https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Factors Associated with Poor Quality of Life in Lung Cancer Patients Undergoing Chemotherapy in Erbil City ABSTRACT Background and aims: Lung cancer is one of the most prevalent types of cancer in the world, and the aim of the study was to determine the quality of life. and its related factors in lung cancer patients undergoing chemotherapy. Methods: A descriptive cross-sectional study design was conducted in Iraq in 2022 on 100 cancer patients undergoing chemotherapy who were randomly collected in Rizgary Teach- ing Hospital and Nanakaly Hospital for blood disease and cancer. The instrument used for data collection consisted of demographic and medical data (age, gender, educational lev- el, marital status, occupation, economic status, residency, cigarette smoking, family histo- ry, stages of lung cancer, and types of lung cancer), another section was the functional assessment of cancer therapy-lung questionnaire (FACT-L), specifically designed for the measurement of quality of life in patients with lung cancer. Categorical data were pre- sented as frequency and percentage and the mean± SD was calculated for continuous da- ta, independent t-test, and Chi-square test was also used; Binary logistic regression was run to determine the effect of the predictors on poor quality of life in lung cancer patients a P-value ≤0.05 was considered statistically significant. Results: The overall quality of life was poor (59%), the mean± SD for Functional Assess- ment of Cancer Therapy Lung Cancer Subscale (FACT-L) was 66.19 ± 10.54, and Trial Out- come Index (TOI) was 39.77±5.51, The following variables were associated with a poor quality of life: age >50 (P-value =0.020, OR= 2.47), female (P-value =0.006, OR= 3.02), un- educated (P-value =0.0005, OR= 1.86), ex-smoker (P-value =0.040, OR= 2.14), insufficient income (P-value =0.037, OR= 2.69). Conclusion: The quality of life of lung cancer was lower in physical well-being, functioning well-being, and lung cancer subscale compared to social/family well-being, and emotional well-being, as generally, the quality of life of most lung cancer patients was poor. keywords: Quality of life; Functional assessment of cancer therapy lung cancer subscale; Chemotherapy. Dler Hamad Ismael; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region- Iraq. (Correspondence: dler.ismael@hmu.edu.krd) 74 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 03/03/2023 Accepted: 29/05/2023 Published: 30/5/2023 mailto:dler.ismael@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Lung cancer is a popular malignancy and the most predictable cause of death world- wide. According to the world health organi- zation an estimated 2.21 million new pa- tients and the mortality rate was 1.8 mil- lion cases in 2020 [1]. Remarkably unfavor- able outcomes are estimated in developing countries where with inadequate healthcare services, there is increased ex- posure to risk factors such as environmen- tal, and economic factors, and lifestyles changed to Western lifestyles [2]. In Iraq, there is increasing in the incidence of can- cer and death, despite implemented of na- tional cancer registries and control pro- gram since 1974, According to the latest estimates from the International Agency for Research reported number of cancer in new cases was >25,000, and cancer-related deaths was14,000 in 2018 (3). The earliest reported cancer incidence rates in Erbil, Duhok and Sulaymaniyah were 50.0 and 61.5, and 61.7 cases/100,000 individuals, respectively [4]. Quality of life (QoL) is one of the most familiar health issues for can- cer patients. QoL is multidimensional and includes the emotional, social, and physical activities of patients.The value of quality of life has to be highly considered, because of the extreme symptom burden and com- monly restricted life expectancy [5]. As a result of the advancement in medical sci- ence and continuing development of treat- ment, the survival rate of patients with cancer has been estimated longer. This has resulted