Life after cervical cancer - Wiley Online Library

145 downloads 0 Views 167KB Size Report
Life after cervical cancer: Quality of life among. Chinese womennhs_616 296..302. Ying Chun Zeng, rn, mphil,1 Dingmei Li, rn, bmed2 and Alice Yuen Loke, rn, ...
Nursing and Health Sciences (2011), 13, 296–302

Research Article

Life after cervical cancer: Quality of life among Chinese women nhs_616

296..302

Ying Chun Zeng, rn, mphil,1 Dingmei Li, rn, bmed2 and Alice Yuen Loke, rn, phd1 1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong and 2Department of Nursing, Huaihua Medical College, Huaihua, China

Abstract

This study explored the meaning of “quality of life” among Chinese survivors of cervical cancer and the impact of cervical cancer survivorship on these women’s quality of life. Written responses were used as the means of data collection. The qualitative data were analyzed by using a qualitative content analysis. The meaning of “quality of life”, as perceived by 35 Chinese survivors of cervical cancer, included being free of disease, having a good standard of living, having a harmonious family atmosphere, and having a harmonious sex life. The impact of cervical cancer on the Chinese women’s quality of life included physical and psychological sequelae, family distress, financial burden, and disruptions to their social functioning and sexual life. Nevertheless, there were positive gains that were reported by these survivors, including changes in their outlook on life, treasuring their life, and better family relationships. This study revealed that the Chinese survivors of cervical cancer identified their sexual life as one of the essential indicators of quality of life. It is necessary to raise nurses’ awareness so that women’s sexuality-related concerns are addressed. Health professionals also should provide relevant supportive care in order to address this target population’s physical and psychosocial needs across the survivorship continuum.

Key words

cancer survivor, cervical cancer, Chinese women, nursing, quality of life, sexuality.

INTRODUCTION Cervical cancer is one of the most common types of cancer in developing countries. Due to widespread screening programs, most cases of cervical cancer are being diagnosed in the earlier stages and with a good prognosis. Despite better survival rates, the survivors of cervical cancer might continue to live with its sequelae (Vistad et al., 2006). Quality of life (QOL) assessment among cancer survivors can aid in the detection of these late effects and long-term sequelae (Victorson et al., 2007).

Quality of life among survivors of cervical cancer Research on the survivors of cervical cancer has reported various QOL concerns. The major physical impacts include the inability to bear children, as well as menopausal, urologic, and gastrointestinal symptoms (Korfage et al., 2009). The common sequelae that disrupt the psychological aspects of life for survivors of cervical cancer include a fear of cancer recurrence and reduced self-confidence (Ashing-Giwa et al., 2004; Bradley et al., 2006). The common social sequelae Correspondence address: Alice Y. Loke, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China. Email: hsaloke@ inet.polyu.edu.hk Received 20 January 2011; accepted 6 May 2011.

© 2011 Blackwell Publishing Asia Pty Ltd.

include social stigma and social isolation, which are linked to social associations between cervical cancer and unsafe sexual practices (Lai et al., 2009). The major sexual and reproductive side-effects of the treatments for cervical cancer include a reduced sexual desire, diminished lubrication, and a shortened vaginal cavity (Jensen et al., 2003; 2004). In summary, these physical, psychological, social, and sexual sequelae severely influence women’s QOL.

Measurement of the quality of life of survivors of cervical cancer A variety of questionnaires has been used to assess the QOL of women with cervical cancer. Zeng et al. (2010) summarized the four types of QOL instruments that have been used: generic (e.g. Medical Outcome Study: 36-Item Short Form Survey) (Distefano et al., 2008), cancer-specific (e.g. European Organization for Research Treatment’s QOL cancer-specific questionnaire) (Greimel et al., 2009), cancer site-specific (e.g. Functional Assessment of Cancer TherapyCervix) (Ashing-Giwa, 2008), and cancer survivor-specific (e.g. Cancer Survivors’ Unmet Needs) (Hodgkinson et al., 2007). These instruments vary in their length and emphasis, but it has been reported that none of them is comprehensive enough to explore all the domains of QOL across the survivorship continuum (Zeng et al., 2010). doi: 10.1111/j.1442-2018.2011.00616.x

