RESEARCH Open Access
Employmen s a us and heal h ela ed
quali y o li e among Hodgkin-lymphoma
su i o s’– esul s based on da a om a
majo ea men cen e in Hunga y
Fe enc Magya i
1*
, Ka olina Kósa
2
, Roland Be ecz
3
, Anna Illés
4
, Zsó ia Mil ényi
1
, Zsó ia Simon
1
and Á pád Illés
1
Abs ac
Backg ound: Due o isk and esponse adap ed ea men s a egies, mo e han 80% o newly diagnosed classical
Hodgkin lymphoma (HL) pa ien s can be cu ed, and become long- e m su i o s. Howe e , a high p opo ion o
su i o s su e om ea men - ela ed long- e m side e ec s such as seconda y malignancy, o gan ailu e,
pe sis en a igue and psychological dis ess. The aim o his s udy was o e alua e psychological dis ess and i s
isk ac o s among ou HL su i o s.
Me hods: One hund ed six y- h ee (50% emale) adul HL su i o s we e con ac ed be ween Janua y 1, 2012
and ma ch 31, 2015 in ou ou pa ien cen e. The pa ien s we e asked o comple e a s anda dized, alida ed,
sel -adminis e ed Hunga ian ques ionnai e wi h demog aphic ques ions and he ollowing scales: Hospi al anxie y
and dep ession scale (HADS14), gene al heal h ques ionnai e (GHQ12), sense o cohe ence (SOC13) pe cei ed s ess
scale (PSS4), dys unc ional a i ude scale (DAS17). Disease and ea men da a we e acqui ed om hospi al eco ds.
Resul s: Majo i y o HL su i o s a e in ea ly adul hood, ou mos impo an goal should be o e u n hem o
no mal li e a e hei lymphoma is cu ed. The employmen s a us a he ime o su ey seemed o be c ucial
so pa ien s we e di ided in o ei he ac i e (n= 93) o inac i e (n= 47) g oup. Re i ed su i o s (n= 19) we e
excluded om he subg oup analysis. Psychological dis ess was signi ican ly lowe in ac i e pa ien s. Mul iple
logis ic eg ession analysis showed signi ican di e ences be ween he inac i e and ac i e subg oups, such as age
a diagnosis (≥30 yea s o below, p= 0.001), educa ion le el (below college s. college, p= 0.032) and ea men
ela ed long- e m side e ec s (yes s. no, p< 0.001). P edic o s o ea men - ela ed long- e m side e ec s a e
emale gende (p= 0.011), chemo he apy p o ocol (ABVD s. o he , p< 0.001).
Conclusions: Ou da a sugges ha employmen s a us and ea men - ela ed long- e m side e ec s play a c i ical
ole in he heal h ela ed quali y o li e ou come among Hunga ian HL su i o s.
Keywo ds: Hodgkin-lymphoma, Employmen , HRQoL, Su i o ship, Long- e m side e ec s
* Co espondence: [email p o ec ed]
1
Depa men o Hema ology, Facul y o Medicine, Uni e si y o Deb ecen,
Deb ecen, Hunga y
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Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180
DOI 10.1186/s12955-017-0758-x
Backg ound
Due o isk and esponse adap ed ea men s a egies,
mo e han 80% o newly diagnosed Hodgkin lymphoma
(HL) pa ien s a any s age can be cu ed, and a e ex-
pec ed o be long- e m su i o s [1–3]. The majo i y o
HL pa ien s a e in ea ly adul hood (median age abou
30 yea s), so he quali y o li e a e ea men closu e is
o undamen al impo ance. Lymphoma su i o s a e
li e longe , and consequen ly a e a isk o expe iencing
ad e se psychical and psychosocial side e ec s o lon-
ge pe iods o ime due o hei disease and i s ea -
men [4]. T ea men ela ed long- e m side e ec s such
as seconda y malignancy, o o gan ailu e educes he
quali y o li e and li e expec ancy o su i o s. The e is
a g owing numbe o p omising s udies ocused on su -
i al ela ed issues in o me HL pa ien s, mainly add ess-
ing o e all heal h- ela ed quali y o li e (HRQoL) [5].
HRQoL as a mul idimensional cons uc is based on he
Wo ld Heal h O ganiza ion’s de ini ion o heal h inco p-
o a ing physical, men al, and social aspec s o heal h [6].
