Quality of life for patients on oncology treatments in the Kingdom of Saudi Arabia: a systematic review.

Background

Cancer cases in the Kingdom of Saudi Arabia (KSA) have increased threefold in the last few years (Alqahtani et al., 2020 ). According to the National Cancer Incidence Report, the most common cancer in KSA in 2020 was breast cancer, affecting 17.8% of females, followed by colorectal cancer at 12.3%, thyroid cancer at 7.4%, and leukemia at 5.9% (National Cancer Center, 2023 ). As is widely emphasised in the literature, the absence of a healthy lifestyle is a prominent risk factor for cancer. This observed increase in risk can be attributed to evolving societal norms in the KSA, limited cancer awareness, and constraints within cancer screening and early detection programmes (de Martel et al., 2020 ; Ferlay et al., 2021 ). It is noteworthy that the older adult population in Saudi Arabia is increasing (Yancik, 1997 ). Age has been identified as a significant factor associated with the increased prevalence of cancer diagnoses and associated mortality due to multiple factors, including the accumulation of cell mutations, compromised immune system, hormonal changes, and chronic inflammation (National Cancer Institute, 2023 ).

Quality of Life (QoL) assessments are widely recognised and validated tools used to gauge patients’ subjective evaluation of their physical, mental, and social well-being (Cai et al., 2021 ). Cancer and its treatment can significantly affect every aspect of a patient’s QoL. Despite its importance, QoL has rarely been reported (Hadidi et al., 2021 ). There are two fundamental ways to gauge the QoL; Cancer-specific instruments focus on issues related to individual disease states, patient groups, or functional areas, whereas general tools measure health profiles and overall patient QoL. However, these approaches are not mutually exclusive (Guyatt et al., 1993 ). Borchert et al. ( 2020 ) explored the scores of EQ-5D, a generic QoL instrument, for patients with colorectal cancer and compared their demographics to the population (Borchert et al., 2020 ). Meanwhile, Musoro et al. ( 2020 ) calculated the differences along the EORTC QLQ, a disease-specific instrument, for patients with colorectal cancer (Musoro et al., 2020 ). Both options offer advantages and disadvantages, rendering them potentially suitable for different scenarios. Research on Health-Related Quality of Life (HRQL) has resulted in tools that can detect minor effects in clinical trials, measure population health status, and inform policy decisions (Hadidi et al., 2021 ; Yancik, 1997 ).

One of the significant challenges in managing cancer is the illness uncertainty associated with diagnosis, treatment, and overall survival (Guan et al., 2021 ). Initially, drug development for cancer treatment had one of the lowest success rates, with less than 5% of the products approved (Wong et al., 2019 ). Even after the drug reaches the market, the survival rate for cancer varies, with the highest being associated with testicular, melanoma, prostate, and thyroid cancer. Lung, esophageal, liver, brain, pancreatic, and mesothelioma have a survival rate of less than 20% (Wong, 2020 ). There has been a tremendous increase in the price of oncological treatments. In the United States alone, direct medical costs for cancer exceeded $80 billion in 2015 and are projected to exceed $200 billion by 2020 (Howlader et al., 2018 ; Mariotto et al., 2011 , pp. 2010–2020). Considering the treatment price or overall survival rates alone may lead to biased decision-making. Instead, value-based decision-making is advocated for optimal choices (Hurst et al., 2019 ). The integration of QoL scores into drug approval processes is evident in the practices of international agencies. For instance, 2008, the National Institute for Health and Care Excellence (NICE) has been at the forefront since 2008, requiring the inclusion of EQ-5D scores in their technology appraisal, thereby highlighting the incorporation of QoL assessments in decision-making (Rowen et al., 2023 ).

The significance of QoL measures are essential for healthcare lies in their ability to provide invaluable insights into patients’ perceptions of their medications and overall well-being (James et al., 2022 ). Therefore, exploring the quality of patients undergoing cancer treatment in the KSA is vital. Providing a summary of QoL measures used for cancer research in Saudi Arabia would guide local researchers toward addressing the issue. This study aimed to collect and summarise articles exploring the quality of patients undergoing oncology treatments in the KSA.

