|Year : 2018 | Volume
| Issue : 2 | Page : 61-69
Quality of life in patients with advanced cervical cancer in Nigeria
Marliyya Sanusi Zayyan1, Matthew Akpa2, David A Dawotola3, Adekunle O Oguntayo1, Abimbola O Kolawole1
1 Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, College of Health Sciences, Kogi State University Anyigba, Kogi State, Nigeria
3 Department of Radiation Oncology, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||6-Jul-2018|
Dr. Marliyya Sanusi Zayyan
Department of Obstetrics and Gynaecology, Gynaecological Oncology Unit, Ahmadu Bello University Teaching Hospital, Zaria
Background: Cancer of the cervix is the most common female genital tract malignancy in Nigeria. Patients present in advanced stages of the disease due to ignorance, poverty, lack of national screening program, and poor utilization of the few available services. At a tertiary referral center, a dearth of resources, coupled with high cancer burden, results in many not only succumbing to their disease but also dying in pain and indignity. Objective: The aim of this study was to determine the quality of life (QoL) in patients with advanced cancer of the cervix. Materials and Methods: This is a cross-sectional descriptive study. Women with advanced cancer of the cervix at Ahmadu Bello University, Zaria, Nigeria, between April 1 and December 31, 2014 were enrolled in this study. Consecutive patients with histologically confirmed cervical cancer; patients with FIGO stages IIB IIIA, IIIB, IVA, and IVB were recruited. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire–core 30 (QLQ-C30) questionnaire was used to assess their QoL. Two trained nursing staff administered the pretested questionnaires. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software. Results: All domains of QoL were affected in the 378 patients with advanced cervical cancer. Physical functions were affected in 264 (69.9%) role functions in 218 (57.7%), cognitive in 138 (36.5%), emotional in 230 (60.8%), and financial in 288 (76.2%). Sexual domain was affected in more than 323 (85%) of the patients. Reduction in various economic facets was reported by 268 (70.9%) patients. In social domain, only 150 (39.7%) family members and 134 (35.4%) friends were reported to have offered financial support. There was no support from governmental or nongovernmental organizations. Conclusion: Severe disruptions in QoL domains occur in patients with advanced cervical cancer.
Keywords: Cervical cancer, Nigeria, quality of life
|How to cite this article:|
Zayyan MS, Akpa M, Dawotola DA, Oguntayo AO, Kolawole AO. Quality of life in patients with advanced cervical cancer in Nigeria. Sahel Med J 2018;21:61-9
|How to cite this URL:|
Zayyan MS, Akpa M, Dawotola DA, Oguntayo AO, Kolawole AO. Quality of life in patients with advanced cervical cancer in Nigeria. Sahel Med J [serial online] 2018 [cited 2019 Jun 19];21:61-9. Available from: http://www.smjonline.org/text.asp?2018/21/2/61/236068
| Introduction|| |
Cervical cancer remains the second most common malignancy among women, with about 528,000 new cases and over 266,000 deaths every year. Developing countries account for more than 85% of the new cases while having only 5% of the global cancer resources. In Nigeria, cervical cancer is the most common female genital malignancy constituting a major cause of mortality and morbidity., The estimated incidence is 250/100,000 new cases every year, which translates to 32 million women, affected with the disease. A total of 9922 cases are diagnosed every year with over 80% mortality rate.,
Regional reports from South-West,, South-East, South-South, North-East, and North-Central , regions agree with the high disease burden.
Nigeria, along with four other countries, makes more than half of the global mortality from cervical cancer.
With a nonexisting national cervical screening program and poor utilization of available services due to ignorance and poverty, cervical cancer is a major contributor to morbidity and mortality among Nigerian women.
Ahmadu Bello University Teaching Hospital (ABUTH) is one of the six referral centers in the country with facilities for cervical cancer treatment. There is high patient load, who often present in advanced stages of the disease., Despite the high cancer burden, no aspect of cancer treatment or prevention is included in the existing National Health Insurance Scheme in Nigeria which means that patients' treatment depends on their ability to personally fund their care. This dependence on “out-of-pocket” funding for cancer treatment often causes delay and failure of management, thus worsening patients' quality of life (QoL).
