Chronic diseases affect the overall quality of life of patients as it negatively impacts different areas in life. The review assessed and qualitatively compared the quality of life (QoL) of patients suffering from three chronic diseases namely patients undergoing hemodialysis, patients with type 2 diabetes mellitus, and patients with breast cancer. Qualitative assessment of previous studies using the Ferrans and Powers quality of life index was conducted. Nineteen (19) full texts were included and comprehensively analyzed. Statistically significant lower scores were noted on the health/functioning and socio-economic domains of patients undergoing hemodialysis and no significant difference in other areas on the quality of life. There was also no significant difference in the overall scores among the three chronic diseases under study. But while the overall QoL of patients are within the same range, results suggest that hemodialysis patients experience the greatest negative impact in terms of socio-economic and health/functioning domains in the QoL. Thus, health interventions, educational programs, and policy formulations should focus on improving these aspects. This would also call for a multi-disciplinary approach to address the issues related to the quality of life of hemodialysis patients.
Chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. The top three chronic diseases include cardiovascular diseases, diabetes, and cancer . The number of people suffering from chronic diseases has increased over time. The World Health Organization estimates that chronic diseases account for almost three-quarters of all deaths worldwide . In the USA, six out of ten adults have a chronic disease  while in the Philippines, chronic diseases namely hypertensive heart disease, chronic kidney disease, and diabetes are the top causes of death from 2007 to 2017 . The rapid aging population, greater longevity, and more advanced treatment options all contribute to the rise . Chronic disease poses an enormous economic and societal burden. It also imposes high and catastrophic cost on patients and their households . Long-term disorders account for 70% of deaths and 75% of annual health care cost in the USA .
Apart from the financial implications, chronic disease disrupts an individual’s life. It can be disabling and may reduce a person’s quality of life (QoL) . According to Ferrans and Powers, QoL is a “person’s sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are most important.” They identified four domains, namely, health/functioning, socio-economic, psychological/spiritual, and family .
In the context of chronic disease, QoL is increasingly recognized as an essential health outcome, representing the ultimate goal of health interventions. This is because most programs are meaningful only if they affect the physical, emotional, and social well-being of the person—that is the quality of life . Chronic diseases affect patients’ physical and functional status. Emotional balance and self-esteem decline because of their increasing dependence on others. Different studies suggest a negative relationship between these diseases and QoL . Patients undergoing long-term treatment experience anxiety and affect the overall quality of life .
Although several studies have been conducted to assess the QoL of patients, there are few published studies making a comparison on the quality of life of patients suffering from different chronic diseases. For the purpose of the study, the researchers decided to include diabetes and cancer as these two are included in the list of top chronic diseases. To make the study more specific, it only included type 2 diabetes mellitus (T2DM) and breast cancer patients. T2DM accounts for more than 85% of the total diabetes prevalence while breast cancer is the most common malignancy among women and accounts for 25.1% of all cancers worldwide [13, 14]. While cardiovascular disease is the top chronic illness identified by different sources, the broad category did not make it to the specific classification intended by the researchers. Cardiovascular diseases are under a group of disorders involving the heart and blood vessels which include six sub-types .
Kidney disease, on the other hand, was included since data show that while it does not belong to the top 3 chronic diseases, 10% of the population worldwide is affected by the illness . It is also often considered a co-morbidity of other more frequent diseases like diabetes and hypertension. Reports from the WHO show that an estimated of 5–10 million people die annually from kidney disease. Around 2.6 million of them receive dialysis, and the need is projected to double by 2030 . Patients undergoing hemodialysis were also included in the study since there are several researches showing that these patients suffer from poor quality of life [18,19,20].
With the aforementioned reasons, the present study used the term chronic diseases in the context of patients undergoing hemodialysis, patients with breast cancer, and patients with T2DM. The researchers aimed to determine the impact of these disease conditions on the QoL of patients. Specifically, the study aimed to determine which among these three groups of patients with chronic diseases suffer the most in terms of QoL and find out the domain most affected in each. A better understanding of these is necessary to plan and distribute scarce health care resources so that patients with chronic disease will experience improved quality of life.
