Quality of life in cervical cancer patients treated with radiation therapy

CANCER AND LONG TERM CONDITIONS

Quality of life in cervical cancer patients treated with radiation

therapy

Małgorzata Pasek, Lilia Suchocka and Krzysztof Urbanski

Aims and objectives. To evaluate the quality of life in hospitalised patients with cervical cancer treated by radiation therapy.

Background. Aside from clinical variables, the quality of life should be considered in the planning and monitoring of the

therapeutic process in patients with cancer. Although it is widely known that this parameter can have a considerable impact

on the therapeutic outcome, it is not routinely screened in oncological patients.

Design. Survey.

Methods. The study was performed in six cancer centres in Poland between June 2004–December 2005, and included 205

women hospitalised for any stage of cervical cancer. The EORTC QLQ-C30 questionnaire (v.3) was used to evaluate

the patients’ quality of life. The survey was conducted three times: (1) stage 1 – before treatment, on admission, (2) stage

2 – after treatment, at discharge, and (3) stage 3 – five to six months after treatment.

Results. Physical functioning was assessed the worst before the radiation treatment and increased gradually throughout fur-

ther stages; all interstage differences proved to be significant. In contrast, emotional functioning was scored the highest

before the initiation of the treatment and was the lowest at stage 2, a difference that proved to be significant. Role function-

ing was highest immediately after the treatment and the lowest prior to the treatment. Differences between stages proved to

be significant. Financial problems increased their negative impact on the quality of patients’ lives significantly throughout

consecutive stages of this study. Age and cancer stage did not significantly influence the way participants perceived their

global health, physical, cognitive, emotional and social functioning, nor their financial difficulties. Overall, the quality of life

was evaluated as highest immediately after the end of radiotherapy.

Conclusion. Although this study revealed that patients with cervical cancer subjected to radiotherapy are satisfied with their

global quality of life, attention should be paid to certain dimensions of the latter (i.e. emotional functioning and role func-

tioning) during post-treatment period.

Relevance to clinical practice. The ability to performing everyday activities independently is perceived as the most important

during all stages of the cervical cancer treatment, and therefore, appropriate support in this matter is necessary on the part

of the nursing personnel.

Key words: cervical cancer, quality of life, radiation therapy

Accepted for publication: 24 June 2012

Introduction

The diagnosis of cancer is an overwhelming event for any

patient and requires significant effort to fight (Surdyka

1997, Chojnacka-Szawlowska 1998). The patient uses a

number of psychological coping mechanisms to manage the

stress connected with the diagnosis, therapy and prognosis.

Therefore, appropriate support is necessary to help the

Authors: Małgorzata Pasek, PhD, Head Nurse, Department of

Nursing Oncology, Maria Skłodowska-Curie Memorial Institute

of Oncology, Cracow; Lilia Suchocka, PhD, Assistant, Department

of Psychotherapy and Psychology of Health, Catholic University of

Lublin, Lublin; Krzysztof Urbanski, PhD, Professor, Gynecologic

Oncologist and Head of the Department of Gynecological Oncology,

Maria Skłodowska-Curie Memorial Institute of Oncology, Cracow,

Poland

Correspondence: Małgorzata Pasek, Head Nurse, Department of

Nursing Oncology, Maria Skłodowska-Curie Memorial Institute of

Oncology, ul Garncarska 11 Cracow, Poland. Telephone:

+48 12 422 99 00.

E-mail: [email protected]

© 2012 Blackwell Publishing Ltd

690 Journal of Clinical Nursing, 22, 690–697, doi: 10.1111/j.1365-2702.2012.04350.x

patient go on with his/her life despite disease-related dis-

comfort and disability.

