THE QUALITY OF LIFE OF PATIENTS WITH HEMATOLOGICAL NEOPLASIA UNDERGOING CHEMOTHERAPY

This study aimed to analyze the quality of life of patients with hematological neoplasia undergoing chemotherapy. A quantitative research was carried out based on the application of the WHOQOL-bref generic questionnaire. The sample was composed of 16 patients in the outpatient high risk chemotherapy sector in a teaching hospital in the city of Curitiba-PR between February and April of 2010. The results showed a prevalence of males with ages between 20 and 64 years old. Among the types of hematological neoplasias, 46.7% were acute lymphocytic leukemia, 33.3% were acute myelogenous leukemia, and 20% were divided between non-Hodgkin’s lymphoma, multiple myeloma, and hairy cell leukemia. The treatment period varied between 2 weeks and 24 months, and the number of chemotherapy sessions between 1 and 80. The analysis showed that the physical and psychological domains suffered the most changes, however, no statistically significant difference between all domains was observed. Cancer arguably changes every aspect of an individual’s life and brings profound changes in their routine and habits of life. Thus, the necessity and importance of nursing care intervention in this process is observed.


INTRODUCTION
Annually, the extent reached by oncological diseases has been gaining more attention with these diseases becoming an evident global public health problem.The World Health Organization (WHO) estimates 27 million new cases and 17 million deaths from cancer in 2030. 1 The term cancer is used generically to represent a set of more than 100 diseases, which have the disordered growth of cells and compression or invasion of tissues and organs in common.Among the types of cancer, hematological neoplasias are expressed by changes in the blood or blood forming tissues.Hematological diseases known as leukemias, lymphomas, and myelodysplastic syndromes showed an estimation of 18, 150 new cases in Brazil, in 2013.In 2012, it was expected that among those cases of incident cancers, approximately 3.5% corresponded to non-Hodgkin's lymphomas and leukemias.Despite leukemia being among the types of cancer with low incidence, it is still a hematologic neoplasia of important clinical relevance 2 because 257 thousand new cases occur worldwide per year. 1 Among the types of treatment, the chemotherapy (QT) is currently the one that shows the best results to cure many types of tumors and increases patient survival.Among the used therapies, it is the most used and the most effective, often curing main hematological neoplasias such as leukemia. 3Chemotherapy consists in the use of drugs, alone or in combination. 4ancer treatments allowed increased survival and cure; however, their conditions carry some of the strongest stigma associated with the disease. 5he broad action of anticancer medicines on different stages of cellular metabolism leads them to affect both malignant cells and healthy tissues causing various side effects. 6The effects of invasive oncologic therapies leave the body vulnerable and debilitated, negatively impacting the patients' quality of life. 7n addition to the deleterious effects of treatment, the impact of a cancer diagnosis may represent an emotional overload for the patient and family leading to several disorders such as depression and anxiety among others.Therefore, assistance must be planned to provide care for the overall health and not only for the disease, aiming at promoting improved quality of life for this individual. 8ue to the treatment's complexity and the different physical and mental demands that afflict these patients, more attention to the dimensions related to the quality of life of these individuals is required.
Therefore, a concern for patients affected by different neoplasias in relation to their quality of life is evident.The WHO conceptualizes quality of life as "the individual's perception of his position in life in the context of culture and value system in which he lives, and in relation to his goals, expectations, standards, and concerns". 9e definition of quality of life is still not unanimously accepted because it is a controversial and broad concept. 10It emerged in the scientific world as an important means to investigate and evaluate the health of individuals 11 similarly to the term health-related quality of life (HRQL), which came to be used to assess how much the chronicity of a health condition interferes in the everyday life of an individual. 12,13n the context of Oncology, quality of life is accentuated as the individuals' subjective vision in relation to their disability and satisfaction with their present level of functioning.This causes the individual to consider being good or not and at the same time to compare with what he sees as possible or ideal. 13n the recent decades, there is a growing concern about the quality of life of cancer patients.The HRQL has been used in clinical studies evaluating chemotherapy drugs to measure the inherent toxicity of this treatment, enabling the investigation to verify positive and negative impacts on the quality of life of patients undergoing chemotherapy treatment. 14tudies on the quality of life of cancer patients are critical to identify affected domains and plan nursing interventions. 15ence, the objective of this study was to analyze the quality of life of patients with hematological neoplasia undergoing chemotherapy.