Materials and Methods
A literature search was conducted using a combination of the following keywords: “quality of life,” “Ferrans and Powers,” “type 2 diabetes mellitus”, “hemodialysis,” and “breast cancer” in the online databases. Titles and abstracts of studies were carefully screened. Full texts of related studies were independently evaluated by two authors considering the eligibility criteria.
The following inclusion criteria were used: (1) studies that assessed the quality of life of breast cancer, hemodialysis, and type 2 diabetes mellitus patients using the Ferrans and Powers quality of life index (QLI) questionnaire, (2) studies that include a complete data on the four domains of quality of life, (3) publications written in English, and (4) studies published from year 2000 to September 2018. The studies excluded are publications that lack access to the full text and non-numerical presentation of data.
A total of 7100 articles were identified through the database search—3100 for type 2 diabetes mellitus, 2640 for breast cancer, and 1360 for hemodialysis. After the removal of non-relevant and duplicate studies, only 199 studies remained—62 for hemodialysis, 66 for breast cancer, and 71 for type 2 diabetes mellitus—and these proceeded to the next stage of the filtering process using the set inclusion and exclusion criteria. For hemodialysis, 10 studies advanced to the qualitative analysis, 4 for type 2 diabetes, and 7 for breast cancer (Fig. 1).
Methodological Quality Assessment of the Included Studies
A total of 21 retrieved studies were further assessed using the Newcastle-Ottawa scale (NOS) to determine their methodological quality. All included articles were rated based on three perspectives: selection (max of 4 points), comparability (max of 2 points), and exposure (max of 3 points). Accumulated score of ≤ 4 points indicates low-quality studies, 5–6 points indicate moderate-quality studies, and scores of ≥ 7 indicate high-quality studies . Studies that were assessed of having low quality were no longer included in the statistical analysis [22, 23].
For studies that qualified after the NOS assessment, the following information was extracted: the main author’s last name, year of publication, the total number of study participants, mean score of the four domains of QoL, and the overall QLI among baseline groups.
One-way analysis of variance (F-Test) was used to test the statistical difference of mean QoL scores of the three disease groups. For at least marginally significant F-test result (p < 0.10), post hoc comparison was performed using least significant difference (LSD). All analyses were computed using the SPSS (Statistical Package for the Social Sciences) program.
The researchers gathered data from studies that use the instrument of Ferrans and Powers in assessing the quality of life (Table 1). QLI is a well-established instrument showing substantial evidence of validity, sensitivity, and reliability . A total of 19 full-text studies were included in this review, 7 for breast cancer [24,25,26,27,28,29,30], 2 for type 2 diabetes [31, 32], and 10 for hemodialysis [33,34,35,36,37,38,39,40,41,42]. The year of publication ranges from 2003 to 2015. Sample size from each study varies with the lowest of having only 11 participants and the highest with 280 participants. Overall, the quality of the included studies was moderate as scored by the NOS. However, based on the results of the individual NOS score, two studies [22, 23] were graded as having low quality and thus, were removed in the statistical analysis.
Ferrans and Powers have modified the tool to create illness-specific versions. However, a common set of items forms the basis for all versions—health and functioning, socio-economic, psychological/spiritual, and family. Scores for all versions range from 0 to 30, which allow comparison of findings across different versions .
In the present study, patients undergoing hemodialysis showed the lowest overall quality of life score (Table 2). However, statistical analysis shows that the score is not significantly different from the other two chronic diseases under study (p = 0.13). On the other hand, analysis of the data on a per domain basis shows that statistical difference on the three diseases was observed on the health/functioning (p = 0.08) and socio-economic (p = 0.03) domains which are evidently lower for hemodialysis patients compared with the other two chronic diseases under study.
