Breast cancer is the most frequently diagnosed malignancy among women globally, accounting for approximately 2.3 million new cases in 2020 alone, with a significant burden in low- and middle-income countries [1]. Advances in early detection, surgical interventions, and adjuvant therapies have dramatically improved survival rates, with the 5-year survival rate exceeding 85% in many settings [2,3]. Consequently, attention has increasingly shifted from survival to the long-term quality of life (QoL) and functional well-being of breast cancer survivors.

Survivorship, while a positive outcome, introduces new dimensions of healthcare needs, including management of physical symptoms (e.g., fatigue, lymphedema), psychological sequelae (anxiety, depression), social reintegration challenges, and sexual dysfunction [4–6]. Studies show that these post-treatment effects can persist for years after therapy completion, influencing daily functioning and overall life satisfaction [7].

The concept of QoL in cancer survivors is multidimensional, encompassing physical, emotional, cognitive, and social aspects of well-being. Validated instruments such as the EORTC QLQ-C30 and its breast cancer-specific module QLQ-BR23 have been widely employed to assess these dimensions [8]. These tools allow clinicians and researchers to objectively quantify the impact of the disease and its treatment on the patient's life.

In India, where breast cancer incidence is rising, survivorship care remains an under-addressed domain. Cultural, socioeconomic, and health system-related barriers often hinder the delivery of comprehensive supportive care services [9]. There is a paucity of studies from India that comprehensively assess QoL among breast cancer survivors in tertiary care settings.

This study was undertaken to fill this gap by evaluating the quality of life and functional status of breast cancer survivors attending follow-up at a tertiary cancer center. Understanding the survivorship burden will help clinicians tailor post-treatment care plans and advocate for integrated survivorship programs.

Study Design and Period:  This was a cross-sectional study conducted at a tertiary cancer centre between July 2020 and June 2021. A total of 101 breast cancer survivors who had completed primary treatment and had survived at least three years post-treatment were enrolled during their follow-up visits.

Inclusion Criteria:

• ECOG Performance Score: 1
• Age: >30 years
• Disease Stage: I to III
• Histology: Any
• Comorbidities: Controlled
• Exclusion Criteria
• ECOG Score >1
• Stage IV disease
• Presence of residual disease
• Second primary malignancy
•  

Ethical Considerations:  The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants after providing detailed study information in their native language. Confidentiality was maintained throughout.

Data Collection Tools:  Participants were assessed using the EORTC QLQ-C30 (version 3.0) and EORTC QLQ-BR23 questionnaires. These tools evaluated various functional domains (e.g., physical, emotional, cognitive, social), global health status, and symptom burden (e.g., fatigue, pain, nausea).

Clinical Assessment:  A detailed history and physical examination, including systemic and local breast/axillary/supraclavicular node evaluation, were performed for each participant.

Scoring and Interpretation:  Questionnaire responses were scored as per EORTC guidelines. Scores were linearly transformed to a scale of 0–100. Higher scores on functional scales indicated better functioning, whereas higher scores on symptom scales indicated greater symptom burden or poorer quality of life.

Statistical Analysis:  Data were compiled in Microsoft Excel and analyzed using SPSS version 17.0. Descriptive statistics summarized demographic and clinical characteristics. ANOVA was used for comparing categorical variables, and a p-value <0.05 was considered statistically significant.

In this study, 101 female patients above the age of 30 years diagnosed with breast cancer were included after taking informed consent from all participants. This study was commenced after taking due permission from the Institutional Review Board of our medical college.

All participants were divided into groups depending their age, type of treatment received and staging of the disease as shown in Table 4.

Table 1: Distribution of participants according to age, treatment received & staging of the disease

 Table 2: Assessment of quality of life in breast cancer survivors by using EORTC QLQ- C30 questionnaire

** For functional scales & Global health status, patients scoring <33.3% are considered as having  „Poor quality of life‟ (QOL) and >66.7% as „Good QOL‟.

*** For symptom scales, patients scoring <33.3% are considered as having „Good QoL‟ and >66.7% as „Poor QOL‟.

Table 2 shows that majority of breast cancer survivors had a good quality of life after receiving treatment. Among the symptoms, fatigue was problematic in 7.9%, insomnia in 13.8% and appetite loss in 12.8% of patients. 87.1% of patients had an overall good quality of life as assessed by the global health status parameter.

Table 3: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-C30 questionnaire in different age groups

1. The grouping variable Age of the patient is a string, so the test for linearity cannot be

computed.