Background

The World Health Organization defines quality of life as

the way an individual perceives his own position in the

context of culture and system of values in which she or he

exists together with own aims, limitations, standards and

concerns; a wide conception comprehensively influenced by

individual’s state of health, cognitive state, social relations,

level of independence and relation to the surrounding

environment (Saxena et al. 1997). Aside from clinical vari-

ables, the quality of life should be considered in the plan-

ning and monitoring of the therapeutic process in patients

with cancer. Although it is widely known that this param-

eter can have a considerable impact on the therapeutic

outcome, it is not routinely screened in oncological

patients. Owing to the relatively favourable prognosis and

increasing survival rates in the fight against cervical cancer,

the issues of quality of life become of vital importance in

female patients affected by this disease and other gynaeco-

logical malignancies. This was documented by a number

of previous studies dealing with the problem in question

(Eisemann & Lalos 1999, Greimel & Freidl 2000, Klee

et al. 2000a,b, Lutgendorf et al. 2002, Miller et al. 2003).

Quite recently, Carter et al. (2010) documented that the

first year after completing the therapy represents a critical

period for the quality of life in cervical cancer survivors.

Prospective longitudinal study by Ferrandina et al. (2012)

confirmed this finding and identified lymphedema and

menopausal symptoms as the most disabling treatment-

related sequelae affecting the quality of life in patients

with cervical cancer. Furthermore, the pretreatment

patient-reported physical well-being was recently identified

as a significant prognostic factor of survival in advanced

patients with cervical cancer participating in Gynecologic

Oncology Group phase III treatment trials (Chase et al.

2012).

In view of this abovementioned evidence, the aim of

this study was to evaluate the quality of life in hospita-

lised patients with cervical cancer treated by radiation

therapy.

Methods

Study subjects

The study was performed in six cancer centres in Poland

(Cracow, Warsaw, Lublin, Gliwice, Kielce, and Bialystok)

between June 2004–December 2005, and included 205

women hospitalised for any stage of cervical cancer.

Demographical and clinical characteristics of the examined

group are presented in Tables 1 and 2. All patients were

treated with radiotherapy, 78% of them also received cis-

platin chemotherapy, and 24% were subjected to surgical

treatment.

Ethical considerations

The participation in this study was voluntary and anony-

mous. All participants expressed a written informed consent

before starting any procedure. The study protocol was

accepted by the local bioethics committee at the Maria

Sklodowska-Curie Memorial Institute of Oncology Cancer

Center in Cracow.

Table 1 Demographical characteristics of the studied population

(n = 157)

Parameter n %

Age (years)

�30 3 1�9131–40 11 7�0141–50 53 33�7651–60 55 35�0361–70 25 15�92>71 10 6�37

Education

Incomplete primary 1 0�64primary 42 26�75Grammar 42 26�75Secondary 57 36�31Higher 15 9�55

Marital status

Not married 10 6�37Married 102 64�97Separated 1 0�64Divorced 12 7�64Widowed 30 19�11Cohabitation 2 1�27

Source of income

Professional work 48 30�57Disability pension 33 21�02Retirement pension 35 22�29Unemployment compensation benefit 10 6�37Other 31 19�75

Place of residence (distance from oncology center)

�5 km 7 4�466–15 km 5 3�1816–30 km 7 4�4631–45 km 18 11�46>45 km 120 76�44


Journal of Clinical Nursing, 22, 690–697 691

Cancer and long term conditions Quality of life in cervical cancer patients

Methodology

The EORTC QLQ-C30 questionnaire (v.3) was used. It

consisted of 30 questions concerning the global evaluation

of quality of life, using a five point scale for function and a

nine point scale for symptoms. This questionnaire was

answered by patients independently, following an explana-

tory conversation. Additionally, in order to evaluate the

demographical and the clinical characteristics of patients, a

questionnaire developed by the authors was used. It con-

tained 19 questions and was filled by the researcher based

on a conversation with the hospitalised patient and on her

medical documentation.

The survey was conducted three times: (1) stage 1 –

before treatment, on admission, (2) stage 2 – after treat-

ment, at discharge, and (3) stage 3 – five to six months

after treatment. At stage 3, questionnaires were sent by

mail to all those who had taken part in the previous stages.

