Lecture
«A patient is always a human personality, with all of his complex experiences, and by no means an impersonal case».
N.N. Petrov, «Questions of Surgical Deontology», 1945
Rehabilitation of the oncology patient is understood not only as the elimination of the disease itself (this is the prerogative of treatment) and the restoration of the body's physical functions, but also as the maximally acceptable restoration of a person's ability to live in his customary environment, which is impossible without addressing the personality of the sick person.
The basic principles of rehabilitation of the oncology patient were formulated more than forty years ago by M.M. Kabanov: partnership between the physician and the patient; the many-sidedness (multidimensionality) of efforts, interventions, and measures directed at the different spheres of the patient's life activity; the unity of biological and psychosocial methods of intervention; a stepwise approach (the phased prescription of rehabilitative measures taking into account the dynamics of the patient's functional and psychoemotional state) [11].
The growing interest in rehabilitation in recent years can most likely be explained by the medical community's awareness of the fact that the quality of life of the oncology patient can be influenced not only by the choice of the type of treatment but also by the conduct of rehabilitative measures. In addition, the psychological rehabilitation of the oncology patient begins as early as the diagnostic stage, when
the patient is directly confronted with the psychotraumatic situation of the disease.
Psychological rehabilitation is an integral part of the rehabilitation of the oncology patient, is directed at adapting him to the situation of the disease, and contributes to improving the patient's quality of life.
In 1985 the FDA (the U.S. Food and Drug Administration) recommended including the assessment of quality of life in clinical studies as a primary or supplementary criterion for evaluating the results of treatment of oncology patients. And already in 1990, at the ASCO (American Society of Clinical Oncology) conference, quality of life was declared the second most important criterion of treatment efficacy for the patient after overall survival and more significant than objective response. Interest in the problem of the quality of life of people suffering from various diseases had taken shape by the middle of the 20th century and required the study not only of the prevalence of diseases but also of their impact on occupational activity.
The first attempt at a medical interpretation of the concept of «quality of life» is found in the works of Professor D.A. Karnovsky of Columbia University, USA, who in 1947 published the article «The Clinical Evaluation of Chemotherapy in Cancer», in which he assessed the impact of chemotherapy on the physical aspects of the quality of life of inoperable oncology patients [11, 27]. Thus, the first patients whose quality of life became the subject of study in medicine were oncology patients.
The development of the concept of quality of life was facilitated by the biopsychological model of medicine proposed in 1980 by American researchers, the aim of which was to take into account the psychosocial aspects of disease.
The concept of quality of life as a key factor in the interaction between physician and patient is most accurately characterized by the widely known principle:
«one must treat not the disease but the patient», formulated as far back as the famous healer of antiquity Hippocrates. In Russia the formula «treat not the disease but the patient» was advocated by the outstanding clinicians
of the 19th century M.Ya. Mudrov (1776–1831) and S.P. Botkin (1832–1889).
The evolution of the paradigms of 20th-century medicine proceeded in parallel with the changing trends in the understanding of public health: the World Health Organization (WHO) broadens the concept of health and defines it as a state of physical, psychological, and social well-being, and not merely the absence of disease. At the same time, the concept of the social determination of health gave rise to the development of a new paradigm of clinical medicine – the concept of quality of life, which came into its own at the end of the 1990s. During this period the WHO recommended considering quality of life as an individual's relationship between his position in the life of society, in the context of the culture and value systems of that society, and the goals of the given individual, his plans, possibilities, and degree of general disorder: «Quality of life is the degree to which individuals or groups of people perceive that their needs are being met and that the opportunities necessary to achieve well-being and self-realization are being provided».
Thus, it can be said that quality of life is the totality of parameters reflecting the measurement of the course of life with an assessment of physical condition, psychological well-being, social relationships, and functional capacities during the period of the development of the disease and its treatment.
At the same time, quality of life became the subject of study in other sciences as well: psychology, sociology, and economics. The initial period of the study of quality of life is characterized by the absence of a unified approach both to the concept itself and to research methodology. In psychology, attention was focused on the affective and cognitive structural components of quality of life [36]; however, as early as the middle of the 20th century, pointing to the need to develop a humanistic paradigm in medicine,
representatives of humanistic psychology (V. Frankl and others) emphasized the need to study and treat the whole person with a unique nature of experiences, freely and responsibly deciding how to act in various situations, including in the situation of disease.
