Incidences of cancer have increased greatly over the past decade in Saudi Arabia, making it an emerging burden and a major public health concern (1–5). A prominent factor that influences this increase is the recent socio-economic shift in Saudi communities, such as citizens adopting a far more sedentary lifestyle and consuming more processed foods (2).

Cancer not only affects physical patients' health but also adds a psychosocial burden, which can increase its debilitating effects. For instance, cancer can reduce patients' quality of life (QoL), thereby worsening disease progression and survival rates (6–9). Moreover, cancer patients are more prone to experience depression, anxiety, and fatigue (10). The authors of a meta-analysis concluded that the prevalence of depression in cancer patients ranges between 8 and 24%, as it varies, depending on the type of cancer, treatment phase, and the type of reporting instrument (11). Anxiety proved to be just as prevalent, as 19% of cancer patients had clinical and 22.6% had subclinical levels of anxiety (8). A study conducted in Saudi Arabia in 2022 to assess QoL and the psychological wellbeing of breast cancer survivors reported that 57% of the patients had moderate to severe depression and 44% had moderate to severe anxiety, yet only 6.8% of these patients reported receiving psychosocial support (12). The treatment of cancer can be equally distressing, as it can cause an array of side-effects, including hair loss, pain, and nausea and vomiting, all which impact patients' levels of functioning negatively and cause further deterioration in the mental and physical QoL (6, 10, 13–17).

QoL was defined by Britannica as “the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events” (18). QoL is a multidimensional concept that measures outcomes in various life domains, which includes physical, role, cognitive, emotional, and social functioning (19). Poor QoL among cancer patients has been reported as high as 82.3% worldwide compared to a recent study done in Saudi Arabia which found that 51% of cancer patients had an overall pool QoL prevalence (15, 20). A systematic review found that the implementation of patient-reported outcome measures can improve communication with cancer patients, enhance treatment response monitoring, and increase patient satisfaction. As a result, it improves fatigue, pain, and loss of appetite among cancer patients (21, 22). Studies conducted in Saudi Arabia have identified various clinical, treatment, and sociodemographic factors that could influence cancer patients' QoL (12, 23–28). Factors such as employment status, educational level, and tumor location were associated with major reductions in all QoL domains (24). More specifically, factors such as age, employment status, income, tumor location, and exercise were associated with social and cognitive functioning, while age, level of education, employment status, and exercise were associated with physical functioning (24–27). Age at diagnosis, level of education, marital status, exercise, psychological program participation, and the Hospital Anxiety and Depression Scale (HADS) scores are predictors of global QoL (12, 24, 26). However, an examination of the impact of other prognostic factors is required to better align the level of care with patients' needs and to enhance the overall wellbeing of cancer patients (28).

Given the significance of the topic and the relative lack of studies on it in Saudi Arabia, the current study aims to identify the sociodemographic, clinical, psychosocial, and cultural factors associated with the QoL of cancer patients.

Two hundred and seventy-six cancer patients participated in this study. Most patients were older than 50 years (56.9%), nearly two-thirds were females (63.8%), and most patients were Saudi (84.1%). The majority of patients were married (82.2%), while nearly three-quarters (72.1%) were unemployed. Most patients (59.1%) had a high school or lower level of education, and 62.3% had a monthly income of 10,000 SAR or less. Furthermore, 70.3% were living in owned residences, mainly in the Central Region (79.7%). The only sociodemographic factor statistically linked to QoL was sex, as QoL was significantly worse among females (X² = 11.149; p = 0.001; see Table 1).

