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

Correlates of cancer-related fatigue in colorectal cancer patients at the time of diagnosis

PURPOSE

To explore the potential correlates of cancer-related fatigue (CRF) at the time of diagnosis, with a specific consideration toward aspects related to physical activity and physical condition.

METHODS

Candidates were patients ≥ 18, diagnosed with colon or rectum cancer (stages I-IV), able to walk a mile or to complete the 6-min walking test. Fatigue was measured through PERFORM which is a multidimensional questionnaire (PQ). Quality of life (EORTC-QLQC30 and EORTC-QLQC29), diet (PREDIMED), and sociodemographic data were also assessed by questionnaires. Physical activity was measured by self-reported questionnaire (IPAQ) and accelerometers, and physical condition through objective tests such as Rockport 1-mile walk, estimated VO2 peak, 6-min walk, sit-to-stand, handgrip and, anthropometric data.

RESULTS

A total of 238 CRC patients (64.8 ± 11.0 mean age, 66.4% men) were recruited. Mean fatigue PQ score was 50.5. Values under 50.2 were associated with reduced QOL. CRF was associated with female sex (p < 0.001), poorer self-reported perceived health (p = 0.008), being retired woman (p = 0.025), poorer QOL (p =  < 0.001), and a previous diagnosis of hypercholesterolemia (p = 0.032). CRF was associated with a number of symptoms such as pain, anxiety, and gastrointestinal symptoms, in addition to dyspnoea, body image, and financial difficulties. CRF was associated to low self-reported PA levels (in women) and more sedentary levels (in men). CRF was not associated with metastatic stage, physical condition, or objectively assessed physical activity.

CONCLUSIONS

One out of four patients presents CRF at the time of CRC diagnosis. Women reported to have significantly higher levels of fatigue than men. Its association with other symptoms such as pain, anxiety, gastrointestinal symptoms, and its tremendous impact on the QOL make it necessary to ask the patients about fatigue in the first consultation. Oncologists should be aware of the importance of documenting this symptom in the clinical record to guarantee the follow-up and management.

Impact of Anastomotic Leakage After Colorectal Cancer Surgery on Quality of Life: A Systematic Review

BACKGROUND

Colorectal anastomotic leakage remains one of the most frequent and dreaded postoperative complications after colorectal resection. However, limited research has been conducted on the impact of this complication on the quality of life of patients who have undergone colorectal cancer surgery.

OBJECTIVE

The aim of this systematic review was to identify, appraise, and synthesize the available evidence regarding the quality of life in patients with anastomotic leakage after oncological colorectal resections to inform clinical decision-making.

DATA SOURCES AND STUDY SELECTION

PubMed, Embase, and the Cochrane Library were searched for studies reporting quality of life using validated questionnaires in patients with anastomotic leakage after oncological colorectal resections. The literature search was performed systematically and according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

OUTCOMES

Outcomes from quality-of-life questionnaires of patients with and without anastomotic leakage were analyzed.

RESULTS

Thirteen articles reporting on 4618 individual patients were included, among which 527 patients developed anastomotic leakage. Quality of life was evaluated using 10 distinct questionnaires administered at various postoperative time points, ranging from 1 month to 14 years. Quality-of-life outcomes differed across studies and time points, but overall scores were most negatively affected by anastomotic leakage up to 12 months postoperatively.

LIMITATIONS

There was a high heterogeneity between the included studies based on the questionnaires used and the time of assessment.

CONCLUSIONS

The published evidence suggests that anastomotic leakage after oncologic colorectal resection is associated with impaired quality of life, especially within the first postoperative year. The impact of anastomotic leakage on quality of life warrants further evaluation and discussion with patients.

Recovery trajectories after major abdominal surgery: A retrospective pooled cohort study

BACKGROUND

Recovery from major surgery can be difficult to predict given the many factors involved in treating disease and restoring preoperative function. Postoperative recovery metrics such as length of stay, complications, and mortality are typically described. However, large data quantities for patient-reported recovery are scarce. In this retrospective study, we aimed to describe the multidimensional recovery trajectory of patients undergoing major abdominal surgery 4-8 weeks after surgery and explore factors related to incomplete overall recovery.

