Health-related quality of life after colorectal cancer in England: a patient-reported outcomes study of individuals 12 to 36 months after diagnosis

Psychological distress and health behaviours in people living with and beyond cancer: a cross-sectional study

This study aimed to examine whether psychological distress was cross-sectionally associated with meeting World Cancer Research Fund (WCRF) recommendations in people living with and beyond cancer. Participants were adults living with and beyond breast, prostate and colorectal cancer, participating in the baseline wave of the Advancing Survivorship after Cancer Outcomes Trial (ASCOT). Anxiety/depression was assessed using the EQ-5D-5L and dichotomised into any/no problems. WCRF recommendations were assessed via pedometers, 24-h dietary recalls, self-reported alcohol intake (AUDIT-C), and self-reported smoking status. Participants were categorised as meeting WCRF recommendations using the following cut-offs: average daily steps (≥ 10,000/day), average weekly aerobic steps (≥ 15,000/day), fruit and vegetables (≥ 400 g/day), fibre (≥ 30 g/day), red meat (< 500 g/week), processed meat (0 g/day), high calorie food (fat ≤ 33% of total daily energy intake and free sugar ≤ 5% of total daily energy intake), alcohol (≤ 14 units/week) and smoking (non-smoking). A composite health behaviour risk index (CHBRI) was calculated by summing the number of WCRF recommendations met (range: 0-9). Among 1348 participants (mean age = 64 years (SD = 11.4)), 41.5% reported anxiety/depression problems. The mean CHBRI score was 4.4 (SD = 1.4). Anxiety/depression problems were associated with lower odds of meeting WCRF recommendations for average daily steps (odds ratio (OR) = 0.73; 95% CI 0.55, 0.97), but not for any other health behaviour. Psychological distress is associated with lower adherence to WCRF recommendations for physical activity in people living with and beyond cancer. Physical activity may be a mechanism linking psychological distress and poorer outcomes among people living with and beyond cancer, and this should be explored in longitudinal studies.

Understanding the associations between receipt of, and interest in, advice from a healthcare professional and quality of life in individuals with a stoma from colorectal cancer: a latent profile analysis

PURPOSE

To explore whether profiles derived from self-reported quality of life were associated with receipt of, and interest in, advice from a healthcare professional in people with a stoma.

METHODS

Secondary analysis of cross-sectional national survey data from England of 4487 people with a stoma from colorectal cancer. The survey assessed quality of life using various scales, receipt and interest in various forms of advice, and physical activity. A three-step latent profile analysis was conducted to determine the optimum number of profiles. Multinomial regression explored factors associated with profile membership. A series of logistic regression models examined whether profile membership was associated with interest in advice.

RESULTS

Five profiles were identified; 'consistently good quality of life', 'functional issues', 'functional and financial issues', 'low quality of life' and 'supported but struggling'. Individuals in the 'functional and financial issues' and 'low quality of life' profiles were more likely to have received financial advice compared to the 'consistently good quality of life' profile. When compared to the 'consistently good quality of life' profile, all other profiles were more likely to report wanting advice across a range of areas, with the strongest associations in the 'low quality of life' profile.

CONCLUSION

Findings indicate that people with a stoma are not a homogenous group in terms of quality of life. Participants in profiles with quality of life concerns report wanting more advice across various categories but findings suggest there is scope to explore how this can be tailored or adapted to specific groups.

Missingness mechanisms and generalizability of patient reported outcome measures in colorectal cancer survivors - assessing the reasonableness of the "missing completely at random" assumption

BACKGROUND

Patient-Reported Outcome Measures (PROM) provide important information, however, missing PROM data threaten the interpretability and generalizability of findings by introducing potential bias. This study aims to provide insight into missingness mechanisms and inform future researchers on generalizability and possible methodological solutions to overcome missing PROM data problems during data collection and statistical analyses.

METHODS

We identified 10,236 colorectal cancer survivors (CRCs) above 18y, diagnosed between 2014 and 2018 through the Danish Clinical Registries. We invited a random 20% (2,097) to participate in a national survey in May 2023. We distributed reminder e-mails at day 10 and day 20, and compared Initial Responders (response day 0-9), Subsequent Responders (response day 10-28) and Non-responders (no response after 28 days) in demographic and cancer-related characteristics and PROM-scores using linear regression.

RESULTS

Of the 2,097 CRCs, 1,188 responded (57%). Of these, 142 (7%) were excluded leaving 1,955 eligible CRCs. 628 (32%) were categorized as initial responders, 418 (21%) as subsequent responders, and 909 (47%) as non-responders. Differences in demographic and cancer-related characteristics between the three groups were minor and PROM-scores only marginally differed between initial and subsequent responders.

CONCLUSION

In this study of long-term colorectal cancer survivors, we showed that initial responders, subsequent responders, and non-responders exhibit comparable demographic and cancer-related characteristics. Among respondents, Patient-Reported Outcome Measures were also similar, indicating generalizability. Assuming Patient-Reported Outcome Measures of subsequent responders represent answers by the non-responders (would they be available), it may be reasonable to judge the missingness mechanism as Missing Completely At Random.

Cross-cultural adaptation and validation of the Arabic version of McGill quality of life: revised questionnaire in the patients with cancer

PURPOSE

The aims of this study were to translate and culturally adapt the McGill Quality of Life Questionnaire-revised (MQOL-R) to modern standard Arabic and to examine its reliability, construct, and discriminative validity in Arab patients with cancer.

MATERIALS AND METHODS

Translation and cultural adaptation of the English MQOL-R to modern standard Arabic were performed according to international guidelines. For psychometric evaluation, 125 participants with cancer were selected and completed the MQOL-R along with Global Health Status/QoL and functional subscales of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), and Eastern Cooperative Oncology Group performance status rating (ECOG-PS). The MQOL-R was tested for internal consistency, test-retest reliability, and construct validity.

RESULTS

The Arabic MQOL-R questionnaire had adequate internal consistency with Cronbach's alphas between 0.75 and 0.91. Test-retest reliability was very strong (ICC2.1 =0.91 to 0.96, p < 0.001). As hypothesized, the Arabic MQOL-R subscales demonstrated moderate to excellent correlation with functional subscales of EORTC QLQ-C30, and moderate to good correlation with Global health status/QoL.

CONCLUSION

The Arabic MQOL-R Questionnaire has adequate psychometric properties. Hence, it can be utilized in rehabilitation settings and research to measure health-related quality of life in the Arabic-speaking cancer population.

Transcranial Direct Current Stimulation for Anxiety During Laparoscopic Colorectal Cancer Surgery: A Randomized Clinical Trial

Importance

Perioperative anxiety is prevalent among patients undergoing surgical treatment of cancer and often influences their prognosis. Transcranial direct current stimulation (tDCS) has shown potential in the treatment of various anxiety-related disorders, but data on the impact of tDCS on perioperative anxiety are limited.

Objective

To evaluate the effect of tDCS in reducing perioperative anxiety among patients undergoing laparoscopic colorectal cancer (CRC) resection.

Design, Setting, And Participants

This randomized clinical trial was conducted from March to August 2023 at the Affiliated Hospital of Xuzhou Medical University. Patients aged 18 years or older undergoing elective laparoscopic radical resection for CRC were randomly assigned to either the active tDCS group or the sham tDCS group. Intention-to-treat data analysis was performed in September 2023.

Interventions

Patients were randomly assigned to receive 2 sessions of either active tDCS or sham tDCS over the left dorsolateral prefrontal cortex on the afternoon of the day before the operation and in the morning of the day of operation.

Main Outcomes and Measures

The main outcome was the incidence of perioperative anxiety from the day of the operation up to 3 days after the procedure, as measured using the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale (range: 0-21, with higher scores indicating more anxiety). Secondary outcomes included postoperative delirium (assessed by the Confusion Assessment Method or Confusion Assessment Method intensive care unit scale); pain (assessed by the 10-point Numeric Rating Scale [NRS], with scores ranging from 0 [no pain] to 10 [worst pain]); frailty (assessed by the Fatigue, Resistance, Ambulation, Illness and Loss of Weight [FRAIL] Index, with scores ranging from 0 [most robust] to 5 [most frail]; and sleep quality (assessed by the Pittsburgh Sleep Quality Index [PSQI], with scores ranging from 0 to 21 and higher scores indicating worse sleep quality) after the 2 sessions of the tDCS intervention.

