International Journal of Environment, Ecology,

Family and Urban Studies (IJEEFUS)

ISSN(P): 2250-0065; ISSN(E): 2321-0109
Vol. 4, Issue 6, Dec 2014, 45-54
TJPRC Pvt. Ltd.

IMPACT OF AGE ON THE QUALITY OF LIFE OF OESOPHAGUS

CANCER PATIENTS IN ASSAM
MANASH PRATIM BARMAN1, JITEN HAZARIKA2 & ANIL KALITA3
1

Assistant Professor, Department of Statistics, Dibrugarh University, Assam, India

2

Professor, Department of Statistics, Dibrugarh University, Assam, India

3

Senior Medical Officer, Dibrugarh University, Assam, India

ABSTRACT
The incidence and mortality of oesophagus cancer patients in Assam is very high which necessatitates the
improvement of rehabilitation and palliative care condition on them. Thus the study of Quality of life is very essential
among them which usually measure the status of rehabilitation and palliative care. Inspiring from these facts, a study was
initiated to assess the quality of life condition of oesohagus cancer patients of Assam by using EORTC QLQ-C30 quality
of life measuring instrument. The study was conducted in Assam Medical College and Hospital during 2010 and 2011.
This paper tries to focus on the impact of age on the quality of life of patients.
A total of 153 oeophagus cancer patients were included in the study. Quality of life condition was evaluated
before treatment and after treatment. The results of the study showed that before treatment almost all the different
dimension of functional scale and symptom scale have influenced on age. But after treatment, patients belonging to
different age groups reported similar pattern of quality of life on different functional and symptom scales. This may be due
to the fact that cancer directed treatments are usually related with different side effects which side lines the influence of age
on quality of life.

KEYWORDS: EORTC QLQ-C30, Kruskal-Wallis H Test, Assam

1. INTRODUCTION
The incidence of oesophagus cancer is very high in the state of Assam. National Cancer Registry Programme,
2013 reported that the incidence of oesophagus cancer is highest among male patients in the cancer registries of Kamrup
(14.5%), Dibrugarh (14.7%) and Chachar (8.7) district during 2009-11(National Cancer Registry Programe, 2013).
Oesophagus cancer is also a leading site among the female population of Assam. Also reports published by National
Cancer Registry Programme (PBCR) from time to time showed that with respect to incidence and mortality, it is one of the
major tobacco related sites both in males and females (National Cancer Registry Programme, 2001; 2002; 2004; 2006;
2007; 2009). This high incidence of oesophaugs cancer in Assam may be mostly due to the typical food habit among the
people residing here. Studies showed that betel nut chewing with or without tobacco, pickle consumption and a typical
locally made food named Kalakhar consumed by the indigenous population of Assam are significant risk factors for
oesophagus cancer in Assam (Phukan et al, 2001; Phukan et al,2001). The survival status which is a key indicator of
quality of cancer care management is also quite poor in the state of Assam. Research showed that oesophagus cancer
patients of Assam survive on the average 10.33 months (95% C.I. 7.79 to 12.88) only which is quite poor. Survival status
of patients also vary with respect to different socio-economic and treatment characteristics (Barman et.al, 2012).
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Manash Pratim Barman, Jiten Hazarika & Anil Kalita

With high incidence and poor survival status it is quite important to study quality of life of the oesophagus cancer
patients of Assam. The perception of quality of life is used to measure the impact of diseases and treatments on different
aspects such as physical, emotional, social etc. of peoples daily lives. Clinicians administrated treatments to patients to
increase survival, reduce the impact of morbidity or make patients feel better. Feeling better may include avoiding
discomfort (e.g. Pain, nausea, breathlessness), disability (i.e. loss of function) and distress (i.e. emotional problems).
For many years clinicians were willing to substitute physiological or laboratory tests for the direct measurement of the
third end point, in part because of difficulty in measurement.
However, during the last 3 decade, the situation has changed and the concept of health related quality of life
evolved which can be used in the direct measurement of how people are feeling and the extent to which they are able to
function their daily activities. The concept of quality of life is very crucial for studying the rehabilitation and palliative care
for patients with chronic disease such as cancer in which the cure is very unlikely. The world Health Organization also
recognized the rehabilitation and palliative care for cancer patients as one of the major component to reduce the impact of
the disease [World Health Organization, 2007].
Considering these facts a study was initiated to assess the quality of life of oesophagus cancer patients of Assam.
This paper explain to influence of age of patients on the on the quality of life of oesphagus cancer patients. The study
utilizes EORTC QLQ-C30 instrument for measuring the quality of life. The next section of this paper is devoted to the
introduction of the above mentioned instrument and its scaling technique. The section 3 of this paper is based on the
collection of data and statistical techniques used in the analysis followed by results and observations (section 4). The paper
ends with a discussion (section 5) on the results.