METHODS

We retrospectively analysed pooled cohort data of adults undergoing elective major abdominal surgery between 2018 and 2024 across three tertiary-level hospitals. Recovery was measured at postoperative days 1, 3, 7, 14, weeks 4-8, and 3 months using the Postoperative Quality of Recovery Scale (PostopQRS). Physiological, nociceptive, emotive, activities of daily living (ADL), and cognitive domains were assessed, with recovery defined as a return to, or improvement of, preoperative baseline levels. Overall recovery was defined as recovery in all domains. Length of stay was assessed for patients who recovered overall, or did not recover, at postoperative weeks 4-8.

RESULTS

Six hundred and fifty-three patients were included, with mean (SD) age of 57.8 (14.4) years. Of these, 36% were aged ≥65 years and 58% were male. The incidence of overall recovery at postoperative week 4-8 was 42%. Domain-level recovery at postoperative weeks 4-8 was 63% for nociception, 81% for emotion, 82% for ADLs, and 83% for cognition. Patients failing to achieve overall recovery at weeks 4-8 had longer mean (SD) lengths of stay compared to those who recovered (11.3 (10.3) vs. 7.3 (7.1) days, p < .001).

CONCLUSIONS

The incidence of overall recovery at postoperative week 4-8 was 42%. Patients with incomplete overall recovery had longer lengths of stay. Multidimensional strategies to improve the recovery trajectory warrant further investigation.

EDITORIAL COMMENT

Major surgical procedures are often followed by a lengthy and difficult recovery period. Traditional measures such as mortality and complications are usually analysed, but this 653-patient study investigated patient-reported recovery scores after major abdominal surgery. Novel findings include that only 42% of patients have recovered fully in all recovery domains at weeks 4-8, and these patients also had longer hospital stays. Preoperative risk factors were analysed for associations with recovery trajectories.

Quality of life and abdominal wall functionality after abdominal wall reconstruction: A prospective single center follow-up study

BACKGROUND

Fascial breakdown with the occurrence of an incisional hernia (IH) is an important and challenging complication of any laparotomy. For a long time, the success of the abdominal wall reconstruction (AWR) was measured only from the surgeon's perspective by defining outcome measures such as wound morbidity and recurrence. The understanding that complete recovery is difficult to assess without considering patients has shifted the paradigm of optimal outcomes to Patient Reported Outcome Measures (PROMS) and Quality of Life (QoL), which are pivotal to evaluate the success and efficacy of AWR.

METHODS

We conducted a prospective follow-up study of 91 patients undergoing mesh-augmented abdominal wall reconstruction for primary or recurrent incisional hernia between January 2021 and December 2023. Demographic data, comorbidities, and hernia characteristics were recorded. All patients were evaluated preoperatively by a native abdomino-pelvic CT scan to assess the characteristics of hernia (length, width, surface, and volume of the incisional hernia sac and of peritoneal cavity), the presence of mesh (if previously inserted), and abdominal wall muscles status. All intervention were performed by the same surgical team according to the techniques described by Rives - Stoppa (RS), Ramirez (ACS), and Novitsky (PCS). Abdominal wall function was assessed using trunk raising (TR) and double leg lowering (DLL) measurements performed preoperatively, 1 month, 6 months, and 1 year postoperatively. At the same time, pre- and post-operative quality of life was analysed using the EQ-5D score.

RESULTS

Mean age of 59.42 ± 12.28 years and a male/female ratio of 35/56 were recorded, most of them being obese. There were 36 (42%) patients with defects larger than 10 cm. The distribution of the type of surgical intervention was: RS 35 patients, ACS 13 patients, and PCS 43 patients. The mean value of combined score for the preoperative abdominal wall functionality was 4.41 ± 1.67 (2-8) while the mean value of preoperative EQ-5D index was 0.652 ± 0.026 (-0.32-1.00). QoL was poor and very poor for 48% (44) of the patients who recorded index values less than 0.56 (50% percentile). Preoperative EQ-5D index was highly correlated with Combined AWF score (r = 0.620; p < 0.0001) and the correlation was specific (AUC = 0.799; p < 0.0001; asymptotic 95%CI = 0.711-0.923). At 12 months, the AWF score increased to 8.13 ± 2.58 (1-10) and the QoL total score to 0.979 ± 0.007 (0.71-1). Good and very good total scores for QoL were recorded for 47 patients (84%) compared to 33 (36%) in the preoperative evaluation (χ2 with Yates continuity correction for two degrees of liberty = 46.04; p < 0.00001).

