Quality of life in long term survivors of colorectal cancer

Protocol for a randomized controlled trial of brief behavioral activation among older adult cancer survivors

INTRODUCTION

As many as 35% of older adult cancer survivors (OACS; i.e., ≥65 years old) have clinically significant depression. OACS often experience fatigue, mild cognitive impairment, and increased medical comorbidities post-cancer that make them susceptible to depression. Behavioral activation (BA) is an empirically supported depression treatment in geriatric psychiatry that guides individuals to reengage in pleasurable and rewarding activities and has great potential for addressing the needs of OACS. This manuscript presents the protocol for a pilot randomized controlled trial (RCT) testing the efficacy of a brief BA intervention adapted to address the needs of OACS (BBA-OACS) by telephone and videoconference delivery.

MATERIALS AND METHODS

An RCT will be conducted at Memorial Sloan Kettering Cancer Center (MSK) in New York City. Participants will be randomized to either BA as a target intervention or supportive psychotherapy (SP) as a standard of care control intervention for outpatient oncology. The target intervention includes 10 weekly sessions of BA consisting of psychoeducation about depression and the rationale for BA, life areas and values assessment, compilation of a list of enjoyable and important activities across values, activity scheduling, and self-monitoring of satisfaction and mood. The standard of care control intervention includes 10 weekly sessions of SP consisting of reassurance, guidance, encouragement, and support for patients with cancer. OACS who have a history of cancer, report elevated depressive symptoms, are fluent in English, and can communicate via telephone or videoconference will be recruited from the MSK Survivorship Clinics across all disease types. Seventy participants will be recruited for the study (10 training cases, 30 in each RCT arm). The primary aim is to evaluate implementation outcomes (i.e., acceptability, feasibility, and fidelity) of BA, relative to SP, for cancer survivorship. The secondary aim is to determine the preliminary effects of BA on depressive symptoms (primary outcome), anxiety, coping, and increased activity level (secondary outcomes) compared to SP. Participants will be asked to complete a set of three surveys pre- and post-intervention.

DISCUSSION

If successful, BBA-OACS would provide frontline clinicians with an accessible, evidence-based treatment for OACS. Future research will evaluate the efficacy of BA in a larger trial and its impact on depression and other healthcare outcomes.

TRIAL REGISTRATION

This study is registered under ClinicalTrials.gov (ID NCT05574127).

SCORE: a randomised controlled trial evaluating shared care (general practitioner and oncologist) follow-up compared to usual oncologist follow-up for survivors of colorectal cancer

BACKGROUND

SCORE is the first randomised controlled trial (RCT) to examine shared oncologist and general practitioner (GP) follow-up for survivors of colorectal cancer (CRC). SCORE aimed to show that shared care (SC) was non-inferior to usual care (UC) on the EORTC QLQ-C30 Global Health Status/Quality of Life (GHQ-QoL) scale to 12 months.

METHODS

The study recruited patients from five public hospitals in Melbourne, Australia between February 2017 and May 2021. Patients post curative intent treatment for stage I-III CRC underwent 1:1 randomisation to SC and UC. SC replaced two oncologist visits with GP visits and included a survivorship care plan and primary care management guidelines. Assessments were at baseline, 6 and 12 months. Difference between groups on GHQ-QoL to 12 months was estimated from a mixed model for repeated measures (MMRM), with a non-inferiority margin (NIM) of -10 points. Secondary endpoints included quality of life (QoL); patient perceptions of care; costs and clinical care processes (CEA tests, recurrences). Registration ACTRN12617000004369p.

FINDINGS

150 consenting patients were randomised to SC (N = 74) or UC (N = 76); 11 GPs declined. The mean (SD) GHQ-QoL scores at 12 months were 72 (20.2) for SC versus 73 (17.2) for UC. The MMRM mean estimate of GHQ-QoL across the 6 month and 12 month follow-up was 69 for SC and 73 for UC, mean difference -4.0 (95% CI: -9.0 to 0.9). The lower limit of the 95% CI did not cross the NIM. There was no clear evidence of differences on other QoL, unmet needs or satisfaction scales. At 12 months, the majority preferred SC (40/63; 63%) in the SC group, with equal preference for SC (22/62; 35%) and specialist care (22/62; 35%) in UC group. CEA completion was higher in SC. Recurrences similar between arms. Patients in SC on average incurred USD314 less in health costs versus UC patients.

INTERPRETATION

SC seems to be an appropriate and cost-effective model of follow-up for CRC survivors.

FUNDING

Victorian Cancer Agency and Cancer Australia.

Does Long-Term Bowel Function Change After Colectomy for Colon Malignancy?

INTRODUCTION

Current understanding of bowel function after colectomy for colon cancer is informed by conflicting data, making preoperative patient counseling difficult. Our previous work demonstrates bowel movement frequency increases by postoperative follow-up, while overall function does not change. Long-term changes are unknown. We aimed to evaluate changes to patient-reported bowel function after colectomy for colon malignancy.

METHODS

This is an observational study of patients that underwent colectomy for colon malignancy and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative and 30-d postoperative clinic visits. Long-term bowel function was assessed using the same questionnaire via telephone or surveillance clinic visit. Mean domain and Total COREFO scores were compared baseline to long-term using paired t-tests. Quality of life analysis was obtained using the Patient Reported Outcome Measurement Information System-10 Global Health questionnaire for patients who completed this measure at surveillance visits or via telephone.

RESULTS

Sixty-six patients met inclusion criteria. Median time between baseline and long-term questionnaire completion was 16 mo (interquartile range 11-30). Stool-related aspects (pain and bleeding with bowel movements, anal skin irritation) improved significantly from baseline to long-term. There were no other differences in any domain or Total COREFO score. Patient Reported Outcome Measurement Information System-10 scores demonstrated quality of life equivalent to the general US population.

CONCLUSIONS

Over the long-term, after colectomy for colon cancer, patients report improvements in stool-related aspects (pain and bleeding with bowel movements, anal skin irritation). Evidence-based preoperative patient counseling should include these findings.

A systematic review of the effects of positive versus negative framing on cancer treatment decision making

OBJECTIVE

Presenting treatment outcomes positively or negatively may differently influence treatment preferences and lead to sub-optimal decision in a medical context. This review systematically organised how positive versus negative framing of treatment outcomes influenced cancer treatment decisions of cancer patients and individuals without a cancer diagnosis.

DESIGN

Three databases (PubMed, PsycInfo and Scopus) were searched for studies reporting the effects of positive versus negative framing on cancer treatment decision-making from 1981 to December 2020.

MAIN OUTCOME MEASURE

The effects of positive versus negative framing on cancer treatment preferences and the elimination of framing effect were evaluated.

RESULTS

A total of 12 studies that met inclusion criteria were reviewed. Framing effect was consistently observed in individuals without a cancer diagnosis. There was not enough evidence to suggest a robust framing effect in cancer patients. Surgery was preferred in positive framing, whereas adjuvant therapy was preferred in negative framing. Justification intervention significantly eliminated framing effect. Mixed framing failed to eliminate framing effect.

CONCLUSION

Current recommendations for presenting treatment options are based on research in cancer-screening decision-making. Knowledge of how positive versus negative framing affect cancer patients' treatment decisions is still limited. Our review highlighted the need for continued research in this area.

Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection

BACKGROUND

Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear.

OBJECTIVE

The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome.

DESIGN

Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires.

SETTING

Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage.

PATIENTS

Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants.

RESULTS

The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003).

LIMITATIONS

The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms.

CONCLUSIONS

In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 .

SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO

ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).

Dignity and psychosocial related variables in elderly advanced cancer patients

INTRODUCTION

Most cancers occur in older individuals, who are more vulnerable due to functional impairment, multiple comorbidities, cognitive impairment, and lack of socio-familial support. These can undermine patients' sense of dignity. This study seeks to compare dignity scores in older patients with advanced cancer on sociodemographic and clinical variables and analyze the predictive value of anxiety, depression, functional limitations, and social support on dignity scores.

METHODS

A prospective, multicenter, observational study conducted with participation of 15 hospitals in Spain from February 2020 to October 2021. Patients with newly-diagnosed, advanced cancer completed the dignity (PPDS), anxiety and depression (BSI), Social Support (Duke-UNC-11), and functional limitations (EORTC-C30) scales. Lineal regression analyses explored the effects of anxiety, depression, functional status, and social support on dignity, adjusting for sociodemographic and clinical variables.

RESULTS

A total of 180 subjects participated in this study. The results of the correlation analysis revealed that dignity correlated negatively with anxiety, depression, and sex, and positively with social support, functional status, and longer estimated survival. Thus, women, and more anxious and depressed individuals scored lower on the dignity scale, whereas patients with more social support, fewer functional limitations, and longer estimated survival scored higher.

