Quality of Life and Its Psychosocial Determinants Among Cancer Patients: Insights from the Qassim Region, Saudi Arabia.

1. Introduction
Cancer remains a major public health challenge worldwide and encompasses a broad range of diseases with substantial physical, psychological, and social consequences. In 2022, an estimated 20 million new cancer cases were reported globally [1,2]. In Saudi Arabia, the cancer burden is expected to double over the next two decades due to population ageing and the increasing prevalence of risk factors [3]. In the Qassim region, cancer incidence showed an increasing trend over 2002–2016, consistent with the broader rise in cancer burden reported in Saudi Arabia [4]. This trend has been attributed to rapid urbanization, lifestyle changes, obesity, and improved diagnostic practices [2,5,6]. As survival rates continue to improve due to advances in early detection and therapy, more individuals are now living with cancer as a chronic condition, which highlights the need to assess and address patients’ quality of life (QoL) and psychosocial well-being [7,8].
Quality of life is often considered a dynamic, multidimensional construct, encompassing all physical, psychological, social, and spiritual domains that reflect a patient’s overall functioning and well-being [9,10]. It not only provides insight into symptom burden and treatment tolerance but also serves as an independent prognostic indicator for overall survival in cancer patients [11,12,13].
Numerous factors are associated with the QoL of patients with cancer. A systematic review of 58 papers from 15 developing nations reported that older age, married status, spirituality, and engagement in palliative care were associated with higher QoL, whereas lower education and depression were associated with lower QoL [14]. Similarly, a large meta-analysis involving 94 interview-based studies found that approximately one-third of cancer patients experience depression, anxiety, or adjustment disorder, significantly impacting QoL [15]. Recent Saudi studies also confirm the substantial psychological burden in oncology populations; in a tertiary-care study in Riyadh, 46% of patients reported moderate-to-severe distress symptoms [3]. Such findings underscore the urgent need for integrating psychosocial assessment and supportive care into oncology practice, consistent with the Multinational Association of Supportive Care in Cancer (MASCC)’s perspective on comprehensive supportive care [8].
Regardless of other demographic factors, adolescent and young adult (AYA) cancer survivors were more likely to report “worse” or impaired QoL compared to the general population [16]. Decision-making in oncology requires balancing longevity and QoL, as patient preferences for length of life (LoL) versus QoL can vary with age, social support, and baseline functioning [17].
Given these considerations and the paucity of data from the Qassim region, the present study aims to explore the sociodemographic and psychosocial determinants of QoL among cancer patients. This study aimed to (1) assess health-related QoL among cancer patients in the Qassim region using the EORTC QLQ-C30, and (2) identify sociodemographic, clinical, and psychological factors associated with poor global QoL. This work seeks to contribute regional evidence to inform holistic cancer care models in Saudi Arabia that integrate physical, emotional, and social dimensions of patient well-being.

2. Materials and Methods
A cross-sectional study was conducted at the Oncology Centre, Qassim, Saudi Arabia, between January and June 2024. The study targeted adult cancer patients attending the center for treatment or follow-up care. Ethical approval was obtained from the Regional Research Ethics Committee, Qassim Institutional Review Board (Approval No. 607-45-1325). The study was conducted in accordance with the Declaration of Helsinki and applicable national and institutional research guidelines.

2.1. Study Objective and Outcome Definition
The primary objective of this study was to identify sociodemographic, clinical, and psychological factors associated with poor global QoL among cancer patients. The primary outcome variable was global QoL, dichotomized as poor (≤60) or good (>60) based on the EORTC QLQ-C30 global health status scale. Independent variables were grouped a priori into three domains: (1) sociodemographic factors, (2) clinical and treatment-related factors, and (3) psychological distress variables (anxiety and depression), in accordance with a biopsychosocial framework of cancer-related quality of life.

