European Journal of Oncology Nursing 14 (2010) 400409

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Quality of life, symptom experience and distress of lung cancer patients

undergoing chemotherapy
Semiha Akin a, *, Gulbeyaz Can b, Adnan Aydiner c, Kursat Ozdilli d, Zehra Durna a
a

Istanbul Bilim University, Florence Nightingale Hospital School of Nursing, Vefabey sokak No: 17, 34349 Gayrettepe/Besiktas, Istanbul, Turkey
Istanbul University, Florence Nightingale School of Nursing, Turkey
c
Istanbul University, Institute of Oncology, Istanbul, Turkey
d
Halic University, Institute of Health Sciences, Istanbul, Turkey
b

a b s t r a c t
Keywords:
Lung cancer
Quality of life
Symptoms
Chemotherapy

The diagnosis of lung cancer in the advanced stage of illness, the poor prognosis associated with the
disease, and the side effects of chemotherapy all have an impact on various dimensions of quality of life
(QoL).
The purpose of the research: The current study was designed to describe the QoL and symptom distress of
lung cancer patients undergoing chemotherapy and to explore the relationships between demographic/
treatment-related characteristics and QoL.
Methods and sample: The sample consisted of 154 lung cancer patients undergoing chemotherapy. The
symptom experiences and QoL of lung cancer patients undergoing chemotherapy were evaluated using
the Memorial Symptom Assessment Scale and Quality of Life Index Cancer Version.
Results: The lung cancer patients had low QoL scores. The scores on the Health and Functioning subscale
were the lowest (20.33  5.59), while those of the Family subscale were the highest (27.66  2.77). The
most common physical symptoms experienced by lung cancer patients were lack of energy, coughing,
pain, lack of appetite, and nausea, while the psychological symptoms were feeling nervous, difculty
sleeping, feeling sad, and worrying. There was a negative relationship between the symptom distress and
quality of life scores (r 0.45; p < 0.000). Females and those with low income levels and performance
status experienced greater symptom distress.
Conclusions: Lung cancer patients receiving chemotherapy suffer many limitations due to the symptoms
and disruptions to their QoL, arising from both the disease process and its treatment. Lung cancer
patients need to be assessed regularly and supported.
2010 Elsevier Ltd. All rights reserved.

Introduction
Lung cancer is one of the leading causes of death worldwide, as
well as in Turkey (Alzahouri et al., 2006; Republic of Turkey
Ministry of Health Statistics, 1999). Lung cancer patients often
experience multiple symptoms related to the disease itself and its
treatment, and those symptoms can independently predict changes
in patient function, treatment failures, and post-therapeutic
outcomes (Fan et al., 2007; Fox and Lyon, 2006). Most lung cancer
patients are diagnosed with advanced disease, often involving
a high symptom burden (Wennman-Larsen et al., 2007). Compared
to other types of cancer, the distress associated with symptoms
* Corresponding author. Istanbul Bilim Universitesi, Florence Nightingale Hastanesi
Hemsirelik Yuksekokulu, Vefabey sokak No: 17, 34349 Gayrettepe/Besiktas, Istanbul,
Turkey. Tel.: 90 212 275 75 82; fax: 90 212 288 20 09.
E-mail address: semihaakin@yahoo.com (S. Akin).
1462-3889/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2010.01.003

arising from lung cancer has been reported as the most intense. The
symptoms of lung cancer patients are a major detriment to their
quality of life (QoL). These symptoms have profound secondary
effects on their emotional, social, physical, and spiritual well-being
(Fan et al., 2007; Thompson et al., 2005; Daly et al., 2007).
Health-related QoL is a multifactorial concept and includes the
effects of disease, the side effects of treatment, and physical and
psychosocial functions. The American Cancer Society has identied
four QoL factors that affect cancer patients and their families: social,
psychological, physical, and spiritual factors (American Cancer
Society, 2007). Virtually all disciplines involved in cancer care have
formally recognized the importance of addressing QoL as an
outcome of cancer treatment. In addition, there is growing appreciation of the extent to which the body and mind are linked, and
thus, psychosocial characteristics and variables can also contribute,
either as moderating or mediating factors, to both symptom experiences and patient outcomes, including survival (Daly et al., 2007).