HRQoL may be impai ed due o ea men -induced o -
ganic dys unc ions, psychological consequences, a igue,
pe sis ing gonadal and cogni i e dys unc ion, di icul ies
in social and ole unc ioning in HL su i o s. HRQoL is
de e mined based on pa ien epo ed ou comes [7]. The
pu pose o ou s udy was o e alua e he equency o psy-
chological dis ess and i s isk ac o s among HL su i o s
based on ou single cen e expe ience.
Me hods
Subjec s and da a collec ion
A c oss-sec ional su ey was conduc ed a he Depa men
o Hema ology o he Uni e si y o Deb ecen. We
designed he s udy o app oxima ely 150 om he 301
egula ly ollowed up pa ien s. Exclusion c i e ia we e
ageunde 18yea sa he imeo su eyandalacko
signed in o med consen . 170 pa ien s we e asked o
pa icipa e in ou s udy. The e usal a e was below 5%.
Al oge he , 163 adul HL su i o s we e iden i ied be-
ween Janua y 1, 2012 and Ma ch 31, 2015 in ou ou -
pa ien clinic whose diagnosis o HL was es ablished
be ween Janua y 1, 1969 and July 1, 2013. Diseases diag-
nosed be o e he ini ia ion o HL ea men we e de ined
as como bidi ies, whe eas ea men ela ed side e ec s
we e de ined as condi ions diagnosed in he ollow-up
phase a e HL ea men based on hospi al eco ds o he
pa ien s.
T ea men p o ocols
P ima y chemo he apy basically in ol ed CV(O)PP (cyclo-
phosphamide, inblas ine [ inc is ine], p oca bazine and
p ednisolone) be o e. A e 1990, COPP/ABV (cyclophos-
phamide, inc is ine, p oca bazine, p ednisolone/ad iamy-
cin, bleomycin and inblas ine) was used. Since 1999, he
ABVD (ad iamycin, bleomycin, inblas ine and daca ba-
zine) p o ocol has been mos equen ly applied. In cases
o elapse, ea men in ol ed BEACOPP (bleomycin,
e oposid, ad iamycin, cyclophosphamide, inc is in, p o-
ca bazine and p ednisolone), DHAP (dexame hasone,
cy a abine and cispla in), o CEP (CCNU, e oposide,
chlo ambucil and p ednisolone) egimens. Radio he apy
o he in ol ed o ex ended ield, man le, in e sed Y o
(sub) o al nodal ype was adminis e ed by a elecobal
de ice be o e 2000 and mo e ecen ly by a linea accele -
a o . Ex ended and in ol ed ield adio he apy we e used
be o e (mean dose, 40 Gy) and a e 1998 (mean dose,
33 Gy), espec i ely (Table 1).
Ques ionnai es
HL su i o s we e asked o comple e a s anda dized,
sel -adminis e ed and alida ed Hunga ian ques ion-
nai e, which included i ems on socio-demog aphic s a-
us (place o esidence, ma i al s a us, educa ional le el,
employmen , impo an li e e en s a e lymphoma
ea men ) and psychia ic ea men (da e and ype o
medica ion)a he imeo diagnosis,aswellas he
scales lis ed below. Da a on he disease and i s ea -
men we e based on hospi al eco ds.
The Hunga ian e sion o he Hospi al Anxie y and
Dep ession scale (HADS-14) has been used in s udies
o dis ess among cance pa ien s in gene al. Each o
he 14 i ems is sco ed on a 4-poin scale (0–3). Sum
sco es o he anxie y and dep ession subscales a e cal-
cula ed by simple addi ion. The cons uc o s o HADS
ecommended wo possible cu -o s (8 o highe o 11
o highe on ei he scale) o case de ini ion. In his
s udy, caseness e e s o he lowe cu -o [8, 9]. Due o
p in ing e o i em 10 in he HADS ques ionnai e was
missing answe 2 and 3.
The Gene al Heal h Ques ionnai e (GHQ-12) is he
mos ex ensi ely used sc eening ins umen o common
Table 1 The ea men p o ocols based on he s age o disease
T ea men Numbe o pa ien s
S age I. S age II. S age III. S age IV. All
ABVD/EBVD + RT 3 52 9 8 72 (51.5%)
ABVD/EBVD –RT 0 5 9 9 23 (16.5%)
COPP/ABVD + RT 1 3 12 0 16 (11%)
COPP/ABVD –RT 0 0 5 2 7 (5%)
CVPP + RT 1 6 4 1 12 (9%)
CVPP –RT 1 0 2 0 3 (2%)
O he 1 2 4 0 7 (5%)
A(E)BVD: ad iamycin (epi ubicin), bleomycin, inblas ine and daca bazine;
CV(O)PP: cyclophosphamide, inblas ine [ inc is ine], p oca bazine and
p ednisolone; COPP/ABV: cyclophosphamide, inc is ine, p oca bazine,
p ednisolone/ad iamycin, bleomycin and inblas ine; O he p o ocols include
MOPP: mus a gen, inc is ine, p oca bazin, p ednisolone, OEPA: inc is ine,
e oposide, p ednisone, and doxo ubicin
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 2 o 9
men al diso de s, in addi ion o being a gene al measu e
o psychia ic well-being. Each i em is sco ed on a 4-poin
scale (co esponding o a symp om p esen : ‘no a all’,
‘same as usual’,‘ a he mo e han usual, o ‘much mo e
han usual’). I can be sco ed in a bimodal ashion (0–0–
1-1), when inal sco es ange om 0 o 12. Acco ding o
his me hod, pa ien s sco ing 5 o mo e a e conside ed: a
isk o anxie y/dep ession [10].
