https://doi.org/10.15218/ejnm.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article Health Related Quality of Life among Patients with Prostate Cancer in Erbil, Iraq ABSTRACT Background and objectives: Prostate cancer is one of the most common types of cancer that affects men, especially older men. The quality of life of men with prostate cancer is affected by several things, such as how long it has been since they were diagnosed and their body mass index. The study aims to identify health-related quality of life domains of participants and compare health-related quality of life among prostatic cancer patients with their body mass index and time passed from cancer diagnosis. Methods: A quantitative descriptive cross-sectional study was conducted from February 2024 to February 2025 on 100 male patients with prostate cancer. Sociodemographic da- ta forms and the European Organization for Research and Treatment of Cancer Quality of life questionnaires (core 30) and the Prostate Cancer Module (25 items) were used to col- lect data from the participants. Descriptive and inferential statistics were used to analyse data by using the Statistical Package for the Social Science SPSS (version 25). Results: Half of the participants were aged 70 or older, and more than half were illiterate and retired. Health-related quality of life function scores differed significantly with body mass index at p-value in role (0.017), emotional (0.010), social (0.016), and sexual func- tioning (0.006), with normal body mass index patients showing better outcomes. In addi- tion, significant differences were reported between the time elapsed since cancer diagno- sis and symptoms such as urinary issues (p-value 0.043), bowel problems (0.009), hormo- nal symptoms (0.004), and sexual activity (0.019). Conclusion: The study concluded that both body mass index and time since diagnosis sig- nificantly affect health-related quality of life in prostate cancer patients. Keyword: Health-related quality of life; Prostate cancer; Body mass index; Time since diagnosis; European Organization for Research and Treatment of Cancer quality of life Hiwa Ahmed Omar; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region- Iraq (Correspondence: hiwa.aomar@hmu.edu.krd) Berivan Star Hamad Ameen; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region-Iraq Bakhtyar Othman Omer; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region-Iraq Yousif Bakr Omar; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region-Iraq 144 Received: 27/07/2025 Accepted: 11/09/2025 Published: 30/11/2025 Copyright ©2025The 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. mailto:hiwa.aomar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article Prostate cancer (PCa) is the second most frequent cancer in males and the fourth most common type of cancer overall [1]. In 2018, there were 1.3 million new cases di- agnosed with prostate cancer in males around the world [2]. A recent analysis of data suggests that PCa is the most fre- quent type of cancer among men in the US, with the number of new cases growing by 21% per year [3]. Prostate cancer is be- coming more common and is the most common cancer in men in Europe. It has great and big effects on healthcare systems in the world. About 450,000 European males are diagnosed with prostate cancer each year. It has surpassed colorectal can- cer and is now the second most prevalent cause of cancer death in men. The number of deaths due to prostate cancer was 107,000 men in Europe in 2018, so it is not a slow-moving illness, but it is increasing more frequently. Prostate cancer ranks as one of the cancers, which affect patients’ quality of life [4]. Age and the length of time the disease lasts are just two out of many other factors that affect the quality of life in patients with this disease. Know- ing and awareness about these factors has a huge impact on the quality of life of pa- tients to know how to deal with the dis- ease and the disease affects the quality of life of patients after affecting them with prostate cancer, because one of the worst things that can happen