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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Factors affecting health-related quality of life among patients with colorectal cancer using the european organization for research and treatment of cancer quality of life core questionnaire-CR29
Soumya Dey1, Abhishek Basu1, Suparna Banerjee2, Rajat Bandyopadhyay1
1 Department of Radiotherapy, Burdwan Medical College and Hospital, Bardhaman, West Bengal, India
2 Department of Pathology, Diamond Harbour Government Medical College, Diamond Harbour, West Bengal, India
| Date of Submission | 21-Nov-2022 |
| Date of Decision | 18-Dec-2022 |
| Date of Acceptance | 22-Dec-2022 |
| Date of Web Publication | 18-Feb-2023 |
Correspondence Address:
Rajat Bandyopadhyay,
D 308, Shreshta Garden, Kalipark, Rajarhat Road, Kolkata - 700 136, West Bengal
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_181_22
Introduction: The deterioration of health caused by colorectal Cancer (CRC) and its treatment leads to physiological, functional, and social damage impairing a CRC patient's health-related quality of life (HRQoL). The study was done to estimate the factors affecting the HR QoL among patients with CRC. Methodology: Fifty-four CRC patients who had completed the treatment with surgery/chemotherapy/radiotherapy in a peripheral Medical College between May 2021 and April 2022 were enrolled. The objective was to assess patient's perceived global health status and QoL (GHS/QoL), functional outcomes, and symptoms measured by the European organization for research and treatment of cancer Quality of life questionnaire core (QLQ-C30) and the CRC-specific QLQ-CR29 and to determine the demographics, clinical, treatment factors and symptom scales of the QLQ-C30/QLQ-CR29 that are associated with of GHS/QoL in patients with CRC Results: The mean age was 46 years, 59% were male, 41% had other long-term medical conditions, an ostomy was present in 30% and 41% of respondents had multimodal CRC treatment with surgery, radiotherapy, and chemotherapy. The final analysis of stepwise multiple regression revealed that four variables namely physical functioning, sexual interest, body image, and fatigue remained significant independent predictors of overall HRQoL score in CRC survivors accounting for 67.4% of the variation in overall HRQoL. Physical functioning made the strongest contribution. Women, at the extremes of the age groups (≥60 years), with an ostomy, without a spouse/partner, and those with other medical conditions in addition reported poorer functioning, symptoms, or overall HRQoL. Conclusions: The current study identifies factors associated with overall HRQoL among CRC survivors. Functional capacity and CRC-related problems were most strongly associated with overall HRQoL among CRC survivors. Greater efforts to identify CRC-related symptoms and diminished physical functional capacity among CRC survivors are warranted in an attempt to improve their overall HRQoL.
Keywords: Colorectal cancer, health-related quality of life, quality of life questionnaire
How to cite this URL:
Dey S, Basu A, Banerjee S, Bandyopadhyay R. Factors affecting health-related quality of life among patients with colorectal cancer using the european organization for research and treatment of cancer quality of life core questionnaire-CR29. J Mar Med Soc [Epub ahead of print] [cited 2023 Mar 23]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=369949 |
| Introduction | |  |
Health-related quality of life (HRQoL) of colorectal cancer (CRC) survivors is a growing concern. CRCs are the third most common cancer and the second leading cause of cancer-related deaths worldwide.[1] The survival rate of CRC continues to increase over the past decades.[2] Colon cancers rank 8th and rectal cancers rank 9th among cancers in men while colon cancer ranks 9th among cancers in women.[3] The 5-year survival rates for both colon and rectal cancer have increased by at least 30% over a 40-year duration.[4] Health deterioration caused by CRC symptoms or the consequences of treatment leads to physiological, functional, and social damage which impairs a CRC patient's HR quality of life (QoL).[5] Targeted interventions could be done effectively on potentially modifiable factors that are predictive of poorer HRQoL.[6],[7],[8]
This study was initiated to assess the factors associated with HR QoL among patients with CRC.