CONCLUSION

In conclusion, being female, having a lower educational level, lower estimated survival, depression, anxiety, less social support, and limited functionality are correlated with less dignity in the elderly with advanced cancer. It is a priority to manage both physical and psychological symptoms in patients with unresectable advanced cancer to mitigate psychological distress and increase their sense of dignity.

Stem Cell-Based Models for Studying the Effects of Cancer and Cancer Therapies on the Peripheral Nervous System

In recent years, the complexity of cancer and cancer therapies and their interactions with the peripheral nervous system have come into focus, but limitations in experimental models have remained a significant challenge in the field. As evidence, there are currently no therapies approved that target cancer-peripheral nervous system or cancer therapy-peripheral nervous system interactions as an anti-neoplastic or anti-neurotoxic agent, respectively. Human pluripotent stem cells offer an appealing model system that, unlike rodent models, is compatible with high throughput, high content applications; techniques that reflect modern drug discovery methodologies. Thus, utilizing the key advantages of stem cell-based models in tandem with the strengths of traditional animal models offers a complementary and interdisciplinary strategy to advance cancer and cancer therapy-peripheral nervous system research and drug discovery. In this review, the current status of the cancer-peripheral nervous system and cancer therapy-peripheral nervous system research is discussed, examples where stem cell-based models have been implemented are described, and avenues where stem cell-based models may further advance the field are proposed.

Health-Related Quality of Life in Metastatic Colorectal Cancer Patients Treated with Curative Resection and/or Local Ablative Therapy or Systemic Therapy in the Finnish RAXO-Study

Metastasectomy and/or local ablative therapy in metastatic colorectal cancer (mCRC) patients often provide long-term survival. Health-related quality of life (HRQoL) data in curatively treated mCRC are limited. In the RAXO-study that evaluated repeated resectability, a multi-cross-sectional HRQoL substudy with 15D, EQ-5D-3L, QLQ-C30, and QLQ-CR29 questionnaires was conducted. Mean values of patients in different treatment groups were compared with age- and gender-standardized general Finnish populations. The questionnaire completion rate was 444/477 patients (93%, 1751 questionnaires). Mean HRQoL was 0.89−0.91 with the 15D, 0.85−0.87 with the EQ-5D, 68−80 with the EQ-5D-VAS, and 68−79 for global health status during curative treatment phases, with improvements in the remission phase (disease-free >18 months). In the remission phase, mean EQ-5D and 15D scores were similar to the general population. HRQoL remained stable during first- to later-line treatments, when the aim was no longer cure, and declined notably when tumour-controlling therapy was no longer meaningful. The symptom burden affecting mCRC survivors’ well-being included insomnia, impotence, urinary frequency, and fatigue. Symptom burden was lower after treatment and slightly higher, though stable, through all phases of systemic therapy. HRQoL was high in curative treatment phases, further emphasizing the strategy of metastasectomy in mCRC when clinically meaningful.

Quality of life of colorectal cancer survivors participating in a pilot randomized controlled trial of physical activity trackers and daily text messages

Purpose

There are over 1.3 million colorectal cancer (CRC) survivors in the USA, many of whom report lower health-related quality of life (HRQoL) years after treatment. This study aimed to explore the effect of digital health tools on HRQoL in CRC survivors.

Methods

We conducted a two-arm, randomized controlled trial of 42 subjects who had completed treatment for CRC. Participants in the intervention arm received a Fitbit Flex™ and daily text messages for 12 weeks. HRQoL was assessed as a secondary endpoint in both arms at enrollment and 12 weeks using the Medical Outcomes Study Short Form Survey (SF-36) and the Functional Assessment of Cancer Therapy–Colorectal (FACT-C). Survey score changes from enrollment to 12 weeks were compared between the two arms using independent t tests, and scores at enrollment and 12 weeks were compared using paired t tests.

Results

An increase in the FACT-C functional well-being subscale was observed in individuals in the intervention arm pre- to post-intervention (median difference, 2; interquartile range (IQR), 1, 4; P = .02). Although the between-group comparison was not statistically significant, no change in the functional well-being subscale was observed in the control arm (median difference, 0; IQR, 1, 1; P = .71). No other measures of HRQoL appeared to differ within arm across time points or between arms.

Conclusion

A 12-week digital physical activity intervention may improve functional well-being among CRC survivors. Larger randomized studies are needed to determine if digital health tools improve functional well-being among CRC survivors and if this improvement can be sustained over time.

Trial registration

NCT02966054; registration date, November 17, 2016

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-06870-5.

Thai oncology nurses' perspectives toward survivorship care plan components and implementation for colorectal cancer survivors

PURPOSE

To describe oncology nurses' perspectives regarding survivorship care plan (SCP) components and implementation for colorectal cancer (CRC) survivors in Thailand.

METHODS

A cross-sectional, descriptive online study was conducted between October and November 2020. Thai oncology nurses were recruited using Facebook and the Line application. Study participants (n = 160) rated the usefulness of four standard SCP components (treatment summaries, surveillance, late/long-term effects, and health promotion and psychosocial needs; n = 23 items) and gave input on the implementation of SCPs in clinical practice (n = 11 items). Data were analyzed using descriptive statistics.

RESULTS

Most oncology nurses supported providing CRC survivors with SCPs (93.2%) and felt that SCPs were an important part of their practice (93.7%). Nurses rated all four SCP components as "very useful," including treatment summaries (76.4%), surveillance (81.9%), late/long-term effects (85.7%), and health behavior and psychosocial concerns (80.2%). In terms of implementation, most nurses indicated that oncologists should prepare (84.4%) and provide SCPs (95%), but 61.9% and 69.4% of nurses, respectively, also believed that they should perform these tasks. In addition, most nurses indicated that they should play a significant role in the ongoing management of CRC survivors (95.7%) and that evidence-based surveillance guidelines are needed (96.2%).

CONCLUSION

Oncology nurses believed that the four SCP components were helpful to the long-term management of CRC survivors, supported SCP provision, and expressed their perceived responsibilities for preparing and delivering SCPs. The findings suggested opportunities for oncology nurses to play a significant role in developing and implementing SCPs. However, additional efforts are needed to expand nurses' roles in survivorship care and establish practice guidelines that will facilitate integration of SCPs into nursing practice.

Quality of life in restorative versus non-restorative resections for rectal cancer: systematic review

Background

Low rectal cancers could be treated using restorative (anterior resection, AR) or non-restorative procedures with an end/permanent stoma (Hartmann’s, HE; or abdominoperineal excision, APE). Although the surgical choice is determined by tumour and patient factors, quality of life (QoL) will also influence the patient's future beyond cancer. This systematic review of the literature compared postoperative QoL between the restorative and non-restorative techniques using validated measurement tools.

Methods

The review was registered on PROSPERO (CRD42020131492). Embase and MEDLINE, along with grey literature and trials websites, were searched comprehensively for papers published since 2012. Inclusion criteria were original research in an adult population with rectal cancer that reported QoL using a validated tool, including the European Organization for Research and Treatment of Cancer QLQ-CR30, QLQ-CR29, and QLQ-CR38. Studies were included if they compared AR with APE (or HE), independent of study design. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were: QoL, pain, gastrointestinal (GI) symptoms (stool frequency, flatulence, diarrhoea and constipation), and body image.

Results

Nineteen studies met the inclusion criteria with a total of 6453 patients; all papers were observational and just four included preoperative evaluations. There was no identifiable difference in global QoL and pain between the two surgical techniques. Reported results regarding GI symptoms and body image documented similar findings. The ROBINS-I tool highlighted a significant risk of bias across the studies.

Conclusion

Currently, it is not possible to draw a firm conclusion on postoperative QoL, pain, GI symptoms, and body image following restorative or non-restorative surgery. The included studies were generally of poor quality, lacked preoperative evaluations, and showed considerable bias in the data.

The burden of colorectal cancer survivors in the Netherlands: costs, utilities, and associated patient characteristics

Purpose

The aim of this study is to assess the societal burden of colorectal cancer (CRC) survivorship 2–10 years post-diagnosis in terms of (1) societal costs, and (2) quality of life/utilities, and to analyze associated patient characteristics.

Methods

This is a cross-sectional, bottom-up prevalence-based burden of disease study, conducted from a societal perspective in the Netherlands. In total, 155 CRC survivors were included. Utilities were measured by the EQ-5D-5L, using the Dutch tariffs. A cost questionnaire was developed to obtain cost information. Subgroup analyses were performed, based on patient characteristics and sensitivity analyses.

Results

Of all CRC survivors, 81(54%) reported no problems for mobility, 133(88%) for self-care, 98(65%) for daily activities, 59(39%) for pain/discomfort, and 112(74%) for anxiety/depression on the EQ-5D-5L. The average EQ-5D-5L utility score was 0.82 (SD = 0.2) on a scale from 0 (death) to 1 (perfect health). Significant differences in utility score were found for gender, tumor stage, number of comorbidities, and lifestyle score. The average societal costs per CRC survivor per 6 months were estimated at €971 (min = €0, max = €32,425). Significant differences in costs were found for the number of comorbidities.