Results

A total of 196 patients (mean [SD] age, 63.5 [11.0] years; 124 [63.3%] men) were recruited and randomly assigned to the active tDCS group (98 patients) or the sham tDCS group (98 patients). After the second tDCS intervention on the day of the operation, the incidence of perioperative anxiety was 38.8% in the active tDCS group and 70.4% in the sham tDCS group (relative risk, 0.55 [95% CI, 0.42-0.73]; P < .001). Patients in the active tDCS group vs the sham tDCS group were less likely to have postoperative delirium (8.2% vs 25.5%) and, at 3 days after the operation, had lower median (IQR) pain scores (NRS, 1.0 [1.0-1.0] vs 2.0 [2.0-2.0]), better median (IQR) sleep quality scores (PSQI, 10.5 [10.0-11.0] vs 12.0 [11.0-13.0]), and lower median (IQR) FRAIL Index (2.0 [1.0-2.0] vs 2.0 [2.0-3.0]).

Conclusions and Relevance

Findings of this randomized clinical trial indicate that administration of 2 preoperative sessions of tDCS was associated with a decreased incidence of perioperative anxiety in patients undergoing elective CRC resection. Active tDCS was also associated with better anxiety scores, pain levels, and sleep quality as well as reduced postoperative delirium and frailty. The findings suggest that tDCS may be a novel strategy for improving perioperative anxiety in patients undergoing CRC resection.

Trial Registration

Chinese Clinical Trial Register Identifier: ChiCTR2300068859.

Developing a multivariable prediction model of global health-related quality of life in patients treated for rectal cancer: a prospective study in five countries

PURPOSE

Rectal cancer and its treatment have a negative impact on health-related quality of life (HRQoL). If risk factors for sustained low HRQoL could be identified early, ideally before the start of treatment, individualised interventions could be identified and implemented to maintain or improve HRQoL. The study aimed to develop a multivariable prediction model for global HRQoL 12 months after rectal cancer treatment.

METHODS

Within COLOR II, a randomised, multicentre, international trial of laparoscopic and open surgery for rectal cancer, a sub-study on HRQoL included 385 patients in 12 hospitals and five countries. The HRQoL study was optional for hospitals in the COLOR II trial. EORTC QLQ-C30 and EORTC QLQ-CR38 were analysed preoperatively and at 1 and 12 months postoperatively. In exploratory analyses, correlations between age, sex, fatigue, pain, ASA classification, complications, and symptoms after surgery to HRQoL were studied. Bivariate initial analyses were followed by multivariate regression models.

RESULTS

Patient characteristics and clinical factors explained 4-10% of the variation in global HRQoL. The patient-reported outcomes from EORTC QLQ-C30 explained 55-65% of the variation in global HRQoL. The predominant predictors were fatigue and pain, which significantly impacted global HRQoL at all time points measured.

CONCLUSION

We found that fatigue and pain were two significant factors associated with posttreatment global HRQoL in patients treated for rectal cancer T1-T3 Nx. Interventions to reduce fatigue and pain could enhance global HRQoL after rectal cancer treatment.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov No. NCT00297791.

The future of cancer care in the UK-time for a radical and sustainable National Cancer Plan

Cancer affects one in two people in the UK and the incidence is set to increase. The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record. There are severe and widening disparities across the country and survival rates remain unacceptably poor for many cancers. This is at a time when cancer care has become increasingly complex, specialised, and expensive. The current crisis has deep historic roots, and to be reversed, the scale of the challenge must be acknowledged and a fundamental reset is required. The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection. The UK finds itself at a crossroads, where the political decisions of governments, the cancer community, and research funders will determine whether we can, together, achieve equitable, affordable, and high-quality cancer care for patients that is commensurate with our wealth, and position our outcomes among the best in the world. In this Policy Review, we describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money.

Survivorship in Early-Stage Rectal Cancer Patients Who Have Received Combined Modality Therapy

Survival rates in early-stage rectal cancer patients have increased over the past few decades. Societies such as the National Comprehensive Cancer Network (NCCN), American Cancer Society (ACS), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO) have proposed guidelines related to cancer survivorship care including formal recommendations to address the needs in early-stage rectal cancer survivors. These guidelines, in addition to new clinical research findings in survivorship will be reviewed, specifically looking at physical, psychosocial, and financial concerns in rectal cancer survivorship.

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.

Associations of self-reported and device-assessed physical activity with fatigue, quality of life, and sleep quality in adults living with and beyond cancer

BACKGROUND

Greater physical activity is associated with improved outcomes in people living with and beyond cancer. However, most studies in exercise oncology use self-reported measures of physical activity. Few have explored agreement between self-reported and device-based measures of physical activity in people living with and beyond cancer. This study aimed to describe physical activity in adults affected by cancer across self-reported and device-assessed activity, to explore levels of agreement between these measures in terms of their utility for categorizing participants as meeting/not meeting physical activity guidelines, and to explore whether meeting guidelines is associated with fatigue, quality of life, and sleep quality.

METHODS

A total of 1348 adults living with and beyond cancer from the Advancing Survivorship Cancer Outcomes Trial completed a survey assessing fatigue, quality of life, sleep quality, and physical activity. The Godin-Shephard Leisure-Time Physical Activity Questionnaire was used to calculate a Leisure Score Index (LSI) and an estimate of moderate-to-vigorous physical activity (MVPA). Average daily steps and weekly aerobic steps were derived from pedometers worn by participants.

RESULTS

The percentage of individuals meeting physical activity guidelines was 44.3% using LSI, 49.5% using MVPA, 10.8% using average daily steps, and 28.5% using weekly aerobic steps. Agreement (Cohen's κ) between self-reported and pedometer measures ranged from 0.13 (LSI vs. average daily steps) to 0.60 (LSI vs. MVPA). After adjusting for sociodemographic and health-related covariates, meeting activity guidelines using all measures was associated with not experiencing severe fatigue (odds ratios (ORs): 1.43-1.97). Meeting guidelines using MVPA was associated with no quality-of-life issues (OR = 1.53). Meeting guidelines using both self-reported measures were associated with good sleep quality (ORs: 1.33-1.40).

CONCLUSION

Less than half of all adults affected by cancer are meeting physical activity guidelines, regardless of measure. Meeting guidelines is associated with lower fatigue across all measures. Associations with quality of life and sleep differ depending on measure. Future research should consider the impact of physical activity measure on findings, and where possible, use multiple measures.

Understanding colorectal cancer patient follow-up: a qualitative interview study

PURPOSE

There are increasing numbers of patients who have been treated for colorectal cancer (CRC) who struggle with ongoing physical and psychological symptoms. 'Cancer survivor' is often used to describe these patients but this terminology remains controversial. This study sought to understand the follow-up experience of CRC patients in the UK and identify the terminology they prefer following diagnosis and treatment.

METHODS

Purposeful sampling of patients from specialist CRC follow-up clinics was performed until data saturation was achieved. Two 1:1 semi-structured qualitative interviews were performed for each participant. Data were analysed thematically.

RESULTS

Seventeen participants, median age = 62, 53% male were interviewed. Several themes were identified. Of note, fear of cancer recurrence dominates patients' agendas at follow-up appointments. There are also clinical and administrative barriers to discussing symptoms including being embarrassed, feeling that their symptoms were not relevant or not having enough time to discuss issues. However, there are several methods which may improve this, such as through the use of video consultations and questionnaires. In addition, patients identified inadequate holistic support despite significant psychological and social distress. Our data suggest that labelling a diverse group of patients as 'cancer survivors' can be problematic.

CONCLUSION

It is important that clinicians systematically screen patients for symptoms that are known to occur following treatment. Clinicians and patients should have routine access to pathways and programmes that can support patients in navigating their life after cancer therapy.

CARE: Protocol of a randomised trial evaluating the feasibility of preoperative intentional weight loss to support postoperative recovery in patients with excess weight and colorectal cancer

AIM

Excess weight increases the risk of morbidity following colorectal cancer surgery. Weight loss may improve morbidity, but it is uncertain whether patients can follow an intensive weight loss intervention while waiting for surgery and there are concerns about muscle mass loss. The aim of this trial is to assess the feasibility of intentional weight loss in this setting and determine progression to a definitive trial.

METHODS

CARE is a prospectively registered, multicentre, feasibility, parallel, randomised controlled trial with embedded evaluation and optimisation of the recruitment process. Participants with excess weight awaiting curative colorectal resection for cancer are randomised 1:1 to care as usual or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian. Progression criteria will be based on the recruitment, engagement, adherence, and retention rates. Data will be collected on the 30-day postoperative morbidity, the typical primary outcome of prehabilitation trials. Secondary outcomes will include, among others, length of hospital stay, health-related quality of life, and body composition. Qualitative interviews will be used to understand patients' experiences of and attitudes towards trial participation and intervention engagement and adherence.