1. No variance within groups - statistics for Dyspnea QoL * Age of the patient cannot be
2. No variance within groups - statistics for Constipation QoL * Age of the patient cannot be
3. No variance within groups - statistics for Diarrhea QoL * Age of the patient cannot be

Table 6 shows that all functional scales i.e. Physical functioning (F=10.947; p=0.000), Role functioning (F=10.988; p=0.000), Emotional functioning (F=14.877; p=0.000), Cognitive functioning (F=22.447; p=0.000), Social functioning (F=8.853; p=0.000), showed statistical significance between different age groups. Among the symptom scales, only fatigue (F=16.555; p=0.000) and appetite loss (F=3.897; p=0.000) showed statistical significance. Other symptom scales were not significant between different age groups.

Table 4: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-C30 questionnaire in different treatment groups

1. The grouping variable Treatment received is a string, so the test for linearity cannot be computed.
2. No variance within groups - statistics for Dyspnea QoL * Treatment received cannot be
3. No variance within groups - statistics for Constipation QoL * Treatment received cannot be
4. No variance within groups - statistics for Diarrhea QoL * Treatment received cannot be

Table 4 shows that fatigue symptom has been a significant issue with patients receiving any type of treatment (F=3.268; p=0.042). Other symptom scales & all functional scales do not show any statistical significance in different treatment groups.

Table 5: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-C30 questionnaire in different stages of the disease

1. No variance within groups - statistics for Dyspnea QoL * Stage of the disease cannot be
2. No variance within groups - statistics for Constipation QoL * Stage of the disease cannot be
3. No variance within groups - statistics for Diarrhea QoL * Stage of the disease cannot be

Table 5 does not show any statistical significance between different functional and symptom scales in different stages of disease.

Table 6: Assessment of quality of life in breast cancer survivors by using EORTC QLQ-BR23 questionnaire

** For functional scales & Global health status, patients scoring <33.3% are considered as having

„Poor quality of life‟ (QoL) and >66.7% as „Good QoL‟.

*** For symptom scales, patients scoring <33.3% are considered as having „Good QoL‟ and >66.7% as „Poor QoL‟.

Table 6 shows that the majority of the patients (breast cancer survivors) in our study had a Good quality of life as reflected in the percentage scores of the functional and symptom scales as mentioned above.

Table 7: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-BR23 questionnaire in different age groups

1. No variance within groups - statistics for Sexual enjoyment QoL * Age of the patient cannot be computed.

Table 7 shows that body image (F=38.839; p=0.000), Sexual functioning (F=78.178; p=0.000), Future perspective (F=26.365; p=0.000), Systemic therapy side effects (F=28.633; p=0.000) and Upset by hair loss (F6.290; p=0.000) have significant differences between different age groups.

Table 8: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-BR23 questionnaire in different treatment groups

1. No variance within groups - statistics for Sexual enjoyment QoL * Treatment received cannot be computed.

Table 8 shows that body image (F=4.453; p=0.014), Sexual functioning (F=7.122; p=0.001), Future perspective (F=6.439; p=0.002) have significant differences between different treatment groups.

Table 9: One way ANOVA analysis done to compare the means of various functional & symptom scales in EORTC QLQ-BR23 questionnaire in different stages of the disease

ANOVA Table

1. No variance within groups - statistics for Sexual enjoyment QoL * Stage of the disease cannot be computed.

Table 9 shows that body image (F=3.940; p=0.023) and sexual functioning (F=5.542; p=0.005) have significant differences between different stages of disease.

Significant advancements in oncology, particularly through evidence-based medicine, have markedly improved both survival rates and quality of care for cancer patients. In recent years, quality of life (QoL) has emerged as a critical endpoint in cancer management, not only for patients but also for their families. While numerous studies have explored QoL across different treatment modalities and techniques for site-specific cancers, fewer have comprehensively examined the association between QoL and functional status throughout and following cancer treatment.

QoL is assessed using psychometric tools that quantify several domains of wellness, including physical functioning, role functioning, bodily pain, general health perceptions, vitality, social and emotional functioning, and mental health [11]. This study specifically aimed to assess changes in health-related QoL—particularly deterioration and recovery—in breast cancer patients.

A study by Bei Yan et al. in Shanghai, China, involving 1,160 breast cancer patients, used the Perceived Social Support Scale and the Functional Assessment of Cancer Therapy - Breast (FACT-B). It concluded that social support and financial aid significantly improved the QoL of breast cancer survivors [12]. In contrast, our study did not observe significant changes in QoL related to financial difficulties or social functioning. This may be attributed to the support received through the AAROGYASRI scheme, which reduced out-of-pocket expenses for treatment.

