An-Najah National University 

Faculty of Graduate Studies 

 

A CROSS-SECTIONAL STUDY OF SELF-

REPORTED SIDE EFFECTS OF BREAST CANCER 

TREATMENT AND THE QUALITY OF LIFE IN 

PALESTINE 

 

By 

Karin Breek 

 

Supervisors 

Prof. Sa'ed H. Zyoud 

Prof. Samah W. Al-Jabi 

 

This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of 

Master of Clinical Pharmacy, Faculty of Graduate Studies, An-Najah National University, 

Nablus - Palestine. 

2025 





III 

Dedication 

This thesis is dedicated to my beloved family, whose unwavering support and 

encouragement have been my foundation throughout this journey. To my parents, for 

their endless love, sacrifices, and belief in my dreams, and to my siblings for their 

constant motivation and understanding. 

To my friends, who have been my pillars of strength, providing me with joy and 

comfort during the challenging times of this academic endeavor. Your friendship and 

encouragement have been invaluable. 

To my educators, whose guidance, wisdom, and knowledge have shaped my academic 

and professional growth. I am profoundly grateful for your mentorship and the 

inspiration you have provided me. 

To my colleagues, for the camaraderie and shared experiences that have enriched my 

learning and made this journey memorable. Your collaboration and support have been 

crucial in achieving this milestone. 

Thank you all for your unwavering support and for believing in me. This achievement is 

as much yours as it is mine. 

Karin Breek 

 

 

 

 

 

 

 

 



IV 

Acknowledgement 

I would like to express my deepest gratitude to all those who have contributed to the 

completion of this thesis. 

First and foremost, I am profoundly grateful to my thesis advisor, Prof. Dr. Sa'ed 

Zyoud, and Prof. Samah Al-Jabi for their unwavering support, invaluable guidance, and 

insightful feedback throughout this research journey. Their expertise and 

encouragement have been instrumental in shaping this work. 

I extend my sincere appreciation to my committee members for their thoughtful 

suggestions, constructive criticism, and generous assistance. 

I am deeply indebted to my family, whose unconditional love, encouragement, and 

sacrifices have been my greatest source of strength. To my parents, for their endless 

support and belief in my abilities, and to my siblings for their constant motivation and 

understanding. 

I am also thankful to my friends, who have stood by me through thick and thin, 

providing me with emotional support and encouragement. Your friendship has been a 

source of comfort and joy during this challenging journey. 

My heartfelt thanks go to my colleagues and fellow students for their camaraderie and 

collaborative spirit. Your support and shared experiences have made this journey 

enriching and memorable. 

I would like to acknowledge the support of An-Najah National University and its 

faculty for providing the necessary resources and a conducive environment for research. 

Special thanks to An-Najah National University Hospital and Al-Watani Hospital for 

their assistance and support. 

Lastly, I am grateful to all the participants of my study, without whom this research 

would not have been possible. Your willingness to share your experiences has been 

invaluable to this work. 

Thank you all for your invaluable contributions to this thesis. 

Karin Breek 



V 

Declaration 

I, the undersigned, declare that I submitted the thesis entitled: 

A CROSS-SECTIONAL STUDY OF SELF-REPORTED SIDE EFFECTS OF 

BREAST CANCER TREATMENT AND THE QUALITY OF LIFE IN 

PALESTINE  

I declare that the work provided in this thesis, unless otherwise referenced, is the 

researcher’s own work, and has not been submitted elsewhere for any other degree or 

qualification. 

 

Karin Breek Student's Name: 

ابريق كارين  Signature: 

16/01/2025 Date: 

 

 



VI 

List of Contents 

Dedication ....................................................................................................................... III 

Acknowledgement .......................................................................................................... IV 

Declaration ....................................................................................................................... V 

List of Contents ............................................................................................................... VI 

List of Tables .................................................................................................................. IX 

List of Figures .................................................................................................................. X 

List of Appendices .......................................................................................................... XI 

Abstract .......................................................................................................................... XII 

Chapter One: Introduction and Theoretical Background ................................................ 14 

1.1 A brief review of the literature ................................................................................ 16 

1.1.1 Breast cancer ......................................................................................................... 16 

1.1.2 Mammography ...................................................................................................... 17 

1.1.3 Staging of breast cancer ........................................................................................ 17 

1.1.4 Treatments for breast cancer ................................................................................. 18 

1.1.5 Side effects of breast cancer therapy ..................................................................... 20 

1.1.6 Breast cancer in Palestine ...................................................................................... 21 

1.1.7 Quality of life ........................................................................................................ 22 

1.2 Problem statement ................................................................................................... 23 

1.3 Research questions ................................................................................................... 24 

1.4 Objectives ................................................................................................................ 24 

1.4.1 General objectives ................................................................................................. 24 

1.4.2 Specific objectives ................................................................................................. 24 

1.5 Importance of the study ........................................................................................... 25 

Chapter Two: Methods ................................................................................................... 26 

2.1 Study design ............................................................................................................. 26 

2.2 Study setting ............................................................................................................ 26 

2.3 Population ................................................................................................................ 26 

2.4 Sample size .............................................................................................................. 26 



VII 

2.5 Sampling procedure ................................................................................................. 27 

2.5.1 Inclusion criteria .................................................................................................... 27 

2.5.2 Exclusion criteria ................................................................................................... 27 

2.6 Data collection and study tools ................................................................................ 27 

2.7 Data and statistical analysis ..................................................................................... 28 

2.8 Ethical approval ....................................................................................................... 28 

Chapter Three: Results .................................................................................................... 29 

3.1 Characteristics of the participants ............................................................................ 29 

3.2 Treatment modalities received by the patients ........................................................ 31 

3.3 Adverse effects of cancer treatment ........................................................................ 31 

3.3.1 Pain ........................................................................................................................ 31 

3.3.2 Gastrointestinal health issues ................................................................................ 32 

3.3.3 Skin and hair health issues .................................................................................... 33 

3.3.4 Sleep and mental health issues .............................................................................. 34 

3.3.5 Respiratory/mouth and throat health issues ........................................................... 35 

3.3.6 Hematologic health issues ..................................................................................... 35 

3.3.7 Genitourinary health issues ................................................................................... 36 

3.3.8 Sensory health issues ............................................................................................. 37 

3.3.9 General health issues ............................................................................................. 37 

3.4 Answers of the patients to the WHOQOL-BREF questionnaire items ................... 38 

3.5 Scores of the different domains of the WHOQOL-BREF questionnaire ................ 40 

3.6 Associations between the demographic and disease characteristics of patients and 

their scores on the different domains of the WHOQOL-BREF questionnaire ...... 40 

3.7 Discussion ................................................................................................................ 51 

3.8 Interpretation and discussion of the main findings .................................................. 51 

3.8.1 Demographics and clinical characteristics ............................................................ 51 

3.9 Treatment modalities and adverse effects ................................................................ 52 

3.10 Patient quality of life ............................................................................................. 53 

3.11 Predictors of quality of life .................................................................................... 53 



VIII 

3.11.1 Impact of treatment on quality of life ................................................................. 54 

3.11.2 Adverse effects and quality of life ...................................................................... 54 

3.12 Summary of the main findings .............................................................................. 54 

3.13 Limitations of the study ......................................................................................... 55 

3.14 Conclusion ............................................................................................................. 55 

3.15 Implications for practice and recommendations ................................................... 56 

List of abbreviations ....................................................................................................... 57 

References ....................................................................................................................... 58 

Appendices ...................................................................................................................... 64 

 ب ............................................................................................................................... الملخص 

 



IX 

List of Tables 

Table 1: Demographic and disease characteristics of the patients .................................. 30 

Table 2: Distribution of answers of the patients to the WHOQOL-BREF questionnaire 

items .................................................................................................................. 39 

Table 3: Predictors of lower scores in the overall quality of life and general health 

scores as measured using the WHOQOL-BREF questionnaire ....................... 43 

Table 4: Predictors of lower physical health scores ....................................................... 45 

Table 5: Predictors of lower psychological health scores ............................................... 46 

Table 6: Predictors of lower social relationship scores .................................................. 48 

Table 7: Predictors of lower environment scores ........................................................... 49 

Table 8: Predictors of lower overall scores .................................................................... 50 

 

  

 



X 

List of Figures 

Figure 1: Treatment modalities received by the patients ................................................ 31 

Figure 2: Prevalence of pain reported by the patients .................................................... 32 

Figure 3: Prevalence of gastrointestinal health issues among patients ........................... 33 

Figure 4: Prevalence of skin and hair health issues ........................................................ 34 

Figure 5: Prevalence of sleep and mental health issues .................................................. 34 

Figure 6: Prevalence of respiratory/mouth and throat health issues ............................... 35 

Figure 7: Prevalence of hematologic health issues among patients ................................ 36 

Figure 8: Prevalence of genitourinary health issues among patients .............................. 36 

Figure 9: Prevalence of sensory health issues among patients ....................................... 37 

Figure 10: Prevalence of general health issues among patients ...................................... 38 

 



XI 

List of Appendices  

 

Appendix A: Data collection form .................................................................................. 64 

Appendix B: Institutional Review Board Approval ....................................................... 70 

Appendix C: Scores of the patients in the different domains of the WHOQOL-BREF 

questionnaire .............................................................................................. 71 

Appendix D: Association between the demographic and disease characteristics of the 

patients and their scores on the different domains of the WHOQOL-BREF 

questionnaire .............................................................................................. 72 

 

 

 



XII 

A CROSS-SECTIONAL STUDY OF SELF-REPORTED SIDE 

EFFECTS OF BREAST CANCER TREATMENT AND THE 

QUALITY OF LIFE IN PALESTINE 

By 

Karin Breek 

Supervisors 

Dr. Sa'ed Zyoud 

Dr. Samah Al-Jabi 

Abstract 

Background: Breast cancer is the most common cancer among women in terms of 

incidence. This study aimed to determine the side effects of breast cancer treatment 

reported by Palestinians with breast cancer and their quality of life. 

Methods: This study was a cross-sectional questionnaire-based survey. The study was 

undertaken in Nablus. The data collection instrument was divided into two distinctive 

sections. Part (A) collected data covering sex, age at diagnosis, clinical symptoms, 

complications, treatment measures, and side effects of the treatments. While part (B) of 

the questionnaire involved the quality-of-life assessment tool, the current study 

employed the WHOQOL-BREF (Arabic version) as an assessment tool. 

