Observational Study on Patient ’ s Satisfactions and Quality of Life ( QoL ) Among Cancer Patients Receiving Treatment with Palliative Care Intent in a Tertiary Hospital in Malaysia

Burden of cancer care is increasing worldwide despite the improvement in modes of cancer treatment and advancement in technology for diagnsoing and treating cancers. In addition, cancers are not only causing high morbidity and suffering, but cancers has become a leading cause of death throughout the world (WHO, 2000). In 2002, the number of new cancer diagnoses increased to 10.9 million and the total of 6.7 million people have reportedly died due to the cancer diseases. It is predicted that by the 2020 the rate of cancer will rise by 50 per cent to 15 million cases and, by 2030 the cancer death is estimated to be as high as 13 percent of total death world wide (WHO, 2007). In Malaysia as well, a similar trend is observed among new cancer cases reported and cancer mortality. In 2003, a total of 21,464 new cases of cancer have been reported


Introduction
Burden of cancer care is increasing worldwide despite the improvement in modes of cancer treatment and advancement in technology for diagnsoing and treating cancers. In addition, cancers are not only causing high morbidity and suffering, but cancers has become a leading cause of death throughout the world (WHO, 2000). In 2002, the number of new cancer diagnoses increased to 10.9 million and the total of 6.7 million people have reportedly died due to the cancer diseases. It is predicted that by the 2020 the rate of cancer will rise by 50 per cent to 15 million cases and, by 2030 the cancer death is estimated to be as high as 13 percent of total death world wide (WHO, 2007).
In Malaysia as well, a similar trend is observed among new cancer cases reported and cancer mortality. In 2003, a total of 21,464 new cases of cancer have been reported

Observational Study on Patient's Satisfactions and Quality of Life (QoL) Among Cancer Patients Receiving Treatment with Palliative Care Intent in a Tertiary Hospital in Malaysia
Wan Puteh Sharifa Ezat 1 *, Ismail Fuad 2 , Yaakub Hayati 3 , Ahmed Zafar 4 , George Albert Wanda Kiyah 5 in Peninsular Malaysia (National Cancer Registry, 2003). Majority of these patients are women. Breast cancer were recorded as the highest number of cancer with 3,738 cases, followed by lung cancer 1,758 cases and 1,557 cases of cervical cancer (National Cancer Registry, 2003).
The morbidity as well as mortality of cancer depends upon the sevrity of cancer that in turn is measured by the 'stage' of cancer. The different stages of cancer is underreported in Malaysia due to various reasons, mainly due to the comprehensiveness and accuracy of the documentation and data collected. Therefore it would be difficult to ascertain the incidence of advanced stage cancer among local population and the subsequent morbidity burden. For most patients with advanced stage of cancer or inability to stand treatment due to poor performance status or high co-morbidities, treatment options are often limited (Henoch et al., 2007). Most of the time, the cancer treatment aims to control symptoms and maintain some reasonabale quality of life for the patients. Treatment with non curative intent may consist many modalities including surgery, chemotherapy, radiotherapy and palliative care.
Palliative care aimed at controlling physical symptoms and psychosocial aspects of patients' illness as well as achieving good quality of patients' life (WHO, 2013). Often it goes concurrently with other treatment modalities in order to achieve good symptoms control. Studies have shown that palliative chemotherapy may play a significant role in improving cancer patient's quality of life (QoL) or prolonging good QoL for reasonable time with advanced cancers (Simmonds, 2000). At the same time, the surgical intervention for spinal metastases and pathological fractures have also proved to improve patients' pain and bring positive impact on overall quality of life to patients with advanced cancer at an acceptable risks (Wai, 2003). Symptoms management are known to be achieved by short course radiotherapy for patients with advanced incurable head and neck cancer (Mohanti et al., 2004). Studies have shown that palliative chemotherapy have played significant role in improving patients with advanced cancer quality of life (QoL) or prolonging good QoL for reasonable time (Simmonds, 2000). Surgical intervention for spinal metastases and pathological fractures also proved to improve patients' pain and bring positive impact on overall quality of life to patients with advanced cancer at an acceptable risks (Glare et al., 2004). Symptoms management are known to be achieved by short course radiotherapy for patients with advanced incurable head and neck cancer (Mohanti et al., 2004). Often it go concurrently with other treatment modalities in order to achieve good symptoms control.
It is interesting that up to our knowledge, there are no studies that relate patients' satisfaction to their non curative treatment regimes to their quality of life. Davidson (2005) and Fukui (2010) have reported that patients' acceptance to a prescribed treatment has a strong relationship with their satisfaction toward the received care either as inpatient or in the community (Davidson et al., 2005;Fukui et al., 2010). Previous studies showed that satisfaction towards treatment can provide a beneficial effect on patients' mental and physical health status (Miyashita et al., 2008;Wong et al., 2008). Therefore, this study attempts to review satisfaction towards non curative treatments for cancer patients and the relationship with their quality of life.