The alida ed Hunga ian e sion o he abb e ia ed
sense o cohe ence (SOC-13) scale was used in he
p esen su ey o measu e he o e all capaci y o cope
wi h s ess ul si ua ions. All 13 i ems a e answe able on
a Like scale om 1 o 7, o al sco es a y be ween 13
and 91. A highe sco e indica es s onge SOC [10].
The Pe cei ed S ess Scale (PSS) is he mos widely
used psychological ins umen o measu ing pe cep ion
o s ess. Sco es o he 4-i em o m ange om 0 o 16.
Po en ial esponses ange om 0 (ne e ) o 4 ( e y o en)
and posi i ely s a ed i ems a e e e se coded be o e i ems
a esummedupwi hhighe sco esindica ingmo epe -
cei ed s ess [11].
The Dys unc ional A i ude Scale o m A (DAS-A)
is designed o measu e he p esence and in ensi y o
dys unc ional a i udes. The highe he sco e, he mo e
dys unc ional a i udes a e cha ac e is ic o an indi id-
ual. The 17 i ems a e di ided in o wo subscales: pe -
ec ionism and dependency. Each i em is sco ed on a
Like scale om 1 o 7. Sum sco es o ei he subscale
a e calcula ed by simple addi ion [12].
S a is ical analysis
S a is ical analysis was pe o med using IBM SPSS 20 so -
wa e. Da a a e desc ibed by he mean, s anda d de ia ion
equencies and pe cen ages. Ca ego ical a iables we e
compa ed be ween g oups using chi-squa ed o Fishe ’s
exac es , as app op ia e. Con inuous a iables we e e al-
ua ed by independen samples - es , Mann-Whi ney es
and ANOVA o K uskal-Wallis es . Spea man’sco ela-
ions we e used measu ing he ela ionship be ween wo
a iables. Signi icance le el was se a p<0.05.Mul iple
logis ic eg ession (backwa d Likelihood Ra io me hod)
was pe o med among HL su i o s o iden i y p edic o s
o employmen s a us Odds a ios (OR) wi h 95% con i-
dence in e als we e es ima ed o he logis ic eg ession
models [13].
Resul s
Pa ien cha ac e is ics
A o al o 163 adul HL su i o s comple ed he su ey.
19 pe sons we e beyond e i emen age o 65 yea s and
4 pe sons had unknown employmen s a us who he e-
o e we e excluded om he subg oup analysis. Da a o
140 HL su i o s (71 emales, 51%) o wo king age we e
in es iga ed and he cha ac e is ics o su i o s a e
p esen ed in Tables 1 and 2. The mean ages o su i-
o s a he ime o diagnosis we e 32.13 ± 13.05 yea s
and a comple ion o he su ey 44.82 ± 14.55 yea s.
57 su i o s (41%) had mixed cell HL, which was he
mos equen his ological sub ype. 73 pa ien s (53%) had
s age I-II and 65 pa ien s (47%) s age III-IV HL. 68
su i o s (49%) had baseline como bidi y (mos common:
ca dio ascula disease 11%, gas oen e ological 10%, de -
ma ological 5%, musculoskele al 5% and haema ological
2% o pa ien s). 95 pa ien s (69%) had ecei ed ABVD
ea men , while 43 pa ien s (31%) had ecei ed some
o he ype o chemo he apy. Radia ion had been adminis-
e ed o 103 pa ien s (74%).
The mos common ea men ela ed long- e m side
e ec s we e examined in ac i e s. inac i e g oups:
ca dio ascula disease 9 (10%) s. 12 (25%) pa ien s
(p= 0.026), pulmona y disease 7 (8%) s. 6 (12%) pa-
ien s, hy oid disease 23 (25%) s. 17 (36%) pa ien s
and pos -i adia ion skin diso de 4 (4%) s. 4 (8%)
pa ien s, espec i ely.