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

Studies involving QoL assessments may help to (a) determine

the effects of disease and treatment, (b) compare alternative
treatments, and (c) detect morbidity so that intervention strategies can be formulated and implemented (Poon, 1995). Healthrelated quality of life is now commonly evaluated as an important
outcome measure in lung cancer clinical trials (Manser et al.,
2006). The QoL of lung cancer patients is affected by several
factors related to the patient, the stage of disease, and the
chemotherapy regimen. The association of lung cancer symptoms,
symptom burden and health-related quality of life warrants the
assessment of side effects of chemotherapy and cancer-specic
symptoms (Chen et al., 2007).
Chemotherapy causes side effects and toxicities which have
profound secondary effects on patients emotional, social, physical,
and spiritual well-being (Fan et al., 2007; Thompson et al., 2005;
Daly et al., 2007). A study reported that advanced non-small-cell
lung cancer patients receiving weekly docetaxel in the form of
second- or third-line chemotherapy experienced signicant side
effects and these side effects can result in treatment withdrawal
(Chen et al., 2008). The common side effects are fatigue, alopecia,
sore mouth, nausea and vomiting, neutropenia, and chemotherapyinduced toxicity (such as hematological toxicity, gastrointestinal
toxicity, neurological toxicity, renal toxicity etc.) (Bahl et al., 2006;
Bezjak et al., 2008; Bircan et al., 2003; Chen et al., 2008). In addition
to these side effects, patients undergoing chemotherapy experience
positive improvements in their QoL and survival rates with respect
to the chemotherapy regimen (Chen et al., 2007; Bircan et al.,
2003). A study reports that some chemotherapy regimens relieve
symptoms, and improve the performance status and QoL of
patients with advanced NSCLC (Belani et al., 2006). In a study
conducted with Turkish lung cancer patients, chemotherapy has
positive effects on some domains of QoL, specically the palliation
of symptoms (such as pain) in both non-small-cell lung cancer
(NSCLC) and small-cell lung cancer (SCLC) patients (Bircan et al.,
2003).
In the case of advanced lung cancer, QoL issues have become an
integral part of the decision-making process about various treatment options. Growing importance is now being attributed to the
proper evaluation and maintenance of the QoL of these patients.
A number of questionnaires have been developed and used in
clinical trials to measure the QoL of patients with lung cancer,
including the European Organisation for Research and Treatment
of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) and its
lung cancer module (EORTC-QLQ-LC13), the Lung Cancer
Symptom Scale, and the Functional Assessment of Cancer
Therapy-Lung Cancer Quality of Life Instrument (Brady et al., 1997;
Bozcuk et al., 2006).
Patients with lung cancer experience a variety of distressing
symptoms, many of which begin prior to diagnosis and continue
throughout the course of the disease and chemotherapy, adversely
affecting functional status and quality of life (Fox and Lyon, 2006).
Information about the QoL in lung cancer patients currrently
having chemotherapy can provide healthcare providers with
a perspective on posttreatment recovery, including the positive
aspects of long-term care, as well as anticipated problems. In order
to help patients to manage effectively the disease and treatmentrelated symptoms and to receive the optimal benets of therapy, it
is vital for healthcare providers to assess the symptom experience
and distress level, and the effects of those symptoms on key patient
outcomes such as QoL and health status.
The purpose of the research: The current study was designed to
describe the QoL and symptom experience and distress of lung
cancer patients undergoing chemotherapy and to explore the
relationships between demographic/treatment-related characteristics and QoL.

401

Research questions:
1. What is the quality of life (QoL) and symptom distress of
Turkish lung cancer patients undergoing chemotherapy?
2. What kind of symptoms do lung cancer patients undergoing
chemotherapy experience?
3. Is there a relationship between the QoL of lung cancer patients
undergoing chemotherapy and their personal, illness, and
treatment variables?
4. Is there a relationship between the symptom distress of lung
cancer patients undergoing chemotherapy and their personal,
illness, and treatment variables?

Methods
Study design and setting
This descriptive study was conducted in the ambulatory
chemotherapy unit at Istanbul University Institute of Oncology in
Turkey. A total of 352 lung cancer patients were treated at the
Institute of Oncology in 2008.
Sample
The research criteria for the sample were determined to reect
the following conditions: (1) receiving chemotherapy for lung
cancer at any stage of their chemotherapy, and any cycle, (2) having
an ECOG performance score between 0 and 3, (3) giving
consent to participate in the research, and (4) reading and speaking
prociently in Turkish. One hundred and eighty-nine lung cancer
patients undergoing chemotherapy were approached, and of this
number, 162 patients were eligible for inclusion in the sample and
agreed to participate in the study. Three patients were excluded
from the study following their return of incomplete questionnaires
and ve patients were too ill to take part in the research. The study
was then conducted with the remaining 154 patients.
Data collection instruments
In this research, three instruments were used for data collection.
Personal characteristics, disease, and chemotherapy variables were
collected using the Patient Questionnaire. The patient questionnaire was supplemented by information from medical records as
necessary. Patients symptoms distress and quality of life (QoL)
were evaluated using the Memorial Symptom Assessment Scale
(MSAS) and Quality of Life Index (QLI)-Cancer Version.
The patient questionnaire
It contains 14 questions related to the socio-demographic
background of the patient (age, gender, marital status, education,
occupation, employment status, perceived income level, and health
insurance), the illness of the patient (histological type and stage of
lung cancer, and ECOG performance), and treatment-related variables (chemotherapy protocol). The performance status of the
patient was evaluated in accordance with the Eastern Cooperative
Oncology Group-Performance Status Rating (ECOG-PSR). The ECOG
is one item measurement of performance status. The total score
ranges from 0 to 4.
Quality of Life Index Cancer Version
The Quality of Life Index (QLI) was developed by Ferrans and
Powers (1985) to measure quality of life (QoL) in terms of satisfaction with life. The QLI measures both the satisfaction and
importance of various aspects of life. Importance ratings are used to
weight satisfaction responses, so that scores reect the

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S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

respondents satisfaction with the aspects of life that they value.