in a continued interest in studying the health-related quality of life (HRQoL) of cancer survivors. So, there is a subsequent need to satisfy cancer patients' needs, ena- bling them to live healthy life [6]. Cancer impacts patients’ quality of life (QOL) in the whole domain. The deterioration in the QoL begins with the identification of cancer and persists with the advancing nature of the treatment. Chemotherapy is one of the well-known treatment choices for patients to fight cancer [7], as well. These treatment effects also have severe unwanted effects on the patient’s quality of life. Moreover, patients who received chemotherapy treatment for a longer time to get the preferred effect and require regular hospital admission for disease treatment, which causes a further burden on cancer patients [8]. There are several factors impacting the quality of life of lung cancer patients undergoing chemotherapy such as age, gender, marital status, education levels, pathological types, family income, and metastasis the independent factors affecting the deterioration of their quality of life [9], there is no study in the literature reporting on the quality of life of lung cancer patients among the Kurdish population. The objective of the present study was to assess the factors associated with poor quality of life of lung cancer patients undergoing chemotherapy. A descriptive cross-sectional study design was performed on 100 Lung cancer patients collected successively in oncology units at both Rizgary Teaching Hospitals and Nanakaly Hospital for blood disease and cancer in Erbil City. The sample of the study was lung cancer patients according to the inclusion criteria were asked to participate in the study in two oncology regional units in Erbil City. Before starting the study, approvals were taken from the College of Nursing /Hawler Medical University and hospital authorities for the conduct of the study. The researcher obtained ethical from; they were assured about data confidentiality informed consent was obtained from all participants before starting interviews with them. The researcher was aware of research ethics therefore patients’ dignity, values, and 75 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article lung cancer subscale. The TOI is described for the measurement of functional out- comes. A 5-point Likert-type scale asked patients to respond to each item with a score of 0–4, where not at all=0, a little bit=1, somewhat = 2, quite a bit=3, and very much=4. The total FACT-L score is the summation of the 5 subscale scores and ranges from 0 to 136 and the TOI score array between (0 to 84). The lung cancer subscale applied a 5-point Likert scale to patient responses to measure the intensity of lung cancer symptoms rated as non = 0, mild= 1, moderate = 2, marked= 3 and se- vere= 4). All statistical analyses using (SPSS software version 26), descriptive and infer- ential statistical tests were performed. Cat- egorical data were presented as frequency and percentage distribution, and the mean± SD was calculated for continuous data. independent t-test and Chi-square test were also used. Binary logistic regres- sion models were used to find and predict factors affecting the quality of life in lung cancer patients ,P-value equal or less than 0.05 was considered statistically signifi- cant. Among the total of 100 patients with lung cancer in Table 1 the findings indicated that, the mean age of patients was 54.25± 8.13 and the highest percentage was 75% more than 50 years old, and 70% of them were male. Regarding educational level, nearly half of them 46% were uneducated, and most of them were married. Regarding occupational status 54% of them were un- employed, also more than half of the par- ticipants were insufficient family income accounting for 61%, and most of them were living in a rural area 65%. In addition, the table showed that the highest percent- age 73% of the participant was ex-smoker, about 18% had a positive family history, and most of the samples had stage III of security may impact during