underpowered, their study indicated that a combination of external beam radiotherapy with intraluminal brachytherapy in advanced esophageal cancer resulted in prolonged symptom palliation and a better QOL compared with the external radiotherapy alone [30].

Six studies assessed the use of CAM to treat cancer patients in PC in Asia and LAC region [20, 24, 41‐44]. A study reported 16% of cancer patients received Chinese medicine, and 14% claimed to take alternative therapy in addition to the standard cancer treatment, but no association with QOL was found [20]. Two studies found the use of traditional medicines such as complementary indigenous Malay therapies [43], and Chinese medicine showed a better QOL/existential subscale, or physical symptoms score [24]. Chaiviboontham [42] stated that nearly 63% of cancer patients tended to use a combination of pharmacological and non-pharmacological PC strategies e.g. psychosocial care, mind–body intervention, and spiritual care; physical management; and traditional medicine, herbs, and diet management to treat their illness. This was associated with the effectiveness of PC, with improvements in symptoms relief and spiritual well-being [42]. Similarly, Pokpalagon et al. [44] reported non-pharmacological PC strategies based on the use of herbal medicines showed a better overall QOL and well-being compared to only standard medical therapy. In contrast, Alfano et al. [41] found few CAM modalities e.g. body-mind intervention and food supplements that negatively affected QOL domains. For example, cancer patients who used body-mind interventions demonstrated poorer cognitive function compared to non-users. However, the same patients also reported greater sexual enjoyment, and positive perception for the future [41].

Despite limited number of studies assessing spirituality/religiosity, various religions were reported, e.g. Buddhism, Protestantism, Catholicism, Evangelic, and Hinduism. Two studies reported that some patients had no religious affiliation [45, 46]. Four Asian studies [42, 44, 46, 47] and one Brazilian study [45] stated that spirituality/religiosity was associated with better scores for QOL/QOL domains. For example, the Brazilian study indicated that around 95% of patients believed spirituality/religiosity helps them during stressful situations, supports them during cancer treatment, is a useful coping mechanism, and is an important aspect for assessment by health professionals [45]. One Thai study showed higher QOL in cancer patients who were exposed to non-pharmacological care strategies (social supports, mediation, or reading Dharma book/bible and making merit) in PC organized by religious institution compared to those who were treated in community/university hospitals. Reading Dharma book/bible and making merit as part of Buddhism practice was the most common non-pharmacological strategy used, because this tended to bring happiness, peaceful life, and strengthening of the ability to face obstacles/misfortunes. It provided with a better stress coping mechanism and a better QOL [44]. Similarly, Kandasamy et al. stated that spirituality/religiosity has been closely linked to PC in India and was an important part of Indian cancer patients’ daily life, which acted as a coping stress mechanism, and could positively influence physical and psychological symptoms of distress [47]. A Korean study suggested that religion often provided comfort, a reason for living, a purpose in life, and harmony to cancer patients during their cancer treatments. Individual spiritual activities such as prayer, meditations, reading religious scriptures were beneficial for patients’ QOL/spiritual well-being, and in close relation with better hope and positive mood [46].

Diagnosis awareness was assessed by five Asian studies [26, 48‐51]. In general, the proportion of patients’ awareness of their diagnosis was low, with a range from 17.5 to 50% [26, 48, 50], with only two studies showing a higher proportion [49, 51]. There are inconsistent reports if diagnosis awareness is associated with better QOL/QOL domains. For example, a South Korean study found a positive association between diagnosis awareness and QOL, role, emotional, and social functioning [50, 51]. Despite the positive association, Lee et al. emphasized that their result should be interpreted carefully [50]. In contrast, three studies reported opposite results [26, 48, 49]. Patients who were unaware of their diagnosis were more likely to have better physical and emotional functioning [48], and better overall QOL [26, 49] compared to those who knew their diagnosis. Fan et al. reported that the information non-disclosure gave a more hopeful outlook for patients, and increased the fighting spirit against the disease [48]. Cultural aspects were likely to play an important role for this non-disclosure. In some Asian cultures, a cancer diagnosis is a taboo concept, and patients often feel stigmatized and ashamed by their health condition; therefore, diagnosis unawareness could attribute to better physical and emotional functioning [48, 49].

Five included studies showed that a high score for depression/anxiety is associated with poor QOL, physical well-being, emotional well-being, and functional well-being [8, 21, 28, 40, 49]. In our review, the proportion of advanced cancer patients feeling depressed and anxious ranged from 21.1 to 62%. This condition might decrease one’s hope and peace, lead to increase of physical pain, risk of suicide, and poor QOL [21, 28]. Chan et al. stated that other psychological domains of QOL e.g. being afraid of the future, feeling sad, and feeling a burden to others might intertwine with depression and anxiety [21]. Similarly, Kim et al. emphasized that depression is strongly associated with hopelessness, which negatively influences physical and psychospiritual well-being, and the immune system [49].

Some factors were found only in one specific region, while some commonly appeared within two or even in all three regions (Tables 3, 4). For example, included studies from the African region mostly explored sociodemographic factors e.g. occupation, income, age, and education (Online Resource 5), whereas the LAC’s studies provided information on factors in clinical settings and only one sociodemographic factor (patient’s perception of diagnosis and treatment). The included studies from the Asian region contributed to various factors in both clinical setting and sociodemographic aspects. The only common factor shared by all regions was specific additional care within PCUs e.g. symptoms management on pain and fatigue, spirituality/religiosity, psychosocial counseling, basic skills training for family caregivers, or exposure to integrated care management [22, 23, 42‐47, 52‐58].