Results: A total of 258 patients with breast cancer participated in this study. In addition 

to breast cancer, 207 (80.2%) patients had one or more comorbid conditions. Of the 

patients, 153 (59.3%) were diagnosed less than 3 years ago. With respect to disease 

stage, 147 (57%) patients were in Stage I, 51 (19.8%) patients were in Stage II, 54 

(20.9%) patients were in Stage III, and 6 (2.3%) patients were in Stage IV. Among the 

patients, 207 (80.2%) received chemotherapy, 159 (61.6%) underwent lumpectomy, 156 

(60.5%) received radiotherapy, and 102 (39.5%) underwent mastectomy. When 

screened for the adverse effects of breast cancer treatments, the patients reported 

adverse effects and health issues that were categorized as follows: pain, gastrointestinal, 

skin and hair, health issues; pain, sleep and mental health, and respiratory/mouth and 

throat, hematologic, genitourinary, sensory, and general health issues. Multiple linear 



XIII 

regression showed that the overall scores were negatively associated with having 

comorbidities, having advanced-stage breast cancer, receiving mastectomy, and 

experiencing headaches, vomiting, depression, anxiety, mood swings, mouth and throat 

sores (mucositis), fever, and insomnia. 

Conclusions:  The findings of this study highlighted the heavy burden of disease and 

therapy-related adverse effects on the quality of life of patients with breast cancer who 

received treatment in Palestine. A multidisciplinary holistic care plan for breast cancer 

patients who integrates physical and mental health support is urgently needed to 

improve the quality of life of these patients. 

Keywords: Breast cancer, Women’s health, Treatment, Adverse effects, Quality of life 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



14 

Chapter One 

Introduction and Theoretical Background 

Breast cancer is the most common cancer among women in terms of incidence (Bray et 

al., 2018). Early detection is still linked to a better prognosis, leading to a greater 

emphasis on timely and enhanced screening measures. More data on the incidence and 

death of almost all malignancies, including breast cancer, are currently available. The 

incidence of cancer and the number of cancer-related fatalities are quickly increasing 

(Porter, 2009). 

Although several causes are being studied to explain these patterns and the disparities in 

breast cancer incidence rates between groups, there is still no consensus. BRCA1 and 

BRCA2 mutations have been studied for a long time and are known to be risk factors 

for breast cancer (Winters, Martin, Murphy, & Shokar, 2017). Changes in menstruation 

(early menarche age and delayed menopause), reproduction (late age at first birth), 

hormonal and alcohol consumption, and obesity are risk factors. On the other hand, both 

breastfeeding and increased physical activity are preventive factors against breast 

cancer. Individuals traveling from low-incidence locations to high-incidence locations 

eventually report a high incidence, indicating that environmental, nutritional, and other 

variables play a role in breast cancer risk (Ziegler et al., 1993). 

Breast cancer is the most common cancer in the United States and worldwide. It is 

ranked second in the United States but first internationally in terms of deaths. The 

prognosis is clearly the best when a breast cancer diagnosis is made early. A 

personalized approach to cancer screening has recently been discussed in the era of 

personalized medicine in an attempt to improve breast cancer diagnosis and early 

detection for better prognosis (Narod, 2018); however, there are challenges associated 

with personalized approaches when dealing with large populations. 

Although progress has been made in the early identification of breast cancer, which has 

resulted in better therapy and a better prognosis, late-stage diagnosis remains a problem, 

and more has to be done for these people. 

Cytoreductive surgery, radiation therapy, targeted endocrine/molecular therapy, and 

chemotherapy are therapeutic techniques used to treat breast cancer (Geay, 2013). 



15 

Because of the heterogeneity of the disease, the treatment strategy necessitates justified 

therapy in each instance on the basis of the characterization and stage of the disease. 

Traditional locoregional treatment techniques include radical mastectomy and modified 

radical mastectomy, which were later phased out in favor of breast-conserving surgery 

with breast radiotherapy. Neoadjuvant (preoperative) chemotherapy for locally 

advanced and operable breast cancer has undergone significant advancements, with 

significant implications for locoregional care. For the poor-prognosis group, systemic 

chemotherapy at the time of distant metastasis recurrence substantially increased 

disease-free survival and overall survival (Aebi et al., 2012). 

Cancer is becoming a growing public health problem for Palestinians in the West Bank 

and Gaza. It is the second leading cause of death in the United States. In the West Bank, 

2189 new cases were recorded in 2013. (51% females, 49% males). Breast cancer is the 

most prevalent cancer among women in the West Bank and Gaza, whereas lung cancer 

is the most common disease among males. Leukemia is the most common cancer 

among children under the age of 15. Cancer is usually discovered in its later stages; at 

least 60% of cancer cases are discovered in Stages III or IV. The late diagnosis was 

exacerbated by culture, limited finances, and a lack of access to medical services. 

(Ministry of Health, 2019). In terms of diagnosis and treatment, four hospitals in the 

West Bank and three in Gaza provide cancer care, whereas one facility in the West 

Bank specializes in providing diagnostic services for breast and gynecological 

malignancies. Most referrals are made to Israeli, Jordanian, and Egyptian hospitals; 

however, referrals to Jordan and Egypt are steadily declining. Isotope scans such as 

PET-CT are not accessible from the West Bank or Gaza. Thus, all patients are sent to 

Israeli hospitals. Cancer care in Palestinian hospitals is increasing with time; however, 

palliative care, targeted therapy, bone marrow transplantation, and tailored therapy 

remain inadequate. A shortage of specialist physicians and medications, chemotherapy, 

and radiation treatment availability must be addressed (Abu Farha, Khatib, Salameh, & 

Zyoud, 2017; Kharroubi & Abu Seir, 2016). 

Maintaining or regaining a high quality of life (QoL) and the capacity to perform daily 

duties successfully after cancer therapy are important. During the previous decade, the 

quality of life of breast cancer patients improved (Schmidt, Wiskemann, & Steindorf, 

2018). Physical exercise and psychological therapies were beneficial in enhancing the 



16 

quality of life in this cohort. However, the care of symptoms such as pain and 

lymphedema and concerns such as anxiety, sexual function, particularly in young 

patients, and future prospects are all themes that should be explored further. 

Furthermore, according to this overview, methodological challenges in evaluating the 

quality of life of breast cancer patients have substantially improved, but there is still a 

long way to go in understanding what matters most to patients (Mokhatri-Hesari & 

Montazeri, 2020Finck, Barradas, Zenger, & Hinz, 2018). This is why this study aimed 

to investigate this population in Palestine and determine their quality of life. 

1.1 A brief review of the literature 

This research objective, strategy, and methodological approach were established on the 

basis of a thorough understanding and revision of the available literature. This section 

examines published research and published data directly related to the study objectives. 

This section covers breast cancer, breast cancer therapy, breast cancer in Palestine, and 

overall quality of life. 

1.1.1 Breast cancer 

Among women worldwide, breast cancer is the most prevalent form of cancer, and a 

significant proportion (70–80%) of patients with early-stage, nonmetastatic disease may 

achieve a complete cure. Advanced breast cancer with distant organ metastases is now 

incurable with existing treatments. Breast cancer is a complex disease at the molecular 

level characterized by the activation of human epidermal growth factor receptor 2 

(HER2, encoded by ERBB2), the activation of hormone receptors (estrogen receptor 

and progesterone receptor), and the presence of BRCA mutations, which are the most 

prevalent molecular characteristics. The choice of treatment options is contingent upon 

the specific molecular subtype. Among women, breast cancer is the most prevalent form 

of cancer and ranks as the second highest cause of death connected to cancer. The 

literature indicates that prior and ongoing research has substantially improved the 

clinical outcomes of patients with breast cancer (Fahad Ullah, 2019; Harbeck et al., 

2019; Waks & Winer, 2019). 

 



17 

1.1.2 Mammography 

Currently, mammography is the most commonly used breast cancer screening tool. 

Because this survey is reasonably straightforward, economical, safe, and inexpensive, 

all of the women to whom it is advised may participate. Mammography is a procedure 

that involves taking numerous X-ray images of the mammary glands (breasts). 

Mammography is carried out in a dedicated room with mammography equipment. It is 

an X-ray machine with a different shape. Therefore, undressing from the waist up prior 

to mammography is necessary. Each breast was photographed separately. The 

procedure might take up to 20 minutes (Fahad Ullah, 2019). 

1.1.3 Staging of breast cancer 

The characteristics of breast cancer, such as its dimensions and the presence of hormone 

receptors, determine the stage of the illness. The cancer stage assists clinicians in 

assessing patient prognosis, optimal treatment choices, and the feasibility of clinical 

trials. 

The process of evaluating breast cancer involves the examination of tissue samples 

taken following a biopsy via histologic analysis. When seen under a microscope, tumor 

grade provides information about the abnormal appearance of tumor cells and tissue. 

The TNM classification is used for the purpose of staging tumors, taking into account 

factors such as tumor size, lymph node involvement, and the presence of metastasis. 

Since clinical examination and imaging methods are not very effective in detecting 

nodal involvement, staging is best performed after surgery, when regional lymph nodes 

may be evaluated. Furthermore, if individuals have palpably abnormal axillary nodes, 

preoperative ultrasonography-guided fine-needle aspiration or core biopsy may be 

conducted. 

If the biopsy is positive, the axillary lymph nodes are often removed during the final 

surgical procedure. Nevertheless, if neoadjuvant chemotherapy effectively decreases the 

node status from N1 to N0, it may be possible to perform sentinel lymph node biopsy. 

The anatomic staging methodology categorizes patients on the basis of the structure of 

the tumor and is used in regions where biomarkers are not consistently accessible 

(Bevers et al., 2018). 



18 

Stages 0 to IV are used to classify noninvasive cancers that are confined to their original 

site. Stage 0 refers to noninvasive cancers that have spread beyond the breast to other 

areas of the body, whereas stage IV refers to invasive cancers that have spread beyond 

the breast to other areas of the body (Breastcancer.org, 2021). 

1.1.4 Treatments for breast cancer 

Several maneuvers, such as surgery, radiotherapy, and pharmacotherapy, are used to 

treat breast cancer. The focus of this part is pharmacotherapy. 

Systemic therapy refers to the administration of medications with the purpose of 

eliminating cancer cells (Gonzalez-Angulo, Morales-Vasquez, & Hortobagyi, 2007). 

Medications have the ability to distribute themselves throughout the whole body, 

allowing them to reach cancer cells in all areas. 

There are several instances of systemic therapy used for breast cancer. The treatment 

options for cancer include chemotherapy, hormonal therapy, targeted therapy, and 

immunotherapy (Waks & Winer, 2019). 

Systemic treatment may be delivered either alone or in conjunction with other systemic 

therapies. In addition, they might be used in conjunction with surgical procedures and 

radiation treatment. 

