Study of factors related to quality of life in patients with locally advanced rectal cancer

F. J. Pérez Lara, A. Navarro Pintilde;ero and A. de la Fuente Perucho

Service of Digestive Surgery. Carlos Haya Regional University Hospital. Málaga, Spain

 

ABSTRACT

Objectives: given the increasing concern about the physical, psychological, and social welfare of patients surgically treated for rectal cancer, we designed a study of the factors influencing quality of life in these patients.
Experimental design: we prospectively analyzed factors related to quality of life in a cohort of patients using the Nottingham Health Profile and the EORTC questionnaire (QLQ-CR 38).
Patients: a total of 116 patients with locally advanced rectal cancer surgically treated in our hospital from 1994 to 1999.
Results: quality of life scores for the various factors studied showed that quality of life was worse in women, in patients with tumors in the middle third of the rectum, and in patients undergoing low anterior resection.
Conclusions: factors influencing quality of life in patients surgically treated for locally advanced rectal cancer included sex, tumor site, and surgical technique. Since only this latter factor is modifiable, we suggest that the surgical technique be individualized in persons with mid-lower and lower-third tumors of the rectum, bearing in mind that quality of life in amputated patients is, in many respects, better than that of patients with preserved sphincters.

Key words: Quality of life. Rectal cancer. Factors.

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Pérez Lara JF, Navarro Pintilde;ero A, de la Fuente Perucho A. Study of factors related to quality of life in patients with locally advanced rectal cancer. Rev Esp Enferm Dig 2004; 96: 746-757.

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Recibido: 18-09-03.
Aceptado: 24-02-04.

Correspondencia: Francisco Javier Pérez Lara. Campos Elíseos, 16, 3º B. 29016 Málaga. Telf.: 650 454 333. e-mail: javinewyork@hotmail.es

 

INTRODUCTION

Cancer of the rectum is an important tumor accounting for 40% of all colorectal cancers. Surgery, which is the definitive treatment in patients with rectal cancer, is aimed not only at curing the patient but also at controlling symptoms (1). Unfortunately, patients are prone to suffering from a series of side effects with this type of surgery, since the dissection of the rectum may damage the autonomic pelvic plexus, thus leading to changes in sexual and urinary functions (2,3).

Unfortunately, there is general lack of agreement among researchers about which method or instrument is most suitable for gathering information on quality of life (QoL).

Several different techniques have been used, including structured, semi-structured, and non-structured interviews, and standardized or non-standardized questionnaires, which have subsequently resulted in a number of inconsistent findings.

Since it is important to base QoL studies on validated questionnaires, and only three of the studies of QoL in rectal cancer patients published in English use well-established and validated questionnaires (4-6), the current status of research regarding this issue is particularly unsatisfactory; it is therefore important that validated questionnaires be used in quality-of-life studies (7). The QLQ-C 30 questionnaire has been used for almost twenty years to evaluate QoL in cancer patients (8-12), and both QLQ-C 30 and QLQ-CR 38 have been tested in prospective randomized studies and hence are validated questionnaires (13,14).

We evaluated factors that determine QoL after surgery for rectal cancer, and where improvements can be made for the psychological, physical, and social welfare of patients.

MATERIAL AND METHODS

We designed a prospective cohort study to evaluate biological, clinical, therapeutic, and pathological factors influencing QoL in our patients with rectal cancer, and studied the specific weight of each factor.

PATIENTS

The study included all 116 patients receiving intention-to-cure, surgical treatment for locally advanced rectal cancer in our department from January 1994 to December 1999. Complete demographic, tumor, and treatment information is avaible in tables I and II.

Patients were followed up at the outpatient clinics, and those who failed to attend were telephoned in order to update data. The first revision took place one month after hospital discharge; revisions took place every six months for two years, and then yearly thereafter.

We undertook univariate and multivariate analyses of factors potentially involved in QoL. Factors were selected after literature reviews, and from those factors commonly involved in QoL measurements of patients surgically treated for rectal cancer. Nine factors were eventually included in the analysis: radiation therapy, tumor site, postoperative complications, sex, age, surgical technique, tumor stage (TNM), postoperative infection, and postoperative chemotherapy. QoL was evaluated using the Nottingham Health Profile and QLQ-CR 38 questionnaire. Patients were interviewed by the same person, either personally or by telephone. Seven patients were lost to the study (five who were unable to respond for varying reasons, such as Alzheimer's disease or senile dementia, and two who could not be traced).