CONCLUSION

CARE will evaluate the feasibility of intensive intentional weight loss as prehabilitation before colorectal cancer surgery. The results will determine the planning of a definitive trial.

Prospective, Multi-Institutional Observational Study of Deterioration in Activities of Daily Living in Elderly Patients After Lung Cancer Surgery

Introduction

To determine the rate of deteriorating activities of daily living (ADL) and to investigate predictive factors in elderly patients undergoing surgery for NSCLC.

Methods

Patients with NSCLC aged 75 years or older who underwent curative surgical resection were evaluated using the Tokyo Metropolitan Institute of Gerontology Index of Competence Instrumental ADL (TMIG-IADL) and the Japanese version of EuroQol 5-dimensions 5-level (EQ-5D-5L) quality-of-life scale administered at baseline and at 6 months postoperative. The primary end point was the rate of living patients without substantial deterioration of TMIG-IADL, defined as a decline greater than or equal to three points. Multivariable logistic regression was performed to determine risk factors for deteriorating ADL.

Results

Between May 2019 and May 2020, 876 of the 986 screened patients enrolled from 47 institutions were eligible and included in the analysis. TMIG-IADL and EQ-5D-5L scores were obtained from 96.0% and 92.6% of the patients, respectively. At 6 months postoperative, 745 patients (85.1%, 95% confidence interval: 82.5%-87.3%) reported no significant ADL deterioration, and 96 of 841 patients (11.4%) with postoperative score data reported significant deterioration. The social domain was the most frequently affected activity. In multivariable analysis, poor performance status, low G8 geriatric screening score, segmentectomy (versus wedge resection), and surgery lasting less than 3 hours were associated with deteriorating ADL. Worsening EQ-5D-5L scores by minimally important difference or more were observed in 22.1% of the patients. Changes in TMIG-IADL and EQ-5D-5L scores were poorly correlated.

Conclusions

Approximately 15% of elderly patients with NSCLC experienced significant ADL deterioration at 6 months postoperative.

Assessment of patients' preferences for new anticancer drugs in China: a best-worst discrete choice experiment on three common cancer types

OBJECTIVES

Despite the advancement in anticancer drug therapies, cancer treatment decisions are often complex and preference-sensitive, making them well suited for studying shared decision-making (SDM). Our study aimed to assess preferences for new anticancer drugs among three common types of patients with cancer to inform SDM.

DESIGN

We identified five attributes of new anticancer drugs and used a Bayesian-efficient design to generate choice sets for a best-worst discrete choice experiment (BWDCE). The mixed logit regression model was applied to estimate patient-reported preferences for each attribute. The interaction model was used to investigate preference heterogeneity.

SETTING

The BWDCE was conducted in Jiangsu province and Hebei province in China.

PARTICIPANTS

Patients aged 18 years or older, who had a definite diagnosis of lung cancer, breast cancer or colorectal cancer were recruited.

RESULTS

Data from 468 patients were available for analysis. On average, the most valued attribute was the improvement in health-related quality of life (HRQoL) (p<0.001). The low incidence of severe to life-threatening side effects, prolonged progression-free survival and the low incidence of mild to moderate side effects were also positive predictors of patients' preferences (p<0.001). Out-of-pocket cost was a negative predictor of their preferences (p<0.001). According to subgroup analysis by type of cancer, the improvement in HRQoL remained the most valuable attribute. However, the relative importance of other attributes varied by type of cancer. Whether patients were newly diagnosed or previously diagnosed cancer cases played a dominant role in the preference heterogeneity within each subgroup.

CONCLUSIONS

Our study can assist in the implementation of SDM by providing evidence on patients' preferences for new anticancer drugs. Patients should be informed of the multiattribute values of new drugs and encouraged to make decisions reflecting their values.

Supportive care needs of patients with colorectal cancer undergoing anticancer therapy: A latent class analysis

Objective

This study was aimed at identifying the potential subgroups of supportive care needs among Chinese patients with colorectal cancer (CRC) through latent class analysis (LCA) and clarifying the characteristics of patients with high needs.

Methods

From January to September 2020, a cross-sectional survey was conducted in the Oncology Department and Radiotherapy Department of four tertiary grade A hospitals in Suzhou by using the general information questionnaire and Comprehensive Needs Assessment Tool for patients with cancer. Potential subgroups of supportive care needs were identified through LCA, and the association between the subgroups and statistical variables was analyzed with chi-square tests to clarify the demographic characteristics of the high-need group. This study was not registered.

Results

A total of 403 patients with CRC were included in the survey. LCA indicated two subgroups of supportive care needs in patients with CRC: a high-need group (51.86% of patients) and a low-need group (48.14% patients). In both groups, the probability of healthcare staff and information needs was high (> 50%). Single/divorced/widowed patients had greater supportive care needs than married patients, and patients with rectal cancer had greater supportive care needs than those with colon cancer.

Conclusions

Patients' healthcare staff and information needs are of critical importance. Focus should be placed on unmarried, patients with rectal cancer, as well as those receiving chemotherapy plus radiotherapy or palliative treatment.

Fatigue, quality of life and associations with adherence to the World Cancer Research Fund guidelines for health behaviours in 5835 adults living with and beyond breast, prostate and colorectal cancer in England: A cross-sectional study

BACKGROUND

Many individuals living with and beyond cancer (LWBC) have ongoing quality of life (QoL) issues, including fatigue. The World Cancer Research Fund (WCRF) provides health behaviour recommendations for people LWBC, and there is some evidence linking adherence to these with improved QoL.

METHODS

Adults LWBC (specifically breast, colorectal or prostate cancer) completed a survey covering health behaviours (diet, physical activity, alcohol consumption and smoking), fatigue (FACIT-Fatigue Scale, version 4) and a broad measure of QoL (EQ-5D-5L descriptive scale). Participants were categorised as meeting/not meeting WCRF recommendations, using the following cut-offs classified as meeting the guidelines: ≥150 min physical activity/week, fruit and vegetables (≥5 portions/day), fibre (≥30 g fibre per day), free sugar (<5% of total calories from free sugar), fat (<33% total energy), red meat (<500 g/week), processed meat (none), alcohol consumption (<14 units/week) and not a current smoker. Logistic regression analyses explored associations between WCRF adherence and fatigue and QoL issues, controlling for demographic and clinical variables.

RESULTS

Among 5835 individuals LWBC (mean age: 67 years, 56% female, 90% white, breast 48%, prostate 32% and colorectal 21%), 22% had severe fatigue and 72% had 1+ issue/s on the EQ-5D-5L. Adhering to physical activity recommendations (odds ratio [OR] = 0.88, confidence interval [CI] = 0.77-0.99), meeting various dietary recommendations (fruit and vegetables OR = 0.79; CI = 0.68-0.91, free sugar OR = 0.85; CI = 0.76-0.96, fat OR = 0.71; CI = 0.62-0.82, red meat OR = 0.65; CI = 0.50-0.85) and not smoking (OR = 0.53, CI = 0.41-0.67) were associated with decreased odds of experiencing severe fatigue. Adhering to physical activity guidelines (OR = 0.71, CI = 0.62-0.82) was also associated with decreased odds of having 1+ QoL issue/s.

CONCLUSIONS

Adherence to various WCRF recommendations, particularly the recommendation for physical activity, was associated with less fatigue and better QoL in a large UK cohort of people living with and beyond breast, colorectal or prostate cancer. Multi-component interventions designed to support people LWBC to improve health behaviours, in line with the levels recommended by the WCRF, may also improve QoL.

Quality of life in early-onset colorectal cancer patients: systematic review

BACKGROUND

There is an increasing incidence of early-onset colorectal cancer; however, the psychosocial impacts of this disease on younger adults have been seldom explored.

METHODS

A systematic review was conducted according to the PRISMA guidelines. The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PubMed, and Scopus were searched, and papers were included if published in English within the last 10 years and if they reported results separately by age (including early-onset colorectal cancer, defined as colorectal cancer diagnosed before the age of 50 years). Critical appraisal of all studies was done using the Joanna Briggs Institute tools. The primary outcome of interest was the global quality of life in patients with early-onset colorectal cancer. Secondary outcomes included the effect on sexual function, body image, finances, career, emotional distress, and social and family functioning.