One hundred and fifty-seven (75%) of the latter were com-

pleted. Higher scores of QLQ-30 scales documented on

consecutive surveys corresponded to a decrease in a given

quality of life dimension, while the lower scores represented

the improved quality of life.

Statistical analysis

Statistical analysis was performed using STATISTICA PL 7.0

package (StatSoft®, Tulsa, OK, USA). Continuous variables

were presented as arithmetic means, standard deviations and

median values. The significance of time course differences

among continuous variables was tested by the Friedman

ANOVA test. Additionally, Spearman’s rank coefficient of

correlation was calculated between the given variables. The

statistical significance of all tests was defined as p � 0�05.

Results

Evaluation of the global health and functioning scales

Surveyed women evaluated their global health as average; no

significant differences in this parameter were observed

between the consecutive stages of this study. Physical func-

tioning was assessed the worst before the radiation treatment

and increased gradually throughout further stages; all inter-

stage differences proved to be significant. In contrast, emo-

tional functioning was scored the highest before the

initiation of the treatment and was the lowest at stage 2

(immediately after irradiation), a difference that proved to

be significant. No significant differences were observed

between the consecutive stages of this study with regard to

cognitive and social functioning. Role functioning was high-

est immediately after the treatment and the lowest prior to

the treatment. Differences between stages proved to be sig-

nificant. According to our surveys, financial problems

increased their negative impact on the quality of patients’

lives significantly throughout consecutive stages of this study

(Table 3).

Age and cancer stage did not significantly influence the

way participants perceived their global health, physical,

Table 2 Clinical characteristics of the studied population (n = 157)

Parameter n %

Histopathology

Squamous cell carcinoma 150 95�54Adenocarcinoma 1 0�64Adenosquamous carcinoma 6 3�82

Stage (FIGO)

IA 1 0�64IB 13 8�28IIA 19 12�09IIB 36 22�94IIIA 6 3�82IIIB 69 43�95IVA 1 0�64IVB 2 1�27Not available 10 6�37

Table 3 Evaluation of global health and functioning at the particu-

lar stages of the study

Parameter Stage n Mean SD Median p

Global health 1 157 55�47 26�11 50�00 ns

2 156 56�89 21�90 50�003 157 57�70 24�45 58�33

Physical

functioning

1 155 75�96 17�42 80�00 <0�000012 157 67�69 18�99 73�333 156 64�79 20�81 66�67

Emotional

functioning

1 156 51�76 22�93 58�33 0�000292 157 59�24 22�10 66�673 156 56�62 23�14 62�50

Cognitive

functioning

1 157 72�51 24�60 83�33 ns

2 157 69�21 24�03 66�673 156 69�55 25�69 66�67

Social

functioning

1 156 72�01 27�17 83�33 ns

2 155 68�28 28�67 66�673 156 73�29 25�87 83�33

Role functioning 1 157 70�06 29�76 66�67 0�000202 157 62�21 29�50 66�673 156 69�66 28�43 66�67

Financial

difficulties

1 155 45�81 33�80 33�33 0�006842 157 47�13 31�36 33�333 155 50�97 32�75 33�33

Point scale for answers: 0–100 (results transformed according to

EORTC QLQ-C30 manual); 0 – very good, 100 – very poor. ns –

not significant.


692 Journal of Clinical Nursing, 22, 690–697

M Pasek et al.

cognitive, emotional and social functioning, nor their

financial difficulties (as confirmed by insignificant values

of Spearman’s rank correlation coefficients – data not

shown).

The most burdensome issues for participants prior to

treatment were worry, depression, anxiety and financial dif-

ficulties caused by the health condition or the treatment

itself. Immediately after the treatment, the greatest difficul-

ties were performing exhausting activities, appetite loss,

worry and fatigue. Five to six months after treatment, the

main problems consisted of a limitation in performing

exhausting activities, occurrence of financial difficulties

caused by the treatment or the state of health, fatigue and

worry.