2. The EORTC QLQ-C30

EORTC QLQ-C30 was developed by the European Organization for Research and Treatment of Cancer (EORTC)
quality of life group [Aaronson et.al, 1993]. The EORTC QLQ-C30, consist of 30 questions on different aspects of quality
of life has been developed to study the quality of life of cancer patients irrespective of sites. A number of research works
have been conducted to study the quality of life of cancer patients by using EORTC QLQ-C30 questionnaire around the
globe [Tian et.al. 2004; Blazeby et.al. 2001; Carlsson et.al. 2004, Fang et.al. 2005; Kessler et.al. 2004]. The EORTC
QLQ-C30 is an integrated system of measuring the quality of life of cancer patients.
It is composed of both multi-item and single-item scales which measures quality of life of cancer patients using
seven dimensions- functional scales, role function, general symptoms, congnition, emotional status, social functioning and
global health status. Each question may be answered by not, a little, quite a bit, or very much, except for the global
health/QoL scale, which is a visual analogue scale from 1(very bad) to 7(excellent). These include five functional
scales, three symptom scales, global health status/QoL scale and six single items. Each of the multi-item scales includes a
different set of items - no item occurs in more than one scale. Structure of the EORTC QLQ-C30 questionnaire is given in
the Table 1.

Impact Factor (JCC): 3.0965

Index Copernicus Value (ICV): 3.0

Impact of Age on the Quality of Life of Oesophagus Cancer Patients in Assam

47

Table 1: Structural Form of EORTC QLQ-C30

3. COLLECTION OF DATA AND STATISTICAL ANLAYSIS

3.1. Data Collection
The study was a hospital based and conducted in Assam Medical College and Hospital (AMCH), Assam, India.
Oesophagus cancer patients diagnosed during the period of 1st January 2010 to 31st December 2011 and who gave consent
to participate were included in the study. Data on quality of life of oesophagus cancer patients were collected twice, first
after the diagnosis of the disease but before treatment and second at the time of first follow-up in the hospital after the
treatment. Before taking consent, the investigators explained the purpose of the study and the EORTC QLQ-C30
questionnaire to the eligible patients and their accompanying persons. After taking the consent, the EORTC QLQ-C30
questionnaire was administrated to the patients and asked them to fill-up the instrument. However, in case of patients who
are unable to do this because of cognitive impairments, communication defects, severe distress caused by their symptoms,
or because of the quality of life measure is too burdensome physically or emotionally [Gill et.al, 1994]. Under these
circumstances, proxy was used who may be a family member or health professionals to complete the quality of life
instruments rather than to loss all information on the patient as advocated by Addington et.al, 2001. Studies conducted by
Gill et.al, 1994 showed that there was a moderate agreement between individual patients and their proxies. He concluded
that proxies were almost as good as patients in detecting changes in some quality of life domains over time. In an another
study, Beach, 1996 observed that there seemed to be sufficient agreement between their assessments of quality of life to
make the information that proxies provided useful when the patients could not be asked directly. The same study compared
the scores on the quality of life questionnaire of the European Organization of Research and Treatment of Cancer (EORTC,
QLQ-C30) from cancer patients and their proxies, characteristics of the patients and proxy accounted for less than 15% of
the variance between them. These studies justifies our afford to use patients companions and family members as their
proxies. As the patients and their proxies had to fill up the questionnaire by their own, it was translated to the local
language of Assamese by using forward backward procedure following the norms approved by EORTC Quality of life
Group.
3.2. Scaling of EORTC QLQ-C30
The scaling technique use in EORTC QLQ-C30 is based on the widely applied Likert method of summated scales
[Likert, 1931]. As the responses of EORTC QLQ-C30 are recorded in ordinal scale, a linear transformation is applied to

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Manash Pratim Barman, Jiten Hazarika & Anil Kalita

standardize the raw score, so that scores range from 0 to 100 which converted the responses to an interval scale [Aaronson
et.al, 1993]. The scoring systems are organized such that a higher score for a functional scale or global health status
represents a high level of functioning or high quality of life; whereas a high score for a symptom scale/item worse (higher)
level of symptom for symptom scales.
3.3. Statistical Analysis
Different descriptive and inferential statistical methods are used for performing the analysis of the data. First the
quality of life scores on different dimensions which are on ordinal scale transformed into standardized score as mentioned
above. The normality of the scores of each dimension is tested by using Kolmogorov-Smirnove (KS) test and accordingly
test of significance are used.