The first monograph offering the domestic scientific community of physicians the foundations of the methodology for studying quality of life in medicine was published in Russia in 1999 [17]. One of the fundamental principles of the concept of quality of life in medicine was the postulate that, in order to assess the state of a person's main functions, a universal criterion is needed, encompassing the characterization of at least four components of well-being: physical, psychological, social, and spiritual. This criterion was regarded as the substantive content of the concept of «quality of life».
In 1982 R.M. Kaplan and Bush proposed the term «health-related quality of life», which made it possible to distinguish the parameters describing the state of health, care for it, and the quality of medical care from the general concept of quality of life [40]. In 1995 the following formulation of health-related quality of life was given
– it is people's assessment of the subjective factors determining their health at the given moment, care for health and actions promoting its strengthening; the ability to attain and maintain a level of functioning that would allow people to pursue their life goals and would reflect their level of well-being [41].
In the opinion of Russian authors, health-related quality of life implies a category encompassing the combination of the conditions of life support and the state of health that make it possible to achieve physical, mental, and social well-being and self-realization [14]. Today it is precisely the well-being of the person, bringing the lives of patients closer to the level of practically healthy people, that is one of the main goals of treatment. Oncology in this respect is no exception.
The question not only of «how long» the patient lived, but also of «how he lived those years», occupies an ever firmer place in the scientific publications of recent years
[25, 27, 30].
The shift in approaches to the provision of medical care is a worldwide contemporary trend: the medical model, which has as its aim only the elimination of the disease and the restoration of the functioning of the human body, is gradually being replaced by a model oriented toward a psychosocial approach. Such a concept requires not only the restoration of the biological function of the body but also the normalization of its psychological and social functioning.
Today there exist many definitions of quality of life, each of which supplements and specifies the interpretation of the term, but to this day there is no generally accepted definition of this concept.
As far back as 1984 R. Zittoun [45] pointed out that a precise definition of the term «quality of life» appears difficult, since it encompasses various aspects: physical (pain, vomiting, restrictions of mobility), toxic (the consequences of drug treatment), personal (individual qualities), happiness (joy, sexuality), relationships (with family members, friends, at work, with attending personnel, etc.), psychosocial, attitude toward one's appearance (absence or deformation of the mammary gland, alopecia, colostomy, etc.), financial, religious, cultural, political, as a result of which its objective comprehension is difficult. But even then it was noted that quality of life is an integrative concept
Considering that philosophical anthropology formulates the methodological premises for studying quality of life, while the specific knowledge is formed by the medical sciences, it is expedient to define quality of life with the integration within it of a primarily sociological and secondarily medical approach. It reads as follows: «quality of life is the adequacy of the individual's psychosomatic state to his social
status». A definition of quality of life similar in meaning was proposed by N.K. Wenger: quality of life is «satisfaction from psychosocial and other forms of activity under the limitations associated with the disease» [13]. The Medical Encyclopedia of Quality of Life, published in the USA, gives a simpler definition: «Quality of life is the degree of satisfaction of human needs». P.W. Jones, the author of the St. George's Respiratory Questionnaire (SGRQ), refines the definition of quality of life from the physician's point of view. It reads as «the correspondence of desires to possibilities that are limited by the disease» [39].
The existing multitude of definitions of quality of life is vivid evidence of the absence of a unified approach to formulating this concept. This is due to the fact that all the components and facets of such a voluminous concept are very difficult to explain [7, 19, 23]. There exist no unified generally accepted criteria and norms of quality of life. The assessment of quality of life is influenced by age, sex, nationality, a person's socio-economic position, the nature of his occupational activity, religious beliefs, cultural level, regional features, cultural traditions, and many other factors. Analysis of the diversity of data from quality-of-life studies shows a conflation and substitution of conceptual definitions: it is important to distinguish the predictors (pain, weakness, degree of severity of symptoms) and the attributes (how pain or weakness affects the body) of quality of life.
The concept of «health-related quality of life» implies that there also exists another aspect that is not related to health: the impact of the environment and of economic, political, and spiritual changes. The concept of «health-related quality of life» makes it possible to give a deep and multifaceted analysis of the physiological, psychological, emotional, and social problems of the patient. In medicine it is predominantly health-related quality of life that is studied, which
is regarded as an integral characteristic of the physical, mental, and social functioning of the healthy and the sick person, based on his subjective perception.