data collec- tion. The participants of this study were lung cancer patients, according to a statis- tical specialist, the sample size was deter- mined to be 100 patients by this statistical formula marked n=Z² pq/d² ( Z =1.96, P= 0.067, q= 0.933, d= 0.05) , to obtain accu- rate data and a representative sample a purposive sampling method was used to select the samples: patients who were willing to participate in the study, age over 18 years, confirmation of the Lung cancer diagnosis by an oncologist, undergoing chemotherapy and Kurdish speaker. The patients excluded were unwillingness to participate in the study, newly diagnosed patients with Lung cancer, uncooperative patients, being treated with psychotropic medication, and patients who have severe illness with serious complications and un- stable. Data were collected between Feb- ruary 2022 and December 2022 through face-to-face interviews. The instrument consisted of demographical characteristics and medical data (age, gender, education- al level, marital status, occupation, eco- nomic status, residency, cigarette smok- ing, family history, stages, and types of lung cancer). The second part was the functional assessment of cancer therapy- general questionnaire (FACT-G) widely used to measure the quality of life in can- cer patients, it was established by a group of oncology specialists [10]. In addition, the Lung Cancer Subscale (LCS) to the FACT-G, together create (FACT-L) which is specifically designed for Lung cancer. It contains 34 items that assess five primary dimensions of QoL: physical well-being (PWB; 7 items), functional well-being (FWB; 7 items), emotional well-being (EWB; 6 items), and social/family well- being (SFWB; 7 items). Lung Cancer Sub- scale (LCS 7 items). The Trial Outcome In- dex (TOI) calculates the total of the physi- cal well-being, functional. well-being, and 76 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article lung cancer 57%, regarding types of lung cancer, adenocarcinoma was the highest percentage 44%, followed by squamous cell carcinoma 35%, small-cell carcinoma 11%, and large-cell carcinoma 9% respec- tively. Moreover, table 1 shows a signifi- cant association between quality of life and age (p=0.003), gender (p=0.005), level of education (p=0.001), family income (p=0.001), residency, (p=0.047), cigarette smoking(p=0.005) and stage of lung cancer (p=0.001), while there was no significant found between quality of life with marital status (p=0.187 ), occupation (p=0.310), family history (p=0.743) and types of lung cancer (p=0.300). 77 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Association between quality of life and variables of the study Demographic and medical data Quality of life (FACT-L) P-value Poor N(%) Good N(%) Total N(%) Age ≤50 4(16.0) 21(84.0) 25(25) 0.003 >50 37(49.3) 38(50.7) 75(75) Gender Male 35(50.0) 35(50.0) 70(70) 0.005 Female 24(80.0) 6(20.0) 30(30) Level of education Uneducated 28(60.9) 18(39.1) 46(46) 0.001 Educated 13(24.1) 41(75.9) 54[(54) Marital status Married 37(39.4) 57(60.6) 94(94) 0.187 Widowed 4(66.7) 2(33.3) 6(6) Occupation Employed 10(62.5) 6(37.5) 16(16) 0.310 Retired 9(64.3) 5(35.7) 14(14) Unemployed 17(31.5) 37(68.5) 54(54) Housewife 5(31.3) 11(68.8) 16(16) Family income Insufficient 44(72.1) 17(27.9) 61(61) 0.001 Sufficient 24(61.5) 15(38.5) 39(39) Residency Urban 22(33.8) 43(66.2) 35(35) 0.047 Rural 19(54.3) 16(45.7) 65(65) Cigarette smoking Non-smoker 5(18.5) 22(81.5) 27(27) 0.005 Ex-smoker 36(49.3) 37(50.7) 73(73) Family history No 33(40.2) 49(59.8) 82(82) 0.743 Yes 8(44.4) 10(55.6) 18(18) Stage of lung caner Stage III 9(15.8) 48(84.2) 57(57) 0.001 Stage IV 32(74.4) 11(25.6) 43(43) Types of lung cancer Large-cell carcinoma 1(11.1) 8(88.9) 9(9) 0.300 Small-cell carcinoma 4(36.3) 7(63.3) 11(11) Squamous cell carcinoma 16(44.4) 20(55.6) 35(35) Adenocarcinoma 19(43.1) 25(56.8) 44(44) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 78 Index (TOI) was 39.77±5.5. Also, the re- sults demonstrate that the quality of life domains was lower in physical well-being 13.74 ± 3.02 functioning well-being 13.15 ± 4.12, lung cancer subscale 12.88 ± 3.54, compared to other domains of social/family well-being 14.29 ± 4.48, emotional well-being 12.13 ± 3.23. higher social well-being (16.84±4.15 to 12.37±3.72), better emotion status (14.91±6.09 to 10.04±5.51), well im- proved functioning status (14.65±4.64 to 12.02±3.29), better able to control lung cancer symptoms (14.09±2.86 to 11.28±3.67) consequently. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2 shows the mean score for quality of life domains was a low mean score ≤ 2 which is considered a poor QoL while a mean score of more than 2 is a good QoL [10], the analysis of the QoL revealed a mean total score of functional assessment of cancer therapy lung cancer subscale (FACT-L) was 66.19 ± 10.54, Trial Outcome Comparison of quality of life of scores ac- cording to stages of lung cancer as shown [in table 3]. The quality of life mean score was significantly higher in stage III lung cancer compared to stage IV, patients with stage III lung cancer had better physical well - being (14.44±3.33 to 13.21±2.67), Table 2. Quality of life scores in lung Cancer Patients undergoing chemotherapy Quality of life domains Min Max Mean ± SD/ Total Mean ± SD/ Scale Physical well-being 7.00 21 13.74 ± 3.02 1.96 ± 0.43 Social/family well-being 5.00 21 14.29 ± 4.48 2.04 ± 0.64 Emotional well-being 1.00 24 12.13 ± 3.23 2.02 ± 1.03 Functioning well-being 7.00 21 13.15 ± 4.12 1.88 ± 0.59 Lung cancer subscale 5.00 21 12.88 ± 3.54 1.84 ± 0.50 Trial Outcome Index 1.89 57 39.77 ± 5.51 1.89 ± 0.26 FACT-L score QoL 47.0 99 66.19 ± 10.54 1.95 ± 0.31 Table 3: Comparison of quality of life of scores according to stages of lung cancer Quality of life Stage of lung cancer III IV Mean Difference t. test p-value Mean±SD Mean±SD Physical well-being 14.44±3.33 13,21±2,67 -1.23 -2.05 0.043 Social well-being 16.84±4.15 12,37±3,72 -4.46 -5.66 0.001 Emotional well-being 14.91±6.09 10,04±5,51 -4.87 -4.18 0.002 Functioning well-being 14.65±4.64 12,02±3,29 -2.63 -3.31 0.001 Lung cancer subscale 14.09±2.86 11.28±3,76 -2.80 -3.61 0.001 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 79 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. A logistic regression model was construct- ed to assess the association between se- lected variables of study as predictors and poor quality of life (FACT-l), as shown in [Table 4]. Variables chosen in the model were based on the bivariate analysis of age, gender, level of education, residency, smoking, and economic status were put into the model. Model fit was measured by the likelihood ratio statistic (χ2= 3.26, p- xvalue=0.004) and the Hosmer and Leme Figure 1 shows a comparison of quality of life sores each scale in male and female lung cancer patients, the male reported higher mean scores compared to females in physical well-being (PWB), social/family show test (χ2= 4.67, p=0.69), the variabil- ity observed in the target variable is ex- plained by the regression mode was R2 = 49.1%. The following variables were as- sociated with a poor quality of life: age >50 (P-value =0.020, OR= 2.47), female (P -value =0.006, OR= 3.02), uneducated (P- value =0.0005, OR= 1.86), ex-smoker (P- value =0.040, OR= 2.14), insufficient fami- ly income (P-value =0.037, OR= 2.69). well-being (SFWB), emotional well-being (EWB), functioning well-being (FWB) lung cancer subscale (LCS), functional assess- ment of cancer therapy-lung (QoL-FACT- L). Table 4: Factors associated with poor quality of life (FACT-L) Variables P-value OR 95% CI Lower Upper Age /year ≤50 Ref. >50 0.020 2.47 1.31 11.8 Gender Male 0.006 3.02 1.68 10.5 Female Ref. Level of education Uneducated 0.005 1.86 1.62 7.58 Educated Ref. Residency Urban Ref. Rural 0.095 2.23 0.85 7.47 Cigarette smoking Non-smoker Ref. Ex-smoker 0.040 2.14 1.06 8.04 Family income Insufficient 0.037 2.69 0.91 7.94 Sufficient Ref. Figure 1: Changes FACT-L total score in male and female patients https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 80 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Also, [Figure 