1. Background
Cancer is among the main causes of death and disability, globally (Hekmatpou & Mehrabi, 2018). Increased prevalence of cancer in recent years and its multiple effects on the biopsychosocial and other life dimensions of the sufferers, has made cancer the main problem of the century (Hekmatpou & Mehrabi 2018; Pourkiani et al. 2010). Leukemia is classified as cancer. According to the latest World Health Organization (WHO) statistics, the incidence of leukemia is 437000 worldwide. Furthermore, its death rate is 309000 per year, and 217000 people will be added to this population by 2040 (IARC, World Cancer Report 2018). 
Leukemia is the seventh most common cancer after breast, stomach, colorectal, lung, bladder, and prostate cancers in Iran. In addition, the number of people affected by this disease is higher than the global statistics and accounts for 5.65% of all newly diagnosed cancers. Leukemia is also the reason for 7.44% of all cancer deaths in Iran (IARC, World Cancer Report2018; Musarezaie et al. 2014). In leukemia, the malignant cells originate from the hematopoietic system, and its increase in bone marrow shows itself with or without the involvement of peripheral blood cells (Holzner et al. 2004). The disease consists of two large groups of myeloid and lymphoid, each of them can be acute or chronic, and fall into the 4 categories, including Acute Myeloid Leukemia (AML), Acute Lymphocytic Leukemia (ALL), Chronic Myeloid Leukemia (CML), and Chronic Lymphocytic Leukemia (CLL).
The goal of treating hematological malignancies is to increase patients’ survival, improve their ability, and maintain an appropriate Quality of Life (QoL) level (Montgomery et al. 2002). The treatment of these malignancies is not generally feasible, and the purpose of treatment is to eliminate symptoms and improve survival. Therefore, QoL has been considered as the main criterion for evaluating patients’ responses to the treatment (Pamuk et al. 2008; Madmoli et al. 2017). Patients with leukemia receive different interventions, like chemotherapy, which significantly affects their QoL.
In other words, those receiving chemotherapies have lower QoL scores, and their anxiety rate is higher than the others (Habek et al. 2004; Redaelli et al. 2004). This disease severely changes patient’s lifestyle (Santos et al. 2006); therefore, the patients’ efforts and their family cooperation are required for optimal adaptation (Golchin et al. 2008). Consequently, QoL has been a spotlight on healthcare area, especially for more than a decade in chronic diseases (Chagani et al. 2017). The interest in evaluating and improving the QoL of patients with chronic diseases, like cancer and their daily functions improvement has significantly enhanced, recently (Safaee et al. 2010).
Patients’ survival is not the only concern; because the basis of nursing, philosophy is improving the life expectancy of those in need of a better life. Nurses’ long and direct contact with patients plays a vital role in evaluating and improving their QoL. Furthermore, studies have suggested that nursing interventions have significantly reduced the treatment side-effects of patients with cancer and improved their QoL (Zeighami Mohammedi et al. 2008). Recent advances in cancer treatment improved patients’ life expectancy; therefore, QoL phenomena has become more important (Hekmatpou & Mehrabi 2018). 
Some studies have been conducted on the QoL of patients with leukemia in Iran; however, data are scarce in this regard, because these studies disregarded its different types. Information about the QoL of patients with different leukemia types not only paves the way for influential therapies but also leads to more effective interventions. Furthermore, by identifying different aspects of these patients’ QoL, those who need more attention will be identified for receiving a comprehensive care plan. Accordingly, the present study aimed to compare the QoL of hospitalized patients with all types of leukemia.