CONCLUSION

Our results suggest that patients can expect to see a significant overall improvement in all five components of QoL measured with the help of Eq. 5D questionnaire. This improvement is dependent by hernia size, and some individual patient's factors (diabetes, cardiovascular diseases, and age over 60 years).

Non-gastrointestinal symptom burden following colorectal cancer treatment-a systematic review

BACKGROUND

Colorectal cancer is one of the most common malignancies worldwide. Improvements in screening and treatment have allowed for earlier detection and longer survival. However, treatments, which may involve surgery, radiotherapy and/or chemotherapy, often lead to patients developing both gastrointestinal and non-gastrointestinal symptoms that can persist long term. This systematic review aims to understand better the non-gastrointestinal symptoms that patients develop after colorectal cancer treatment and how these are identified and assessed through the use of questionnaires.

METHOD

The review was conducted according to PRISMA guidelines. Scopus, PubMed, Web of Science, PsycINFO and Cochrane Library were searched. Eligible studies evaluated the non-gastrointestinal symptoms that patients had developed and continued to have at 12 months or longer after treatment. Studies that were performed on patients who were within 12 months of treatment, who had a recurrent or a secondary cancer, had stage 4 cancer/were palliative or that looked solely at gastro-intestinal symptoms were excluded. Articles were limited to studies on human subjects written in English published between February 2012 and July 2024.

RESULTS

The searches identified 3491 articles. Thirty-seven articles met the inclusion criteria, of which, 33 were quantitative, 2 were qualitative and 2 were mixed methods study designs. Nearly two-thirds (n = 22) were cross-sectional studies, whereas 14 were longitudinal. One study had both a cross-sectional and longitudinal component to it. Most studies were of medium to high quality based on the Newcastle Ottawa Scale (n = 23) and were conducted in 14 countries, the majority of which were performed in the Netherlands (n = 14). The majority of participants in the included studies (n = 30/37) were men. There were also three studies that were performed with only female participants and one study that was performed with male participants only. The age range of research participants across all the studies was 29 to 89 years. Forty-five different validated questionnaires containing 5-125 question items were used to collect information on the side effects and impact of colorectal cancer treatment. Completion rate for questionnaires varied from 30 to 100% (median 63.5%). These determined effects on quality of life, emotional/psychological distress, sexual and urinary dysfunction, neuropathy, fatigue and hip pain.

CONCLUSION

This systematic review highlighted a wide range of longer-term non-gastrointestinal symptoms that frequently adversely affect QoL following treatment. These studies included highlighting the importance of nutrition/diet, physical activity, spirituality and communication in managing these long-term side effects.

Impact of comorbidity on health-related quality of life in newly diagnosed patients with lymphoma or multiple myeloma: results from the PROFILES-registry

With the increasing prevalence of comorbidity in an ageing population, it is crucial to better understand the impact of comorbidity on health-related quality of life (HRQoL) after lymphoma or multiple myeloma (MM) diagnosis. We included 261 newly diagnosed patients (67% response rate) diagnosed with lymphoma or MM between October 2020 and March 2023 in a longitudinal survey. The European Organisation for Research and Treatment of Cancer (EORTC) questionnaires were used to measure generic and disease-specific HRQoL. Evidence-based guidelines for interpretation of the EORTC questionnaires were used to identify clinical importance. Patients were classified as having 'no comorbidity', 'mild comorbidity' (e.g. arthrosis or rheumatism), or 'moderate-severe comorbidity' (e.g. heart or lung disease), using the adapted self-administered comorbidity questionnaire. At diagnosis, the mean age was 64 years, 63% were male and 38% reported no comorbidity, 33% mild comorbidity, and 29% moderate-severe comorbidity. Patients with mild or moderate-severe comorbidity reported clinically relevant worse HRQoL at diagnosis than patients without comorbidity. One year post-diagnosis most outcomes showed clinically relevant improvement, irrespective of comorbidity. However, outcomes of physical functioning (β=-7.9, p < 0.05), global health status (β=-7.6, p < 0.05), bone pain (β = 8.1 to 9.1, p < 0.05), muscle/joint pain (β = 14.5 to 18.8, p < 0.01) and muscle weakness (β = 10.4 to 15.6, p < 0.05) improved less among those with comorbidity, and clinically relevant differences between comorbidity groups persisted over time. With clinically relevant worse HRQoL at diagnosis and less recovery of HRQoL during the first year after diagnosis in patients with comorbidity, consideration of both prognosis and HRQoL is important when making treatment decisions.