4. RESULTS AND OBSERVATIONS

For the present study, a total number of 204 number of oesophagus cancer patients were enrolled. Out of 204
patients, 153 (74.63%) patients completed the Assamese version of EORTC QLQ-C30 twice i.e. before treatment and after
treatment. So, 153 numbers of patients were included for the final analysis. The average age of the study subjects were
55.76 years (SD: 11.82 years). There was male preponderance in the sample with about 65% of the study subjects were
male. Majority of about 76% of the patients were from the rural area. The profile of the study subjects are presented in the
table 2
Table 2: Demographic and Treatment Profile of the Oesophagus Cancer Patients
Variable
Age
< 50 years
50 to 59
60 to 69
70 and
above
Sex
Male
Female
Caste
General
OBC
ST
SC
TG
Unknown

Frequency

(%)

42
43
48

(27.451)
(28.105)
(31.373)

Variable
Religion
Hindu
Muslim
Christian

20

(13.072)

Buddhist

99
54

(64.706)
(35.294)

45
61
16
14
14
3

(29.412)
(39.869)
(10.458)
(9.150)
(9.150)
(1.961)

Location
Rural
Urban
Treatment
Chemotherapy
Radiotherapy
Surgery

Frequency

(%)

128
17
2

(83.660)
(11.111)
(1.307)

(3.922)

117
36

(76.471)
(23.529)

31
101
21

(20.261)
(66.013)
(13.725)

4.1. Testing of Normality of Quality of Life Scores

After converting the raw scores of both the occasion i.e, before treatment and after treatment into standardized
scores, normality of the scores were tested by using the K-S test. The standardized scores of all the dimensions of the
EORTC QLQ-C30 on both the occasions were found to be different from normal distribution which is presented in table 3

Impact Factor (JCC): 3.0965

Index Copernicus Value (ICV): 3.0

49

Impact of Age on the Quality of Life of Oesophagus Cancer Patients in Assam

Table 3: Results of KS Test

Scales
Global
Physical
Role
Emotional
Cognitive
Social
Fatigue
Nausea &
Vomiting
Pain
Dyspnoea
Insomnia
Appetite
Constipation
Diarrhoea
Financial

Before Treatment
Statistic p-Value
0.174
0.000
0.112
0.000
0.273
0.000
0.165
0.000
0.316
0.000
0.410
0.000
0.115
0.000

After Treatment
Statistic p-Value
0.170
0.000
0.110
0.000
0.207
0.000
0.118
0.000
0.235
0.000
0.274
0.000
0.165
0.000

0.263

0.000

0.225

0.000

0.236
0.266
0.250
0.249
0.433
0.476
0.348

0.000
0.000
0.000
0.000
0.000
0.000
0.000

0.166
0.265
0.262
0.217
0.415
0.407
0.313

0.000
0.000
0.000
0.000
0.000
0.000
0.000

As the scores on all dimensions of EORTC QLQ-C30 at both the occasions are non-normal so non-parametric
tests are used are used for further analysis.
4.2. Comparisons of Quality of Life Scores with Respect to Age
The study subjects are divided in to four groups with respect to their ages viz, less than 50 years, 50 to 59 years,
60 to 69 years and 70 years and above. Mean and standard deviation are calculated for all the dimensions of quality of life
with respect to the different age groups. Kruskal-Wallis H test is used to compare the scores of quality of life on different
dimension with respect to age. The results of Kruskal-Wallis H test are presented in tables 4 and 5
Table 4: Comparison of EORTC QLQ C-30 Mean Scores w. r. t. Age (Before Treatment)
Age group
Scale
Global
Physical
Role
Emotional
Cognitive
Social
Fatigue
Nausea &
Vomiting
Pain
Dyspnoea
Insomnia
Appetite
Constipation
Diarrhoea
Financial

Less than 50
Years

50 To 59
Years

60 to 69 Years

70 Years and
Above

p-Value

53.57 (17.86)
77.78 (20.75)
82.94 (22.54)
71.63 (25.31)
90.87 (16.55)
90.48 (16.52)
58.62 (24.20)

51.94 (15.84)
77.21 (20.69)
80.23 (25.00)
75.00 (27.28)
87.59 (20.60)
91.09 (15.99)
40.57 (25.42)

49.31 (17.52)
66.25 (20.46)
72.92 (26.99)
81.25 (22.90)
82.99 (25.61)
91.67 (16.49)
50.00 (24.79)

39.58 (17.70)
56.33 (28.90)
65.83 (28.34)
69.58 (25.26)
65.00 (34.16)
88.33 (19.57)
64.44 (21.21)