Chemotherapy employs pharmaceutical agents to eradicate cancer cells by inhibiting 

their growth, division, and proliferation. Neoadjuvant chemotherapy is administered 

before surgery to reduce the size of a large tumor, facilitate the surgical procedure, or 

lessen the likelihood of the tumor returning. Another alternative is adjuvant 

chemotherapy, which is given after surgery to reduce the likelihood of recurrence 

(Hassan, Ansari, Spooner, & Hussain, 2010). 

A chemotherapy regimen, sometimes referred to as a schedule, consists of a collection 

of medications given in a certain number of cycles within a predetermined time frame. 

Chemotherapy may be delivered on several schedules on the basis of the most effective 

approach identified in clinical research for that specific treatment plan. For example, it 

might be given on a weekly basis, biweekly, triweekly, or even quadruple weekly. 

There are many categories: docetaxel, paclitaxel, doxorubicin, epirubicin, pegylated 

liposomal doxorubicin, capecitabine, carboplatin, cisplatin, cyclophosphamide, eribulin, 



19 

fluorouracil (5-FU), gemcitabine (Gemzar®), ixabepilone, methotrexate, paclitaxel, and 

vinorelbine (Hassan et al., 2010). 

Additionally, the majority of tumors that have positive results for estrogen or 

progesterone receptors exhibit a favorable response to hormone treatment. Breast cancer 

hormone therapy and menopausal hormone therapy (MHT) are distinct treatments. 

MHT, an acronym for hormone replacement treatment or postmenopausal hormone 

therapy (HRT), is an alternative name for MHT. Hormone therapies for breast cancer 

are often referred to as "antihormone" or "antiestrogen" therapies. They may either 

inhibit the function of hormones or decrease hormone levels in the body. Hormonal 

treatment consists of two main types of medications, tamoxifen and aromatase 

inhibitors, which include anastrozole, exemestane, and letrozole (Drãgãnescu & 

Carmocan, 2017). 

Moreover, targeted treatment specifically targets genes, proteins, or the tissue 

environment that play a role in the development and survival of cancer (Mohamed, 

Krajewski, Cakar, & Ma, 2013). These medicines are far more focused than 

chemotherapy and function in a distinct manner. This treatment inhibits the proliferation 

and metastasis of cancer cells while minimizing damage to healthy cells. Not all 

malignancies have the same objectives. Physicians may conduct diagnostic 

examinations to identify the genetic material, proteins, and other constituents present in 

the tumor to determine the optimal course of therapy. Moreover, ongoing research 

inquiries are continuing to reveal new insights into distinct molecular targets and 

innovative treatments. 

Initially, hormonal therapies were approved as pioneering types of targeted therapy for 

breast cancer. For the purpose of managing HER2-positive breast cancer, therapeutic 

interventions specifically targeting HER2 were subsequently approved. There are 

several medications with specific treatment plans and objectives, including trastuzumab, 

pertuzumab, trastuzumab, hyaluronidase, neratinib, adrastuzumab emtansine, olaparib, 

alpelisib, lapatinib, and tucatinib (Den Hollander, Savage, & Brown, 2013). 

 



20 

1.1.5 Side effects of breast cancer therapy 

The adverse effects of chemotherapy may differ on the basis of factors such as the 

individual patient, the specific drug(s) administered, whether additional medications 

were taken in conjunction with chemotherapy and the timing and amount of the doses. 

The possible side effects of the treatment include fatigue, increased susceptibility to 

infections, nausea and vomiting, hair loss, reduced appetite, diarrhea, constipation, 

numbness, tingling, pain, premature menopause, weight gain, and chemo-brain or 

cognitive impairment (Moo, Sanford, Dang, & Morrow, 2018). These undesirable 

consequences are often prevented or managed well by the use of supportive medications 

throughout therapy, and patients often cease treatment after it is completed. Physicians 

should be asked about the use of cold cap therapies for ameliorating hair loss. In rare 

instances, long-term complications may arise, such as cardiac impairment, irreversible 

neuropathy, or the development of secondary malignancies such as leukemia or 

lymphoma. While individual experiences may vary, a significant number of individuals 

undergoing chemotherapy report feeling healthy and actively fulfilling their familial, 

occupational, and physical exercise responsibilities during the treatment process (Waks 

& Winer, 2019). 

The possible side effects of aromatase inhibitors include muscle and joint soreness, hot 

flashes, vaginal dryness, increased susceptibility to osteoporosis and fractures, and, in 

rare instances, increased cholesterol levels and hair loss (Garreau, DeLaMelena, Walts, 

Karamlou, & Johnson, 2006). 

Women diagnosed with primary invasive breast cancer receive both local and systemic 

treatment. Local interventions, including surgical procedures and radiation treatment, 

are used to reduce the likelihood of cancer recurrence in the breast, chest wall, and 

adjacent lymph nodes. These localized treatments have the potential to inhibit the 

metastasis of cancer and reduce mortality rates associated with breast cancer in certain 

situations. Cytotoxic chemotherapy and hormone therapy are used as systemic 

treatments after local treatment to prevent the spread of cancer throughout the body and 

reduce the overall risk of death from breast cancer (Partridge, Burstein, & Winer, 2001). 

Recent guidelines from the National Institutes of Health Consensus Conference, the 

National Comprehensive Cancer Center Network, and other groups recommend the use 



21 

of adjuvant chemotherapy, tamoxifen, or both for women with invasive breast tumors 

larger than 1 cm in diameter, regardless of the involvement of axillary lymph nodes. 

Shapiro and Rocht reviewed the side effects of adjuvant therapy in breast cancer; their 

findings are summarized below (Shapiro & Recht, 2001): 

− Myelosuppression: Approximately 10--14 days after each cycle of adjuvant 

chemotherapy, a small-to-moderate decrease in the white-cell count occurs. 

− Nausea and vomiting: Mild to moderate nausea and vomiting occur, but only 

approximately 5% of women experience severe symptoms. 

− Neurotoxicity: Taxanes cause sensory and motor peripheral neuropathy. The severity 

of neuropathy is typically mild to severe, and it is dependent on the individual 

dosage, cumulative dose, and delivery schedule. 

− Weight gain: Most women with breast cancer who are given cyclophosphamide, 

methotrexate, or fluorouracil gain weight as a result of their treatment. The typical 

weight increase is between 2 and 6 kg. 

− Ovarian failure: Six months of treatment with cyclophosphamide, methotrexate, and 

fluorouracil leads to permanent ovarian failure in 70% of women over 40 years old 

and 40% of women younger than 40 years old. 

− Cardiac toxicity: Doxorubicin causes cardiomyopathy by directly damaging the 

myocardium. 

− Second cancer: There is minimal evidence that receiving cyclophosphamide, 

methotrexate, or fluorouracil increases the chance of developing second cancer. 

− Fatigue and quality of life: Most people are tired, and roughly two-thirds of them 

describe their fatigue as moderate or severe. Anemia, vasomotor symptoms that 

induce sleep disturbances, and sadness might all be contributing factors. 

1.1.6 Breast cancer in Palestine 

According to the latest Health Annual Report (2020), breast cancer is the most common 

cancer in the country, with 526 cases reported in 2020. A total of 32.0% of all cancer 

cases are female, with an incidence rate of 38.4 per 100,000 females (Palestinian 

Ministry of Health, 2020). 

Among Palestinian women, breast cancer was the first type of cancer documented and 

accounted for 28.9% of all recorded cancer cases. Moreover, breast cancer is the 



22 

primary factor leading to death in women, with colon cancer being the subsequent cause 

(Ministry of Health, Palestine, 2017). 

The Palestine Health Annual Report 2020 includes statistics on health sector themes 

such as government expenditures and programs, health facility utilization, health 

infrastructure, and general demographic and population data and health indicators. In 

addition, infectious disorders, malignancies, and mortality are also covered. 

1.1.7 Quality of life 

Several demographic and clinical characteristics have been found to influence the 

quality of life of breast cancer patients. 

HRQoL (health-related quality of life) is a subset of QoL focused on physiological 

elements of well-being, such as the absence of disease and sickness. HRQoL is a 

multidimensional concept used to monitor public health statistics. HRQoL is linked to 

certain variables that make it more specific than generic QoL. For example, health risks 

and conditions, physical functioning, social support, and socioeconomic position 

correlate with HRQoL at the individual level. For public health researchers, HRQoL has 

been a crucial idea since recording these data allows for broad patterns in disease; 

mortality and morbidity may be anticipated on the basis of the prevalence of this notion 

of well-being (Khanna & Tsevat, 2007). 

These findings suggest that there is a bidirectional association between measures of 

QoL. QoL appears to be linked to better health outcomes, and greater levels of QoL 

tend to be linked to better health outcomes. While the physiological part of well-being is 

linked to HRQoL, it is also linked to social and psychological well-being. According to 

researchers, improvements in HRQoL are also linked to considerably improved 

psychological and social well-being. As a result, it appears that focusing on HRQoL has 

benefits that extend beyond physical well-being. While all parts of QoL are subjective 

owing to personal criteria that define well-being, these individual ideas of well-being 

and QoL are crucial intervention outcome variables because of their impact on 

numerous dimensions of health. As a result, it is critical to recognize that health-related 

QoL is important for people with cancer in general and women with breast cancer in 

particular. 



23 

In Arab and surrounding nations, recent interest in quality of life (QOL) as a medical 

outcome metric has sparked research in chronic medical and general populations. 

Therefore, it is critical to adopt psychometrically sound and cross-culturally reliable 

evaluation tools to compare findings across nations to develop this interest. 

The World Health Organization Quality of Life (WHOQOL-BREF), a shorter version 

of the widely used QOL assessment instrument that comprises 26 items in the domains 

of physical health, psychological health, social relations ships, and the environment 

The WHOQOL-BREF was created concurrently in many cultures, avoiding the 

traditional debate over the difficulty of using a questionnaire written in one culture in a 

different culture. In addition, because the items are phrased in culture-neutral 

vocabulary, the instrument has high potential for simple cross-cultural use. 

Additionally, the elements contain highly valued life context characteristics that are not 

often associated with health. As a result, it is a general tool for assessing health-related 

quality of life (HRQOL), as well as social, environmental, and subjective well-being 

concerns. The WHOQOL-BREF Arabic translation has been demonstrated to have 

considerable structural integrity. In addition, this translated version has been validated 

and shown to have high reliability (Ohaeri & Awadalla, 2009). 

The current study uses this tool to measure the quality of life of breast cancer patients in 

Palestine. 

1.2 Problem statement 

Breast cancer is becoming more prevalent in Palestine, and the treatment for this disease 

is obnoxious. When treated either nonpharmacologically (surgery or radiation) or 

pharmacologically (chemotherapy, hormonal, targeted), patients are prone to side 

effects. Reporting patients' side effects is crucial to improving their quality of life. 