Advanced stages of cancer or its treatment with radiation or chemotherapy adversely affects the QoL.,, Necessary surgical intervention in late disease such as colostomy or ureterostomy to relieve bowel or urinary tract obstruction may be permanent, disrupting routine activities and causing emotional distress. In Nigeria, many women with cervical cancer die painful, undignified deaths.,,,
Screening, early detection, established management protocol, organized palliative care, and utilization of hospice not only reduce mortality from the disease but also improve the quality of lives of the patients in developed countries. Parts of the world where these strategies are implemented have succeeded in making advanced cervical cancer an uncommon disease.
With high burden of advanced disease and rudimentary palliative care, QoL issues become very important. It is thus hoped that this work will serve as a useful tool that will impact on measures to improve the QoL of cervical cancer patients in particular and cancer patients in general.
The aim of this study was to determine the QoL among patients with advanced cervical cancer at ABUTH, Zaria.
- To assess the effect of diagnosis and treatment of advanced cervical cancer on social support and economic functions
- To assess the impact of treatment on sexual life and physical functions
- To determine the effect of diagnosis and treatment of advanced cervical cancer on global QoL.
| Materials and Methods|| |
The study was carried out on patients with advanced cancer of the cervix in both the Gynecology and Oncology Clinics and the Gynecology and Radio-oncology wards of ABUTH, Zaria, using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire–core 30 (QLQ–C30) as the instrument of the study.
This is a questionnaire developed to assess the QoL of cancer patients.
It is a copyrighted instrument, which has been translated and validated into 81 languages and is used in more than 3000 studies worldwide. Permission was obtained for use of the most recent version of QLQ-C30 (Version 3.0) with a fax message to Texas. The document was used without alteration, a condition attached to the permission. All parameters were answered by the patients as presented in the questionnaire, and analysis was done using wordings and grading of various QoL issues as written in the EORTC QLQ-C30 for cervical cancer.
The questionnaire was translated into Hausa for ease of administration to patients who understood only Hausa. Translation was done by two native Hausa speakers according to the guidelines for translation of the EORTC.
Patients' HIV status was assessed as part of their management in the hospital but not referred to or considered in this study since it is not a feature of the EORTC questionnaire.
It was a cross-sectional descriptive study.
The study period was from April 1, 2014 to December 31, 2014.
The number of patients appropriate for the study was calculated to be 384 using the following formula:
Where, z = Standard normal deviation at 95% confidence interval = 1.96
P = Proportion or prevalence of the disease = 0.5,
Patients with histologically proven cervical cancer staged at FIGO Stage IIB to IVB were included in the study.
Patients with recurrent cervical cancer, previous treatment for other cancers, and those who did not consent to be interviewed were excluded from the study.
Case definition of advanced cancer of the cervix
Advanced cancer of the cervix was defined as histologically confirmed stages IIB to IVB cancer of the cervix.
Consecutive consenting women with histologically confirmed advanced cancer on or awaiting definitive treatment were recruited. A structured questionnaire – the EORTC QLQ–Core 30 – was administered to the patients by two nursing staff who were earlier trained on the use of the questionnaire.
Other sociodemographic data were retrieved from the folders and recorded against the corresponding number of the questionnaire on a separate record sheet. Qualitative research was done by interviewers who were trained to ask questions from a close-ended questionnaire on the social support, financial burden, and sexual life of the patient. Medical photographs to illustrate some of the complications of advanced cervical cancer were taken after informed consent was obtained.
All the information retrieved from the patient, folder, and the EORTC questionnaires was coded and entered into a pro forma. Statistical Package for the Social Sciences (IBM SPSS version 17.02 2009) was used for data analysis.
Univariate analysis using age as continuous variable and parity, educational level, marital status, tribe, and occupation as categorical variables was performed. Qualitative data were analyzed by grouping responses into categories and assigning codes to each category. Descriptive statistics, frequency tables, and mean were used to summarize the sociodemographic and QoL data. Bivariate analysis was done using cross-tabulations and level of significance was calculated by Pearson's Chi-square test at P < 0.05.