2] shows the lung cancer sub- scale of symptoms the highest percentage of lung cancer patients had severe difficul- ty breathing 43%, poor appetite 41%, Cancer is one of the main problems throughout the world. It is frequently in- creasing day by day, and many cancer pa- tients need to improve their quality of life. It is detected that the incidence of cancer in old age raised continuously, as older age may itself be an important risk factor due to certain physiologic changes that go along with the ageing process, in addition to the presence of a variety of comorbidi- ties, and adverse effects associated with the medications for chronic disease [11, 12]. The results show the mean age of the patients was 54.25± 8.13 and the main proportion of the age group of lung cancer patients was more than 50 years old, and about 70% were male that significant asso- ciation with the quality of life, which agree with a study conducted in an oncology cen- ter in Hilla City, 2019 which revealed that most of the participants were men, their cough 40%, shortness of breath 38%, chest tightness 34%, and other symptoms 49% unclear thinking was marked and 39% moderate weight loss. age 60 years and above (13). Also, in the current study supported by a study done in Egypt most of the sample was male, which might reflect the higher smoking rate and industrial and environmental pol- lutant exposures among males in these countries, in the current study, males had a better quality of life than female similar to the existing literature, also showed that the females gender was significantly asso- ciated with the poor QOL[14, 15] . Higher education has been displayed to have a positive effect on survival for cancer pa- tients. In current study, the highest per- centage of samples were illiterate and had a significant association with quality of life this agrees with the study shows that edu- cation is one factor that positively affects QoL. Moreover, patients who completed primary or further education were ob- served to have better social and physical Figure 2. Lung cancer symptoms intensity for patients undergoing chemotherapy DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 81 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. functions [16, 17]. In this study, most of the participants were living in rural areas, which was supported by a study that re- ported lung cancer more frequently caused death in rural areas [18]. Insufficient monthly income accounted for significantly associated with the quality of life in com- parison with a study that has shown that individual income measures are significant- ly and independently associated with can- cer risk factors, quality of life, and survival [19]. Cigarette smoking appears to be a risk factor that influences the quality of life of patients with lung cancer [20] in this study demonstrated that patients who smoked previously are three times more at risk for developing lung cancer than non-smokers and had significant impacts on quality of life. Patients with stage III lung cancer had significantly better physical well-being, higher social well-being, emotional status, well-improved-functioning status, and better ability to control Lung Cancer symp- toms which agrees with a study done in Turkey when considering the stage of the tumor, the scale scores varied significantly in all dimensions among patients with stage III cancer [21] . In addition, the study done in China by [22] found that stage IV lung cancer patients had lower all domains of FACT-L scores than stage III patients. The current study focused on patients with advanced-stage lung cancer, the highest percentage of symptoms perceived by pa- tients were severe in difficulty breathing, poor appetite, cough, shortness of breath, and chest tightness, which was supported by a study in the case of small cell lung cancer, the most frequent symptoms were cough, dyspnea, pain and weight loss [23], in other instances, which seems to be simi- lar to the results of another study in Swe- den showed that the symptom