Employmen s a us
The majo i y o HL su i o s had been in ea ly adul -
hood a he ime o diagnosis. Hence, he mos impo -
an goal o hem is o e u n o no mal li e including
wo k a e hei lymphoma is cu ed. Employmen a he
ime o he su ey was de ined as c ucial ac o o no -
mal li e so he su i o s we e spli in o wo subg oups
based on employmen s a us: ac i e (93 pa ien s) and
inac i e (47 pa ien s, see Fig. 1). Age a diagnosis o HL
(p< 0.001), comple ion o he su ey (p < 0.001), edu-
ca ional le el (p= 0.017) and ea men - ela ed long-
e m side e ec s (p< 0.001) we e signi ican ly di e en
be ween he inac i e and ac i e subg oups as shown in
Table 2. Employed su i o s we e on a e age 10 yea s
younge a he ime o he su ey, hey had hei diag-
nosis 7.5 yea s ea lie , almos wice as many o he had
college deg ees, and hal o hem had ea men ela ed
long- e m side e ec s compa ed o he inac i e g oup.
Odds a ios and 95% CI o inac i e e sus ac i e em-
ploymen s a us by HL su i o s’clinical da a a e p e-
sen ed in Fig. 2.
Men al heal h o su i o s
Thi y- ou su i o s (25%) had caseness sco es wi h
HADS anxie y and 14 (10%) wi h HADS dep ession.
Howe e , means o HADS anxie y and dep ession, pe -
cei ed s ess (PSS), s ess-dep ession-anxie y (DAS o al)
and pe ec ion as a dys unc ional a i ude (DAS pe ec-
ion) we e ound o be signi ican ly highe among in-
ac i e HL su i o s. 14 (10%) o HL su i o s had
abno mal le els o dis ess wi h GHQ, bu 5 imes mo e
o hem we e inac i e compa ed o he ac i e ones. In
e ms o sense o cohe ence as a measu e o gene alised
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 3 o 9
coping esou ces, ac i e su i o s had signi ican ly highe
mean sco e. Wi h he excep ion o dependency, as a dys-
unc ional a i ude, all o he measu es e lec ed conside -
ably less a ou able men al heal h among hose who had
been inac i e. The esul s o men al heal h ques ionnai es
a e shown in Table 3.
We de ined se e e men al ulne abili y as ha ing ab-
no mal sco es on a leas 3 es s acco ding o which
15 su i o s (7 inac i e, 5 ac i e, 3 pensione s) we e
iden i ied as in u gen need o ca e. 2/3 o hem (10
su i o s) we e e e ed o specialis (clinical psych-
ologis /psychia is ). 5 pe sons e e ed o he eam
Table 2 Cha ac e is ics o su i o s o wo king age and independen a iables o employmen by he esul s o mul iple logis ic
eg ession analysis
All
pa ien s
(n= 140)
Inac i e
employmen
s a us
(n = 47)
Ac i e
employmen
s a us
(n = 93)
Uni a ia e analysis Mul iple analysis
pODDS 95% CI pODDS 95% CI
Age a su ey > = 40 y . 76 (54%) 15 (32%) 61 (66%) <0.001 4.357 2.038–9.316
s. <40 y . 64 (46%) 32 (68%) 32 (34%)
Age a dg. > = 30 y . 80 (57%) 16 (34%) 64 (69%) <0.001 4.276 2.028–9.016 0.001 3.556 1.548–8.168
s. <30 y . 60 (43%) 31 (66%) 29 (31%)
Elapsed ime > =10 y . 66 (47%) 24 (51%) 42 (45%) 0.436 1.325 0.652–2.689
s. <10 y . 74 (53%) 23 (49%) 51 (55%)
Male 69 (49%) 23 (49%) 46 (49%) 0.953 0.979 0.485–1.975
s. emale 71 (51%) 24 (51%) 47 (51%)
Residence: illage 32 (23%) 12 (26%) 20 (22%) 0.592 1.252 0.507–2.062
s. ci y 108 (77%) 35 (74%) 73 (78%)