Quality of life among Chinese women

An increasing amount of quantitative evidence on QOL among Chinese survivors of cervical cancer has become available in recent years (e.g. Liu et al., 2006; Zhang et al., 2009). However, there is a lack of qualitative insight into the impact of cervical cancer and its related treatments on Chinese women’s survivorship experiences. It is the intention of this qualitative study to explore the QOL among Chinese survivors of cervical cancer.

AIMS The purposes of this study were to explore the meaning of QOL among Chinese survivors of cervical cancer and the impacts of cervical cancer survivorship on these women’s QOL.

METHODS Design In order to obtain information on Chinese cervical cancer survivors’ perceptions of QOL, a descriptive, exploratory design, using the QOL model of Ferrell et al. (1997) as a framework for the exploration, was used.

Sample and setting All the participants were recruited from a tumor hospital in mainland China. A purposive sampling strategy was used to select the participants. For the purposes of the study, a “survivor of cervical cancer” was defined as an individual who was alive after the initial treatment for cervical cancer. The inclusion criteria for the sample were: (i) Chinese women who were at least 18 years old and had a diagnosis of cervical cancer; (ii) completion of the primary cancer treatment; and (iii) currently cancer-free. The exclusion criteria for the sample were: (i) no cancer recurrence or metastasis; (ii) diagnosed with secondary cancer; and (iii) lacking basic literacy so as to not understand and write in Chinese.

Data collection Method of data collection Compared with face-to-face interviews, written responses have the advantage of putting the participants under less interaction pressure (Salander, 2002). Written qualitative responses do not require transcription, so this method is less time-consuming and more cost-effective (Hamilton & Bowers, 2006). Other advantages are that written responses might overcome the barrier of dialects, as persons in mainland China typically speak many different Chinese dialects, even within the same province, but the written form is understandable across these language groups. The impersonal nature of written responses also might help the participants to express their feelings or perceptions that they would not be willing to describe in a face-to-face interview (Hunt & McHale, 2007). In particular, when survivors of cervical cancer are asked about sensitive issues, such

297

as sexual health, they are more likely to share their perceptions in written form rather than by expressing them verbally. However, the disadvantages of written responses are the lack of interaction between the interviewer and interviewee and the absence of spontaneous responses that are obtained in face-to-face interviews (Holloway & Wheeler, 2002).

Process of data collection The data were collected from August to December 2009. Eligible women were invited to complete a demographic form and some open-ended questions (Appendix I) about their perceptions of QOL. The design of this written response sheet was framed by the QOL model of Ferrell et al. (1997). All the participants were recruited from the tumor hospital’s gynecologic outpatient department, which included patients with gynecologic cancer at their follow-up visits. A gynecologic oncologist helped with the data collection. The women were asked to return their written responses to the hospital or by mail.

Data analysis A qualitative content analysis was adopted to analyze the qualitative data. The written responses were read by the first author, who tried to be familiar with the data and to obtain a general understanding of the data. The first author reread all the written responses carefully, highlighted sections of the text, and started to write down as many headings as possible in order to describe all aspects of QOL among the Chinese survivors of cervical cancer. Then, the first author cut out the highlighted sections of the text and grouped all the headings in a list, with similar headings grouped together and developed into a temporary list of categories and subcategories. The temporary list was compared with the raw written responses and the final list of categories and subcategories was produced, covering all aspects of the written responses. The second author worked separately to categorize the statements before meeting to discuss and agree on the categories.