2.2. Study Population and Sampling
The target population included adult patients (aged ≥18 years) with a confirmed diagnosis of cancer, who were either undergoing treatment or attending follow-up appointments at the Oncology Centre. Patients were eligible if they could understand Arabic and provided informed consent. Only participants who completed the questionnaire were included in the final analysis. Exclusion criteria included patients with cognitive impairment, severe psychiatric illness, or terminal medical instability that could preclude meaningful participation. A consecutive sampling approach was used to recruit eligible participants during the study period.
The required sample size was estimated a priori using Cochran’s formula for prevalence studies. Assuming a low-quality-of-life prevalence among cancer patients of 82%, a 95% confidence level, and a 5% margin of error, the sample size was calculated to be 227 participants. Over the study period, 233 eligible patients were identified, of whom 187 completed the questionnaire, corresponding to a response rate of 80.3%. Accordingly, the final analysis included 187 patients who completed the questionnaire during the study period.

2.3. Data Collection and Survey Instrument
Data were collected through face-to-face structured interviews conducted by trained research staff. The survey instrument consisted of four main sections: (1) sociodemographic and clinical characteristics, (2) QoL assessment, (3) depression and anxiety screening, and (4) beliefs and coping behaviors. Sociodemographic information included age, gender, marital status, education level, employment status, nationality, and region of residence. Clinical variables included cancer type and stage, time since diagnosis, treatment modality, psychiatric history, and use of alternative therapies.

2.4. Quality of Life Assessment
QoL was assessed using the validated Arabic version of the European Organization for Research and Treatment of Cancer (EORTC; Brussels, Belgium) Quality of Life Questionnaire-C30 (QLQ-C30) [3,18]. This widely used instrument evaluates multiple dimensions of QoL among cancer patients and has been validated in multiple populations, including Arabic-speaking cohorts. It comprises five functional subscales (physical, role, cognitive, emotional, and social functioning), one global health status/QoL scale, and nine symptom subscales (fatigue, pain, nausea and vomiting, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties). Most items are rated on a 4-point Likert scale (1 = not at all, 4 = very much), except for the global QoL scale, which uses a 7-point response format.
Raw scores were linearly transformed to a 0–100 scale, where 0 represents the minimum possible score, and 100 represents the maximum possible score, according to the EORTC scoring guidelines [19,20]. Higher scores on functional and global QoL scales indicate better functioning or well-being, whereas higher scores on symptom scales indicate greater symptom severity [19,20]. The EORTC QLQ-C30 consists of 30 items. QoL was categorized into “poor” (≤60) and “good” (>60) based on cutoffs from Derogar et al. [3,18,21].

2.5. Assessment of Psychological Distress
Depression and anxiety were evaluated using the Arabic-language versions of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively [22,23]. Both tools have been validated for use in Arabic-speaking populations and have demonstrated high internal consistency [24,25]. In the current sample, both psychological scales showed good internal consistency, with Cronbach’s α values of 0.841 for the PHQ-9 and 0.878 for the GAD-7. The PHQ-9 consists of nine items, each scored from 0 to 3. The total score ranges from 0 to 27, with higher scores indicating greater severity of depressive symptoms. A total score ≥ 10 was used to indicate clinically significant depression. In addition, the algorithmic criteria for major depressive disorder were applied: a score of “more than half the days” on either item 1 or 2, combined with at least four other symptoms and a response of “several days” or more on item 9.
The GAD-7 assesses anxiety severity using seven items, each scored from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 21, with higher scores indicating greater severity of anxiety symptoms. Scores were categorized as follows: 0–4 (none), 5–9 (mild), 10–14 (moderate), and 15–21 (severe). A score ≥ 10 was used as the threshold for clinically significant anxiety, consistent with the prior literature [22,23]. The PHQ-9 and GAD-7 were used in this study as screening measures of depressive and anxiety symptom severity and do not constitute formal diagnostic instruments.