Conclusions

This study shows a considerable burden of CRC survivors 2–10 years after diagnosis, in comparison with survivors sooner after diagnosis and with healthy individuals in the Netherlands.

Implications for Cancer Survivors

Long-term care of CRC survivors should focus on improving the societal burden by identifying modifiable factors, as summarized in the WCRF/AICR lifestyle score, including body composition, physical activity, and diet.

Cannabis use is associated with patient and clinical factors in a population-based sample of colorectal cancer survivors

PURPOSE

This study aimed to characterize patient and clinical factors associated with cannabis (marijuana) use among patients diagnosed with colorectal cancer (CRC).

METHODS

We identified CRC patients, diagnosed from 2016 to 2018, using the Seattle-Puget Sound Surveillance, Epidemiology, and End Results (SEER) cancer registry. CRC patients were recruited via mail and telephone, and participants completed a questionnaire eliciting information on medical history, demographics, and lifestyle factors, including cannabis use. Cancer stage was obtained from SEER registry data.

RESULTS

Of 1,433 survey respondents, 339 (24%) were current cannabis users. Current cannabis use was associated with younger age at diagnosis, lower BMI, and a higher prevalence of cigarette smoking and alcohol consumption (p-value < 0.05). Cannabis use was also associated with lower quality of life scores (FACT-C) and advanced-stage cancer (p-value < 0.05).

CONCLUSION

Cannabis use among CRC patients was common. Patients with more advanced disease were more likely to report cannabis use. Use also varied by some personal factors, consistent with patterns in the general population. Given the high prevalence of cannabis use among CRC patients, research is needed to determine the benefits and harms of cannabis use for symptom management in cancer patients.

Associations of Household Income with Health-Related Quality of Life Following a Colorectal Cancer Diagnosis Varies With Neighborhood Socioeconomic Status

BACKGROUND

Existing evidence indicates household income as a predictor of health-related quality of life (HRQoL) following a colorectal cancer diagnosis. This association likely varies with neighborhood socioeconomic status (nSES), but evidence is limited.

METHODS

We included data from 1,355 colorectal cancer survivors participating in the population-based Puget Sound Colorectal Cancer Cohort (PSCCC). Survivors reported current annual household income; we measured HRQoL via the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) tool. Using neighborhood data summarized within a 1-km radial buffer of Census block group centroids, we constructed a multidimensional nSES index measure. We employed survivors' geocoded residential addresses to append nSES score for Census block group of residence. With linear generalized estimating equations clustered on survivor location, we evaluated associations of household income with differences in FACT-C mean score, overall and stratified by nSES. We used separate models to explore relationships for wellbeing subscales.

RESULTS

We found lower household income to be associated with clinically meaningful differences in overall FACT-C scores [<$30K: -13.6; 95% confidence interval (CI): -16.8 to -10.4] and subscale wellbeing after a recent colorectal cancer diagnosis. Relationships were slightly greater in magnitude for survivors living in lower SES neighborhoods.

CONCLUSIONS

Our findings suggest that recently diagnosed lower income colorectal cancer survivors are likely to report lower HRQoL, and modestly more so in lower SES neighborhoods.

IMPACT

The findings from this work will aid future investigators' ability to further consider the contexts in which the income of survivors can be leveraged as a means of improving HRQoL.

Cost-Effectiveness of Anti-Epidermal Growth Factor Receptor Therapy Versus Bevacizumab in KRAS Wild-Type (WT), Pan-RAS WT, and Pan-RAS WT Left-Sided Metastatic Colorectal Cancer

Objectives

We aimed to compare the economic value of chemotherapy plus anti-epidermal growth factor receptor (anti-EGFR) monoclonal antibody (mAb) against chemotherapy with bevacizumab (Bev, an anti-vascular endothelial growth factor mAb) as first-line treatment in KRAS wild-type (WT), pan-RAS WT and pan-RAS WT left-sided metastatic colorectal cancer (mCRC) patients from the Hong Kong societal perspective.

Materials and Methods

We developed Markov models and 10-year horizon to estimate costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of chemotherapy plus anti-EGFR therapy against chemotherapy plus Bev in KRAS WT, pan-RAS WT, and pan-RAS WT left-sided mCRC. We considered two times of the local gross domestic product per capita (GDPpc) as the willingness-to-pay (WTP) threshold (2× GDPpc; US$97,832).

Results

Adding anti-EGFR mAb to chemotherapy provides additional 0.24 (95% confidence interval [CI] 0.19-0.29), 0.32 (95% CI 0.27-0.37), and 0.57 (95% CI 0.49-0.63) QALY compared to adding Bev in KRAS WT, pan-RAS WT, and left-sided pan-RAS WT mCRC populations respectively. The corresponding ICER is US$106,847 (95% CI 87,806-134,523), US$88,565 (95% CI 75,678-105,871), US$76,537 (95% CI 67,794-87,917) per QALY gained, respectively.

Conclusions

Anti-EGFR therapy is more cost-effective than Bev as a first-line targeted therapy in left-sided pan-RAS WT and pan-RAS WT, with ICER <US$100,000/QALY, compared to KRAS WT mCRC population.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People

OBJECTIVE

To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults.

PATIENTS AND METHODS

A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019.

RESULTS

With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy.

CONCLUSION

Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Communication in decision aids for stage I-III colorectal cancer patients: a systematic review

OBJECTIVES

To assess the communicative quality of colorectal cancer patient decision aids (DAs) about treatment options, the current systematic review was conducted.

DESIGN

Systematic review.

DATA SOURCES

DAs (published between 2006 and 2019) were identified through academic literature (MEDLINE, Embase, CINAHL, Cochrane Library and PsycINFO) and online sources.

ELIGIBILITY CRITERIA

DAs were only included if they supported the decision-making process of patients with colon, rectal or colorectal cancer in stages I-III.

DATA EXTRACTION AND SYNTHESIS

After the search strategy was adapted from similar systematic reviews and checked by a colorectal cancer surgeon, two independent reviewers screened and selected the articles. After initial screening, disagreements were resolved with a third reviewer. The review was conducted in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DAs were assessed using the International Patient Decision Aid Standards (IPDAS) and Communicative Aspects (CA) checklist.

RESULTS

In total, 18 DAs were selected. Both the IPDAS and CA checklist revealed that there was a lot of variation in the (communicative) quality of DAs. The findings highlight that (1) personalisation of treatment information in DAs is lacking, (2) outcome probability information is mostly communicated verbally and (3) information in DAs is generally biased towards a specific treatment. Additionally, (4) DAs about colorectal cancer are lengthy and (5) many DAs are not written in plain language.

CONCLUSIONS

Both instruments (IPDAS and CA) revealed great variation in the (communicative) quality of colorectal cancer DAs. Developers of patient DAs should focus on personalisation techniques and could use both the IPDAS and CA checklist in the developmental process to ensure personalised health communication and facilitate shared decision making in clinical practice.

Cost-Effectiveness Analysis of Stereotactic Ablative Radiation Therapy in Patients With Oligometastatic Cancer

PURPOSE

The Stereotactic Ablative Radiation therapy for Comprehensive Treatment of Oligometastatic Tumors phase 2 randomized clinical trial found that stereotactic ablative radiation therapy (SABR) improved outcomes among cancer patients with oligometastatic disease. Yet, the cost of SABR along with the large number of patients with oligometastatic disease raises the important question of value. This study sought to evaluate the cost-effectiveness of the addition of SABR compared with standard therapy alone among cancer patients with oligometastatic disease.

METHODS AND MATERIALS

We constructed a Markov model to simulate treatment with stereotactic ablative radiation therapy or standard therapy among patients with oligometastatic cancers. The model derived transition probabilities from Stereotactic Ablative Radiation therapy for Comprehensive Treatment of Oligometastatic Tumors clinical trial data to estimate risks of toxicity, disease progression and survival. Health care costs and health utilities were estimated from the literature. Probabilistic and one-way sensitivity analyses evaluate model uncertainty. Cost-effectiveness was estimated from both the health care sector and societal perspectives with an incremental cost-effectiveness ratio (ICER) defined as dollars per quality-adjusted life year (QALY). An ICER less than $100,000/QALY was considered cost-effective. One-way and probabilistic sensitivity analyses were used to examine model uncertainty.

RESULTS

The addition of SABR increased total costs by $54,260 (health care sector perspective) or $72,799 (societal perspective) and improved effectiveness by 1.88 QALYs compared with standard therapy, leading to an ICER of $28,906/QALY (health care sector perspective) or $38,783/QALY (societal perspective). The model was modestly sensitive to assumptions about tumor progression, although the model was not sensitive to assumptions about survival or cost of treatment. Probabilistic sensitivity analyses demonstrated that SABR was the cost-effective treatment option 99.8% (health care sector perspective) or 98.7% (societal perspective) of the time.