Educa ion le el:
elemen a y 50 (36%) 24 (53%) 26 (28%) 0.014 3.346 1.282–8.734 0.032 3.320 1.112–9.914
s. college 37 (27%) 14 (30%) 38 (41%)
elemen a y 0.568 1.336 0.494–3.609 0.235 1.967 0.644–6.007
s. high school 52 (37%) 8 (17%) 29 (31%)
Single 68 (50%) 23 (52%) 45 (49%) 0.714 1.144 0.557–2.347
s. li e oge he 68 (50%) 21 (48%) 47 (51%)
S age 3–4 73 (53%) 24 (52%) 41 (45%) 0.399 1.357 0.668–2762
s. 1–2 65 (47%) 22 (48%) 51 (55%)
Bulk 42 (32%) 11 (27%) 31 (34%) 0.409 0.710 0.314–1.605
s. wi hou bulk 90 (68%) 30 (73%) 60 (66%)
B symp om 61 (46%) 20 (49%) 41 (44%) 0.691 1.161 0.555–2.433
s. no B symp om 71 (54%) 21 (51%) 50 (56%)
ECOG 1–2 22 (17%) 8 (20%) 14 (16%) 0.593 1.299 0.497–3.390
s. ECOG 0 108 (83%) 33 (80%) 75 (84%)
Como bidi y 68 (49%) 25 (53%) 43 (44%) 0.437 1.321 0.654–2.667
s. no como bidi y 72 (51%) 22 (47%) 50 (56%)
T ea men : ABVD 43 (31%) 16 (34%) 27 (30%) 0.599 1.224 0.576–2.597
s. o he 95 (69%) 31 (66%) 64 (70%)
I adia ion 103 (74%) 35 (74%) 68 (73%) 0.864 1.072 0.482–2.387
s. no i adia ion 37 (26%) 12 (26%) 25 (27%)
T ea men esponse: PR 72 (51%) 4 (9%) 5 (5%) 0.484 1.637 0.418–6.409
s. SD 68 (49%) 43 (81%) 88 (95%)
T ea men ela ed side e ec : yes 72 (51%) 36 (77%) 36 (39%) <0.001 5.182 2.343–11.460 <0.001 5.254 2.196–12.524
s. no 68 (49%) 11 (23%) 57 (61%)
Relapse 21 (15%) 7 (15%) 14 (15%) 0.980 0.983 0.369–2.641
s. no elapse 119 (85%) 40 (85%) 79 (85%)
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 4 o 9
Fig. 1 Su i o s’employmen s a us a comple ion o su ey (o ganog am)
Fig. 2 ORs and 95% CI o inac i e s. ac i e employmen s a us by clinical da a in HL su i o s o wo king age. The analysis was pe o med by
bina y logis ic eg ession. Values unde 1 a e ela ed o he ac i e employmen s a us, abo e 1 o inac i e employmen s a us
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 5 o 9

psychologis . Subsequen ly, 3 o he 7 inac i e pa ien s
e u ned o wo k.
Independen p edic i e ac o s o employmen s a us
Mul iple logis ic eg ession analysis was ca ied ou by
s a ing wi h all po en ial de e minan a iables and
elimina ing he non-signi ican ones. Signi ican di e -
ences be ween inac i e and ac i e g oups we e ound
ega ding (being a leas o o e ≥30 yea s. below) a
diagnosis (p= 0.001), educa ion le el (elemen a y
school o abo e s. college, p= 0.032) and ea men
ela ed long- e m side e ec s (yes s. no, p< 0.001;
Table 2).
P edic i e ac o s o ea men ela ed long- e m side
e ec s
P edic i e ac o s o ea men ela ed long- e m side
e ec s a e p esen ed in Table 4. Females had a highe
a e o ea men - ela ed long- e m side e ec s com-
pa ed o males (p= 0.011), hose on ABVD egimen
su e ed mo e side e ec s compa ed o hose who had
ecei ed o he egimens (p< 0.001). Relapse a e
(p= 0.003) and baseline como bidi ies (p< 0.001) we e
signi ican ly highe among emale su i o s (71 pa ien s)
(no shown). Independen a iables o ea men - ela ed
long- e m side e ec s a e emale gende (OR: 2.67 (95%
CI 1.327–5.375); p= 0.006) and o he egimens han
ABVD (OR: 6.17 (95% CI 2.788–13.655); p<0.001).