Materials and Methods
This is a cross-sectional study from 1 st June 2012 till 28 th February 2013 among adult cancer patients (18 years and above) undergoing palliative treatment at a teaching hospita in Kuala Lumpur. Both inpatients as well as out patients were included in the study. The sample size (n=120) was calculated using the sample size of two proportions with an attrition rate of 20%. A total of 120 cancer patients undergoing palliative care treatment were recruited using Convenience sampling method. Data is collected using three (3) different data collection tools, these include: i) Patient level data Collection form for Demographic data; ii) Patient Satisfaction Questionnaire version III (PSQ III); and iii) Quality Of Life Questionnaire (QoL) using SF-36 version II. This data collectein is supplemented with face to face interviews. Approval for the research was obtained from the the teaching hospitals' Research Ethics Committee.
Questionnaire 'A' collects demographic data that include; age, gender, race, religion, marital status, highest obtained education level, type of cancer, stage of cancer, type of treatment, comorbidities and household income including financial aid received (if any) in MYR. Questionnaire 'B' is the Patient Satisfaction Questionnaire-18, summarized from the Patient Satisfaction Questionnaire version III and it measures the patient satisfaction with palliative treatment received. Questionnaire 'C' uses Quality Of Life Questionnaire (QoL) using SF-36 version II to measures the Quality of Life for patients recieving palliative care.
Quality Of Life Questionnaire (SF-36) version II consists of 36 questions, divided into 8 domains. These domains include; social function, general mental health, role limitations (based on emotional problems and sustainability due to disease), physical functioning, limitations based on their role physical, bodily pain and general health perception. Each domains is further divided into two main composite components, these are composite physical component and mental composite component.
Data on the type of the cancer shows that the majority of patients (40 patients; 33.4%) receiving palliative treatment has Lung cancer; followed by reast cancer (24 patients; 20.0%), Colon cancer (19 patients; 15.8%), and Prostrate cancer (12 patients; 10.0%). Whereas 25 patients (20.8%) has other miscellanious cancers. Data on the cancer stage shows that 49.2% patients (59 patients) has stage 4 cancer, followed by stage 3 cancer (53 patients; 44.1%), and only 8 patients (6.7%) has stage 2 cancer. There were no stage 1 cases, as not many cases are referred whilst still in the early stages due to underdetection DOI:http://dx.doi.org/10.7314/APJCP.2014.15.2.695 Satisfaction and QoL Among Cancer Patients Receiving Palliative Care in a Tertiary Hospital in Malaysia and poor take up on screenings. As high as 53.3% of the patients (64 patients) have been diagnosed with cancer more than 2 years whereas 46.7% of the patient population (56 patients) were diagnosed cancer within 2 years from the time of the survey. As high as 50.8% of the patients (61 patients) on the palliative treatment were on chemotherapy, followed by radiotherapy (30 patients; 25%) and surgery (18 patients; 15%). Majority of the patients (83 patients; 69.1%) do not have any other diseses recorded besides cancer. Whereas only 19 patients,10 patients and 1patient were suffering from Diabetes, Heart problem and Hypertension respectively (Table 2). Table 3 depicts the distribution of patient satisfaction score measured through PSQ III, based on the seven domains. These seven domains are general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor and accessibility of services provided. The findings found that respondents' communication scores were the highest at 50.60 (±9.07), followed by interpersonal quality at 48.48±6.18.

Patients quality of life based on domains
Quality of life among the cancer patients receiving palliative treatment at the hospital is assessed using eight domains. These are Social functioning, General mental health, Role limitations based on Physical Function, Role Limitations based on Emotion, Bodily Pain, General Mental Health Perceptions, Energy, General Health Perceptions and Social Function (Table 4). The result showed that the quality of life for cancer patients undergoing palliative care based on domain score is highest (99.16±9.12) on the domain of Role limitation (emotional). Whereas the domain for bodily pain scored lowest on the quality of life experienced by cancer patients undergoing palliative care (37.02±14.44).
The comparison was made between the physical and mental composite components based on the obtained mean and standard deviation. The mental composite score is slightly higher (44.93±6.84) as compared to the mean and standard deviation of the physical composite components (42.24±7.91).
The relationship between the demographic characteristics i.e. age, gender, religion, education level and household income and the patients satisfaction with the treatment using one way ANOVA and post hoc analysis indicated the significant differences between general satisfaction domains among the different ethnicities (F=4538; p=0.013). Chinese respondents have higher satisfaction scores (28.09) on the general satisfaction towards treatment received. There was a significant difference between marital status and general satisfaction (F=4507 and p=0.050). Mean scores of the respondents who are single have highest general satisfaction (27.77) when undergoing palliative treatment compared to widows, widowers and divorcees who had lower satisfaction (25.25).
There was a significant difference within the general satisfaction scores among the patients with different types of cancer receiving palliative treatment (F=3859; p <0.001). Patient suffering from colon cancer have higher   (Table  5). Table 6 shows the the differences in the physical and mental components of quality of life scores for the patients undergoing the palliative treatment for cancer. There is no significant difference in the scores of physical component for the quality of life for the age, gender, race, religion, marital status and household income., there are significant differences between the level of education and quality of life based on the physical component score (F=6211; p<0.001).

