Impact of cosmetic care on quality of life in breast cancer patients

JEADV ISSN 1468-3083
ORIGINAL ARTICLE
Blackwell Publishing Ltd
Impact of cosmetic care on quality of life in breast cancer patients
during chemotherapy and radiotherapy: an initial randomized
controlled study
G Titeca,*†§ F Poot,†§ D Cassart,‡ B Defays,† D Pirard,†§ M Comas,† P Vereecken,†¶††
V Verschaevec, P Simon,† M Heenen†
†
‡
§
¶
Erasme University Hospital, Free University of Brussels, Belgium
Institut de Statistique et de Recherche Opérationnelle and European Centre for Advanced Resaerch in Economics and Statistics, Brussels, Belgium
Notre Dame de Grâce Clinic, Gosselies, Belgium
Bordet Institute, Brussels, Belgium, †† CHU, Brugmann, Brussels, Belgium
Keywords
cosmetic care, quality of life, breast cancer
*Corresponding author, Department of
Dermatology, Notre Dame de Grâce Clinic,
Gosselies, 212, chaussée de Nivelles, B−6041
Gosselies, Belgium, tel. +32 71 379 654;
fax +32 71 379 623;
E-mail: [email protected]
Received: 24 October 2005,
accepted 13 July 2006
DOI: 10.1111/j.1468-3083.2006.02080.x
Abstract
Background Breast cancer is the most common cancer in women and
therefore represents a major problem in public health. Data from patients’ selfreport questionnaires provide valuable information about the side-effects that
patients may view as having a significantly detrimental impact on their quality
of life (QOL) and yet are not always recognized as important by healthcare
professionals. Cosmetology is a specific care for patients and there is actually no
scientific evidence regarding effects on QOL for women with breast cancer.
Objective The purpose of this study is to assess the impact of cosmetic care on
QOL in breast cancer patients during chemotherapy and radiotherapy.
Methods We developed a prospective, multicentre, randomized, controlled
study including 27 patients. All the patients had to fill in a French-validated
dermatologic specific quality-of-life questionnaire to compare the QOL of the
two groups, the cosmetic group and the control group, at three different times
of the adjuvant treatment.
Results The results show a statistically significant difference between the
cosmetic group and the control group in two areas of QOL: mood state and selfperception of the disease.
Conclusion This study emphasizes the interest of cosmetic care in breast
cancer patients. However, further larger trials are needed to confirm this study.
Introduction
Breast cancer is the most common cancer in women and
therefore represents an important problem in public
health.1 Most patients with primary breast cancer can be
optimally treated with breast-conserving local treatments.
The addition of systemic hormone therapy and chemotherapy reduces the risk of death by 25–50% in patients
with invasive carcinoma.2
These treatments are effective but are also sources of
side-effects; chemotherapy is particularly a source of effects
on the hair, nails and on the skin. On a psychological
and aesthetic point of view, alopecia is probably one of the
most difficult side-effects for patients. Moreover, disease
and cancer treatments contribute to modify patients’
perception of their own body, their ‘body image’.
Data from patients’ self-report questionnaires provide
valuable information about the side-effects that patients
may view as having a significantly detrimental impact on
their quality of life (QOL) and yet are not always recognized
as important by healthcare professionals.
Such information is very important in enabling patients
to make informed choices regarding treatment options.3
However, there are still surprisingly few published reports
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
771
Impact of cosmetic care on QOL in breast cancer patients
from comprehensive QOL studies comparing such
treatments and thus little is known about the relative
impacts of each of these on QOL.4–7
Cosmetology is a specific care offering not only face
moisturizing care, moisturizing massages, corrective
make-up, manicure, and pedicure, but also specialized
hair counsels (wigs, scarf, headband) to help patients to
take care of themselves and to correct the side-effects of
anti-cancer treatment such as alopecia, paleness, dryness
of the skin, scars, erythema, and nail dystrophy.
Unfortunately, so far there is no scientific evidence of
the benefit of cosmetology on QOL. The aim of our study
was to assess the impact of cosmetology and hair care on
QOL in breast cancer patients during the whole treatment
(chemotherapy and radiotherapy).