Investigation on the quality of life is considered a key measure to evaluate the outcomes of chronic disease treatment. The World Health Organization defines the QoL as the individual’s perceptions of their living conditions, in terms of culture and values of the society and the goals, expectations, standards, and individual interests .
Chronic diseases are slow in progression, long in duration, and they require medical treatment. The presence of which is related to unhappiness and psychological distress . The majority of chronic diseases worsen the overall health of patients. They limit their capacity to live well and limit their functional status and productivity . Long-term illnesses cause changes in the routine and daily activities, pose recurrent crises and physical, emotional, and financial overload. All these lead to insecurity and social dilemma and subsequently affect the quality of life [8, 47].
Since different studies show that lower QoL is directly related to patient mortality rates , understanding how chronic diseases affect the QoL will enable the sick individuals to maintain functionality, independence, and general satisfaction from their lives for a longer duration. For example, patients who suffer on one domain in the QoL like the health/ functioning should find ways on how to improve the other aspects. In the study of Megari et al. , the researchers explained that people with chronic illness have identified spirituality as a resource in promoting QoL . In other studies, the type of treatment and presence of social support are correlated with the quality of life among chronically ill patients [48, 49]. The patients, their family, and health care providers can explore on these aspects to help improve the overall QoL. The key is finding a balance to counteract the negative impact of their illness on their quality of life.
While no statistically significant difference was noted on the overall quality of life among the three chronic diseases under study, hemodialysis patients still showed the lowest QoL. This is similar with other studies showing that patients undergoing hemodialysis experience poor QoL [19, 20, 42, 46, 50,51,52]. Patients with chronic renal failure experience the inability to excrete metabolic waste and show fluid and electrolyte imbalance. Afflicted individuals resort to hemodialysis, as this is the most common method of management for end-stage renal disease . The primary purpose of hemodialysis is to reach the highest level of function and well-being of patients. However, the inflexible treatment causes stress to patients. The need for frequent visits to dialysis centers which averages to 2–3 sessions per week with each session lasting for 3–4 h affects and implies changes in both their professional and personal lives [18, 51].
Different studies also noted that patients undergoing hemodialysis experience feelings of lack of ability and control over the disease and the treatment. Financial implications, inability to maintain jobs, multiple drug therapies, special nutrition program, and the inability to deal with physical and mental disabilities affect their overall quality of life . Low income status and increased duration on hemodialysis were noted as negative predictors of QoL among patients on maintenance hemodialysis . On the other hand, higher education and understanding of their disease condition demonstrated better quality of life among hemodialysis patients. Patients who are taught about the basic principles of their treatment regimen including dietary restrictions are better able to handle their disease. The relationship of patients with the medical team was also positively correlated with better QoL. Researchers explained that this happens when the health care providers are able to help reduce the stress of patients through different supportive techniques . Some of the health care aspects ranked as helpful include staff’s responsiveness to pain or discomfort, staff’s helpfulness and sensitivity, and ease of reaching dialysis staffs through telephone .
Patients with Type 2 Diabetes Mellitus
In the study, patients with T2DM exhibited the same poor quality of life as breast cancer patients. The quality of life of diabetic patients worsens when complications start to develop or co-morbidities coexist . Factors associated with increased burden include the seriousness of the disease, inadequate access to proper diabetes program, and inadequate quality care . Poorer QoL has also been associated with uncontrolled diabetes. The burden of the disease comes from the never-ending demands of care like the need for a controlled diet program, regular exercise, daily blood glucose monitoring, and insulin injections. As the treatment regimen advances, the QoL decreases .