At all stages of the study, patients’ independence in per-

forming everyday activities was assessed as the highest for

eating, getting dressed, washing and using the toilet. At

stage 2, women experienced discomfort linked with the

occurrence of nausea, vomiting and diarrhoea, significantly

more often than at stages 1 and 2.

Overall, the quality of life was evaluated as highest

immediately after the end of radiotherapy.

Occurrence of selected symptoms connected with the

disease and/or treatment

Our patients reported increasingly frequent fatigue and

dyspnea throughout consecutive stages of this study. In con-

trast, the frequency of diarrhoea decreased gradually

according to consecutive study periods. Nausea and vomit-

ing, appetite loss and constipation were least frequent prior

to the treatment, but their prevalence increased significantly

immediately following the treatment (stage 2) and was

again reduced five to six months thereafter. All those afore-

mentioned interstage differences in the frequency of those

symptoms proved to be significant. The interstage differ-

ences in the frequency of pain and insomnia proved to be

insignificant (Table 4).

Discussion

The level of health-related quality of life is recently becom-

ing a central element within therapeutic standards in clini-

cal practice. There are two ways to evaluate quality of life:

objectively and subjectively, the most frequent being the

objective one. The latter is related to the clinical conception

of the disease and is conducted by medical professionals.

The evaluation mainly concerns the state of health based

on the physician’s diagnosis, visual and laboratory follow-

up results, and on determining the social and economic

standing, the working environment, the quality and

quantity of environmental contacts and so on. In the sub-

jective approach, the patient evaluates his/her own life’s cir-

cumstances. Specialists consider this method to be much

more valuable than the objective one, as it addresses the

health issue as perceived by the patient and his/her biologi-

cal, cognitive, social, spiritual and cultural spheres. Despite

the fact that objective indicators are important, they are

not always in harmony with the patient’s own perception

of his/her state of health. Correlations between objective

and subjective determinants of quality of life are often low

(Schipper et al. 1996).

The goal of the conducted research was the evaluation of

the quality of life by women suffering from cervical cancer

and treated with radiation therapy. Our study included 157

women in three instances: prior to, directly after and five to

six months following radiotherapy. This allowed to identify

the changes that the examined patients were going through

with regard to the general quality of life, the general evalu-

ation of their health, as well as their bio-cognitive-social-

cultural function. Similar methodological standards were

Table 4 Occurrence of physical symptoms at particular stages of

the study

Symptom Stage n Mean SD Median p

Fatigue 1 157 39�49 21�25 33�33 0�041912 157 46�21 22�49 44�443 156 47�15 23�46 38�89

Nausea and

vomiting

1 155 6�34 11�75 0�00 <0�000012 156 23�72 25�19 16�673 156 9�94 15�00 0�00

Pain 1 156 32�59 27�26 33�33 ns

2 157 27�49 22�95 33�333 156 33�87 26�94 33�33

Dyspnea 1 156 17�95 21�88 0�00 0�001852 157 18�90 22�73 0�003 155 24�73 27�35 33�33

Insomnia 1 155 42�58 31�22 33�33 ns

2 156 47�65 32�38 33�333 156 44�44 31�07 33�33

Appetite loss 1 156 24�15 27�45 33�33 <0�000012 156 48�50 31�07 33�333 156 23�93 26�72 33�33

Constipation 1 154 12�77 17�55 0�00 < 0�000002 156 34�40 29�67 33�333 156 25�85 25�84 33�33

Diarrhoea 1 156 33�12 28�46 33�33 0�000382 157 31�42 28�56 33�333 156 23�72 29�82 0�00

Point scale for answers: 0–100 (results transformed according to

EORTC QLQ-C30 manual); 0 – never, 100 – very often. ns – not

significant.




used in the quality of life research performed by Greimel

and Freidl (2000), while examining women with surgically

treated gynaecological neoplasms. Women were surveyed

prior to treatment, and three months and one year thereaf-

ter (Greimel & Freidl 2000). Eisemann and Lalos (1999)

conducted research concerning the psychological state and

social support of women with gynaecological tumours prior

to, as well as six and 12–15 months following treatment.

