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Abstract

This article is a cross-sectional study of 216 women undergoing adjuvant hormone therapy for breast cancer in two oncology centers in northern Morocco. Quality of life (QoL) was assessed using the Functional Assessment of Cancer Therapy (FACT) questionnaire and its endocrine subscale (ES). The relationship between rural–urban status in our sample and QoL was assessed by linear regression analysis using sociodemographic and clinical variables as covariates. Our results show that physical and functional well-being are significantly (p < 0.001) higher in rural areas (24 and 29, respectively) than in urban areas (16 and 19, respectively), while social and emotional well-being are significantly (p < 0.001) higher in urban areas (22 and 21, respectively) than in rural areas (15 and 16, respectively). However, there was no significant difference (p = 0.097) between rural and urban breast cancer survivors regarding endocrine symptom burden. Regarding the effect of sociodemographic and clinical factors on overall HRQOL of breast cancer survivors, hormone type was shown to have a significant effect on overall HRQOL (FACT-ES) of rural and urban breast cancer survivors (𝛽 = +0.849 and 𝛽 = +0.678, respectively). A similar effect was observed for ES (𝛽 = +0.896 and 𝛽 = +0.180, respectively).

In contrast, other factors (age, marital status, economic status, menopausal status, type of surgery) did not have a significant effect on HRQOL (FACT-ES) or ES.

The study highlighted the need for increased psychosocial supportive care efforts for rural breast cancer survivors to improve their QoL.

Keywords

Urban rural quality of life breast cancer survivor hormonal therapy

1. Introduction

Breast cancer is the most common cancer in women worldwide, with more than 2.2 million new cases, and more than 685 thousand deaths reported in 2020 [1]. In Morocco, breast cancer is also the first cancer in women with 11747 (38.9%) new cases and 3695 (10.5%) deaths in 2020. Incidence rates differ between urban and between urban and rural areas [2].

Certainly, thanks to the increased progress in the therapeutic arsenal of breast cancer, the survival rate has increased significantly with an overall survival at 5 years of 90% in high-income countries [1,3,4]. Similarly, in Morocco, the fight against cancer has undergone a profound restructuring since 2010 with the launch of the first National Plan for Cancer Prevention and Control and the implementation of the second plan 2020-2029, which advocates the consolidation and perpetuation of the achievements of the first plan, to correct the shortcomings identifications [5]. Following these efforts, several indicators assessing the quality of breast cancer care have been improved including the 5-year survival rate, which has reached 80.6% [6].

In addition, the increase in survival has brought light to other challenges related mainly to the psychosocial and physical side effects of hormonal therapy, which can negatively influence the long-term QoL of survivors. Some studies show that women’s QoL declines after initial breast cancer treatment, and this decline may persist or worsen during hormonal treatment [7–9]. Several determinants may be behind this decrease, among them: young age, menopausal status, educational level, comorbidities, low economic level, and proximity and access to health services, which also have their effects related to living in a rural environment [10–12].

However, the results referring to the relationship between rurality and QoL of cancer survivors are inconsistent, reporting both improvements in QoL in rural patients while others report decreases [13–16].

In USA, the results of a recent study (published in 2020) of 566 non-Hodgkin’s lymphoma survivors examining the association between rural status and QoL demonstrated a positive effect of rurality on most QoL subscale domains, but with a marked need for supportive care [16]. In contrast, a previous small sample study (N = 46) found that breast cancer survivors residing in more rural areas reported lower overall quality of life and functional well-being and more breast cancer-specific symptom burden than urban residents [17].

At the European level, a large study in Germany (N = 1927) reported that survivors from rural areas had poorer QoL than their urban counterparts [10]. In addition, the results of a study in Turkey of 1606 breast cancer survivors on hormonal therapy showed that survivors living in rural areas reported better overall QoL scores (physical, functional, and emotional) than women living in urban areas, while Social Domain and Endocrine Symptom Scores did not differ significantly by urban–rural residence [18]. In contrast, in Australia, a study of 600 survivors one year after breast cancer diagnosis found that QoL among urban and rural survivors was statistically similar [19].

In the African context, including Morocco, to our knowledge, no study has been conducted to examine differences in QoL of rural–urban breast cancer survivors prescribed hormonal therapy. Given the limitations of existing knowledge and the inconsistency of the findings, it is important to further investigate the association between QoL of breast cancer survivors on hormone therapy and rural–urban living.