At the end of the 20th century the WHO quality-of-life study group defined quality of life as «an individual's perception of his/her position in life in the context of the social and evaluative systems in which he/she lives, in relation to his/her goals, hopes, standards, and concerns» and established the following criteria for assessing health-related quality of life:
physical (strength, energy, fatigue, pain, discomfort, sleep, rest);
psychological (positive emotions, thinking, learning, memory, concentration, self-esteem, appearance, negative experiences);
level of independence (everyday activity, working capacity, dependence on medications and treatment);
social life (personal relationships, the subject's social value, sexual activity);
environment (well-being, safety, everyday living conditions, material security, the availability and quality of medical and social provision, availability of information, opportunity for education and professional development, leisure, ecology);
spirituality (religion, personal beliefs) [21].
In the study of quality of life, three main components are assessed, which can be determined in a personal conversation or with the help of special questionnaires:
functional capacities – the ability to carry out everyday activity and social, intellectual, and emotional functions, and to attain economic security;
perception – a person's views and judgments about the values of the above-mentioned components, the perception of the general state of health, the level of well-being, and satisfaction with life;
symptoms and their consequences – they are a consequence of the underlying or concomitant diseases and are reduced or disappear as a
result of intervention.
In planning multicenter international clinical studies conducted in accordance with the rules of Good Clinical Practice (GCP), one of the tasks of a standard and objective assessment is the analysis of patients' quality of life. With the aim of standardizing the study of quality of life and its optimal assessment, new methodologies are being developed.
The main instruments for studying quality of life are profiles
– the assessment of each component of quality of life separately – and questionnaires, which imply a comprehensive assessment of the phenomenon of quality of life. Both may be general, that is, assessing health as a whole, and specific – for studying particular nosologies. At the same time, in the opinion of a number of authors, profiles and questionnaires do not assess the clinical severity of the disease but reflect how the patient endures his disease [38, 40, 43]. Today there exist about 400 quality-of-life questionnaires. With the aim of systematizing activity in the study of quality of life, the MARI Research Institute was created in France in 1995; it coordinates research in this field, approves the questionnaires that have been developed, and recommends them for use. In Russia a major role in the development of the methodology for studying quality of life was played by the Interethnic Center for the Study of Quality of Life under the leadership of Doctor of Medical Sciences, Professor A.A. Novik [47].
To assess the quality of life of oncology patients, both general and specific questionnaires are used.
General questionnaires:
The Quality of Well-Being Index (QWB).
The Sickness Impact Profile (SIP).
The Nottingham Health Profile (NHP).
The Quality of Life Index (QLI).
The quality-of-life assessment questionnaire of the European Quality of Life Group (EuroQoL).
The general health questionnaire (SF-36).
The most widely used general questionnaires intended for studying quality of life in patients with malignant neoplasms are the general health questionnaire SF-36 and the quality-of-life assessment questionnaire of the European Quality of Life Group EuroQoL. Their advantage is their wide prevalence, the simplicity of conducting the survey, and high validity. The general health questionnaire SF-36 is used in more than 90% of clinical studies in Russia [25, 27-30].
Specific questionnaires:
The questionnaire of the European Organisation for Research and Treatment of Cancer
(EORTC QLQ-C30).
The Functional Assessment of Cancer Therapy questionnaire (FACT-G).
The Functional Living Index – Cancer (FLIC).
The Cancer Inventory of Problem Situations (CIPS).
The Cancer Rehabilitation Evaluation System (CARES).
In addition, in everyday practice scales and profiles for assessing individual symptoms of oncological disease are widely used, first and foremost for pain: the Brief Pain Inventory (BPI), the McGill Pain Questionnaire, the
Memorial Pain Assessment Card, and for weakness: the Brief Fatigue Inventory (BFI), the Pearson-Byars Fatigue Feeling Checklist, the Cancer Fatigue Scale.
The study of health-related quality of life in oncology plays a significant role both in research work and in clinical practice. The methodology of quality-of-life research makes it possible to describe precisely the complex system of the many-faceted and multidimensional disturbances that occur in the oncology patient in the course of the development of the disease and its treatment. As applied to oncological practice, the concept of quality-of-life research has broad possibilities for use and makes it possible to:
optimize the standardization of treatment methods;
carry out the evaluation of new treatment methods, relying on the international criteria adopted in most developed countries;
raise the quality of the evaluation of new drug preparations;
ensure full-fledged individual monitoring of the patient's condition with an assessment of the early and long-term results of treatment;
develop prognostic models for various forms of cancer;
assess the effectiveness of prevention programs [10].