Items that are rated as more important have a greater impact on
scores than those rated as being of lesser importance. The instrument consists of two parts: the rst measures satisfaction with
various aspects of life and the second measures the importance of
those same aspects. Scores are calculated to gauge overall QoL in
four domains: Health and Functioning, Psychological/Spiritual,
Social and Economic, and Family. The total score of the scale ranges
from 0 to 30, with a lower score indicating that the QoL is affected
more negatively (Ferrans and Powers, 1985).
The QLI (total scale) Cronbachs alphas range from 0.84 to 0.98;
from 0.70 to 0.93 for the Health and Functioning subscale; from 0.71
to 0.92 for the Social and Economic subscale; and from 0.80 to 0.93
for the Psychological/Spiritual subscale. For the Family subscale,
alphas ranged from 0.63 to 0.92 (Ferrans and Powers, 1985).
Memorial Symptom Assessment Scale (MSAS)
The MSAS is a Likert-type scale assessing 32 physical and
psychological symptoms (Lobchuk et al., 2006; Portenoy et al.,
1994). MSAS scoring yields several validated subscale scores. The
10-item MSAS-Global Distress Index (MSAS-GDI) is considered to be
a measure of overall symptom distress. The GDI is the average of the
frequency of four prevalent psychological symptoms (feeling sad,
worrying, feeling irritable, and feeling nervous) and the distress
associated with six prevalent physical symptoms (lack of appetite,
lack of energy, pain, feeling drowsy, constipation, and dry mouth).
The Physical Symptom Subscale score (MSAS-PHYS) is the average
of the frequency, severity, and distress associated with 12 prevalent
physical symptoms: lack of appetite, lack of energy, pain, feeling
drowsy, constipation, dry mouth, nausea, vomiting, change in taste,
weight loss, feeling bloated, and dizziness. The Psychological
Symptom Subscale score (MSAS-PSYCH) is the average of the
frequency, severity, and distress associated with six prevalent
psychological symptoms: worrying, feeling sad, feeling nervous,
difculty sleeping, feeling irritable, and difculty concentrating. The
Total MSAS score (TMSAS) is the average of the symptom scores of
all 32 symptoms assessed in the MSAS instrument. Each symptom
score represents the average of its dimensions. Higher values indicate greater severity, higher frequency, and more distress (Lobchuk
et al., 2006; Portenoy et al., 1994).
In the MSAS scoring system, the physical symptoms score is zero if
the symptom is not present; 0.8 if the symptom is present but causes
no distress; 1.6 if the symptom is present and causes a little bit of
distress; 2.4 if the symptom is present and somewhat causes distress;
3.2 if the symptom is present and causes quite a bit of distress; 4.0 if
the symptom is present and causes great distress. The psychological
symptoms score is zero if the symptom is absent; 1 if the symptom is
present but occurs rarely; 2 if the symptom is present and occurs
occasionally; 3 if the symptom is present and occurs frequently; and 4
if the symptom is present and occurs almost constantly (http://
summit.stanford.edu/pcn/M07_Dyspnea/media/memorial_
symptom_subscales.pdf retrieved May 2009 (MSAS, 2009)).
The reliability of the Turkish versions of the The Quality of Life
Index (QLI) and Memorial Symptom Assessment Scale (MSAS) was
tested by Can et al. (unpublished) on Turkish lung cancer patients.
The study found that the Turkish versions of the Quality of Life
Index and Memorial Symptom Assessment Scale were reliable and
valid for use with adult Turkish lung cancer patients. The alpha
value for the Health and Functioning subscale was 0.86; the
Psychological/Spiritual subscales alpha score was 0.79; the Social
and Economic subscales alpha value was 0.62; the Family subscales was 0.60; and the Overall Quality of Life Indexs alpha value
was 0.89 (Can et al., unpublished). Alphas ranged from 0.69 to 0.74
for the MSAS-GDI, MSAS-PHYS, and MSAS-PSYCH subscales. Total
MSAS alpha value was 0.86 (Can et al., unpublished).