Hence, the current study explores the measures undertaken to report, dig, and seek to 

determine what patients are experiencing. This will improve pharmaceutical care and 

push patients toward an optimum quality of life.\ 

 



24 

1.3 Research questions 

− What were the side effects that breast cancer patients experienced because of the 

treatment? 

− How did the patient interact with the side effects that emerged because of the 

treatment? 

− How do these side effects affect patients’ quality of life? 

− What was the current quality of life of the patient? 

− What was the relationship between quality of life and the side effects that the patients 

experienced? 

1.4 Objectives 

1.4.1 General objectives 

This study aimed to determine the side effects of breast cancer treatment reported by 

Palestinians with breast cancer and their quality of life. 

1.4.2 Specific objectives 

− To determine the side effects that breast cancer patients experience because of 

treatment. 

− Understanding how the patient interacts with the side effects emerged because of the 

treatment. 

− To explore the effects of these side effects on patients’ quality of life. 

− To evaluate the current quality of life of the patients. 

− To assess the relationship between quality of life and side effects that patients 

experience because of breast cancer treatment. 

 

 

 

 

 



25 

1.5 Importance of the study 

Pharmaceutical care, specifically clinical care, involves providing the correct treatment 

of the disease and managing the side effects that might emerge from this treatment by 

going to the next step to improve quality of life. 

This study provides knowledge to healthcare professionals about the side effects that 

patients experience because of breast cancer treatment. Additionally, clinicians should 

understand the quality of life of breast cancer patients in Palestine. Understanding this 

would be helpful for improving the quality of healthcare provided to patients. To 

improve quality of life, it is mandatory to understand what the patient is currently 

experiencing by making him report the side effects the patients were experiencing and 

their impact on their daily life. 

 



26 

Chapter Two 

Methods 

2.1 Study design 

This study was a cross-sectional questionnaire-based survey. 

2.2 Study setting 

The study was undertaken in Nablus, a major city in the Northern West Bank, Palestine. 

Two hospitals were involved, namely, Al-Watani Hospital and An-Najah National 

University Hospital. These two hospitals are the only hospitals that deal with cancer 

patients in Nablus, which is why they were chosen among all hospitals in the city. 

Additionally, these hospitals serve as referral hospitals, as they accept patients from 

other cities in the country. 

2.3 Population 

Females with breast cancer disease in Nablus. 

2.4 Sample size 

According to the latest Health Annual Report (2020), breast cancer is the most common 

cancer in the country, with 526 cases reported in 2020 in the West Bank.  

Raosoft® is an online tool used freely to calculate the sample size for surveys (available 

at: http://www.raosoft.com/samplesize.html). Raosoft® was used to calculate the sample 

size for this study. 

By applying 5% as a margin of error, a 95% confidence level, and a population size of 

526 women with breast cancer in the West Bank, the resulting sample size was 223 

women.  

To yield a representative sample for a known proportion, the equation by Cochran 

(1963:75) shown below was recommended. Z is a constant for the determined 

confidence level, P is the expected prevalence or proportion, and d is the margin of 

error. 

 

1 



27 

The proportion reported by the annual health report is 16.5%; by applying the equation 

to the study design, Z equals 1.96, P is 16.5%, and d is 5%. Therefore, the result would 

be 212, which was near that calculated by Raosoft. 

However, to compensate for any risk of missing data or withdrawal of patients, the 

determined sample size was 250 patients. In this study, all women were recruited from 

Nablus governorate.  

2.5 Sampling procedure 

The current study included patients with breast cancer who received medical treatment 

for their condition. In addition, patients from Najah National University Hospital and 

Al-Watani Hospital were included in the study. 

Patients were recruited from the oncology clinic on the basis of the inclusion criteria, 

asked to provide written informed consent, and then asked to fill out the questionnaire. 

2.5.1 Inclusion criteria 

− Female breast cancer patients 

− Above 18 years of age 

− Received treatment for breast cancer (chemotherapy, hormonal, or targeted) 

− Agree to participate in the study and cooperate 

2.5.2 Exclusion criteria 

− Pregnant 

− Patients with mental illness 

2.6 Data collection and study tools 

Given the significance of data standardization for a study’s internal validity, data 

collection was standardized by employing a data collection form. 

The data collection instrument was divided into two distinctive sections. Part (A) 

collected data covering age at diagnosis, clinical symptoms, complications, treatment 

measures, and side effects of the treatments. 

While part (B) of the questionnaire involved the quality-of-life assessment tool, the 

current study employed the WHOQOL-BREF (Arabic version) as an assessment tool. 



28 

The World Health Organization Quality of Life (WHOQOL-BREF) is a shorter version 

of the WHO-QOL (100-item) assessment instrument that comprises 26 items in the 

domains of physical health, psychological health, social relationships, and the 

environment. Data collected via the WHOQOL-BREF need to be calculated to 

determine QOL. The table below presents how to calculate the scores. 

2.7 Data and statistical analysis 

The scores of the items in each domain of the WHOQOL-BREF questionnaire were 

summed. After that, the scores in each domain were transformed to 0--100 via the 

following equation: 

         2 

The term "actual raw score" refers to the values obtained by adding up certain 

quantities. The "lowest possible raw score" represents the smallest value that can be 

obtained by adding up these quantities (which would be 4 for all aspects). The "possible 

raw score range" is the difference between the highest possible raw score and the lowest 

possible raw score (which would be 16 for all aspects: 20 minus 4). 

The data were entered and analyzed with the IBM Statistical Package for Social 

Sciences (IBM SPSS) version 21. Data are expressed as the means ± SDs for continuous 

variables and as frequencies and percentages for categorical variables. Differences in 

the means of the transformed scores of each domain between categories were tested via 

t tests or analysis of variance (ANOVA) followed by Tukey’s post hoc tests. A p value 

of < 0.05 was considered statistically significant. 

2.8 Ethical approval 

All aspects of the study protocol, including access to and use of patient clinical 

information, were authorized by the Institutional Review Boards (IRBs) and local health 

authorities. 

We confirm that the collected data were used for clinical research only. The information 

was confidential and was not used for any purpose other than this study. Written 

informed constant was given by participants that confirmed data privacy, and all the 

data were kept safe and used only for research purposes. The questionnaire could be 

completed in 15-20 min.  

 



29 

Chapter Three 

Results 

3.1 Characteristics of the participants 

A total of 258 patients with breast cancer participated in this study. The characteristics 

of the patients are described in Table 1. The demographic and clinical characteristics of 

the patients are displayed in this table. When the age was categorized around the mean, 

135 (52.3%) patients were younger than 50 years, and 123 (47.7%) were 50 years or 

older. Blood group A was the most common blood group among the patients, followed 

by blood groups O, B, and AB. Among the patients, 99 (38.4%) had a normal weight, 

and 159 (61.6%) were either overweight or obese. The majority (66.3%) of the patients 

were currently married, and 33.7% were never married. With respect to educational 

status, 156 (60.5%) patients had a school education, and 102 (39.5%) had a university 

education. The vast majority of the patients (93%) were nonsmokers, and only 7% were 

either current smokers or ex-smokers. When asked about their family history, 72 

(27.9%) of the patients had a family history of cancer. 

In addition to patients with breast cancer, the majority (80.2%) of the patients had one 

or more comorbid conditions. More than half (59.3%) of the patients were diagnosed 

less than 3 years ago. With respect to disease stage, 147 (57%) patients were in Stage I, 

51 (19.8%) patients were in Stage II, 54 (20.9%) patients were in Stage III, and 6 

(2.3%) patients were in Stage IV. The detailed characteristics of the patients are shown 

in Table 1. 



30 

Table 1  

Demographic and disease characteristics of the patients 

Variable n (%) 

Demographics  

Age (years)  

< 50 135 (52.3) 

≥ 50 123 (47.7) 

BMI  

Normal weight 99 (38.4) 

Overweight/obese 159 (61.6) 

Marital status  

Never married 87 (33.7) 

Ever married (married/divorced/widowed) 171 (66.3) 

Educational level  

School 156 (60.5) 

University 102 (39.5) 

Smoking  

Nonsmoker 240 (93) 

Smoker/Ex-smoker 18 (7) 

Family history of cancer  

No 186 (72.1) 

Yes 72 (27.9) 

Disease history  

Have a comorbidity  

No 51 (19.8) 

Yes 207 (80.2) 

Time since diagnosis (years)  

< 3 153 (59.3) 

≥ 3 105 (40.7) 

Stage  

I 147 (57) 

II 51 (19.8) 

III 54 (20.9) 

IV 6 (2.3) 

 



31 

3.2 Treatment modalities received by the patients 

Figure 1 shows the treatment modalities received by the patients who participated in this 

study. Among the patients, 207 (80.2%) received chemotherapy, 159 (61.6%) 

underwent lumpectomy, 156 (60.5%) received radiotherapy, and 102 (39.5%) 

underwent mastectomy. 

Figure 1  

Treatment modalities received by the patients 

 

3.3 Adverse effects of cancer treatment 

When screened for the adverse effects of breast cancer treatments, the patients reported 

adverse effects and health issues that were categorized as follows: pain; gastrointestinal, 

skin and hair; health issues; pain; sleep and mental health; and respiratory/mouth and 

throat, hematologic, genitourinary, sensory, and general health issues. 

3.3.1 Pain 

Figure 2 shows the prevalence of pain among patients who received treatment for breast 

cancer. As shown in the figure, armpit discomfort was the most commonly reported 

pain that affected approximately 75% of the patients. Similarly, chest pain and phantom 

breast pain were reported by approximately 65% and 60% of the patients, respectively. 

The patients were also affected by headaches and back pain, as approximately 55% and 

50% reported suffering from these types of pain, respectively. 



32 

Approximately 45% and 40% of the patients reported abdominal and muscle (mylagia) 

pain, respectively. The patients also reported suffering from bone and joint pain, leg 

cramps, and sore throat (Figure 2). 

Figure 2  

Prevalence of pain reported by the patients 

 

3.3.2 Gastrointestinal health issues 

Figure 3 shows the prevalence of gastrointestinal health issues reported by the patients 

who participated in this study. Approximately 80% of the patients experienced nausea, 

and approximately 60% experienced vomiting. Approximately half of the patients 

experienced heartburn, and approximately 40% of the patients experienced diarrhea. 

On the other hand, gas (flatulance) and constipation were less frequently reported by the 

patients who participated in this study, as shown in Figure 3. 

 

 

 

 

 



33 

Figure 3  

Prevalence of gastrointestinal health issues among patients 

 

3.3.3 Skin and hair health issues 

Figure 4 shows the prevalence of skin and hair health issues among the patients who 

participated in this study. 