0.035
0.001
0.05
0.098
0.005
0.911
0.001

13.20 (24.01)

21.32 (29.84)

27.78 (32.13)

42.50 (34.82)

0.001

26.98 (27.78)
17.46 (19.87)
29.37 (25.72)
29.37 (31.50)
14.29 (26.69)
5.56 (19.36)
55.56 (24.05)

27.13 (29.33)
27.13 (25.46)
31.78 (29.05)
31.01 (33.66)
12.40 (27.24)
10.08 (24.70)
52.71 (25.44)

31.25 (28.69)
33.33 (27.51)
35.42 (29.50)
41.67 (32.62)
15.28 (27.47)
10.42 (20.81)
52.08 (24.70)

50.00 (35.04)
53.33 (29.42)
50.00 (31.53)
50.00 (31.53)
16.67 (29.62)
11.67 (19.57)
53.33 (22.69)

0.05
0.000
0.109
0.026
0.840
0.267
0.731

From table 4, it can be observed that, before treatment, the global quality of life score of patients detoriates
significantly with the increase of age (p-value : 0.035), the global quality of life value ranges from 53.57 of patients of age
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less than 50 years to 39.58 of patients of age 70 years and above. The mean scores of physical and role functioning reduces
significantly as age advances. Thus oespohagus cancer patients with older ages reported poor levels of physical and role
functioning than younger counterpart. Cognitive functioning scores of the patient decreases significantly (p-value: 0.005)
with the increase of age i.e, patients belonging to older age groups experiencing a poor cognitive functioning. The result
shows that emotional and social scale dimensions of quality of life does not have any impact on the age. For different
symptom scales, the extreme old age patients i.e, patients of age 70 years and above reported significantly poor levels of
quality of life in terms of fatigue scale than the cancer patients of younger age groups. The condition of Nausea &
Vomiting also detoraites significantly (p-value : 0.001) with the increase of age of oesophagus cancer patients. The score
of Nausea & Vomiting condition ranges from 13.20 belonging to the patients of age less than 50 years to 42.5 of patients of
age 70 years and above. Higher level of the scale means worse level of Nausea & Vomiting condition. Similar type of
results can be observed in case of pain and Dyspnoea scale. The condition for both the symptom scales worsen (increases)
with the increase of age of the patients. The quality of life condition of Insomnia, Constipation and Diarrhoea has not
shown any influence with respect to age of the patients. The scores of all the three symptom scales are significantly not
different among patients of the four age groups under consideration. The symptom scale of Appetite condition of
oesophagus cancer patients goes significantly worsen with the increase of age. The age of the patients does not have any
influence on the financial status of the patients. A similar kind of analysis is also done for the same patients based on the
scores provided by them after undergoing cancer directed treatment. The results of which are presented in the table 5
Table 5: Comparison of EORTC QLQ C-30 Mean Scores w.r.t. Age (After Treatment)
Age group
Scale
Global
Physical
Role
Emotional
Cognitive
Social
Fatigue
Nausea &
Vomiting
Pain
Dyspnoea
Insomnia
Appetite
Constipation
Diarrhoea
Financial

Less than 50
Years

50 to 59 Years

60 to 69
Years

70 Years and
Above

pValue

41.67 (15.29)
61.59 (22.03)
67.86 (27.40)
57.94 (20.74)
74.21 (23.34)
75.40 (25.30)
53.97 (19.41)

41.67 (15.54)
58.45 (22.29)
70.54 (24.08)
63.37 (24.27)
77.91 (25.39)
77.52 (29.74)
56.59 (22.07)

39.24 (15.75)
58.75 (19.33)
69.79 (21.1)
63.02 (18.59)
74.65 (27.07)
77.78 (27.36)
57.87 (18.76)

37.08 (20.32)
49.33 (23.24)
60.00 (24.42)
63.33 (27.09)
74.17 (29.85)
79.17 (28.55)
61.67 (19.24)

0.412
0.210
0.614
0.589
0.837
0.840
0.618

27.78 (28.91)

17.44 (24.66)

26.74 (26.35)

28.33 (21.01)

0.124

50.00 (21.46)
35.71 (25.92)
36.51 (21.85)
37.30 (28.71)
15.87 (23.56)
14.27 (24.58)
73.02 (19.81)

43.41 (21.86)
34.11 (25.71)
34.11 (28.63)
26.36 (28.69)
17.05 (30.32)
20.93 (29.12)
65.89 (23.56)

49.31 (21.18)
30.56 (22.63)
30.56 (24.63)
30.56 (28.21)
11.81 (23.31)
17.36 (27.50)
63.89 (21.56)