RESULTS

The search yielded 168 manuscripts and 15 papers were included in the review after screening. All studies were observational, and included a total of 18 146 patients, of which 5015 were patients with early-onset colorectal cancer. The studies included scored highly using Joanna Briggs Institute critical appraisal tools, indicating good quality and a low risk of bias, but data synthesis was not performed due to the wide range of scoring systems that were used across the studies. Six papers reported significant negative impacts on quality of life in patients with early-onset colorectal cancer. Three of the four studies that compared the quality of life in patients with early-onset colorectal cancer with older patients found that the younger group had worse mean quality-of-life scores (P ≤ 0.05). Secondary outcomes measured in five studies in relation to sexual dysfunction, body image, financial and career impacts, and social and family impacts and in eight studies in relation to emotional distress were found to be more severely impacted in those with early-onset colorectal cancer compared with those with late-onset colorectal cancer.

CONCLUSION

Whilst data are limited, the impact of colorectal cancer is different in patients with early-onset colorectal cancer compared with older patients in relation to several aspects of the quality of life. This is particularly prominent in areas of global quality of life, sexual functioning, family concerns, and financial impacts.

Management of treatment-related sequelae following colorectal cancer

AIM

Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment.

METHOD

A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included.

RESULTS

Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units.

CONCLUSION

Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Colorectal cancer survivors' long-term recollections of their illness and therapy up to seven years after enrolment into a randomised controlled clinical trial

BACKGROUND

As a consequence of effective treatment procedures, the number of long-term survivors of colorectal cancer is ever increasing. Adopting the method of a previous study on breast cancer patients, the goal of the present research was to investigate colorectal cancer patients' recollections of their illness and treatment experiences up to seven years after they have been enrolled in a randomised controlled clinical trial on the direct improvement of quality of life (RCT DIQOL).

METHODS

Colorectal cancer survivors in Bavaria, Germany were mailed a questionnaire on average 78·3 months after the start of their therapy and enrolment into RCT DIQOL. The questionnaire enquired about their worst experience during the colorectal cancer episode, positive aspects of the illness, and any advice they would give to newly diagnosed patients. Patient responses were categorised by two independent raters and cross-checked by a third independent rater. Frequencies of these categories were then quantitatively analysed using descriptive statistics.

RESULTS

Of 146 remaining survivors initially enrolled in RCT DIQOL, 96 (66%) returned the questionnaire. The majority (33%) of statements regarding the worst experience was referring to "psychological distress", followed by "indigestion and discomfort during defecation" (17%), and "cancer diagnosis" (16%). Among survivors with history of a stoma, the majority (36%) regarded "stoma" as their worst experience. With 45%, "change in life priorities" has been the most frequent positive category before "support by physicians/ nurses" (25%). 43% of the survivors deemed "fighting spirit" as most important advice to overcome the disease.

CONCLUSION

Even after many years, colorectal cancer survivors clearly remember experiences from the time of their illness. Echoing the results of the previous breast cancer survivors' study, "psychological distress", "change in life priorities" and "fighting spirit" emerged as prominent concepts. In addition, some aspects like the impact of a stoma are of specific importance for colorectal cancer survivors. These findings can be used to inform programmes to improve patient- and quality of life centred aftercare of tumour patients.

CLINICAL TRIAL INFORMATION

NCT04930016, date of registration 18.06.2021.

Quality of life and patient reported symptoms after colorectal cancer in a Swedish population

AIM

A proportion of patients treated for colorectal cancer have impaired quality of life (QoL) but it is uncertain if the level of QoL differs from the corresponding background population. This population-based cohort study aimed to evaluate health-related QoL in colorectal cancer patients and compare their QoL with that of a Swedish reference population.

METHODS

Patients who underwent surgery for colorectal cancer Stages I-III in the Stockholm-Gotland region in 2013-2015 received the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the QLQ-CR29 questionnaires and the low anterior resection syndrome score, 1 year after surgery. Patient and tumour data were collected from the Swedish Colorectal Cancer Registry. The patient cohort was matched to a Swedish reference population regarding EORTC QLQ-C30. Global QoL was compared to the reference population and a patient group with impaired QoL was defined. Detailed patient-reported outcomes were analysed in relation to global QoL in the patient cohort.

RESULTS

A total of 925 patients returned the questionnaires and 358 patients (38.70%) reported a clinically relevant impaired global QoL compared to the reference population. Patients with impaired QoL reported clinically relevant and statistically significantly more complaints regarding bowel habits, pain and anxiety. After adjustment for sex, age and stoma, anxiety was the strongest predictor for impaired QoL, with OR 6.797 (95% CI 4.677-9.879).

CONCLUSION

A substantial proportion of patients treated for colorectal cancer have impaired global QoL. This impairment is strongly associated with several physical symptoms and anxiety.

Clinical efficacy of Daikenchuto (DKT: TJ-100) for gastrointestinal symptoms in patients with a history of colon and rectosigmoid cancer surgery: a randomized crossover study

PURPOSE

This randomized crossover trial investigated the effects of Daikenchuto (DKT: TJ-100) on gastrointestinal symptoms of patients after colon and rectosigmoid cancer surgery.

METHODS

Among patients who had completed surgery for colon cancer, including rectosigmoid cancer, over 6 months ago, 20 who complained of gastrointestinal symptoms were enrolled. Subjects were randomly assigned to two sequences: sequences: A and B. In period 1, sequence A subjects were orally administered DKT, whereas sequence B subjects were untreated for 28 days. After a 5-day interval, in period 2, sequences A and B were reversed. Quality-of-life markers (GSRS and VAS), the Sitzmark transit study, the orocecal transit time (lactulose hydrogen breath test) and Gas volume score were evaluated before and after each period with findings compared between the presence of absence of DKT administration.

RESULTS

Between sequences, there were no significant differences in clinicopathological characters or any evaluations before randomization. There was no carryover effect in this crossover trial. The administration of DKT significantly ameliorated the GSRS in total, indigestion, and diarrhea, although the planned number of subjects for inclusion in this trial was not reached.

CONCLUSIONS

DKT may ameliorate subjective symptoms for postoperative patients who complain of gastrointestinal symptoms.

Survival Outcomes after Elective or Emergency Surgery for Synchronous Stage IV Colorectal Cancer

Patients with stage IV colorectal cancer (CRC) who have not undergone primary tumor resection (PTR) are at risk of sudden medical emergencies. Despite the ongoing controversy over the necessity and timing of PTR in patients with stage IV CRC, studies comparing the survival outcomes of elective and emergency surgery in this population are scarce. This is a retrospective study conducted at a single institute. The patients were divided into two groups: the elective surgery (ELS) group (n = 46) and the emergency surgery (EMS) group (n = 26). The primary outcome was 2-year overall survival (OS). During a median follow-up period of 27.0 months, the 2-year OS was significantly better in the ELS group (80% vs. 42.9%, p = 0.002). No significant differences were observed in the 2-year relapse-free survival and 30-day postoperative complication rates. Planning and performing elective surgery could help increase the survival rate of patients with synchronous stage IV CRC, especially those that undergo simultaneous or staged metastasectomy.

Determinants of sleep quality in 5835 individuals living with and beyond breast, prostate, and colorectal cancer: a cross-sectional survey

PURPOSE

The present study aimed to quantify the level of sleep problems in 5835 breast, prostate, and colorectal cancer survivors, and explore a number of potential determinants of poor sleep quality in the present sample. BMI, diet, and physical activity were of particular interest as potential determinants.

METHODS

Participants who completed the 'Health and Lifestyle after Cancer' survey were adults who had been diagnosed with breast, prostate, or colorectal cancer (mean time since cancer diagnosis was 35.5 months, SD=13.56). Sleep quality was assessed using the Pittsburgh Sleep Quality Index. BMI was calculated from self-reported height and weight. Participants were categorised as meeting/not meeting the World Cancer Research Fund (WCRF) recommendations for fibre, fruit and vegetables, added sugar, red meat, processed meat, fat, alcohol, and physical activity. Analyses accounted for demographic and clinical factors.

RESULTS

Fifty-seven percent of those with sleep data were classified as poor sleepers (response rate 79%). Being female, having a higher number of cancer treatments, more comorbid conditions, and being more anxious/depressed increased the odds of being a poor sleeper. After adjustment for these factors, there were no associations between diet/alcohol/physical activity and sleep. However, BMI was associated with sleep. Individuals in the overweight and obese categories had 22% and 79% higher odds of being poor sleepers than individuals in the underweight/healthy weight category, respectively.

CONCLUSIONS

The findings suggest that there may be a need to develop sleep quality interventions for cancer survivors with obesity. Even after adjustment for multiple clinical and demographic factors, BMI (particularly obesity) was associated with poor sleep. Thus, researchers and health professionals should find ways to support individuals with overweight and obesity to improve their sleep quality.

IMPLICATIONS FOR CANCER SURVIVORS

The present findings highlight that poor sleep is a common issue in cancer survivors. Interventions seeking to improve outcomes for cancer survivors over the longer term should consider sleep quality.

Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors

PURPOSE

Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life.

METHODS

In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life.

RESULTS

The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]).

CONCLUSION

In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

Colonoscopy surveillance following adenoma removal to reduce the risk of colorectal cancer: a retrospective cohort study

BACKGROUND

Colonoscopy surveillance is recommended for some patients post polypectomy. The 2002 UK surveillance guidelines classify post-polypectomy patients into low, intermediate and high risk, and recommend different strategies for each classification. Limited evidence supports these guidelines.

OBJECTIVES

To examine, for each risk group, long-term colorectal cancer incidence by baseline characteristics and the number of surveillance visits; the effects of interval length on detection rates of advanced adenomas and colorectal cancer at first surveillance; and the cost-effectiveness of surveillance compared with no surveillance.

DESIGN

A retrospective cohort study and economic evaluation.

SETTING

Seventeen NHS hospitals.

PARTICIPANTS

Patients with a colonoscopy and at least one adenoma at baseline.

MAIN OUTCOME MEASURES

Long-term colorectal cancer incidence after baseline and detection rates of advanced adenomas and colorectal cancer at first surveillance.

DATA SOURCES

Hospital databases, NHS Digital, the Office for National Statistics, National Services Scotland and Public Health England.

METHODS

Cox regression was used to compare colorectal cancer incidence in the presence and absence of surveillance and to identify colorectal cancer risk factors. Risk factors were used to stratify risk groups into higher- and lower-risk subgroups. We examined detection rates of advanced adenomas and colorectal cancer at first surveillance by interval length. Cost-effectiveness of surveillance compared with no surveillance was evaluated in terms of incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained.

RESULTS

Our study included 28,972 patients, of whom 14,401 (50%), 11,852 (41%) and 2719 (9%) were classed as low, intermediate and high risk, respectively. The median follow-up time was 9.3 years. Colorectal cancer incidence was 140, 221 and 366 per 100,000 person-years among low-, intermediate- and high-risk patients, respectively. Attendance at one surveillance visit was associated with reduced colorectal cancer incidence among low-, intermediate- and high-risk patients [hazard ratios were 0.56 (95% confidence interval 0.39 to 0.80), 0.59 (95% confidence interval 0.43 to 0.81) and 0.49 (95% confidence interval 0.29 to 0.82), respectively]. Compared with the general population, colorectal cancer incidence without surveillance was similar among low-risk patients and higher among high-risk patients [standardised incidence ratios were 0.86 (95% confidence interval 0.73 to 1.02) and 1.91 (95% confidence interval 1.39 to 2.56), respectively]. For intermediate-risk patients, standardised incidence ratios differed for the lower- (0.70, 95% confidence interval 0.48 to 0.99) and higher-risk (1.46, 95% confidence interval 1.19 to 1.78) subgroups. In each risk group, incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained with surveillance were lower for the higher-risk subgroup than for the lower-risk subgroup. Incremental costs per quality-adjusted life-year gained were lowest for the higher-risk subgroup of high-risk patients at £7821.

LIMITATIONS

The observational design means that we cannot assume that surveillance caused the reductions in cancer incidence. The fact that some cancer staging data were missing places uncertainty on our cost-effectiveness estimates.

CONCLUSIONS

Surveillance was associated with reduced colorectal cancer incidence in all risk groups. However, in low-risk patients and the lower-risk subgroup of intermediate-risk patients, colorectal cancer incidence was no higher than in the general population without surveillance, indicating that surveillance might not be necessary. Surveillance was most cost-effective for the higher-risk subgroup of high-risk patients.

FUTURE WORK

Studies should examine the clinical effectiveness and cost-effectiveness of post-polypectomy surveillance without prior classification of patients into risk groups.

TRIAL REGISTRATION

This trial is registered as ISRCTN15213649.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 26. See the NIHR Journals Library website for further project information.

Collection of cancer Patient Reported Outcome Measures (PROMS) to link with primary and secondary electronic care records to understand and improve long term cancer outcomes: A protocol paper

Introduction

More people are living with and beyond a cancer diagnosis. There is limited understanding of the long-term effects of cancer and cancer treatment on quality of life and personal and household finances when compared to people without cancer. In a separate protocol we have proposed to link de-identified data from electronic primary care and hospital records for a large population of cancer survivors and matched controls. In this current protocol, we propose the linkage of Patient Reported Outcomes Measures data to the above data for a subset of this population. The aim of this study is to investigate the full impact of living with and beyond a cancer diagnosis compared to age and gender matched controls. A secondary aim is to test the feasibility of the collection of Patient Reported Outcomes Measures (PROMS) data and the linkage procedures of the PROMs data to electronic health records data.

Materials and methods

This is a cross-sectional study, aiming to recruit participants treated at the Leeds Teaching Hospitals National Health Service Trust. Eligible patients will be cancer survivors at around 5 years post-diagnosis (breast, colorectal and ovarian cancer) and non-cancer patient matched controls attending dermatology out-patient clinics. They will be identified by running a query on the Leeds Teaching Hospitals Trust patient records system. Approximately 6000 patients (2000 cases and 4000 controls) will be invited to participate via post. Participants will be invited to complete PROMs assessing factors such as quality of life and finances, which can be completed on paper or online (surveys includes established instruments, and bespoke instruments (demographics, financial costs). This PROMs data will then be linked to routinely collected de-identified data from patient’s electronic primary care and hospital records.

Discussion

This innovative work aims to create a truly ‘comprehensive patient record’ to provide a broad picture of what happens to cancer patients across their cancer pathway, and the long-term impact of cancer treatment. Comparisons can be made between the cases and controls, to identify the aspects of life that has had the greatest impact following a cancer diagnosis. The feasibility of linking PROMs data to electronic health records can also be assessed. This work can inform future support offered to people living with and beyond a cancer diagnosis, clinical practice, and future research methodologies.

Understanding the psychosocial impact of colorectal cancer on young-onset patients: A scoping review

Objective

The incidence of young‐onset (<50 years) colorectal cancer (CRC) has been increasing internationally. The psychosocial experience of younger cancer patients is vastly different from older patients, especially in domains such as financial toxicity, body image, and sexual dysfunction. What is unknown is the cancer type‐specific experience. The aim of the current scoping review was to examine (1) the psychosocial factors and/or outcomes associated with young‐onset CRC and (2) other determinants that influences these outcomes.

Methods

A systematic search was conducted on four databases (PubMed, CINAHL, Scopus and PsycINFO) from inception to December 2020 using key terms and combinations. Primary literature that examined the psychosocial (e.g., quality‐of‐life, emotional, social, sexual) impact of young‐onset CRC were included.

Results

A total of 1389 records were assessed by four reviewers, with a total of seven studies meeting inclusion criteria (n = 5 quantitative, n = 1 qualitative and n = 1 case series). All studies indicated there was significant psychosocial impact in younger CRC patients, including emotional impact, social impact, physical burden, sexual impact, work impact, unmet needs, financial impact and global quality of life. Three studies explored other determinants that influenced the psychosocial experience and found that socioeconomic background (e.g., being female, lower education), CRC treatment (e.g., chemotherapy) and health status were associated with worse psychosocial impact.

Conclusions

Young‐onset CRC patients face severe psychosocial impact unique to this age group, such as self‐image and sexual impact. Social support services and resources needs to be uniquely tailored. More empirical investigations are required to understand its long‐term impact and influence of other psychosocial domains.

This scoping review of psychosocial impact in young‐onset colorectal cancer patients uncovered significant psychosocial impact which are in‐line with previous studies on young cancer (e.g., emotional impact, social impact, physical burden) as well as impact unique to colorectal cancer (e.g., self‐image, embarrassment with bowel movements and the impact of stoma). More empirical investigations are required to understand its long‐term impact and influence of other psychosocial domains.

Stability of health-related quality of life and morbidity burden from 18 months after diagnosis of prostate cancer: results of a UK-wide population-based outcome cohort

Objective

To evaluate the dynamic nature of self-reported health-related quality of life (HRQL) and morbidity burden in men diagnosed with prostate cancer, we performed a follow-up study of the Life After Prostate Cancer Diagnosis (LAPCD) study cohort 12 months after initial survey.

Methods

The LAPCD study collected information from 35,823 men across the UK who were 18–42 months post-diagnosis of prostate cancer. Men who were still alive 12 months later were resurveyed. Generic HRQL (EQ-5D-5L plus self-assessed health rating) and prostate cancer-specific outcomes (EPIC-26) were assessed. Treatment(s) received was self-reported. Previously defined clinically meaningful differences were used to evaluate changes in outcomes over time.