All aspects of the study were reviewed and authorized by the ABUTH Ethical Committee on15th April 2015. All participants were fully counseled about the study and assured that they reserved the right not to participate or to withdraw from the study without any penalty. Written consent for photographs was obtained from both the patients and Ethical Committee.
| Results|| |
Of the 384 patients recruited over the study period of 9 months, 378 respondents were interviewed. Six patients failed to meet inclusion criteria.
Majority of the patients, i.e., 242 (64%) were interviewed at the radio-oncology clinic, 62 (16.4%) from gynecology clinic, 50 (13.2%) from gynecology ward, and 24 (6.3%) patients from oncology ward while the least 24 (6.3%) were interviewed on the oncology ward.
[Table 1] summarizes the sociodemographic characteristics of the respondents. The modal age of the respondents was 49 years and the mean was 50.9 years. There were two peaks of occurrence of cervical cancer. One hundred and twenty-two (32.3%) respondents were in the 40–49 years' age group while 110 (29.1%) respondents were in the 50–59 years' age group. There were two patients in the 20–29 years' age range. [Figure 1] is a pie chart showing the age distribution.
Grand multiparity was common among respondents with 290 (76.7%) having had five or more children, however 12 (3.2%) were nulliparous.
There were 258 (68.3%) married women while 104 (27.5%) were widows.
The Hausa ethnic group constituted the largest single ethnic group with 156 women (41.3%). Other tribes excluding Ibo and Yoruba constituted 164 (43.1%) respondents.
Majority, i.e., 238 (63%) of the respondents had no formal education; however, 38 (10.1%) had tertiary education.
Only 40 (10.6%) respondents had gainful employment; the rest were homemakers, 188 (49.7%); petty traders, 114 (30.2%); and subsistence farmers, 20 (5.3%).
Squamous cell carcinoma accounted for 342 (91.5%) of the cases with 294 (77.8) being the large cell nonkeratinizing variant [Figure 2]. There were 22 (5.8%) cases of adenocarcinoma while adenosquamous cancer affected only 2 (0.5%) patients. FIGO stage IIIB was the most frequent with 118 (49.7%) patients [Table 2].
Treatment modality included chemotherapy, 92 (24.3%); radiation therapy, 18 (4.8%); and chemoradiation, 92 (24.3%). Only 34 (9.0%) had completed a treatment modality. There were 142 (37.6%) patients who were awaiting treatment but admitted for blood transfusion and other forms of supportive treatments.
Quality of life
Three quarters of the patients had social support from their nuclear or extended family. There was no support from any governmental or nongovernmental organization. Social support was significantly lower for women below 50 years of age with significant difference found in relation to all categories of social support (P < 0.05) [Table 3].
|Table 3: Perception on effect of diagnosis and treatment of advanced cervical cancer on social support and economic factors by age|
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Perception of financial difficulty occurred in more than three quarters of the respondents, only 90 (23.8%) did not have any difficulties. Reduction in income generation was experienced by 259 (68.7%) while 268 (70.9%) respondents had reduction in overall living standard. Up to 192 (50.8%) respondents had difficulty with provision of basic needs and 148 (39.2%) had difficulty in purchasing drugs. Women above 50 years of age suffered more profound reduction in economic functions (P < 0.05) [Table 3].
Respondents had limitation of physical function as 94 (24.9%) reported trouble taking a short walk and 92 (24.3%) had trouble with strenuous activity [Table 4]. Some 173 (46%) patients were unable to do their daily chores, thus adversely affecting their families. Although 176 (46.5%) reported none, 38 (10.1%) had severe depression; there was a direct relationship between stage of disease and degree of depression.
|Table 4: Effect of diagnosis and treatment of advanced cervical cancer on functions based on the European Organization for Research and Treatment of Cancer quality of life questionnaire core 30 scoring|
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Three quarters of the patients experienced pain, 60% of whom categorized it as severe. Pain was mainly due to advanced disease but occasionally due to complications of treatment such as radiation burns. Incapacitating pain was reported by 60 (15.9%) patients.