2. Materials and Methods
This was a descriptive cross-sectional study. One hundred patients with leukemia hospitalized in Ayatollah Khansari Hospital in Arak City, Iran were selected by purposive sampling method. Moreover, they were assessed for 6 months in 2018. The inclusion criteria were admission to the oncology and hematology ward with at least 3 months passed since cancer diagnosis. Exclusion criteria included transferring to other wards (e.g. ICU), patients or their immediate family death, and cancer metastasis. A cancer diagnosis was based on the laboratory and imaging tests, confirmed by an oncologist. The researcher, while expressing the research objectives, obtained the patients’ written consents. Necessary explanations, such as optional participation in the study, the confidentiality of the provided information and possibility of withdrawal from the study were provided to selected patients. 
The data gathering tools were a demographic form and the QoL questionnaire for cancer patients approved by the European Organization for Research and Treatment of Cancer (EORTC). Demographic questions included patients’ age, gender, marital status, the number of children, occupation, academic background, residence type, insurance status, cancer type, illness duration, as well as the history of past specific diseases and its related treatments. 
EORTC QLQ-C30 QoL questionnaire is a standard scale belonging to EORTC and used to assess cancer patients’ QoL (Safaee et al. 2007). The questionnaire has 30 questions in 5 functional subscales, including physical condition (five questions), role play (two questions), emotional function (two questions), cognitive function (four questions), and social function (two questions), questions referred to symptoms (fatigue, nausea, vomiting, pain, shortness of breath, sleep disturbances, appetite loss, constipation, diarrhea, financial problems), and overall QoL. To determine QoL, the analyzed data were classified into three levels; good (scores: ˃75), relatively good (scores: 50-75), and poor (scores: <50). Higher scores in functional subscale and overall QoL indicate a better patient status in that area; higher scores related to symptoms indicate a lower QoL. 
The face validity of the Persian version of the QLQ‑C30 has been confirmed, and its Cronbach’s alpha reliability was between 0.76 and 0.93; thus, it can be used in epidemiological and clinical cancer studies with confidence. The third version of this questionnaire has been validated in Iran (Safaee et al. 2007, 2008a) and its Persian version is also confirmed by EORTC (Safaee et al. 2008a; Safaee et al. 2008b). Descriptive statistics, including frequency, mean, and standard deviation, were used. Statistical tests such as Chi-squared test, Fisher’s exact test, and t-test were also applied. Acquired data were analyzed by SPSS V. 21. α≤0.5 was considered as significant. 
3. Results
Among the patients, 53% were males, and 47% were females with a Mean±SD age of 51±83.16 years. Regarding leukemia type, 40% were diagnosed with chronic lymphocytic leukemia, 10% with acute lymphocytic leukemia, 24% with chronic myeloid leukemia, and 26% were admitted with acute myeloid leukemia (Table 1).

 

Based on the findings, the overall Mean±SD QoL score was 62.2±12.59, which was at a relatively good range. The Mean±SD QoL scores for different leukemia types were 60.10±14.31 for chronic lymphocytic leukemia, 59.51±12.83 for acute lymphocytic leukemia, 66.61±10.94 for chronic myeloid leukemia, and 62.84±6.33 for acute myeloid leukemia. 
Among the different subscales of QoL, patients with ALL received the lowest score, while patients with CML acquired the highest score. In the emotional dimension, patients with AML gained the lowest score and those with CML had the highest score. In cognitive dimension, patients with ALL had the lowest score and those with AML obtained the highest score. Finally, in social dimension, patients with AML and those with ALL had the lowest and highest scores, respectively (Table 2).

Regarding the experienced symptoms, fatigue was the most annoying symptom reported by the samples. Among the symptoms, nausea and vomiting were higher in CML, pain in AML, dyspnea in CML, decreased impaired olfactory sense in ALL, reduced appetite in CLL, and diarrhea and constipation in patients with ALL (Table 2). Female gender, having a university degree, being a housewife, and living in rural areas were associated with higher QoL score. There was a significant relationship between age, residency, and marital status, and total QoL (P<0.05).
4. Discussion
QoL is regarded as a sign of responding to treatment and is a part of a disease control program. By analyzing the data related to this concept, a valuable source of information will be available to evaluate the quality of healthcare services and preventive interventions.