Approximately 70% of the patients reported experiencing hair loss (alopecia), and 

approximately 60% reported experiencing skin rashes and injection site reactions. In 

addition, approximately 40% of the patients reported experiencing itching. 

On the other hand, skin discoloration was reported by approximately 305 patients. Dry 

skin, nail changes, and skin sensitivity were less commonly reported by patients, as 

shown in Figure 4.  

 

 

 

 

 

 

 

 



34 

Figure 4  

Prevalence of skin and hair health issues 

 

3.3.4 Sleep and mental health issues 

Figure 5 shows the prevalence of sleep and mental health issues reported by the 

patients. Approximately 70% of the patients experienced anxiety. Approximately 60% 

of the patients reported experiencing depression and insomnia (trouble sleeping). 

Similarly, more than half of the patients reported experiencing mood swings, as shown 

in Figure 5. 

Figure 5 

Prevalence of sleep and mental health issues 

 



35 

3.3.5 Respiratory/mouth and throat health issues 

Figure 6 shows the prevalence of respiratory/mouth and throat health issues reported by 

the patients. 

In this study, mouth and throat sores, cold and flu symptoms, and breathing problems 

were reported by more than 30% of the patients, as shown in Figure 6. Similarly, 

approximately 25% of the patients reported experiencing dry mouth and runny noses. 

Approximately 20% of the patients reported having cough. On the other hand, nose 

bleeding was less commonly reported by patients, as shown in Figure 6. 

Figure 6  

Prevalence of respiratory/mouth and throat health issues 

 

3.3.6 Hematologic health issues 

Figure 7 shows the prevalence of hematologic health issues reported by the patients who 

participated in this study. 

Approximately 70% of the patients had anemia. On the other hand, approximately 40% 

of patients reported experiencing bleeding and bruising problems. Similarly, 

approximately 30% of the patients reported experiencing seroma and hematoma, as 

shown in Figure 7. 

 



36 

Figure 7  

Prevalence of hematologic health issues among patients 

 

3.3.7 Genitourinary health issues 

Figure 8 shows the prevalence of genitourinary health issues reported by the patients 

who participated in this study. Approximately 45% of the patients reported experiencing 

vaginal dryness, and approximately 30% of the patients reported experiencing loss of 

libido. In addition, approximately 25% of the patients reported experiencing vaginal 

discharge, urinary tract infections, and urine discoloration, as shown in Figure 8. 

Figure 8  

Prevalence of genitourinary health issues among patients 

 



37 

3.3.8 Sensory health issues 

Figure 9 shows the prevalence of sensory health issues reported by the patients who 

participated in this study. 

In this study, neuropathy was the most common sensory health issue reported by the 

patients, with approximately half of the patients reported to be affected. Approximately 

35% of the patients reported experiencing numbness. Moreover, approximately 20% 

reported experiencing vision and eye problems. Taste and smell changes and hearing 

problems were less frequently reported by the patients who participated in this study, as 

shown in Figure 9. 

Figure 9  

Prevalence of sensory health issues among patients 

 

3.3.9 General health issues 

Figure 10 shows the prevalence of general health issues reported by the patients who 

participated in this study. 

Approximately 60% of the patients reported experiencing weakness. Similarly, 

approximately half of the patients reported experiencing appetite changes. 

Approximately 40% of the patients reported experiencing fever, and approximately 35% 

of the patients reported experiencing weight changes and liver problems. Approximately 

1 in 5 patients reported experiencing dehydration. On the other hand, memory loss, scar 



38 

tissue formation, and delayed wound healing were less commonly reported by patients, 

as shown in Figure 10. 

Figure 10  

Prevalence of general health issues among patients 

 

3.4 Answers of the patients to the WHOQOL-BREF questionnaire items 

Table 2 displays the distribution of the answers of the patients to the WHOQOL-BREF 

questionnaire items. 

With respect to general health and quality of life, approximately 35% of the patients 

reported being dissatisfied or very dissatisfied with their overall health and quality of life. 

Moreover, pain and a lack of energy were the most frequent physical complaints 

expressed by the patients who participated in this study. Approximately half of the 

patients reported that they had experienced physical pain that significantly limited their 

ability to perform their activities. Moreover, approximately 45% of the patients stated 

that they had experienced a lack of energy for their daily life activities. A considerable 

percentage of the patients reported that they had experienced frequent negative feelings, 

including depression and anxiety. 

Notably, a percentage of the patients stated that they were dissatisfied with their sex 

life. More than half of the patients expressed concerns about their limited opportunity 

for leisure activities, as shown in Table 2. 



39 

Table 2  

Distribution of answers of the patients to the WHOQOL-BREF questionnaire items 

Item 1, n (%) 2, n (%) 3, n (%) 4, n (%) 5, n (%) 

Overall Quality of Life and General Health      

How would you rate your quality of life?* 45 (17.4) 48 (18.6) 81 (31.4) 54 (20.9) 30 (11.6) 

How satisfied are you with your health?* 36 (14) 57 (22.1) 87 (33.7) 54 (20.9) 24 (9.3) 

Physical Health      

To what extent do you feel that physical 

pain prevents you from doing what you need 

to do? 

69 (26.7) 54 (20.9) 33 (12.8) 78 (30.2) 24 (9.3) 

How much do you need any medical 

treatment to function in your daily life? 
42 (16.3) 54 (20.9) 48 (18.6) 78 (30.2) 36 (14) 

Do you have enough energy for everyday 

life? 
42 (16.3) 108 (41.9) 42 (16.3) 54 (20.9) 12 (4.7) 

How well are you able to get around? 42 (16.3) 63 (24.4) 81 (31.4) 54 (20.9) 18 (7) 

How satisfied are you with your sleep 45 (17.4) 75 (29.1) 72 (27.9) 39 (15.1) 27 (10.5) 

How satisfied are you with your ability to 

perform your daily living activities? 
39 (15.1) 114 (44.2) 42 (16.3) 48 (18.6) 15 (5.8) 

How satisfied are you with your capacity for 

work? 
33 (12.8) 78 (30.2) 81 (31.4) 36 (14) 30 (11.6) 

Psychological      

How much do you enjoy life? 27 (10.5) 60 (23.3) 99 (38.4) 45 (17.4) 27 (10.5) 

To what extent do you feel your life to be 

meaningful? 
45 (17.4) 54 (20.9) 87 (33.7) 54 (20.9) 18 (7) 

How well are you able to concentrate? 54 (20.9) 51 (19.8) 78 (30.2) 51 (19.8) 24 (9.3) 

Are you able to accept your bodily 

appearance? 
27 (10.5) 69 (26.7) 93 (36) 51 (19.8) 18 (7) 

How satisfied are you with yourself? 45 (17.4) 51 (19.8) 87 (33.7) 54 (20.9) 21 (8.1) 

How often do you have negative feelings 

such as blue mood, despair, anxiety, 

depression?* 

36 (14) 45 (17.4) 72 (27.9) 66 (25.6) 39 (15.1) 

Social relationships      

How satisfied are you with your personal 

relationships? 
39 (15.1) 39 (15.1) 87 (33.7) 48 (18.6) 45 (17.4) 

How satisfied are you with your sex life? 30 (11.6) 57 (22.1) 84 (32.6) 33 (12.8) 54 (20.9) 

How satisfied are with the support you get 

from your friends? 
33 (12.8) 39 (15.1) 84 (32.6) 48 (18.6) 54 (20.9) 

Environment      

How safe do you feel in your daily life? 27 (10.5) 72 (27.9) 99 (38.4) 30 (11.6) 30 (11.6) 

How healthy is your physical environment? 33 (12.8) 54 (20.9) 90 (34.9) 63 (24.4) 18 (7) 

Have you enough money to meet your 

needs? 
57 (22.1) 63 (24.4) 78 (30.2) 45 (17.4) 15 (5.8) 

How available to you is the information that 

you need in your daily to-day life? 
21 (8.1) 54 (20.9) 96 (37.2) 57 (22.1) 30 (11.6) 

To what extent do you have the opportunity 

for leisure activities? 
60 (23.3) 66 (25.6) 78 (30.2) 42 (16.3) 12 (4.7) 

How satisfied are you with the condition of 

your living place? 
48 (18.6) 57 (22.1) 78 (30.2) 45 (17.4) 30 (11.6) 

How satisfied are you with your access to 

health services? 
60 (23.3) 66 (25.6) 84 (32.6) 24 (9.3) 24 (9.3) 

How satisfied are you with your transport? 72 (27.9) 66 (25.6) 60 (23.3) 42 (16.3) 18 (7) 

Note. 1: Very poor/dissatisfied/Not at all, 2: Poor/dissatisfied/a little/slightly, 3: Neither poor nor good/a 

moderate amount/neither satisfied nor dissatisfied, 4: Good/satisfied/very much/very often/very much, 5: 

Very good/very satisfied/an extreme amount/always/extremely 

 



40 

3.5 Scores of the different domains of the WHOQOL-BREF questionnaire 

Table 3 shows the scores of the patients in the different domains of the WHOQOL-

BREF questionnaire. 

The scores of the patients indicated that their overall quality of life and wellbeing were 

moderately low, as indicated by the transformed score of 47.1%. This moderately low 

score was observed across the different domains of the WHOQOL-BREF questionnaire, 

including overall quality of life and general health, physical health, psychological 

health, social relationships, and the environment, as shown in Appendix C. 

3.6 Associations between the demographic and disease characteristics of patients 

and their scores on the different domains of the WHOQOL-BREF questionnaire 

Table 4 shows a univariate analysis of the associations between the demographic and 

disease characteristics of the patients and their scores on the different domains of the 

WHOQOL-BREF questionnaire. 

As shown in Table 4, compared with younger patients, older patients were significantly 

associated with lower physical health scores (p = 0.002), psychological health scores (p 

= 0.029), social relationships (p = 0.046), environments (p = 0.009), and overall scores 

(p = 0.018). 

Similarly, being overweight or obese was significantly associated with lower overall 

quality of life scores (p = 0.039), physical health (p = 0.024), social relationships (p = 

0.010), environment (p = 0.035), and overall scores (p = 0.032) than were normal 

weight. 

Compared with never married patients, married patients reported significantly lower 

social relationship scores (p = 0.046). 

On the other hand, the patients who had a university education reported significantly 

higher overall quality of life scores (p = 0.048), physical health scores (p = 0.031), 

social relationship scores (p = 0.014), environments (p = 0.051), and overall scores (p = 

0.037) than did the patients who had only a school education. 

Similarly, nonsmokers reported significantly higher overall quality of life scores (p = 

0.037), physical health scores (p = 0.034), psychological health scores (p = 0.050), 



41 

social relationship scores (p = 0.006), and overall scores (p = 0.031) than smokers and 

ex-smokers did. Moreover, the patients who had comorbidities reported significantly 

lower scores across all domains of the WHOQOL-BREF questionnaire. 

