Elsevier

Gynecologic Oncology

Volume 112, Issue 2, February 2009, Pages 358-364
Gynecologic Oncology

Cervical cancer survivorship in a population based sample

https://doi.org/10.1016/j.ygyno.2008.11.002Get rights and content

Abstract

Objective

Though cervical cancer is preventable, this cancer nonetheless poses serious mortality and morbidity threats to American women and women globally. The purpose of this study is to utilize a multidimensional framework to assess Health-related Quality of Life (HRQOL) and its salient predictors among a population based sample of cervical cancer survivors.

Methods

A cross-sectional design was used with a population-based sample ascertained from the California Cancer Surveillance Program. Descriptive, bivariate and multivariate regression analyses were conducted.

Results

Participants were 560 cervical cancer survivors: English-speaking Latina- (nĀ =Ā 88), Spanish-speaking Latina- (nĀ =Ā 199) and European- (nĀ =Ā 273) Americans. The greatest concerns were documented for family/social and emotional well-being, and body image and sexual health. In general, Latina-Americans reported poorer overall HRQOL, functional, emotional, and social/family wellbeing compared to European-Americans. Differences in HRQOL persisted by ethnic/language group after controlling for covariates. Radiation, comorbidity, role limitations, perceived health status, psychological wellbeing, body image, sexual impact, doctor-patient relationship, and social support were significant predictors of overall HRQOL. The regression model explained 58% of the variance in predicting HRQOL.

Conclusion

These cervical cancer survivors reported poor to moderate HRQOL with persistent psychosocial challenges. Our findings indicate that lower SES, monolingual Latinas are at greatest risk for poor HRQOL outcomes. Clinicians should pay attention to their patients' socio-ecological context as a risk factor for poorer outcomes; and provide early referrals to resources that are low cost and culturally and linguistically appropriate.

Introduction

An estimated 11,070 women in the U.S. will be diagnosed with invasive cervical cancer in 2008 [1]. Cancer of the cervix uteri is a cancer of poor and underserved women primarily. The incidence rate among Latina-Americans, 16.2 per 100,000 is twice that of European-Americans. Moreover, cervical cancer mortality is markedly higher among Latinas [1], [2], [3]. However, the future treat of cervical cancer may be greatly reduced due to the advent of new vaccines to prevent the disease [4]. Furthermore, cervical cancer can be detected in its precancerous phase via the Pap-test and curative treatments are available for very early stages. Yet, this cancer still poses serious mortality and morbidity threats to American women and women globally.

Further, the 2007 Institute of Medicine (IOM) report on the psychosocial needs of cancer survivors documents that the psychosocial impact is under-addressed; this problem is exacerbated for ethnic minority survivors [1], [5], [6], [7], [8]. Studies of cervical cancer survivors (CCS) in the U.S. indicate that these survivors face late-term and long-term side effects that adversely impact daily functioning and may affect overall health-related quality of life (HRQOL) [9], [10], [11], [12], [13]. Persistent physical sequelae includes fatigue, pain, neuropathy, bladder and bowel problems, and reproductive and sexual dysfunction, particularly for those who received radiation treatment [9], [10], [14], [15], [16]. Psychosocial concerns include depression, anxiety, difficulty concentrating, and stress over family responsibilities [9], [14], [17], [18], [19], [20], [21], [22], [23]; and relational and sexual issues [10], [13], [24], [25], [26]. Psychological risk factors include lack of social support, younger age, limited socioeconomic resources, and weaker religious beliefs [13], [14], [18], [27], [28]. Despite these concerns, CCS and their families often unfortunately lack the necessary symptom management resources (e.g. targeted interventions, support groups, psychooncology services) during diagnosis, treatment and into survivorship [9], [13], [14], [29]. Additionally, studies suggest ethnic differences in physical and psychosocial outcomes [9], [30].

HRQOL is a multidimensional framework appraising physical, functional, emotional and social well-being [31], [32] through the individual's assessment of management of day-to-day activities. The prevailing perspective considers socio-ecological factors (e.g. neighborhood, life-burden) important but understudied factors [33], [34], [35], [36]. However, socio-ecological factors may exert important influence on HRQOL [37], [38].

Therefore, the purpose of this study is to examine HRQOL utilizing the Contextual Model that expands the HRQOL framework to include cultural and socio-ecological dimensions[38]. This Model includes the: a) socio-ecological context, b) cultural context, c) demographic context, d) health care system context, e) general health and comorbidity, f) cancer-related medical factors, g) health efficacy, and h) psychological well-being. This paper addresses the following research questions: 1) Do HRQOL outcomes vary by ethnicity/language? and 2) What are the predictors of HRQOL among CCS?

Our hypotheses are:

  • (H1) Spanish-speaking Latina-Americans will report poorer HRQOL compared to European-Americans.

  • (H2) Spanish-speaking Latina-Americans will report the poorer health perceptions compared to European-Americans.

  • (H3) HRQOL will be predicted by medical/cancer-related, current health status, psychological and sexual impact, demographic, cultural, health care system and socio-ecologic factors.

Section snippets

Subjects and sampling

After obtaining UCLA IRB approval, CCS in Southern California identified through the California Cancer Surveillance Program (CSP) and hospital cancer registries were recruited between June 2002 and June 2004. Eligible participants were: (1) 18 years or older, (2) within 1ā€“5 years of diagnosis and cancer-free; (3) stages I-III; and (4) not diagnosed with another type of cancer or another major disabling medical (e.g., stroke, heart disease) or psychiatric (e.g., schizophrenia, major depression)

Results

We mailed recruitment letters to 2524 European- and Latina-American CCS. More than half (57%) were unreachable (deceased or incorrect address or phone number). Most potential participants were ascertained through the Los Angeles registry (62%), with 17% obtained through the Orange registry, 12% through the Desert Sierra registry, 4% through the specialized cancer center and 5% through the community hospitals. In total, 1088 CCS were accessible; of these reachable CCS, 201 CCS (18%) were

Conclusions and discussion

This report is the first multiethnic, multilingual study of HRQOL among CCS. We achieved our objectives of examining HRQOL among population-based sample of CCS that include Latina Americans, and developing a predictive model that included socio-ecological factors. The findings supported our hypotheses and are consistent with the literature documenting the chronic psychosocial and sexual impact of cervical cancer. These results make important contributions to the literature and increase our

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Acknowledgment

Research supported by a grant from the California Cancer Research Program (#2110008).

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