Online Exclusive Article

Quality of Life and Related Factors in Patients With Newly Diagnosed Advanced Lung Cancer: A Longitudinal Study

Yu-Chien Liao

Shiow-Ching Shun

Wei-Yu Liao

Chong-Jen Yu

Pan-Chyr Yang

Yeur-Hur Lai

lung cancer, quality of life, self-efficacy, symptoms
ONF 2014, 41(2), E44-E55. DOI: 10.1188/14.ONF.E44-E55

Purpose/Objectives: To examine the changes in quality of life (QOL), symptoms, self-efficacy for coping with cancer, and factors related to those changes in patients with newly diagnosed advanced lung cancer.

Design: Longitudinal and correlational.

Setting: Oncology inpatient wards and outpatient departments of a medical center in northern Taiwan.

Sample: 101 patients newly diagnosed with stage IIIB or IV lung cancer.

Methods: Questionnaires were used to assess patients' QOL, symptoms, and self-efficacy before treatment and at one and three months following treatment. Factors related to the changes in global QOL and five functional dimensions were analyzed using six generalized estimating equation models.

Main Research Variables: QOL, symptoms, and self-efficacy for coping with cancer.

Findings: Patients reported moderate levels of global QOL, symptom severity, and self-efficacy for coping with cancer. They also reported high physical and cognitive functions, but relatively low role and social functions. Factors were significantly related to the most functional dimensions, including self-efficacy, fatigue, pain, sleep difficulties, and demographic- and disease-related factors. Self-efficacy was the most robust factor for predicting QOL.

Conclusions: Patients with advanced lung cancer experience a compromised global QOL and relatively low social and role functioning during the first three months following cancer diagnosis. Levels of self-efficacy and symptoms significantly affected changes in QOL and functioning.

Implications for Nursing: Applying a systematic assessment of changes in QOL and developing comprehensive interventions with self-efficacy training and symptom management are strongly recommended for clinical care to improve the QOL of patients with advanced lung cancer.

