Impact of Psychological and Socioeconomic Factors on Management of Bone Tumours with Custom-made Endoprosthesis Reconstruction

INTRODUCTION

Treatment options for bone tumours have changed significantly during the past few decades. A combination of chemotherapy, radiation therapy and surgery is used in the multidisciplinary treatment.^[1] Previously, amputation was considered the principal surgical treatment assuring a radical margin; however, improved chemotherapy schedules permit sparing the limb and increased survival.^[2,3]

Most of our patients belong to lower and upper socioeconomic classes.^[4] The word ‘cancer’ creates immense psychological stress, not only for the patient but also for their families, and a proper psychological support system may improve this scenario.

MATERIALS AND METHODS

We analysed the patients who underwent bone resection with custom-made prosthesis reconstruction in our institution between 2013 and 2022. We included all patients from 10 years to 60 years of age. We excluded the patients who are not in follow-up and patients who have expired. We prepared a questionnaire which included 22 questions to assess the impact of psycho-social and economic factors on the treatment of bone tumours.

RESULTS

The average monthly income for the patient/head of family is 16500 INR (4500–33000 INR).

The average duration from diagnosis to the start of treatment was 26 days. (19–33 days). The average total duration of disease before surgery was 95 days (which includes chemotherapy and a plan for prosthesis). The average days of in-hospital stay was 53 days. The average number of days of hospital stay after surgery was 14 days (10–18 days).

The average amount spent during the hospital stay was about 240 INR/day (in spite of providing food to patients free of cost), or around 12720 INR. The average amount spent on transport alone was 84000 INR.

The average loss of work after surgery was about 90 days (60–120 days). The average days of leave taken in school/ college were 135 days. Hence, in total, there was a loss of work for a period of around seven and a half months. About 92.3% of these patients were not paid any kind of salary/ compensatory pay during these days.

About 69.2% of patients had to change occupations, and 55.5% were forced to quit their occupations. About 90.9% of patients had a fear of recurrence. About 77.2% of patients found difficulty indulging in recreational/sports activities. This figure reaches up to 94.1% if the tumour involves the lower extremities.

About 45.4% of patients felt that their family members were unable to empathise with their situation. About 59% of patients had sleep difficulties. About 72.7% had difficulties in sexual life after treatment.

About 36.3% of patients were well satisfied with their prosthesis. About 31.85% were satisfied but not up to their expectations, while 31.85% were not satisfied with the prosthesis.

DISCUSSION

According to the modified Kuppuswamy classification^[4] for socioeconomic status, which is widely used in our country, most of our patients belong to the lower and upper classes. As per this classification, the average income for lower socioeconomic status is <9307 INR. In our study, the average per capita income is 16500 INR.

Most of our patients were not able to get the appropriate initial form of treatment, such as a proper biopsy or initiation of chemotherapy, for a period of one month. During this one-month duration, some of our patients may even end up undergoing inappropriate investigation or inappropriately placed biopsy. This adds up to an additional economic burden and may impact the performance of the limb salvage surgery.

The daily average amount spent during the hospital stay was about 240 INR, and the major portion of this goes to meet the need for food for the attenders [Graph 1]. The average number of attendees per person was two. So, for daily expenses alone, they have to spend around three-fourths of their average monthly income during their hospital stay. These expenses can be cut short to some extent if we restrict the number of attendees to the patient to one during the hospital stay.

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Graph 1:

Economic burden.

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One of the huge expenditures during the treatment course was transportation. The average cost for transportation during the treatment course was about 84,000 INR [Graph 1]. Since public transport is not compatible with musculoskeletal tumour patients, most of our patients prefer private transportation to reach the hospital from different parts of our state.

The average period of loss of work was about 7½ months (which includes both treatment course and post-operative and rehabilitation period) in 1 year. So for these 7½ months, 92.3% of patients were not paid any salary or compensation, and it almost led to a loss of about 1.2 lakhs INR. Hence, in total, the average economic deficit crosses more than 2 lakhs INR, which surpasses the average 1-year income of the patient [Graph 2].

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Graph 2:

Factors where more than 50% of patients were affected.

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Among these patients, 69.2% had to go for a change of occupation [Graph 2]. The irony is some of the patients were forced to quit their jobs by their employers due to the fear of cancer spreading to them [Graph 2]. This reflects badly on awareness about cancer and its spread among the general public in developing countries.

Cancer patients often endure pain, which can significantly increase their anxiety, despair and sense of helplessness.^[5-7] Patients may have pain as a direct result of their underlying illness or as a result of treatments such as radiation therapy, chemotherapy or surgery used to treat their cancer. This leads to sleep disturbances and a lack of interest in sexual activities in our patients [Graph 2]. This can be encountered by proper psychological counselling and with adequate and prompt physiotherapy along with proper analgesics.

The majority of cancer patients experience varied degrees of psychological stress, one of which is fear of cancer recurrence (FCR).^[8] In our study, almost more than 90% of patients experience the FCR. Numerous research has discovered a link between high FCR and poor QOL, psychological comorbidities, increased distress and physical limits.^[9-11]

Participating in sports and other physical and recreational activities has never been easy for cancer survivors. Recreational activity restriction in our patients is largely influenced by psychological despair and pain, in addition to the moderate physiological restrictions following a custom-made endoprosthesis reconstruction. Yet, research has shown that exercise helps cancer survivors in several ways, including psychological and QOL outcomes, physical functioning, body weight and composition, immune system performance and cardiovascular fitness.^[12]

Summarising all the above factors, the overall satisfaction for the custom-made endoprosthesis in bone tumours is about 36.3% only [Graph 3]. The remaining patients are either not at all satisfied or have very high expectations about the custom-made endoprosthesis and its function.

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Graph 3:

Patients’ satisfaction rate.

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CONCLUSION

There should be direct coordination between health care providers – social welfare department – policy makers. To reduce the financial burden and to improve QOL, services like the national cancer helpline along with a cancer care ambulance for transportation might help the patients, especially for musculoskeletal cancer. Frequent cancer survivor programmes will aid these patients to regain their self-confidence.