Materials and methods
The patients of the cosmetic group received individual counselling to choose the wig (model, colour), to do its maintenance and to have refund by insurance company. Moreover,
this group received, by the same investigator (dermatologist
qualified in cosmetic care), a 2-h session including face
moisturizing care, body moisturizing massage with oils or
moisturizing creams, camouflage, manicure, pedicure and
make-up every month. Finally, they had an interview for
conclusion after the last session of radiotherapy (Table 2).
Data were analysed using the statistics software SPSS
12. Significance was assessed using the chi-squared or
Fisher tests and was set at P < 0.05.
Likert scale responses were arbitrarily subdivided in
two groups: never, seldom, not at all, somewhat, I don’t
know, not concerned corresponding to ‘not altered QOL’
group, and sometimes, often, always, moderately, very
much, extremely corresponding to ‘altered QOL’ group.
Results
Patients
Between January 2001 and August 2004, 27 female
patients aged 18 years old and over were included in two
centres (Erasme University hospital and Notre Dame de
Grâce Clinic Gosselies). Inclusion criteria were stage II
breast cancer treated by lumpectomy (excision of the
tumour with preservation of the breast) with positive
axillary lymph-node dissection receiving adjuvant chemotherapy and radiotherapy. Patients were treated either by
cyclophosphamide, methotrexate and fluorouracil (CMF)
or fluorouracil, epirubicin and cyclophosphamide (FEC)
administrated at intervals of 3 or 4 weeks for 4 months
(CMF) to 6 months (FEC). Approval for study was first
obtained from the local ethics committee.
Patients were informed of the target of the study and
were randomized in two groups, the cosmetic group and
the control group. The cosmetic group received cosmetic
care during the chemotherapy and the radiotherapy. The
control group did not received cosmetic care.
Methods
Patients were administered a French validated dermatologic specific quality of life questionnaire,8 the VQDermato, including 28 questions about seven different
fields of QOL: self-perception, daily life activity, mood state,
social functioning, leisure/activity, treatment-induced
restriction, and physical discomfort8 (Table 1).
All the patients had to fill in this questionnaire three
times during the adjuvant treatment: before the first
chemotherapy (time 0), after the second cycle of chemotherapy (time 1), and at the end of radiotherapy (time 2).
All the patients had an interview before the first cure of
chemotherapy (approximately 12 days before the first cure).
772
Titeca et al.
Patient’s characteristics
In the cosmetic group we find 14 patients age 39–60
(mean 51); 2 patients had CMF chemotherapy, 12 had
FEC chemotherapy, and all had radiotherapy.
In the control group we find 13 patients age 40–79
(mean 57), 1 had CMF chemotherapy, 12 had FEC chemotherapy, and all had radiotherapy (Table 3).
All patients except two developed alopecia, one in each
group.
Impact of cosmetic care on QOL
Table 4 show the number of patients (cosmetic group and
control group) for each responses group: ‘QOL not altered’
and ‘QOL altered’ at three different moments of the
treatment (times 0, 1 and 2).
Three questions showed a difference between the two
groups of patients but only after all the treatment (time 2).
Cosmetic patients were less discouraged than patients
receiving any cosmetic care (question no. 17/P = 0.032).
Treated patients stayed more self-confident (question no.
23/P = 0.032). Cosmetic patients stayed more confident
on the future (question no. 24/P = 0.04).
We can thus notice that the treated patients keep a better
quality of life in two explored fields, the field of the ‘selfperception of the disease “and the field of” mood state’.
Discussion
The quality of life becomes one useful tool in the medical
field, not only to analyse the impact of a disease but also
to evaluate impact of treatments.
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Titeca et al.
Impact of cosmetic care on QOL in breast cancer patients
Table 1 VQ-Dermato questionnaire
VQ-Dermato in French (validated version)
VQ-Dermato in English (indicative translation – not validated in English)
Durant les quatre dernières semaines, votre maladie a-t-elle entraîné des
difficultés:
Q1 – pour marcher?
Q2 – pour vous occuper de votre maison : ménage, cuisine, petits travaux
d’entretien?
Q3 – pour faire votre toilette, vous raser, vous maquiller?
Q4 – dans le choix de vos habits; vous n’avez pas pu mettre certains vêtements
ou ceux que vous souhaitiez?
Q5 – pour vos loisirs: sport, exposition au soleil, musique, bricolage,
jardinage?