 This study compared the QoL of hospitalized patients with all types of leukemia. It also assessed the relationship between QoL and patients’ characteristics. The patients’ overall Mean±SD QoL score was 62.29±12.59, which was at a relatively good level. This finding was consistent with some other studies (Dehkordi et al. 2006; Shaban et al. 2004). Furthermore, compared to prior studies, the patients’ QoL was better; this could be due to the differences in biopsychological support and care provided by patients’ families (Glaus et al. 2000; Lee et al. 2001; Sammarco et al. 2001). In terms of QoL in patients with all types of leukemia, those with CML had the highest QoL score 16.69±10.94. In addition, the patients with ALL had a lower QoL; therefore, those with ALL require more attention.
Our patients had experienced many physical symptoms due to the disease process and received treatments. Generally, patients with hematologic malignancies have significant physical symptoms, such as fatigue, insomnia, drowsiness, pain, shortness of breath and neuropathy, diarrhea, vomiting, and olfactory disorder, as a complication of cancer progression and their treatment side effects (Buckley et al. 2017; Verleden et al. 2010). Moreover, about 63% of patients with leukemia, experience at least one treatment side effect (Fulbright et al. 2011; Kopp et al. 2012).
The Mean±SD age of studied patients was 51.83±16 years. In Pakistan, the mean age of patients in a related study was 48 years, which is close to ours (Chagani et al. 2017); however, according to Cella et al. (2012), the average age of leukemia patients was 60.1 years. It seems that this 10-year difference in the average age of the disease onset between the current study and Cella et al. study in the United States could be related to the higher level of QoL in the US, which delays cancer occurrence (Cella et al. 2012).
Assessing different QoL dimensions in our study suggested that the weakest performance is in the social area; this is consistent with some other studies in Iran (Esmailnasab Taymoori & Darabi 2013; Mardani Hamule et al. 2009). Furthermore, the best performance belonged to the physical dimension which is not consistent with the results of Esmailnasab et al. (2013), Blazeby et al. (2005), and Kobayashi et al. (2008); they found that cognitive function obtained the highest score (Esmailnasab Taymoori & Darabi 2013; Blazeby et al. 2005; Kobayashi et al. 2008).
QoL reflects the biopsychosocial functions of individuals in response to the diseases and received treatments (Mohaddesi et al. 2013). In our study, patients with ALL received the lowest QoL score, while those with CML acquired the highest. Among the different dimensions of QoL, patients with AML gained the lowest score in the emotional dimension, and those with CML had the highest one. In cognitive dimension, patients with ALL had the lowest score and patients with AML obtained the highest; whereas, in another study, patients with CML obtained the lowest score in emotional dimension (Shanafelt et al. 2007). However, in another study, the type of leukemia was not significantly associated with patients’ QoL (Hadi, Namvar & Montazeri 2011). This difference may be because, in all four types of leukemia, most patients received chemotherapy, they were often hospitalized, and involved with the same infection and disease complications (). Similar results were observed in a study by Santos et al. (2006).
Generally, the findings revealed that patients with myeloid leukemia had a better QoL, compared to those with lymphocytic leukemia. In addition, the needs of patients with leukemia are different according to leukemia type. Accordingly, the knowledge of nurses and other healthcare staff about these findings could promote care and help to improve the QoL of patients’ with different leukemia types. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved in the Medical Ethics Committee of Arak University of Medical Sciences (code: IR.ARAKMU.REC.1393.175.18). The study participants were assured of the confidentiality of their information and provided a written consent form to participate in the study.
Funding
This project was supported by the Vice-Chancellor of Research Department of Arak University of Medical Sciences.
Authors' contributions
All authors contributed to this article and read and approved the final manuscript for submission.
Conflict of interest
There are no conflicts of interest to be declared by the authors.
Acknowledgments
The authors gratefully acknowledge the Research Council of Arak University of Medical Sciences for its financial support. 


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