Despite the short history of quality-of-life research in oncology, results of clinical studies have already been obtained that do not coincide with generally accepted opinion. For example, in a randomized study in patients with disseminated breast cancer, the parameters of quality of life were higher with continuous chemotherapy than with the use of intermittent treatment [37].
An international study of quality of life in patients with breast cancer with bone metastases showed that patients rate chronic pain as the most important criterion for assessing quality of life,
associating it with difficulties in everyday life and anxiety about the loss of independence and freedom of movement [25].
The study by Tannock I.F. et al. [45] demonstrated a significant advantage of using a combination of prednisolone and mitoxantrone compared with prednisolone alone for reducing pain syndrome in bone metastases of prostate cancer. Although survival in both groups was the same (11 months), the patients receiving both drugs noted better indicators of functional status, an improvement in mood, and in overall quality of life.
Motsch C. et al. [43] in a randomized study compared combined treatment (surgery + radiation therapy) and radiation therapy in locally advanced laryngeal cancer. It emerged that, in the absence of significant differences in life expectancy, quality of life in the combined-treatment group was significantly higher.
Several studies have revealed the value of quality of life as a predictor of survival. For example, in the study by Coates A. et al. [37], conducted in a group of women receiving chemotherapy for breast cancer, it was shown that the quality-of-life index and the physical well-being scale are a more accurate indicator of prognosis than such a well-known parameter as the patient's performance status. Patients with better quality-of-life parameters lived longer. Similar results, attesting to the importance of the quality-of-life parameter as a predictor of survival, were obtained in a number of randomized clinical studies [41]. The quality-of-life parameter in advanced non-small cell lung cancer [38, 42] had greater prognostic significance for life expectancy than the generally accepted clinical data on the extent of the disease and the efficacy of primary treatment.
Quality-of-life studies have already entered the everyday practice of high-quality clinical research. The data obtained through scientific means
can help the physician in determining the optimal treatment tactics, and the patient – in choosing the most acceptable treatment option [42]. In addition, the measurement of quality of life can suggest the correct choice among several treatment alternatives, which is especially relevant in connection with the appearance of new drug preparations and medical technologies.
The analysis of quality of life in planning the treatment program of each oncology patient appears important, given the account of data on the high correlation of the level of quality of life with survival indicators. The quality of life of oncology patients is an important criterion for assessing the efficacy of treatment, has prognostic significance, and offers the possibility of individualizing symptomatic therapy.
A dynamic study of quality of life after the completion of treatment makes it possible to carry out long-term monitoring of the patient's condition in the rehabilitation period and to diagnose early and late adverse events [35].
The improvement of the quality of life of oncology patients, especially in the course of antitumor drug therapy, is the aim of «supportive therapy» and «accompanying therapy»:
analgesic therapy;
the prevention and treatment of infectious complications;
the treatment and prevention of nausea and vomiting and gastrointestinal complications;
the treatment and prevention of hematological disturbances;
the treatment and prevention of neurological, cutaneous, and other complications of antitumor drug therapy;
the treatment of tumor pleurisy, pericarditis, and ascites;
psychosocial support of oncology patients.
For patients with malignant neoplasms, the improvement of quality of life is achievable through the use of high-technology methods of antitumor treatment (surgical treatment, radiation
therapy, systemic drug therapy). With the help of surgical operations, for example, in endoprosthetic replacement in patients with malignant neoplasms, it has been possible to preserve the patient's physical function fully or partially, or with the help of plastic surgery to reduce or eliminate a defect (for example, in mammoplasty). Systemic drug therapy (hormone therapy, chemotherapy, targeted therapy, immunotherapy), prescribed for manifestations of visceral crisis, eliminates not only the pain syndrome but also all the other symptoms of the disease that cause the oncology patient to suffer. Such measures improve not only the physical well-being of the patient but also have a positive effect on his psychological state, social relationships, and so forth [17].
Quality of life is the second most significant criterion for assessing the results of antitumor therapy after survival and more important than the primary tumor response. Prolonged and severe treatment, isolation from the customary environment, loss of working capacity (permanent or temporary), and disablement are often factors of social and mental maladaptation. The absence of timely psychological help can lead to psychopathological changes in the patient's personality.
Attention to quality of life in oncology brings to the fore the patient's assessment of his condition and his life in the situation of disease and treatment, which are accompanied by the patient's emotional experiences. In this connection the subjective nature of quality of life cannot be assessed without taking into account the psychological parameters of the patient's personality [17].