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    Aaronson, N.K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N.J., … de Haes, J.C. (1993). The European Organization for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute, 85, 365-376. doi:10.1093/jnci/85.5.365
    Agero, A.L., Dusza, S.W., Benvenuto-Andrade, C., Busam, K.J., Myskowski, P., & Halpern, A.C. (2006). Dermatologic side effects associated with the epidermal growth factor receptor inhibitors. Journal of the American Academy of Dermatology, 55, 657-670. doi:10.1016/j.jaad.2005.10.010
    Baker, F., Denniston, M., Haffer, S.C., & Liberatos, P. (2009). Change in health-related quality of life of newly diagnosed cancer patients, cancer survivors, and controls. Cancer, 115, 3024-3033. doi:10.1002/cncr.24330
    Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
    Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Worth.
    Barbera, L., Seow, H., Howell, D., Sutradhar, R., Earle, C., Liu, Y., … Dudgeon, D. (2010). Symptom burden and performance status in a population-based cohort of ambulatory cancer patients. Cancer, 116, 5767-5776. doi:10.1002/cncr.25681
    Berterö, C., Vanhanen, M., & Appelin, G. (2008). Receiving a diagnosis of inoperable lung cancer: Patients' perspectives of how it affects their life situation and quality of life. Acta Oncologica, 47, 862-869.
    Boehmer, S., Luszczynska, A., & Schwarzer, R. (2007). Coping and quality of life after tumor surgery: Personal and social resources promote different domains of quality of life. Anxety, Stress, and Coping, 20, 61-75. doi:10.1080/10615800701195439
    Bozcuk, H., Dalmis, B., Samur, M., Ozdogan, M., Artac, M., & Savas, B. (2006). Quality of life in patients with advanced non-small cell lung cancer. Cancer Nursing, 29, 104-110.
    Brown, D.J., McMillan, D.C., & Milroy, R. (2005). The correlation between fatigue, physical function, the systemic inflammatory response, and psychological distress in patients with advanced lung cancer. Cancer, 103, 377-382. doi:10.1002/cncr.20777
    Brown, J.K., Cooley, M.E., Chernecky, C., & Sarna, L. (2011). A symptom cluster and sentinel symptom experienced by women with lung cancer [Online exclusive]. Oncology Nursing Forum, 38, E425-E435. doi:10.1188/11.ONF.E425-E435
    Campbell, L.C., Keefe, F.J., McKee, D.C., Edwards, C.L., Herman, S.H., Johnson, L.E., … Donattuci, C.F. (2004). Prostate cancer in African Americans: Relationship of patient and partner self-efficacy to quality of life. Journal of Pain and Symptom Management, 28, 433-444. doi:10.1016/j.jpainsymman.2004.02.020
    Cella, D. (2004). Quality of life considerations in patients with advanced lung cancer. Seminars in Oncology, 31(Suppl. 11), 16-20. doi:10.1053/j.seminoncol.2004.10.004
    Chen, M.L., Yu, C.T., & Yang, C.H. (2008). Sleep disturbances and quality of life in lung cancer patients undergoing chemotherapy. Lung Cancer, 62, 391-400.
    Chie, W.C., Yang, C.H., Hsu, C., & Yang, P.C. (2004). Quality of life of lung cancer patients: Validation of the Taiwan Chinese version of the EORTC QLQ-C30 and QLQ-LC13. Quality of Life Research, 13, 257-262. doi:10.1016/j.lungcan.2008.3.016
    Cooley, M.E. (1998). Quality of life in persons with non-small lung cancer: A concept analysis. Cancer Nursing, 21, 151-161.
    Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E.S., Humphreys, J., … Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33, 668-676.
    Fayers, P.M., Aaronson, N.K., Bjordal, K., Groenvold, M., Curran, D., & Bottomley, A. (2001). The EORTC QLQ-C30 scoring manual (3rd ed.). Brussels, Belgium: European Organisation for Research and Treatment of Cancer.
    Ferrans, C.E., Zerwic, J.J., Wilbur, J.E., & Larson, J.L. (2005). Conceptual model of health-related quality of life. Journal of Nursing Scholarship, 37, 336-342. doi:10.1111/j.1547-5069.2005.00058.x
    Goldstraw, P. (2009). The 7th edition of TNM in lung cancer: What now? Journal of Thoracic Oncology, 4, 671-673. doi:10.1097/JTO.0b013e31819e7814
    Gralla, R.J. (2004). Quality-of-life considerations in patients with advanced lung cancer: Effect of topotecan on symptom palliation and quality of Life. Oncologist, 9(Suppl. 6), 14-24. doi:10.1634/theoncologist.9-90006-14
    Grant, M., Ferrell, B., Schmidt, G.M., Fonbuena, P., Niland, J.C., & Forman, S.J. (1992). Measurement of quality of life in bone marrow transplantation survivors. Quality of Life Research, 1, 375-384.