To this end, this research aims to examine the difference between rural and urban breast cancer survivors in northern Morocco with respect to their QoL while using endocrine therapy. In order to help health care providers, consider the existing disparities between the two groups by taking into account their origin, which may improve the quality of health services provided to these women by giving them effective and appropriate care.

2. Material and methods

2.1. Study population

The present study is a cross-sectional study of 216 breast cancer survivors on hormonal treatment between (2015–2020). These women were identified from the local cancer registry located at the focal point of each province in the Tangier-Tetouan -Al-Hoceima region. The registry includes demographic and clinical information for all newly diagnosed women.

Inclusion criteria included women with breast cancer (stage I–IV) who had undergone surgery (mastectomy or conservative) and received chemotherapy and/or radiotherapy, and who were on adjuvant hormonal therapy (Tamoxifen or AI). The study included a database of 324 women, of whom 216 were able to answer our questions (response rate: 67%).

Sociodemographic variables included age (under 45 and over 45), relationship status (single, married, divorced, widowed), education level (illiterate, primary, secondary, university), number of children (none, one child, two children, three or more children), employment status (not employed, employed), socioeconomic status (low, medium, and high), type of medical insurance (CNOPS, CNSS, RAMED, other), and location (rural, urban).

Clinical variables available in the regional cancer registry database included cancer stage (I, II, III/IV), type of endocrine therapy (Tamoxifen and AI), type of postoperative therapy (chemotherapy, radiation, both), menopausal status (premenopausal, menopausal, induced menopausal), duration of prescribed endocrine therapy (less than 6 months, 6 to 1 year, 1 to 2 years, +2 years). Verbal informed consent was obtained from all participants.

2.2. Measurement of quality of life

The tools used for the assessment of QoL domains were the Functional Assessment of Cancer Therapy (FACT-G) questionnaire and an endocrine subscale (ES) [20,21]. Responses were scored as described in the FACT-ES version-4 guidelines. The FACT-G includes physical well-being (PWB) with 7 items (GP1-GP7), social/family well-being (SWB) with 7 items (GS1-GS7), emotional well-being (EWB) with 6 items (GE1-GE6), functional well-being (FWB) with 7 items (GF1-GF7). The FACT-ES represent FACT-G in addition to endocrine symptoms (ESS-19) with 19 items (ES1-BRM1). The higher the FACT-ES score, the better the QoL. The FACT instrument has excellent reliability and validity. It is also validated for use in different countries and with rural populations [22,23].

3. Statistical analyses

To examine the association between sociodemographic, clinical, and QoL dimensions and place of residence (rural/urban), statistical analyses were performed using SPSS version 21.0. Descriptive statistics included frequencies and percentages for categorical variables (socio-demographic and clinical) and medians and interquartile range (IQR) for continuous variables (FACT-ES). Differences between rural and urban variables were obtained using chi-square test for categorical variables and nonparametric tests (Wilcoxon–Mann–Whitney) for continuous variables. The minimum important difference (MID) for interpreting group differences in QoL for the FACT scales is estimated to be 3 to 8 points [24,25], and two or more points for the subscales, as recommended by the FACT developer [20].The relationship between the rural–urban variable and overall QoL (FACT-ES) was obtained using linear regression analysis. Sociodemographic and clinical variables were used as predictors of overall QoL.

4. Results

In this study, 216 breast cancer survivors completed the questionnaire, of which 59.3% (128) identified themselves as coming from the urban area and 40.7% (88) from the rural area. Approximately 71.8% (155) were over 45 years old and 28.2% (61) were under 45 years old. Our sample had a high illiteracy rate (64.4% (139)). Regarding marital status, 58.8% (127) were married and 28.2% (61) were single. About 46.3% (100) had three or more children, and 34.3% (74) had none. In our sample, 95.4% (216) were unemployed women. About 69% (149) reported having a medium economic level and 30.1% (65) a low economic level. Regarding the type of insurance, 87.5% (189) have RAMED, which is a government health system that provides access to medication and treatment for low-income patients. According to the chi-square test (Table 1), the rate of single survivors is significantly higher in rural areas, while the rate of married survivors is significantly higher in urban areas (p = 0.020). Although the number of employed breast cancer survivors in our sample is low (4.6% (10), there are relatively more employed survivors in urban areas than in rural areas (p = 0.043). This reflects the economic level of our patients, which is significantly low in rural areas, whereas it is more average in urban areas (p = 0.004).