In our study, most patients demonstrated an overall good QoL. However, domains such as fatigue, body image, sexual dysfunction, sexual enjoyment, sleep disturbances, social functioning, and hair loss showed a degree of impact on QoL.

The rising number of breast cancer survivors can be attributed to earlier diagnosis, widespread screening, and the availability of multimodal treatment options. These trends have extended survivorship, highlighting the importance of monitoring patient-reported outcomes, including QoL [13].

We observed a statistically significant association between age and several QoL domains: physical, role, emotional, cognitive, and social functioning; fatigue; appetite loss; body image; sexual functioning; side effects of systemic therapy; and hair loss. These associations were particularly pronounced in patients over 50 years of age. Jeanne Mandelblatt et al. similarly reported that symptoms such as fatigue, especially in older women treated with Tamoxifen, negatively impacted QoL, increasing the risk of anxiety and depression [14].

Tina Hsu et al., in a study of 535 women with localized breast cancer, found that QoL tends to improve over time post-treatment, reaching levels comparable to age-matched non-cancer controls, with minor deficits in cognitive function and financial well-being [15]. These findings were largely consistent with our observations. However, our study duration was limited to 1.5 years post-treatment, whereas Leno Koch et al.’s 10-year longitudinal study found that QoL restrictions persisted, especially in younger survivors, potentially indicating a gap in long-term psychosocial support [16].

Fatigue emerged as a significant issue in our cohort. As per the National Comprehensive Cancer Network (NCCN), fatigue is a persistent, distressing symptom not proportional to recent activity and interferes with normal functioning [17]. The etiology of cancer-related fatigue is multifactorial, involving inflammatory cytokines, dysregulation of the hypothalamic-pituitary-adrenal axis, circadian rhythm disruptions, and muscle wasting [18,19]. The NCCN recommends routine screening for fatigue during and after cancer treatment using simple rating tools.

Management strategies for fatigue include identifying and treating reversible causes (e.g., anemia, sleep disturbances, pain), incorporating occupational therapy techniques, encouraging physical activity, and considering pharmacological interventions such as methylphenidate in select cases.

In our study, age was also significantly associated with body image concerns. Younger survivors (20–40 years) reported more dissatisfaction with their appearance, aligning with findings by Chow et al., who observed worse body image scores in younger survivors [18].

Similarly, sexual functioning scores were significantly associated with age, with older women (>60 years) reporting greater sexual dysfunction. This trend was corroborated by Ahn et al., who noted reduced sexual functioning with advancing age [20]. Our findings are also supported by a South Indian study by Dubashi et al., which reported marginally worse sexual function in the breast conservation group compared to those undergoing mastectomy [21], and a Dutch study by Bantema-Joppe et al., which found better sexual functioning among younger survivors [22].

In contrast, our study did not find a significant relationship between age and sexual enjoyment, diverging from findings by Byeong-Woo Park et al. and Judy Harrison et al., who reported lower sexual QoL among older survivors post-surgery [23].

When stratified by treatment type, only fatigue, body image, sexual functioning, and future perspective showed statistically significant differences across the three groups:

• Group 1: Modified Radical Mastectomy + Chemotherapy + Radiotherapy
• Group 2: Breast Conservation Surgery + Chemotherapy + Radiotherapy
• Group 3: Modified Radical Mastectomy + Chemotherapy

Similarly, when stratified by disease stage, body image and sexual functioning scores showed significant differences, while other functional and symptom scores did not.

These findings underscore the importance of integrating cancer control research into routine clinical practice, particularly during or shortly after treatment, to optimize survivorship care. As the population of breast cancer survivors continues to grow, emphasis must be placed on treatments that prioritize patient-reported outcomes. Survivors should be encouraged to express their experiences, which is crucial for psychological recovery and social reintegration.

It is also essential to acknowledge and support survivors in addressing body image concerns at their own pace. Social and psychological support systems must be sensitively tailored to individual needs, recognizing that post-treatment adjustment is a personal and often gradual journey.

In this study, we identified the most common long-term sequelae affecting the quality of life (QOL) among breast cancer survivors. Our analysis revealed that QOL tends to decline with increasing age. However, due to the limited number of participants aged over 60 years, we could not statistically establish a significant difference in QOL for this group compared to younger age groups. Younger women generally reported better QOL, although they experienced greater concerns related to body image, fatigue, and appetite loss. Overall, breast cancer survivors under the age of 50 demonstrated a better quality of life than their older counterparts.

Ethical Clearance: Ethical Clearance Certificate was obtained from the Institutional Ethics Committee (IEC) prior to commencement of study

Conflict of Interest: Nil - No conflict of interest

Source of funding: Self

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