| Methodology | | |
In this cross-sectional hospital-based study, CRC patients who had completed treatment with surgery/chemotherapy/radiotherapy and attended the radiotherapy department in a peripheral medical college between May 2021 and April 2022 were enrolled. Taking a population size of 2300 (cancer patients attending outpatient department per year), confidence limit 95%, margin of error 5%, and population proportion 50%, and calculated sample size was 330. Due to the ongoing pandemic, only 54 patients could be recruited. Histologically proven colorectal carcinoma patients between 18 and 70 years with Eastern Cooperative Oncology Group 0–2 were included in this study. Patients with deranged blood counts, liver and renal dysfunction, prior cancer therapy, and pregnancy were excluded from the study.
Respondents filled out two questionnaires: The European Organization for Research and Treatment of Cancer Quality of life Core Questionnaire (EORTC QLQ-C30) version 3.0 and the European Organization for Research and Treatment of Cancer QoL Module-Colorectal Cancer (EORTC QLQ-CR29) version 2.1. The HRQoL outcomes of CRC survivors were assessed through the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Items in both questionnaires had point scales. The score was calculated by averaging the points which were converted into a score ranging from 0 to 100 as per EORTC scoring manual (Fayers et al).[9] Data were compared within the sample in relation to various characteristics. The level of symptoms reported by respondents was divided into two categories: No symptoms at all and those with mild, moderate, or severe symptoms. The sociodemographic data and other characteristics were obtained from respondents using the sociodemographic data form.
Statistical analyses were executed using the Statistical Package for Social Sciences software program, SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics including frequency and percentages were used to describe variables and reveal the characteristics of the respondents. Descriptive statistics such as mean, standard deviation, and range were used to report HRQoL outcomes' scores.
| Results | | |
Out of 54 CRC survivors evaluated, 32 (59%) were males. The mean respondent age was 46 years [Table 1]. Respondents were at different time periods since the diagnosis. Forty-one percent of respondents had other chronic medical conditions. Most of the patients presented in stage II (30%) and III (35%) of Tumor Node Metastasis staging (TNM) staging. An ostomy was present in 30% of respondents. Overall, 41% of respondents had multimodal treatment with surgery, radiotherapy, and chemotherapy. In the EORTC QLQ-C30, the overall HRQoL mean score was 68.3 [Table 2]. For the functional scales of the EORTC QLQ-C30, the mean score was highest for cognitive functioning and lowest for physical functioning. For the symptom scales on the EORTC QLQ-C30, the mean score was highest for fatigue and lowest for nausea and vomiting. For the functional scales of the EORTC QLQ-C29, the mean score was highest for weight and lowest for sexual interest. For the symptom scales on the EORTC QLQ-C29, the mean score was highest for impotence and lowest for dysuria [Table 3]. | Table 2: The European Organization for Research and Treatment of Cancer Quality of Life Module-Colorectal Cancer 30 mean scores of colorectal cancer survivors
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 | Table 3: The European Organization for Research and Treatment of Cancer Quality of Life Module-Colorectal Cancer 29 mean scores of colorectal cancer survivors
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Women reported lower emotional functioning, more diarrhea, financial difficulties, worse body image, and lower sexual interest. Global health status (GHS)/QoL and physical functioning were lower in CRC survivors at the extremes of age groups (≥60 years). They experienced more dryness in the mouth, least sexual interest score, and worse urinary problems. CRC survivors with an ostomy reported a lower level of social functioning, role functioning, had poorer body image, and more abdominal pain than those without an ostomy. CRC survivors with additional medical conditions were worse off in GHS/QoL, physical, and role functioning. They also reported a higher level of pain, fatigue, insomnia, and anxiety. Married responders reported better GHS/QoL and physical functioning.