In different studies, researchers have noted the factors correlated with diabetes QoL. They have noted that the presence of complications, hypertension, increasing body mass index, depression severity, longer duration of diabetes, and diet with more red meat were associated with poor QoL among type 2 diabetics. On the other hand, better quality of life was seen when patients do more exercise and check glucose frequently. Researchers have also stressed the importance of patient’s adherence and self-care activities since these play crucial roles in the prevention of complications [58, 59]. This is because previous studies pointed out that if two or more complications are present, patients with diabetes have higher chances of showing clinical symptoms of depression and anxiety which further lowers their quality of life .
Patients with Breast Cancer
Similar with T2DM, breast cancer patients also show better QoL than hemodialysis patients. This may be explained with the assumption that breast cancer patients have greater chances to survive and heal completely especially if diagnosed during its early stages. Unlike T2DM that will be a lifelong treatment and hemodialysis requiring a kidney transplant, breast cancer can be treated on a relatively shorter term and does not always have to be on a lifetime basis. Several studies noted that the QoL of breast cancer patients improves over time [25, 61]. Since the present study did not classify the patients according to the duration of cancer, it may be possible that patients included in the analysis have been cancer survivors and thus, explains the higher QoL compared with hemodialysis patients. Sharma reported that patients in the advanced stage of the cancer have the lowest scores on QoL .
Although breast cancer shows better QoL in comparison with hemodialysis, the results are still significantly lower compared with the general population . A systematic review of studies shows that breast cancer patients with co-morbidities, treated with chemotherapy, with less social support, with more unmet needs, and poor financial situation have a poorer quality of life [64, 65]. The QoL of breast cancer patients is associated with more limitations in activities of daily living. Psychosocial factors like partner relationship, sexual functioning, and body image were linked to the impaired quality of life. The type of surgery also influences where mastectomy has worse QoL than breast-conserving treatment .
Although the present study did not cover the factors affecting the QoL of patients with chronic diseases, it is important to note that previous studies correlated it with age, educational level, ethnicity , compliance with treatment regimen, relationship with health care providers and their family, and openness with their condition .
Quality of Life Domains
Quality of life is a broad concept affected by the person’s physical health, psychological state, personal beliefs, social relationships, and their relationship to salient features of their environment. The present study showed that of all the four domains in the quality of life, the health/functioning domain suffered the most. Many studies call it the health-related quality of life (HRQoL). Patrick and Erickson defines HRQoL as the value assigned to duration of life as modified by the impairments, functional states, perceptions, and social opportunities that are influenced by disease, injury, treatment, or policy .
Among hemodialysis patients, the physical health dimension is strongly associated with morbidity and mortality . The low physical health scores demonstrate that daily activities were disturbed in hemodialysis patients as they were more dependent on renal replacement treatment for their survival. While the present study did not categorize patients as to the type of dialysis modality used, one study reported that in-center dialysis patients had lower physical functioning compared with home modality patients . Another study explored the impact of exercise programs on the physical fitness of hemodialysis patients, and the results were significantly better after the initiation of intervention . The results of both studies suggest that health care providers should consider carefully the treatment options for hemodialysis patients to at least minimize the negative impact of the illness and help improve their QoL.
In terms of breast cancer, pain, surgery, fatigue, arm morbidity, sexual dysfunction, and post-menopausal symptoms were the impairment directly correlated with health-related quality of life [72, 73]. As for the diabetes patients, low scores were also noted in the study, and the poor scores are still similar with the studies of Kumar and Thommasen where findings show that diabetes and its complications have the strongest implication on the physical health . Wandell suggested that the most important factor for the deterioration of QoL among people with diabetes was the presence of complications .
Another domain that significantly suffers for patients undergoing hemodialysis is the socio-economic aspect. Similar to previous studies, socio-economic factors are important components of the quality of life since they strongly affect the functional capacity of a person to live independently . In terms of chronic diseases, this is due to the cost of living with chronic disease and the extra financial burden that translates to worsening emotional health . Chronic illness poses catastrophic socio-economic effects on the individual and their households. Factors exacerbating the hardship include limited government financial support, multiple medications, and unemployment. As a result of the economic stressors, households make a difficult decision between prioritizing health care over basic needs .
