Quality of Life of Women after Mastectomy in Two Training Hospitals in the City of Douala, Cameroon

Charlotte Nguefack Tchente^1*, Jean Paul Ndamba Engbang², Christian Eyoum³, Meguia Kamdem⁴, Lucie Sorelle Lekuikeu Tchuinte⁵, Albertine Eloundou⁶, Henri Essome⁷, Michel Ekono⁸, Pierre Marie Tebeu⁹, Emile Telesphore Mboudou¹⁰

¹Department of obstetrics and gynecology, Douala general hospital, Douala, Cameroon

²Department of oncology, Douala Laquintinie hospital, Douala, Cameroon

³Department of psychiatry, Douala Laquintinie hospital, Douala, Cameroon

⁴Faculty of Medicine and pharmaceutical science, university of Douala, Douala, Cameroon

⁵Medical student, Ross university school of medicine, Bridgetown, ‎Barbados

⁶Department of oncology, Douala general hospital, Douala, Cameroon

⁷Department of obstetrics and gynecology, Douala Laquintinie hospital, Douala, Cameroon

⁸Department of obstetrics and gynecology, Faculty of Medicine and pharmaceutical science, university of Douala, Douala, Cameroon

⁹Department of obstetrics and gynecology, Yaoundé teaching hospital hospital, Yaoundé, Cameroon‎

¹⁰Department of obstetrics and gynecology, Douala obstetrics-gynecology and pediatric hospital, Douala, Cameroon

^*Corresponding Author: Charlotte Tchente Nguefack, Department of Obstetrics and Gynecology, Douala General Hospital. Faculty of Medicine, University of Douala. Po Box 303 Douala, Cameroon

Received: 09 December 2021; Accepted: 23 December 2021; Published: 24 January 2022

1. Introduction

The World Health Organization (WHO) defines breast cancer as a genetic alteration occurring within a cell of the mammary gland with anarchic prolif-eration, invasion and destruction of the tissue of the breast, as well as the ability to give distant metastases [1]. Breast cancer is a major global public health problem due to its high incidence and mortality. It is the most common cancer in women worldwide; According to a study conducted by GLOBOCAN in 2018, there are about 2.1 million new cases (11.6%) and 626,679 deaths (6.6%) related to breast cancer worldwide [2]. Its incidence is four to ten times higher in Western countries compared to Asia and Africa [2]. The incidence and mortality per 100,000 women in major countries and regions of the world has been estimated as follows: In America, it is 60 with a mortality of 12; In Europe, 79.3 with a mortality of 14.6; In Asia, 37.1 with a mortality of 12.4. In Africa, the average incidence is 38 with a mortality of 16.6. There is a variable distribution in Africa according to regions with a maximum for North Africa (48.9). South Africa follows with 46.2, then West Africa (37.3), East Africa (29.9), and finally Central Africa with 27.9 [2]. In Cameroon, the incidence of breast cancer is 2625 new cases and 26.8% of mortality in women [3]. It is also the most frequent gynecological cancer with 34% of cases, followed by cervical cancer in the city of Yaoundé [4].

The management of breast cancer includes chemotherapy, targeted therapy, hormonal therapy, radiotherapy, and conservative or radical maste-ctomy. Mastectomy is a procedure performed under general anesthesia to remove the area of the breast where the tumor is located, often including the areola and the nipple [5]. It is indicated for inflammatory cancers (after neoadjuvant chemotherapy); when the tumor size is large (generally more than 5 cm, but adjustable according to the ratio between tumor volume and breast volume), and when there is multifocal cancer or even a recurrence on the same breast after conservative treatment [6]. In addition, the frequent discovery of ductal carcinoma in situ (DCIS) leads to a paradox, because they are usually less aggressive but will sometimes be treated with mastectomies because of their diffuse extension throughout the breast [7]. Finally, other indications for mastectomy are the existence of genetic mutations (BRCA1 or BRCA2), family history of breast cancer, and high-risk histological lesions [7].

A significant reduction in breast cancer-related mortality has been observed since the end of the 20th century, with constant diagnostic and therapeutic progress [8]. However, despite these advances, the surgical treatment of breast cancer still involves mastectomy in more than 20% of cases in France and 92.6% of cases in Cameroon [9, 10]. This treatment has many consequences on the physical aspect of a woman and requires both physical and psychological rehabilitation [11]. Nowadays beauty and appearance are increasingly valuable on the female body [12]. Female breasts are also sources of eroticization, the perfect symbol of fertility, femininity, sensuality and sexuality [13]. The experience of mastectomy varies considerably from one woman to another, leading to varying degrees of disruption in self-image, femin-inity and sexuality [9]. According to Lehmann, this mutilation is difficulty accepted by women in three levels: the body image is altered, the identity of these women is affected and so are their sexual and emotional lives [13]. In Cameroon, surgical treatment of breast cancer is most often radical (92.6% mastectomy according to Nguefack et al.) this is due to the diagnosis of breast cancer at advanced stages in 2/3 of cases [10]. Thus, being diagnosed with cancer and treated with mastectomy is certainly one of the most memorable experiences in a woman's life. Moreover, reconstructive surgery is quite rare in Cameroon. While many studies to date have explored the epidemiology, clinic and management of breast cancer in Cameroon, very few studies have focused on the experience of women after mastectomy, hence this research.