On evaluation, a moderate-to-strong positive significant correlation was observed between overall HRQoL and all functional domains in the EORTC QLQ-C30 including physical, role, emotional, cognitive, and social functioning [Table 4]. Overall HRQoL was also positively correlated with all functional scales of the EORTC QLQ-C29 including, body image, anxiety, weight, and sexual interest [Table 5]. A moderate-to-strong significant negative correlation was observed between overall HRQoL and most symptom scales of the EORTC QLQ-C30 such as fatigue, pain, appetite loss, and financial difficulties [Table 6]. A moderate significant negative correlation was observed between overall HRQoL and most of the symptom scales of the EORTC QLQ-C29 such as urinary frequency, abdominal pain, sore skin, and stoma care problems [Table 7] and [Table 8]. | Table 4: Correlation coefficients (r) between overall health-related quality of life and other measured variables
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 | Table 5: Correlation coefficients (r) between overall health-related quality of life and other measured variables
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 | Table 6: Correlation coefficients (r) between overall health-related quality of life and other measured variables
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 | Table 7: Correlation coefficients (r) between overall health-related quality of life and other measured variables
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 | Table 8: Correlation between overall health-related quality of life and measured variables
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In the first phase of the stepwise multiple regression analysis, sociodemographic and other personal characteristics variables were modeled together. This analysis yielded marital status and the presence of other diagnosed medical conditions as significantly predictive of overall HRQoL among CRC survivors. In the second phase, variables in the EORTC QLQ-C30 questionnaire (physical functioning, role functioning, emotional functioning, social functioning, fatigue, and financial difficulties) found to be moderately to strongly correlated with overall HRQoL were modeled together. This analysis produced physical functioning, emotional functioning, and fatigue as significant unique predictors of overall HRQoL among CRC survivors. In the third phase, variables in the EORTC QLQ-C29 questionnaire (body image, anxiety, sexual interest, urinary frequency, dry mouth, and ostomy care problems) which have moderate-to-strong correlation with overall HRQoL were modeled together. The result of this analysis revealed that anxiety, body image, and sexual interest were significant independent predictors of overall HRQoL score. In the last phase, all the eight independent predictor variables of overall HRQoL identified were tested with a final stepwise multiple regression analysis. The final analysis revealed that four variables namely physical functioning, sexual interest, body image, and fatigue remained significant independent predictors of overall HRQoL score in CRC survivors accounting for 67.4% of the variation in overall HRQoL. Physical functioning made the strongest contribution. Higher level of physical functioning, lower level of body image disturbance, and lesser severity of problems with sexual interest were related to better overall HRQoL, whereas a higher level of fatigue was related to poorer overall HRQoL. Different severities of problem were reported in each of the symptom domains in the EORTC QLQ-C30 and EORTC-QLQ-C29 [Figure 1]. | Figure 1: Percentage of respondents reporting mild to severe symptoms (using the EORTC QLQ-C30 and EORTC QLQ-C29). *Respondents reporting they had an ostomy present were excluded from this analysis. EORTC QLQ: European Organization for Research and Treatment of Cancer Quality of life Core Questionnaire
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Problems relating to bowel, urinary and sexual function were among the five most prevalent symptoms, with urinary frequency (90.00%), fatigue (82.90%), and impotence (79.30%) being the three most reported symptoms, respectively.
| Discussion | | |
The current study shows that CRC survivors experience impairments in functioning, well-being, and overall HRQoL which differ across gender, age, ostomy status, marital status, and comorbidity status. Women, those at the extremes of the age groups (≥60 years), those with an ostomy, those without a spouse/partner, and those that have been diagnosed with at least one other medical condition in addition to CRC reported poorer functioning, symptoms, or overall HRQoL. Similar findings were reported in previous studies of CRC survivors' HRQoL outcomes (Tsunoda et al. 2007, Hornbrook et al. 2011, Grant et al. 2011, Färkkilä et al. 2013, Downing et al., 2015, and Rodriguez et al. 2015).[10],[11],[12],[13],[14],[15] Women reported poorer emotional functioning, body image, and experienced more symptoms similar to a prior study on gender differences among CRC survivors (Krouse et al. 2009).[16] The disparity between male and female CRC survivors may be explained by the effects of functional status on well-being as confirmed by Krok et al.[17] Overall HRQoL and physical functioning were lower in those at the extreme of the age groups (≥60 years) among CRC survivors as also seen by Jansen et al. in 2011.[18]
The social and role function were significantly reduced in CRC survivors with an ostomy. CRC survivors with an ostomy perceived their body image more negatively. Sharpe et al. in 2011,[19] Grant et al. in 2011,[12] Sun et al. in 2013,[20] and Mols et al. in 2014[21] showed in CRC survivors, ostomy negatively affects psychological well-being and social function by causing disturbances to body image, as well as restrictions in physical and social activities.