Regarding the clinical characteristics of our sample, 68.1% (147) have stage II breast cancer, 57% (84) of which are from urban areas, and 29.6% (64) have stage III or IV, 64% (41) of which are also come from urban areas. Regarding hormone therapy, 56.9% (123) are on “Tamoxifen”, especially in rural areas where 67% of survivors are on this type of treatment and 43.1% (93) on “AI” 69% of them come from urban areas. About 49.5% (107) of them are menopausal, while 34.3% (74) have treatment-induced menopause. About 75.5% (163) have undergone mastectomy, while 24.5% (53) have undergone conservative surgery. In addition, 76.4% (165) had both chemotherapy and radiation therapy. Regarding the prescribed duration of hormonal therapy, 48.6% (105) have been on treatment for more than 2 years, while 30.1% (65) have been on hormonal therapy less than 6 months.

Table 1
Sociodemographic characteristics of breast cancer survivors by urban and rural residence

Rural % (N) Urban % (N) 𝜒² test P value

40.7% (88) 59.3% (128)* 7.407 0.006*

Age <45 years 30.7% (27) 26.6% (34) 0.437 0.509

≥45 years 69.3% (61) 73.4% (94)

Education levels Illiterate 69.3% (61) 69.9% (78) 7.083 0.069

Primary school 13.6% (12) 16.4% (21)

Secondary school 17.0% (15) 15.6% (20)

University 0.0% (0) 7.0% (9)

Marital status Single 39.8% (35)* 20.3% (26) 9.827 0.020*

Married 48.9% (43) 65.6% (84)*

Divorced 4.5% (4) 6.2% (8)

Widowed 6.8% (6) 7.8% (10)

Number of children None 43.2% (38) 28.1% (36) 6.131 0.105

One child 5.7% (5) 7.0% (9)

Two children 13.6% (12) 12.5% (16)

Three or more children 37.5% (33) 52.3% (67)

Job Unemployed 98.9% (87)* 93.0% (119) 4.104 0.043*

Employed 1.1% (1) 7.0% (9)*

Economic level Low 42.0% (47)* 21.9% (28) 11.043 0.004*

Medium 58.0% (51) 76.6% (98)*

High 0.0 % (0) 1.6% (2)

Medical cards CNOPS 4.5% (4) 10.9% (14) 3.726 0.293

CNSS 4.5% (4) 3.1% (4)

RAMED 90.9% (80) 85.2% (109)

Other 0.0% (0) 0.8% (1)

		Rural % (N)	Urban % (N)	𝜒² test	P value
		40.7% (88)	59.3% (128)*	7.407	0.006*
Age	<45 years	30.7% (27)	26.6% (34)	0.437	0.509
	≥45 years	69.3% (61)	73.4% (94)
Education levels	Illiterate	69.3% (61)	69.9% (78)	7.083	0.069
	Primary school	13.6% (12)	16.4% (21)
	Secondary school	17.0% (15)	15.6% (20)
	University	0.0% (0)	7.0% (9)
Marital status	Single	39.8% (35)*	20.3% (26)	9.827	0.020*
	Married	48.9% (43)	65.6% (84)*
	Divorced	4.5% (4)	6.2% (8)
	Widowed	6.8% (6)	7.8% (10)
Number of children	None	43.2% (38)	28.1% (36)	6.131	0.105
	One child	5.7% (5)	7.0% (9)
	Two children	13.6% (12)	12.5% (16)
	Three or more children	37.5% (33)	52.3% (67)
Job	Unemployed	98.9% (87)*	93.0% (119)	4.104	0.043*
	Employed	1.1% (1)	7.0% (9)*
Economic level	Low	42.0% (47)*	21.9% (28)	11.043	0.004*
	Medium	58.0% (51)	76.6% (98)*
	High	0.0 % (0)	1.6% (2)
Medical cards	CNOPS	4.5% (4)	10.9% (14)	3.726	0.293
	CNSS	4.5% (4)	3.1% (4)
	RAMED	90.9% (80)	85.2% (109)
	Other	0.0% (0)	0.8% (1)

*Statistically significant difference at (P < 0.05) between urban and rural breast cancer survivors.