Nottingham Health Profile

The Nottingham Health Profile is a generic questionnaire which enables the researcher to compare QoL among study patients. It is not a specific questionnaire for cancer patients, so that consideration is not given to changes in QoL due to treatment received -for instance, side effects of chemotherapy, or changes in QoL arising from colostomy. It was included in the study because it enabled us to compare group-related results to a healthy population. The Nottingham Health Profile, which has been validated in Spain by Instituto Municipal de Investigacioacute;n Médica at Barcelona, consists of 45 questions with yes/no answers, and it measures six dimensions: energy, pain, emotional responses, sleep, social isolation and physical mobility.

EORTC QLQ-CR 38 Questionnaire

In 1980 EORTC set up a QoL group, which in 1986 started a research program aiming at an integral approach to the assessment of QoL for cancer patients involved in clinical trials, which resulted in the design of the QLQ-CR 30 questionnaire. A specific model was later created for use in patients with colorectal cancer (QLQ-CR 38), regardless of cancer stage and treatment given, which has recently been validated in The Netherlands. QLQ-CR 38 includes two modules: function (body image, sexual function, sexual enjoyment, and future perspectives) and symptoms (urinary problems, chemotherapy-related side effects, gastrointestinal symptoms, male sexual problems, female sexual problems, defecation problems, stoma problems, and weight loss).

Statistical analysis

Student's t test was used for two-factor comparisons, and ANOVA for multiple-factor comparisons in the univariate analysis. Predictive variables were then included in a backward stepwise logistic regression analysis to evaluate their independent prognostic value. Differences with a p lt; 0.1 were considered statistically significant, which entails an alpha error below 10%.

RESULTS

The univariate analysis showed statistically significant QoL factors to be sex, site, and surgical technique. In the Nottingham Health Profile (Fig. 1), where a higher score reflects a worse QoL, women scored above men in all dimensions (men: 16.93, women: 31.91). This difference was greater than that usually seen between genders in the general population (men: 11, women: 19.7). The tumor site with the highest score was the middle third, so that it was these patients who had the worst QoL; this difference, however, was not statistically significant for any dimension (p = 0.206) (population score: 15.5; study scores: upper third = 19.45, middle third = 27.81, lower third = 21.24). Patients with a lower anterior resection had the worst QoL according to the Nottingham Health Profile, with scores which were statistically significant for the dimensions of energy (p = 0.083), pain (p = 0.051), emotional response (p = 0.004), and overall score (p = 0.062). The population score was 15.5, and the study score was: anterior resection = 20.11, lower anterior resection = 33.48, abdominoperineal amputation = 20.52.

In the functional scales of QLQ-CR 38 (Fig. 2) the maximum score (100) equates to complete functionality, with lower scores reflecting lower functionality and thus a poorer QoL. Women scored less than men in almost all items, with statistically significant differences for sexual function (p = 0.006) and sexual enjoyment (p = 0.002). Tumor site in the middle third reflected poorer QoL in all items except sexual function, though statistically significant differences were only seen in the multivariate analysis (p = 0.09). Again, the multivariate but not univariate analysis showed statistically significant differences for patients with lower anterior resection, with the poorest scores in all items except body image and sexual function, for which amputated patients had the worst scores.

In the symptom scales of QLQ-CR 38 (Fig. 3) a higher score reflects more severe symptoms, so that the higher the score the worse the QoL. Here, too, women scored higher than men in all items, differences becoming statistically significant for gastrointestinal symptoms (p = 0.000), weight loss (p = 0.045), and overall score (p = 0.028). Tumors in the middle third were those with the highest overall score (p = 0.052), and thus involved the most symptomatic patients. Differences resulting from surgical technique were not great, with the exception of statistically significant differences on the scale of male sexual problems, where amputated patients experienced more symptoms (p = 0.003).

A multivariate linear regression analysis showed independent factors of QoL to be the following: in the Nottingham Health Profile, sex (worse QoL for women: p = 0.001); in QLQ-CR 38 (functional scale), tumor site (worse for tumors in the middle third: p = 0.09), sex (worse for women: p = 0.003), and surgical technique (worse for patients treated by lower anterior resection: p = 0.074); and in QLQ-CR 38 (symptom scale), tumor site (worse symptoms for tumors of the middle third: p = 0.063).