There was a direct relationship between pain intensity and stage of the disease. Patients on chemotherapy and chemoradiation had more pain than those on radiotherapy. [Figure 3] is a clustered bar chart showing pain levels in relation to the treatment modality. Patients not on treatment had more pain compared to those on chemoradiation or chemotherapy [Figure 4].
|Figure 3: Bar chart showing perception of financial difficulty to treatment modality|
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|Figure 4: Clustered bar chart showing the relationship between pain and treatment|
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The symptomatic effect of diagnosis and treatment of advanced cervical cancer as listed on the EORTC QLQ-30 showed multiplicity of symptoms in all the patients interviewed [Table 5].
|Table 5: Effect of diagnosis and treatment of advanced cervical cancer on symptoms based on the European Organization for Research and Treatment of Cancer quality of life questionnaire core 30 scoring|
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Patients who were on radiotherapy or have completed treatment had the least expression of pain. Other forms of debility observed included fecal or urinary obstruction. Total urinary incontinence was observed in 6 (1.58%) and fecal incontinence in 3 (0.79%) patients. These debilities, though not a part of the EORTC QLQ-C30, are very significant quality-of-life issues.
Sexual function was considered no longer important by 323 (85%) patients, but 42 (11.1%) respondents were still having coitus. There was statistically significant difference between younger and older patients with 24 (14.6%) of those below 50 years still sexually active compared to 18 (8.4%) for those above 50 years (P < 0.05).
Global quality of life
Self-assessment of global QoL using its two components, i.e., overall physical health and overall QoL indicates gross affection.
The physical health and global QoL were assessed to be poor by 20 (5.3%) and 22 (5.8%), respectively. This is against 48 (12.7%) and 28 (7.4%) who considered the two components as excellent, respectively. If scores of 1–4 of physical health and global QoL are considered, however, 182 (48.1%) and 174 (46%) fall in this range, respectively.
Perception of very poor overall QoL was found among 2 of the 18 (11.1%) patients on radiotherapy, 10 of 142 (7%) of those not on any treatment, and 6 of 92 (6.5%) of those on chemotherapy. Excellent overall QoL was expressed by only 8 of 34 (17.6%) of those who have completed any form of treatment, 16 of 92 (15.2%) of those on chemoradiation, and 4 of 18 (22.2%) of those on radiation therapy [Table 6].
| Discussion|| |
Advanced cervical cancer occurred mostly among middle-aged women. It occurred most frequently in the age group of 40–49 years which agrees with the findings of Kyari et al., Musa et al., and Iyorke et al. This is the age of great social and economic responsibility for the woman, especially in developing countries. This fact is substantiated in this study group by their mean parity.
Education is a major health determinant., Female education in northern parts of Nigeria is generally low, and lack of formal education was observed in 63% of this group. Illiteracy, poverty, and lack of formal education could encourage negative health-seeking behaviors and increase mortality from cancer. Lack of formal education may be a contributory factor to high-risk social behaviors while illiteracy and poverty are related to both late presentation and failure to bear the cost of treatment.
Squamous cell cancer formed 91.5% of this study which is similar to 89.5% of findings by Mohammed et al. in 2006, Ijaya et al. from Ilorin found 85.7%, and Umanah et al. reported 88%., This is at variance with the widely reported rising incidence rates of adenocarcinoma in comparison with squamous cancers in other parts of the world., Adenocarcinoma made <6% of the study group. Adenosquamous was very uncommon.
QoL domains are impacted severely by various cancers and their treatment., The results of this study show high prevalence of self-reported perception on reduction in all aspects of QoL.
Reduction in income was reported by 68.8% of patients with gainful employment. This impacts negatively on compliance of treatment and follow-up. In a study of 120 newly diagnosed cervical cancer patients, Arrossi et al. found reduction in family income as a result of the disease or to result in noncompliance with radiotherapy.
Cancer care is expensive, and there is an urgent need to include it in the National Health Insurance Scheme, which presently categorically excludes it.
With regard to the domain of social support, the distribution of perceived support from various groups reflects the events in our larger society where medical care is mostly a personal affair.
Support for cancer patients is generally low because of the strain it places on caregivers who often withdraw their support. Another Nigerian study by Ohaeri et al. found “objective” burden and severe problems with finances in patients and caregivers with cervical cancer, but there was no social stigma for the patient.
On sexual domain, majority (85%) were no longer interested in sexual intercourse. Emotional trauma, deranged physical function, and symptoms produced by advanced cervical cancer and its treatment, all contribute to the disruption of sexual life. Sexuality often undergoes permanent change following advanced cervical cancer or treatment by radiotherapy. Krumm and Lamberti reported changes in sexual behavior following radiation treatment for cervical cancer. Similarly, a study of QoL among Chinese women with gynecologic cancer reported gross disruption of sexuality and general lack of interest.