Regarding the differences in clinical characteristics between rural and urban areas (Table 2), the results did not find any significant differences, except for the type of hormone used (p = 0.013). In fact, there was significantly higher proportion of breast cancer survivors who received Tamoxifen in rural areas, while a significant high proportion of those who received AI in urban areas (Table 2).

Table 2

Clinical characteristics of breast cancer survivors (stage I–IV) who received prescribed hormone therapy by urban and rural residence

	Variables	Rural % (N)	Urban % (N)	𝜒² test	P value
		40.7% (88)	59.3% (128)*	7.407	0.006*
Stage of Cancer	Stage-I	2.3% (2)	2.3% (3)	0.885	0.642
	Stage-II	71.6% (63)	65.6% (84)
	Stage-III & IV	26.1% (23)	32.0% (41)
Hormone	Tamoxifen	67.0% (59)	50.0% (64)*	6.180	0.013*
	AI	33.0% (29)	50.0% (64)*
Menopausal status	Premenopausal	17.0% (15)	15.6% (20)	2.593	0.273
	Menopausal	43.2% (38)	53.9% (69)
	Menopausal due to treatment	39.8% (35)	30.5% (39)
Surgery	Mastectomy	57.0% (66)	75.8% (97)	0.017	0.896
	Conservative	25.0% (22)	24.2% (21)
Treatment post-surgery	Chemotherapy	18.2% (16)	16.4% (21)	0.970	0.616
	Radiotherapy	4.5% (4)	7.8% (10)
	Chemo + Radiotherapy	77.3% (68)	75.8% (97)
Prescribed endocrine period	Less than 6 months	35.2% (31)	26.6% (34)	2.719	0.438
	Between 6 & 12 months	14.8% (13)	16.4% (21)
	Between 1 & 2 years	6.8% (6)	4.7% (6)
	More than 2 years	43.2% (38)	52.3% (67)

*Statistically significant difference at (P < 0.05) between urban and rural breast cancer survivors.

5. QoL and endocrine symptoms

According to the Wilcoxon–Mann–Whitney test (Table 3), breast cancer survivors living in rural areas reported significantly higher physical and functional QoL (p < 0.001), whereas social and emotional subscales were significantly (<0.001) higher in breast cancer survivors living in urban areas. However, endocrine symptom burden showed no significant difference, even relatively higher in rural areas.

Table 3
Evaluation (Median; IQRs) of QoL between urban and rural survivors of stages I–IV breast cancer according to FACT-ES and their subscales

QoL All participants (N = 216) Rural (N = 88) Urban (N = 128) Wilcoxon–Mann–Whitney test

Median IQR Median IQR Median IQR z-Score p-value

PWB 16 16–24 24 24–24 16 15–16 −12.451 <0.001*

SWB 21 15–22 15 14.25–15 22 21–23 −11.913 <0.001*

EWB 20 17–21 16 15–17 21 20–22 −12.471 <0.001*

FWB 20 19–23 24 23–24.75 19 18-20 −12.206 <0.001*

ES 39 39–55 39 39–58 48 39–55 −1.659 0.097

FACT-ES 120 117–133 119 118–135 125 117–132 −0.209 0.834

QoL	All participants (N = 216)	Rural (N = 88)	Urban (N = 128)	Wilcoxon–Mann–Whitney test
PWB	16	16–24	24	24–24	16	15–16	−12.451	<0.001*
SWB	21	15–22	15	14.25–15	22	21–23	−11.913	<0.001*
EWB	20	17–21	16	15–17	21	20–22	−12.471	<0.001*
FWB	20	19–23	24	23–24.75	19	18-20	−12.206	<0.001*
ES	39	39–55	39	39–58	48	39–55	−1.659	0.097
FACT-ES	120	117–133	119	118–135	125	117–132	−0.209	0.834

QoL: quality of life; FACT = Functional Assessment of Cancer Therapy, IQR: inter-quartile range; * the difference is significant at 0.05 according to Wilcoxon–Mann–Whitney test, PWB: Physical well-being, SWB: Social/family well-being, EWB: Emotional well-being. FWB: Functional well-being, FACT-ES Score = PWB+SWB+EWB+FWB +ES; ES: Endocrine symptom subscale.