At the N.N. Petrov Research Institute of Oncology, a study was conducted with the aim of establishing the connection of quality of life with the socio-psychological characteristics and features of the attitude toward the diagnosis in patients with oncogynecological pathology.
With the help of the clinical-psychological method (clinical conversation, observation), the substantive side of the patients' experiences was studied. The experimental-psychological method was directed at identifying the features of the psychosocial aspect of the patients' quality of life (EORTC QLQ-C30) and showed the following results:
The quality of life of oncogynecological patients does not depend on the diagnosis (cancer of the cervix uteri, cancer of the corpus uteri, ovarian cancer).
Quality of life depends on the stage of treatment. At the «before surgery» stage, women, regardless of whether or not they underwent preoperative therapy, had higher indicators on the scales of role (p<0.02) and cognitive functioning (p<0.03), and lower – on the symptomatic scales «fatigue» (p<0.01) and «pain» (p<0.02). At the «after surgery» stage, patients presented more fears with regard to treatment; they were frightened by helplessness, exhaustion, and pain, which could intensify later. The expectation of negative consequences associated with treatment created additional emotional tension, which manifested at the somatic level.
The patients' recognition of the malignant nature of the disease was combined with lower indicators on the scale «cognitive functioning» (p<0.01) and more pronounced symptomatic scales «fatigue» (p<0.02) and «loss of appetite» (p<0.03). The decline in the quality of life of the oncology patient in the process of his acceptance of the malignant nature of the disease is not unexpected: the patient experiences emotional suffering. Naturally, he strives to avoid it. In this way the patient unconsciously defends himself psychologically against suffering. But when the unconscious psychological defense ceases to work, the patient is, so to speak, «compelled» to cope with the suffering, and for this it is necessary for some time of life to be with it, to be in it. And, of course, quality of life at this moment may decline. But it is precisely suffering that impels
the person toward changes, and only by passing «through it» is the patient able to restore the emotional equilibrium disrupted by the news of the disease and to adapt to the changed life situation.
A connection was revealed between quality of life and the oncogynecological patient's ability to find a subjective cause of her disease. In patients who were able to relate the history of their life to what was happening now, the indicators on the scale «physical functioning» were higher compared with those who perceived the disease as «something external» (p<0.03).
An interrelationship was revealed between the indicators of quality of life and the patients' experience of interacting with oncology patients. The lowest indicators on the scale «emotional functioning» were had by women who had previously avoided information about oncological diseases (p<0.04). In patients who had experience of interacting with oncology patients, the indicators on the scale «emotional functioning» were higher. They perceived the disease and life as a whole more realistically, as a result of which their emotional life was not fixated only on the situation of the disease.
It was found that the patients' quality of life is interrelated with their level of education. In patients with higher and incomplete higher education, the indicators on the scale «emotional functioning» were higher compared with those who had secondary education (p<0.04). It can be assumed that a higher educational level of the patient is a predictor of her emotional competence in her own inner world: the woman orients herself better in the subjective space of her life and is aware of the significance of emotional work.
It was shown that the absence of permanent employment in a patient is combined with the maximal severity of such symptomatic scales as
«fatigue» (p<0.02), «nausea» (p<0.01), and «sleep disturbance» (p<0.02). This could be associated with the instability of their life even before the disease.
Patients who noted that their relationships in the family in connection with the disease «became better and stronger» had a higher quality of life compared with those whose family relationships «did not change»: significant differences were found on the symptomatic scales «fatigue» (p<0.05), «pain» (p<0.03), «nausea» (p<0.01), «constipation» (p<0.03), and «diarrhea» (p<0.03). These data confirm the view that the family is one of the main resources for a person in the situation of disease. The patients' notion that «relationships in the family did not change» in connection with the disease reduces anxiety and is a defense of their psychological safety. The patients' family status was reflected in quality of life: the maximal indicators on the scale «role functioning» were noted in women in a registered marriage and in widows.
Patients with children had higher indicators on the functional scales «social functioning» (p<0.03) and «role functioning» (p<0.04) («caring for children ‘pulls you out’ of any state», in the patient's words). However, patients with children also had higher indicators on the scales «fatigue» (p<0.01), «sleep disturbance» (p<0.02), and «financial difficulties» (p<0.01). In this connection, it should be noted that two seemingly contradictory tendencies exist simultaneously: the presence of a family and children supports patients in the situation of disease, and it also creates a basis for anxiety.