Deteriorations in the quality of life of patients were significantly associated with the 

time since receiving a diagnosis of breast cancer. Patients who were diagnosed with 

breast cancer less than 3 years prior reported significantly higher overall quality of life 

scores (p = 0.043), psychological health scores (p = 0.025), and environment scores (p = 

0.046). Similarly, there was a significant increase in deterioration across all domains of 

the WHOQOL-BREF questionnaire with increasing advancement in the stage of cancer. 

Patients who were in Stage I reported significantly higher scores across all domains of 

the WHOQOL-BREF questionnaire. 

The patients who received lumpectomy reported significantly higher scores across all 

domains of the WHOQOL-BREF questionnaire. On the other hand, the patients who 

received mastectomy reported deterioration in different domains of the WHOQOL-

BREF questionnaire. Similarly, patients who received chemotherapy also reported 

deterioration in different domains of the WHOQOL-BREF questionnaire. Moreover, 

patients who received radiotherapy had significantly lower overall quality of life scores 

than patients who did not receive radiotherapy. 

Patients who had adverse effects and health issues, including pain; gastrointestinal, skin 

and hair; health issues; pain; sleep and mental health; respiratory/mouth and throat; and 

hematologic, genitourinary, sensory, and general health issues, reported deterioration in 

different domains of their quality of life. Patients who had abdominal pain, bone and 

joint pain, chest pain, phantom breast pain, armpit discomfort, back pain, muscle pain 

(myalgia), headaches, nausea, vomiting, diarrhea, depression, anxiety, mood swings, 

anemia, urine discoloration, loss of libido, hematoma (blood build-up), seroma (fluid 

build-up), hair loss, mouth and throat sores (mucositis), injection site reactions, fever, 

weight changes, neuropathy, insomnia (trouble sleeping), weakness, and liver problems 

(hepatotoxicity) reported significantly lower scores in the different domains of the 

WHOQOL-BREF questionnaire, as shown in Appendix D. 

 



42 

The factors that were significantly associated with deterioration in the different domains 

of the WHOQOL-BREF questionnaire were included in multiple linear regression 

models to control for confounding factors.  

Deteriorations in overall quality of life and general health scores were predicted by 

having comorbidities, having advanced-stage breast cancer, receiving mastectomy, 

experiencing vomiting, depression, anxiety, fever, and insomnia.  Table 3 shows the 

predictors of lower scores in the overall quality of life and general health scores as 

measured using the WHOQOL-BREF questionnaire. 



43 

Table 3  

Predictors of lower scores in the overall quality of life and general health scores as measured 

using the WHOQOL-BREF questionnaire 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

BMI -2.85 2.76 -0.05 -1.03 0.302 

Educational level -4.42 2.57 -0.07 -1.72 0.087 

Smoking -5.21 4.34 -0.04 -1.20 0.231 

Have a comorbidity -10.82 3.23 -0.14 -3.35 0.001 

Time since diagnosis 2.52 3.06 0.04 0.82 0.411 

Stage -15.53 1.62 -0.46 -9.60 0.000 

Lumpectomy 3.13 2.88 0.05 1.09 0.279 

Mastectomy -27.04 3.06 -0.44 -8.83 0.000 

Radiotherapy -4.22 2.74 -0.07 -1.54 0.124 

Chemotherapy 2.83 3.12 0.04 0.91 0.366 

Abdominal pain 0.99 2.40 0.02 0.41 0.682 

Bone and joint pain 4.52 3.44 0.07 1.32 0.190 

Chest pain -3.65 12.37 -0.06 -0.30 0.768 

Phantom breast pain -8.75 12.13 -0.14 -0.72 0.471 

Armpit discomfort -3.84 2.83 -0.06 -1.36 0.176 

Back pain 3.75 3.03 0.06 1.24 0.217 

Muscle pain (Myalgia) -3.70 3.08 -0.06 -1.20 0.231 

Nausea -3.26 2.85 -0.05 -1.15 0.253 

Vomiting -13.54 2.72 -0.23 -4.97 0.000 

Diarrhea -0.91 2.51 -0.01 -0.36 0.717 

Depression -13.99 3.08 -0.23 -4.54 0.000 

Anxiety -10.29 2.86 -0.15 -3.59 0.000 

Mood swings -5.44 2.98 -0.09 -1.82 0.069 

Anemia -5.49 3.18 -0.09 -1.73 0.086 

Urine discoloration 5.34 3.77 0.07 1.42 0.158 

Loss of libido 2.75 3.18 0.04 0.87 0.387 

Hematoma (blood build-up) -0.95 3.06 -0.01 -0.31 0.757 

Seroma (fluid build-up) -4.73 3.01 -0.07 -1.57 0.118 

Mouth and throat sores 

(mucositis) 
-5.20 2.77 -0.08 -1.88 0.061 

Injection site reaction -0.85 2.94 -0.01 -0.29 0.772 

Fever -9.18 2.62 -0.15 -3.50 0.001 

Weight changes 3.94 3.16 0.06 1.25 0.214 

Neuropathy 1.10 2.97 0.02 0.37 0.711 

Insomnia (trouble sleeping) -7.70 2.57 -0.13 -3.00 0.003 

Weakness -1.54 2.98 -0.03 -0.52 0.606 

Liver problems 

(Hepatotoxicity) 
-0.93 2.75 -0.01 -0.34 0.735 

 



44 

Deteriorations in physical health scores were predicted by lower educational achievement, 

being a smoker/ex-smoker, having comorbidities, having advanced-stage breast cancer, 

receiving mastectomy, experiencing headaches, vomiting, depression, anxiety, anemia, 

urine discoloration, mouth and throat sores (mucositis), fever, insomnia (trouble 

sleeping), and weakness. Table 4 shows the predictors of lower physical health scores. 



45 

Table 4  

Predictors of lower physical health scores 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

Age 0.93 2.40 0.02 0.39 0.699 

BMI 2.61 2.36 0.04 1.11 0.270 

Educational level -6.35 2.43 -0.11 -2.61 0.010 

Smoking -8.51 4.25 -0.07 -2.00 0.047 

Have a comorbidity -10.32 3.15 -0.14 -3.28 0.001 

Stage -14.58 1.62 -0.43 -9.02 0.000 

Lumpectomy 2.67 2.66 0.04 1.01 0.316 

Mastectomy -22.96 3.13 -0.38 -7.33 0.000 

Chemotherapy -0.84 3.11 -0.01 -0.27 0.788 

Abdominal pain 1.05 2.37 0.02 0.44 0.659 

Bone and joint pain -0.30 3.46 0.00 -0.09 0.931 

Chest pain -9.86 11.62 -0.16 -0.85 0.397 

Phantom breast pain -3.65 11.74 -0.06 -0.31 0.756 

Armpit discomfort -2.14 2.78 -0.03 -0.77 0.442 

Back pain -2.31 2.83 -0.04 -0.82 0.416 

Muscle pain (Myalgia) 2.18 2.64 0.04 0.83 0.409 

Headaches 4.57 2.20 0.08 2.08 0.039 

Nausea -4.78 2.76 -0.07 -1.73 0.085 

Vomiting -7.13 2.68 -0.12 -2.66 0.008 

Depression -7.80 2.98 -0.13 -2.62 0.009 

Anxiety -15.79 2.72 -0.24 -5.80 0.000 

Mood swings -4.95 2.85 -0.08 -1.74 0.084 

Anemia -8.62 3.21 -0.14 -2.68 0.008 

Urine discoloration 8.43 3.54 0.12 2.38 0.018 

Seroma (fluid build-up) 2.84 2.84 0.04 1.00 0.318 

Rash -1.18 2.75 -0.02 -0.43 0.669 

Hair loss -1.79 2.70 -0.03 -0.67 0.506 

Mouth and throat sores 

(mucositis) 
-7.35 2.76 -0.12 -2.67 0.008 

Injection site reaction -2.05 2.93 -0.03 -0.70 0.483 

Fever -11.84 2.70 -0.20 -4.38 0.000 

Neuropathy -0.85 2.88 -0.01 -0.29 0.768 

Insomnia (trouble sleeping) -11.00 2.45 -0.19 -4.49 0.000 

Weakness -9.81 2.85 -0.16 -3.44 0.001 

Liver problems 

(Hepatotoxicity) 
0.04 2.69 0.00 0.02 0.987 

 

Deteriorations in psychological health scores were predicted by having comorbidities, 

having advanced-stage breast cancer, receiving mastectomy, experiencing muscle pain 

(myalgia), vomiting, depression, anxiety, mouth and throat sores (mucositis), fever, 

weight changes, and insomnia (trouble sleeping). Table 5 shows the predictors of lower 

psychological health scores. 



46 

Table 5  

Predictors of lower psychological health scores 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

Age 3.35 2.41 0.06 1.39 0.166 

Have a comorbidity -11.74 3.08 -0.16 -3.82 0.000 

Time since diagnosis 4.66 2.55 0.08 1.83 0.069 

Stage 
-15.34 1.52 -0.47 

-

10.09 
0.000 

Lumpectomy 3.06 2.59 0.05 1.18 0.239 

Mastectomy -26.46 2.85 -0.45 -9.30 0.000 

Chemotherapy 2.35 2.90 0.03 0.81 0.418 

Abdominal pain -1.95 2.39 -0.03 -0.82 0.416 

Bone and joint pain 0.33 3.28 0.01 0.10 0.920 

Chest pain -0.59 11.04 -0.01 -0.05 0.957 

Phantom breast pain -12.78 11.17 -0.22 -1.14 0.254 

Armpit discomfort -2.35 2.62 -0.04 -0.90 0.371 

Back pain 2.19 2.77 0.04 0.79 0.429 

Muscle pain (Myalgia) -9.66 3.12 -0.16 -3.10 0.002 

Nausea -4.97 2.74 -0.07 -1.82 0.070 

Vomiting -11.31 2.59 -0.20 -4.37 0.000 

Diarrhea 3.58 2.46 0.06 1.46 0.147 

Depression -12.85 2.82 -0.22 -4.55 0.000 

Anxiety -8.93 2.80 -0.14 -3.19 0.002 

Mood swings -3.93 2.77 -0.07 -1.42 0.157 

Anemia -4.58 3.13 -0.07 -1.46 0.145 

Urine discoloration 2.08 3.45 0.03 0.60 0.547 

Loss of libido -1.80 2.84 -0.03 -0.64 0.526 

Seroma (fluid build-up) -4.48 2.84 -0.07 -1.58 0.116 

Hair loss -4.63 2.95 -0.08 -1.57 0.117 

Mouth and throat sores 

(mucositis) 
-5.35 2.51 -0.09 -2.13 0.034 

Injection site reaction -1.89 2.76 -0.03 -0.68 0.494 

Fever -8.22 2.46 -0.14 -3.34 0.001 

Weight changes 10.20 3.36 0.17 3.04 0.003 

Neuropathy 0.89 2.61 0.02 0.34 0.734 

Insomnia (trouble sleeping) -6.67 2.36 -0.12 -2.83 0.005 

Weakness 1.35 2.90 0.02 0.47 0.641 

Liver problems 

(Hepatotoxicity) 
-2.63 2.63 -0.04 -1.00 0.318 

 



47 

Deteriorations in social relationship scores were predicted by lower educational 

achievement, having comorbidities, having advanced-stage breast cancer, receiving 

mastectomy, experiencing vomiting, depression, anxiety, mood swings, seroma (fluid 

build-up), dry mouth, mouth and throat sores (mucositis), fever, and insomnia (trouble 

sleeping). Table 6 shows the predictors of lower social relationship scores. 