The clinical characteristics of the patients with cancer are shown in Table 2. It was revealed that the most commonly diagnosed cancer was breast cancer (43.8%), and stage 2 was the most common stage (16.3%). Furthermore, the most common intervention was chemotherapy (85.2%). The proportion of patients who visited psychiatrists was 8.7%, while 6.5% have been diagnosed with psychiatric disorders. All patients diagnosed with psychiatric problems were on psychiatric medications. The most commonly diagnosed psychiatric disorder was depression (73.3%), followed by adjustment (13.3%), stress (6.7%), and anxiety (6.7%). The method mostly used to self-treat was Islamic Ruqya (spiritual healing; 48.6%), and the cause of the cancer most often perceived was the evil eye or magic (28.6%) (43). In addition, the overall mean score for satisfaction toward health care was 8.78 (SD 1.56), while the overall mean score for satisfaction toward social support was 8.82 (SD 1.71). In the comparison to QoL, we found that the prevalence of poor QoL was significantly higher among patients who visited a psychiatrist (X² = 4.847; p = 0.028) or were taking psychiatric medication (X² = 5.276; p = 0.022), while the prevalence of good QoL was significantly higher among patients who had received biological treatment (X² = 4.474; p = 0.034) and who had reported satisfaction toward health care (U = 5,589.5; p = 0.001).

The assessment of the psychological factors in relation to QoL is shown in Table 3. It was found that the prevalence of patients with anxiety, depression, and distress was 21.7, 19.6, and 38.4%, respectively. Poor QoL was more common among patients with anxiety (X² = 27.482; p < 0.001), depression (X² = 44.713; p < 0.001), and distress (X² = 33.057; p < 0.001).

The mean score of the QoL functional scales was 77.1 (SD 20.8). Among its dimensions, the mean scores for physical, role, cognitive, and social functioning were 77.1, 80.6, 83.1, 82.9, and 81.2, respectively. Likewise, the mean score for symptoms scales was 29.9 (SD 29.9). The mean scores for fatigue, pain, and financial difficulties were 36.9, 27.5, and 18.5, respectively. The mean scores of the functional scales (U = 2,472; p < 0.001), with physical functioning (U = 2863; p < 0.001), role functioning (U = 3,647; p < 0.001), cognitive functioning (U = 4,377; p < 0.001), and social functioning (U = 3,939; p < 0.001) were significantly higher among patients with good QoL, while the mean scores of the symptom scales (U = 2,876; p < 0.001), fatigue (U = 3,315.5; p < 0.001), and pain (U = 3,252; p < 0.001), were significantly higher among patients with poor QoL. Interestingly, the mean score of financial difficulties was significantly higher among patients with good QoL (U = 4,646; p < 0.001).

A multivariate regression analysis was subsequently performed to determine the independent predictors associated with poor QoL. Based on the results, on the one hand, it was found that female sex, depression, and distress were independently associated with poor QoL. Moreover, satisfaction with healthcare was associated with good QoL. Female patients had a 2-fold higher risk of poorer QoL than male patients (AOR = 2.912; 95% CI = 1.394–6.081; p = 0.004). We also observed that patients with depression (AOR = 3.201; 95% CI = 1.410–7.265; p = 0.005) and distressed patients (AOR = 3.290; 95% CI = 1.682–6.438; p = 0.001) were three times more likely to have poor QoL, whereas satisfaction with health care was associated with good QoL (AOR = 1.284; 95% CI = 1.060–1.556; p = 0.011). On the other hand, biological intervention, treatment with psychiatric medication, and anxiety did not show a significant effect after adjustment of the regression model (p > 0.05; see Table 4).

The current study focuses on factors associated with QoL among cancer patients. Previous studies have concluded that age, education, and economic status were associated with QoL (16, 44, 45). The results of this study revealed that QoL was not influenced by any demographic characteristics or socioeconomic status, except for female sex. However, depression and distress were found to be associated with poor QoL, while satisfaction with healthcare was associated with good QoL.

This study found that all domains of functioning were impaired among patients with poor QoL, which aligns with findings by Hinz et al. (46). Among such patients in this study, social functioning was found to be the most impaired subdomain. Previous studies have emphasized the importance of social support for cancer patients, which has a great impact on QoL (47, 48).

In this study, patients with poor QoL suffered from increased fatigue. Fatigue is the most commonly experienced side effect of cancer and cancer treatment (13, 49, 50). In addition, it is more common in older patients and among those with a lower socioeconomic status (50). It has been demonstrated that increased levels of fatigue are not only associated with ongoing chemotherapy sessions but can also last for several years after the completion of chemotherapy (13, 49, 51). However, many patients experiencing fatigue do not receive any support from healthcare providers to reduce their fatigue (13).