Factors influencing the physical component of quality of life
On the the disease factors, the variable 'types of cancer' shows significant difference between the quality of life of patients based on types of cancer measured using the physical component score. ANOVA was used to identify the differences of score among the different types of cancer using physical component (F=5962; p<0.001). Whereas the variables 'stage of cancer', 'type of treatment', 'duration of diagnosis' and 'comorbidity with other disease' does not show any significant difference within the  For the mental component, the variables of gender, ethnicity, education level, marital status, religion and household income show no significant difference. Whereas, age showed a significant difference within the patients' population (r=-0.386, p<0.001). This indicates that older the age of the respondent, the lower is the quality of life.
Based on the mental component score, only the variable 'types of cancer' shows the significant differences between quality of life within the cancer patients undergoing the palliative therapy at a teaching hospital (F=5962; p<0.001). The variable 'diagnosis period' also show significant difference within the study population (t=5153; p<0.001). Responden who were diagnosed cancer within 2 years have better quality of life as compare to the patients diagnosed with cancer for more than 2 years. Other variables 'stage of cancer', 'type of treatment received' and 'comorbidity' do not show any significant difference within the study population.
Besides that, variables 'financial supports status' also does not show any significant difference in quality of life (mental component) within the study population. But, the variable amount of financial support (total financial support) shows significant differences within the study population (F=7168; p<0.001). Cancer patients who received financial supports MYR 5000 or more show higher quality of life than the patients who receive financial assistance of MYR 1000 or less.

Satisfaction and patients' quality of life
We wanted to see if there exists any relationship between the patient satisfaction with the quality of life score (both Physical and Mental component) ( Table 7).
Results of the Pearson correlation analysis are shown for the relationship between the quality of life (physical as well as mental component) with domain of general satisfaction, technical quality, interpersonal relationship, communication, financial aspects, times spent with the doctor, and accessibility to the facilities provided for cancer patient undergoing palliative treatment.
Results shows a weak positive relationship but significant between the quality of life in physical component with general satisfaction domain (r=0.232, p=0.011). This result shows clearly that the satisfisfaction of cancer patient receiving palliative treatment is based on general satisfaction aspects for the better quality of life in physical component. Technical quality also has a weak negative but significant correlation (r=-0.312, p<0.01). This means the higher the patients' satisfaction based on the technical quality lower the quality of life in aspect of physical component.
For mental component of quality of life, the variables 'time with the doctor' shows a weak negative but significant correlation (r=-0192, p=0.036). That means the higher the quality of life (measured with respondent's mental component score), the lower their level of satisfaction based on time spend with the doctor. Satisfaction with accessibility aspects also have a weak negative but significant correlation (r=-0279, p<0.001). That means the higher quality of life of cancer patients receiving the palliative treatment, the lower mental component of the quality of life based on accessibility aspects.