Ethical considerations Ethical approval was obtained from the Human Subjects Ethics Application Review System of The Hong Kong Polytechnic University, Hong Kong, and the hospital’s Human Subjects Research Review Committee before the start of this study. Information sheets about the purpose of the study were provided to all the participants and their participation was voluntary. After the participants’ consent was obtained, the researcher further explained the process of data collection and reassured them that they could withdraw from the study at any time. A code number for each participant was used to ensure anonymity. In order to maintain the confidentiality of the research data, the raw data could be accessed only by the researcher.

Rigor in qualitative studies Rigor in qualitative studies is assured through achieving the credibility and confirmability of the results (Speziale & © 2011 Blackwell Publishing Asia Pty Ltd.

298

Table 1.

Y-C. Zeng et al.

Meaning of “quality of life”, as perceived by Chinese women

Component

Participant

Health condition Good health and free of disease Issues related to daily living Normal living Having basic living materials Regular living habits, such as eating, sleeping, and entertaining activities Living independently and having a good standard of living Being happy Having hope for the future Being easily satisfied with life Social relationships Good social relationships generally and good interpersonal relationships with friends and colleagues Financial condition Quality of life depends on the financial condition and having to save as much as possible to afford the cost of cancer treatments and living expenses Good, with enough money to use Family issues Family harmony, good family relationships, and individuals and things in the family are running smoothly Work-related issues Working conditions, being able to independently finish work, good quality of work, and recognition from colleagues Issues related to sex life The importance of sexual activity and the existence of harmony in the sexual relationship with the husband/partner

CCS3, 9, 15–17, 19, 20, 24, 26, 29, 30–35 CCS16, 21 CCS11 CCS18 CCS2, 4, 10, 23, 25, 28 CCS9, 16, 24, 29 CCS20, 22 CCS15 CCS4, 13, 20, 24

CCS1 CCS12, 13, 15, 27 CCS7, 9, 13, 17, 18, 25, 28, 34

CCS4, 14, 15, 31

CCS7, 12, 17, 26, 29

CCS, cervical cancer survivor.

Carpenter, 2007). This study recruited participants with experience that was related to cervical cancer and its impacts on QOL, which enhanced the true value of the results through the purposive sampling strategy. In addition, this study enhanced the credibility of the study’s results by adopting the “member checking” strategy; that is, checking with the participants with regard to the accuracy of the results (Leech & Onwuegbuzie, 2007). The member check involved two participants in the current study, one at an early disease stage and the other at an advanced disease stage. Both of them agreed with the interpretations and findings, including the codes, subcategories, and categories. The confirmability was achieved by an audit trail: the second author used the thematic content analysis on the same set of data independently, yielding similar results.

RESULTS Demographic and medical characteristics of the survivors of cervical cancer A total of 42 eligible women was accessed and invited to participate in the study. Thirty-five women responded to the invitation to provide a narrative account of their experience. Most of the survivors of cervical cancer were aged in their 30s (14) or 40s (13). Eighteen had a high school education or above. Ten were working at the time of the data collection. Twenty-three had been unemployed since their cancer diag© 2011 Blackwell Publishing Asia Pty Ltd.

nosis. Most were married, but nine divorced after their cancer diagnosis. Twenty of the survivors of cervical cancer were diagnosed at an early stage of the disease. Eighteen had received a combination of cancer treatments (surgery, chemotherapy, or radiotherapy). Fifteen respondents had 1–2 years of postprimary treatment.

Meaning of “quality of life” The participants were asked, “Could you please describe the meaning of ‘quality of life’ in your own words?”, and they provided the major components of the meaning of QOL according to their own perception (Table 1). The most common one was that “QOL” meant being in good health and free of disease. The second component was women’s concerns about daily living, such as “normal living” and having a good living standard. Other issues that were related to daily living included regular living habits and being easily satisfied with life. The third component was related to social and interpersonal relationships, such as the quality of the women’s relationships with family members, colleagues, and society at large. The fourth component concerned the participants’ financial condition, such as having enough money to afford the cost of cancer treatment. The fifth component was related to family issues: having a happy family or having harmonious family relationships. The sixth component was work-related issues: being able to work independently and having the

Quality of life among Chinese women

quality of one’s work recognized by colleagues. The final one was related to the participants’ sex life. Some women considered sexual activity and a harmonious sexual relationship with their partner as important indicators of their QOL.