Methods

The primary objective for this systematic review was to collect articles on the QoL of patients undergoing oncology treatments living in the KSA from 2000–2023 by using a standardised tool. The methods followed the PRISMA 2020 statement checklist (2020) for reporting systematic reviews (Moher et al., 2009 ). All suggested method sections were applied except for the Certainty assessment, as this systematic review did not generate a meta-analysis ( Supplemental Appendix 1 ). The systematic review accelerator (SRA) was used to organise the search and enable multiple reviewers to conduct and validate the process (Clark et al., 2020 ). Two reviewers independently screened and extracted data from studies, with a third resolving disagreements. Data included patient demographics, cancer type, treatment, and QoL instruments. We assessed methodological quality and summarised QoL findings.

Eligibility criteria

A query was established by adopting Population, Intervention, Control, Outcomes, Study design and Timeframe (PICOST) guidelines for systematic research. The inclusion criteria were studies that reported cancer patients (population), treatments (interventions and comparators), mentioned QoL measurements (outcomes), and were established in hospitals located in Saudi Arabia (settings) between 2000 and 2023. Table 1 summarises the PICOST criteria.

The exclusion criteria were studies with self-reported cancer, those that did not report treatments, those in which QoL measurement was not mentioned, those published before 2000, and articles conducted outside Saudi Arabia. Articles in abstract format only or from journals without a reviewing process were purposefully removed from the search results.

Information source and selection process

PubMed Advance, EBSCO, ProQuest, Web of Science, Cochrane Library, and OVID library were searched using the unified methods suggested by the polyglot function in SRA, a tool for converting the search inquiries used in bibliographic databases across various platforms to ensure consistency (Clark et al., 2020 ). The search was conducted on the month of April, 2023. The resulting titles were checked for duplicates prior to screening. All screenings were performed by two independent reviewers (R.Z) and (N.A). Each reviewer followed a simple checklist tool that is based on (PICOST), and to ensure clarity the comparator and intervention were merged into one category. In case of disagreements, a third reviewer determined the screening results (A.T). Supplemental Appendix 2 shows the checklist utilised in the review process. Figure 1 shows all processes from screening to selection of the final pool adapting PRISMA diagram for articles identification and screening (Moher et al., 2009 ).

Search strategy

Participants were defined as those diagnosed and treated for cancer. The general definition of cancer was broad and based on World Health Organization guidelines (Ferlay et al., 2021 ). The specific definition of cancer is adapted to each affiliated reviewed article. The interventions were all pharmacological treatments for cancer, including both FDA – and non-FDA-approved medications. For comparison, all listed treatments for cancer in the interventions were included in addition to radiation, surgery, and placebo. The outcomes were patient-reported or QoL measures (generic or cancer-specific disease). The settings were defined by all studies published in the KSA. The study designs included randomised trials, observational, cohort (longitudinal), case–control, and cross-sectional studies. Lastly, the timeframe was specified from using databases filter to articles published between 2000 and 2023. This extended timeframe was applied to address the limited number of publications on QoL in KSA, as reported in previous literature (Althemery, 2021 ). Supplemental Appendix 3 lists all details regarding the PICOST used to generate the search query.

Data collection process and items

The main independent reviewers (R.Z and N.A) categorised the resulting articles by date of publication, site, type of cancer, QoL tool, and treatment type, separately. Then, the lead author (A.T) validated the results and merged the results. Another round of analysis for the reviewed articles was conducted focusing on the type of QoL instruments utilised in each article.

Study risk of bias and analysis

All reviewed studies were graded for quality using a validated checklist instrument tailored for observational cohort and cross-sectional studies and developed by the US National Heart, Lung and Blood Institute along with the Research Triangle Institute International. One researcher graded each article by answering fourteen questions. Detailed information regarding the checklist and questions are found in Supplemental Appendix 4 .

Effect measures

A standardised tool used to fill in article information by the main reviewers (R.Z and N.A) and all missing pieces of information were reported. The final articles were described based on their year of publication, city, type of cancer studied, number of patients, and treatment type. Moreover, detailed information on the patients’ reported outcomes and QoL was summarised. Pooled frequencies were calculated by adding the registered number of patients, sex, and marital status. The pooled average age was calculated as the sum of the product of the number of patients in each article (pi) multiplied by the average age reported in the affiliated article (xi), divided by the sum of the patients included in the review:

Results

Twelve articles met the inclusion criteria, in which the QoL or patient-reported outcomes (PROs) were explored in patients diagnosed with cancer living in the KSA from 2000 until 2023. The first and latest publications were published in 2014 and 2022, respectively. Additionally, 2022 had the highest number of publications, with four articles (Al-Hoqail et al., 2022 ; AlFayyad et al., 2022 ; Alyousef et al., 2022 ; Qedair et al., 2022 ), followed by 2020, with three articles (Alsafadi et al., 2020 ; Bazarbashi et al., 2020 ; Shaheen et al., 2020 ). One article was published in 2019 (Baharoon et al., 2019 ), and two articles published in 2018 (Ahmed et al., 2017 , p. 2018; Baharoon et al., 2019 ; Ibrahim et al., 2014 ; Soudy et al., 2018 ), and the remainder were published prior to 2018 (Ahmed et al., 2017 , 2018 ; Baharoon et al., 2019 ; Ibrahim et al., 2014 ; Soudy et al., 2018 ). Two cities contributed to all publications: Riyadh with 10 publications and Jeddah with two. King Abdulaziz Medical Cities (KAMC) in Riyadh and Jeddah offered the most publications, with six each. The King Faisal Specialized Hospital and Research Center in Riyadh (KFSHRC) appeared in three publications, followed by the King Fahad Medical City (KFMC) and the King Saud University Hospital (KSU) with two publications each. Finally, Prince Sultan Medical City (PSMC) conducted one study only.

A total of 2,430 cancer patients were surveyed, of whom 1,377 were female (56.67%). The pooled average age was 51.23 for all studied samples; the youngest patients being 11 years old, whereas the oldest was above 65. Eight articles reported on marital status, of which 1,458 participants were married. Approximately half of the participants were patients with colorectal cancer (n = 563) or breast cancer (n = 550). Other cancer diagnoses included lymphoma, thyroid carcinoma, leukemia, multiple myeloma, and unspecified types.

There is a general agreement that the QoL of patients with various types of cancer declined (6 articles). Alyousef et al. ( 2022 ), Qedair et al. ( 2022 ), and Ibrahim et al. ( 2014 ) have found that QoL scores for patients with cancer were reasonable compared to other countries. Clinical symptoms, particularly pain, have shown to be significant complications of cancer and its treatments. Table 2 lists these reviewed articles.

Six articles mentioned pharmacological interventions, whereas the remaining articles did not mention which pharmacology had been utilised. Two of the six studies thoroughly focused on pharmacological treatments; one on patients with multiple myeloma was performed by Shaheen et al. ( 2020 ), specifically on neuropathy side effects resulting from chemotherapy. Another study by Soudy et al. ( 2018 ) explored QoL in cancer therapy and bone marrow transplantation, and pharmacological intervention included an ESHAP regimen (etoposide, solumedrol, Ara-C, and cisplatin with or without rituximab as salvage chemotherapy) and a BEAM regimen (busulfan, etoposide, Ara-C, and melphalan). Ahmed et al. ( 2017 ) and Ibrahim et al. ( 2014 ) focused on pain in patients undergoing anticancer treatment. Moreover, some articles mentioned pharmacological treatment without detailed reporting: Al-Hoqail et al. ( 2022 ) explored the QoL of breast cancer patients, with interest being surgery and physical therapy rather than chemotherapy. Alsafadi et al. ( 2020 ) categorised patients with nasopharyngeal cancer by their treatment type, and patients undergoing chemotherapy were categorised into one group ( Table 3 ).

Four studies utilised generic instruments to measure the quality of life (QoL): the SF-36 and EQ-5D (Ahmed et al., 2017 , 2018 ; Al-Hoqail et al., 2022 ; Ibrahim et al., 2014 ; Soudy et al., 2018 ). Two studies found that breast cancer patients had a lower score of physical functioning in the SF-36 (Ahmed et al., 2017 ; Al-Hoqail et al., 2022 ). The presence of lymphoma decreased the physical functioning score by 0.2, while immunotherapies lowered the score of physical functioning in SF-36 by an average of 15. In Saudi Arabia, cancer patients who received immunotherapies had a significantly lower score of pain domain in the SF-36, compared to other domains (Ahmed et al., 2018 ).