burden in lung cancer patients, the most prominent symptoms were dyspnea., fatigue., cough- ing., insomnia., and appetite loss [24]. The analysis of the QoL revealed a mean total score of the functional assessment of can- cer therapy lung cancer subscale (FACT-L) was 66.19 ± 10.54, trial outcome index (TOI) was 39.77±5.51. whereas a study done in Germany shows that FACT-L total score was 86 ±21.5, and TOI 50.5 ±14.9 [25]. Furthermore, this study seems to be the most impacted in our study samples in physical well-being and functioning well-being, which lowers scores com- pared to social/family well-being, and emotional well-being that comes along with previous studies done in USA, Ger- many, and France [26, 27]. The present study was carried out on a limited sample and the generalization of the results should be done with caution, selecting an available sampling method according to the type of study due to the diversity and metastasis of cancers. Moreover consid- ering important variables such as types of treatment including radiotherapy and surgery and the presence of other diseas- es associated with cancer were other lim- itations that affected the outcome of the study In summary, lung cancer patients had lower quality of life in physical well-being, functioning well-being, and lung cancer subscale, Compared to social/family well- being, and emotional well-being. In gen- eral, the quality of life of most lung can- cer patients was poor The authors declare that they have no competing interests. Not applicable. Conclusion Conflicts of interest Funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 82 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] Wong MCS, Lao XQ, Ho KF, Goggins WB, Tse SLA. Incidence and mortality of lung cancer: global trends and association with socioeconomic status. Sci Rep 7, 14300 2017; doi:org/10.1038/s41598-017-14513-7 [2] Fitzmaurice C, Abate D, Abbasi N, Abbasta- bar H, Abd-Allah F, Abdel-Rahman O et al. Global, regional, and national cancer inci- dence, mortality, years of life lost, years lived with disability, and disability-adjusted life- years for 29 cancer groups, 1990 to 2017: A Systematic Analysis for the Global Burden of Disease Study. JAMA Oncol. 2019; 5, 1749- 68. doi: 10.1001/jamaoncol.2019.2996. [3] Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of inci- dence and mortality worldwide for 36 can- cers in 185 countries. CA Cancer J Clin. 2018; 68(6):394-24. doi: 10.3322/caac.21492 [4] Khoshnaw N, Mohammed HA, Abdullah DA. Patterns of Cancer in Kurdistan - Results of Eight Years Cancer Registration in Sulaymani- yah Province-Kurdistan-Iraq. Asian Pac J Can- cer Prev. 2015;16(18):8525-31. doi: 10.7314/ apjcp.2015.16.18.8525. [5] Reale ML, De Luca E, Lombardi P, Marandino L, Zichi C, Pignataro D, et al . Quality of life analysis in lung cancer: A systematic review of phase III trials published between 2012 and 2018. Lung Cancer. 2020; 139:47-54. doi: 10.1016/j.lungcan.2019.10.022. Epub 2019 Oct 31. [6] Ravasco P. Nutrition in Cancer Patients. J Clin Med. 2019; 8(8):1211. doi: 10.3390/ jcm8081211. [7] Fitch KV and Pyenson BS. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management; 2010 Available from https://us.milliman.com/en/insight/ research / health/ cancer-patients-receiving- chemotherapy-opportunities-for-better- management/ [8] Rashid YA, Ghafoor ZA, Masood N, Mehmood T, Awan S,Ansar T, et al. Psycho- social impact of cancer on adult patients. J Pak Med Assoc. 2012;62(9):905-9. PMID: 23139973. [9] Bovero A, Sedghi NA, Opezzo M, Botto R, Pinto M, Ieraci V, et al. Dignity-related exis- tential distress in end-of-life cancer patients: prevalence, underlying factors, and associat- ed coping strategies. Psycho- Oncology. 