Impact of cervical cancer survivorship on the Chinese women’s quality of life According to the QOL model of Ferrell et al. (1997), QOL includes physical, psychological, social, and spiritual wellbeing. Sexual health issues also were perceived as important indicators of QOL by the participants in the current study. Thus, the analysis of the impact of cervical cancer survivorship on the participants’ QOL was classified into five domains, as described below. “CCS” in the parentheses after the quotations refers to “cervical cancer survivor”.

Domain 1: Impacts on physical well-being Physical health impacts included a loss of appetite, poor sleep quality, a loss of hair, weight changes, premature menopause symptoms due to the removal of the ovaries or ovarian failure, constipation, and dysuria: I was very sensitive to radiotherapy. After treatment, I had no appetite and poor quality of sleep. Also, my immune system was weaker than before, so that I caught cold easily . . . (CCS3, 36 years old). . . . leg edema and hyperspasmia, hot flushes, midnight sweating, and severe constipation . . . (CCS12, 33 years old; CCS18, 42 years old).

Domain 2: Impacts on psychological well-being

299

After the cancer diagnosis, I quit my job. Just staying at home and having nothing to do, I felt isolated (CCS20, 41 years old). . . . I lost my job due to my disease. My social networks were narrowed as a consequence . . . (CCS29, 43 years old). Changes in roles and responsibilities. Many of the women stated that the household roles and the responsibility for daily chores had been taken over by their husband or parents. These women felt uncomfortable with this situation, as it rendered them dependent and unable to carry out the duties that they easily had taken care of previously: I used to do all the housework, such as cleaning, cooking, etc. After the disease diagnosis, I had no desire and was getting too tired to do these things. My family members did as much as they could to look after me (CCS12, 33 years old). Being a burden to the family. One aspect that was experienced by the women was placing an emotional burden on their husband: . . . worrying about my disease influenced my family members’ quality of life, especially for my children. Since getting the disease, I had become more irritable. Sometimes, I would quarrel with my husband. Now, the whole family suffered from lots of pressure (CCS15, 32 years old; CCS28, 47 years old). The other aspect was the financial burden that was placed on the family, such as having to afford cancer treatment:

Cervical cancer and its related treatments also can have psychological sequelae: anxiety, depression, becoming irritable, feeling guilty due to burdening the family, fatigue, and worrying about the disease. A fear of cancer recurrence was one common negative psychological concern. Other subthemes included a sense of vulnerability, such as reduced self-esteem and sense of self:

In order to come to hospital to undertake systematic treatment, all my family members have to save as much as possible in daily living. In order to pay for my treatment, my whole family borrowed a lot of money from others. Particularly since I haven’t returned to work, I am under a lot of financial pressure (CCS1, 35 years old).

One year after surgery, my mood was not stable and I would have significant mood swings. I felt more irritable, worried about the disease, and afraid of cancer recurrence . . . (CCS18, 42 years old).

Coping methods and sources of support. The participants had numerous sources of support for coping with their disease. The most common one was caring and psychological and/or social support from the family. Some women even perceived that their family members gave them too much support:

Sometimes, I felt very anxious and worried about the possible recurrence of cancer, resulting in sleeplessness, feeling dirty, and having no sense of self (CCS9, 48 years old; CCS31, 52 years old).

Domain 3: Impacts on social well-being Changes in daily life and a feeling of social isolation. Although some women perceived no change in their daily life, more than half perceived cancer as having negative impacts on their social functioning, including a more limited social network and a feeling of isolation:

. . . my family members always tell me that my life is not just belonging to myself. No matter what happens, I have to live for my family (CCS3, 36 years old). All family members very [much] emphasized my health conditions. They did whatever they could for me. But, I don’t want to get so much caring, it has adverse effects on me and lets me feel depressed (CCS4, 42 years old). Also, the women could obtain support and care from their relatives, friends, and colleagues: © 2011 Blackwell Publishing Asia Pty Ltd.