Regarding the effect of sociodemographic and clinical characteristics on the overall QoL of breast cancer survivors, multivariate analysis (Table 4), shows that the age, marital status, economic status, stage of cancer, menopausal status, type of surgery, and post-surgery treatment of breast cancer survivors living either in rural or urban areas have no significant effect on QoL (FACT-ES) or its subscales. However, the type of hormone has significant positive effect on overall QoL (FACT-ES) of breast cancer survivors living in rural or urban areas (𝛽 = +0.849 and 𝛽 = +0.678 respectively). Similar effect is observed for its subscale (ES) (𝛽 = +0.896 and 𝛽 = +0.180 respectively).

These results reflect the important role of hormonal therapy on the QoL of breast cancer survivors. Even though, SWB is negatively impacted (𝛽 = −0.285) by hormonal therapy particularly for breast cancer survivors in urban area, noting that according to our results SWB is significantly higher in urban area versus rural area.

The educational level (awareness level) has significant negative (𝛽 = −0.180) effect on overall QoL (FACT-ES) of breast cancer survivors living in urban area. This negative effect is mostly significant on PWB (𝛽 = −0.234) and SWB (𝛽 = −0.243) in urban area.

The number of children has negative significant (𝛽 = −0.229) effect on PWB of breast cancer survivors living in urban area. This is obvious because our sample have more married women in urban area with three or more children.

Job has significant negative (𝛽 = −0.238) effect on SWB of breast cancer survivors living in urban area. The high proportion of unemployment rate in our sample can explain this outcome.

Table 4

Multivariate analysis: Associations between urban–rural variation and QoL and endocrine symptoms

Beta values	FACT-ES		PWB		SWB		EWB		FWB		ES
	R	U	R	U	R	U	R	U	R	U	R	U
Age	0.072	0.075	0.188	0.039	0.180	0.009	0.012	0.133	0.103	0.059	0.017	0.042
Education level	0.019	–0.180	0.081	–0.234	0.122	–0.243	0.024	0.072	0.149	−0.174	−0.023	−0.071
Marital status	−0.048	0.046	0.044	−0.004	0.067	0.022	−0.175	−0.025	0.137	0.014	−0.061	0.045
Number of children	0.041	−0.115	0.155	–0.229	−0.006	−0.066	0.226	0.091	−0.012	−0.183	−0.004	−0.046
Job	0.009	−0.044	0.051	−0.096	−0.051	–0.238	0.032	0.013	−0.105	−0.019	0.015	0.028
Economic level	−0.005	−0.092	−0.062	0.109	0.015	−0.171	−0.075	−0.092	0.030	−0.118	0.008	−0.046
Type of insurance	−0.026	−0.117	−0.061	0.146	−0.034	–0.209	0.034	−0.081	0.046	−0.176	−0.024	−0.062
Stage of cancer	0.042	−0.006	0.144	−0.003	−0.010	−0.149	0.101	0.110	−0.134	0.006	0.028	0.013
Type of hormone	0.849	0.678	0.010	−0.129	−0.035	–0.285	−0.126	−0.110	0.087	−0.138	0.896	0.842
Menopausal status	−0.101	0.048	−0.036	0.079	0.070	−0.044	−0.081	−0.079	0.014	0.095	−0.099	0.041
Type of surgery	−0.064	−0.005	−0.115	−0.060	0.120	−0.077	−0.094	−0.052	−0.131	−0.044	−0.034	0.038
Post-surgery treatment	0.05	0.023	0.141	0.029	0.088	−0.012	0.050	−0.065	0.042	0.037	0.013	0.024

Bold: p < 0.05; U: urban; R: rural; PWB: physical well-being; SWB: social well-being; EWB: emotional well-being; FWB: functional well-being; ES: endocrine symptoms subscale.

6. Discussion

To our knowledge, the present study is the first in Morocco, examining variation in QoL among breast cancer survivors prescribed hormone therapy (Tamoxifen or AI). Our results show that women living in either urban or rural areas exhibited high overall QoL. This is inconsistent with the results of a recent US study (2020) of a large sample (N = 271,640) to assess rural–urban differences in QoL for cancer survivors. This survey showed generally, that the QoL subscale scores and overall scores are higher for participants living in urban than rural areas [26]. The same conclusion was drawn from another study recently conducted on a sample of 566 non-Hodgkin’s lymphoma (NHL) cancer survivors, using SF-36 PCS as a QoL assessment tool, which reported that rural survivors had low scores compared to urban survivors [16].