CONCLUSIONS

The addition of SABR increased costs and improved quality adjusted survival, overall leading to a cost-effective treatment strategy for patients with oligometastatic cancer.

Factors influencing physical activity in patients with colorectal cancer

BACKGROUND

Physical activity (PA) is a modifiable health behaviour in patients with colorectal cancer (CRC). Knowing the possible predictors of PA will contribute to producing physical and psychological benefits for CRC patients.

OBJECTIVE

To investigate the factors that influence PA in patients with CRC.

METHODS

This cross-sectional study was conducted with 47 participants with CRC. Demographic and clinical characteristics, neuropathic pain (Douleur Neuropathique 4 (DN4)), peripheral muscle strength (knee extensor and flexor, hip extensor and flexor, and ankle dorsiflexor muscle strength), balance (Balance Master System (BMS) and Berg Balance Scale (BBS)), fatigue (Brief Fatigue Inventory (BFI)), PA (International PA Questionnaire Short Form (IPAQ-SF)), and quality of life (36-item Short Form Health Survey (SF-36)) were evaluated. Multiple linear regression analysis was used to determine the variables that have the greatest influence on PA.

RESULTS

IPAQ-SF score had moderate correlations with knee extensor muscle strength (r = 0.310, p = 0.034), BBS (r = 0.361, p = 0.013), and limit of stability test (movement velocity) score (r = 0.385, p = 0.008), BFI- severity of fatigue (r = - 0.488, p = 0.001), impact of fatigue on daily functioning (r = - 0.421, p = 0.003), and the SF-36 sub-parameters (role limitations due to physical health problems, physical functioning, general health perceptions and vitality) (p < 0.05). Role limitations due to physical problems, knee extensor muscle strength, and severity of fatigue had the greatest influence on PA in patients with CRC with explaining 43% of the variance in PA.

CONCLUSIONS

This study suggests that quality of life, knee extensor muscle strength, and fatigue have the greatest influence on PA in patients with CRC.

Health status, lifestyle habits, and perceived social support in long-term cancer survivors: a cross-sectional study

OBJECTIVE

To compare the presence of comorbidities and self-perceived health and social support between long-term cancer survivors and people without a history of cancer from a clinical trial examining the effects of a multiple risk behavior intervention.

RESULTS

Of the 4259 people studied, 190 (4.46%) were cancer survivors. They had a mean ± SD age of 62.8 ± 7 years vs. 58.7 ± 8 years (P < 0.01) for non-cancer people and were more likely to be on long-term sick leave (11.9 vs. 3.5%, P < 0.001). No differences were observed for smoking, adherence to the Mediterranean diet, physical activity, obesity, or social support. Cancer survivors were more likely to have worse self-perceived health (OR 1.82; 95% CI 1.02-2.75), more comorbidities (OR 1.68; 95% CI 1.18-2.39), COPD (OR 2.17; 95% CI 1.25-3.78), and depression (OR 1.65; 95% CI 1.06-2.57). Older age and worse self-perceived health were independent predictors of survivorship in the adjusted analysis.

Physical functional limitations and psychological distress in people with and without colorectal cancer: findings from a large Australian study

PURPOSE

To quantify physical disability and psychological distress in people with and without colorectal cancer (CRC).

METHODS

Questionnaire data (2006-2009) from 267,153 Australian general population members aged ≥ 45 years participating in the 45 and Up Study (n = 213,231 following exclusions) were linked to cancer registry and hospital admission data, to ascertain CRC status. Modified Poisson regression estimated adjusted prevalence ratios (PRs) for physical disability and psychological distress in participants with CRC versus those without.

RESULTS

Compared with participants without CRC (n = 210,836), CRC survivors (n = 2395) had significantly higher physical disability prevalence (11.9% versus 19.5%, respectively), PR = 1.11 (95% CI = 1.03-1.20); and a similar prevalence of distress (23.1% versus 20.2%), PR = 1.03 (0.94-1.20). Adverse outcomes were associated with certain clinical characteristics. Compared with participants without CRC, CRC survivors diagnosed 5-< 10 and ≥ 10 years, with regional spread, and without recent cancer treatment had broadly similar outcomes; survivors with metastatic CRC and recent treatment had 30-60% higher prevalence of disability and distress. Compared with participants with neither CRC nor disability, PRs for distress were 4.71 (4.22-5.26) for those with disability and CRC; and 4.22 (4.13-4.31) for those with disability without CRC.

CONCLUSIONS

Physical disability is elevated in CRC survivors. Psychological distress is elevated 4- to 5-fold with disability, regardless of CRC diagnosis, with lesser increases around diagnosis and treatment.

IMPLICATIONS FOR CANCER SURVIVORS

CRC survivors with less advanced disease and who have not been recently diagnosed or treated have physical disability and psychological distress comparable to the general population. Survivors with disability are at particularly high risk of psychological distress.

Quality of life and the negative impact of comorbidities in long-term colorectal cancer survivors: a population-based comparison

PURPOSE

Colorectal cancer (CRC) is the third most common cancer in the USA. The objective of this study was to compare quality of life (QoL) across long-term colorectal cancer survivors and unaffected matched controls while adjusting for comorbidities.

METHODS

The National Cancer Institute (NCI)-funded Colon Cancer Family Registry (CCFR) was used to randomly select and recruit CRC survivors (≥ 5 years from diagnosis) and matched controls for a cross-sectional survey. Nine geographically diverse sites in the USA from the CCFR participated in the study. Telephone interviews were conducted using computer-assisted methods to assess QoL.

RESULTS

A total of 403 cases and 401 controls were included in the final sample. Unadjusted comparison revealed no significant difference between CRC survivors and controls with respect to measures of fatigue, social, emotional, functional, and physical well-being. Multivariate logistic regression revealed that case status had a significant negative influence on colorectal cancer-specific QoL measures. Higher comorbidity indices had a significant negative influence on overall QoL regardless of case status.

CONCLUSIONS

Quality of life among long-term CRC survivors is similar to control subjects, with the exception of worse CRC-specific QoL measures. Higher comorbidity indices were independently associated with poor QoL for both cases and controls.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors and healthcare providers should be aware that long-term QoL is comparable to the general population; however, there is potential that digestive tract-specific issues may persist.

Physical activity interventions for disease-related physical and mental health during and following treatment in people with non-advanced colorectal cancer

BACKGROUND

Colorectal cancer is the third most commonly diagnosed cancer worldwide. A diagnosis of colorectal cancer and subsequent treatment can adversely affect an individuals physical and mental health. Benefits of physical activity interventions in alleviating treatment side effects have been demonstrated in other cancer populations. Given that regular physical activity can decrease the risk of colorectal cancer, and cardiovascular fitness is a strong predictor of all-cause and cancer mortality risk, physical activity interventions may have a role to play in the colorectal cancer control continuum. Evidence of the efficacy of physical activity interventions in this population remains unclear.

OBJECTIVES

To assess the effectiveness and safety of physical activity interventions on the disease-related physical and mental health of individuals diagnosed with non-advanced colorectal cancer, staged as T1-4 N0-2 M0, treated surgically or with neoadjuvant or adjuvant therapy (i.e. chemotherapy, radiotherapy or chemoradiotherapy), or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), along with OVID MEDLINE, six other databases and four trial registries with no language or date restrictions. We screened reference lists of relevant publications and handsearched meeting abstracts and conference proceedings of relevant organisations for additional relevant studies. All searches were completed between 6 June and 14 June 2019.

SELECTION CRITERIA

We included randomised control trials (RCTs) and cluster-RCTs comparing physical activity interventions, to usual care or no physical activity intervention in adults with non-advanced colorectal cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, performed the data extraction, assessed the risk of bias and rated the quality of the studies using GRADE criteria. We pooled data for meta-analyses by length of follow-up, reported as mean differences (MDs) or standardised mean differences (SMDs) using random-effects wherever possible, or the fixed-effect model, where appropriate. If a meta-analysis was not possible, we synthesised studies narratively.