Cancer pain is a multidimensional symptom that causes profound distress and significant morbidity. Pain perception in this study was related to the stage of the disease as 52% of the patients with stage IVA reported intense pain. This figure is similar to 57% reported by Francois, but lower than 73% reported by Nuhu et al. from Ibadan. Elumelu et al. found 93.8% of 80 patients to have pain that required symptom control at initial presentation.
Control of cancer pain is expensive and often unrewarding, significantly reducing QoL.
Depression was perceived by 202 (53.5%) patients. Degree of depression (as graded by the questionnaire) was related to the stage of disease. Massie and Holland reported a lower prevalence rate (12%–23%) of depression in gynecologic cancers compared with oropharyngeal and pancreatic cancers. Many of the affected patients in this study probably have poor insight to their disease due to ignorance and lack of education.
The global QoL is a net effect of the changes in various facets that constitute QoL. In this study, there was a positive correlation between physical health and QoL in patients who report low scores (1–4) but not in patients who reported score 6–7 of global QoL [Table 6]. This implies that severe affection of physical health negatively impacted the patients' QoL. Comparing the various treatment modalities with overall physical health, patients on radiotherapy enjoyed better physical health than those on chemotherapy or chemoradiation. The difference was statistically significant (P < 0.05). This may be due to side effects of chemotherapy. This complex relationship between physical health and QoL has been highlighted in other studies.,
| Conclusions|| |
Cancer of the cervix, often in advanced stages, afflicts middle-aged multiparous women in Nigeria. Majority of the victims are unemployed and depend on their immediate families for social and financial support. Patients report gross disruptions of all facets of QoL. Intensive health awareness campaigns would enhance early presentation and improve not only cure rates but also the QoL of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al.
GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globocan.iarc.fr
. [Last accessed on 2017 Feb 12].
Adewole IF, Benedet JL, Crain BT, Follen M. Evolving a strategic approach to cervical cancer control in Africa. Gynecol Oncol 2005;99:S209-12.
Anorlu RI, Obodo K, Makwe CC. Cancer mortality among patients admitted to gynecological wards at Lagos university Teaching Hospital, Nigeria. Int J Gynaecol Obstet 2010;110:268-9.
Anorlu RI. Cervical cancer: the Sub-Saharan African perspective. Reprod Health Matters 2008;16:41-9.
Musa J, Nankat J, Achenbach CJ, Shambe IH, Taiwo BO, Mandong B, et al.
Cervical cancer survival in a resource-limited setting-North Central Nigeria. Infect Agent Cancer 2016;11:15.
Olutoyin GO, Olusola BF, Kayode AA, Olusegun SO. Histological pattern of cervical cancers in South Western Nigeria. Trop J Obstet Gynaecol 2004;21:118-21.
Iyorke CA, Ugwu GO, Ezugwu EC, Ezugwu FO, Lawani LO, Onyebuchi AK. Challenges associated with management of gynaecological cancer in a tertiary hospital in South East Nigeria. Int J Women's Health 2014;6:123-30.
Umanah IN, Ugiabe EE, Olu-Eddo AN. Female genital malignancies in a Niger Delta Region of Nigeria. Ibom Med J 2013;6:23-8.
Kyari O, Nggada H, Mairiga A. Malignant tumours of the female genital tract in North Eastern Nigeria. East Afr Med J 2004;81:142-5.
Ijaya MA, Aboyeji AP, Olatinwo AW, Buhari MO. Clinico-pathological presentation of primary cervical cancer seen in Ilorin, Nigeria. Niger J Surg Res 2002;4:89-92.
Mohammed A, Ahmed SA, Oluwole OP, Avidime S. Malignant tumours of the female genital tract. An analysis of 513 cases. Ann Afr Med 2006;5:93-6.
Oguntayo O, Zayyan M, Kolawole A, Adewuyi S, Ismail H, Koledade K, et al.
Cancer of the cervix in Zaria, Northern Nigeria. Ecancermedicalscience 2011;5:219.