300

My neighbor and colleagues’ support and caring let me come through all those hard times during my treatment (CCS18, 42 years old; CCS25, 51 years old).

Domain 4: Effects on spiritual well-being Some of the women tried to find meaning in their disease and made different deductions about the meaning of life: We have no need to complain too much about life, as we will all die some day. This is the natural law. Getting cancer . . . is fate and we have to face our own fate and other kinds of suffering in our lives (CCS33, 58 years old). Many of the other women perceived certain positive gains from their cancer experience. These changes included a more positive outlook on life, such as treasuring life more, appreciating their relationships with others, viewing the cancer experience as a rebirth, the relationship with their husband becoming more intimate, and their family relationship becoming more harmonious: . . . compared with before I had cancer, now I have a more positive outlook on life and enjoy it every day (CCS1, 35 years old). Compared with before the cancer, my relationship with my husband has become more intimate, I am more content with life and more aware of my health, and I treasure life and feel grateful to be alive (CCS17, 46 years old; CCS20, 41 years old).

Domain 5: Disruptions to sexual life There were negative changes in the women’s sex life. Since the diagnosis and treatment of cervical cancer, many of the survivors (13 out of 35) had not resumed sexual activities.The reasons included not having a partner, being too tired to have sex, a fear of sexual activity weakening the potency of the cancer treatment, and the husband not initiating sexual activity due to a fear of the disease: Since the surgery, there has been no sexual activity, as I am worried that sexual intercourse might influence the effect of the treatment . . . (CCS1, 35 years old). Before the surgery, our sex life was really good. Since the surgery, there has been no sexual activity. My husband and I sleep in different beds. Relevant factors include fear of disease, the negative impact of thinking about sexual intercourse, and the lack of sexual desire (CCS9, 48 years old). Some of the women reported that they were currently sexually active but that there was a reduced frequency and/or quality of their sexual activity because of vaginal dryness, dyspareunia, and worry about the disease: The frequency is the same but . . . the quality of our sex life is not as good. There are lots of factors, including vaginal dryness, pain during sexual intercourse, and my © 2011 Blackwell Publishing Asia Pty Ltd.

Y-C. Zeng et al.

husband also being afraid of contracting the disease . . . (CCS7, 31 years old; CCS29, 43 years old).

DISCUSSION The results of this study support a growing body of knowledge that is related to the QOL among survivors of cervical cancer. In this study, most of the Chinese survivors of cervical cancer defined QOL as being in good health and free of disease. Other Chinese survivors of cervical cancer perceived QOL as being happy with the quality of their interpersonal relationships. The results of the current study are similar to those of previous studies that took place in Hong Kong: the Chinese cancer survivors in these studies also viewed “normal living”, a good working life, happiness, and support from their family as essential indicators of QOL (Molassiotis et al., 2000). In the current study, the Chinese survivors of cervical cancer perceived numerous physical impairments, such as poor sleep quality, a loss of appetite, vomiting, and a loss of fertility, which is similar to the results of other research in Western countries (Ashing-Giwa et al., 2004; Distefano et al., 2008; Greimel et al., 2009). The psychological impacts included depression, a fear of cancer recurrence, feeling guilty, and reduced self-esteem. The social rejection of survivors of cervical cancer is common in China, as cervical cancer is viewed as “dirty” and is labeled as a sexually transmitted disease that is related to early sexual activity and multiple sexual partners (Lai et al., 2009), which might result in a negative impact on women’s emotional well-being (Chan et al., 2001). Therefore, nurses should be developing mechanisms to provide support for women’s fear about the cancer spreading and their uncertainty about the future. This study also identified the ongoing challenges in the women’s personal and social lives. The demographic data clearly revealed that the impact of cervical cancer and its subsequent treatments brought about changes in the women’s marital and employment status. Nine women were divorced and 23 out of 35 women were unemployed after the completion of their cancer treatment. This study also found that some of the women were unable to take care of their usual daily living activities, such as housework and child care, which they saw as their duties and responsibilities. Therefore, cervical cancer was still causing problems in the flow of the women’s daily life. Coping strategies are thought to play an important role in managing the physical and psychological sequelae that are associated with a cancer diagnosis and treatment (Costanzo et al., 2006). There are differences between the coping strategies that are used by women in China and those that are used by women in Western countries. Religious beliefs and spiritual applications are important in coping with and fighting the disease and increasing the hope for cancer survival in Western cultures (Ferrell et al., 2002). It was reported in one study that almost all (95%) of the patients with gynecologic cancer in Turkey used worship and prayer as disease-control methods and psychological support mechanisms (Akyuz et al., 2007). In another study in the USA, praying also was a