Lutgendorf et al. (2002) examined women with reproduc-

tive tract tumours before and at one-year post-treatment.

Miller et al. (2003) concentrated on patients suffering from

endometrial and cervical cancers, gathering their data prior

to therapy and at six and 12–15 months afterwards. Klee

et al. (2000a,b) examined the quality of life of women suf-

fering from cervical cancer directly after the treatment and

at 1, 3, 6, 12, 18 and 25 months later.

The patients participating in the study had the same

therapeutic standards. All were hospitalised in an oncologi-

cal centre because of cervical cancer and were treated

with radiotherapy. The percentage distribution of age and

the histopathological nature of the cervical cancer in

the study group was similar to that of prior studies (Klee

et al. 2000a,b), proving that the examined group was

representative.

Almost 88% of patients were capable of self-care.

According to Bidzan et al. (2001), physical state and often

limited capacity may induce a feeling of psychological and

social limitations. In life-threatening situations, the hierar-

chy of values changes, prioritising relationships with the

close ones and religious values (De Walden-Galuszko 1994,

Bidzan et al. 2001).

To achieve the goal of this research, the EORTC QLQ

C-30 questionnaire was used at three stages: before treat-

ment, directly after completing the therapy and five to six

months later. A similar study, using the same questionnaire,

was conducted by Klee et al. (2000a). Their study group

consisted of 230 women with cervical cancer treated with

radiotherapy. The study took place over the two years fol-

lowing radiotherapy, examining the participants immedi-

ately after the treatment and at 1, 3, 6, 12, 18 and

24 months thereafter (Klee et al. 2000a,b).

In the present study, patients evaluated their health state

as average during all stages. This data are consistent with

that published by Galuszka (2005). Also Klee et al.’s

(2000a) research found patients to evaluate the state of

their health positively, but with an improvement at six

months following the treatment when compared to immedi-

ately after the therapy. Miller et al. (2002), in their study

on women with gynaecological cancers, shows a differing

data. At six months following the treatment, they found

that the longer the period after the treatment, the lower the

patients’ opinions about their own physical state (Miller

et al. 2002).

Our research shows that patients have evaluated their

emotional state (worry, tension, anxiety, depression)

directly and five to six month after the treatment just a bit

lower than did women examined by Klee et al. (2000a).

Additionally, our patients found their health state to disturb

their family and social life more often than did the women

studied by Klee et al. (2000a). Miller et al.’s (2003) study

found the most common emotions experienced by women

with gynaecological neoplasms at six month after the treat-

ment to be irritation (40%), worry (34%), fear (25%), the

need to talk with someone (24%), sorrow (21%) and

lacking sense of control over one’s own life (17%).

When generalising the results of our study, we note a

depreciated emotional functioning directly after and at five

to six months, following treatment as compared to that

prior to the treatment. This requires a special attention on

behalf of professional healthcare workers as well as of lay-

men such as family and friends. The examined women eval-

uated their cognitive, social and role functioning as lowest

at those times. These fields should thus be considered in the

patient’s treatment plan.

When analysing the occurrence of physical symptoms in

the conducted study, it has been noticed that diarrhoea

most often occurred directly at the end of the treatment,

and rarely five to six month later. It almost never occurred

prior to the treatment. This confirms the findings of Klee

et al. (2000b), who also noticed diarrhoea to be most com-

mon during the first three months following treatment.

Abayomi et al. (2005) also show that the most common

gastrointestinal side effect was diarrhoea, which also com-

plicated social functioning, especially the ability to leave

the house. Nausea and vomiting occurred occasionally

directly after the radiotherapy, while constipation was

rarely reported at all stages of our research, and lack of

appetite was especially strong directly after the end of treat-

ment. Those observations concur with Klee et al.’s findings

(2000b). Patients evaluated pain to be greatest before treat-

ment and at five to six months thereafter, while other pub-

lished studies found pain to be most severe directly after

treatment rather than five to six months later (Klee et al.

2000b).