2.6. Statistical Analysis
All statistical analyses were performed using IBM SPSS Statistics version 30 (IBM Corp., Armonk, NY, USA). Continuous variables were reported as means and standard deviations or medians and interquartile ranges, depending on their distribution. Categorical variables were summarized as frequencies and percentages. The Shapiro–Wilk test was used to assess normality for continuous variables. Associations between QoL categories and categorical variables (e.g., gender, marital status, cancer type) were analyzed using the chi-square test or Fisher’s exact test, as appropriate. Comparisons of non-normally distributed continuous variables between groups were performed using the Mann–Whitney U test. To identify factors associated with global QoL, multivariable binary logistic regression was conducted. The dependent variable was global QoL, coded as 0 = poor QoL and 1 = good QoL. The model included clinically relevant variables selected a priori according to the study objectives and the biopsychosocial framework, including sociodemographic, clinical, treatment-related, and psychological variables. PHQ-9 and GAD-7 scores were entered into the model as continuous variables. Model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test, Cox–Snell R2 and Nagelkerke R2, and multicollinearity was evaluated using variance inflation factors; no evidence of problematic multicollinearity was identified. Given the exploratory nature of the study and the large number of comparisons conducted, the results of univariate analyses should be interpreted cautiously. The primary inferential analysis was based on the multivariable logistic regression model. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p-value < 0.05 was considered statistically significant.