Quality of life among Chinese women

commonly used coping strategy for the female cancer survivors after treatment (Lauver et al., 2007). Most of the Chinese survivors of cervical cancer in this study coped with their disease with the support and caring of their family. Beliefs and values that are related to the family are as strong as religious beliefs for Chinese persons (Chen, 2001). This is why most Chinese survivors of cervical cancer view family support as an essential coping strategy. Chan et al. (2001) conducted a study to investigate the social support that was perceived by patients with gynecologic cancer in Hong Kong and their results showed that the participants emphasized the importance of interpersonal relationships and reported their social support as coming mainly from family members. Regarding the effects on spiritual well-being of life after the diagnosis and treatment of cervical cancer, this study demonstrated that the Chinese survivors of cervical cancer perceived a more positive outlook on life and treasured life more. These results are also consistent with those of studies that were conducted in Western countries (Hodgkinson et al., 2007; Akyuz et al., 2008; Clemmens et al., 2008). An additional positive impact that was identified by survivors of gynecologic cancer in Hong Kong included being sensitive to others’ needs (Molassiotis et al., 2002). Many studies have indicated that sexual problems often are related to the treatment for gynecologic cancer (Molassiotis et al., 2002). In this study, 13 out of 35 participants reported the complete cessation of sexual activity after their cancer treatment or since the diagnosis of cervical cancer and eight indicated that there were significant changes in their sex life, including a reduced frequency and quality of sexual activity. The rate of reduced or no sex life was relatively high among the Chinese survivors of cervical cancer. This finding might be related to Chinese culture. Taoist beliefs about the regulation of sexual activities in order to preserve one’s health suggest that a Chinese woman and her spouse should reduce or cease sexual activities after the diagnosis and treatment of cancer in order to facilitate the recovery of the woman’s health (Tang et al., 1996). Although sexual issues are not discussed openly and are viewed as a cultural taboo in Chinese communities (Khoo, 2009), the unexpected finding from this study was that some Chinese survivors of cervical cancer defined the importance of their sex life and the harmony of the sexual relationship with their husband as one of the major indicators of their QOL. Therefore, cervical cancer survivors’ sexuality issues should receive as much attention as other aspects of women’s health.

Recommendations for future research and practice Further research that provides diverse methods of data collection, such as interviewing rather than written responses, is needed. In the Chinese culture, sexuality issues are not discussed openly and are viewed as a cultural taboo. However, in this study, some of the participants defined the importance of sexual activity and the harmony of their sex life as a major indicator of their QOL. Further research is needed to explore how sexuality-related issues impact Chinese cervical cancer

301

survivors’ QOL in detail. In clinical practice, nurses and other healthcare providers in China should address cervical cancer survivors’ sexuality-related concerns.