Matthew FM, Steven DB, Jamine DF, Stephen BM. What are quality of life measurements measuring? BMJ 1998;316:542-5.
Małgorzata P, Suchocka L, Urbański K. Quality of life in cervical cancer patients treated with radiation therapy. J Clin Nurs 2012;22:690-7.
Harris K, Holden C, Chen M. Background Information on National Indicators for Social Determinants of Health. Paper Presented to the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, National Opinion Research Center; 5 January, 2010.
Hawighorst-Knapstein S, Fusshoeller C, Franz C, Trautmann K, Schmidt M, Pilch H, et al.
The impact of treatment for genital cancer on quality of life and body image – Results of a prospective longitudinal 10-year study. Gynecol Oncol 2004;94:398-403.
Eze JN, Emeka-Irem EN, Edegbe FO. A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in Southeast Nigeria. Clin Med Insights Oncol 2013;7:151-8.
Taylor RJ, Morrell SL, Mamoon HA, Wain GV. Effects of screening on cervical cancer incidence and mortality in New South Wales implied by influences of period of diagnosis and birth cohort. J Epidemiol Community Health 2001;55:782-8.
Harrison KA. Child-bearing, health and social priorities: A survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol 1985;92 Suppl 5:1-119.
Wiebe E, Denny L, Thomas G. Cancer of the cervix uteri. Int J Gynaecol Obstet 2012;119 Suppl 2:S100-9.
UNDP. Human Development Report. New York, University Press; 2005.
Adamou N, Umar UA. Delayed presentation of patients with gynaecological malignancies in Kano, North-Western Nigeria. Open J Obstet Gynecol 2015;5:333-40.
Smith HO, Tiffany MF, Qualls CR, Key CR. The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States – A 24-year population-based study. Gynecol Oncol 2000;78:97-105.
Bray F, Carstensen B, Møller H, Zappa M, Zakelj MP, Lawrence G, et al.
Incidence trends of adenocarcinoma of the cervix in 13 European countries. Cancer Epidemiol Biomarkers Prev 2005;14:2191-9.
Arrossi S, Matos E, Zengarini N, Roth B, Sankaranayananan R, Parkin M, et al.
The socio-economic impact of cervical cancer on patients and their families in Argentina, and its influence on radiotherapy compliance. Results from a cross-sectional study. Gynecol Oncol 2007;105:335-40.
Ohaeri JU, Campbell OB, Ilesanmil AO, Ohaeri BM. Psychosocial concerns of Nigerian women with breast and cervical cancer. Psychooncology 1998;7:494-501.
Krumm S, Lamberti J. Changes in sexual behavior following radiation therapy for cervical cancer. J Psychosom Obstet Gynaecol 1993;14:51-63.
Molassiotis A, Chan CW, Yam BM, Chan SJ. Quality of life in Chinese women with gynaecological cancers. Support Care Cancer 2000;8:414-22.
Das S, Jeba J, George R. Cancer and treatment related pains in patients with cervical carcinoma. Indian J Pallliat Care 2005;11:74-81.
Francois L, Colleau SM, Brasseur L, Cleeland CS. Multicentre study of cancer pain and its treatment in France. BMJ 1995;10:1034-7.
Nuhu FT, Odejide OA, Adebayo KO, Yusuf AJ. Psychological and physical effects of pain on cancer patients in Ibadan, Nigeria. Afr J Psychiatry (Johannesbg) 2009;12:64-70.
Elumelu N, Adenipekun A, Soyannwo O, Aikomo OO, Amanor-Boadu SM, Ogundalu OO. Palliative care experience in breast and uterine cervical cancer patients in Ibadan, Nigeria. Internet J Pain Symptom Control Palliat Care 2013;10:4-9.
Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry 1990;51:12-7.
Dahiya N, Acharya AS, Bachani D, Sharma D, Gupta S, Haresh K, et al.
Quality of life of patients with advanced cervical cancer before and after chemoradiotherapy. Asian Pac J Cancer Prev 2016;17:3095-9.
Sloan JA, Cella D, Frost M, Guyatt GH, Sprangers M, Symonds T. Assessing the clinical significance of quality-of-life measures in oncology research: State of the science. Clin Ther 2002;24:1-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]