50.00 (24.78)
36.67 (26.27)
36.67 (28.41)
36.67 (26.27)
18.33 (27.52)
16.67 (27.57)
63.33 (21.36)

0.442
0.783
0.660
0.267
0.643
0.766
0.186

Interesting results can be observed while analyzing the quality of life scores of the oesophagus cancer patients
after undergoing cancer directed treatment. After undergoing cancer directed treatment, age of the patients has no any
statistically significant influence on the global (overall) health status of the patients. The scores of all the functional scales
viz, physical, role, emotional, cognitive and social across different age groups are more or less similar and statistically
insignificant of patients who undergo cancer directed treatment. Similar kind of results can be observed in case of symptom
scales also. From table 5, it can be observed that the scores of all the symptoms scales are insignificant across the four age
groups.
Impact Factor (JCC): 3.0965

Index Copernicus Value (ICV): 3.0

51

Impact of Age on the Quality of Life of Oesophagus Cancer Patients in Assam

5. DISCUSSIONS
Quality of life is the most important single measure for monitoring and evaluating the rehabilitation and palliative
care of cancer patients where surviving is less likely. EORTC QLQ-C30 is one of the most popular instruments of
measuring the quality of life of cancer patients. The EORTC QLQ-C 30 was developed specially for European cancer
patients, thus for implementing this instrument to cancer patients of other population; the reliability and validity of the
instrument must be tested in context of that study population [Lee et.al, 2005; Silpakit et.al, 2006; Urdaniz et.al, 2008;
Chaukar et.al, 2005; Jocham et.al, 2009]. Thus before using this instrument to the oesophagus cancer patient of Assam, a
study was conducted to assess the reliability and validity of EORTC QLQ-C30 in the context of oesophagus cancer
patients of Assam (Barman et.al. 2012). The results of the study showed that all the dimensions of measuring quality of life
of EORTC QLQ-C30 are found to be reliable and valid. Following the results of the study, the researcher used the EORTC
QLQ-C30 to study the quality of life of oesophagus cancer patients of Assam.
Studies were conducted across the globe to access the impact of age on the quality of life of different cancer sites.
Schmidt et.al, 2005 studied the impact of age on patients with rectal cancer. The findings of the study confirmed that
quality of life of patients is dynamic over age. For older patients (> 70 years of age) quality of life detoriates in the
dimensions of global health, physical functioning and fatigue. Kannan et.al. 2011, in their study on quality of life women
with breast cancer showed that age of patients has significant influence on the quality of life patients. Jordhy M.S. et.al.
2001, studied the impact of socio-demographic and medical characteristics on quality of life in advanced cancer patients.
Results of the study showed that age of patients has influence on health related quality of life. Older age was significantly
associated with better emotional and social functioning, less sleeping disturbance and a lower financial impact
The present research work studies the impact of age on the quality of life of esophagus cancer patients of Assam
on two occasions first after the diagnosis of the disease but before treatment and second after the treatment. Analysis of
quality of life data before treatment shows that the global health status of patients of older age group is abysmal in
comparison to the patients of younger age groups. A similar kind of picture can be seen in case of functional status, role
status and cognitive functioning. All these functional scales show significant association with age of the patients. While the
scores of emotional and social scales remain unchanged with respect to age.
The results of the study also show that the problems related to the symptoms of fatigue, Nausea & Vomiting, pain,
Dyspnoea and Appetite increases significantly with the increase of age of the patients. The problems related to Insomnia,
Constipation and Diarrhoea also increases with age but these are not statistical significant. The financial constrains has
nothing to do with age of the patients.

CONCLUSIONS
Interesting results can be observed while studying the quality life of patients after undergoing cancer directed
treatment. Patients belonging to different age groups reported similar scale of quality of life scores on all dimensions of
functioning scales as well as in global health status. In the symptom scales also the problems related to fatigue, Nausea &
Vomiting, pain, Dyspnoea, Appetite, Insomnia, Constipation and Diarrhoea are more or less similar to the patients in
different age groups after undergoing treatment. These results are very much unlike with the results before treatment.
This may be due to the fact that cancer directed treatments are usually related with different side effects which side lines
the influence of age on quality of life.
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Manash Pratim Barman, Jiten Hazarika & Anil Kalita

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Impact Factor (JCC): 3.0965

Index Copernicus Value (ICV): 3.0

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Impact of Age on the Quality of Life of Oesophagus Cancer Patients in Assam

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Manash Pratim Barman, Jiten Hazarika & Anil Kalita

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Impact Factor (JCC): 3.0965

Index Copernicus Value (ICV): 3.0