CERVICAL CANCER AND QUALITY OF LIFE: AN INTEGRATIVE REVIEW CÂNCER DE COLO DO ÚTERO E QUALIDADE DE VIDA: UMA REVISÃO INTEGRATIVA

Objective: To analyze the publications regarding the quality of life of women with cervical cancer. Method: This is an integrative review performed in the indexed LILACS, MEDLINE and SCIELO databases. The descriptors “Quality of Life” AND “Cervical Neoplasms”, “Quality of Life” AND “Woman's Health” and “Woman's Health” AND “Cervical Neoplasms” were used, in which articles published in the period from 2010-2018 that met the inclusion criteria were selected. Results: The research resulted in three articles in Lilacs, three in Medline, and five in Scielo, totaling 11 articles. The research used three questionnaires, such as EORTC QLQ-C30, WHOQOL-bref, and FACT-Cx. These instruments are the most widely used today to measure the quality of life and health conditions in broad aspects. It was observed that cervical cancer positively affects women's quality of life in social and emotional aspects. Conclusion: Quality of life, although with a positive evaluation, should encourage the formulation of public health policies aimed at improving this target audience's quality of life. The discovery of the disease brings several fears, including the thought of death. In addition, it has a physical and psychological impact on these women's lives.


INTRODUCTION
Cervical cancer develops slowly. Changes in cancer-stimulating cells are discovered on the Papanicolaou test. It is important to take this test every three years after two consecutive negative annual tests. Human papillomavirus (HPV) infection is a major risk factor for the development of cervical cancer (INCA, 2017a).
This type of cancer is the third most common tumor in the female population, and it is the fourth leading cause of cancer death in women in Brazil. For Brazil's 2018-2019 biennium, 16,370 new cases of cervical cancer are expected, with an estimated risk of 15.43 cases per 100,000 women (INCA, 2017b).
Cervical cancer is developed through a lesion preceding the epithelium at the squamouscolumnar junction. Some risk factors are listed next: smoking, immunosuppressed system, Human papillomavirus (HPV) infection, socioeconomic conditions, early initiation of sexual activities, among others (SILVEIRA; MAIA; CARVALHO, 2018).
Regarding treatment, it has some modalities, such as chemotherapy, radiotherapy, and surgery. This is the main modality, chosen most of the time. Neoplastic chemotherapy has been widely used, as drug purification and the elaboration of administration protocols allow the use of more than one compound, as well as contouring side effects through the application of symptomatic, salvage and protective therapy (FRIGO;ZAMBARDA, 2015).
As for diagnosis, this is mostly done through routine cervical cytology or biopsy of the suspected area. Colposcopy is used in the presence of abnormal cytology, aiming to direct the biopsy. Conization, on the other hand, is recommended when the biopsy does not clearly define the existence or not of the invasion and when microinvasive neoplasia is suspected (INCA, 2019).
Cervical cancer staging adopts the FIGO or TNM classification system to define installed lesions. For the specification considers several factors, among them: the invasion or not of the lesion, macroscopic or microscopic changes of the disease, the stromal infiltration concavity, the lesion dimension, the range of associated structures, lymph node involvement, and the presence or absence of SARDINHA, A. H. L. et al. The need for treatment and diagnosis of cervical cancer reflects physically and psychologically in women's lives, as they are fearful of the prognosis, as well as the changes caused by the disease and its treatment, which may change their quality of life (DALLABRIDA et al., 2014).
Given the above, the study was justified by the importance of knowing the quality of life of women with cervical cancer, to formulate public policies that improve these women's quality of life. Therefore, this study aims to analyze the publications regarding the quality of life of women with cervical cancer.

METHODS
This is an integrative literature review, consisting of six phases, such as: 1st phase: elaboration of the guiding question, 2nd phase: literature search or sampling, 3rd phase: data collection, 4th phase: critical analysis of the studies included, 5th phase: discussion of the results, and 6th phase: presentation of the integrative review (SOUZA; SILVA; CARVALHO, 2010).
The integrative review is considered a tool of the Evidence-Based Practice (EBP) that aims to systematically condense knowledge, using evidence from clinical practice (SILVA; FARIAS, 2018).
The guiding question was: How does cervical cancer affect women's quality of life? For the search of the articles, we used the descriptors and their combinations in the Portuguese and English languages: "Quality of Life", "Cervical Neoplasms" and "Woman's Health".
The search was done in the following databases: LILACS (Literature in Health Sciences in Latin America and the Caribbean, in Portuguese), MEDLINE (Medical Literature Analysis and Retrieval System Online), and SciELO (Scientific Electronic Library Online). The descriptors were crossed as follows: "Quality of Life" AND "Cervical Neoplasms", "Quality of Life" AND "Woman's Health", and "Woman's Health" AND "Cervical Neoplasms".
The inclusion criteria that we established were: available articles published in Portuguese, English, and Spanish, between 2010 and 2018, and that met the objectives of the study, with full text available online. Among the exclusion criteria, we can mention: articles that did not fit the theme and that were not within the time frame, as well as double indexed articles in the databases and incomplete articles.