Data collection
The lung cancer patients were approached directly by the
researcher and asked if they wanted to participate in the study. The
patients were then evaluated to see whether they met the inclusion
criteria. The patients who met the criteria were informed and invited
to participate the study. The data was collected over 10 months.
Ethical considerations
Permission to use the scales in this study was obtained from the
developers before starting. In order to conduct this research,
permission was also obtained from the institution. Ethical approval
was granted to conduct this study by the ethical committee of the
university hospital. Patients were invited to participate in the study
and were informed before verbal consent was obtained. It was
stated that their return of the questionnaire implied their consent
to participate. The patients who agreed to participate and returned
the questionnaires were then included in the study. The researchers
guaranteed patients that their identities and answers would be
kept condential.
Statistical analysis
Data analysis was performed using SPSS software (version 11.5
of the SPSS). Descriptive statistics, means, median, frequencies, and
percentages were used to show the distribution of personal characteristics, illness-related characteristics, and the scale scores. In
comparing the mean or median values of the scales for personal
and illness-related variables, non-parametric tests were utilized
(MannWhitney U and KruskalWallis variance tests, and Spearmans correlation test).
Results
Personal and illness-related characteristics
The sample was predominantly men (84.4%), married individuals (85.7%), and primary school graduates (42.9%). The characteristics of the sample are shown in Table 1. The majority of
participants were between the ages of 40 and 49 (33.8%) and 50 and
59 (34.4%). Nearly half of the sample (48%) had a perceived middle
income, and a third (35.1%) had a low perceived income. Nearly 30
percent (27.3%) of the patients stopped working due to their cancer
diagnosis.
Nearly seventy percent of participants (68.8%) were receiving
chemotherapy for the diagnosis of non-small-cell lung cancer
(NSCLC), 31.2% for small-cell lung cancer (SCLC). Patients with stage
IV non-small-cell lung cancer (NSCLC) comprised 35.1% (n 54),
while those with stage III non-small-cell lung cancer (NSCLC) totalled
26.9% (n 40) of lung cancer patients. Patients with extensive-stage
small-cell lung cancer (SCLC) comprised only 19.5% (n 30) of the
sample (Table 2). The ECOG performance score of the study group was
0 for 51.3% (n 79) of the sample. The patients were receiving
Vepeside Cisplatin (26%, n 40), Docetaxel Cisplatin/Carboplatin
(25.3%, n 39), and Vinorelbine Cisplatin/Carboplatin (18.8%,
n 29). The clinical characteristics are presented in Table 2.
Symptom experiences and quality of life of the patients
The mean of the total and subgroup scores from the Memorial
Symptom Assessment Scale were low [Total MSAS (0.74  0.45),
MSAS-GDI (0.80  0.60), MSAS-PSYCH (0.76  0.68), and MSASPHYS (0.77  0.51)] (Table 3)]. These results reveal that the

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

Table 1
Personal Characteristics (n 154).

Table 2
Clinical Characteristics (n 154).
n

Gender
Males
Females

403

106
48

68.8
31.2

130
24

84.4
15.6

Histological types of lung cancer

Non-Small-Cell Lung Cancer (NSCLC)
Small-Cell Lung Cancer (SCLC)

10
29
52
53
10

6.5
18.8
33.8
34.4
6.5

Stage of lung cancers

Stage II NSCLC
Stage III NSCLC
Stage IV NSCLC
Limited-stage SCLC
Extensive-stage SCLC

12
40
54
18
30

7.8
26.9
35.1
11.7
19.5

132
22

85.7
14.3

Education level
Basic literacy
Primary school
Secondary
High school
University

12
66
19
30
27

7.8
42.9
12.3
19.5
17.5

ECOG performance score*

0
1
2
3

79
60
9
6

51.3
39
5.8
3.9

Occupation
Retired
Self-employed
Clerk
Housewife
Worker

65
39
20
15
15

42.2
25.4
13
9.7
9.7

Chemotherapy cycle
1st cycle
2nd cycle
3rd cycle
4th cycle
5th cycle
6th cycle or above

29
31
36
25
15
18

18.8
20.1
23.4
16.2
9.8
11.7

Perceived level of income

Low
Moderate
Good

54
74
26

35.1
48
16.9

Chemotherapy protocol
Vepeside Cisplatin
Docetaxel Cisplatin/Carboplatin
Vinorelbine Cisplatin/Carboplatin
Vepeside Cisplatin Topotecan
Vinorelbine Cisplatin
Paclitaxel Cisplatin/Carboplatin
Vinorelbine Gemcitabine

40
39
29
15
13
11
7

26
25.3
18.8
9.7
8.5
7.1
4.6

81

52.6

42
31

27.3
20.1

150
2
2

97.4
1.3
1.3

Age
2029
3039
4049
5059
6069
Marital status
Married
Single

Employment status
Unemployed due to different reasons
(being a housewife, retirement, etc.)
Unemployed due to illness
Employed
Health insurance
Health Insurance
Uninsured
Private Health Insurance

symptom frequency and distress among lung cancer patients

receiving chemotherapy was relatively low.
The common physical symptoms experienced by lung cancer
patients undergoing treatment were lack of energy, coughing, pain,
lack of appetite, and nausea, and their psychological symptoms
were feeling nervous, difculty sleeping, feeling sad, and worrying
(Fig. 1). Mean scores for individual symptoms were relatively low.
Only the mean score of one symptom (lack of energy) was over
1.6, indicating that this symptom was causing a little distress.
Although symptom distress scores were relatively low, the lung
cancer patients had low (poor) quality of life scores (QLI-total
scale). The Health and Functioning subscale scores were the lowest
(20.33  5.59), while the Family subscale scores were the highest
(27.66  2.77) (Table 3). There was a negative relationship between
symptom distress and the quality of life (QoL) scores (r 0.45;
p < 0.000).
Variables associated with the quality of life and symptom
experiences of lung cancer patients
There were statistically signicant differences in mean quality of
life scores between groups, for age, gender, marital status, level of
education, perceived income level, employment status, ECOG
performance score, and chemotherapy protocols (Tables 4 and 5).
Compared to patients aged 5059, the Health and Functioning
subscale was affected more negatively for patients ranging in age