3. Results
A total of 233 cancer patients met the inclusion criteria, of whom 187 completed the questionnaire, corresponding to an 80.3% response rate. The median age of participants was 48 years (range, 18–94). The majority of participants were female (73.8%) and Saudi (84.5%), and most were married (81.3%). A significant portion had a high school education or lower (63.1%) and a monthly income of 10,000 SAR or less (67.4%). The median time since cancer diagnosis was 7 months (IQR: 4.00–14.25). The median anxiety score was 2 (IQR, 0–7) and the median depression score was 6 (IQR, 3–11). The mean global health status score was 73.8 (SD = 22.2). Most patients (n = 139; 74.3%) had good global QoL (score > 60), whereas 48 (25.7%) reported poor global QoL. No statistically significant associations were observed between sociodemographic factors and global QoL, although older participants and Saudi nationals tended to report better global QoL than their counterparts (see Table 1). The mean scores of physical functioning (p < 0.001), role functioning (p < 0.001), cognitive functioning (p < 0.001), and social functioning (p < 0.001) were significantly higher among patients with good global QoL. Conversely, symptom scales were significantly higher among patients with poor QoL, including fatigue (p < 0.001), nausea and vomiting (p = 0.005), pain (p < 0.001), dyspnea (p = 0.010), insomnia (p < 0.001), appetite loss (p = 0.022), constipation (p = 0.042), diarrhea (p = 0.008), and financial difficulties (p = 0.003) (see Table 2).
Table 3 summarizes participant clinical characteristics. Among 187 cancer patients, breast cancer was the most common (52.2%), followed by colorectal cancer (16.1%), gynecological cancer (8.3%), lymphoma (6.7%), and others (16.7%). Nearly one-half (48.7%) had an unknown cancer stage; Stage 2 (18.7%) and Stage 3 (12.8%) were the next most frequent. Chemotherapy history was reported by 84% of patients, and radiotherapy was reported by 28.9%. Most participants (92.0%) had no psychiatric history. The leading perceived cause of cancer was “evil eye or magic” (33.7%), and 56.7% used Islamic Ruqya as an alternative treatment. Regarding the association between clinical characteristics and global QoL, in the univariate analysis, hormonal therapy (p = 0.022) and psychiatric history were significantly associated with poor global QoL (visiting a psychiatrist, p = 0.011; diagnosed with a psychiatric disorder, p = 0.001; and taking psychiatric medication, p = 0.036). Moreover, other factors, such as cancer type, cancer stage, personal beliefs, and alternative treatments, were not significantly associated with global QoL. Furthermore, there were no significant differences in healthcare satisfaction or social support satisfaction between patients with poor global QoL and those with good global QoL. These univariate analyses were exploratory and were interpreted cautiously. The primary inferential analysis was based on the multivariable model that included clinically relevant variables selected a priori.
Using a cutoff score of ≥10 on the GAD-7, 12.8% (24/187) of participants were classified as having clinically significant anxiety. This was significantly associated with global QoL: anxiety was present in 33.3% of participants with poor global QoL, compared with 5.8% among those with good global QoL. Using a broader cutoff score of ≥5 on the GAD-7, mild to severe anxiety was observed in 34.2% (64/187) of participants, including 12.1% with moderate to severe anxiety. Among individuals with poor global QoL, 56.2% experienced anxiety (with 12.8% reporting moderate to severe anxiety). In contrast, 26.6% of patients with good QoL showed symptoms of anxiety (5.7% moderate to severe anxiety); see Table 4.