2. Methodology

This was cross sectional study which took place in the gynecology, oncology and radiotherapy unit of Douala General Hospital and Laquintinie Hospital, both referral centers for management of breast cancer in Douala, Cameroon. We included consenting patients who had mastectomy for breast cancer and came for routine follow-up from October 1, 2019 to April 30, 2020. Patients who had conservative surgery, local recurrence and psychologically unsta-ble patients were excluded. The minimum sample size was estimated with the Lorentz formula. Considering the frequency of 92% of mastectomy in Douala [10]; we obtained a sample size of 105 cases. We have obtained ethical clearance number 2188 CEI-Udo/08/2020/T from the institutional ethic committee of the University of Douala. Research authorization was obtained from the directors of the 2 hospitals. Data was collected using a pre-tested data collection sheet. Collected variables include socio-demographic and anthropometric data (age at diagn-osis of cancer, sex, marital status, ethnicity, nation-ality, parity, height, weight), clinical data (clinical size of the tumor and staging at diagnosis, presence or absence of ulceration), therapeutic data (surgery, chemotherapy, radiotherapy, hormone therapy and complications of treatment), data on quality of life (physical, social, sexual, emotional, functional and psychological QOL). To assess quality of life, we used questions from the following recognized quality of life questionnaires that we adapted to our context:

1. EORTC QLQ-BR45: this assesses the quality of life after breast cancer.
2. WHOQOL-BREF: this evaluates the overall quality of life.
3. FACT-MBIS: this evaluates body image
4. FACT-B: this assesses the quality of life after breast cancer

Our questionnaires consisted of 39 questions with each answer scored from 0 to 4 (0: never, 1: slightly, 2: occasionally, 3: enough, 4: significantly). The answers were to relate to the events that took place in the previous two weeks. The questions were grouped according to the different aspects of quality of life (6 groups):

1. Group1: physical quality of life (11 questions)
2. Group2: social quality of life (10 questions)
3. Group3: sexual quality of life (7 questions)
4. Group4: emotional quality of life (4 questions)
5. Group5: functional quality of life (2 questions)
6. Group6: psychological quality of life (5 questions)

Epi info software version 7.2 and Microsoft Excel 2013 were used for statistical analysis. We conducted a descriptive analysis of the study population: quali-tative variables were expressed in frequency and percentage; quantitative variables were expressed by the median with outliers, mean and standard devia-tion. Univariate analysis was performed to identify factors affecting quality of life, Chi-squared and Fisher tests allowed us to assess association between qualitative variables. Statistical significance was set at p < 0.05 with a 95% confidence interval.

3. Results

3.1 General characteristics of the study population

The mean age at the time of recruitment was 48.2 years ± 10 with extremes of age ranging from 30 to 70 years and a median of 48. The most represented age group was 40 to 50 years with 38.2 % of cases. Most patients worked in the private sector (42.5%). Secondary level of education was the most repre-sented (47%), followed by primary and university level with respectively 27.5% and 25.5%. Married women represented 54.4% of the studied population. Concerning clinical characteristics of patients, mean gravidity was 4.1 pregnancies ± 2.1 with extremes ranging from 0 to 12.

The mean parity was 3.4 deliveries ± 1.8 with extremes ranging from 0 to 11. 8.8% of patients had a history of mastectomy in their family, with 40% of cases being an extended family member (cousin or aunt). The mean size of the remaining breast at the time of recruitment was 37.8 cm ± 2.6 with extremes ranging from 32 to 42 cm for a median of 38. The most represented group was 34 to 38cm. The left breast was most affected (53.9%). Following the TNM classification of breast cancer, majority of patients were classified T3 and T4 (76.3% of cases); N1 (64.6%); 89.1% of patients had lymph node involvement. Metastases at diagnosis were found in 16.1% of the study population. In our series, 8.8% of patients had ulcerated tumors at the time of diagnosis.