Significant deficits in overall HRQoL, physical and role function including, other problems were more prevalent in CRC survivors with other diagnosed medical conditions. These findings are consistent with studies by Downing et al. in 2015[14]and Rodriguez et al. in 2015.[15]
Unlike this study, several longitudinal studies have found differences in HRQoL outcomes among CRC survivors in relation to the time from diagnosis of CRC. Symptoms such as insomnia, dyspnea, constipation (Arndt et al. 2006)[22] and diarrhea (Arndt et al. 2006,[22] Caravati-Jouvenceaux et al. 2011[23] and Jansen et al. 2011)[24] were found to persist and gradually worsen with time, between 3 and 15 years postdiagnosis. Bennett et al.,[25] showed that symptoms, physical and emotional health were not related to time since diagnosis of cancer. Both studies of Bennett et al. and this study are cross-sectional studies, lacking baseline data.
The health-promoting benefit of marriage has been documented among cancer survivors (Goldzweig et al. 2009[26] and Morgan et al. 2011).[27] In our study, CRC survivors who were single had lower overall HRQoL similar to the study by Chambers et al.[28] which revealed that being single is a risk factor for poor HRQoL.
Problems relating to bowel, urinary, and sexual function were common in the respondents. Downing et al. (2015)[14] reported a similar category of prevalent symptoms but lesser than the present study. The high prevalence of symptoms such as urinary frequency, fatigue, impotence, flatulence, and stool frequency is a significant finding of the current study similar to other studies (Bregendahl et al. 2013,[29] Chen et al. 2015,[30] and Sánchez-Jiménez et al. 2015).[31]
Multivariable analysis revealed a significant relationship between overall HRQoL and other factors such as physical functioning, sexual interest, body image, and fatigue which significantly affect CRC survivors' perception of their overall HRQoL. This is similar to previous studies on fatigue (Gray et al. 2011,[32] Ness et al. 2013,[33] and Santin et al. 2015[34]), body image (Benedict et al. 2016)[35] and physical activity (Tsunoda et al. 2007,[10] Lynch et al. 2008.,[36] Lee et al. 2015[37]) on overall HRQoL in CRC survivors. CRC survivors' overall HRQoL scores were not associated with age when other variables were factored in. Similarly, gender, time since CRC diagnosis, and ostomy status were not relevant in overall HRQoL in the current study.
As higher levels of physical function, lower levels of problems with sexual interest, and better perception of body image were associated with higher overall HRQoL scores, healthcare providers should address these problems in CRC survivors. This assessment could help identify risk groups for poor overall HRQoL requiring additional support and resources. Early intervention could be pivotal in improving overall HRQoL in CRC survivors. Recent studies have suggested that physical activity even at a moderate level improves physical function and overall HRQoL in CRC survivors (Husson et al. 2015).[38] The implementation of long-term care and support strategies to manage persistent cancer-related symptoms such as fatigue could directly or indirectly improve overall HRQoL in CRC survivors.
| Conclusions | | |
The current study identifies factors associated with overall HRQoL among CRC survivors. Functional capacity- and CRC-related problems were most strongly associated with overall HRQoL among CRC survivors. Physical function, sexual interest, body image, and fatigue significantly influenced the overall HRQoL of CRC survivors. Increased efforts to identify and alleviate CRC-related symptoms and diminished physical functional capacity among CRC survivors are warranted in an attempt to improve their overall HRQoL.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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