We also demonstrated that radiotherapeutically treated

patients with cervical cancer are often tired and require

rest, this becoming increasingly pertinent at consecutive

stages of the study. In Klee et al.’s (2000b) study, this

seemed to be most true directly after treatment, but not five

to six months later. Feebleness occurred more often directly



M Pasek et al.

after treatment than before and at five to six months after.

Klee et al. (2000b) noted feebleness to be more prevalent

directly after treatment and at 5–6 later, but this difference

was not found to be significant in their research.

In this study, self-evaluation of the examined women was

satisfactory at all treatment stages. This confirms the find-

ings of Chojnacka-Szawlowska (1994), who stated that the

level of self-evaluation among women suffering from cervi-

cal cancer was similar to that of healthy ones.

The women participating in the study evaluated their

general quality of life as rather good when there were no

treatment side effects, and neither age nor cancer stage

influenced this finding. Similarly, Wenzel et al. (2002)

found the evaluation of the general quality of life as well as

emotional, social and physical functioning of patients with

ovarian cancer to be independent of their health state, as it

did not differ from that of healthy participants. In Lutgen-

dorf et al.’s (2002) research, the study participants

expressed a significant improvement of the quality of life

despite a worsening of their physical function and of their

general frame of mind. In contrast, Bradley et al. (2006)

demonstrated that the occurrence of side effects had an

influence on the perceived quality of life.

The conducted research shows that neither the age of the

examined patients nor their cancer’s stage influenced the

self-evaluation of the quality of their life at any stage of

our study. This confirms prior data presented by De

Walden-Galuszko (1994), Greimel and Freidl (2000) and

Ohara-Hirano et al. (2004). Also Bradley et al. (2006)

showed that clinical status did not influence the quality of

life.

The prognosis of a patient with cancer depends on the

type of cancer, its localisation, its stage, as well as the

available treatment modalities. These depend in turn on

the living situation, social conditions and other variables

(Adamczak & Sek 1997). Adamczak and Sek (1997)

showed that if the patient’s activity improves his/her quality

of life despite his/her illness, then his/her determination and

responsibility towards his/her own health becomes neces-

sary both during the treatment and thereafter. The drive to

regain control over one’s own life gives meaning to the dis-

ease, which tends to restore the sense of self-worth and life

satisfaction, which are conducive to achieving it (Adamczak

& Sek 1997, Losiak 1999). Basinska’s (2001) research con-

firms this approach, with her patients being unable to

conceive overcoming the disease due to the fact that they

could not rationalise the situation and see the extent of

their resources.

Although relatively large group of participating patients

with cervical cancer and prospective character represent

principal strengths of our multicenter study, we are also

well aware of its potential limitations. They mostly pertain

to the third survey (five to six months after treatment),

which was based solely on the EORTC QLQ-C30 question-

naires returned by mail. Therefore, in contrast to stages 1

and 2, we were unable to address the quality of life of our

participants to their clinical status. Furthermore, as many

as one-fourth of initially enrolled patients did not partici-

pate in the third survey.

Conclusion

(1) This study revealed that patients with cervical cancer

are satisfied with their global quality of life and its compo-

nents. (2) This was found to be independent of the patient’s

age, cancer stage and the occurrence of the treatment’s side

effects. (3) The ability to performing everyday activities

independently is perceived as the most important during all

stages of the treatment.

Relevance to clinical practice

The diagnosis of cancer is an overwhelming event for any

patient and requires significant effort to fight. Cervical can-

cer patients are satisfied with their global quality of life and

its components, independently of their age, cancer stage

and the occurrence of the treatment’s side effects. The abil-

ity to performing everyday activities independently is per-

ceived as the most important during all stages of the

treatment, and therefore, appropriate support in this matter

is necessary on the part of the nursing personnel.

Contributions

Study design: MP, WMW; data collection and analysis:

MP, KU, JM and manuscript preparation: MP, WMW.

Conflict of interest

None.

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Quality of life in cervical cancer patients treated with radiation therapy