The average time between cancer diagnosis and mastectomy was 8.4 months ± 9.7 with outliers ranging from 1 to 56 months for a median of 5.5 months. The most represented group was between 3 and 6 months. The mean time between mastectomy and recruitment was 14.6 months ± 21 with extremes ranging from 1 to 99 months for a median of 6 months. Many patients were seen 12 months after mastectomy (29.5%). 13.8% of patients had postop-erative complications, with wound infection being the most common postoperative complication. Abnormal healing (mostly hypertrophic scars) affected 4.9% of patients. Patients using an external prosthesis repres-ented 77.4% of cases; textile prostheses were the most used (97.4%). Overall, 93% of patients were treated with chemotherapy; the most common side effect of chemotherapy in these patients was hair loss. Radiotherapy was done in 32.3% of cases, the major side effect being skin burn. Hormonal therapy was administered in 22.1% of patients and no side effect was related to this treatment.

3.2 Quality of life

3.2.1 Cross-sectional analysis: Physical, social and sexual quality of life was normal in 58.8%, 25.4% and 11.7% respectively (Table 1). The functional and emotional quality of life was impaired in 63.4% and 92.2% respectively. All patients had an impaired psychological quality of life (Table 2). Overall, no patient had a normal quality of life after undergoing mastectomy. The majority of patients (84.3%) had a markedly impaired overall quality of life. While evaluating the overall quality of life on a scale of 0 to 4, we realized that women who were treated with mastectomy had QOL scores in the functional and psychological domains above the mean (2.7 and 3). In contrast, in the sexual and emotional domains, they achieved an intermediate average score (1.2 and 1.5). The average scores were close to the minimum in the physical and social domains (0.3 and 0.5).

3.2.2 Factors influencing quality of life: Women aged between 30-40 years and single women were at greater risk of presenting with altered physical quality of life (OR 6.11 [2-18.58] and OR 3.1 [1.2-7.7]). Those with tumor sizes between 2 and 5cm had a 4.9 increased risk. Hormone therapy also increased the risk of altered physical quality of life (OR 3.8 [1.1-12]). Time between diagnosis and mastectomy of less than 3 months (OR 0.3 [0.1-0.8]) and age between 50 to 60 years (OR 0.33 [0.1-0.9]) appeared to be protective factors (Table 3, 4, 5). No factor significantly influenced the global quality of life in this study (Table 6).

Table 1: Physical, social and sexual quality of life.

Table 2: Functional, emotional and psychological quality of live.

Table 3: Sociodemographic characteristics associated to physical quality of live.

*Bad: big scar, keloid, delayed healing due to infection

Table 4: clinical characteristics associated to physical quality of life.

Table 5: Analysis of therapeutic characteristics associated to physical quality of life.

QOL*: Quality Of Life

Table 6: Sociodemographic factors associated to global quality of life.

4. Discussion

The mean age at recruitment was 48.2 ± 10 years with extremes of age ranging from 30 to 70 years and a median of 48 years. This average age is close to that reported in Cameroon by Belley Priso et al. in 2010 (47.4 years), Engbang et al. in 2015 (48.1 years), Mayi-tsonga et al., in Gabon (48 years), as well as Togo et al. in Mali (47.4 years) [14-17]. This average age is lower than that of Emidio et al in Brazil in 2017, Shozo et al. in Japan in 2009, Jing et al. in Germany in 2009, Benjamen et al. in Australia in 2015, who found the respective mean ages of 54 years, 61 years, 57.7 and 55 years respectively [18-21]. Breast cancer appears early in black, African or African American women, which could partly explain this difference. The role of certain gene mutations is increasingly mentioned in this early genesis of breast cancer [22]. In our cases, married women represented 54.4% of the studied population. The proportion of married women differs in different studies: Shozo et al. in Japan in 2009 (82.9%), Emidio et al in Brazil in 2017 (36%), Liang in China in 2014 (90%), Mustafa et al in Turkie in 2014 (94.8%), and Jing et al. in Germany in 2009 (50%) [18-20, 23, 24].

In our study population, the mean parity was 3.19 ± 2.3 with extremes ranging from 0 to 10. This data is comparable to those of Essiben et al. in 2013 who found an average parity of 3.9 ± 2.1 with extremes ranging from 0 to 10 [25]. Tumors in advanced stages (T3 and T4) were most frequently diagnosed (76.9%); this data is comparable to that of Mayi-tsonga et al. in Gabon, who also found the T3 and T4 stages in the majority of cases (74%) [16]. Patients in developing countries often consult late not only because of lack of education and money, but also because of cultural or religious beliefs. Regarding quality of life, the psychological domain obtained the highest average score (3). According to Sousa et al in Brazil, the psychological domain also had the highest average score (14.7 on a scale of 4 to 20) [26]. Breast cancer and mastectomy are associated with beliefs and imaginations that haunt thoughts of women in their daily lives [27]. According to Greendale et al. in North America, women who were satisfied with their partner reported being psychologically well adjusted [28]. In addition, partners of women with breast cancer can be a source of emotional support or a source of stress, thereby having a positive or negative influence on the QOL of these patients [29]. Depending on the type of relationship a woman after mastectomy will have with her partner, her quality of life can change profoundly [30].