    Heitzmann, C.A., Merluzzi, T.V., Jean-Pierre, P., Roscoe, J.A., Kirsh, K.L., & Passik, S.D. (2011). Assessing self-efficacy for coping with cancer: Development and psychometric analysis of the brief version of the Cancer Behavior Inventory (CBI-B). Psycho-Oncology, 20, 302-312. doi:10.1002/pon.1735
    Henoch, I., Bergman, B., Gustafsson, M., Gaston-Johansson, F., & Danielson, E. (2007). The impact of symptoms, coping capacity, and social support on quality of life experience over time in patients with lung cancer. Journal of Pain and Symptom Management, 34, 370-379. doi:10.1016/j.jpainsymman.2006.12.005
    Hermann, C.P., & Looney, S.W. (2011). Determinants of quality of life in patients near the end of life: A longitudinal perspective. Oncology Nursing Forum, 38, 23-31. doi:10.1188/11.ONF.23-31
    Hopwood, P., & Stephens, R.J. (2000). Depression in patients with lung cancer: Prevalence and risk factors derived from quality-of-life data. Journal of Clinical Oncology, 18, 893-903.
    Karnofsky, D.A., Abelmann, W.H., Craver, L.F., & Burchenal, J.H. (1948). The use of nitrogen mustards in the palliative treatment of carcinoma. Cancer, 1, 634-656.
    Kurtz, M.E., Kurtz, J.C., Stommel, M., Given, C.W., & Given, B.A. (2000). Symptomatology and loss of physical functioning among geriatric patients with lung cancer. Journal of Pain and Symptom Management, 19, 249-256.
    Langendijk, J.A., Aaronson, N.K., de Jong, J.M., ten Velde, G.P., Muller, M.J., Lamers, R.J., … Wouters, E.F. (2001). Prospective study on quality of life before and after radical radiotherapy in non-small-cell lung cancer. Journal of Clinical Oncology, 19, 2123-2133.
    Larsson, M., Ljung, L., & Johansson, B.B. (2012). Health-related quality of life in advanced non-small cell lung cancer: Correlates and comparisons to normative data. European Journal of Cancer Care, 21, 642-649. doi:10.1111/j.1365-2354.2012.01346.x
    Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
    Lev, E.L., Daley, K.M., Conner, N.E., Reith, M., Fernandez, C., & Owen, S.V. (2001). An intervention to increase quality of life and self-care self-efficacy and decrease symptoms in breast cancer patients. Scholarly Inquiry for Nursing Practice, 15, 277-294.
    Li, T.C., Li, C.I., Tseng, C.H., Lin, K.S., Yang, S.Y., Chen, C.Y., … Lin, C.C. (2012). Quality of life predicts survival in patients with non-small cell lung cancer. BMC Public Health, 12, 790. doi:10.1186/1471-2458-12-790
    Liang, K.Y., & Zeger, S.L. (1986). Longitudinal data analysis using generalized linear models. Biometrika, 73, 13-22. doi:10.1093/biomet/73.1.13
    Liao, Y.C., Liao, W.Y., Shun, S.C., Yu, C.J., Yang, P.C., & Lai, Y.H. (2011). Symptoms, psychological distress, and supportive care needs in lung cancer patients. Supportive Care in Cancer, 19, 1743-1751. doi:10.1007/s00520-010-1014-7
    Liu, G., & Liang, K.Y. (1997). Sample size calculations for studies with correlated observations. Biometrics, 53, 937-947.
    Lövgren, M., Tishelman, C., Sprangers, M., Koyi, H., & Hamberg, K. (2008). Symptoms and problems with functioning among women and men with inoperable lung cancer—A longitudinal study. Lung Cancer, 60, 113-124. doi:10.1016/j.lungcan.2007.09.015
    McCorkle, R., & Quint-Benoliel, J. (1983). Symptom distress, current concerns and mood disturbance after diagnosis of life-threatening disease. Social Science and Medicine, 17, 431-438.
    Mercadante, S., & Vitrano, V. (2010). Pain in patients with lung cancer: Pathophysiology and treatment. Lung Cancer, 68, 10-15. doi:10.1016/j.lungcan.2009.11.004
    Merluzzi, T.V., Nairn, R.C., Hegde, K., Martinez Sanchez, M.A., & Dunn, L. (2001). Self-efficacy for coping with cancer: Revision of the Cancer Behavior Inventory (version 2.0). Psycho-Oncology, 10, 206-217. doi:10.1002/pon.511
    Merluzzi, T.V., Nairn, R.C., & Martinez Sanchez, M.A. (1999). A manual for the Cancer Behavior Inventory. South Bend, IN: University of Notre Dame, Department of Psychology.
    Merluzzi, T.V., & Martinez Sanchez, M.A. (1997). Assessment of self-efficacy and coping with cancer: Development and validation of the Cancer Behavior Inventory. Health Psychology, 16, 163-170.
    Montazeri, A. (2009). Quality of life data as prognostic indicators of survival in cancer patients: An overview of the literature from 1982 to 2008. Health and Quality of Life Outcomes, 7, 102-122. doi:10.1186/1477-7525-7-102
    Montazeri, A., Milroy, R., Hole, D., McEwen, J., & Gillis, C.R. (2001). Quality of life in lung cancer patients: As an important prognostic factor. Lung Cancer, 31, 233-240.