Results

A total of 28,450 men across all disease stages completed follow-up surveys (85.8% response). Of the 21,700 included in this study, 89.7% reported no additional treatments since the first survey. This group experienced stable urinary and bowel outcomes, with good function for most men at both time points. On-going poor (but stable) urinary issues were associated with previous surgery. Sexual function scores remained low (mean: 26.8/100). Self-assessed health ratings were stable over time. The largest declines in HRQL and functional outcomes were experienced by men reporting their first active treatment between surveys.

Discussion

The results suggest stability of HRQL and most specific morbidities by 18–42 months for men who report no further treatment in the subsequent 12 months. This is reassuring for those with good function and HRQL but re-enforces the need for early intervention and support for men who experience poor outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06650-7.

Patient-reported health-related quality of life after colorectal surgery

<b>Introduction:</b> Colorectal cancer is one of the most common cancers worldwide. In most of these patients, quality of life is deteriorated. </br></br> <b>Aim:</b> The aim of our study was to analyze how the disease affects health-related quality of life (HRQoL) and to examine the role of demographic, disease-related, and other factors in the overall quality of life. The second aim was to identify areas where HRQoL could be improved. </br></br> <b> Material and methods:</b> A cross-sectional questionnaire survey was conducted. The study included a modified version of EQ-5D, as well as clinical and socioeconomic characteristics of the country. Patients over the age of 18, who had colorectar surgery, and were followed up at our clinic, were included in the survey. </br></br> <b>Results:</b> In patients after colorectal surgery, bowel control is a major concern that has an impact on their quality of life. The majority of patients expressed gratitude for the care they received and thanked the health-care providers for it. With the EQ-5D modified questionnaire, the concept of "perfect" health was reviewed and analyzed. A response "no difficulty" in any of the five domains was classified as perfect health. Only one-third of the patients said their health was “ideal” (no problems in any of the EQ-5D five domains). </br></br> <b>Discussion:</b> According to the results of this study, patients with CRC have considerably poorer HRQoL than the general population, as indicated by the EQ-5D utility scores. This discovery is in line with some previous research. </br></br> <b>Conclusion:</b> Colorectal surgery survivors' total HRQoL has been found to be lower than in the general population.

Cost-Effectiveness of Colorectal Cancer Genetic Testing

Colorectal cancer (CRC) remains the second leading cause of cancer-related deaths worldwide. Approximately 3–5% of CRCs are associated with hereditary cancer syndromes. Individuals who harbor germline mutations are at an increased risk of developing early onset CRC, as well as extracolonic tumors. Genetic testing can identify genes that cause these syndromes. Early detection could facilitate the initiation of targeted prevention strategies and surveillance for CRC patients and their families. The aim of this study was to determine the cost-effectiveness of CRC genetic testing. We utilized a cross-sectional design to determine the cost-effectiveness of CRC genetic testing as compared to the usual screening method (iFOBT) from the provider’s perspective. Data on costs and health-related quality of life (HRQoL) of 200 CRC patients from three specialist general hospitals were collected. A mixed-methods approach of activity-based costing, top-down costing, and extracted information from a clinical pathway was used to estimate provider costs. Patients and family members’ HRQoL were measured using the EQ-5D-5L questionnaire. Data from the Malaysian Study on Cancer Survival (MySCan) were used to calculate patient survival. Cost-effectiveness was measured as cost per life-year (LY) and cost per quality-adjusted life-year (QALY). The provider cost for CRC genetic testing was high as compared to that for the current screening method. The current practice for screening is cost-saving as compared to genetic testing. Using a 10-year survival analysis, the estimated number of LYs gained for CRC patients through genetic testing was 0.92 years, and the number of QALYs gained was 1.53 years. The cost per LY gained and cost per QALY gained were calculated. The incremental cost-effectiveness ratio (ICER) showed that genetic testing dominates iFOBT testing. CRC genetic testing is cost-effective and could be considered as routine CRC screening for clinical practice.

Quality of Life After Bladder Cancer: A Cross-sectional Survey of Patient-reported Outcomes

BACKGROUND

Little is known about health-related quality of life (HRQOL) following treatment for bladder cancer (BC).

OBJECTIVE

To determine this, we undertook a cross-sectional survey covering 10% of the English population.

DESIGN, SETTING, AND PARTICIPANTS

Participants 1-10 yr from diagnosis were identified through national cancer registration data.

INTERVENTION

A postal survey was administered containing generic HRQOL and BC-specific outcome measures. Findings were compared with those of the general population and other pelvic cancer patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Generic HRQOL was measured using five-level EQ-5D (EQ-5D-5L) and European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ)-C30. BC-specific outcomes were derived from EORTC QLQ-BLM30 and EORTC QLQ-NMIBC24.

RESULTS AND LIMITATIONS

A total of 1796 surveys were completed (response rate 55%), including 868 (48%) patients with non-muscle-invasive BC, 893 (50%) patients who received radiotherapy or radical cystectomy, and 35 (1.9%) patients for whom treatment was unknown. Most (69%) of the participants reported at least one problem in any EQ-5D dimension. Age/sex-adjusted generic HRQOL outcomes were similar across all stages and treatment groups, whilst problems increased with age (problems in one or more EQ-5D dimensions: <65 yr [67% {95% confidence interval or CI: 61-74}] vs 85+ yr [84% {95% CI: 81-89}], p =  0.016) and long-term conditions (no conditions [53% {95% CI: 48-58}] vs more than four conditions [94% {95% CI: 90-97}], p < 0.001). Sexual problems were reported commonly in men, increasing with younger age and radical treatment. Younger participants (under 65 yr) reported more financial difficulties (mean score 20 [95% CI: 16-25]) than those aged 85+ yr (6.8 [4.5-9.2], p <  0.001). HRQOL for BC patients (for comparison, males with problems in one or more EQ-5D dimensions 69% [95% CI: 66-72]) was significantly worse than what has been found after colorectal and prostate cancers and in the general population (51% [95% CI: 48-53], all p <  0.05).

CONCLUSIONS

HRQOL following BC appears to be relatively independent of disease stage, treatment, and multimodal care. Issues are reported with sexual function and financial toxicity. HRQOL after BC is worse than that after other pelvic cancers.

PATIENT SUMMARY

Patients living with bladder cancer often have reduced quality of life, which may be worse than that for other common pelvic cancer patients. Age and other illnesses appear to be more important in determining this quality of life than the treatments received. Many men complain of sexual problems. Younger patients have financial worries.

Long-term health-related quality of life following colorectal cancer surgery: patient-reported outcomes in a remote follow-up population

AIM

Remote follow-up (RFU) after colorectal cancer (CRC) surgery allows delivery of surveillance tests without the need for regular outpatient clinical appointments. However, little is known about health-related quality of life (HRQoL) in RFU patients. The main aim of this study was to quantify HRQoL in our RFU population to identify particular patient groups that may benefit from a more personalised approach to follow-up, including access to a survivorship clinic.

METHOD

EQ-5D, QLQ-C30 and QLQ-C29 questionnaires were distributed to CRC patients enrolled in a RFU programme. The primary outcome of HRQoL scores was analysed by year of RFU, demographics, operation type, stoma and adherence to RFU protocols.

RESULTS

A total of 428 respondents were included, with a mean age of 71 years (SD 10.1 years) and a median RFU time of 2.6 years [interquartile range (IQR) 1.6-4.8 years]. 'Perfect health' was reported by 26.6% of patients. The median EQ-5D index score was 0.785 (IQR 0.671-1) and the median QLQ-C30 Global HRQoL score was 75 (IQR 58.3-83.3). Women had a significantly lower EQ-5D median score of 0.767 (IQR 0.666-0.879, P = 0.0088). Lower QLQ-C30 HRQoL scores were seen in stoma patients (median 66.6, IQR 58.3-83.3, P = 0.0029). Erectile dysfunction (P = 0.0006) and poor body image (P = 0.001) were also reported more frequently in stoma patients. Patients undergoing right-sided resection reported a lower median EQ-5D score of 0.765 (IQR 0.666-0.879, P = 0.028) and higher pain severity (P = 0.0367) compared with left-sided resections. There were 128 (29.4%) patients who breached RFU protocol and were seen in ad hoc colorectal clinics. However, there was no statistical difference in HRQoL between patients who adhered to or breached RFU protocols.

CONCLUSION

Overall HRQoL in patients in RFU is good, with no difference in those strictly followed up remotely. However, women, patients with right-sided resection and patients with a stoma may require additional clinical reviews.

Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer

BACKGROUND

Improved survival means that cancer is increasingly becoming a chronic disease. Understanding and improving functional outcomes are critical to optimising survivorship. We quantified physical and mental health-related outcomes in people with versus without cancer, according to cancer type.

METHODS

Questionnaire data from an Australian population-based cohort study (45 and Up Study (n = 267,153)) were linked to cancer registration data to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes-severe physical functional limitations (disability), moderate/high psychological distress and fair/poor quality of life (QoL)-in participants with versus without cancer, for 13 cancer types.

RESULTS

Compared to participants without cancer (n = 244,000), cancer survivors (n = 22,505) had greater disability (20.6% versus 12.6%, respectively, PR = 1.28, 95%CI = (1.25-1.32)), psychological (22.2% versus 23.5%, 1.05 (1.02-1.08)) and poor/fair QoL (15.2% versus 10.2%; 1.28 (1.24-1.32)). The outcomes varied by cancer type, being worse for multiple myeloma (PRs versus participants without cancer for disability 3.10, 2.56-3.77; distress 1.53, 1.20-1.96; poor/fair QoL 2.40, 1.87-3.07), lung cancer (disability 2.81, 2.50-3.15; distress 1.67, 1.46-1.92; poor/fair QoL 2.53, 2.21-2.91) and non-Hodgkin's lymphoma (disability 1.56, 1.37-1.78; distress 1.20, 1.05-1.36; poor/fair QoL 1.66, 1.44-1.92) and closer to those in people without cancer for breast cancer (disability 1.23, 1.16-1.32; distress 0.95, 0.90-1.01; poor/fair QoL 1.15, 1.05-1.25), prostate cancer (disability 1.11, 1.04-1.19; distress 1.09, 1.02-1.15; poor/fair QoL 1.15, 1.08-1.23) and melanoma (disability 1.02, 0.94-1.10; distress 0.96, 0.89-1.03; poor/fair QoL 0.92, 0.83-1.01). Outcomes were worse with recent diagnosis and treatment and advanced stage. Physical disability in cancer survivors was greater in all population subgroups examined and was a major contributor to adverse distress and QoL outcomes.

CONCLUSIONS

Physical disability, distress and reduced QoL are common after cancer and vary according to cancer type suggesting priority areas for research, and care and support.

Prevalence and predictors of poor sexual well-being over 5 years following treatment for colorectal cancer: results from the ColoREctal Wellbeing (CREW) prospective longitudinal study

OBJECTIVES

To describe prevalence and predictors of poor sexual well-being for men and women over 5 years following treatment for colorectal cancer.

DESIGN

Prospective longitudinal study, from presurgery to 5 years postsurgery, with eight assessment points. Logistic regression models predicted sexual well-being from presurgery to 24 months and 24 months to 60 months; time-adjusted then fully adjusted models were constructed at each stage.

SETTING

Twenty-nine hospitals in the UK.

PARTICIPANTS

Patients with Dukes' stage A-C, treated with curative intent, aged ≥18 years and able to complete questionnaires were eligible.

OUTCOME MEASURES

The dependent variable was the Quality of Life in Adult Cancer Survivors sexual function score. Independent variables included sociodemographic, clinical and psychosocial characteristics.

RESULTS

Seven hundred and ninety participants provided a sexual well-being score for at least one time point. Thirty-seven per cent of men and 14% of women reported poor sexual well-being at 5 years. Baseline predictors for men at 24 months included having a stoma (OR 1.5, 95% CI 1.02 to 2.20) and high levels of depression (OR 2.69/2.01, 95% CI 1.68 to 4.32/1.12 to 3.61); men with high self-efficacy (OR confident 0.33/0.48, 95% CI 0.18 to 0.61/0.24 to 1.00; very confident 0.25/0.42, 95% CI 0.13 to 0.49/0.19 to 0.94) and social support (OR 0.52/0.56, 95% CI 0.33 to 0.81/0.35 to 0.91) were less likely to report poor sexual well-being. Predictors at 60 months included having a stoma (OR 2.30/2.67, 95% CI 1.22 to 4.34/1.11 to 6.40) and high levels of depression (OR 5.61/2.58, 95% CI 2.58 to 12.21/0.81 to 8.25); men with high self-efficacy (very confident 0.14, 95% CI 0.047 to 0.44), full social support (OR 0.26; 95% CI 0.13 to 0.53) and higher quality of life (OR 0.97, 95% CI 0.95 to 0.98) were less likely to report poor sexual well-being. It was not possible to construct models for women due to low numbers reporting poor sexual well-being.

CONCLUSIONS

Several psychosocial variables were identified as predictors of poor sexual well-being among men. Interventions targeting low self-efficacy may be helpful. More research is needed to understand women's sexual well-being.

Risk of positive selection bias in longitudinal surveys among cancer survivors: Lessons learnt from the national Norwegian Testicular Cancer Survivor Study

BACKGROUND

Selection bias due to non- or incomplete compliance is challenging in surveys. Using data from a longitudinal survey in testicular cancer survivors (TCSs), we identify factors predicting incomplete compliance.

METHOD

In a questionnaire-based national survey (1998-2016; three waves) 1,813 > 5 year TCSs were invited to report post-treatment adverse health outcomes (AHOs). We separated complete from partial participants (participation in all three waves versus participation only once or twice). At each wave we additionally identified responders and non-responders based on their questionnaire return at the respective wave. Multivariable logistic regression analysis identified associations between AHOs reported at the first wave and partial participation. Survival differences between Responders and Non-Responders were assessed by the Kaplan-Meier estimate and the logrank test. Level of significance: p < 0.05.

RESULTS

Of 1813 TCSs 1,346 TCSs (79 %) completed the first wave's questionnaire, and 783 (58 %) became complete and 653 (42 %) partial participants. Poor socio-economics, unhealthy life style, major co-morbidity and chemotherapy-related AHOs reported at the first survey wave were associated with a significant 1.5-1.9 times increased risk for partial participation. At the two last waves non-responders had significantly decreased overall survival compared with responders.

CONCLUSION

Our longitudinal study indicates positive selection bias during the 17 years of a longitudinal survey among TCSs, with fewer AHOs among Complete than among Partial Participants. If not sufficiently compensated for by data from external sources and/or statistical methods, attrition bias in longitudinal surveys may limit the external validity of findings related to cancer survivors' self-reported AHOs.

Systematic review: the effect of right hemicolectomy for cancer on postoperative bowel function

BACKGROUND

Right-sided cancer accounts for approximately 30% of bowel cancer in women and 22% in men. Colonic resection can cause changes in bowel function which affect daily activity. The aims are to assess the impact of right hemicolectomy for cancer on bowel function and to identify useful treatment modalities for managing bowel dysfunction after right hemicolectomy.

METHOD

The review was conducted in line with PRISMA. Eligible studies evaluated the impact of right hemicolectomy on bowel function in those treated for colorectal neoplasia or assessed the effect of surgical technique or other intervention on bowel function after right hemicolectomy. Right hemicolectomy for inflammatory bowel disease or benign cases only were excluded. Articles were limited to studies on human subjects written in English published between January 2008 and December 2018.

RESULTS

The searches identified 7531 articles. Nine articles met the inclusion criteria, of which eight were cohort studies and one was a randomised trial. Loose stool, increased bowel frequency and/or nocturnal defaecation following right-sided colectomy occurs in approximately one in five patients. Some of these symptoms may improve spontaneously with time. Bile acid malabsorption and/or small bowel bacterial overgrowth may be the cause for chronic dysfunction. Some studies report that no or little difference in outcome between right-sided and rectal resections likely suggests poor function after right-sided resection.

CONCLUSION

Right hemicolectomy can result in changes to bowel function. Patients should be counselled preoperatively, and follow-up should be designed to identify and effectively treat significantly altered bowel function.

Does quality of life return to pre-treatment levels five years after curative intent surgery for colorectal cancer? Evidence from the ColoREctal Wellbeing (CREW) study

Background

The ColoREctal Wellbeing (CREW) study is the first study to prospectively recruit colorectal cancer (CRC) patients, carry out the baseline assessment pre-treatment and follow patients up over five years to delineate the impact of treatment on health and wellbeing.

Methods

CRC patients received questionnaires at baseline (pre-surgery), 3, 9, 15, 24, 36, 48 and 60 months. The primary outcome was Quality of Life in Adult Cancer Survivors (QLACS); self-efficacy, mental health, social support, affect, socio-demographics, clinical and treatment characteristics were also assessed. Representativeness was evaluated. Predictors at baseline and at 24 months of subsequent worsened quality of life (QOL) were identified using multivariable regression models.