Loss o wo k a e HL ea men
The e we e 13 su i o s in he ac i e g oup, who los
hei wo k a e ea men bu la e ound new jobs. 20
su i o s became inac i e due o job loss in he inac i e
g oup o whom 17 pe sons as opposed o only 5 o he
13 in he ac i e g oup had ea men - ela ed long- e m
Table 3 Quali y o Li e ques ionnai es o su i o s
All pa ien s (n= 140) Inac i e(I) (n= 47) Ac i e(A) (n= 93) P (I-A)
Mean ± SD
HADS anxie y 5.46 ± 3.54 6.69 ± 3.64 4.87 ± 3.35 0.004
HADS dep ession 3.05 ± 3.19 4.87 ± 3.84 2.17 ± 2.38 <0.001
PSS 4.55 ± 2.80 5.93 ± 2.83 3.87 ± 2.53 <0.001
SOC 66.90 ± 11.26 62.55 ± 69.03 69.03 ± 10.51 0.002
DAS o al 49.35 ± 18.94 54.79 ± 22.01 46.80 ± 16.86 0.022
DAS pe ec ion 28.41 ± 12.61 31.98 ± 14.94 26.74 ± 11.07 0.024
DAS dependency 20.94 ± 8.01 22.81 ± 8.35 20.07 ± 7.74 0.063
Numbe o pa ien s (%)
HADS anxie y
no mal sco e: 0–7104 (75%) 26 (57%) 78 (84%) 0.004
bo de line: 8–11 21 (15%) 12 (27%) 9 (10%)
abno mal: 11–21 13 (10%) 7 (16%) 6 (6%)
HADS dep ession
no mal sco e: 0–7124 (90%) 35 (78%) 89 (96%) 0.005
bo de line: 8–10 8 (6%) 6 (13%) 2 (2%)
abno mal: 11–21 6 (4%) 4 (9%) 2 (2%)
GHQ
no mal sco e: 0–4124 (90%) 35 (78%) 89 (96%) 0.002
abno mal: ≥514 (10%) 10 (22%) 4 (4%)
HADS Hospi al Anxie y and Dep ession scale, GHQ Gene al Heal h Ques ionnai e, PSS Pe cei ed S ess, Scale, SOC Sense o Cohe ence Scale, DAS Dys unc ional
A i ude Scale
Table 4 P edic o s o ea men ela ed long- e m side e ec s
T ea men ela ed
long- e m side
e ec s
No ea men
ela ed long- e m
side e ec s
P
Gende
Male (n= 69) 28 (41%) 41 (59%) 0.011
Female (n= 71) 44 (62%) 27 (38%)
Chemo he apy
A(E)BVD (n= 95) 38 (40%) 57 (60%) <0.001
O he han ABVD
(n= 43)
33 (77%) 10 (23%)
A(E)BVD: ad iamycin, (epi ubicin), bleomycin, inblas ine and daca bazine;
O he han ABVD: CV(O)PP:cyclophosphamide, inblas ine [ inc is ine],
p oca bazine and p ednisolone; COPP/ABV:cyclophosphamide, inc is ine,
p oca bazine, p ednisolone/ad iamycin, bleomycin and inblas ine
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 6 o 9
side e ec s (p= 0.009). These esul s a e p esen ed in
Fig. 3.
Discussion
The cu e o Hodgkin lymphoma is one o he success s o -
ies o cance medicine in he wen ie h cen u y. This e-
sul ed in a con inuously g owing numbe o HL su i o s
a isk o long- e m sequel and quali y impai men in
hei li es. The majo i y o HL su i o s ha e been in ea ly
adul hood so hei mos impo an goal is o e u n o
no mal li e once hei disease is cu ed [7]. Wo k is a c i -
ical aspec o no mal li e so ou s udy in es iga ed long-
e m HL su i o s by hei employmen s a us, excluding
hose o e e i emen age (65 yea s).
Two- hi d o ou su i o s was ac i e a he comple ion
o he su ey. They had been signi ican ly younge a he
ime o HL diagnosis as well as a he comple ion o he
su ey; hey had highe educa ional le el, and less
ea men - ela ed long- e m side e ec s compa ed o in-
ac i e su i o s. Nei he gende , no cha ac e is ics o he
disease a he ime o diagnosis we e ound o be di e en
be ween he ac i e and inac i e g oups. HL su i o s’em-
ploymen s a us a ies om 71% o 85% [14–17]; ou da a
a e close o he lowe end o his ange. Hunga ian HL
su i o s ha e o he op ions ega ding wo k a e ea -
men . 25% o all pa icipan s became disabili y pensione s
ha p o ide a s eady albei low income, a de ini i e
ad an age compa ed o employmen o some pa ien s.
Unemploymen a e in he adul popula ion o he coun y
acco ding o da a o he Hunga ian Cen al S a is ical
O ice (a ailable a : h ps://www.ksh.hu/) was 7.2% in he
No h-eas e n egion o Hunga y ( o 2012 o 2015,
among 40–49 age g oup, bo h gende ), almos 1.5 imes
highe han in ou s udy popula ion (5%). In con as , he
a io o inac i e pe sons was 1.5 imes highe among HL
su i o s (21% s. 14.5%). (Bo h g oups a e o wo king
age, bu unemployed pe sons sea ch o wo k and egis-
e ed as such, inac i e pe sons do no sea ch o wo k.)