Limitations of the study The present study had a few limitations. There was just one tumor hospital involved as the research setting, thus making it difficult to establish the transferability of the study’s results. Another limitation was the use of written responses as the only means of data collection. Written responses lack the interaction and spontaneity of face-to-face interviews, although the participants might be more likely to share sensitive issues, such as women’s sexual health, via written responses because there is less interaction pressure. Participants with a low educational level might have been excluded from this study.

CONCLUSION The results of this study revealed that being healthy or free of disease was a common indicator of QOL among the Chinese survivors of cervical cancer. Although the women perceived certain positive gains from their cancer experience, such as personal growth and better family relationships, their cancer diagnosis and relevant cancer treatment had ongoing physical, psychological, social role/responsibility, and sexual implications for their well-being. In order to improve the QOL and overall survival outcomes of survivors of cervical cancer, Chinese nurses and other health professionals should provide relevant supportive care to address this target population’s physical, psychological, social, spiritual, and sexual needs across the survivorship continuum.

REFERENCES Akyuz A, Dede M, Cetinturk A et al. Self-application of complementary and alternative medicine by patients with gynecologic cancer. Gynecol. Obstet. Invest. 2007; 64: 75–81. Akyuz A, Guvenc G, Ustunsoz A, Kaya T. Living with gynecologic cancer: experience of women and their partners. J. Nurs. Scholarsh. 2008; 40: 241–247. Ashing-Giwa KT. Enhancing physical well-being and overall quality of life among underserved Latina-American cervical cancer survivors: feasibility study. J. Cancer Surviv. 2008; 2: 215–223. Ashing-Giwa KT, Kagawa-Singer M, Padilla GV et al. The impact of cervical cancer and dysplasia: a qualitative, multiethnic study. Psycho-oncology 2004; 13: 709–728. Bradley S, Rose S, Lutgendorf S, Costanzo E, Anderson B. Quality of life and mental health in cervical and endometrial cancer survivors. Gynecol. Oncol. 2006; 100: 479–486. Chan YM, Ngan HYS, Li BYG et al. A longitudinal study on quality of life after gynecologic cancer treatment. Gynecol. Oncol. 2001; 83: 10–19. Chen YC. Chinese values, health and nursing. J. Adv. Nurs. 2001; 36: 270–273. Clemmens DA, Knafl K, Lev EL, McCorkle R. Cervical cancer: patterns of long-term survival. Oncol. Nurs. Forum 2008; 35: 897– 903. Costanzo ES, Lutgendorf S, Rothrock NE, Anderson B. Coping and quality of life among women extensively treated for gynecologic cancer. Psycho-oncology 2006; 15: 132–142.

© 2011 Blackwell Publishing Asia Pty Ltd.