General population normative values for the EORTC QLQ-C30 by age, sex, and health condition for the French general population

BACKGROUND

General population normative values for the widely used health-related quality of life (HRQoL) measure EORTC QLQ-C30 support the interpretation of trial results and HRQoL of patients in clinical practice. Here, we provide sex-, age- and health condition-specific normative values for the EORTC QLQ-C30 in the French general population.

METHODS

French general population data was collected in an international EORTC project. Online panels with quota samples were used to recruit sex and age groups. Number and type of comorbidities were assessed. Descriptive statistics were used to calculate general population values for each QLQ-C30 scale, separately for sex, age, and presence of one- and more chronic health conditions. A multivariate linear regression model has been developed to allow estimating the effect of sex, age, and the presence for one- and more chronic health conditions on EORTC QLQ-C30 scores. Data was weighted according to United Nation statistics adjusting for the proportion of sex and age groups.

RESULTS

In total, 1001 French respondents were included in our analyses. The weighted mean age was 47.9 years, 514 (51.3%) participants were women, and 497 (52.2%) participants reported at least one health condition. Men reported statistically significant better scores for Emotional Functioning (+9.6 points, p = 0.006) and Fatigue (-7.8 point; p = 0.04); women reported better profiles for Role Functioning (+8.7 points; p = 0.008) and Financial Difficulty (-7.8 points, p = 0.011). According to the regression model, the sex effect was statistically significant in eight scales; the effect of increasing age had a statistically significant effect on seven of the 15 EORTC QLQ-C30 scales. The sex- and age effect varied in its direction across the various scales. The presence of health conditions showed a strong negative effect on all scales.

CONCLUSION

This is the first publication of detailed French normative values for the EORTC QLQ-C30. It aims to support the interpretation of HRQoL profiles in French cancer populations. The strong impact of health conditions on QLQ-C30 scores highlights the importance of considering the impact of comorbidities in cancer patients when interpreting HRQoL data.

Health-related quality of life among patients with esophageal, gastric, and colorectal cancer at Kenyatta National Hospital

BACKGROUND

Despite the advancement of modern treatment approaches, several studies indicated a diminished health-related quality of life (HRQoL) in patients with gastrointestinal cancer. However, there is insufficient data about the HRQoL of gastrointestinal cancer patients in Kenya.

AIMS

The study aimed to investigate HRQoL and its determinants in gastrointestinal cancer patients at Kenyatta National Hospital.

METHODS

A cross-sectional study was employed among 160 esophageal, 103 gastric, and 96 colorectal cancer patients. The patient list, identified by unique hospital identification numbers, was obtained from records. Eligibility was assessed based on predetermined criteria, and the hospital identification numbers were reshuffled. Study participants were then randomly selected daily during the data collection period. Data were collected using a researcher-administered European Organization for Research and Treatment of Cancer quality of life questionnaire. The data entry and analysis were carried out using Statistical Package for the Social Sciences 26.0 statistical software. A bivariate and multivariate binary logistic regression analysis was employed to investigate determinants of HRQoL at a 0.05 level of significance.

RESULTS

Most esophageal (N = 118, 73.7%), gastric (N = 75, 72.8%), and colorectal (N = 72, 75%) cancer patients had poor overall HRQoL. In the social (p = .04) and cognitive (p = .02) domain of HRQoL, esophageal cancer patients had a significantly lower mean score as compared to gastric cancer patients. Colorectal cancer patients had the highest mean score in physical functioning (p = .01) as compared with gastric cancer patients. Nonetheless, gastric cancer patients had the highest mean score in emotional functioning domains of quality of life as compared to esophageal (p = .04) and colorectal (p < .001) cancer patients The study revealed a low mean HRQoL score in the majority of the symptom domains of quality of life. A statistically significant difference in all domains of HRQoL was not observed in various treatment modalities of gastrointestinal cancer. Advanced-stage (stages III and IV) and co-morbidities were significant determinants of poor HRQoL.