Depression, indicated by a PHQ-9 cutoff score of ≥10, was identified in 29.9% (56/187) of participants. This was significantly associated with global QoL: depression was present in 56.3% (27/48) of participants with poor global QoL, compared with 20.9% (29/139) of participants with good global QoL. Using the diagnostic algorithm approach (individuals who scored 2 or more “more than half the days” in Questions #1 or #2, plus four or more other questions, and a score of “several days” or more in Question #9 on the PHQ-9), 10.7% of participants were identified as having depression, which was also significantly associated with poor global QoL. Among participants with poor global QoL, 25.0% met the diagnostic algorithm criteria for depression, compared with 5.8% of those with good global QoL; see Table 4.
A multivariable logistic regression analysis was conducted to identify factors associated with global QoL among cancer patients. The dependent variable was coded as 0 = poor QoL and 1 = good QoL. The overall model demonstrated acceptable fit (Hosmer–Lemeshow χ2 = 2.613, df = 8, p = 0.956) and explained a moderate proportion of the variance in QoL (Cox–Snell R2 = 0.233; Nagelkerke R2 = 0.342). In the adjusted model, higher depression scores were significantly associated with lower odds of reporting good QoL (AOR = 0.85, 95% CI [0.77–0.95], p = 0.004). Anxiety score, age, sex, cancer type, treatment modalities, and psychiatrist visit were not statistically significant in the adjusted model (Table 5).
The cohort reported a mean global health status score of 73.8 (SD = 22.2). Among the five functional scales, cognitive functioning had the highest mean score (73.9, SD = 29.2), while role functioning had the lowest mean score (67.6, SD = 33.8). Regarding symptom burden, fatigue had the highest mean score (44.7, SD = 31.1), closely followed by insomnia (44.0, SD = 40.2). Conversely, the smallest mean scores were observed in diarrhea (16.9, SD = 27.1) and financial difficulties (18.0, SD = 32.8). In addition to the dichotomized global QoL outcome used in the regression analysis, the original continuous EORTC QLQ-C30 scores were also analyzed descriptively to provide a more comprehensive assessment of health-related quality of life (Table 6).
Analysis of the TCI thresholds for the functioning scales demonstrated that a substantial proportion of patients reported clinically relevant impairment across all domains. The percentage of patients scoring below the TCI cutoff (indicating a problem) ranged from 31.6% to 47.6%. Physical functioning (PF) was the most affected domain, with nearly one-half of the sample (47.6%, n = 89) scoring below the threshold (<83). This was followed by role functioning (RF) at 39.0% (n = 73) and emotional functioning (EF) at 34.8% (n = 65). The domains with the lowest reported impairment were social functioning (SF) (32.6%, n = 61) and cognitive functioning (CF; 31.6%, n = 59); see Table 7.
In analyzing symptom scale data using the Therapeutic Change Index (TCI) cutoff, which defines a clinically important problem, fatigue (FA) was the most prevalent issue, affecting 45.0% (n = 84) of cases (TCI cutoff > 39). Pain (PA) followed as the second most common problem, observed in 38.0% of cases (n = 71; TCI cutoff > 25). Other significant symptoms included sleep disturbances (SL) (32.6%, n = 61) and appetite loss (AP) (28.9%, n = 54), both with a TCI cutoff of >50. Symptoms like nausea and vomiting (NV) (25.7%, n = 48), constipation (CO) (25.1%, n = 47), and dyspnea (DY) (19.3%, n = 36) were also observed, while financial impact (FI) (17.6%, n = 33) and diarrhea (DI) (15.5%, n = 29) were the least prevalent; see Table 8.