Discussion

Twelve articles explored the quality of patients undergoing oncology treatments living in the KSA, with most of these articles focusing on breast and colorectal cancer. This was expected, as both types have higher incidence rates in the KSA (National Cancer Center, 2023 ). It also shows that local cancer researchers are exploring ways to optimise cancer therapy beyond traditional survival analysis methods for the studied treatments. These methods include generic QoL measures, disease-specific measures, and patient willingness to pay scales. Female patients with breast cancer have shown lower QoL, particularly in later stages of cancer, and multiple tumours (Ahmed et al., 2017 , 2018 ; Al-Hoqail et al., 2022 ). Internationally, Qan’ir et al. ( 2022 ) explored the QoL of patients with cancer in the sub-Saharan region and found that breast cancer was the most studied disease, with certain domains such as coping with the illness, symptom control, and religious beliefs significantly affecting their QoL.

By exploring review articles chronologically, we found a significant increase in publications post-2019. Indeed, the QoL has become essential in the KSA in various sectors, including healthcare. This attention was motivated by the launch of Saudi Vision 2030, and it is evident that local cancer researchers are adopting QoL as a clinical outcome (Chowdhury et al., 2021 ). Despite the recent increase in publications, more cancer research is required to reflect the clinical and social outcomes of patients with cancer. Cancer has the highest financial burden compared to other chronic conditions, and new pharmaceutical treatments are readily available (Schlueter et al., 2020 ; Serra-Burriel et al., 2023 ). PROs can be crucial in helping decision-makers and local health technology assessment groups evaluate new cancer treatments and improve the overall quality of care. Ultimately, this could address delays or shortages in accessing oncological treatments in the KSA (AlAzmi et al., 2020 ).

There is a general agreement that cancer patients are associated with the decline of QoL as seen in Shaheen et al. ( 2020 ), Baharoon et al. ( 2019 ), Ahmed et al. ( 2018 ), and Ahmed et al. ( 2017 ) studies. However, Alyousef et al. ( 2022 ), Qedair et al. ( 2022 ), and Ibrahim have shown that QoL for cancer patients is a complex issue, noting a good QoL associated with their studied sample. Clinical symptoms, particularly pain, fatigue, and nausea, remain a major burden of the disease, and healthcare systems could offer more interventions to help relieve these concerns.

Riyadh and Jeddah accounted for all cancer studies. This reflects the practices by which the two cities offer the most cancer care. Government-based hospitals provide free tertiary cancer care in larger cities, and patients in rural areas can be transferred to these hospitals. However, the American Society of Clinical Oncology (ASCO) has called for attention to patients living in rural areas because of the long travel time associated with treatments and lower clinical trial involvement (Levit et al., 2020 ). Although patients in rural areas are more prone to adverse clinical outcomes and cancer-related mortalities (Henley et al., 2017 ), some community hospitals in the United States have adopted satellite clinics to address this issue. They can provide specialised cancer treatment and care in convenient locations (Curtis & Eschiti, 2018 ).

This systematic review article is one of the few that shed light on QoL related to cancer treatments in the Middle East, particularly in Saudi Arabia. This can be used as a guide for future research to explore areas that have not yet been studied. The limited use of well-validated generic instruments, such as the EQ-5D, or the lack of QoL research in specific cancer types, such as the corpus utero, brain, lung, and liver, provides opportunities for future research. Moreover, future work can address some of the limitations of this review, such as focusing on qualitative research that can provide additional value from patients’ perspectives. The findings of this review article should be interpreted with caution because the publications spanned a period of ten years, during which there were significant advancements that could have impacted the QoL for patients (Wong, 2020 ). However, the results included the publication dates of each article to assist the reader in making more precise interpretations.

Utilising validated QoL measurements into routine practice for cancer care and advocating other policies that support the QoL-equipped interventions can assess policymakers and practitioners to make value-based decisions. The results have shown that many areas of research, from qualitative approaches to disease-specific quantitative methods, need support from both government and private institutes.

Conclusion

This systematic review highlights the recent attention given to the patient’s reported outcomes of cancer patients in the Kingdom of Saudi Arabia, particularly for breast and colorectal cancers. Even though pain has been identified as a significant burden, more research is required using validated tools and focusing on specific types of cancer. That will ultimately help improve patient care in Saudi Arabia.

Supplementary Material

Appendix_4.docx

Appendix_2.docx

Appendix_1.docx

Appendix_3.docx

Funding Statement

This work was supported by Deanship of Scientific Research, Prince Sattam bin Abdulaziz University: [Grant Number PSAU /2023/R/1445].

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Associated Data

Supplementary Materials

Appendix_4.docx

Appendix_2.docx

Appendix_1.docx

Appendix_3.docx