48 

Table 6  

Predictors of lower social relationship scores 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

Age -1.13 2.74 -0.02 -0.41 0.681 

BMI 1.52 4.65 0.02 0.33 0.744 

Marital status -5.42 4.69 -0.08 -1.15 0.250 

Educational level -7.19 3.08 -0.11 -2.33 0.021 

Smoking -6.60 4.77 -0.05 -1.38 0.168 

Have a comorbidity -13.83 3.68 -0.17 -3.76 0.000 

Stage -16.59 1.80 -0.46 -9.21 0.000 

Lumpectomy -0.08 3.13 0.00 -0.03 0.979 

Mastectomy -26.50 3.26 -0.41 -8.13 0.000 

Chemotherapy -6.68 3.63 -0.08 -1.84 0.067 

Abdominal pain 2.70 2.84 0.04 0.95 0.342 

Bone and joint pain 6.11 4.02 0.09 1.52 0.129 

Chest pain -7.66 12.19 -0.12 -0.63 0.531 

Phantom breast pain -4.96 12.56 -0.08 -0.39 0.694 

Back pain 5.15 3.22 0.08 1.60 0.111 

Dry skin 3.14 4.75 0.04 0.66 0.509 

Nausea -0.04 3.35 0.00 -0.01 0.990 

Vomiting -8.74 3.23 -0.14 -2.70 0.007 

Depression -11.71 3.38 -0.18 -3.46 0.001 

Anxiety -13.60 3.36 -0.19 -4.04 0.000 

Mood swings -7.12 3.44 -0.11 -2.07 0.040 

Anemia 2.08 4.32 0.03 0.48 0.631 

Urine discoloration -1.96 4.73 -0.03 -0.41 0.679 

Loss of libido 6.95 4.39 0.10 1.58 0.115 

Hematoma (blood build-up) 0.61 3.90 0.01 0.16 0.877 

Seroma (fluid build-up) -9.13 3.62 -0.13 -2.52 0.012 

Hair loss -6.62 3.54 -0.10 -1.87 0.063 

Dry mouth -8.75 3.26 -0.12 -2.68 0.008 

Mouth and throat sores 

(mucositis) 
-7.34 3.22 -0.11 -2.28 0.023 

Injection site reaction -2.73 3.85 -0.04 -0.71 0.480 

Fever -8.43 2.80 -0.13 -3.01 0.003 

Dehydration 4.02 3.63 0.05 1.11 0.269 

Cold and flu symptoms 7.48 4.12 0.11 1.82 0.071 

Weight changes 5.76 3.73 0.09 1.54 0.124 

Neuropathy 0.12 3.15 0.00 0.04 0.969 

Numbness 2.52 2.72 0.04 0.93 0.355 

Insomnia (trouble sleeping) -11.86 2.65 -0.19 -4.48 0.000 

Weakness -2.10 3.37 -0.03 -0.62 0.535 

Liver problems 

(Hepatotoxicity) 
-1.31 3.46 -0.02 -0.38 0.706 

 



49 

Deteriorations in the environment scores were predicted by having comorbidities, time 

since diagnosis, advanced stage of breast cancer, not receiving lumpectomy, receiving 

mastectomy, experiencing headaches, vomiting, depression, anxiety, mood swings, 

urine discoloration, fever, and insomnia (trouble sleeping). Table 7 shows the predictors 

of lower environment scores. 

Table 7  

Predictors of lower environment scores 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

Age 0.02 2.34 0.00 0.01 0.993 

BMI -0.26 2.40 0.00 -0.11 0.914 

Have a comorbidity -7.27 3.00 -0.10 -2.42 0.016 

Time since diagnosis 5.90 2.48 0.10 2.38 0.018 

Stage -14.20 1.51 -0.44 -9.40 0.000 

Lumpectomy 5.29 2.55 0.09 2.07 0.040 

Mastectomy -24.80 2.82 -0.43 -8.78 0.000 

Chemotherapy 1.74 2.88 0.02 0.60 0.547 

Abdominal pain 2.97 2.27 0.05 1.31 0.193 

Bone and joint pain 5.99 3.27 0.10 1.83 0.068 

Chest pain 1.21 10.80 0.02 0.11 0.911 

Phantom breast pain -9.91 10.96 -0.17 -0.90 0.367 

Armpit discomfort -4.00 2.57 -0.06 -1.56 0.121 

Back pain -3.41 2.58 -0.06 -1.32 0.188 

Muscle pain (Myalgia) -0.77 2.52 -0.01 -0.31 0.761 

Headaches 5.47 2.08 0.10 2.63 0.009 

Nausea -4.21 2.63 -0.06 -1.60 0.111 

Vomiting -8.92 2.52 -0.16 -3.54 0.000 

Depression -7.21 2.84 -0.12 -2.54 0.012 

Anxiety -12.33 2.56 -0.19 -4.82 0.000 

Mood swings -8.39 2.74 -0.15 -3.07 0.002 

Anemia -4.43 3.05 -0.07 -1.45 0.148 

Urine discoloration 7.73 3.38 0.11 2.28 0.023 

Loss of libido -1.27 2.97 -0.02 -0.43 0.670 

Seroma (fluid build-up) -1.04 2.70 -0.02 -0.38 0.702 

Hair loss -2.97 2.59 -0.05 -1.15 0.253 

Mouth and throat sores 

(mucositis) 
-3.81 2.57 -0.06 -1.48 0.140 

Injection site reaction -2.97 2.76 -0.05 -1.08 0.283 

Fever -10.89 2.52 -0.19 -4.32 0.000 

Neuropathy 1.04 2.58 0.02 0.40 0.687 

Insomnia (trouble sleeping) -10.84 2.32 -0.19 -4.67 0.000 

Weakness -4.25 2.69 -0.07 -1.58 0.115 

Liver problems 

(Hepatotoxicity) 
-0.26 2.58 0.00 -0.10 0.918 

 



50 

Deteriorations in the overall scores were predicted by having comorbidities; having 

advanced-stage breast cancer; receiving mastectomy; and experiencing headaches, 

vomiting, depression, anxiety, mood swings, mouth and throat sores (mucositis), fever, 

and insomnia (trouble sleeping). Table 8 shows the predictors of lower overall scores. 

Table 8  

Predictors of lower overall scores 

Domain/Variable 
Unstandardized 

Coefficients 
SE 

Standardized 

Coefficients 
t p 

Age 1.48 2.46 0.03 0.60 0.546 

BMI -1.19 2.55 -0.02 -0.47 0.641 

Educational level -4.83 2.53 -0.08 -1.91 0.057 

Smoking -4.66 4.25 -0.04 -1.10 0.274 

Have a comorbidity -10.52 3.15 -0.14 -3.34 0.001 

Time since diagnosis 4.88 2.58 0.08 1.89 0.060 

Stage -15.40 1.58 -0.46 -9.76 0.000 

Lumpectomy 1.71 2.76 0.03 0.62 0.536 

Mastectomy -24.63 2.98 -0.41 -8.27 0.000 

Chemotherapy 0.30 3.05 0.00 0.10 0.922 

Abdominal pain 0.76 2.46 0.01 0.31 0.757 

Bone and joint pain 3.59 3.34 0.06 1.07 0.284 

Chest pain 1.84 11.33 0.03 0.16 0.871 

Phantom breast pain -13.14 11.42 -0.22 -1.15 0.251 

Armpit discomfort -3.83 2.70 -0.06 -1.42 0.158 

Back pain 1.09 2.88 0.02 0.38 0.706 

Muscle pain (Myalgia) -5.67 3.26 -0.10 -1.74 0.084 

Headaches 4.37 2.18 0.07 2.01 0.046 

Nausea -3.73 2.81 -0.05 -1.33 0.185 

Vomiting -10.61 2.66 -0.18 -3.99 0.000 

Diarrhea 3.08 2.51 0.05 1.23 0.221 

Depression -10.30 2.96 -0.17 -3.48 0.001 

Anxiety -11.98 2.98 -0.18 -4.02 0.000 

Mood swings -6.84 2.82 -0.12 -2.42 0.016 

Anemia -4.84 3.27 -0.08 -1.48 0.140 

Urine discoloration 2.39 3.66 0.03 0.65 0.515 

Loss of libido 2.29 3.52 0.04 0.65 0.516 

Seroma (fluid build-up) -3.82 2.93 -0.06 -1.30 0.194 

Hair loss -3.49 3.10 -0.06 -1.13 0.261 

Mouth and throat sores 

(mucositis) 
-5.88 2.70 -0.09 -2.18 0.031 

Injection site reaction -2.18 2.89 -0.04 -0.75 0.452 

Fever -10.01 2.61 -0.17 -3.84 0.000 

Weight changes 6.39 3.47 0.10 1.84 0.067 

Neuropathy -0.81 2.76 -0.01 -0.29 0.768 

Insomnia (trouble sleeping) -9.87 2.43 -0.17 -4.06 0.000 

Weakness -3.07 3.15 -0.05 -0.97 0.331 

Liver problems 

(Hepatotoxicity) 
-1.63 2.68 -0.03 -0.61 0.543 

 



51 

3.7 Discussion 

3.8 Interpretation and discussion of the main findings 

3.8.1 Demographics and clinical characteristics 

This study provided a comprehensive overview of the demographic variables and 

clinical characteristics of Palestinian women who received different treatment 

modalities for breast cancer. The findings of this study revealed that the Palestinian 

women with breast cancer who participated were relatively young, with a mean age of 

approximately 50 years. Moreover, more than half (61.6%) of the women were 

overweight or obese. Obesity was previously identified as a predictor of the 

development of breast cancer (Brown, 2021; Devericks, Carson, McCullough, Coleman, 

& Hursting, 2022). It has been suggested that hormones, inflammatory biomarkers, and 

insulin resistance can be involved in the pathogenesis of breast cancer (Brown, 2021). 