MAIN RESULTS

We identified 16 RCTs, involving 992 participants; 524 were allocated to a physical activity intervention group and 468 to a usual care control group. The mean age of participants ranged between 51 and 69 years. Ten studies included participants who had finished active treatment, two studies included participants who were receiving active treatment, two studies included both those receiving and finished active treatment. It was unclear whether participants were receiving or finished treatment in two studies. Type, setting and duration of physical activity intervention varied between trials. Three studies opted for supervised interventions, five for home-based self-directed interventions and seven studies opted for a combination of supervised and self-directed programmes. One study did not report the intervention setting. The most common intervention duration was 12 weeks (7 studies). Type of physical activity included walking, cycling, resistance exercise, yoga and core stabilisation exercise. Most of the uncertainty in judging study bias came from a lack of clarity around allocation concealment and blinding of outcome assessors. Blinding of participants and personnel was not possible. The quality of the evidence ranged from very low to moderate overall. We did not pool physical function results at immediate-term follow-up due to considerable variation in results and inconsistency of direction of effect. We are uncertain whether physical activity interventions improve physical function compared with usual care. We found no evidence of effect of physical activity interventions compared to usual care on disease-related mental health (anxiety: SMD -0.11, 95% confidence interval (CI) -0.40 to 0.18; 4 studies, 198 participants; I2 = 0%; and depression: SMD -0.21, 95% CI -0.50 to 0.08; 4 studies, 198 participants; I2 = 0%; moderate-quality evidence) at short- or medium-term follow-up. Seven studies reported on adverse events. We did not pool adverse events due to inconsistency in reporting and measurement. We found no evidence of serious adverse events in the intervention or usual care groups. Minor adverse events, such as neck, back and muscle pain were most commonly reported. No studies reported on overall survival or recurrence-free survival and no studies assessed outcomes at long-term follow-up We found evidence of positive effects of physical activity interventions on the aerobic fitness component of physical fitness (SMD 0.82, 95% CI 0.34 to 1.29; 7 studies, 295; I2 = 68%; low-quality evidence), cancer-related fatigue (MD 2.16, 95% CI 0.18 to 4.15; 6 studies, 230 participants; I2 = 18%; low-quality evidence) and health-related quality of life (SMD 0.36, 95% CI 0.10 to 0.62; 6 studies, 230 participants; I2 = 0%; moderate-quality evidence) at immediate-term follow-up. These positive effects were also observed at short-term follow-up but not medium-term follow-up. Only three studies reported medium-term follow-up for cancer-related fatigue and health-related quality of life.

AUTHORS' CONCLUSIONS

The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. We are uncertain whether physical activity interventions improve physical function. Physical activity interventions may have no effect on disease-related mental health. Physical activity interventions may be beneficial for aerobic fitness, cancer-related fatigue and health-related quality of life up to six months follow-up. Where reported, adverse events were generally minor. Adequately powered RCTs of high methodological quality with longer-term follow-up are required to assess the effect of physical activity interventions on the disease-related physical and mental health and on survival of people with non-advanced colorectal cancer. Adverse events should be adequately reported.

Patient-reported symptom burden as a prognostic factor in treatment with first-line cetuximab plus chemotherapy for unresectable metastatic colorectal cancer: Results of Phase II QUACK trial

Background

It remains unclear whether patients’ self‐perceptions of symptoms at baseline clinically impact the prognostic relevance, treatment efficacy, or toxicity profiles in metastatic colorectal cancer (mCRC) patients treated with the first‐line cetuximab and standard chemotherapy.

Methods

The data were collected from a prospective trial that assessed the relationships between quality of life (QOL), treatment efficacy, and adverse events (AEs).

Results

The analysis of 137 mCRC patients revealed a significant association between the presence of baseline tumor‐related symptoms and a lower overall survival (OS) compared to the absence of symptoms (HR, 2.49; 95% CI, 1.37‐4.62; P = .003). The asymptomatic responders had favorable outcomes compared to the symptomatic nonresponders (2‐year OS rates: 83.6% and 35.9%, respectively), while the symptomatic responders had similar outcomes to the asymptomatic nonresponders. The median postprogression survival differed significantly: 10.2 months for the symptomatic patients and 15.9 months for the asymptomatic patients (HR, 2.29; 95% CI, 1.25‐4.29, P = .008). The objective response rates and patient toxicity profiles were similar irrespective of the severity of baseline symptoms.

Conclusion

Baseline symptoms were associated with worse OS but not with impaired treatment efficacy or more frequent AEs in mCRC patients treated with cetuximab in addition to chemotherapy.

Relationship between health literacy and quality of life among cancer survivors in China: a cross-sectional study

OBJECTIVE

To evaluate the association between health literacy (HL) and quality of life (QOL) among cancer survivors in China.

DESIGN

Cross-sectional study in China.

SETTING AND PARTICIPANTS

This is a cross-sectional observational study of 4589 cancer survivors aged 18 years and older from the Shanghai Cancer Rehabilitation Club. Participants were enrolled and completed the questionnaires between May and July 2017.

MEASUREMENT

HL was assessed by three established screening questions and QOL was evaluated using the simplified Chinese version of the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 items. Answers to all questionnaires were collected through face-to-face interviews or through self-administered questionnaires for literate participants. Participants were excluded if they did not answer any one of the HL questions. Baseline characteristics were compared by levels of HL using χ² test for categorical variables and Wilcoxon rank-sum test for non-normal continuous variables. The item response theory (IRT) was used to evaluate the existing measure of HL. Linear regression and logistic regression models were used to investigate the association between HL and QOL. SAS V.9.4 and MULTILOG V.7.03 were used in the analysis.

RESULTS

There were 4589 participants included in the study. The calculated results of IRT scale parameters of HL entries indicate that the entries have better discrimination and difficulty. Of the 4589 respondents, 159 (3.5%) had low HL. After adjusting for sociodemographic characteristics, treatment regimen and years with cancers, for each one-point decrement in HL score the QOL score increased by 2.07 (p<0.001). Cancer survivors with low HL were less likely than those with adequate HL to achieve better QOL. In logistic regression, low HL was independently associated with poor QOL (adjusted OR, 2.81; 95% CI 1.94 to 4.06; p<0.001).

CONCLUSIONS

Low HL was independently associated with poor QOL among cancer survivors of the Shanghai Cancer Rehabilitation Club.

Mental Health Disorders are More Common in Colorectal Cancer Survivors and Associated With Decreased Overall Survival

OBJECTIVES

To determine the risk and risk factors for mental illness among colorectal cancer (CRC) survivors across short-term and long-term follow-up periods.

METHODS

We used the Utah Cancer Registry to identify CRC survivors diagnosed between 1997 and 2013. Mental health diagnoses were available in electronic medical records and statewide facilities data that were linked by the Utah Population Database. CRC survivors were matched to individuals from a general population cohort. The risk of developing a mental illness was compared between cohorts. The association between mental illness and mortality was also analyzed.

RESULTS

In total, 8961 CRC survivors and 35,897 individuals in a general population cohort were identified. CRC survivors were at increased risk for any mental health diagnosis at 0 to 2 years (hazard ratio [HR], 3.70; 95% confidence interval [CI], 3.47-3.95), >2 to 5 years (HR, 1.23; 95% CI, 1.09-1.38), and >5 years (HR, 1.20; 95% CI, 1.07-1.36) after cancer diagnosis. CRC survivors were also at increased risk of depressive disorders specifically during the same time periods. At >5 years, CRC survivors still had an increased risk of developing many mental health diagnoses. Factors associated with increased risk of any mental health disorder among CRC survivors included colostomy and Charlson Comorbidity Index of 1+. There was an increased risk of death for CRC survivors diagnosed with any mental health disorder (HR, 2.18; 95% CI, 2.02-2.35) and depression (HR, 2.10; 95% CI, 1.92-2.28).

CONCLUSIONS

CRC survivors are at increased risk for mental health disorders in the short-term and long-term. Survivors who develop mental health disorders also experience decreased survival.

Supportive care needs of patients following treatment for colorectal cancer: risk factors for unmet needs and the association between unmet needs and health-related quality of life-results from the ColoREctal Wellbeing (CREW) study

Purpose

To investigate unmet needs of patients with colorectal cancer (CRC) at the end of treatment and whether unmet needs improve over time. Identify predictors of need following treatment and whether unmet need is associated with worse health-related quality of life (HRQoL).

Methods

As part of the UK ColoREctal Wellbeing (CREW) cohort study, patients treated for CRC completed the Supportive Care Needs Survey Short Form-34 (SCNS SF-34) 15 and 24 months following surgery, along with questionnaires measuring HRQoL, wellbeing, life events, social support, and confidence to manage their cancer before surgery, 3, 9, 15, and 24 months post-surgery.

Results

The SCNS SF-34 was completed by 526 patients at 15 months and 510 patients at 24 months. About one-quarter of patients had at least one moderate or severe unmet need at both time points. Psychological and physical unmet needs were the most common and did not improve over time. Over 60% of patients who reported 5 or more moderate or severe unmet needs at 15 months experienced the same level of unmet need at 24 months. HRQoL at the beginning of treatment predicted unmet needs at the end of treatment. Unmet needs, specifically physical, psychological, and health system and information needs, were associated with poorer health and HRQoL at the end of treatment.

Conclusions

Unmet needs persist over time and are associated with HRQoL. Evaluation of HRQoL at the start of treatment would help inform the identification of vulnerable patients. Assessment and care planning in response to unmet needs should be integrated into person-centred care.

Implications for Cancer Survivors

Early identification of CRC patients at risk of unmet needs will help infrom personalised survivorship care plans. The implementation of personalised and tailored services are likely to confer HRQoL gains.

Electronic supplementary material

The online version of this article (10.1007/s11764-019-00805-6) contains supplementary material, which is available to authorized users.