The findings of this study show that poor QoL is associated with a decrease in physical function and an increase in fatigue. Cancer patients should be encouraged to exercise regularly, as exercise can decrease fatigue and improve QoL (52). In this study, the pain scores of patients with poor QoL were found to be considerably higher than the mean scores of the other patients. The thinking is that pain has a negative impact on patients' psychological health, sleep, and daily activities, which, subsequently, decreases their QoL (53). In addition, breast cancer patients with metastases had worse QoL and greater pain scores (54).

The present study found that patients with depression were three times more likely to have impaired QoL, a finding that is supported by the findings of other studies (47, 55). For instance, it was found in a meta-analysis that the prevalence of depression in patients with cancer ranged from 8 to 24% (11). The prevalence of depression in the present study was 19.6%, but only 8.7% of the patients had visited a psychiatric clinic. Therefore, screening for depression and other psychological symptoms in cancer patients and referrals to specialists are strongly advised. Moreover, female patients had a 2-fold higher risk of a poorer QoL. Studies have found that female patients had worse mental QoL than males, and depression is more common among women (17, 28, 45, 56). Hence, women who have poorer QoL may also have mental-related symptoms.

Interestingly, almost one third of the present study's patients attributed their cancer to supernatural causes, such as the evil eye or magic, and almost half used Islamic Ruqya (spiritual healing); however, these factors were not associated with the level of their QoL. These findings are consistent with a recent Saudi study that reported the trends of the perceptions related to the causes of cancer between 2008 and 2018, in which the authors found a significant increase, from 1.3 to 33.1%, in the belief of the “evil eye” as a cause of cancer (57). Another study on the use of complementary and alternative medicines among patients with cancer in Saudi Arabia found that patients were using Zamzam water (59.8%), honey (54.3%), black seed (35.1%), and water that had the Quran recited over it (29.8%) (58). These findings emphasized the strong influence of religion on peoples' lives, especially when confronted with life-threatening illnesses. Therefore, a systematic approach toward educating patients and the public as well as the licensing of spiritual cancer care workers to formalize their practice through education and training might be required to improve patient care and patient outcomes (57). Overall, the assessment of spiritual/religious needs can be considered as the first step in designing needs-tailored interventions (59).

This study has some limitations. First, the study's sample was recruited from one center. Hence, further multicenter studies are warranted to examine the generalizability of the results. Second, we only included patients with breast cancer, CRC, and lymphoma. Hence, other studies exploring other types of cancer could further enrich our understanding of the QoL of cancer patients. Third, this study is a cross-sectional study. Thus, future research could extend this work by conducting a longitudinal study. Finally, it was difficult to determine the prevalence of the factors associated with poor quality of life given the heterogenicity of psychosocial and clinical variables associated with poor quality of life therefore. Further studies should consider enough sample size to measure the psychosocial and clinical variables associated with poor quality of life among cancer patients.

Despite these limitations, this study provides valuable insights into cancer patients' QoL and the many factors impacting it. Addressing such factors in healthcare can improve the wellness and overall health of patients, especially cancer patients.

Our study aimed to identify the sociodemographic, clinical, psychosocial, and cultural factors associated with the QoL of cancer patients. Concerning the sociodemographic aspect, the female gender was an independent factor which contributed to the poor QoL. Among contributing clinical factors, our results indicated that pain, fatigue, and dissatisfaction with health care all significantly affect the QoL among cancer patients. The only psychosocial factor contributing to poor QoL was depression. Our findings support the need for more programs and interventions to improve the social services for cancer patients, along with the need to explore the social difficulties oncology patients face and address such obstacles through improving social services by expanding the scope of social workers' contribution.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by the Institutional Review Board of the College of Medicine at King Saud University (project#E-17-2769). The patients/participants provided their written informed consent to participate in this study.

All authors made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, took part in drafting the article or revising it critically for important intellectual content, agreed to submit it to the current journal, gave final approval to the version to be published, and agree to be accountable for all aspects of the work.