As for the subscales including physical (PWB) and functional (FWB) well-being, women in our study living in rural areas reported significantly higher levels of the physical and functional dimension. This is probably justified on the one hand by the “positive attitude” those rural women adopt as a coping strategy for their disease [27,28]. On the other hand, by the nature of life in the rural environment, which is characterized by a healthy food and a quiet natural environment and a clean area, despite the difficulties of access to health care services [29,30]. In addition, women in rural areas are known for their patience and dynamism in carrying out their domestic and extra-domestic tasks, such as farming, which constitutes a place of relaxation for them, as reported in one study emphasizing that women who are solely responsible for domestic tasks generally have a better QoL [31].

On the other hand, these results do not corroborate with findings from some previous studies. In fact, most of reviewed studies them reported a lower QoL with respect to daily physical life in rural breast cancer survivors and mentioned that rural patients suffer from arthralgia and have greater needs in the areas of physical and daily life [14,17,19]. For emotional well-being, several studies found that rural survivors reported psychological problems such as depression, stigma, and hopelessness more than urban women [32,33]. This can be explained by the fact that cities have more entertainment facilities (cinemas, yoga rooms, libraries, internet network ...) and associations specific for psychological care [28,34,35].

For social well-being (SWB), our research showed that urban survivors have higher social/family well-being compared to women living in rural areas, which is an unexpected finding, given that social ties in rural communities are strong and well-cohesive. This may be due to the fact that the city offers opportunities for social integration more than rural areas, thanks to the availability of several organizations and associations specialized in the holistic care of women in the field of oncology, namely: therapeutic follow-up, psychological support and even help with social integration [12,36]. However, a study conducted among the general population in Ireland found a high level of psychosocial well-being in populations living in rural areas [37,38]. Whereas, in a recent study, researchers found no significant difference in social well-being between urban and rural breast cancer survivors [26].

The inconsistency of our results with these studies can be explained on the one hand by the existing disparities in living conditions in rural areas between different countries regarding economic, cultural and social aspects. In addition, psychosocial morbidity and unmet needs may also be higher in cancer patients residing in rural areas, on the one hand, because of the isolation of information and support services, the demands/expectations imposed on them and the greater number of roles they could play [39–41]. On the other hand, by the way in which women living in rural areas manage and adapt to the adverse effects of hormonal therapy [19,28].

In relation to the effect of sociodemographic and clinical characteristics on the overall QoL of breast cancer survivors living in rural or urban areas, the results of the present study showed that most of the factors namely: age, marital status, economic status, cancer stage, menopausal status, type of surgery, and post-surgical treatment of cancer survivors had no significant effect on QoL (FACT-ES) or its subscales.

This does not corroborate with the results of previous studies that found these factors to be predictors of QoL [18,35,42–44]. This discrepancy in results may be related to the existing discrepancy between the context of the studies in terms of living conditions that differ from country to country. This requires further study in Morocco to better understand this difference.

However, our study showed that hormone therapy with either Tamoxifen or AI had a significant positive effect on the overall QoL of breast cancer survivors whether they resided in urban or rural areas.

The literature supports these results. Given that the findings from the three large clinical trials on adjuvant endocrine-related symptoms and QoL assessment, namely: ATAC, IES, TEAM showed that AI and Tamoxifen were all associated with improvements in overall QoL, which did not differ significantly between the hormonal therapy groups, despite the different side effect profiles [45–47].

The current FIT results on endocrine system and treatment-related distress symptoms were also similar to those in the ATAC, IES and TEAM trials in demonstrating that they did not have significant differences in endocrine symptoms over time by type of hormonal therapy. Thus, symptom distress in women taking adjuvant endocrine therapy appears to be similar across trials, regardless of design, measurement, and sample size [47–49].

These findings corroborate with the results of our study regarding the positive effect of both types of treatment on endocrine symptom burden.

The main limitation of this work is its cross-sectional nature, which examined HRQOL in heterogeneous groups at different times during hormone therapy.

A future study using a longitudinal design may provide more reliable conclusions.

7. Conclusion

In conclusion, the results of the present study on breast cancer survivors undergoing hormone therapy indicate that rural residence is associated with significantly lower social and emotional QoL compared with urban survivors. This can be addressed through the establishment of specific supportive care units and the development of partnerships with social and community agencies. Future studies should continue to examine the relationship between rural residence and QoL among breast cancer survivors on hormone therapy to identify individual psychosocial levels and also explore factors influencing QoL among breast cancer survivors in order to target interventions and resource equity.

Conflict of interest

The authors declare no conflict of interest.

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