4. Discussion
This study represents the first comprehensive assessment of health-related quality of life (HRQoL) among cancer patients in the Qassim region of Saudi Arabia, utilizing the validated Arabic version of EORTC QLQ-C30 [18,20]. Our findings establish a preliminary regional baseline and identify areas of clinical and research interest in this understudied population. The study was guided by a biopsychosocial framework, in which clinical disease factors, functional limitations, symptom burden, and psychological distress are considered relevant correlates of patients’ global QoL.
EORTC results can be interpreted by comparison with normative data, thresholds for clinical importance, minimal important differences, and the EORTC’s reference manual for pooled international cancer patient data [26,27,28,29,30]. Comparison with general population data reveals a picture of impaired function and greater symptom burden among cancer patients in Qassim. Across all functional scales, mean scores were consistently lower than established norms (e.g., physical functioning at 69.6 vs. a normative score of 85.1). Conversely, mean scores for all symptom scales were considerably higher, indicating substantial distress (e.g., fatigue 44.7 vs. normative 29.5; pain 36.4 vs. normative 23.5). The TCI offers a clinically meaningful estimate of the patient burden [27]. A large proportion of the Qassim cohort reported clinically significant problems across key functional and symptom scales. Specifically, 47.6% of patients scored below the TCI threshold for physical functioning (PF; <83), while 45.0% and 38.0% scored above the TCI threshold for fatigue (FA; >39) and pain (PA; >25), respectively. A recent global meta-analysis has placed the prevalence of pain after cancer treatment near 39% [31].
Compared to the international pooled cancer patient reference values, the Qassim cohort’s mean global QoL score of 73.8 (SD 22.2) was higher (better) than the international reference of 61.3 [30], yet accompanied by lower functional status—particularly in physical functioning (69.6 vs. 76.7), cognitive functioning (73.9 vs. 82.6), and social functioning (72.8 vs. 75.0)—and substantially greater symptom burden in fatigue (44.7 vs. 34.6), pain (36.4 vs. 27.0), insomnia (44.0 vs. 28.9), and appetite loss (33.0 vs. 21.1) [27]. This finding—where global QoL status is maintained despite specific symptom reports—is reported in QoL research and may indicate response shift, a concept in which patients change their internal standards for QoL after diagnosis and surviving severe negative experiences, or may reflect strong family and social support systems [32]. An intra-country comparison with a Riyadh cohort [3] revealed a similar proportion of patients reporting good global QoL (Qassim: 74.33% vs. Riyadh: 73.2%, using the same cutoff of global QoL score ≤ 60), but the Qassim group demonstrated lower functional status (physical functioning: 69.6 vs. 80.6; role functioning: 67.6 vs. 83.1; cognitive functioning: 73.9 vs. 82.9; social functioning: 72.8 vs. 81.2) and greater symptom severity (fatigue: 44.7 vs. 36.9; pain: 36.4 vs. 27.5). Both studies were limited by a high proportion of unknown disease stage (Qassim: 48.7%; Riyadh: 51.4%), necessitating a focus on the overall case mix for comparison. The high proportion of patients with unknown cancer stage is an important limitation, as illness severity affects QoL—for example, inpatients were reported to have lower scores (68.6) than outpatients (72.3), highlighting the impact of patient acuity [7].
Our results suggest an association between psychological distress and global QoL. Anxiety was present in 12–34% of participants and depression in 10–29%, depending on scoring criteria; both were associated with lower global QoL in the unadjusted analyses. Additionally, a psychiatric history, particularly psychiatrist visits, was associated with poorer global QoL in the unadjusted analysis. In multivariable analysis, however, the depression score was the only variable independently associated with QoL, whereas the anxiety score, psychiatrist visit, and selected clinical factors were not statistically significant after adjustment. Another study, which was done in Riyadh, Saudi Arabia, reported a 21.7% and 29% anxiety and depression prevalence, respectively, using the same cutoff score used in this study [3]. This variation in prevalence may be related to differences in study timing, geographic location, lower functional status, higher symptom burden, cancer type, and sample characteristics. A systematic review and meta-analysis conducted in February 2025 revealed that the global prevalence of depression and anxiety in cancer patients was 33.16% (95% CI = 27.59–38.74) and 30.55% (95% CI = 24.04–37.06) [31]. The observed associations between QoL and symptoms of anxiety and depression are supported in the literature. For example, a longitudinal study from Greece showed that psychological distress symptoms, including depression and anxiety, were significantly associated with lower HRQoL among early non-metastatic colorectal cancer patients [33]. Moreover, a local study showed that depression, anxiety, and distress were significantly associated with poor global QoL [3].
Patients’ beliefs about cancer etiology and treatment were comparable between this study and the Riyadh cohort [3]. “Evil eye or magic” was the most common perceived cause in Qassim (33.7%) and Riyadh (28.6%), and Islamic Ruqya was used as an alternative treatment by 56.7% and 48.6% of patients, respectively [3]. While these beliefs did not demonstrate a statistically significant association with global QoL in this study, their high prevalence highlights the cultural and spiritual framework through which patients in Qassim understand and cope with their illness.
These findings have important implications for policy and practice. They support the incorporation of routine HRQoL and psychological distress screening into oncology care and highlight the need for multidisciplinary supportive services that address symptom burden, psychological well-being, and functional limitations. They also support a biopsychosocial understanding of cancer care, in which QoL is shaped by interacting clinical, psychological, and functional factors.
The primary strength of this study is its originality, as it is the first to focus on HRQoL in Qassim and to use validated, Arabic-translated instruments (EORTC QLQ-C30, GAD-7, PHQ-9). Nevertheless, the study has certain limitations. The cross-sectional design precludes the determination of causal relationships. Furthermore, the single-center recruitment may limit the generalizability of findings beyond the Qassim Health Cluster. Also, a large proportion of participants had an unknown cancer stage (48.7%), which limited the assessment of the relationship between disease stage and HRQoL and may have influenced the interpretation of the findings. Moreover, only 15 participants reported a previous diagnosis of a psychiatric disorder or psychotropic treatment. This low number likely stems from the core question, “Have you ever visited a psychiatrist?”, which may have led participants to omit subsequent related questions if they answered negatively. Furthermore, the question’s phrasing may not have captured instances in which a psychiatrist saw a patient during an inpatient consultation. This design is problematic because non-psychiatrist clinicians (e.g., family medicine physicians) often provide psychiatric diagnosis and intervention. Future research should use broader instruments to capture psychiatric history more comprehensively.

5. Conclusions
This study found that overall QoL was relatively preserved despite a significant burden from severe physical symptoms (fatigue and pain) and impaired functional status in Qassim. Psychological distress, including anxiety and depression, was common and associated with poorer QoL. These findings support a biopsychosocial approach to cancer care. We recommend integrating mental health screening and multidisciplinary supportive care protocols into oncology care to address psychological distress, symptom burden, and functional limitations and improve patient well-being. Future longitudinal studies are needed to clarify temporal relationships.