In addition, comorbid conditions were highly prevalent (80.2%) among the Palestinian 

women with breast cancer who participated in this study. This high prevalence 

highlights the complexities in managing breast cancer in this population of patients. 

Notably, diabetes mellitus, hypertension, cardiovascular disease, and hormonal issues 

can further complicate treatment, deteriorate outcomes, and reduce the overall survival 

and quality of life outcomes of patients (Anwar et al., 2021; Nyrop et al., 2021; Park et 

al., 2021). Notably, the majority of the patients were in their early stages of breast 

cancer. These findings indicate that women suffer a considerable burden of disease. 

Moreover, these findings indicate an urgent need for early detection and improvement 

of management strategies for breast cancer itself and comorbid conditions. The adoption 

of a multidisciplinary approach for the treatment of women with breast cancer should be 

encouraged. multidisciplinary treatments, including oncologists, clinical pharmacists, 

mental health specialists, and other healthcare professionals, can share expertise to 

manage these comorbid conditions along with cancer treatment. Multidisciplinary 

efforts might also include routine screening for comorbid conditions, screening for 

treatment-related adverse effects, and developing personalized care plans. 

Additionally, given these young patient populations and high obesity levels, health 

authorities are encouraged to develop and implement targeted screening programs. 

Moreover, weight management interventions should also be prioritized among women 

who are at risk of breast cancer. Educational and awareness campaigns should 



52 

encourage healthy lifestyles. These targeted interventions might reduce the odds of 

developing breast cancer and improve patient outcomes. 

3.9 Treatment modalities and adverse effects 

The findings of this study revealed that chemotherapy was the most prevalent (80.2%) 

treatment modality received by patients, followed by lumpectomy (61.6%) and 

radiotherapy (60.5%). Although these treatment modalities are standard in the 

management of breast cancer (Bhushan, Gonsalves, & Menon, 2021; Riis, 2020), 

significant adverse effects have been shown to be associated with certain breast cancer 

treatment modalities. These adverse effects include different forms of pain, 

gastrointestinal issues, and skin and hair problems, among other health issues. In this 

study, armpit discomfort, chest pain, and phantom breast pain were common forms of 

pain reported by the patients. In addition, gastrointestinal issues, including nausea and 

vomiting, were also commonly reported by the patients in this study. Chemotherapy is a 

mainstay in the treatment of breast cancer and is often used to reduce the size of the 

tumor prior to surgery (as neoadjuvant therapy) or to remove residual cancer cells after 

surgery (as adjuvant therapy) (Asaoka, Gandhi, Ishikawa, & Takabe, 2020; 

Montemurro, Nuzzolese, & Ponzone, 2020; Wang & Mao, 2020).  

However, lumpectomy and radiotherapy are standard and commonly used procedures in 

breast-conserving therapy (McClelland, Burney, Zellars, Ohri, & Rhome, 2020; Vaidya 

et al., 2020). Previous studies have extensively reported the adverse effects of 

chemotherapy and other treatment modalities used to manage breast cancer (Basak, 

Arrighi, Darwiche, & Deb, 2022; Burguin, Diorio, & Durocher, 2021; Franzoi et al., 

2021). The findings of this study highlight the need to comprehensively educate patients 

on the potential adverse effects of these treatment modalities, when to seek medical 

help, and how these adverse effects can be managed. Moreover, oncologists, clinical 

pharmacists, and other clinicians should make efforts to routinely assess and monitor 

the adverse effects of the therapeutic options used to treat breast cancer. Moreover, a 

program for timely interventions should be developed and implemented to mitigate 

these adverse effects. Supportive efforts might consider using antiemetics to manage 

nausea and vomiting, analgesics to manage the different forms of pain, and 

dermatological products to manage skin and hair health issues. These efforts can 



53 

improve the outcomes and quality of life of patients. Moreover, personalizing treatment 

modalities can reduce adverse effects and improve patient outcomes. 

3.10  Patient quality of life 

The quality of life of the patients was assessed via the WHOQOL-BREF questionnaire. 

As indicated by the transformed scores, the quality of life of the patients was relatively 

low across the different domains, as indicated by the scores of each domain. In this 

study, physical pain and a lack of energy were the most common physical health 

complaints that significantly limited the ability of the patients to perform their activities. 

It is well established that physical symptoms significantly affect the quality of life of 

patients, including those with breast cancer (Aydin et al., 2021; Koboto et al., 2020; 

Kovačević, Miljković, Višnjić, Kozarski, & Janković, 2020; Marinkovic et al., 2021; 

Shamloo, Nasiri, Maneiy, Kiarsi, & Madmoli, 2020). Moreover, mental health issues, 

including anxiety and depression, were also common among the patients who 

participated in this study. These findings highlight another need to adopt a 

multidisciplinary approach to care for patients with breast cancer. Through this 

approach, clinicians and mental health specialists can join efforts to reduce the 

prevalence of these issues and support patients with breast cancer. 

3.11  Predictors of quality of life 

In this study, several predictors of lower quality of life scores were identified. These 

predictors included older age, obesity, comorbid conditions, and advanced breast cancer 

stage. The findings reported in this study were consistent with those previously reported 

in prior studies and highlighted the complex cross-talks between the demographics, 

clinical characteristics, and different aspects of the quality of life of the patients (Aydin 

et al., 2021; Koboto et al., 2020; Kovačević et al., 2020; Marinkovic et al., 2021; 

Shamloo et al., 2020). These findings indicate a need to personalize care plans, 

educational materials, and counseling sessions to meet the needs of individual patients. 

In this study, patients who had higher education levels and did not smoke reported 

higher quality of life scores across different domains of the WHOQOL-BREF 

questionnaire. These findings indicate that lifestyle and educational interventions might 

be beneficial for improving the quality of life outcomes of patients. 



54 

3.11.1 Impact of treatment on quality of life 

In this study, the quality of life of the patients was affected by the treatment modality 

they received. Patients who received mastectomy or chemotherapy reported significant 

deterioration in quality of life across all domains. These findings were consistent with 

those reported in previous studies. It is well established that invasive treatments are 

more likely to be associated with a higher incidence of adverse effects and, 

subsequently, greater deterioration of the quality of life of patients. On the other hand, 

patients who received lumpectomy reported less deterioration in their quality of life. 

These findings suggest that breast-conserving therapies are associated with less 

deterioration in the quality of life of patients. 

3.11.2  Adverse effects and quality of life 

In this study, vomiting, depression, anxiety, and insomnia were significant predictors of 

deteriorated quality of life, as indicated by the scores across the different domains of the 

WHOQOL-BREF questionnaire. These findings indicate that managing such adverse 

effects can improve the quality of life of patients with breast cancer. For example, 

clinical pharmacists and clinicians can suggest the use of antiemetics to reduce the 

incidence of nausea and vomiting. Moreover, mental health specialists and other 

healthcare providers can contribute to reducing the incidence of depression, anxiety, and 

insomnia among breast cancer patients. Such efforts can improve the quality of life 

outcomes of patients. 

3.12 Summary of the main findings 

Breast cancer is the most common solid malignancy among women (Bray et al., 2018). 

Recently, there have been significant advances in the techniques used to treat breast 

cancer (Bhushan et al., 2021). These advances have increased the survival of affected 

patients (Bhushan et al., 2021; Riis, 2020). Notably, these treatment options are not 

without adverse effects. For the first time, in Palestine, this study sought to determine 

the prevalence of adverse effects experienced by Palestinian women who received 

treatment for breast cancer. Moreover, the study also sought to assess the impact of 

these adverse effects on the quality of life of affected patients. 

The findings of this study revealed that Palestinian women with breast cancer 

experienced a heavy burden of disease and therapy-related adverse effects. These 



55 

adverse effects significantly impact different aspects of the quality of life of patients as 

assessed via the WHOQOL-BREF questionnaire. The findings of this study revealed 

that a considerable proportion of the patients were relatively young, overweight/obese, 

and were mostly in the early stages of the disease. The most common treatment 

modality received by patients is chemotherapy, followed by lumpectomy and 

radiotherapy. Different forms of pain, gastrointestinal issues, skin and hair problems, 

and mental health issues are highly prevalent disease- and therapy-related adverse 

effects among patients. In general, the quality of life of the patients was considered low. 

Advanced breast cancer stage, the presence of comorbid conditions, and experiencing 

disease and therapy-related adverse effects were significant predictors of poor quality of 

life. On the other hand, higher education attainment and being a nonsmoker were 

associated with better quality of life outcomes. The findings of this study are worthy of 

consideration for oncologists, clinical pharmacists, mental health specialists, and other 

healthcare providers who care for patients with breast cancer. 

3.13 Limitations of the study 

This study has several limitations: 

− This study was conducted with a cross-sectional design. This design is limited in its 

ability to establish causal relationships as opposed to the interventional designs. 

− This study was merely observational, and no interventions were investigated to 

reduce adverse effects or improve the quality of life of the patients. 

− The data collected in this study were self-reported. It is well established that self-

reported data are subject to desirability and recall bias. 

3.14  Conclusion 

The findings of this study highlighted the heavy burden of the disease and therapy-

related adverse effects on the quality of life of patients with breast cancer who received 

treatment in Palestine. Providing comprehensive assessment, personalizing care plans, 

and reducing the incidence of adverse effects can improve the quality of life and 

wellbeing of patients with breast cancer. A multidisciplinary holistic care plan for breast 

cancer patients who integrates physical and mental health support is urgently needed to 

improve the quality of life of these patients. 



56 

3.15  Implications for practice and recommendations 

On the basis of the results of this study, the following implications and 

recommendations can be made: 

− Comprehensive management plans to address physical, psychological, relationship, 

and environmental aspects of the quality of life of breast cancer patients should be 

developed and implemented. 

− Early screening and interventions to detect and manage disease and therapy-related 

adverse effects are needed to improve the quality of life of patients. 

− Personalized care plans that consider the demographic and clinical characteristics of 

patients should be developed to improve patient outcomes. 



57 

List of abbreviations 

Abbreviation Meaning 

BMI  Body mass index  

BRACA Breast cancer genes  

HRQOL Health related quality of life  

HRT Hormone replacement therapy  

IBM International business machines corporation 

MHT Menopausal hormone therapy 

PET Positron emission tomography scan 

PHIC  Palestinian health insurance corporation 

QOL Quality of life  

TNM  Tumor size, lymph node, metastatic spread  

WHOQOL The world health organization quality of life  

 

 



58 

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