2018;27:2631–2637. doi: 10.1002/ pon.4884. [10] Cella D, Chang CH. A discussion of item response theory and its applications in health status assessment. Med Care. 2000;38(9 Suppl):II66-72. doi: 10.1097/00005650-200009002-00010. [11] Torre LA, Siegel RL, Jemal A. Lung Cancer Statistics. Adv Exp Med Biol. 2016;893:1- 19. doi: 10.1007/978-3-319-24223-1_1. [12] Kim HJ, Choi CM, Kim SG. The younger pa- tients have more better prognosis in lim- ited disease small cell lung cancer. Tuberc Respir Dis. 2016;79:274–281 doi: 10.4046/ trd.2016.79.4.274 [13] Al-Khateeb Z, Mahdi L. Prevalence of Lung Cancer in Al Najaf Governorate Registered in Middle Euphrates Oncology Center dur- ing 2019 and 2020. J Fac Med Bagdad . 2022 ;64(1):22-30. doi:org/10.32007/ jfacmedbagdad. 6411887 [14] Akl YM, Emam RH, Sabry IM, Ali AA. Clini- co‑pathological profileof bronchogenic carcinoma cases presented to chest de- partment, CairoUniversity in the last 10 years. Egypt J Chest Dis 2013;62:705‑12. doi.org/10.1016/j.ejcdt.2013.09.019. [15] Chagani P, Parpio Y, Gul R, Jabbar AA. Qual- ity of Life and Its Determinants in Adult Cancer Patients Undergoing Chemotherapy Treatment in Pakistan. Asia Pac J Oncol Nurs. 2017 Apr-Jun;4(2):140-146. doi: 10.4103/2347-5625.204499. [16] Evans CJ, Trudeau E, Mertzanis P, Marquis P, Peña BM, Wong J, et al . Development and validation of the Pain Treatment Satis- faction Scale (PTSS): a patient satisfaction questionnaire for use in patients with chronic or acute pain. Pain. 2004;112 (3):254-266. doi: 10.1016/ j.pain.2004.09.005. [17] Guvencli M, Yalniz E, Komurcuoglu B, Erbaycu AE 2, Karakurt G The Impact of Chemotherapy on the EORTC QLQ-C30 and LC-13 Quality of Life Scales in Patients with Lung CancerTepecik Eğit Hast Derg. 2021; 31(3): 344-354 | doi: 10.5222/ terh.2021.73626 [18] Atkins GT, Kim T, Munson J. Residence in Rural Areas of the United States and Lung Cancer Mortality. Disease Incidence, Treat- ment Disparities, and Stage-Specific Surviv- al. Ann Am Thorac Soc. 2017;14(3):403- 411. doi: 10.1513/AnnalsATS.201606- 469OC. REFERENCE https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 83 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [19] Toubat O, Atay SM, Kim AW, Ding L, Farias AJ, Ebner PJ etal. Disparities in Guideline- Concordant Treatment for Pathologic N1 Non-Small Cell Lung Cancer. Ann Thorac Surg. 2020;109:1512-20. doi: 10.1016/ j.athoracsur.2019.11.059 [20] Dimunová L, Dankulincova V, Zuzana M, Jana B, Relationship between quality of life of lung cancer patients and smoking. Central European Journal of Nursing and Midwife- ry.2018; 9. 812. doi:10.15452/ CEJNM.2018.09.0009 [21] Aydoğan B, Göksel T, Erbaycu A, Öz A, Pinar C, Gürsul K, etal. The Psychometric Proper- ties and Clinical Use of the Turkish Version of the Functional Assessment of Cancer Thera- py–Lung (FACT-L) Scale. J Basic Clin Health Sci 2019; 3:139-144 .doi.org/10.30621/ jbachs.2019.652 [22] Zhang Z, Chen A, Xie F, Li X, Hu G, Lin G. Low prognostic nutrition index predicts poorer quality of life in late-stage lung cancer. Ann Palliat Med. 2020;9(6):3976-3984. doi: 10.21037/apm-20-1892. [23] Ruano-Raviña A, Provencio M, Calvo de Juan V, Carcereny E, Moran T, Rodriguez-Abreu D, etal . Lung cancer symptoms at diagnosis: results of a nationwide registry study. ESMO Open. 2020;5(6):e001021. doi: 10.1136/ esmoopen-2020-001021. [24] Larsson M, Ljung L, Johansson BB. Health- related quality of life in advanced non-small cell lung cancer: correlates and comparisons to normative data. Eur J Cancer Care (ENGL). 2012 ;21(5):642-9. doi: 10.1111/j.1365- 2354.2012.01346.x. Epub 2012 Apr 23. [25] Kuon J, Vogt J, Mehnert A, Alt-Epping B, van Oorschot B, Sistermanns J et al. Symptoms and Needs of Patients with Advanced Lung Cancer: Early Prevalence Assessment. Oncol Res Treat. 2019;42(12):650-659. doi: 10.1159/000502751. Epub 2019 Oct 21. [26] Iyer S, Roughley A, Rider A, Taylor-Stokes G. The symptom burden of non-small cell lung cancer in the USA: a real-world cross- sectional study. Support Care Cancer. 2014;22(1): 181–7. doi: 10.1007/s00520-013 -1959-4. Epub 2013 Sep 12. [27] Iyer S, Taylor-Stokes G, Roughley A. Symp- tom burden and quality of life in advanced non-small cell lung cancer patients in France and Germany. Lung Cancer. 2013 Aug; 81(2): 288–93. doi: 10.1016/j.lungcan.2013.03.008. Epub 2013. https://creativecommons.org/licenses/by-nc-sa/4.0/