Q6 – pour profiter du soleil, pour vivre dehors au soleil?
Q7 – pour vous concentrer: travail, lecture?
Q8 – pour dormir?
During the 4 weeks, did your disease affect, restrict or
interfere with:
Q1 – the way you walk or move?
Q2 – your housework?
Q3 – your personal care (wash, ,shave, apply, make-up)?
Q4 – the chose of your clothes (you could not wear some of your clothes
you wished)?
Q5 – your recreation time: sport, sun exposure, music, do-it-yourself,
gardening?
Q6 – the way you enjoy the sun, you live in the sun?
Q7 – your ability to concentrate (in working, reading)?
Q8 – sleeping?
Durant les quatre dernières semaines, votre maladie vous a-t-elle gêné dans:
Q9 – dans votre vie sociale: sorties au restaurant, au cinéma, au café, allez
chez le coiffeur ou chez les commerçants … ?
Q10 – vos relations avec vos proches: famille, amis?
Q11 – votre vie affective avec votre conjoint(e), votre partenaire?
Q12 – votre activité sexuelle avec votre conjoint(e), votre partenaire?
During the 4 weeks, did your disease bother you in:
Q9 – your social life: going to the restaurant, bar, hairdresser or
shopping … ?
Q10 – your relationship with your family and friends?
Q11 – your sentimental life with your spouse or partner?
Q12 – your sexual relationships with your spouse or partner?
Durant les quatre dernières semaines, du fait de votre maladie, vous avez?
Q13 – ressenti de la fatigue?
Q14 – éprouvé le besoin de cacher votre maladie de peau: par le maquillage,
les vêtements?
Q15 – eu les sentiments d’être dévisagé(e), rejeté(e) par les autres?
Q16 – été stressé(e), énervé(e)?
Q17 – été découragé(e)?
Q18 – été angoissé(e)?
Q19 – été agressif, irritable?
Q20 – eu le sentiment d ‘être différent des autres?
Q21 – eu le sentiment d’être sale, repoussant?
Q22 – eu le sentiment d’être seule, isolé(e)?
Q23 – eu le sentiment d’être diminué(e), de manquer de confiance en vous?
Q24 – manqué de confiance dans l’avenir?
During the 4 last weeks, did you feel:
Q13 – tired?
Q14 – that you had to hide your skin disease?
Durant les quatre dernières semaines, jugez-vous que le (ou les) traitement(s)
de votre maladie a (ont) été?
Q25 – contraignant(s)?
Q26 – désagréable(s)?
During the last 4 weeks, was the treatment of your disease?
Q15 – that people were staring at you or rejecting you?
Q16 – stressed, irritable?
Q17 – discouraged?
Q18 – anxious?
Q19 – aggressive, irritable?
Q20 – different from the others?
Q21 – dirty, repulsive?
Q22 – alone, isolated)?
Q23 – you were diminished, you lack self-confidence?
Q24 – no confidence for the future?
Q25 – restricting?
Q26 – uncomfortable?
Durant les quatre dernières semaines, votre maladie a-t-elle entraîné:
Q27 – des démangeaisons?
Q28 – des brûlures, des picotements, des tiraillements ou toute autre forme
de douleur?
During the 4 weeks, did your disease cause:
Q27 – itching?
Q28 – burning, prickling, or any other type of pain?
Five Likert scale responses:
«Jamais, rarement, Parfois, Souvent, Toujours» for questions 1–8, 13–24 and
27, 28
«Pas du tout , Un peu, Modérement, Beaucoup, Extrêmement / Enormement»
for questions 9–12 and 25, 26
+ Non concerné, Ne sait pas
Five Likert scale responses:
‘Never, seldom, sometimes, often and always’ for questions 1–8, 13–24
and 27, 28
‘Not at all, somewhat, Moderately, very much, extremely’ for questions
9–12 and 25, 26
+ Not concerned, I don’t know
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
773
Impact of cosmetic care on QOL in breast cancer patients
Titeca et al.