302

Distefano M, Riccardi S, Capelli G et al. Quality of life and psychological distress in locally advanced cervical cancer patients administered pre-operative chemoradiotherapy. Gynecol. Oncol. 2008; 111: 144–150. Ferrell B, Ervin K, Smith S, Marek T, Melancon C. Family perspectives of ovarian cancer. Cancer Pract. 2002; 10: 269–276. Ferrell BR, Grant MM, Funk B, Otis-Green S, Garcia N. Quality of life in breast cancer survivors as identified by focus groups. Psycho-oncology 1997; 6: 13–23. Greimel ER, Winter R, Kapp KS, Haas J. Quality of life and sexual functioning after cervical cancer treatment: a long-term follow-up study. Psycho-oncology 2009; 18: 476–482. Hamilton RJ, Bowers BJ. Internet recruitment and e-mail interviews in qualitative studies. Qual. Health Res. 2006; 16: 821–835. Hodgkinson K, Butow P, Fuchs A et al. Long-term survival from gynecologic cancer: psychosocial outcomes, supportive care needs and positive outcomes. Gynecol. Oncol. 2007; 104: 381–389. Holloway I, Wheeler S. Qualitative Research in Nursing (2nd edn). Oxford: Blackwell Science, 2002. Hunt N, McHale S. A practical guide to the e-mail interview. Qual. Health Res. 2007; 17: 1415–1421. Jensen PT, Groenvold M, Klee MC, Thranov I, Petersen MA, Machin D. Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer. Int. J. Radiat. Oncol. Biol. Phys. 2003; 56: 937–949. Jensen PT, Groenvold M, Klee MC, Thranov I, Petersen MA, Machin D. Early-stage cervical carcinoma, radical hysterectomy, and sexual function. Cancer 2004; 100: 97–106. Khoo SB. Impact of cancer on psychosexuality: cultural perspectives of Asian women. Int. J. Nurs. Pract. 2009; 15: 481–488. Korfage IJ, Essink-Bot M, Mols F, Poll-Franse LV, Kruitwagen R, Ballegooijen MV. Health-related quality of life in cervical cancer survivors: a population-based study. Int. J. Radiat. Oncol. Biol. Phys. 2009; 73: 1501–1509. Lai BP, Tang CS, Chung TKH. Age-specific correlates of quality of life in Chinese women with cervical cancer. Support. Care Cancer 2009; 17: 271–278. Lauver DR, Connolly-Nelson K, Vang P. Stressors and coping strategies among female cancer survivors after treatments. Cancer Nurs. 2007; 30: 101–111. Leech NL, Onwuegbuzie AJ. An array of qualitative data analysis tools: a call for data analysis triangulation. Sch. Psychol. Q. 2007; 22: 557–584. Liu Z, Wang J, Wang GQ, Luo W. [Investigation of the quality of life after radiotherapy of cervical cancer patients.] Mod. Oncol. 2006; 14: 1180–1181 (in Chinese). Molassiotis A, Chan CWH, Yam BMC, Chan SJ. Quality of life in Chinese women with gynecological cancers. Support. Care Cancer 2000; 8: 414–422.

© 2011 Blackwell Publishing Asia Pty Ltd.

Y-C. Zeng et al.

Molassiotis A, Chan CWH, Yam BMC, Chan SJ, Lam CS. Life after cancer: adaptation issues faced by Chinese gynaecological cancer survivors in Hong Kong. Psycho-oncology 2002; 11: 114– 123. Salander P. Bad news from the patient’s perspective: an analysis of the written narratives of newly diagnosed cancer patients. Soc. Sci. Med. 2002; 55: 721–732. Speziale HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative (4th edn). Philadelphia: Lippincott Williams & Wilkins, 2007. Tang CSK, Siu BN, Lai FDM, Chung TKH. Heterosexual Chinese women’s sexual adjustment after gynecologic cancer. J. Sex Res. 1996; 33: 189–195. Victorson D, Cella D, Wagner L, Kramer L, Smith ML. Measuring quality of life in cancer survivors. In: Feuerstein M (ed.). Handbook of Cancer Survivorship. New York: Springer, 2007; 79– 110. Vistad I, Fossa SD, Dahl AA. A critical review of patient-rated quality of life studies of long-term survivors of cervical cancer. Gynecol. Oncol. 2006; 102: 563–572. Zeng YC, Ching SY, Loke AY. Quality of life measurement in women with cervical cancer: implications for Chinese cervical cancer survivors. Health Qual. Life Outcomes 2010; 8: 30. [Cited 20 Oct 2010.] Available from URL: http://www.hqlo.com/content/8/ 1/30 Zhang XQ, Wan CH, Lu YB et al. [Development and evaluation of quality of life instruments for cancer patients – cervix cancer (QLICP-CE).] China Oncol. 2009; 18: 183–186 (in Chinese).

APPENDIX I Written response sheet (English translation) 1 In your words, what does “quality of life” mean? 2 How do you perceive the impact of cervical cancer on your quality of life? • What do you think about the impact on your physical health? • What do you think about the impact on your psychological health? • What do you think about the impact on your social role and function? • What do you think about the impact on your spiritual well-being? • What do you think about the impact on your sexual health?