Patient-Reported Unmet Needs in Colorectal Cancer Survivors After Treatment for Curative Intent

BACKGROUND

With improving survival from colorectal cancer, there is a growing population of patients undergoing surveillance. National accreditation organizations have increasingly endorsed formal survivorship care planning. To effectively design patient-centered survivorship programs, an understanding of the prevalence of unmet psychosocial and symptomatic needs is required.

OBJECTIVE

The aim of this study is to understand the breadth of unmet needs among survivors of colorectal cancer.

DESIGN

This is a cross-sectional survey of patients undergoing surveillance after curative-intent therapy for colorectal cancer.

SETTING

This study was conducted June 2017 to January 2018 at an academic cancer center.

PATIENTS

There were 99 patients (58 with colon cancer, 41 with rectal cancer).

MAIN OUTCOME MEASURES

We measured patient-reported unmet needs by using a modification of the Cancer Survivor Unmet Needs instrument, within domains of emotional (stress, concerns about recurrence), relationship (fertility, interpersonal), logistical (need for accessible parking, case management), financial, treatment-related (neuropathy, bowel function), and surveillance-related needs.

RESULTS

The mean (±SD) age was 58 (±12), and the time from diagnosis was 34 (±18) months. Overall, 74% of patients reported at least one unmet need, 49% reported emotional needs, 24% relationship needs, 24% financial needs, 25% logistical needs, and 33% surveillance needs. Thirty-six (62%) patients with colon cancer and 37 (90%) patients with rectal cancer reported at least one ongoing problem (p = 0.002). Thirty-five (82%) patients with rectal cancer reported an unmet treatment-related need in comparison with 23 (40%) patients with colon cancer (p < 0.001). The median (interquartile range) number of ongoing needs were 1 (0-5) in patients with colon cancer and 4 (2-8) in patients with rectal cancer (p = 0.007).

LIMITATIONS

This study was limited by its small sample size and lack of generalizability, given the tertiary care setting.

CONCLUSIONS

The majority of colorectal cancer survivors reported unmet needs years after completion of curative-intent therapy. Patients with rectal cancer were significantly more likely to have unmet needs and may benefit from additional care during survivorship. Colorectal cancer survivorship programs should incorporate psychosocial and symptomatic care in addition to cancer surveillance. See Video Abstract at http://links.lww.com/DCR/A885.

Quality of life and costs of patients prior to colorectal surgery

Objective: To assess the quality of life and societal costs of patients prior to colorectal surgery in the Netherlands.Methods: This study is embedded in a previous randomized controlled trial (SANICS II). The quality of life was measured using EQ-5D-5L questionnaires. The iMTA medical consumption questionnaire (iMCQ) and the iMTA productivity costs questionnaire (iPCQ) were used to identify and measure healthcare and productivity costs. Subgroup analyses were performed based on age and gender.Results: A total of 178 patients were included in the cost analysis and a total of 161 patients in the quality of life analysis. The three-month mean societal cost per patient amounted to €3,211 of which €1,459 was due to productivity losses. The mean utility was 0.88 per patient. Gender was an important predictor in quality of life with men scoring significantly higher than women (0.92 versus 0.82) at p < 0.0001.Conclusion: Colorectal cancer represents a high economic burden in the Netherlands. Further research with repeated cost and quality of life measurements would be needed to explore the change over time and the effects of surgery.

Health-related quality of life in Slovenian patients with colorectal cancer: a single tertiary care center study

Background

The aim of this study was to evaluate the influence of the surgical treatment on Slovenian colorectal cancer patients’ health-related quality of life and to compare the results to the health-related quality of life of the general Slovenian population.

Patients and methods

A total of 413 patients with colorectal cancer operated on at the Abdominal Surgery Department at the Ljubljana University Medical Center between January 1st, 2016 and December 31st, 2017 were sent two standardized and validated questionnaires: the EORTC QLQ-C30 version 3 and EORTC QLQ-CR29. The questionnaires were returned by 197 patients.

Results

Compared to the general population, poorer physical (p < 0.001), role (p = 0.002), cognitive (p = 0.021), and social functioning (p < 0.001) with higher frequency of constipation (p < 0.001), diarrhea (p < 0.001), and financial difficulties (p < 0.001) were reported by the colorectal patients. Female patients reported lower cognitive (p = 0.034) and emotional (p = 0.008) functioning, as well as higher frequency of bloating (p = 0.049) and hair loss (p = 0.01). Compared to the younger group of patients, lower physical functioning (p < 0.001) and higher urinary frequency (p = 0.007), urinary incontinence (p = 0.007), buttock pain (p = 0.007), and anxiety regarding body weight (p = 0.031) were detected among the older group of colorectal patients.

Conclusions

The global health status of colorectal patients in Slovenia is comparable to that of the general Slovenian population, but there is a significantly lower level in some of the quality-of-life scales.

Recommendations for follow-up of colorectal cancer survivors

Colorectal cancer (CRC) is one of the tumours with the highest incidence and mortality in the Spanish population. Nevertheless, the advances in prevention and treatment have contributed to an increased number of patients who survive for prolonged periods of time. In addition, despite recurrences, improved survival following metastasis resection is likewise on the rise. This underscores the importance of carrying out follow-up programmes even in low-risk patients for the early detection of recurrence. The main objective of this article is to provide a set of recommendations for optimising the follow-up of CRC survivors as well as for managing the sequelae that result from either pharmacological or surgical treatment.

Cost-effectiveness analysis of UGT1A1*6/*28 genotyping for preventing FOLFIRI-induced severe neutropenia in Chinese colorectal cancer patients

AIM

To assess the cost-effectiveness of UGT1A1*6/*28 genotyping compared with no genotyping or no dose adjustment before irinotecan administration in China.

MATERIALS & METHODS

A decision tree model was developed to evaluate costs and health outcomes represented as quality-adjusted life years gained. Model inputs for the frequency of genotypes, the probability of neutropenia under FOLFIRI chemotherapy and direct costs and utilities were obtained from published sources. One-way sensitivity analyses were performed.

RESULTS

The strategy of genotyping with dose reduction dominated all remaining strategies. Compared with the strategies of no genotyping and genotyping with unchanged dose, it resulted in only marginal quality-adjusted life year increases (0.0011 and 0.0012) but a cost reduction of $651.12 and $805.22 per patient, respectively. One-way sensitivity analyses revealed that the model was relatively robust.

CONCLUSION

UGT1A1*6/*28 genotyping was cost saving for Chinese colorectal cancer patients.

Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study

Background

The group of colorectal cancer (CRC) survivors continues to grow worldwide. Understanding health-related quality of life (HRQOL) determinants and consequences of HRQOL impairments in long-term CRC survivors may help to individualize survivorship care plans. We aimed to i) examine the HRQOL status of CRC long-term survivors, ii) identify cross-sectional sociodemographic and clinical correlates of HRQOL, and iii) investigate the prospective association of HRQOL after CRC diagnosis with all-cause mortality.

Methods

We assessed HRQOL within a Northern German cohort of 1294 CRC survivors at a median of 6 years after CRC diagnosis using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Cross-sectional correlates of different HRQOL dimensions were analyzed using multivariable-adjusted logistic regression models with HRQOL as a binary variable. With multivariable-adjusted Cox proportional hazards regression models, hazard ratios (HR) of all-cause mortality were estimated per 10-point-increments of an HRQOL summary score, a global quality of life scale, and HRQOL functioning and symptom domains.

Results

The median HRQOL summary score was 87 (interquartile range: 75–94). Sex, age, education, tumor location, metastases, other cancers, type of therapy, and current stoma were identified as correlates of different HRQOL scales. After a median follow-up time of 7 years after HRQOL assessment, 175 participants had died. Nearly all HRQOL domains, except for cognitive functioning and diarrhea, were significantly associated with all-cause mortality. A 10-point-increment in the summary score decreased the risk of death by 24% (HR: 0.76; 95% CI: 0.70–0.82).

Conclusions

HRQOL in CRC survivors appeared to be relatively high in the long term. Various clinical and sociodemographic factors were cross-sectionally associated with HRQOL in long-term CRC survivors. Lower HRQOL was associated with increased all-cause mortality. Individualized healthcare programs for CRC survivors (including psychosocial screening and interventions) are needed to detect decreased HRQOL and to further improve long-term HRQOL and survival.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5075-1) contains supplementary material, which is available to authorized users.