In ligh o he ac ha he p opo ion o disabled HL
su i o s a ies om 9% in Sweden [17] o 19% in
Denma k [18], mo e e o needs o be pu in o helping
Hunga ian pa ien s ind hei way back o wo k. Employ-
men s a us, he men al heal h o long- e m su i o s o
cance (lymphoma) should also be a ocus o esea ch.
Ou s udy used a ious ools o in es iga e he men al
s a us o HL su i o s; a s ong co ela ion was obse ed
be ween employmen s a us and psychological well-
being. Ac i e (wo king) su i o s we e signi ican ly less
dep essed, less anxious, less pe ec ionis han hei
inac i e pee s; hey p o ed o be much mo e esilien as
e lec ed by hei sense o cohe ence; and co espond-
ingly, only one- i h o hem we e pa hologically dis-
essed compa ed o he inac i e ones.
The majo i y o cu ed HL pa ien s su i e wi hou psy-
chological dis ess a case le el wi h HADS ques ionnai e
[19]. P e ious s udies o anxie y and dep ession in lymph-
oma pa ien s using HADS obse ed p e alence o anxie y
be ween 15 and 42%, and dep ession be ween 4 and 35%
[20]. The p e alence o anxie y and dep ession we e 25%
and 10% using HADS in ou s udy popula ion, well wi hin
he ange o o he s udies. So a he e ha e been ew
published da a wi h GHQ o haema ological diso de s.
B oe s e al. epo ed esul s o pa ien s 3 yea s a e bone
ma ow ansplan among whom 13% showed men al
s ess by he GHQ, a pe cen age compa able o ha in he
gene al popula ion [21]. Ha ila e al. [22] ound no di e -
ence in GHQ sco es be ween long- e m ALL su i o s
and con ols. Ou expe ience e ealed ha 10% o HL
su i o s had abno mal le els o dis ess wi h GHQ, wi h
a much lowe p opo ion among wo king su i o s. Ou
indings wi h he SOC ques ionnai e a e simila o hose
o We e g en e al. [23] who ound a mean o SOC
(66.8 ± 11.2) in he Swedish popula ion ha was almos
iden ical o he mean o ou pa ien s. The e a e no li e a-
u e da a wi h DAS and PSS scales in haema ological
diso de s.
Fig. 3 Loss o wo k a e lymphoma ea men by pa ien epo s
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 7 o 9
Fi e p e ious s udies wi h clinical da a ( ou o hem
ques ionnai e-based) in es iga ed employmen speci ic-
ally in HL su i o s. Fobai e al. epo ed in 1986 ha
male gende , dep ession, age a o o e 30 yea s, ene gy
loss, and cu en disease s a us co ela ed wi h he num-
be o hou s wo ked. Nei he s age no ea men ype
p edic ed ime o e u n wo k [14]. Ab ahamsen pub-
lished da a in 1998on HL su i o s’employmen s a us
acco ding o which 95% o 557 pa ien s ea ed be-
ween1971–1991 had e u ned o wo k a e 18 mon hs.
Female p edominance was obse ed among unemployed
su i o s du ing he ollow-up pe iod (64% o women
and 85% o men wo ked a e 18 mon hs o he s a o
ea men ) [24]. Chen e al. epo ed ha male gende
and sca ing o he head and neck we e isk ac o s o
ha ing been denied a job due o medical his o y [15].
Glimelius e al. highligh ed in 2015 ha ad anced s age
HL su i o s ea ed wi h ull-dose chemo he apy we e
a isk o wo k loss which was no explained by elapsed
disease, seconda y malignancies o ca dio ascula dis-
ease [17]. Beh inge e al. published a ou able da a on
social ein eg a ion and ea men ou come among HL
su i o s. Thei analysis e ealed a signi ican nega i e
associa ion o se e e a igue (sFA) and employmen s a-
us in su i o s: 5 yea s a e he apy, 51% and 63% o
emale and male su i o s, espec i ely, wi h sFA had
been in employmen o in p o essional educa ion, com-
pa ed wi h 78% and 90% wi hou sFA, espec i ely
(p< 0.001) [25].