RESULTS
To streamline the understanding of data search, the flowchart was used to direct the databases used, the findings in the databases, as well as sample numbers and excluded works, as shown in Figure 1. As shown, the research resulted in three articles in LILACS, three in MEDLINE, and five in SCIELO. Excluding the repeated ones, the total sample consisted of 11 articles, listed as shown in the flowchart and organized in table 1. Of these, five articles were in English and six in Portuguese.

DISCUSSION
The findings found in the publications were: use of a quality of life questionnaire and domains with impacts on the health of women with cervical cancer. To outline the discussion process, after reading and carefully analyzing the selected studies, it was found that the research used three questionnaires, such as EORTC QLQ-C30, WHOQOL-bref, and FACT-Cx. These instruments are the most used today to measure the quality of life and health conditions in broad aspects of the community.
The FACT-Cx questionnaire was used in two articles. The application of this questionnaire showed that cervical cancer positively affects the quality of life. The most affected domains were functional well-being, concerns and social/family welfare.
In the article written by Santos et al., (2012), the most affected domains were functional wellbeing and concerns. On the other hand, in the study carried out by Fernandes, Kimura, (2010) the most affected domains were additional concerns, emotional well-being and social/family welfare. Pêssoa et al., (2016) shows in her study that physical and functional well-being were the most affected domains. This study shows a significant increase in fatigue, a significant reduction in quality of life, and a reduction in functional capacity. Fatigue is a subjective experience involving physical, psychological and cognitive aspects. It can be acute (extreme tiredness resulting from physical or mental stress, which can be improved by resting) or chronic (fatigue without improvement after resting, loss of functionality, limitation of daily activities, and reduced work capacity). SARDINHA, A. H. L. et al.
Biosci. J., Uberlândia, v. 36, n. 5, p. 1771-1777, Sept./Oct. 2020 http://dx.doi.org/10.14393/BJ-v36n5a2020-49902 Two articles used the WHOQOL-bref questionnaire. The perception of the quality of life of the women followed in the studies was considered satisfactory. The most compromised domains were the physical and environmental ones.
In the research described in the article by Fialho et al., (2014), the overall assessment of the quality of life was positive, even though the population had low economic conditions and educational levels. The article written by Jorge and Silva (2010), on the other hand, showed that the physical and environmental domains were the most affected. The perception of the quality of life of the women followed in the studies was considered satisfactory, even when given the recognition of the severity of the prognosis.
The study by Correia et al., (2018) shows that the physical and environmental domains presented the worst scores. Regarding the physical domain, the facets with the lowest scores refer to pain, discomfort, energy and fatigue, sleep and rest, drug dependence, and treatment dependence. The lower scores in the environmental domain can be explained by the fact that most of the women surveyed live in poverty conditions. Seven articles used the EORTC QLQ-C30 questionnaire and, in all of them, the quality of life was considered satisfactory. The main domains of affected health-related quality of life were: emotional function, role performance, pain, fatigue, insomnia, and loss of appetite.
For the authors Aredes; Garcez; Chaves (2017), the domains related to the functional scale and symptom scale were the most affected. Physical capacity, role performance, social function, and total functional scale are related to the functional scale, while nausea, vomiting, weight loss, and diarrhea refer to the symptom scale. The study by DALLABRIDA et al., (2014) showed that women with cervical cancer had a very satisfactory quality of life.
According to the article written by HUANG et al., (2017), the women showed lower cognitive and emotional functioning, and also experienced very severe fatigue and insomnia. The article written by Lofrano;Coura; pointed to a negative impact on diarrhea and peripheral neuropathy symptom.
The study carried out by NICOLUSSI et al., (2014) states that the interviewees' quality of life was considered good. The main domains of affected health-related quality of life were: emotional function, role performance, pain, fatigue, insomnia, and loss of appetite. The article by SILVEIRA et al., (2016) shows that women's quality of life was classified as good. The emotional function was the most affected item, besides physical function, role performance, and symptoms such as pain, insomnia, and loss of appetite.
PASEk; Suchocka; Urbask'ni, (2012) revealed in their article that cervical cancer patients are satisfied with their overall quality of life and its components. Following treatment, the greatest difficulties were the performance of strenuous activities, loss of appetite, concern, and fatigue.

CONCLUSIONS
Cervical cancer is a public health problem, as the number of women victims of this disease is increasing each year, and it is relevant to intensify preventive actions, health education, awareness on the search for prevention in health facilities, and early diagnosis.
In all surveys, the interviewees rated their quality of life as satisfactory and were measured using the three most commonly used questionnaires: EORTC-QLC30, WHOQOL-bref, and FACT-Cx. Even with the positive quality of life assessment found in the publications, it is considered necessary to encourage the formulation of public policies that have better results in this target audience's quality of life.
The discovery of this disease brings several fears, including the thought of death. In addition, it has a physical and psychological impact on these women's lives. The multi-professional team needs to work together to better assist these women.