*
ECOG performance scores. 0 Fully active, able to carry on all pre-disease
performance without restriction. 1 Restricted in physically strenuous activity but
ambulatory and able to carry out work of a light or sedentary nature, e.g., light house
work, ofce work. 2 Ambulatory and capable of all selfcare but unable to carry out
any work activities. Up and about more than 50% of waking hours. 3 Capable of
only limited selfcare, conned to bed or chair more than 50% of waking hours.

from 30 to 39 (c2kw 14.35; p 0.006). Male lung cancer patients

reported their QoL to be worse in the Quality of Life Index (QLI-total
scale) and the Health and Functioning subscale (Zmwu 2.92,
p 0.03). Patients with basic literacy had lower Social and
Economic subscale scores than university graduates (c2kw 13.06;
p 0.01) (Table 4).
As the level of income decreased, the scores on the total scale
and domains decreased (p < 0.05). In comparison to married
patients, the Overall Quality of Life Index, the Social and Economic
subscale, and the Family subscale for non-married patients were
negatively impacted (p < 0.05). For patients who had ceased work
after their lung cancer diagnosis, the Quality of Life Index (QLI-total
scale), Health and Functioning, Psychological/Spiritual, and Social
and Economic subscales were affected more negatively (p < 0.05)
(Table 4).
Patients receiving Vepeside Cisplatin Topotecan or Vinorelbine Gemcitabin had lower Total QLI scores, but the mean scores
were not found to be statistically signicant (p > 0.05). Patients
receiving the Vinorelbine Gemcitabine protocol had higher
MSAS-Global Distress Index, MSAS-Physical Symptom, and MSASPsychological Symptom subscales scores than those receiving
Vinorelbine Cisplatin
and
Paclitaxel Cisplatin/Carboplatin
chemotherapy protocols (p < 0.05). Patients receiving the Vinorelbine Gemcitabine protocol also had higher Total MSAS scores
than those receiving the Vinorelbine Cisplatin protocol (p < 0.05).
Statistically signicant differences were found between scores
on the Memorial Symptom Assessment Scale and the variable
scales, such as gender, perceived income level, ECOG performance,
and chemotherapy protocol. The mean scores in the MSAS-Global

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S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

Table 3
The mean scores of Memorial Symptom Assessment Scale and Quality of Life Index Scales (n 154).

Memorial symptom assessment scale

MSAS_Global Distress Index

MSAS_Physical Symptom Subscale
MSAS_Psychological Symptom Subscale
Total MSAS

Quality of life index

Health and Functioning Subscale

Social and Economic Subscale
Psychological/Spiritual Subscale
Family Subscale
Quality of Life Index_total scale

Distress Index, MSAS-Physical Symptom Subscale, MSAS-Psychological Symptom Subscale, and Total MSAS were lower in female
patients. The MSAS-Global Distress Index, MSAS-Psychological
Symptom Subscale, and Total MSAS were lower in patients with
lower income levels than in higher-income-level patients (p < 0.05)
(Tables 4 and 5).
As ECOG performance scores worsened scores for the Quality of
Life Index (QLI-total scale), Health and Functioning subscale, and
Psychological/Spiritual subscale were negatively affected.
Compared to patients whose ECOG performance score was 0 or
1, those with scores of 2 also had higher (worse) scores in the
dimensions of the MSAS-Global Distress Index and MSAS-Psychological Symptom subscale (p < 0.05). The MSAS-Physical Symptom
subscale and Total MSAS were adversely affected for patients with
an ECOG performance score of 3, compared to those with a score
of 0 and 1 (p < 0.05) (Table 5).
There was no statistical difference in age, marital status,
education level, employment status, histological type, and stage of
lung cancer in relation to MSAS scores (p > 0.05) (Table 5).There
were no statistically signicant differences in the variable scores,
such as the histological type and stage of lung cancer, and the
chemotherapy protocol in relation to quality of life scores (p > 0.05)
(Table 5).
Discussion
Despite advances in lung cancer treatment and improvements
enacted in dealing with common symptoms and side effects, most
patients suffer considerably, experiencing profound changes in
their quality of life (QoL) due to the diagnosis itself, the stage of
cancer, and chemotherapy (Bertero et al., 2008; Sola` et al., 2004). In
recent years, increased efforts have been made to address the QoL
of lung cancer patients in developing countries. This study aimed to
assess QoL and symptom distress in Turkish lung cancer patients
undergoing chemotherapy and found that different dimensions of
QoL were negatively affected and patients experienced several
symptoms, but low levels of symptom distress.
The cancer patients who reported more limitations due to their
symptoms also experienced a greater decline in physical functioning, reduced QoL, and increased mortality (Doorenbos et al.,
2006). The QoL of lung cancer patients varied according to sociodemographic, and illness and treatment-related characteristics.
Other studies show that the variables of gender, age, marital status,
improved health condition, depressed mood, and the number of
comorbid diseases can affect the QoL of lung cancer patients
(Bozcuk et al., 2006; Sarna et al., 2005; Steele et al., 2005). Similar
to the current studys ndings, Mohan et al. (2006) reported that
the physical and psychological domains of QoL correlated signicantly with performance status, and that lung cancer patients with
a higher performance status had better physical, psychological, and
social QoL than those with a lower performance status (Mohan