DISCUSSION

QoL represents an individual's capacity to undertake daily activities, combined with satisfaction with one's state of health and balance between disease control and therapy-related side effects (15,16). Patients with rectal cancer suffer from a series of physical, social, and psychological problems after curative surgical treatment (17). Physical problems mostly relate to sexual function (18,19), as well as to intestinal (20,21) and urinary (22,23) problems. Men suffer from sexual problems such as impotence and ejaculatory difficulties, and women mainly from dyspareunia. Urinary problems include incontinence, urine retention, and dysuria. The prevalence of these symptoms is usually greater in patients with abdominoperineal amputation versus those with anterior resection (24). Most studies report a higher incidence of fecal incontinence after lower anterior resection.

In lower rectal tumors attempts may be made to preserve the sphincter by low anastomosis, but this sometimes results in numerous side effects, such as defecatory urgency or fecal incontinence (25). However, when a tumor precludes sphincter preservation because of its low location, rectal amputation and a left iliac fossa colostomy become necessary. The idea of sphincter-preserving surgery arose with the aim of improving QoL without compromising oncological safety. Nevertheless, anterior resection results in trauma to the sphincters due to the digital dilatation of the anal canal prior to the insertion of the circular stapler, and to the stapler itself. Horgan et al. (26) showed that sphincter pressure was significantly decreased after anterior resection.

The consequences of rectal surgery lead to important changes in QoL (27). Grumann (28) undertook a study of QoL in patients with rectal cancer, comparing abdominoperineal amputation to lower anterior resection by means of a validated questionnaire; he noted that QoL was not poorer in amputated patients, and results in these patients were in fact even better than in patients undergoing lower anterior resection. Hamashima reported a study suggesting that long-term quality of life could be recognized according to the characteristics of rectal cancer patients, regardless of the presence of a stoma (29).

In our study, too, patients with an abdominoperineal amputation had a better overall QoL than those with a low anastomosis, who reported a lower degree of satisfaction with their postoperative state. Indeed, patients with a lower anterior resection only reported a better QoL for male sexual problems, there being more lesions of the hypogastric plexus in amputated patients.

One possible explanation for these results may be the patients' expectations before surgery. Before undergoing an amputation patients consider how colostomy will affect their future life in light of the negative concepts held by the community concerning this operation. Although most patients due to undergo abdominoperineal amputation are very worried about the potential negative consequences of colostomy, they soon realize that their restrictions are more bearable than previously suspected. Patients with a low anastomosis are convinced that their symptoms will disappear after surgery. However, many patients will eventually feel unsatisfied and frustrated in view of their new surgery-associated problems.

Patients with tumors in the middle third of the rectum reported the worst score for location. This would seem logical considering that most patients with tumors in the lower third undergo abdominoperineal amputation, whereas many of those with tumors in the middle third have a lower anterior resection, so that results are to a certain extent extrapolatable.

Numerous QoL studies in groups with different pathologies have reported better results for men versus women (30-32). Our study showed that rectal cancer results in worsened QoL for women, far above the normal difference in the general population. Several explanations have been suggested for this. One is that women have more health-related problems, such as autoimmune disease or premenstrual syndrome, though this would not account for such great differences in QoL (33). Another suggestion is that because women have a greater life expectancy, they also have more physical problems, thus resulting in poorer QoL (34). Other authors suggest social disadvantages as a reason, since industrialized countries are still male-oriented, and the lower overall status of women may result in lower subjective QoL (35). A more simple explanation for these differences is that women generally find it easier than men to communicate personal information. It is socially acceptable for women to express their feelings and problems, whereas men tend to adopt a role of tolerating all sorts of problems (33).

In conclusion, QoL studies in cancer patients are of increasing importance. Their main aim is to determine the impact of tumors and their treatment on patient welfare. Besides the traditional patterns of following up such parameters as survival, relapse, or metastasis, testing QoL in these patients is also necessary to provide an overall idea of treatment outcome. Our study shows that QoL-modifying factors in patients undergoing surgery for locally advanced rectal cancer are sex, tumor site, and surgical technique. However, as only surgical technique is modifiable, we believe that the most suitable technique for patients with tumors of the mid-lower third will depend on each individual case, bearing in mind that QoL in amputated patients is to some extent better than in patients with preserved sphincters.

ACKNOWLEDGEMENTS

The authors wish to thank MAG. Sprangers (Department of Medical Psychology, J404, Academic Medical Centre, University of Amsterdam) for providing EORTC QLQ-CR 38, and JM Antoacute;, J Alonso, SM Hunt (IMIM-Barcelona) for the Nottingham Health Profile questionnaire. The authors are also grateful to Ian Johnstone for his English language editing.

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