In the field of medicine, one popular definition of the construct of quality of life (QOL), based on the World Health Organization's definition of health, is that it concerns physical, psychological and social functioning, incorporating positive aspects of wellbeing as well as negative aspects of disease  Health – related QOL (HRQOL) is that aspect attributable to the disease and its treatment, and generally consists of assessments of functional health status (i.e., limitations on physical, psychological and social functioning imposed by the disease) and global wellbeing .
Although there has been considerable research on the QOL of women with breast cancer , the results may not be significantly affecting clinical decision – making because the clinical significance of findings is not specified [4, 5]. More studies are therefore needed to make QOL assessment feasible, understandable and scientifically viable in oncology research and practice . In particular, HRQOL assessments in oncology facilitate doctor – patient communication, they point to areas where patients may experience serious problems, they can be used as diagnostic tools for problem- oriented follow – up care, and the data are strong predictors of survival [6, 7].
These issues are highly relevant in Arab countries, such as Kuwait, where there is paucity of studies on QOL in cancer [8, 9], and the development of modern oncology services has led to improved survival rates, thereby making the disease to be a chronic condition. In addition, there are indications that different cultural groups may emphasize different aspects of their QOL . For example, analysis of a large international database of the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire (EORTC QLQ – C30) indicated that, compared with subjects from the UK, physical and social functioning were less important in predicting the global QOL of subjects from Islamic countries, while cognitive functioning was more influential for South Asia and Latin America . This obviates the need to assess the local perspectives on international QOL instruments, so that the data can be used to guide the choice of interventions and for cross-cultural comparisons to contribute to the emerging QOL theory . Accordingly, researchers have sought to highlight the factors that predict HRQOL among women with breast cancer. The common findings are as follows: First, younger age and chemotherapy are risk factors for diminished QOL [12–16]. Second, the association of stage of breast cancer with QOL is more controversial, with some authors finding no significant relationship [15, 17], while others report significant impact, in line with expectation of known groups validity [3, 9, 18, 19]. Also controversial is the impact on QOL, of the type of breast surgery [12, 14, 15], and time since surgery and chemotherapy [12, 20]. Third, disease – free women tend to have global QOL scores similar to the general population .
In this study, we sought to present an Arab perspective on the above issues, by using the EORTC QLQ – C30  and its breast cancer specific module (BR -23)  to assess women attending the outpatient service of the Kuwait Cancer Control Center (KCCC) for chemotherapy. We chose the EORTC QLQ for the following reasons. First, although it was articulated in Europe, it has been found to be reliable and valid in diverse cultures, including, the United Arab Emirates , Iran , Turkey , Japan , India , China , Korea , and Nigeria . Hence, there is an impressive body of international data with which to compare our results. Second, an Arabic translation of the questionnaire already exists, approved by the authors of the instrument.
The Kuwaiti perspective is important because it adds the contribution from a country where the pathobiological features of the disease indicate that it affects women at a relatively younger age and it seems to be more aggressive than what is currently seen in Europe, North America, Australia, and parts of Asia . In addition, the highly developed cancer service at the KCCC is easily accessible to all in this materially affluent city – state, and is provided free – of – charge to all Kuwaiti nationals. Since met needs for care have been known to be associated with QOL [28, 29], one wonders whether these favorable social/institutional care factors could contribute to make the HRQOL of Kuwait women to be comparable to the international data, despite the unfavorable factors (e.g., pathobiological features mentioned above, and use of chemotherapy). In Kuwait, breast cancer is the most common malignancy among women, accounting for 30.3% of all cancer types, and death occurs in approximately 43% of patients .
The objectives of the study were as follows: First, to highlight the HRQOL scale scores for Kuwaiti women in stable clinical condition with breast cancer, in comparison with the international data. Second, to examine the association of HRQOL with socio-demographic characteristics, stage of disease, type of treatment received in the past (i.e., surgery and radiotherapy), and duration since last treatment (for chemotherapy, surgery and radiotherapy). Third, to assess the variables that predict the global health status/QOL scale (GQOL) and the five functional scales of the QLQ – C30 (i.e., physical, role, emotional, cognitive, and social functioning), in comparison with the international data. In particular, we examined the relationship between GQOL, the five functional scales and the symptom scales/items .
Based on the literature, we hypothesized that despite unfavorable biological/treatment factors (i.e., their relatively younger age, more aggressive tumor and the fact that most were on chemotherapy at the time of assessment) [12–16], Kuwaiti women would have comparable HRQOL scores with the international data because of favorable social/care factors [28, 29]. Second, there is significant association between HRQOL scale scores and other demographic variables, stage of disease, time since last treatment, and previous surgery and radiotherapy. Third, as indicated by data from other Islamic countries , physical and social functioning would be less important in predicting the GQOL. On the other hand, since the occurrence of physical symptoms can cause a change in QOL  the symptom scales will be prominent predictors of GQOL.