MATERIAL AND METHOD
This is a quantitative research, with a cross-sectional design, developed in the High-risk Chemotherapy Sector and Chemotherapy Outpatient Clinic from a teaching hospital in the city of Curitiba, State of Paraná, between February and April of 2010.
Study participants were patients with hematological neoplasias undergoing chemotherapy treatment.The population was composed of 16 patients who met the inclusion criteria: being an adult, from both genders, with a diagnosis of hematologic neoplasia, undergoing chemotherapy treatment, being hospitalized in the High-risk Chemotherapy Sector or tended at the Outpatient Chemotherapy clinic, and being able to answer the study questions.After inclusion in the study, all patients were evaluated in the High-risk Chemotherapy Sector and the Outpatient Chemotherapy clinic during hospitalization or consultation during the application of the study protocol.
The data was collected using a form containing two parts: one, aimed at sociodemographic, clinical, and therapeutic data; and one containing the WHOQOL-bref questionnaire to evaluate the quality of life.
The WHOQOL-bref instrument, validated in Brazil 16 , consists of 26 questions: two general and the other representing each one of the 24 facets that make up the original instrument.It consists of four domains: physical, psychological, social, and environmental relations.There are five degrees of intensity for The most cited chemotherapy drugs in the study sample included: cytarabine, daunorubicin, and methotrexate.The lack of use of a broader range of drugs was probably because the interviewed patients attended a single institution where the same protocols are applied according to the diagnosis, that is, because most had diagnosis of LLA and LMA, the variability between treatment schemes was reduced.
Tables 1 and 2 show the results from the WHOQOL-bref questionnaire for the assessment of quality of life.It is possible to observe that the average standard deviation calculation in Table 1 with the low scores in Table 2 (although not statistically significant p = 0. 17) is related to the physical and psychological domains, i.e. the most affected domains: domain 1 and domain 2, respectively.Table 3 demonstrates how the participants assessed quality of life.The options of answers were: "very bad", "bad", "nor bad or good", "good", and "very good".None of the participants answered having a "very bad" QV.The option that obtained the highest percentage was "good" QV, with 53.4% of the responses.
Table 4 presents the subject's level of satisfaction in relation to health.The response options were: "very dissatisfied", "dissatisfied", "neither satisfied nor dissatisfied", "satisfied", and "very satisfied".The option "dissatisfied" was not answered by any of the participants and was excluded from the table.The answer with the highest percentage was "satisfied" with their health, in 46.7% of all responses.

DISCUSSION
The sociodemographic analysis shows a predominance of males with ages between 20 and 64 years old.These data are characteristic of this type of neoplasia, both for gender and age. 10 The data also corroborated data from the INCA 1 that reports incidence of cancer predominantly in the population with low level of education and age above 40 years.This age group is compatible with workers and retirees represented in this research.
The fact that 60% of the participants did not live in the region of Curitiba is noteworthy among the most significant notes about quality of life; this circumstance influences the QV of these patients, directly or indirectly, because it is harder for them to routinely receive visitation from friends and acquaintances.each question, worth different points, and subjected to the patient's choosing.
To meet the proposed objectives, a descriptive statistical analysis was performed on the data using the statistical program Statistical Package for Social Sciences (SPSS) and according to the WHO recommendations 17 for evaluation of answers to the quality of life WHOQOL-bref questionnaire, and for statistical analysis.
Non-parametric tests were used to verify the relationship between the WOOQOL-bref domains and disease-related measurements.The Kruskal-Wallis test was used to verify significant differences between the averages of variables with more than two categories.The Mann-Whitney non-parametric test was used for variables with two categories.The tests were conducted at a significance level of 5%.
All ethical procedures required by the Resolution 196/96 from the National Health Council were adopted for the participants' inclusion in this study.The objectives, the voluntary character of the study, guaranteed anonymity, and data confidentiality were explained to participants, who subsequently signed a Volunteer Informed Consent form.
The project was submitted to the Research Ethics Committee from the Curitiba Clinical Hospital and approved on January 27, 2010 under protocol number 2117.012/2010-01.