    Montazeri, A., Milroy, R., Hole, D., McEwen, J., & Gillis, C.R. (2003). How quality of life data contribute to our understanding of cancer patients' experiences? A study of patients with lung cancer. Quality of Life Research, 12, 157-166. doi:10.1023/a:1022232624891
    Morrow, G.R., Lindke, J., & Black, P. (1992). Measurement of quality of life in patients: Psychometric analyses of the Functional Living Index-Cancer (FLIC). Quality of Life Research, 1, 287-296.
    National Comprehensive Cancer Network. (2014). NCCN Clinical Practice Guidelines in Oncology: Non-small cell lung cancer [v.2.2014]. Retrieved from
    Northouse, L.L., Mood, D.W., Schafenacker, A., Montie, J.E., Sandler, H.M., Forman, J.D., … Kershaw, T. (2007). Randomized clinical trial of a family intervention for prostate cancer patients and their spouses. Cancer, 110, 2809-2818. doi:10.1002/cncr.23114
    Östlund, U., Wennman-Larsen, A., Gustavsson, P., & Wengström, Y. (2007). What symptom and functional dimensions can be predictors for global rating of overall quality of life in lung cancer patients? Supportive Care in Cancer, 15, 1199-1205. doi:10.1007/s00520-007-0239-6
    Porter, L.S., Keefe, F.J., Garst, J., McBride, C.M., & Baucom, D. (2008). Self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their informal caregivers: Associations with symptoms and distress. Pain, 137, 306-315. doi:10.1016/j.pain.2007.09.010
    Revicki, D.A., Osoba, D., Fairclough, D., Barofsky, I., Berzon, R., Leidy, N.K., & Rothman, M. (2000). Recommendations on health-related quality of life research to support labeling and promotional claims in the United States. Quality of Life Research, 9, 887-900.
    Robins, J.M., Rotnitzky, A., & Zhao, L.P. (1995). Analysis of semiparametric regression models for repeated outcomes in presence of missing data. Journal of the American Statistical Association, 90, 106-121.
    Rottmann, N., Dalton, S.O., Christensen, J., Frederiksen, K., & Johansen, C. (2010). Self-efficacy, adjustment style and well-being in breast cancer patients: A longitudinal study. Quality of Life Research, 19, 827-836. doi:10.1007/s11136-010-9653-1
    Sarna, L., Cooley, M.E., Brown, J.K., Chernecky, C., Padilla, G., Danao, L., … Elashoff, D. (2010). Women with lung cancer: Quality of life after thoracotomy: A 6-month prospective study. Cancer Nursing, 33, 85-92. doi:10.1097/NCC.0b013e3181be5e51
    Sarna, L., Padilla, G., Holmes, C., Tashkin, D., Brecht, M.L., & Evangelista, L. (2002). Quality of life of long-term survivors of non-small-cell lung cancer. Journal of Clinical Oncology, 20, 2920-2929. doi:10.1200/JCO.2002.09.045
    Sarna, L., & Riedinger, M.S. (2004). Assessment of quality of life and symptom improvement in lung cancer clinical trials. Seminars in Oncology, 31(Suppl. 9), 1-10. doi:10.1053/j.seminoncol.2004.04.007
    Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014). Cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64, 9-29. doi:10.3322/caac.21208
    Sprangers, M.A., Tempelaar, R., van den Heuvel, W.J., & de Haes, H.C. (2002). Explaining quality of life with crisis theory. Psycho-Oncology, 11, 419-426. doi:10.1002/pon.601
    Taiwan Cancer Registry. (2010). Cancer incidence and mortality rated in Taiwan. Retrieved from
    Tanaka, K., Akechi, T., Okuyama, T., & Nishiwaki, Y., & Uchitomi, Y. (2002). Impact of dyspnea, pain, and fatigue on daily life activities in ambulatory paitents with advanced lung cancer. Journal of Pain and Symptom Management, 23, 417-423. doi:10.1016/S0885-3924(02)00376-7
    Wang, X.S., Fairclough, D.L., Liao, Z., Komaki, R., Chang, J.Y., Mobley, G.M., … Cleeland, C.S. (2006). Longitudinal study of the relationship between chemoradiation therapy for non-small-cell lung cancer and patient symptoms. Journal of Clinical Oncology, 24, 4485-4491. doi:10.1200/JCO.2006.07.1126
    Weisman, A.D., & Worden, J.W. (1976). The existential plight in cancer: Significance of the first 100 days. International Journal of Psychiatry in Medicine, 7, 1-15. doi:10.2190/UQ2G-UGV1-3PPC-6387
    Wilson, I.B., & Cleary, P.D. (1995). Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA, 273, 59-65. doi:10.1001/jama.1995.03520250075037
    World Health Organization. (2014). Cancer fact sheet. Retrieved from
    Zabora, J., BrintzenhofeSzoc, K., Curbow, B., Hooker, C., & Piantadosi, S. (2001). The prevalence of psychological distress by cancer site. Psycho-Oncology, 10, 19-28. doi:10.1002/1099-1611