Discussion
The purpose of this research is to investigates and determine the relationship between quality of life and patient satisfaction among the patients receiving cancer palliative treatment. Based on result of the study, most of the cancer patients undergoing palliative treatment have a higher quality of life based on the mental aspect than the physical aspects. This is due to their health condition precisely and according to the disease that id spreading and that caused them to lose their ability a bit based on physical aspects (Siddiqua et al., 2012).
The results presented shows a significant relationship between satisfactions toward palliative treatment received (general satisfaction, the technical quality, time spent with the doctor, and accessibility aspects based on the facilities provided) and the quality of life (Physical Component and Mental Component). Research findings by Avery and friends (2006) at a Hospital in United Kingdom (N=181 cancer patients undergoing palliative care) showed that there is no relationship between quality of life and satisfaction with the treatment received. This may be because the quality of life of cancer patients remains low weather they received curative treatment or palliative care, because there was no difference between the quality of life among the satisfied patients or not satisfied patients based the treatment received. The researcher also believes that quality of life of cancer patients undergoing palliative treatment is determined by the types of treatment and the outcome of quality of life patient and not based on the satisfaction with treatment. Research findings is also supported by the study that was done by Kleeberg and  friends (2005) which found that there was a relationship between the quality of life of patients by satisfaction with the treatment received.
In another study conducted among 3,384 cancer patients in Germany showed that the satisfaction with treatment, particularly in the selection decision satisfaction, the doctor communication with patients, and treatment organizations provide higher impact on quality of life because it not only can increase the functionality of the patient physically but it can improve their mental functioning because with the information provided for treatments make them better understand and to meet their needs and circumstances when they seek for treatment.
Besides that, there is negative relationship in quality based on the physical component score, the more better the quality of life of cancer patients undergoing palliative treatment, the lower their level of satisfaction on the treatment given. This may be due to the fact that the health condition of such patients are getting worse and requires them to get and try all types of treatment and undergo medical checkup to find out about their health.
Cancer disease is easily spread and will attack other part of the body. The physical condition may be getting worse and require the patient to seek treatment at various places based on their treatment regimen. Besides that they may had to use a lot of energy for moving from one place to another place, even though they may get nurse supports along with other people support around them. These conditions may make these patient easily tired and feel uncomfortable.
This finding of this study is also supported by research done by Wong et al. (2008) that shows that there was no relationship between the quality of life of patients and the treatment satisfaction with services received, particularly in the aspect of the technical quality in facility. The study by Wong et al., was conducted include 235 patients with liver cancer and 334 patients with lung cancer in Hong Kong, and it shows that the patients satisfaction based on the facility have an impact toward quality of life patient because it facilitate patients to get treatment easily. But, it is also affect them in physical aspects. Even though medical devices are complete and available but still patient is needed to be fully monitored by a doctor. Although treatment can relieve the pain, but the primary disease still exist, that may continue to cause suffering and require them undergoing many types of treatments. That may burden patients more and requires the patient to do a lot of movement and that may make them uncomfortable.
There are negative correlation between patient satisfaction on accessibility and the time spent by the doctor. This negative relationship by times spent with the doctor is based on mental component aspect. This means that more they spending time with the doctor, the lower their quality of life will become. This is because more time the cancer patient spent with their doctor, more aware the patients become about their medical condition, and that may caused them to become depress. More so if the health condition of the patient is getting worse it may require the doctor to spend more time with the patient and monitor to improve their functionality and reduce the pain. If their health conditions become more worse it also makes them stay in the hospital longer and require the doctor to monitor strictly their conditions. This situation may make these patients more depressed because they feel that their life is getting shorter.
Another study done by Asadi et al. (2004) found that there was a relationship between satisfaction and quality of life in mental component aspects. Patient's health condition may require the patient to get several treatments to reduce their pain and complications that are caused by treatment. Satisfaction or dissatisfaction have an impact toward quality of life because even if the patients are satisfied by the services provided or not, it does not guarantee a good quality of life because of the pressure to get various treatment causes them to feel it as a burden.
Besides that, results also show that there is a negative relationship between satisfactions and the accessibility aspects with the quality of life in mental component. The patient in stage 4 cancers may require getting special treatment to reduce the pain that they faced. If conditions become more serious its require patients to seek treatment more often and often go through various of medical check to follow up their health condition in more details and this may make them feel more pressure and distressed. Although they were satisfied with the treatment given, but their quality of life in terms of mental component may become very low.
Based on the study findings, researchers found that there was a significant relationship between satisfactions toward treatment received and the quality of life of cancer patients undergoing palliative treatment, especially in terms of accessibility, technical quality, and time spend with doctor and general satisfaction.
In conclusion, patients undergoing palliative care were classified as patients who do not have very good chance to be cured. The purpose of palliative care is to maximize quality of life of such patients from different aspects in particular physical, mental and spiritual (Kumar et al., 2008). The improvements in the quality life of cancer patients can be achieved via a range of services network to meet the needs of patients and the care giver. Another good approach is to look for the satisfaction from the service aspect, apart from social aspects as well as disease aspects to enhance the quality of life and provide more comfort and treatments available to them. Hence, this study was carried out to reviews the quality of life of cancer patients undergoing palliative care and the factors the mainly affect their satisfaction toward treatments.From the findings of this research, quality of life and satisfaction with palliative care have a relationship and are related with each other. Satisfaction with treatment will contribute to the better quality of life for cancer patients who received the palliative treatments because the main objectives of the palliative care is to obtain the optimal quality of life (Leung et al., 2010) and increase their ability in dealing toward treatment process.