Table 2 Programme of the meetings
Control group
Cosmetic group
12 days after the 1st cure of chemotherapy (1st time): Meeting
12 days before the 1st cure of chemotherapy (1st time): Meeting
Planning explanation + delivery of the list of the advised
Belgian wig makers + VQ-Dermato to fill in at home
First visit: Planning explanation + Proposal of a hair cut very short before the possible
loss of the hair + choice of capillary prosthesis + delivery of VQ-Dermato to fill in at home
12 days after the second cure (2nd time):
12 days after the second cure (2nd time): Meeting
VQ-Dermato to fill in at home. Sent by post mail
Planning for Cosmetic Care and first séance of cosmetic care + VQ-Dermato to fill in
at home. Specific cosmetic care programme established for each patient with the
dermatologist
After the last radiotherapy (3rd time):
After the last radiotherapy (3rd time): Meeting
VQ-Dermato to be fill-in at home. Sent by post mail
Conclusions + VQ-Dermato to fill in at home
Table 3 Patient’s characteristics
Mean age
(years)
Number of patients
CMF chemotherapy
Number of patients
FEC chemotherapy
Number of patients
radiotherapy
Cosmetic group
14 patients
51 (39 to 60)
2
12
14
Control group
13 patients
57 (40 to 79)
1
12
13
To date, in a surprising way, only a few publications deal
with the topic of QOL.
In order to study the impact of the cosmetic care on the
quality of life of the breast cancer patients in the course of
chemotherapy and radiotherapy, we developed a prospective, multicentre, randomized, controlled study including
27 patients. In spite of little information about all the
QOL, this study shows significant differences between
the two groups of the patients but only at the end of the
treatment; indeed at this time, patients who received
cosmetic care remain more self-confident and are more
optimistic.
The fact that the difference is only significant at the end
of the treatment shows that it is interesting to follow the
patients throughout treatment and not only during one
session of chemotherapy or radiotherapy.
Although no study was carried out among breast cancer
patients, we know that self-confidence is altered in these
patients and this might interfere with their compliance to
treatments.9,10
Therefore, it should be important to focus on patients’
psychological life and to develop all kind of support that
can help them to stay hopeful and confident about the
future as illustrated in our trial. We really think that
cosmetology is helpful and the most important support
774
for women is probably hair care because of its significant
impact on the ‘body image’.
Moreover, we insist on the fact that this study was entirely
free for patients and that the financial aspect could represent
a brake with the cosmetic care for some patients. Therefore, it seems important to analyse possibility of a financial
support by the health insurances or government. It could
also realized by cosmetic company as it is already the case
in France for the association ‘L’Etincelle’ devoted to the
quality of life of the women suffering from breast cancer.
In our study, all the cosmetic care was provided by
people properly trained in ‘hospital cosmetic care’. Unfortunately they are currently very few. To develop this
approach on a large scale, it seems possible to us to set up
a nurse training elaborated by people experienced in
cosmetology and oncology. Cosmetic care provided by those
specially trained nurses stand be available in gynaecology
departments treating breast cancer and in oncology
departments and could be extended to other male and
female cancers patients as well.
Acknowledgements
This study was supported by a grant provided by Lancôme
Belgium.
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Titeca et al.
Time 0: before treatment
Time 1: during treatment
Time 2: after treatment
Responses group
QOL not altered
Number of patient
QOL altered
Number of patient
QOL not altered
Number of patient
QOL altered