Among hemodialysis patients, socio-economic factors like education, employment, income, and funding are important parameters affecting the QoL. Patients with better QoL are often those with better economic status since they are able to afford expensive treatments like dialysis and medications .
Overall, the greatest interest in the present study is the significant gap observed among hemodialysis patients in terms of health/functioning and socio-economic factors. The poorer health/functioning of HD patients may be explained in part because patients with renal failure suffer from impairment in mobility and experience limitations in the performance of activities of daily living . While breast cancer and T2DM patients may also feel limitations with their physical functions, these are not as profound as hemodialysis especially if the breast cancer is in the early stages and if DM is controlled.
In another study comparing dialysis patients and solid organ cancer patients, the researchers’ data showed that compared with solid organ cancer patients, survival among dialysis patients was lower. The poorer results for hemodialysis patients may be due to the lagging development in terms of lifesaving therapies, limited research for kidney disease compared with “high profile” diseases like cancer, several barriers to transplant, and the higher complications among hemodialysis patients . One author even noted that cancer research has already resulted in many therapeutic advances over the last decade and only a relatively few treatment breakthroughs in kidney disease .
The results of the study suggest that patients especially those undergoing hemodialysis should take further steps to improve their health/functioning and socio-economic domains as these are the most affected aspects in their QoL. Strategies in increasing scores in these domains include educational interventions focusing on improving their knowledge, promoting exercise, and becoming more proactive in their treatment management.
On the part of health care providers, understanding the QoL of patients provides information that can indicate areas in which patient is most affected and help them make better choices in patient care. With the knowledge that hemodialysis patients suffer most in terms of health/functioning and socio-economic, more care and attention should be directed to them to help them achieve better health outcome and quality of life. However, this is not to discount the fact that both T2DM and breast cancer patients will also benefit from better relationship with their health care practitioners. The use of evidence-based research when choosing the treatment to give their patients should be equally weighed with the effect on their QoL.
Lastly, for policy makers, estimation of the impact of these three chronic diseases can help in the planning and distribution of scarce resources especially to those who are in greatest need. Cancer and diabetes are well recognized as significant public health issues while the contribution of kidney disease to the global burden of disease is not well recognized as evident by few countries with dedicated kidney disease prevention and control programs. Polkinghorne further cited that research for kidney disease also lags behind other diseases .Consequently, the results of the study call for an urgent need for well-designed policy to address the issues faced by hemodialysis patients.
Limitations of the Study
It was notable that T2DM has relatively lower number of quality studies retrieved compared with the other two diseases under study. Furthermore, classification on the quality of life based on the stage of the disease onset was not explored in the study. Thus, differences in the results brought about by the lower number of studies for T2DM and variations of disease progression among the study groups may have limited the analysis. The researchers did not also include demographic variables in the analysis since each of the studies that qualified presented their results differently. In the present study, homogeneity was no longer assessed since the studies included used the same research tool for data collection which could limit their heterogeneity.
The present study qualified the quality of life of patients undergoing hemodialysis, patients, patients with T2DM, and patients with breast cancer. Hemodialysis patients suffer most in terms of health/functioning and socio-economic domains suggesting the need for more interventions that will help these patients cope with the physical challenges and socio-economic impact of the disease. Failure to focus on their needs may subsequently have impact on their quality of life. Further research to compare the quality of life of patients with chronic diseases and its possible comparison with the general healthy population is highly suggested.
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Arceo, E., Dizon, G., Salunga, M.A. et al. A Review of the Quality of Life of Hemodialysis, Breast Cancer, and Type 2 Diabetes Mellitus Patients. SN Compr. Clin. Med. 2, 149–157 (2020). https://doi.org/10.1007/s42399-020-00222-2
- Quality of life
- Chronic disease
- Type 2 diabetes mellitus
- Breast cancer
- Hemodialysis patients