to a patient's health is the impairing of quality of life [5]. Most prostate tumors are confined when they are found (clinical stage T1a to T2c, with no signs of lymph node invasion or distant metastases) [2]. The five-year rela- tive survival rate for localized prostate can- cer is around 100%, which is far higher than the general population. The survival rates for all stages are 98% and 96% at 10 and 15 years, respectively [6]. As a result, the health-related quality of life (HRQoL) of patients with prostate cancer (PCa) often declines over time, particularly three years after diagnosis [7]. Having a high quality of life (QoL) does not mean living longer [8]. To find out how well cancer tre- atments work, it is necessary to examine both the cancer survival rate and the health-related quality of life (HRQoL) of people with PCa. Prostate cancer is a con- dition that mostly affects the quality of life of the patient, making it difficult for them to do everyday things. Patients and their families have many emotional and social challenges because of a chronic sickness [9]. This study aimed to identify health re- lated-quality of life domains in patients with prostate cancer and compare it with body mass index and time passed from prostate cancer diagnosis. A descriptive cross-sectional study design was carried out from February 2024 to Ma- y 2025 among 100 patients who were diag- nosed with prostate cancer at Rizgary and Nanakaley Teaching Hospitals in Erbil City. The sample size was determined by Z2 p q/ d2, z = confidence interval 95% (1.96), p= prevalence= (0.07), q = (1-p) = (0.93), d = sampling error (0.05) [10]. Non-probability, purposive sampling techniques were used to collect the relevant study data. The in- clusion criteria include adult male patients more than 18 years old who had PCa and were diagnosed with PCa more than three months. The exclusion criteria included patients who had psychiatric or mental problems and patients with communicati- on problems. The researcher obtained an approval letter from the ethics committee at Hawler Medical University/ College of Nursing (Code No.2475, date 1/1/2024). The official approval was taken from the general directorate of health, Rizgary and Nanakaly Teaching Hospitals in Erbil city. ء 145 Copyright ©2025 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.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article in symptom domains, the higher score means worse condition [5]. Regarding data analyses Statistical Package for Social Sci- ence (SPSS) version 25, was used for calcu- lating descriptive statistical data analysis (such as frequency, percentage, mean and standard deviation), and for comparison of health-related quality of life (HRQoL) with body mass index and time since cancer di- agnosis, inferential statistical data analysis (ANOVA test) was used. Table 1 shows the distribution of socio- demographic characteristics of 100 pa- tients diagnosed with prostate cancer PCa, half of them 50% were aged 70 years and older, while 33% were between 60–69 years, and the lowest 17% were below 60 years. All participants were married. Re- garding education, 52% were illiterate, 21% had elementary education, 18% had institute-level education, and only 9% had a college degree respectively. In terms of occupation, 51% were retired, 37% unem- ployed, and only 12% were employed. Less than half, 38%, of the participants report- ed needing help with daily living activities, while 62% were Independent. Regarding the time since diagnosis, 46% had been diagnosed for 1–3 years, 28% for less than one year, and 26% for more than 3 years. Additionally, 42% of the patients reported being smokers, and 37% had a history of sexual problems prior to diagnosis. Regard- ing BMI, 45% of the patients had normal weight, 35% of them were overweight, and 20% were obese. Informed consent was obtained from pa- tients after explaining the aim of the study before starting the interview. Data collect- ed by questionnaire includes three parts: The first part is "socio-demographic char- acteristics," like age, marital status, level of education, occupation, need for help with daily tasks, time since cancer diagnosis, underlying disease, smoking habit, history of sexual problems before cancer diagno- sis, and body mass index (BMI). The second part is about quality of life and uses a questionnaire made by the European Or- ganization for Research and Treatment of Cancer. The Quality of Life Questionnaire- Core 30 Version 3 (EORTC QLQC30 V. 3), has 30 questions in total, divided into five functional scales: physical, role, cognitive, emotional, and social function. There were also nine symptom scales and one global health-status/quality of life scale. The symptom scales measured fatigue, nausea, pain, shortness of breath, insomnia, loss of appetite, constipation, diarrhea, and finan- cial problems. There were four possible answers for each question: "not at all" (1), "a little" (2), "quite a little" (3), and "very much" (4). The worldwide health-status/ quality of life scale featured answers that ranged from very poor (1) to excellent (7) [5]. The third part: The Prostate Cancer Module of the Quality of Life Question- naire (EORTC QLQ - PR25), has 25 ques- tions, which are divided into six symptom scales and function: urine symptoms, bow- el symptoms, incontinence, hormone symptoms, sexual activity, and sexual func- tion. There were four answers for each item: not at all (1), a little (2), quite a little (3), and very much (4). [11]. The question- naires gave us a formula to use to figure out the function score, which was then changed to a number between 0 and 100. The scores for each domain were given separately. In the functional domains, a higher scores meant a better condition but 146 Copyright ©2025The 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.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article Table 2 shows health-related quality of life (HRQoL) scores, between body mass index (BMI) categories (normal, overweight and obese). Patients with normal BMI had high- er scores in physical functioning (29.78 ± 24.40), role functioning (31.11 ± 26.73), and emotional functioning (31.39 ± 20.79), indicating better quality of life compared to overweight and obese pa- tients. BMI significantly affected p-values for emotional functioning (0.010), role functioning (0.017), social functioning (0.016), and sexual functioning (0.006), with obese individuals reporting lower scores in these domains. However, global health status, fatigue, and pain did not differ significantly by BMI categories p- value (> 0.05). Table 3 revealed that the comparing health -related quality of life (HRQoL) score with the time passed since cancer diagnosis, As a general Patients diagnosed from 1–3 years ago had higher scores in role func- tioning (28.53 ± 24.53) and emotional functioning (28.67 ± 20.56) compared to those recently diagnosed or with long- term diagnoses (>3 years). Time since diag- nosis significantly affected at p-values for urinary symptoms (0.043), bowel symp- toms (0.009), hormonal symptoms ( 0.004), and sexual activity (0.019). Other domains such as fatigue, pain, and global health status in these findings showed no statistically significant differences across the diagnosis duration groups. 147 Copyright ©2025 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. Table1: Socio-demographic Characteristics of Prostate Cancer Patients (N = 100) Socio-Demographic Characteristics Category Frequency (n) Percent (%) Age Group >60 17 )17( 60–69 33 )33( ≥70 50 )50( Marital Status Married 100 )100( Educational Level Illiterate 52 )52( Elementary 21 )21( Institute 18 )18( College 9 )9( Occupation Employed 12 )12( Unemployed 37 )37( Retired 51 )51( Needs Help with Daily Living Activities Yes 38 )38( No 62 )62( Time Passed Since Cancer Diagnosis >1 year 28 )28( 1–3 years 46 )46( >3 years 26 )26( Smoking Habit Yes 42 )42( No 58 )58( History of Sexual Problems Before Diagnosis Yes 37 )37( No 63 )63( Body Mass Index Normal 45 )45( Overweight 35 )35( Obese 20 )20( https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article 148 Copyright ©2025 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:Health related quality of life and symptoms scales by body mass index Body Mass Index Normal (n=45) (Mean ± SD) Overweight (n=35) (Mean ± SD) Obese (n=20) (Mean ± SD) P-value ANOVA QLQ-C30 Functioning Scale Global HRQOL 81.66±41.42 82.85±37.75 97.50±40.16 0.33 Physical Functioning 29.78 ±24.40 20.43 ±20.05 18.25 ±22.38 0.083 Role Functioning 31.11 ±26.73 18.21 ±19.02 15.63 ±24.63 01010 Cognitive Functioning 25.28 ±20.38 20.36 ±17.96 15.00 ±18.85 0.132 Emotional Functioning 31.39 ±20.79 27.14 ±18.93 15.00 ±18.29 01010 Social Functioning 33.89 ±23.18 29.64 ±23.50 15.63 ±23.25 01010 QLQ-C30 Symptom Scale Fatigue 26.11 ±25.41 20.95 ±21.43 22.92 ±21.94 0.614 Nausea and Vomiting 9.72 ±23.06 4.64 ±10.97 1.88 ±6.12 0.180 Pain 23.89 ±23.21 22.14 ±27.47 20.63 ±24.43 0.880 Dyspnea 9.44 ±18.68 9.29 ±14.96 8.75 ±16.77 0.989 Insomnia 27.22 ±25.46 20.71 ±23.86 20.00 ±23.79 0.393 Appetite Loss 16.11 ±23.33 13.57 ±24.51 8.75 ±18.63 0.491 Constipation 11.67 ±21.72 14.29 ±24.47 6.25 ±13.75 0.412 Diarrhea 10.00 ±20.23 6.43 ±15.27 3.75 ±12.23 0.366 Financial Difficulties 33.89 ±24.52 32.86 ±24.08 20.00 ±25.13 0.094 QLQ-PR25 Scale Urinary Symptoms 18.77 ±19.09 24.76 ±21.15 21.53 ±19.97 0.416 Bowel Symptoms 6.30 ±13.31 11.43 ±18.86 5.42 ±19.17 0.300 Hormonal Symptoms 6.81 ±14.83 10.36 ±17.87 9.38 ±18.31 0.622 Sexual Activity 18.33 ±14.86 19.46 ±19.81 10.63 ±20.08 0.181 Sexual Functioning 30.78 ±24.45 26.86 ±27.74 8.75 ±21.70 01000 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article prostate cancer were married, old and had low educational levels [11,12]. Regarding occupation, the present study findings agree with the findings of a study done by Hacettepe University Faculty of Medicine on 173 patients, in which more than half of the prostate cancer patients were retired [13]. Furthermore, regarding the smoking habits and sexual history, the majority of the patients were nonsmokers, and ap- proximately one-third of the patients had sexual dysfunction before diagnosis. It agrees with the result of a study done in Iran on 210 patients, which showed that most of them were nonsmokers and more than 35% received treatment for sexual 149 The present study findings demonstrate that the highest percentages of prostate cancer patients were aged 70 years and older and married. A high percentage were illiterate and the majority were re- tired. The current findings are supported by a cross-sectional study conducted in Egypt from Ain Salam University Hospital on 101 patients diagnosed with prostate cancer, which showed that over 60% of prostate cancer patients were aged above 65, with the majority of them being re- tired and illiterate. Similarly, another study supports the findings of the present study, which conducted in Jordan, found that most of the patients diagnosed with Copyright ©2025The 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 3: Health related quality of life and symptoms scales by time passed from cancer diagnosis Time passed from Diagnosis <1 year 1–3 year < 3 year (n=28) (n=40) (n=20) (Mean ± SD) (Mean ± SD) (Mean ± SD) P-value ANOVA QLQ-C30 Functioning Scale Global HRQOL 92.41±43.07 84.78±38.72 78.36±43.81 0.45 Physical Functioning 23.75 ±24.21 25.33 ±20.85 22.69 ±25.66 0.891 Role Functioning 19.20 ±22.17 28.53 ±24.53 19.23 ±26.51 0.170 Cognitive Functioning 21.43 ±22.01 22.83 ±18.50 19.23 ±18.79 0.757 Emotional Functioning 24.33 ±21.34 28.67 ±20.5 25.48 ±19.60 0.644 Social Functioning 30.80 ±26.24 26.90 ±23.27 29.81 ±23.74 0.773 QLQ-C30 Symptom Scale Fatigue 15.77 ±16.09 28.26 ±26.20 24.04 ±22.89 0.081 Nausea and Vomiting 7.14 ±16.11 8.15 ±21.44 2.40 ±6.14 0.383 Pain 14.73 ±17.70 27.99 ±28.16 21.63 ±23.33 0.080 Dyspnea 4.46 ±11.89 11.96 ±19.54 9.62 ±15.93 0.181 Insomnia 15.18 ±18.43 29.35 ±25.44 22.12 ±26.76 0.051 Appetite Loss 11.61 ±20.95 17.93 ±25.64 8.65 ±18.63 0.216 Constipation 16.07 ±26.54 10.87 ±20.17 7.69 ±16.98 0.348 Diarrhea 7.14 ±17.82 7.61 ±16.56 7.69 ±18.40 0.992 Financial Difficulties 33.04 ±27.26 29.35 ±22.55 30.77 ±26.75 0.828 QLQ-PR25 Scale Urinary Symptoms 16.37 ±17.51 26.81 ±20.45 17.31 ±19.94 01043 Bowel Symptoms 3.27 ±14.58 13.41 ±17.87 3.21 ±13.96 01000 Hormonal Symptoms 2.23 ±13.09 14.27 ±17.31 5.29 ±15.68 01004 Sexual Activity 11.83 ±17.71 22.55 ±16.16 13.46 ±19.10 01010 Sexual Functioning 23.75 ±29.21 26.30 ±25.33 24.04 ±25.50 0.901 DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 Erbil j. nurs. midwifery, Vol. 8, No. (2), Nov 2025 Original Article Finland showed that men with prostate cancer significantly improved in sexual functioning and urinary control 12 to 24 months after disease [20]. In addition, an- other study in Canada confirmed that long- term survivors (≥3 years post-diagnosis) promote better quality of life outcomes [21]. Health-related quality of life in the PCa was affected by the patients’ body mass index; this findings highlights the importance of paying attention to functioning scales such as role, emotional and social function and sexual function in the quality of life of prostate cancer 25 items (QLQ-PR 25) scale: Regarding time passed after prostate cancer diagnosis, it is important to pay attention to patients’ symptom scales and quality of life of prostate cancer such uri- nary, bowel, hormonal and sexual activity. [1] Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A, et al. Global cancer statis- tics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries,correction in: CA A Cancer Journal for Clinicians. 2020;70:313 doi:10.3322/caac.21492. [2] Rawla P. Epidemiology of prostate cancer. World Journal of Oncology. 2019;10(2):63– 89. doi:10.14740/wjon1191. [3] Siegel RL, Miller KD, Jemal A. Cancer statis- tics, 2020. CA: A Cancer Journal for Clini- cians.2020;70(1):7–30. doi:10.3322/ caac.21590 [4] Wirth M, van der Poel H, Anderson J, Grae- fen M, Stief C, Wiegel T, et al. The European Prostate Cancer Centres of Excellence: A novel proposal from the European Associa- tion of Urology Prostate Cancer Centre Con- sensus Meeting. European Urology.2019;76 (2):179–186.doi:10.1016/ j.eururo.2019.01.025 [5] Fayers P, Aaronson N, Bjordal K, Groenvold M, Curran D, Bottomley A, et al. The EORTC QLQ-C30 Scoring Manual (3rd edition). Brus- sels: European Organisation for Research and Treatment of Cancer; 2001. problems before the diagnosis [14]. More- over, a retrospective cohort study, which was conducted at two oncology hospitals in Saudi Arabia, revealed that most pa- tients with prostate cancer were married, aged above 65, and living with chronic comorbidities [15]. About health-related quality of life (HRQoL) and symptoms com- pared with body mass index (BMI) catego- ries, there are significant relationships be- tween body mass index (BMI) and several health-related quality of life (HRQoL) do- mains, including emotional functioning, role functioning, social functioning, and sexual functioning. Patients with a normal BMI reported better quality of life across these domains compared to overweight and obese participants. The results of the present study are consistent with the find- ings of a study that was conducted, which showed that elevated BMI had a negative effect on sexual and emotional functions in men with this type of cancer [16]. More- over, the current study findings come along with a cross-sectional study con- ducted in the Netherlands on 314 patients, which body mass index had significant as- sociation with better scores on physical, role, social, and emotional functioning scales measured by EORTC QLQ-C30 and PR25 modules [17,18]. Regarding time passed after diagnosis, Table 3 shows that health-related quality of life domains such as urinary symptoms, bowel function, hor- monal symptoms, and sexual activity sig- nificantly affected the quality of the pa- tient’s life. Patients diagnosed less than one year reported more severe symptoms than those patients who had passed the disease for 1 to 3 years or more. These findings are compatible with the result of a study conducted in South Korea, which found that symptom burdens were highly affected during the first year after diagno- sis and gradually tended to decrease [19]. Additionally, a cohort study done in 150 Copyright ©2025The 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. 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