Mean

Median

SD

0.80
0.77
0.76
0.74

0.65
0.64
0.61
0.69

0.60
0.51
0.68
0.45

Minimum
0.00
0.00
0.00
0.10

Maximum
2.40
2.47
2.78
2.43

20.33
22.64
24.73
27.66
23.84

21.74
23.14
25.71
28.80
24.46

5.59
4.18
4.34
2.77
3.24

4.62
10.14
4.29
16.50
13.50

29.50
30.00
30.00
30.00
29.41

et al., 2006). Doorenbos et al. (2006) report that females with lung
cancer experience lower physical functioning than males. The
results of the current study also reveal that elderly, male, nonmarried lung cancer patients, and those with perceived low income
levels, low education levels, and/or low physical performance may
need more physical, psychological and social support in order to
improve their QoL.
The symptoms experienced by lung cancer patients negatively
affect their emotional, social, physical, and spiritual well-being (Fan
et al., 2007; Thompson et al., 2005). Graves et al. (2007) report that
problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical
functioning, and cognitive functioning were associated with higher
reports of distress. Specic symptoms of depression, anxiety, pain
and fatigue were most predictive of distress in lung cancer patients.
Aside from the side effects it can causes, chemotherapy help to
reduce symptom distress. The low level of symptom distress of the
Turkish lung cancer patients in this study might be due to the
positive effects of chemotherapy on the control of symptoms.
Conversely, the low distress scores may be due to the low level of
sensitivity of the instrument used in this study.
Knowledge of symptom prevalence and distress can be used to
develop empirically based interventions that can potentially reduce
distressing symptoms and improve QoL (Cooley et al., 2003).
Several studies have noted that adults with lung cancer experience
more symptom distress than patients with other types of cancer
(Cooley et al., 2003; Degner and Sloan, 1995; Tishelman et al.,
2005). Patients with advanced disease reported more distress than
those with early-stage disease; women reported more distress than
men, and older patients had less distress than younger patients
(Degner and Sloan, 1995). Another study has found that women
with lung cancer had signicantly worse physical functioning than
women with breast cancer (Doorenbos et al., 2006). The current
study found that females and patients with lower income and
performance levels reported higher levels of symptom distress,
along with more physical and psychological symptoms. This
suggests that these groups of patients may need a greater level of
support and education with respect to physical and psychological
symptom management. Despite the sample of female patients
being considerably smaller than that of male lung cancer patients,
these ndings highlight that women, whose roles and responsibilities are more likely to be central in private, social, and economic
domains, need to be supported throughout the process of lung
cancer treatment.
Overall QoL is signicant for patients with advanced lung
cancer; therefore, symptom and QoL assessments are vital for the
evaluation of the efcacy of emerging cancer treatments. Patients
receiving chemotherapy experience different levels of symptom
distress with regard to chemotherapy agents. One study reports
that the docetaxel-platinum regimens relieve symptoms in patients
with advanced NSCLC (Belani et al., 2006). The current study

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

405

Fig. 1. Symptoms experienced by lung cancer patients during treatment.

ndings show that lung cancer patients receiving Vinorelbine Gemcitabine and Docetaxel Cisplatin/Carboplatin
reported a high level of physical and psychological symptoms,
together with a high rate of general symptom distress. Similar to
the ndings of a study carried out on Turkish lung cancer patients
(Bozcuk et al., 2006), our ndings reveal that patients personal,
treatment, and illness-related characteristics may help predict the

degree of symptom distress and the QoL of lung cancer patients

undergoing chemotherapy.
One study found that personal support related positively to QoL
and partially mitigated the effects of symptom distress, whereas
social support helped to decrease the negative effects of symptoms
on QoL (Manning-Walsh, 2005). The current study found a negative
relationship between symptom distress and QoL scores (r 0.45;

406

Table 4
Personal characteristics associated with quality of life and symptom distress of lung cancer patients.
Quality of Life Index (QLI)-Cancer Version
Total QLI
Mean rank
Gender
Male
Female
Zmwu

Health and functioning

subscale
Mean rank

Memorial Symptom Assessment Scale (MSAS)