In our study, one of the most compromised scores was in the functional domain (2.7), which corro-borates the results found by Sousa et al. in Brazil, where the functional domain had a score of 12.1 on a scale of 4 to 20 [30]. In Brazil, patients’ complaints were mostly pain and discomfort [26]. They expre-ssed dissatisfaction with their ability to carry out activities of daily living [26]. In 2016, Canário et al. (also in Brazil) conducted a study which yielded results similar to ours. A high prevalence of the symptoms mentioned above has been found, thus affecting the functional domain [31]. For the sexual QOL, the score was 1.2. Nowadays beauty and appearance have become increasingly valuable on a woman’s body. In addition, the breasts are also sources of eroticization, the perfect symbol of fertility, femininity, sensuality, sexuality [12]. Participants in our study obtained average score in the social domain of 0.5. This result is different not only from the conclusions of Kluthcovsky et al. in Brazil (2012), where the highest average score for quality of life was in the social domain, but also results found by Al-Ghazal et al. in London (2000), Amivhetti and Caffo in Italy (2001), Yan et al. in China (2016), and Neto et al in Brazil (2017) [18, 32-35]. This difference could be explained by the fact that the diagnosis of breast cancer is made at advanced stages in 2/3 of the cases in Cameroon [10]. Many people care about patient recovery. Also, in the economic context, breast cancer treatment is extremely costly [36]. The patients would thus be more concerned about financial problems than social problems.

In this study, physical QOL had the lowest mean score (0.3). We can conclude that, participants’ preo-ccupation is treatment or cure, and not physical appearance. Young age significantly increased alter-ed physical QOL. This may be due to the trauma created by mastectomy in these patients who have not yet finished their maternity or for whom body image remains very important. These observations are close to those of Musarezaie et al who found an association between age and mental quality of life [37]. Some single women are still looking for partners and may feel inadequate after mastectomy. This can explain the higher risk (2, 3) of impaired physical quality of life in this group as found in our study. Musarezaie et al did not find a significant association between quality of life and marital status [37], probably because they analyzed the overall quality of life and not specifically the physical quality of life. We did not observe any factors significantly associated with impaired overall quality of life.

Shim et al found that there was a direct relationship between the patient's level of education and their QOL [38], Kaminska et al also reported association between low level of education and altered quality of life [39]. These observations were not found in our study, probably due the limited sample size. It is known that patients with higher level of education, patients better understand their pathology and will less likely have altered QOL. When including all domains of quality of life, we found that no patient had achieved a normal life after having a maste-ctomy. In other words, mastectomy was responsible for an alteration in the QOL in all patients (although this alteration varied amongst women). Our results are similar to those of Kim et al. in Korea (2014), Howes et al in Australia (2016), and Shozo et al. in Japan (2009) who obtained the highest alterations in QOL in the group of patients who had undergone total mastectomy without reconstruction [40, 10, 21]. The experience of mastectomy varies considerably from one woman to another, leading to varying degrees of disruption in self-image, femininity and sexuality [12].

4.1 Limitations of the study

During this study, we were confronted with the lack of QOL assessment scale adapted to our context; a large number of patients with an impaired quality of life compared to those with a normal quality of life, which made it impossible to better investigate factors associated with the deterioration in QOL.

5. Conclusion

Women who had mastectomy for breast cancer are relatively young, married, with a high level of education. They are multiparous patients whose tumors were greater than 5 cm or inflammatory, most often with lymph node involvement. Mastectomy in these patients was most often accompanied by neoadjuvant chemotherapy and adjuvant radio-therapy. The majority of patients who had maste-ctomy used tissue prosthesis. The overall quality of life was altered in all of the patients, but when we look at the different domains, the physical, social and functional qualities of life were less altered than the sexual, emotional, and psychological qualities of life. Factors associated with impaired physical quality of life included young age, tumor size between 2 and 5cm and being on hormone therapy. No factor was associated with impaired overall quality of life. Thus, all Cameroonian women (especially young, single women) who have been treated with mastectomy should benefit from pre- and postoperative psycholo-

gical care to improve QOL.

Acknowledgments

We thank patients who kindly participated in this study.

Disclosure

There is no conflict of interest.

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