Thus, socio-psychological parameters exert an enormous influence on the quality of life of oncology patients [19].
A special aspect of improving quality of life is psychosocial support, which is dealt with by a new direction in
oncology – psycho-oncology. Psycho-oncology is a field of interdisciplinary research at the intersection of oncology, psychiatry, clinical psychology, and the social sciences; it is called upon to ensure the most effective adaptation of the oncology patient. Mental and social adaptation to the situation of disease significantly increases the psychosocial aspect of the patient's quality of life [22]. In Russia, psycho-oncology developed through the creation of onco-psychology, which is a branch of clinical psychology within the framework of the psychology of crisis and extreme situations and is directed at overcoming the consequences caused by oncological disease, which also contributes to improving the quality of life of oncology patients.
The situation of disease and all the subsequent changes in the patient's way of life unfold many intrapersonal conflicts, thus being a «field» of psychological traumatization and of the actualization of psychic traumas present in one's experience and not worked through. The experiences caused by the situation of disease may outwardly be expressed in the form of psychogenic reactions: a deterioration of the emotional status (depression, anxiety) leads to a restriction of social contacts. Psychogenic reactions are of an ambivalent nature for quality of life, being simultaneously a form of mental adaptation and a factor of social maladaptation. The degree of severity of psychogenic reactions can differ not only among different patients but also vary in one and the same patient at certain stages of diagnosis, treatment, and rehabilitation. Social maladaptation may manifest in the refusal of treatment, non-compliance with the regimen, and a change of priorities (for example, refusal of radical mastectomy to the detriment of health and life expectancy). Undoubtedly, the developing situation significantly reduces the quality of life of the oncology patient, and of great importance for the success of treatment is psychological rehabilitation directed at comprehensive adaptation (mental and social) with the aim of developing in them a positive motivation for treatment [17].
A significant role in improving the quality of life of the oncology patient is played by the significant environment – the family. The patient's readiness to continue the treatment begun, his attitude, and the assessment of his own possibilities also largely depend on relatives. The feeling of helplessness, of the impossibility of helping a loved one, «compels» relatives to psychologically distance themselves from the oncology patient; they may experience an anger that is difficult to conceal, arising from the sense of powerlessness and the absence of control over the situation. As a rule, the cause of such reactions is a feeling of guilt and a sense of helplessness. In such cases the relatives themselves are in need of individual help from a psychotherapist or a medical/clinical psychologist [20].
There exist a number of theories oriented toward improving quality of life, on which the algorithms of psychological help are based.
The most widespread theory – Discrepancy Theory – proceeds from the subject's perception of the gap between the expected and the actual effect of treatment [44]. The possibility of improving the patient's quality of life arises when the gap is reduced through effective treatment of the disease, adequate correction of symptoms, social support of the patient, and a change in the patient's attitude toward the disease and treatment. Life is truly of high quality when no large gap is observed between the ideal and reality; life loses its quality when there exists a large gap between the ideal (hopes, ambitions, dreams) and the actual (reality: here and now) [33].
Thus, in order to improve the psychosocial aspect of the quality of life of the oncology patient, it is necessary to reduce the gap between ideals (corrected expectations) and possibilities (improvement of quality of life at the present time).
From the above it follows that quality of life can be improved if the patient adequately assesses his possibilities and corrects his expectations. This is very important to take into account when interacting with the oncology patient and his relatives. At the same time, taking this aspect of quality of life into account may lead to certain psychological difficulties associated with the oncology patient's acceptance of the disease, for the resolution of which it is necessary to involve medical/clinical psychologists. In addition, the correction of timely recognized psychically conditioned reactions in oncology
patients and members of their families, alongside other forms of therapy in the oncology clinic, increases adaptability and thereby improves the patient's quality of life.
The main goal of the entire system of medical and psychological help in oncology is the restoration and/or preservation of quality of life. Within the framework of this definition, survival, i.e. life itself, is the first goal. Other biological outcomes of the disease and the treatment process – the tumor's response to treatment, the duration of the effect, toxicity, and so on – are secondary. The understanding of the insufficiency of assessing only the biological consequences of the impact of the malignant process on the patient has singled out the restoration of quality of life as a new goal of treatment [28, 44].
The quality of life of the oncology patient is a dynamic state, a function that changes over time, and therefore it too must be assessed over a certain span as a changing parameter, dependent on the type and course of the disease, the treatment process, and the system of provision of medical care.
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