Social and economic
subscale
Mean rank

Psychological/spiritual
subscale
Mean rank

Family
subscale
Mean rank

Global distress
index
Mean rank

Physical symptom
subscale
Mean rank

Psychological
symptom subscale
Mean rank

Total MSAS
Mean rank

53.06
82.01
2.92**

62.67
80.24
1.77

74.33
78.08
0.37

70.42
78.81
0.86

83.60
56.91
3.15**

77.52
58.80
2.19*

97.33
71.97
2.61**

81.40
55.68
3.04**

c2kw

84.70
59.69
74.52
88.51
79.10
8.36

93.10
55.84
71.16
91.03
85.95
14.35**

71.50
69.21
76.68
86.62
63.45
4.41

87.95
65.29
75.03
83.25
84.85
4.04

76.35
77.10
77.74
75.82
87.45
0.61

53.56
71.77
59.49
58.67
62.80
2.85

45.94
74.06
63.75
55.95
65.25
5.79

62.60
84.40
75.26
76.09
68.35
2.34

48.43
74.59
59.59
56.12
52.35
5.93

Marital status
Married
Non-married
Zmwu

80.60
58.91
2.11*

79.24
67.07
1.18

80.86
57.32
2.29*

80.31
60.66
1.91

81.04
56.25
2.47*

60.90
64.55
- 0.42

62.34
60.22
0.24

76.83
71.16
0.56

60.34
58.11
0.25

70.58
82.02
68.68
71.87
82.00
2.46

81.04
81.89
75.89
66.55
78.50
2.56

52.50
76.44
57.79
86.03
95.59
13.06*

77.21
83.68
72.74
67.77
76.69
2.92

74.71
83.16
70.50
78.32
68.93
2.72

60.55
64.51
64.53
64.48
50.88
2.82

57.60
66.95
61.43
59.98
56.34
1.80

69.42
80.40
72.79
77.07
68.88
1.72

58.00
63.73
67.43
60.33
47.18
4.34

55,82
81,76
110.38
27.57***

64.69
77.98
102.73
12.79**

69.81
81.45
82.23
2.61

67.50
63.61
44.66
6.40*

69.40
60.57
51.70
3.74

83.62
77.04
56.80
6.49*

69.69
60.13
41.64
9.02*

Agea
2029
3039
4049
5059
6069

Education levelb
Basic literacy
Primary school
Secondary
High school
University

c2kw
Perceived level of incomec
Low
Moderate
Good

c2kw
Employment statusd
Unemployed due
to different reasons
Unemployed due to illness
Employed

c2kw

57.65
82.57
104.31
21.05***

61.17
84.34
91.96
11.7 1**

92.68

87.92

86.68

91.26

87.37

52.65

53.63

70.67

52.57

56.40
82.63
14.06**

60.69
82.23
8.57*

58.49
83.85
10.59**

61.94
80.30
8.39*

69.52
77.86
3.02

67.17
61.75
2.30

68.38
61.63
2.36

82.55
74.64
1.449

65.68
59.63
1.92

* p < 0.05 ** p < 0.01 *** p < 0.001.

a
The patients in 3039 age group had lower Health and Functioning Subscale scores compared to the patients in the 5059 age group (p < 0.01).
b
The patients with basic literacy had lower Social and Economic Subscale scores compared to university graduate patients (p < 0.05).
c
The patients with low income level had lower Total QLI, Health and Functioning Subscale, Social and Economic Subscale, and Psychological/Spiritual Subscale scores compared to patients with moderate or good income level
(p < 0.01). The patients with low income level had higher Global Distress Index, Psychological Symptom Subscale and Total MSAS scores compared to those with moderate or good income level (p < 0.05).
d
The patients who are unemployed due to illness had lower Total QLI, Health and Functioning Subscale, Social and Economic Subscale, and Psychological/Spiritual Subscale scores compared to the patients who are
employed or unemployed due to different reasons (p < 0.05).

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

60.21
80.69
2.06*

Table 5
Illness-related characteristics associated with quality of life and symptom distress of lung cancer patients.
Quality of Life Index (QLI)-Cancer Version
Total QLI
Mean rank

Memorial Symptom Assessment Scale (MSAS)