Number of patient
QOL not altered
Number of patient
QOL altered
Number of patient
Patient’s group
Control
Cosmetic
Control
Cosmetic
P-value
Control
Cosmetic
Control
Cosmetic
P value
control
cosmetic
Control
Cosmetic
P value
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15
Question 16
Question 17
Question 18
Question 19
Question 20
Question 21
Question 22
Question 23
Question 24
Question 25
Question 26
Question 27
Question 28
12
11
13
13
10
12
10
5
12
13
13
13
3
12
12
7
8
7
11
11
12
11
10
10
9
7
10
7
12
9
13
13
9
10
9
7
11
12
12
11
6
13
14
10
11
9
12
12
14
14
12
13
9
11
14
10
1
2
0
0
3
1
3
8
1
0
0
0
9
0
0
5
4
5
1
1
0
1
2
2
3
5
2
5
1
4
0
0
4
3
4
6
2
1
1
2
8
1
0
4
3
5
2
2
0
0
2
1
5
3
0
4
0.760
0.322
/
/
0.500
0.297
0.500
0.348
0.500
0.500
0.500
0.240
0.296
0.538
/
0.387
0.404
0.536
0.560
0.560
/
0.463
0.641
0.440
0.437
0.246
0.203
0.387
8
6
8
8
7
6
8
5
8
9
9
9
4
7
8
3
5
4
8
6
11
8
6
6
9
8
9
8
12
9
12
12
9
10
9
8
10
12
12
8
5
11
11
8
10
7
9
9
8
11
8
8
8
8
11
10
1
3
1
1
2
3
1
4
1
0
0
0
5
2
1
6
4
5
1
3
1
1
3
3
0
1
0
1
0
3
0
0
3
2
3
4
2
0
0
4
7
1
1
4
2
5
3
3
1
1
4
4
4
4
1
2
0.429
0.523
0.429
0.429
0.647
0.353
0.414
0.472
0.612
/
/
0.083
0.623
0.388
0.686
0.142
0.183
0.425
0.414
0.523
0.686
0.686
0.681
0.681
0.083
0.258
0.571
0.612
8
8
10
9
8
9
6
8
9
9
10
9
2
11
10
6
5
5
7
9
10
9
5
4
8
10
8
8
11
9
10
9
9
8
8
7
9
10
11
8
4
11
11
7
10
8
9
9
10
10
10
9
8
10
11
7
3
3
1
2
3
2
5
3
2
2
1
2
9
0
0
5
6
6
4
2
1
2
6
7
3
1
3
3
0
2
1
2
2
3
3
4
2
1
0
3
7
0
1
4
1
3
2
2
1
1
1
2
3
1
0
4
0.107
0.500
0.762
0.707
0.500
0.500
0.330
0.500
0.707
0.500
0.500
0.500
0.318
/
0.500
0.500
0.032
0.193
0.318
0.707
0.762
0.500
0.032
0.040
0.682
0.762
0.107
0.500
775
Impact of cosmetic care on QOL in breast cancer patients
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Table 4 Statistics – Fisher test
Impact of cosmetic care on QOL in breast cancer patients
Titeca et al.
References
1 Jensen AB. Psychosocial factors in breast cancer and their
possible impact upon prognosis. Cancer treat Rev 1991; 18:
191–210.
2 Hortobagyi GN. Treatment of breast cancer. N Engl J Med
1998; 339: 974–984.
3 Fallowfield LJ. Evolution of breast cancer treatments:
current options and quality-of-life considerations.
Eur J Oncol Nurs 2004; 8: S75–S82.
4 Del Mastro L, Costantini M, Morasso G et al. Impact of two
different dose-intensity chemotherapy regimens on
psychological distress in early breast cancer patients.
Eur J Cancer 2002; 38: 359–366.
5 Riccardi A, Tinelli C, Brugnatelli S et al. Doubling of the
epirubicin dosage within the 5-fluorouracil, epirubicin and
cyclophosphamide regimen: a prospective, randomized,
multicentric study on antitumor effect and quality of life in
advanced breast cancer. Int J Oncol 2000; 16: 769–767.
6 Bottomley A, Therasse P, Piccart M et al. Health-related
quality of life in survivors of locally advanced breast cancer:
776
7
8
9
10
an international randomised controlled phase III trial. Lancet
Oncol 2005; 6: 287–294.
Brandberg Y, Michelson H, Nilsson B et al. Quality of life in
women with breast cancer during the first year after random
assignment to adjuvant treatment with marrow-supported
high-dose chemotherapy with cyclophosphamide, thiotepa,
and carboplatin or tailored therapy with fluorouracil,
epirubicin, and cyclophosphamide: Scandinavian Breast
Group Study 9401. Clin Oncol 2003; 21: 3659–3664.
Grob JJ, Auquier P, Martin S, Lancon C, Bonerandi JJ.
Development and validation of a quality of life
measurement for chronic skin disorders in French:
VQ-Dermato. Dermatol 1999; 199: 213–222.
DiMatteo MR, Lepper HS, Croghan TW. Depression is a
risk factor for noncompliance with medical treatment:
meta-analysis of the effects of anxiety and depression on
patient adherence. Arch Intern Med 2000; 160:
2101–2107.
Somerset W, Stout SC, Miller AH, Musselman D. Breast
cancer and depression. Oncology (Huntingt) 2004; 18:
1021–1034.
© 2007 The Authors
JEADV 2007, 21, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology