Women With Breast Cancer Undergoing Chemotherapy: Implications in Quality of Life

Clinical, Emotional, Cognitive and Neuropsychophysiological Impact of a Hedonic Aroma in Women With Breast Cancer Undergoing Chemotherapy: Implications in Quality of Life.

Breast cancer is a major public health problem and is the main cancer disease in women worldwide and in Europe. In Portugal it is the most common cancer, the third cause of cancer death, following the European trend.

Breast cancer (BC) triggers a myriad of physical and psychosocial stressors with repercussions on quality of life (QoL). This study is a pioneering Randomized Controlled Trial (RCT) in Portugal, which seeks to study the impact of a hedonic aroma during chemotherapy on women with breast cancer (3, 6 and 9 weeks, and 3 months after completion of chemotherapy). To this end, participants will be randomly assigned to one of the groups. The experimental group (EG) will be exposed to chemotherapy together with a hedonic aroma, while the control group (CG) will only be exposed to chemotherapy. Both groups will be assessed on psychological morbidity, illness perception, self-efficacy for coping, executive function, cortisol levels, side-effects, beliefs about chemotherapy and QoL.

The aim of this study is to assess the impact of a hedonic aroma on the clinical, emotional and neurocognitive variables that contribute to reducing the side effects of chemotherapy and promoting QoL in women with BC.

Study Overview

• Status: Completed
• Conditions: Breast Cancer Female
• Intervention / Treatment: Biological: Inhalation of essential oils

Detailed Description

The sample is non-probabilistic, consisting of 56 participants in the control group (CG) and 56 in the experimental group (EG). According to the calculations made for RCT studies (Noordzij et al., 2010), it will take approximately a total of 100 participants (50 participants per group) to detect a 10-point difference between the groups in the result variable QoL (e.g. EORCT QLQ-C30), with a population standard deviation of 15.43, according to previous study data (Lua et al., 2015), assuming a power of 90% and a significance level of 5%.

This study contemplates four moments of evaluation: T1 (baseline: 2nd Cycle of CT but before intervention), T2 (6 weeks - 3rd Cycle), T3 (9 weeks - 4th Cycle) and T4 (3 months after the end of the CT). These moments were chosen taking into account the classes of drugs used in the CT. Each cycle has an interval of 21. This is a randomized controlled clinical trial (RCT) being single blind (the participant does not know which group he belongs to, only the investigator) and longitudinal.

Intervention procedure:

From the 2nd. Chemotherapy cycle (T1), the GC received the standard chemotherapy treatment; while the EG, in addition to the standard chemotherapy treatment, inhaled a hedonic aroma selected at the time of the chemotherapy (among three types of essential oils: bergamot, exotic verbena and geranium). The participant, as she received the CT, would inhale the aroma in a phased manner and under the supervision of the researcher, until the end of the treatment (about two hours). This intervention took place over three cycles of CT (2nd, 3rd and 4th Cycles). Inhalation was carried out using cotton rolls impregnated with the selected oil, since the more directly the odoriferous molecules are applied to the nose, the greater their impact into the organism (Schneider, 2016). However, since it was necessary that the researcher supervised the participants during the inhalation process, the number of times the researcher was in contact with participants from both groups (GC and EG) were the same: 4 times during the chemotherapy treatment to assure the participants from the EG would not have more contacts what could bias the results.

• Study Type: Interventional
• Enrollment (Actual): 112
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Portugal
  • Estrada De Santa Luzia
    • Viana Do Castelo, Estrada De Santa Luzia, Portugal, 4904-858
      • António Fradão

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• women with BC in stages 0-2;
• level 0-2 on the Zubrod scale,
• without cognitive impairment,
• adjuvant chemotherapy (AQ) treatment.

Exclusion Criteria:

• Severe mental disturbance;
• olfactory impairment (≤6), evaluated before CT through the instrument smell diskettes and only in the EG participants

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Experimental Group; The Experimental Group participants will be submitted to the inhalation of the hedonic aroma during the chemotherapeutic treatment, this being the intervention of the study.The control group is not subject to intervention.	Biological: Inhalation of essential oils; Intervention "Inhalation of essential oils": From the T1 (2nd Cycle CT), Experimental Group Arms will undergo the inhalation of the hedonic aroma selected by them at the time of chemotherapy (among several types of aromas). It is intended that the participant, when receiving the CT, inhales the aroma phase-in and under the investigator's observation until the end of the treatment (about two hours). The inhalation of essential oils will occur using cotton rolls impregnated with the selected oil. The control group is not subject to intervention during chemotherapy treatment.
NO_INTERVENTION: Control Group; The control group is not subject to intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality of life - The experimental group presented, in comparison to the control group, lower level of QLQ	Assessment instruments: the European Organization for Research and Treatment of Cancer - Quality of Life (EORTC QLQ-C30) (Aaronson et al., 1993; Pais-Ribeiro, Pinto & Santos, 2008). Interpretation of the results, the higher the value obtained, the better the total quality of life - total quality of life result, through weighting formulas carried out by the European Organization for Research and Treatment of Cancer (EORTC) (http://groups.eortc.be/qol/manuals)	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Anxiety and depression - The experimental group presented, in comparison to the control group, lower anxiety and depression	Assessment instruments: Hospital Anxiety and Depression Scale (HADS, Pais-Ribeiro et al., 2007) comprising both anxiety and depression scales. Scores range between 0 and 42 (anxiety between 0 and 21 and depression the same), with higher results indicating higher levels of distress.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Distress	Assessment instruments: Emotions Thermometer (TE, Mitchell, Baker-Glenn, Granger, & Symonds, 2010; Teixeira et al., 2019) consisting of five analogue-visual scales, with four domains to identify emotional complications (distress, anxiety, depression, anger) and one outcome domain (need for help). In each thermometer de scores range between 0 and 10. A high result indicates emotional distress.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Saliva cortisol	The collection of saliva for the evaluation of cortisol concentrations was performed using salivettes® (Starsedt). The procedure to assess salivary cortisol concentrations was implemented according to the protocol stipulated by IBL International (Cortisol Saliva ELISA, IBL International GMBH).	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Subscales of the Quality of Life in Breast Cancer	Assessment instruments: the European Organization for Research and Treatment of Cancer - Quality of Life, Module for Breast Cancer (EORTC QLQ-BR23, Sprangers et al., 2006. In this study, only the breast symptoms (scores range between 4-16), body image (scores range between 4-16), sexual functioning (scores range between 2-8) and side effects (scores range between 7-28) subscales were used. High scores indicate higher body image, sexual functioning and breast symptoms.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Illness Perceptions	Assessment instruments: Illness Perception Questionnaire (IPQ-Brief, Broadbent, Petrie, Main, & Weinman, 2006; Figueiras et al., 2010). This instrument comprises 9 items that assess patients' cognitive and emotional representations of the disease. There is one item that is open-ended and asks the perceived causes of the disease (not used in the study). Scores range between 0 and 80. Higher scores indicate a more threatening illness perception.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Self-efficacy for coping	Assessment instruments: Cancer Behavior Inventory-Brief Version (CBI-B, Heitzmann et al., 2011). This instrument evaluates self-efficacy for coping in cancer patients through 12-item. Scores range between 12 and 108 and higher scores indicate more effective coping strategies.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Working memory	Assessment instruments: WAIS III Subtest - Digit Span (Wechsler, 2008). It evaluates patients' working memory in clinical practice consisting of two parts: The Digit Span Forward (scores range between 0-16 maximum) and Digit Span Backward (DSB) (scores range between 0-14 maximum). High scores indicate high immediate auditory memory and working memory.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Cognitive Flexibility	Assessment instruments: Trail Making Test (TMT, Partington & Leiter, 1949; Cavaco et al., 2013). This instrument is composed of part A, which evaluates attention, visual tracking and speed of graphomotor coordination and information processing; and Part B evaluates Part A functions and the ability to switch between a set of stimuli. Lower raw indices and higher adjusted scores correspond to better cognitive performance.	Changes from the 2nd cycle of CT(T1) (each cycle takes, on average, 2 hours with 3-week intervals) until 4th cycle of CT, assessed up to an average 1,5 months (T3) and again in the follow up (T4) (3 months after to the end CT, an average 6 months
Beliefs about chemotherapy	Assessment instruments: Beliefs about chemotherapy (BMQ, Horne, Weinman, & Hankins, 1997; Pereira, Pedras, & Machado, 2013). This instrument is composed of 18 items and comprises two sections: BMQ - Specific and BMQ-General. In this study, only the specific section was used regarding chemotherapy. The BMQ - Specific section incorporates two sub-scales of five items each: Specific Needs and Specific Concerns related to the dangers of dependence and toxicity and concerns regarding long-term side effects, respectively. The total on the Specific Needs Scale ranges from 5 to 25 and on the Specific Concerns Scale from 5 to 25. Higher scores in each subscale indicate stronger beliefs regarding the need of treatment and regarding concerns towards the treatment, respectively.	Changes from the 2nd cycle of chemotherapy (T1) (each cycle takes, on average, 2 hours with 3-week intervals between each cycle) until the date of 4th cycle of CT, assessed up to an average 1,5 months (T3)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Sociodemographic and Clinical Data	Assessment instruments: This instrument was developed specifically for this study, and included 11 items to assess sociodemographic variables (age, marital status, education, and occupation) and clinical variables (type of surgery, disease stage, number of planned cycles, tumor grade, sentinel lymph node, molecular markers and take hormone therapy).	Time Frame: before chemotherapy (CT) treatment
ECOG Performance Status (Oken et al., 1982)	The Zubrod scale evaluates patients' performance status, where 0 refers to fully functional and asymptomatic and 5 to dead. It was used for inclusion criteria (West & Jin, 2015).	Time Frame: before CT for inclusion criteria
Smell Diskettes (Simmen, Briner & Hess, 1999).	This test consists of eight reusable diskettes containing different odors. It is a test that aims to evaluate the olfactory function. According to the results, a score between 7 and 8 corresponds to a normal olfactory function and ≥6 presents a compromised olfactory function (as for example with a hyposmia or anosmia).	Time Frame: before CT for inclusion criteria
Short Assessment of Health Literacy (SAHL, Lee et al., 2010; Apolinario et al., 2012).	This instrument assesses the degree of health literacy through the recognition of medical words, associating them with other words of similar meaning. Higher scores indicate a higher level of health literacy. A cutoff point of <14 has been assumed to distinguish between adequate and inadequate literacy (Apolinario et al., 2012).	Time Frame: before CT for inclusion criteria

Collaborators and Investigators

• Sponsor: University of Minho
• Collaborators: Foundation for Science and Technology, Portugal
• Investigators: Principal Investigator: Marta Pereira, Master, University of Minho

Publications and helpful links

General Publications

• Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993 Mar 3;85(5):365-76. doi: 10.1093/jnci/85.5.365.
• Sprangers MA, Groenvold M, Arraras JI, Franklin J, te Velde A, Muller M, Franzini L, Williams A, de Haes HC, Hopwood P, Cull A, Aaronson NK. The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. J Clin Oncol. 1996 Oct;14(10):2756-68. doi: 10.1200/JCO.1996.14.10.2756.
• Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70. doi: 10.1111/j.1600-0447.1983.tb09716.x.
• Broadbent E, Petrie KJ, Main J, Weinman J. The brief illness perception questionnaire. J Psychosom Res. 2006 Jun;60(6):631-7. doi: 10.1016/j.jpsychores.2005.10.020.
• Pais-Ribeiro J, Silva I, Ferreira T, Martins A, Meneses R, Baltar M. Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale. Psychol Health Med. 2007 Mar;12(2):225-35; quiz 235-7. doi: 10.1080/13548500500524088. English, Portuguese.
• Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982 Dec;5(6):649-55. No abstract available.
• Apolinario D, Braga Rde C, Magaldi RM, Busse AL, Campora F, Brucki S, Lee SY. Short Assessment of Health Literacy for Portuguese-speaking Adults. Rev Saude Publica. 2012 Aug;46(4):702-11. doi: 10.1590/s0034-89102012005000047. Epub 2012 Jul 10.
• Cavaco S, Goncalves A, Pinto C, Almeida E, Gomes F, Moreira I, Fernandes J, Teixeira-Pinto A. Trail Making Test: regression-based norms for the Portuguese population. Arch Clin Neuropsychol. 2013 Mar;28(2):189-98. doi: 10.1093/arclin/acs115. Epub 2013 Jan 7.
• Figueiras M, Marcelino DS, Claudino A, Cortes MA, Maroco J, Weinman J. Patients' illness schemata of hypertension: the role of beliefs for the choice of treatment. Psychol Health. 2010 Apr;25(4):507-17. doi: 10.1080/08870440802578961.
• Heitzmann CA, Merluzzi TV, Jean-Pierre P, Roscoe JA, Kirsh KL, Passik SD. Assessing self-efficacy for coping with cancer: development and psychometric analysis of the brief version of the Cancer Behavior Inventory (CBI-B). Psychooncology. 2011 Mar;20(3):302-12. doi: 10.1002/pon.1735.
• Lee SY, Stucky BD, Lee JY, Rozier RG, Bender DE. Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers. Health Serv Res. 2010 Aug;45(4):1105-20. doi: 10.1111/j.1475-6773.2010.01119.x. Epub 2010 May 24.
• Mitchell AJ, Baker-Glenn EA, Granger L, Symonds P. Can the Distress Thermometer be improved by additional mood domains? Part I. Initial validation of the Emotion Thermometers tool. Psychooncology. 2010 Feb;19(2):125-33. doi: 10.1002/pon.1523.
• Noordzij M, Tripepi G, Dekker FW, Zoccali C, Tanck MW, Jager KJ. Sample size calculations: basic principles and common pitfalls. Nephrol Dial Transplant. 2010 May;25(5):1388-93. doi: 10.1093/ndt/gfp732. Epub 2010 Jan 12. Erratum In: Nephrol Dial Transplant. 2010 Oct;25(10):3461-2.
• Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychology and health. 1999; 14(1): 1-24.
• Pais-Ribeiro JL, Pinto C, Santos C. Validation study of the Portuguese version of the QLC-C30-V. 3. Psicologia, Saúde & Doenças. (2008; 9(1): 89-102.
• Partington JE, Leiter RG. Partington's pathway test. Psychological Service Center Bulletin. 1949; 9-20.
• Schneider R. There Is Something in the Air: Testing the Efficacy of a new Olfactory Stress Relief Method (AromaStick(R)). Stress Health. 2016 Oct;32(4):411-426. doi: 10.1002/smi.2636. Epub 2015 Mar 18.
• Simmen D, Briner HR, Hess K. [Screening of olfaction with smell diskettes]. Laryngorhinootologie. 1999 Mar;78(3):125-30. doi: 10.1055/s-2007-996844. Erratum In: Laryngorhinootologie 1999 Jun;78(6):A24. German.
• Teixeira RJ, Machado JC, Faria S, Remondes-Costa S, Brandao T, Branco M, Moreira S, Pereira MG. Brief emotional screening in oncology: Specificity and sensitivity of the emotion thermometers in the Portuguese cancer population. Palliat Support Care. 2020 Feb;18(1):39-46. doi: 10.1017/S1478951519000208.
• Wechsler D. Escala de Inteligência de Wechsler para Adultos-Terceira Edição [Wechsler Adult Intelligence Scale-Third Edition] (WAIS-III). Lisboa: Cegoc. 2008
• West HJ, Jin JO. JAMA Oncology Patient Page. Performance Status in Patients With Cancer. JAMA Oncol. 2015 Oct;1(7):998. doi: 10.1001/jamaoncol.2015.3113. No abstract available.
• Pereira MG, Pedras S, Machado JC. Validation of the questionnaire of beliefs towards medicines in type 2 diabetic patients. Psicologia: Teoria e Pesquisa. 2013; 29: 229-236.
• Pereira M, Moreira CS, Izdebski P, Dias ACP, Nogueira-Silva C, Pereira MG. How Does Hedonic Aroma Impact Long-Term Anxiety, Depression, and Quality of Life in Women with Breast Cancer? A Cross-Lagged Panel Model Analysis. Int J Environ Res Public Health. 2022 Jul 28;19(15):9260. doi: 10.3390/ijerph19159260.

Study record dates

Study Major Dates

• Study Start (ACTUAL): March 6, 2017
• Primary Completion (ACTUAL): April 4, 2019
• Study Completion (ACTUAL): April 4, 2019

Study Registration Dates

• First Submitted: May 28, 2018
• First Submitted That Met QC Criteria: July 1, 2018
• First Posted (ACTUAL): July 12, 2018

Study Record Updates

• Last Update Posted (ACTUAL): August 5, 2021
• Last Update Submitted That Met QC Criteria: August 4, 2021
• Last Verified: August 1, 2021

More Information

Terms related to this study

• Keywords: Breast Cancer; Quality of Life; Salivary cortisol; Adjuvant Chemotherapy; Essentials Oils; Neuropsychophysiology
• Additional Relevant MeSH Terms: Skin Diseases; Neoplasms; Neoplasms by Site; Breast Diseases; Breast Neoplasms
• Other Study ID Numbers: 175519021995

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No