Social and economic

subscale
Mean rank

Psychological/spiritual
subscale
Mean rank

Family
subscale
Mean rank

Global distress
index
Mean rank

60.67
75.75
79.07
58.00
79.67
82.68
49.57
2.57

70.08
75.96
79.96
56.35
76.51
86.18
43.54
1.79

39.58
71.54
82.96
57.65
79.90
80.21
61.07
6.72

80.08
72.79
77.55
65.95
78.32
79.39
54.29
2.63

80.75
75.38
70.21
79.45
81.64
73.60
64.11
7.68

49.40
75.58
64.22
59.71
50.31
48.93
89.35
18.08**

c2kw

83.75
79.60
40.33
30.00
14.74**

84.22
79.23
45.28
20.00
16.56**

82.30
76.63
48.11
67.0
5.18

82.54
79.00
49.17
38.67
9.27*

80.40
80.40
53.67
46.08
6.46

57.55
58.70
95.64
96.38
11.52**

Histological types of lung cancer

Non-Small-Cell Lung Cancer (NSCLC)
Small-Cell Lung Cancer (SCLC)
Zmwu

74.49
80.85
.828

75.05
79.64
.597

76.48
76.54
.008

73.77
82.42
1.126

72.14
85.95
1.844

89.83
79.37
67.65
86.89
77.23
4.456

103.00
75.28
68.69
82.78
77.75
6.470

83.33
86.13
68.17
88.50
69.37
6.170

90.96
69.88
72.69
88.06
79.03
3.902

63.50
80.59
68.11
89.25
83.97
6.010

2
ckw

ECOG performance scoreb

0
1
2
3

Stage of lung cancers

Stage II NSCLC
Stage III NSCLC
Stage IV NSCLC
Limited-stage SCLC
Extensive-stage SCLC

c2kw

Physical symptom
subscale
Mean rank
43.20
84.17
61.43
62.00
48.87
51.39
88.07
21.01**

Psychological symptom
subscale
Mean rank

Total MSAS
Mean rank

69.70
86.08
77.61
82.00
63.27
64.42
105.88
13.52*

58.90
70.95
58.24
63.36
49.61
50.43
88.12
15.17*

58.78
59.03
87.71
104.0
10.05*

70.18
74.86
109.44
111.00
10.54*

54.74
59.49
86.50
107.00
11.04*

62.52
55.59
.995

62.26
57.90
.620

78.81
66.72
1.592

60.93
54.29
.961

56.21
58.38
67.61
54.89
56.05
2.734

55.96
59.84
65.90
52.43
61.55
1.946

64.92
75.37
84.54
69.94
64.90
5.096

48.88
60.22
64.98
50.12
56.88
3.355

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

Chemotherapya
Vepeside Cisplatin
Docetaxel Cisplatin/Carboplatin
Vinorelbine Cisplatin/Carboplatin
Vepeside Cisplatin Topotecan
Vinorelbine Cisplatin
Paclitaxel Cisplatin/Carboplatin
Vinorelbine Gemcitabine

Health and functioning

subscale
Mean rank

* p < 0.05 ** p < 0.01 *** p < 0.001.

a
The patients receiving Docetaxel Cisplatin/Carboplatin had higher Physical Symptom Subscale scores compared to those receiving Vinorelbine Cisplatin (p < 0.01). The patients who receive Vinorelbine Gemcitabine
had higher Physical and Psychological Symptom Subscale scores, Total MSAS and Global Distress Index scores compared to those receiving Vinorelbine Cisplatin or Paclitaxel Cisplatin/Carboplatin (p < 0.05).
b
The patients with ECOG performance status 0 had higher Total QLI scores compared to those with ECOG performance score 2 or 3 (p < 0.01). The patients with ECOG performance score 3 had lower Health and Functioning
Subscale and Psychological/Spiritual Subscale scores compared to those with ECOG performance score 0 or 1 (p < 0.05). The patients with ECOG performance score 2 had higher Global Distress Index and Psychological/Spiritual
Subscale scores compared to the patients with ECOG performance score 0 or 1 (p < 0.05). The patients with ECOG performance score 3 had higher Total MSAS and Physical Symptom Subscale scores compared to those with ECOG
performance score 0 and 1 (p < 0.05).

407

408

S. Akin et al. / European Journal of Oncology Nursing 14 (2010) 400409

p < 0.000). Another study reports a signicant correlation between

symptoms and QoL (Steele et al., 2005). There is a need to continue
to assess symptom distress and the adequacy of personal support
throughout the cancer trajectory, and to facilitate the utilization of
support resources when necessary.
Limitations
The study had several limitations. One of the most obvious
limitations of this study is that patients were recruited at any
stage of chemotherapy and quality of life (QoL) data was only
available for each patient at one time point; therefore, it is not
possible to show any trends between cycles, and it may be that
important QoL differences are lost because these groups have
been combined in the analysis. The other limitations that need to
be highlighted are that the sample is heterogeneous with respect
to the stage and histology of the lung cancer and chemotherapy
regime. Furthermore, the sample was predominantly male, so the
results do not enable conclusions to be drawn regarding female
lung cancer patients. There is a need for further research on the
QoL of lung cancer patients that aims to provide more detailed
information about this sample and to provide comprehensive care
and support.
Conclusions
Lung cancer patients receiving chemotherapy suffer many limitations due to the symptoms and disruptions in their quality of life,
arising from both the disease process and its treatment. There is
a widely recognized difculty keeping patients on adjuvant therapy,
because of the side effects (Martelli-Reid et al., 2008). Chemotherapy-related side effects need to be appropriately assessed and
managed for patients to receive the optimal benets of therapy
(Alam et al., 2006). An understanding of the research conducted in
this area is important for developing further knowledge and for
potentially improving symptom management (Cooley, 2000). Identication of the presence and predictors of distress are the rst steps
toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients distress.
Conict of interest
None declared.
Acknowledgement
We would like to thank all patients who agreed to participate in
the study.
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