Results

A representative cohort of 1017 non-metastatic CRC patients were recruited from 29 UK cancer centres. Around one third did not return to pre-surgery levels of QOL five years after treatment. Baseline factors associated with worsened QOL included >2 comorbidities, neoadjuvant treatment, high negative affect and low levels of self-efficacy, social support and positive affect. Predictors at 24 months included older age, low positive affect, high negative affect, fatigue and poor cognitive functioning.

Conclusions

Some risk factors for poor outcome up to five years following CRC surgery, such as self-efficacy, social support and comorbidity management, are amenable to change. Assessment of these factors from diagnosis to identify those most likely to need support in their recovery is warranted. Early intervention has the potential to improve outcomes.

Study protocol: a randomized controlled trial comparing the efficacy of therapist guided internet-delivered cognitive therapy (TG-iConquerFear) with augmented treatment as usual in reducing fear of cancer recurrence in Danish colorectal cancer survivors

BACKGROUND

Cognitive therapy has been shown to reduce fear of cancer recurrence (FCR), mainly in breast cancer survivors. The accessibility of cognitive behavioural interventions could be further improved by Internet delivery, but self-guided interventions have shown limited efficacy. The aim of this study is to test the efficacy of a therapist guided internet-delivered intervention (TG-iConquerFear) vs. augmented treatment as usual (aTAU) in Danish colorectal cancer survivors.

METHODS/DESIGN

A population-based randomized controlled trial (RCT) comparing TG-iConquerFear with aTAU (1:1) in n = 246 colorectal cancer survivors who suffer from clinically significant FCR (Fear of Cancer Recurrence Inventory Short Form (FCRI-SF) ≥ 22 and semi-structured interview). Evaluation will be conducted at 2 weeks, 3 and 6 months post-treatment and between-group differences will be evaluated. Long-term effects will be evaluated after one year. Primary outcome will be post-treatment FCR (FCRI-SF). Secondary outcomes are global overall health and global quality of life (Visual Analogue Scales 0-100), bodily distress syndrome (BDS checklist), health anxiety (Whiteley-6), anxiety (SCL4-anx), depression (SCL6-dep) and sickness absence and health expenditure (register data). Explanatory outcomes include: Uncertainty in illness (Mishels uncertainty of illness scale, short form, MUIS), metacognitions (MCQ-30 negative beliefs about worry subscale), and perceived risk of cancer recurrence (Visual analogue Scale 1-100).

DISCUSSION

This RCT will provide valuable information on the clinical and cost-effectiveness of TG-iConquerFear vs. aTAU for CRC survivors with clinical FCR, as well as explanatory variables that may act as outcome moderators or mediators.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04287218, registered 25.02.2020. https://clinicaltrials.gov/ct2/results?cond=&term=NCT04287218&cntry=&state=&city=&dist=.

Health-related quality of life in cancer patients treated with immune checkpoint inhibitors: A systematic review on reporting of methods in randomized controlled trials

OBJECTIVE

Immune checkpoint inhibitors (ICIs) have recently shown tremendous promise in the treatment of diverse cancers. The available data suggests that ICIs are well tolerated in terms of health-related quality of life (HRQOL) compared to other anticancer therapies. However, it appears that instruments currently used to evaluate HRQOL in this context may fail to capture important symptomatology unique to ICIs. This systematic review was designed to assess the adequacy of methods used to report HRQOL in cancer patients treated with ICIs and to identify the quality of life scales used.

METHOD

A systematic review was performed (systematic registration number: PROSPERO: CRD42019121427). A search of the PubMed, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences collection, and SocINDEX databases was carried out for publications in English and in French. Relevant databases were searched from the earliest records through to March 2019. Publications were selected if they reported on HRQOL in patients with cancer treated by ICIs. Risk of bias was scored using the Cochrane Collaboration bias assessment tool.

RESULTS

Our search identified 144 publications between 2012 and 2019, of which 15 RCTs met the inclusion criteria. The results suggest that even though the overall reporting of HRQOL was deemed to be of good quality, the data available was marred by methodological aspects such as the lack of HRQOL research hypotheses and the lack of questionnaires validated for cancer patients treated with immunotherapy.

CONCLUSION

This study provides a comprehensive analysis of the current state of the art and identifies gaps in knowledge on HRQOL analysis with respect to ICIs. It also suggests avenues for further research.

Quality of life trajectories in survivors of acute myocardial infarction: a national longitudinal study

AIM

To define trajectories of perceived health-related quality of life (HRQoL) among survivors of acute myocardial infarction (AMI) and identify factors associated with trajectories.

METHODS

Data on HRQoL among 9566 survivors of AMI were collected from 77 National Health Service hospitals in England between 1 November 2011 and 24 June 2015. Longitudinal HRQoL was collected using the EuroQol five-dimension questionnaire measured at hospitalisation, 1, 6 and 12 months post-AMI. Trajectories of perceived HRQoL post-MI were determined using multilevel regression analysis and latent class growth analysis (LCGA).

RESULTS

One or more percieved health problems in mobility, self-care, usual activities, pain/discomfort and anxiety/depression was reported by 69.1% (6607/9566) at hospitalisation and 59.7% (3011/5047) at 12 months. Reduced HRQoL was associated with women (-4.07, 95% CI -4.88 to -3.25), diabetes (-2.87, 95% CI -3.87 to -1.88), previous AMI (-1.60, 95% CI -2.72 to -0.48), previous angina (-1.72, 95% CI -2.77 to -0.67), chronic renal failure (-2.96, 95% CI -5.08 to -0.84; -3.10, 95% CI -5.72 to -0.49), chronic obstructive pulmonary disease (-3.89, 95% CI -5.07 to -2.72) and cerebrovascular disease (-2.60, 95% CI -4.24 to -0.96). LCGA identified three subgroups of HRQoL which we labelled: improvers (68.1%), non-improvers (22.1%) and dis-improvers (9.8%). Non-improvers and dis-improvers were more likely to be women, non-ST-elevation myocardial infarction (NSTEMI) and have long-term health conditions, compared with improvers.

CONCLUSIONS

Quality of life improves for the majority of survivors of AMI but is significantly worse and more likely to decline for women, NSTEMI and those with long-term health conditions. Assessing HRQoL both in hospital and postdischarge may be important in determining which patients could benefit from tailored interventions.

TRIAL REGISTRATION

NCT01808027 and NCT01819103.

Measurement of Health-Related Quality of Life Among Colorectal Cancer Patients Using the Vietnamese Value Set of the EQ-5D-5L

PURPOSE

Health-related quality of life (HRQoL) is an important construct in clinical settings, and it is crucial that it should be properly measured. As the EuroQol-5-dimensions-5 levels (EQ-5D-5L) is more effective for such measurement than the 3-level model, data on economic models, clinical studies, and public health evaluations previously collected through the EQ-5D-3L need to be revaluated using the EQ-5D-5L. This study evaluated colorectal cancer (CRC) patients' HRQoL scores using the Vietnamese EQ-5D-5L value set.

PATIENTS AND METHODS

The cross-sectional study included CRC patients treated at a tertiary public hospital. HRQoL was assessed using the EQ-5D-5L, and HRQoL utility scores were calculated using the Vietnamese value set. Tobit regression examined factors associated with HRQoL.

RESULTS

The analysis included 197 CRC patients. Ages ranged from 20 to 87 years (M = 57.64, SD = 13.5); 42.2% and 57.8% were diagnosed with cancer of the colon or rectum/anus, respectively. Mean EQ-5D-5L was 0.561 (range, -0.5115 to 1). Most participants experienced anxiety/depression (88%), followed by pain/discomfort (87%), mobility (71%), usual activity (69%), and self-care (67%). Advanced CRC stage (stage II: β -0.303, se 0.08; stage III: β -0.305, se 0.07; stage IV: β -0.456, se 0.07) and surgery (β -0.113, se 0.05) were negatively associated with EQ-5D-5L scores. Advanced education (high school: β 0.273, se 0.07); college/vocational: β 0.134se 0.05; university/higher: Coef 0.213, se 0.08;) and older age (age group 35-44: β 0.253, se 0.10; 45-54: β 0.327, se 0.09; 55-64: β 0.355 se 0.09; 65+ β 0.204, se 0.09) were positively associated with EQ-5D-5L scores.

CONCLUSION

Patients in advanced CRC stages or undergoing surgery experienced lower HRQoL and higher prevalence of anxiety/depression and pain/discomfort. Older age and high educational attainment predicted high HRQoL. This study provides information on CRC patients' health utility based on various patient characteristics, which can be used in future economic evaluations.