RESULTS
A total of 16 subjects participated in the study; 11 men and 5 women with ages between 20 and 64 years old.One subject was excluded from the study for not being under chemotherapy treatment.Four patients died in the course of the study.
A total of 60% (n = 10) of the participants lived in other cities and 40% (n = 6) in Curitiba.
The treatment period ranged between two weeks and 24 months and chemotherapy sessions between one and 80.The data related to hematological diseases and side effects resulted in the following numbers: 22% nausea, 22% alopecia, 13% mucositis, 6% inappetence, 6% vomiting, and 31% others.The cancer diagnosis itself promotes the social isolation of patients.Another factor that is also preponderant in this situation is the long periods of treatment, which in the case of the studied population it becomes an important item to be highlighted because more than half of the participants do not live in the city where the treatment is performed.Thus, the distance from home and family becomes a negative aspect that may interfere directly in worsening their quality of life.Therefore, the conviviality with family and friends who encourage their experience of everyday activities is crucial to influence the improvement of QV.
Conversely, the interference of daily activities in life such as work and leisure, can contribute, in addition to social isolation, for feelings of uselessness and as being a "load" for the family, given that many of these patients are providers for their families and their isolation bring concerns related to home maintenance and financial resources.This financial difficulty is reported by other authors 18 as the result of most patients becoming unable to continue working in remunerated activities during the course of their oncological treatment, thus, predisposing to poor QV, and often limiting the basic sustenance of the individual and his family.
Adversities as these could invariably be harmful to the therapeutic path.The therapeutic process refers to a variety of side effects that are undesirable and cause discomfort as reported in an analysis conducted with cancer patients undergoing chemotherapy treatment.Nausea and pain are among the most frequent adverse effects from chemotherapy. 19The impact of nausea on QV also features statistical relevance, especially at the beginning of the treatment. 10he results presented in the application of the Quality of Life Assessment Questionnaire, the WHOQOL-bref, according   ing quality of life and are also mentioned in another research. 21he patient begin to feel excluded from the social surroundings when his image is changed, creating negative feelings about appearance and isolating the individual from the conviviality with people, which resumes the discussion already held previously.
It is important to note that cancer arguably changes every aspect of an individual's life and brings profound changes into his routine and habits.This impairment of ability to perform everyday activities is derived directly from decreased selfesteem, anxiety, and impairment of body image, which are perceived and reported by patients. 22ematological diseases and their treatments can cause many changes in the functioning of the body and on the patient's appearance, leading to the feeling of inability and discomfort for everyone.These factors can generate stress followed by depression in more vulnerable patients. 23oncerns regarding body image come at a time when the patient begins to perceive his body with feelings of self-loathing, of low status before others, and inability to keep their interpersonal relationships. 22The change in appearance is linked to the fact that society identify them as cancer carriers, which may involve a process of stress and negative feelings.
Anxiety and stress are highly affected items in individuals with diagnoses of malignant diseases and such symptoms are incorporated into their lifestyle and are related to: insecurity, uncertainty about the future, and loss of self-control, physical ability, beauty, freedom, and commitment to friendships, and social entanglements. 22he predominance of the answer "good" was observed in the analysis of results when participants rated their quality of life.These data support other findings in the literature in which the concept of quality of life is based on the perception of the meanings that people attach to their life experiences considering satisfaction with life in the core of this concept. 24n other studies, quality of life is observed as the subjective understanding of different aspects of life in relation to the state of health.In the case of cancer patients, it is an adaptation process directly influenced by sociodemographic and medical characteristics that may facilitate or hinder the adaptation to illness. 25he factors that contributed to this response may be related to reports of being unconditionally supported by family, friends, and health professionals, and the easy access to health services, good service, and free access to the medicines they need.Thus, they consider having a good QV at the time of the chemotherapy treatment.
When the participants were asked to talk about their satisfaction with regards to health, it was observed that the highest percentage of responses was "satisfied".
Despite all the difficulties presented in the treatment of neoplastic disease, the analysis of the responses from partici-to the data shown in Tables 1 and 2, highlight the physical and psychological domains as the most affected.The physical domain, in accordance with the instrument, is related to questions about pain and discomfort, energy and fatigue, sleep and rest, mobility, everyday life activity, dependence on medications and treatment, and capacity for work.
The physical domain analyzed during the study can be affected by limitations within the diagnosis, chemotherapy side effects, and some presented comorbidities such as febrile neutropenia, diabetes, hypertension, and acquired immunodeficiency syndrome.These factors lead to tiredness and fatigue throughout long periods of treatment and use of medications that are toxic to the body, in addition to invasive and painful procedures such as catheter implantation and bone marrow biopsy and aspiration causing physical limitations and generating restrictions and/or removal from work during the treatment period.
In the physical domain, also relevant to this study, the results show that fatigue is the symptom that most alters the patient's QV. 10 In another study on evaluation of quality of life in cancer patients undergoing adjuvant chemotherapy, the chemotherapy side effects category, after three months, showed that some symptoms such as nausea and vomiting, fatigue, insomnia, and pain increased during the course of treatment when compared with the beginning of the treatment, reflecting a decline in the physical function. 8n another research on chronic diseases, the importance of three major dimensions was investigated: mental health, physical functioning, and social functioning on the perception of quality of life and health.The physical functioning dimension was smaller than the others including variables such as energy, fatigue, and pain. 20nother area affected in this study was the psychological area, which is composed by the following issues: positive and negative feelings, memory and concentration, body image and appearance, and beliefs.This domain may be affected by the diagnosis and use of chemotherapy by being related to the concept of death, and strengthened by the presence of death in other patients with similar disease in addition to the lack of information about the disease and treatment protocols. 10he diagnosis of cancer interferes significantly in QV, mainly in the physical and emotional aspects.Cancer, despite the scientific and technological advances in medicine, is still regarded as a synonym of death. 11nother relevant point in this domain that deserves attention is the body image.The study that evidenced nausea and pain as prevalent during oncological treatment also referenced some self-image problems that may be related to the event of alopecia, which reached the same percentage of the event of nausea. 19The self-image related factors are important in assess-pant 14, a 22 years old patient, who underwent chemotherapy treatment for over a year after being diagnosed again with recurrent leukemia and being under an intensified treatment protocol, showed that he is very satisfied with his health and plans to get married soon.Even after his evaluation of quality of life as neither good nor bad, he says that he began to give more value to life and tries to enjoy it to the extreme after the illness.
The analyses of answers from participants with severe disease show that despite all their difficulties, they feel well and maintain a good level of autonomy.