Health-Related Predictors of Quality of Life in Cancer Patients in Saudi Arabia

Research on Saudi Arabian cancer patients is a priority at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. Because there is limited research on the quality of life (QoL) of Saudi Arabian cancer patients, the aim of this study was to identify the predictors of the QoL in a sample of Saudis with cancer. In August 2016, a cross-sectional study was conducted on 438 patients with a variety of cancer types (145 breast, 109 colorectal, 38 leukemia, 45 lymphoma, and 99 other types) who attended the Oncology Outpatient Clinics at KAMC. Sociodemographics, clinical symptoms, and cancer treatments were collected for each patient. We used the SF-36 instrument to assess QoL. Of the cancer patients studied, 28.4% had a family history of cancer, and, according to subgroup analyses, the elderly, those lacking formal education, the unemployed, those diagnosed with Stage III/IV, and those with metastasis had significantly worse physical functions than the other cancer patients. According to multiple linear regression analyses, cancer patients who exercised regularly tended to have better physical function, emotional role function, vitality, social function, and general health (increase in SF-36 scores of 8.82, 9.75, 5.54, 6.66, and 4.97, respectively). Patients with first-year-after-cancer diagnosis tended to have poor emotional wellbeing, social function, and general health (decrease in SF-36 scores of 5.20, 7.34, and 6.12, respectively). Newly diagnosed cancer patients and patients who did not exercise tended to experience significantly poor QoL in several domains; thus, the effectiveness of exercise must be assessed in Saudi cancer patients as an intervention to improve QoL.

Comorbidities are associated with poorer quality of life and functioning and worse symptoms in the 5 years following colorectal cancer surgery: Results from the ColoREctal Well-being (CREW) cohort study

Objective

More people are living with the consequences of cancer and comorbidity. We describe frequencies of comorbidities in a colorectal cancer cohort and associations with health and well‐being outcomes up to 5 years following surgery.

Methods

Prospective cohort study of 872 colorectal cancer patients recruited 2010 to 2012 from 29 UK centres, awaiting curative intent surgery. Questionnaires administered at baseline (pre‐surgery), 3, 9, 15, 24 months, and annually up to 5 years. Comorbidities (and whether they limit activities) were self‐reported by participants from 3 months. The EORTC QLQ‐C30 and QLQ‐CR29 assessed global health/quality of life (QoL), symptoms, and functioning. Longitudinal analyses investigated associations between comorbidities and health and well‐being outcomes.

Results

At baseline, the mean age of participants was 68 years, with 60% male and 65% colon cancer. Thirty‐two per cent had 1 and 40% had ≥2 comorbidities. The most common comorbidities were high blood pressure (43%), arthritis/rheumatism (32%), and anxiety/depression (18%). Of those with comorbidities, 37% reported at least 1 that limited their daily activities. Reporting any limiting comorbidities was associated with poorer global health/QoL, worse symptoms, and poorer functioning on all domains over 5‐year follow‐up. Controlling for the most common individual comorbidities, depression/anxiety had the greatest deleterious effect on outcomes.

Conclusions

Clinical assessment should prioritise patient‐reported comorbidities and whether these comorbidities limit daily activities, as important determinants of recovery of QoL, symptoms, and functioning following colorectal cancer. Targeted interventions and support services, including multiprofessional management and tailored assessment and follow‐up, may aid recovery of health and well‐being in these individuals.

Quality of life and physical activity in long-term (≥5 years post-diagnosis) colorectal cancer survivors - systematic review

BACKGROUND

Due to the increasing number of long-term (≥5 years post diagnosis) colorectal cancer survivors, long-term quality of life of these patients is highly relevant. Several studies have reported a positive association between physical activity and quality of life in colorectal cancer survivors, however, so far no systematic review has been published which focuses on long-term colorectal cancer survivors.

MATERIAL AND METHODS

A systematic review was conducted using the databases PubMed, Web of Science, PsychINFO, and CINAHL. Studies which investigated associations between physical activity and quality of life in long-term colorectal cancer survivors were included.

RESULTS AND CONCLUSION

Ten articles based on seven studies were identified. Long-term colorectal cancer survivors who were physically active reported better quality of life than long-term survivors who were not physically active. Both, moderate to vigorous physical activity and lower levels like light physical activity were associated with higher quality of life. Most studies assessed the association between physical activity and quality of life cross-sectionally but one prospective study which measured physical activity and quality of life at three different points in time also found associations between physical activity and quality of life. The association between physical activity and quality of life seemed to be stronger among women than among men. The findings of this systematic review support an association between physical activity and quality of life in long-term colorectal cancer survivors. However, the evidence is limited as most studies were based on cross-sectional and observational design.

Human Kallikrein 14 (Klk14) Expression in Salivary Gland Tumors

Objective

To analyze the expression of human kallikrein 14 (KLK14) in salivary gland tumors.

Methods

A standard immunoperoxidase staining technique was used to assess the expression profile of KLK14 in normal salivary glands and tumors including pleomorphic adenoma (PA; n=17), adenoid cystic carcinoma (ACC; n=13) and mucoepidermoid carcinoma (MEC; n=9). Tumor stage, grade, patient age and gender, and site of occurrence were recorded. These clinical parameters were correlated with KLK14 levels in malignant tumors. The expression profiles for KLK3, 5, 6, 8 and 13 were also retrieved.

Results

Normal salivary glands, PA, ACC and MEC showed strong expression of KLK14 in ductal and non-ductal cells. Both PA and ACC showed higher KLK14 levels than normal glands and MEC tissues. There were no statistically significant associations between levels of KLK14 and clinical parameters.

Conclusions

The differences in the levels of KLK14 suggest that KLKs may aid in the differential diagnosis of salivary gland tumors. The coexpression of KLKs suggests their possible involvement in an enzymatic pathway activated in salivary gland. KLK14 may be a promising new biomarker in salivary gland tumors.

Symptom Severity and Quality of Life Among Long-term Colorectal Cancer Survivors Compared With Matched Control Subjects: A Population-Based Study

BACKGROUND

Data are lacking regarding physical functioning, psychological well-being, and quality of life among colorectal cancer survivors >10 years postdiagnosis.

OBJECTIVE

The purpose of this study was to examine self-reported physical functioning, quality of life, and psychological well-being in long-term colorectal cancer survivors compared with age- and sex-matched unaffected control subjects.

DESIGN

Participants completed a cross-sectional survey.

SETTINGS

The colorectal cancer survivors and unaffected control subjects were recruited from the Ontario Familial Colorectal Cancer Registry.

PATIENTS

A population-based sample of colorectal cancer survivors (N = 296) and their age- and sex-matched unaffected control subjects (N = 255) were included. Survivors were, on average, 15 years postdiagnosis.

MAIN OUTCOME MEASURES

Quality of life was measured with the Functional Assessment of Cancer Therapy-General scale, bowel dysfunction with the Memorial Sloan-Kettering Cancer Center scale, urinary dysfunction with the International Consultation on Incontinence Questionnaire-Short Form, fatigue with the Functional Assessment of Chronic Illness Therapy-Fatigue scale, and depression with the Center for Epidemiologic Studies-Depression scale.

RESULTS

In linear mixed-model analyses adjusting for income, education, race, and comorbid medical conditions, survivors reported good emotional, functional, physical, and overall quality of life, comparable to control subjects. Fatigue and urinary functioning did not differ significantly between survivors and control subjects. Survivors reported significantly higher social quality of life and lower depression compared with unaffected control subjects. The only area where survivors reported significantly worse deficits was in bowel dysfunction, but the magnitude of differences was relatively small.

LIMITATIONS

Generalizability is limited by moderately low participation rates. Findings are likely biased toward healthy participants. No baseline assessment was available to examine change in outcomes over time.

CONCLUSIONS

Long-term colorectal cancer survivors appear to have comparable quality of life and, in some areas, better well-being than their unaffected peers. Bowel dysfunction may continue to be an ongoing issue even 15 years after colorectal cancer diagnosis. Overall quality of life can be expected to be good in this group of older survivors. See Video Abstract at http://links.lww.com/DCR/A476.

The Return to Work Experiences of Colorectal Cancer Survivors

Abstract: During the past 15 years, the number of colorectal cancer survivors has risen dramatically. While it is unclear how many colorectal cancer survivors were employed at the time of diagnosis, it is reasonable to expect a significant proportion of these survivors were temporarily displaced from the work force. This article describes the return to work experiences of 250 colorectal cancer survivors. The majority (80%) of the survivors were employed at diagnosis and 89% returned to work. Of those who returned to work, 81% sustained employment 5 years postdiagnosis. Results indicate survivors were successful in their attempt to return to work and sustain employment. However, 34% of survivors delayed their return beyond 2 months postdiagnosis. After controlling for ethnicity, education, and disease severity, the reason for delay was related to chemotherapy treatment Prospective studies of colorectal cancer survivors to document barriers to work return can guide interventions and occupational services to keep survivors healthy and in the workplace.

SCORE: Shared care of Colorectal cancer survivors: protocol for a randomised controlled trial

Background

Colorectal cancer (CRC) is the most common cancer affecting both men and women. Survivors of CRC often experience various physical and psychological effects arising from CRC and its treatment. These effects may last for many years and adversely affect QoL, and they may not be adequately addressed by standard specialist-based follow-up. Optimal management of these effects should harness the expertise of both primary care and specialist care. Shared models of care (involving both the patient’s primary care physician [PCP] and specialist) have the potential to better support survivors and enhance health system efficiency.