Acco ding o ou da a, lowe age a diagnosis, college-
le el educa ion, and no ea men - ela ed long- e m side
e ec s a e independen p edic i e ac o s o employmen
a e ea men comes o an end. The isks ac o s o
ea men - ela ed long- e m side e ec s a e emale gende ,
chemo he apy o he han ABVD. The educ ion o dose
and ield o adia ion he apy and he applica ion o ABVD
egimen had become mo e ailo ed o HL ea men ha
migh ha e led o he educ ion o ea men - ela ed long-
e m side e ec s which became appa en in ou s udy
popula ion a e 2002. T ea men - ela ed long- e m side
e ec s had a clea ly nega i e impac on inac i e employ-
men s a us. Acco ding o ou esul s, he equency o
ca dio ascula disease is signi ican ly highe among in-
ac i e su i o s.
Conclusion
Ou da a sugges ha employmen s a us, educa ion
and ea men - ela ed long- e m side e ec s (hypo hy -
eodism, ca diomyopa hy, co ona y scle osis, al ulopa hy,
pulmona y ib osis, pos i adia ion skin and muscle a o-
phy) play a c i ical ole in he quali y o li e o HL su i-
o s. In o de o help HL pa ien s become no only
su i o s bu ully unc ioning, cu ed pe sons capable
o wo king, he u he de elopmen o a ge -speci ic
he apeu ic modali ies (an i-CD30 a ge ing wi h
b en uximab- edo in, p og ammed dea h 1 (PD-1)
blocke s) is needed along wi h clinical s udies ha in-
clude ollow-up measu emen s o quali y o li e.
A g owing numbe o s udies p o ide e idence o he
necessi y o wo k ehabili a ion a e he cu e o cance
(among hem Hodgkin-lymphoma). Denma k has a wide-
sp ead ax- inanced wel a e sys em which p o ides an
op ion o pe sons wi h pe manen ly educed wo k cap-
aci y o e i e due o hei disabili y and be inancially
compensa ed [18]. In Sweden, mul idisciplina y in e -
en ions p omo e a heal hy wo k en i onmen /li es yle
in ol ing physical, psychological, and oca ional com-
ponen s [17]. Social ein eg a ion p og am has also
been a ailable o oncological pa ien s in Hunga y.
Howe e , he Hunga ian ollow-up guidelines do no
include ecommenda ions o wo k ehabili a ion p o-
g am o HL su i o s. Based on ou in es iga ion, we
sugges ed an ex ended social ein eg a ion p og am o
Hunga ian HL pa ien s also. A clinical psychologis as
membe o ou haema ological eam p o ides psycho-
logical suppo o pa ien s in ou depa men . The e
exis s an ac i e Lymphoma Ci il Pa ien Fo um ha
p o ides nume ous oppo uni ies o inc ease ou pa-
ien s’psychological well-beeing. Con ol examina ions
c ea e ime o encoun e s be ween haema ologis and
pa ien s du ing which psychological guidance acili a es
HL su i o s o s ep ou o he pa ien ole.
Acknowledgemen s
We wan o hank all pa ien s, who so gene ously pa icipa ed in his s udy.
The au ho s would like o acknowledge Kala in Hodosi o he suppo in he
s a is ical analysis.
Funding
None.
A ailabili y o da a and ma e ials
“Please con ac ou o da a eques .”
Au ho s’con ibu ions
S udy comple ion and designed by: FM, ZSS, KK. Da a analysed by: FM, AI,
ZSS, KK. Pape w i en by: FM. S udy supe ised by: RB, KK, ZSM. Manusc ip
app o ed by: ÁI. All au ho s ead and app o ed he inal manusc ip .
E hics app o al and consen o pa icipa e
E hical app o al o he s udy was ob ained om he ce i ied Medical E hics
Commi ee o he Uni e si y o Deb ecen, Hunga y. The pa icipa ing
pa ien s we e signed he consen .
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es .
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Magya i e al. Heal h and Quali y o Li e Ou comes (2017) 15:180 Page 8 o 9
Au ho de ails
1
Depa men o Hema ology, Facul y o Medicine, Uni e si y o Deb ecen,
Deb ecen, Hunga y.
2
Depa men o Beha iou al Sciences, Facul y o Public
Heal h, Uni e si y o Deb ecen, Deb ecen, Hunga y.
3
Depa men o
Psychia y, Facul y o Medicine, Uni e si y o Deb ecen, Deb ecen, Hunga y.
4
Depa men o Anaes hesiology and In ensi e Ca e Facul y o Medicine,
Uni e si y o Deb ecen, Deb ecen, Hunga y.
Recei ed: 28 Ma ch 2017 Accep ed: 13 Sep embe 2017
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