CONCLUSION
The presented data leads to the conclusion that there were no statistically significant differences between the physical and psychological, and social and environmental relations domains.The sample size could possibly justify this result.On the other hand, because of the low scores in the physical domain, some changes might occur in the quality of life of patients with hematological neoplasia as the result of the disease's limitations itself and treatment effects.
The assessment of QV demonstrated that 73.4% assessed it as good and very good, and 66.7% were satisfied or very satisfied with their health condition.These data corroborate the literature data that indicates that the concept of quality of life is centered in the perception of the meaning that people ascribe to their life experiences, to the unconditional support of family, friends, and health professionals, a good service received, and free access to the medicines they need.Based on these indicators they consider having a good QV during the time of chemotherapy treatment.
Future studies on quality of life of patients with hematological neoplasia could address larger samples, which could highlight differences in quality of life according to treatment time, differently than what was found in this study.

Table 1 -
Mean values and standard deviation of domains, Curitiba, 2010 Source: data from the study.

Table 2 -
Description of the maximum scores by WOOQOL-bref domains, Curitiba, 2010 Source: data from the study.

Table 3 -
Assessment of quality of life by the study participants, Curitiba, 2010 Source: data from the study.

Table 4 -
Satisfaction of the study participants regarding their health, Curitiba, 2010