Methods/design

SCORE (Shared care of Colorectal cancer survivors) is a multisite randomised controlled trial designed to optimise and operationalise a shared care model for survivors of CRC, to evaluate the acceptability of the intervention and study processes, and to collect preliminary data regarding the effects of shared care compared with usual care on a range of patient-reported outcomes. The primary outcome is QoL measured using the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. Secondary outcomes are satisfaction with care, unmet needs, continuity of care and health resource use. The shared care model involves replacement of two routine specialist follow-up visits with PCP visits, as well as the provision of a tailored survivorship care plan and a survivorship booklet and DVD for CRC survivors. All consenting patients will be randomised 1:1 to either shared care or usual care and will complete questionnaires at three time points over a 12-month period (baseline and at 6 and 12 months). Health care resource use data will also be collected and used to evaluate costs.

Discussion

The evaluation and implementation of models of care that are responsive to the holistic needs of cancer survivors while reducing the burden on acute care settings is an international priority. Shared care between specialists and PCPs has the potential to enhance patient care and outcomes for CRC survivors while offering improvements in health care resource efficiency. If the findings of the present study show that the shared care intervention is acceptable and feasible for CRC survivors, the intervention may be readily expanded to other groups of cancer survivors.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617000004369p. Registered on 3 January 2017; protocol version 4 approved 24 February 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2245-4) contains supplementary material, which is available to authorized users.

Comparative Effectiveness of Up To Three Lines of Chemotherapy Treatment Plans for Metastatic Colorectal Cancer

Modern chemotherapy agents transformed standard care for metastatic colorectal cancer (mCRC) but raised concerns about the financial burden of the disease. We studied comparative effectiveness of treatment plans that involve up to three lines of therapies and impact of treatment sequencing on health and cost outcomes. We employed a Markov model to represent the dynamically changing health status of mCRC patients and used Monte-Carlo simulation to evaluate various treatment plans consistent with existing guidelines. We calibrated our model by a meta-analysis of published data from an extensive list of clinical trials and measured the effectiveness of each plan in terms of cost per quality-adjusted life year. We examined the sensitivity of our model and results with respect to key parameters in two scenarios serving as base case and worst case for patients' overall and progression-free survivals. The derived efficient frontiers included seven and five treatment plans in base case and worst case, respectively. The incremental cost-effectiveness ratio (ICER) ranged between $26,260 and $152,530 when the treatment plans on the efficient frontiers were compared against the least costly efficient plan in the base case, and between $21,256 and $60,040 in the worst case. All efficient plans were expected to lead to fewer than 2.5 adverse effects and on average successive adverse effects were spaced more than 9 weeks apart from each other in the base case. Based on ICER, all efficient treatment plans exhibit at least 87% chance of being efficient. Sensitivity analyses show that the ICERs were most dependent on drug acquisition cost, distributions of progression-free and overall survivals, and health utilities. We conclude that improvements in health outcomes may come at high incremental costs and are highly dependent in the order treatments are administered.

Quality of life and symptoms in long-term survivors of colorectal cancer: results from NSABP protocol LTS-01

PURPOSE

Little is known about health-related quality of life (HRQL) in long-term survivors (LTS) of colorectal cancer (CRC).

METHODS

Long-term CRC survivors (≥5 years) treated in previous National Surgical Adjuvant Breast and Bowel Project trials were recruited from 60 sites. After obtaining consent, a telephone survey was administered, which included HRQL instruments to measure physical health (Instrumental Activities of Daily Living [IADL], SF-12 Physical Component Scale [PCS], SF-36 Vitality Scale), mental health (SF-12 Mental Component Scale [MCS], Life Orientation Test, and Impact of Cancer), and clinical symptoms (Fatigue Symptom Inventory [FSI], European Organization for Research and Treatment of Cancer Colorectal Module [EORTC-CR38], and Brief Pain Inventory). A multivariable model identified predictors of overall quality of life (global health rating).

RESULTS

Participants (N = 708) had significantly higher HRQL compared with age group-matched non-cancer controls with higher mean scores on SF-12 PCS (49.5 vs. 43.7, p = <0.05), MCS (55.6 vs. 52.1, p = <0.05), and SF-36 Vitality Scale (67.1 vs. 59.9, p = <0.05). Multivariable modeling has demonstrated that better overall physical and mental health (PCS and MCS), positive body image (EORTC-CR38 scale), and less fatigue (FSI), were strongly associated with overall quality of life as measured by the global health rating. Interestingly, ability to perform IADLs, experience of cancer, gastrointestinal complaints, and pain, were not important predictors.

CONCLUSIONS

In long-term CRC survivors, overall physical and mental health was excellent compared with general population. Other disease-related symptoms did not detract from good overall health.

IMPLICATIONS FOR CANCER SURVIVORS

LTS of CRC within the setting of a clinical trial have higher HRQL than the general population, and treatment regimens do not appear to be associated with any significant late effects on quality of life.

TRIAL REGISTRATION

NSABP LTS-01: NCT00410579.

Lack of Support and Information Regarding Long-Term Negative Effects in Survivors of Rectal Cancer

BACKGROUND

Rectal cancer is a common cancer. Curative treatment frequently includes surgery, radiation, and chemotherapy, all of which can result in long-term adverse effects.

OBJECTIVES

This descriptive, hypothesis-generating study sought to obtain input from survivors of rectal cancer regarding key features of their long-term experience.

METHODS

The authors administered a 12-question, Internet-based survey to self-identified rectal cancer survivors to assess (a) how neuropathy, fatigue, trouble with ostomy or bowel movements, and trouble with sexual function affect daily life and (b) whether knowing about these symptoms a priori would have changed their treatment decisions. Responses are presented descriptively. Qualitative analysis assessed themes reported in response to an open-ended question.

FINDINGS

Responses from 116 survivors of rectal cancer, 55 of whom provided open-ended responses, were obtained. Respondents were predominantly young and several years from treatment. They reported that their lives were affected "a lot" by bowel or ostomy trouble, trouble with sexual function, fatigue, and nerve toxicity. Survivors reported that knowing whether symptoms would affect their lives "a lot" would have changed their treatment decisions with a priori knowledge of these lasting effects. Key qualitative themes were the lack of information about and support for negative effects.

A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia

AIM

Our aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy.

METHODS

Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess 'early' bowel function. Patients who underwent surgery 2 to 4 years previously were recruited for assessment of 'intermediate' bowel function. Healthy relatives were recruited as controls. The Memorial Sloan-Kettering Cancer Centre and EQ-5D questionnaires were used to assess bowel function and QOL, respectively. Statistical assessment included regression analyses, parametric and non-parametric tests. The association between QOL and Memorial Sloan-Kettering Cancer Centre (MSKCC) scores was evaluated using Spearman's rank correlation.

RESULTS

Ninety-one patients were recruited for assessment of 'early' and 85 for 'intermediate' bowel function. There were 85 controls. Patients had a significantly higher number of bowel movements at each follow-up (p < 0.001). At 12 months after surgery, patients reported difficulty with gas-stool discrimination. The 'intermediate' group were found to have lower scores for flatus control (<0.001) and total frequency score (p 0.03), indicating worse function. Patients with higher total MSKCC scores, no symptoms of urgency and those able to control flatus reported better QOL (p 0.006, 0.007 and 0.005, respectively) at 6 and 12 months. Gas-stool differentiation and complete evacuation correlated with better QOL in the 'intermediate' bowel function group (p 0.02 and 0.02, respectively).

CONCLUSION

Colonic resection adversely affects elements of bowel function up to 4 years after surgery. Good colonic function, represented by higher MSKCC scores, correlates with better QOL.

The care of the colorectal cancer survivor

PURPOSE OF REVIEW

The gastroenterology literature emphasizes factors that increase colorectal cancer (CRC) incidence but presents little about management after initial CRC treatments. The purpose of this review is to describe the remarkably increasing numbers of CRC survivors in whom surveillance guidelines are often not followed and patient care is fragmented. The gastroenterologist can play an important role in this care to improve prognosis and overall health.

RECENT FINDINGS

Existing surveillance recommendations by specialty societies for CRC survivors are fairly consistent but implementation occurs in less than half. The gastroenterologist can help to coordinate care to ensure appropriate surveillance and also can help to diagnose and treat chemotherapy and radiotherapy complications in survivors which can affect the quality of life long after the initial treatment. The gastroenterologist also can focus on host factors, including management of obesity, exercise programs, and the diet and can introduce potential chemopreventive agents such as nonsteroidal anti-inflammatory drugs when positive prospective studies are forthcoming. Interested gastroenterologists also have a role in participating in such prospective studies.

SUMMARY

The gastroenterologist should enhance her/his role for coordinated management of CRC survivors to improve patient surveillance care, to treat posttherapy complications and encourage preventive measures to improve prognosis and quality of life.