CONCLUSIONS

The overall HRQoL of gastrointestinal cancer patients was poor. Advanced-stage cancer and co-morbidities were significant determinants of poor HRQoL. Therefore, intensification of routine monitoring of the disease and the treatments should be actively implemented to improve the HRQoL.

Trajectories of health-related quality of life and symptom burden in patients with advanced cancer towards the end of life: Longitudinal results from the eQuiPe study

BACKGROUND

Support for health-related quality of life (HRQOL) is an essential part of cancer care in the final stages of life, yet empirical guidance regarding HRQOL and symptom trajectories is lacking.

AIM

To assess the change in HRQOL and symptom burden in the last year of life in patients with advanced cancer and its association with health care-related factors, cancer-specific treatment, and comorbidity.

METHODS

A prospective, multicenter, observational study in patients with advanced cancer (eQuiPe). Three monthly questionnaires included European Organization for Research and Treatment of Cancer Quality of Life-C30 and reported continuity of care. Multivariable mixed-effects analysis was used to assess the association between HRQOL and health care-related factors.

RESULTS

A total of 762 deceased patients were included with a mean age of 66 (SD, 10) years and 52% were male. The most common primary tumors were lung (29%), colorectal (20%), and breast cancer (13%). Mean overall HRQOL decreased in the last 9 months of life, with the greatest decrease in the last 3 months (β -16.2). Fatigue, pain, appetite loss, dyspnea, constipation, and nausea worsened significantly in the last year of life. Multimorbidity (β -7.5) and a better reported continuity of care (β 0.7) were both significantly associated with the trajectory of HRQOL.

CONCLUSION

Mean overall HRQOL begins to decline 9 months before death, highlighting the need for early identification and (re)assessment of different symptoms as aspects of HRQOL follow different trajectories. Multimorbidity and reported continuity of care may be associated with the trajectory of HRQOL.

Multimorbidity in people living with and beyond cancer: a scoping review

Globally, both cancer incidence and survival are increasing. Early cancer detection and improved treatment means many people with cancer will survive for ten or more years following diagnosis. Multimorbidity, defined as two or more chronic conditions, is up to three times higher in people living with and beyond cancer (LWBC) compared to the general population. This scoping review summarises the research evidence on the association between cancer and multimorbidity in people LWBC. It explores five key domains in people LWBC: 1) prevalence of multimorbidity, 2) association between ethnicity and socio-economic status (SES) and multimorbidity, 3) association between health status and multimorbidity, 4) adverse health consequences of cancer and related treatments, and 5) whether being a cancer survivor impacts treatment received for multimorbidity. It focuses on ten common cancers with high survival rates: prostate, breast, non-Hodgkin lymphoma, bowel/colorectal, kidney, head and neck, bladder, leukaemia, uterine and myeloma. A search of Medline, CINAHL, Embase, PsychINFO and Web of Science databases identified 9,460 articles, 115 of which met the inclusion criteria. Articles were included in the review that involved multimorbidity in adult cancer patients. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. This review included work from 20 countries, most studies were from the US (44%). The results showed that the most common long-term conditions in people LWBC were: hypertension, heart conditions, depression, COPD, and diabetes. The most reported incident comorbidities after a cancer diagnosis were congestive heart failure, chronic pain, and chronic fatigue. Multimorbidity tended to be higher amongst people LWBC from ethnic minority groups and those with lower SES. Quality of life was poorer in people LWBC with multimorbidity. The review identified the need for a uniform approach to measure multimorbidity in cancer patients across the world. Further research is required to compare multimorbidity before and after a cancer diagnosis, to explore the association of multimorbidity with ethnicity and socio-economic status and to determine whether a cancer diagnosis impacts care received for multimorbidity in people LWBC.

Resectability, Resections, Survival Outcomes, and Quality of Life in Older Adult Patients with Metastatic Colorectal Cancer (the RAXO-Study)

Older adults are underrepresented in metastatic colorectal cancer (mCRC) studies and thus may not receive optimal treatment, especially not metastasectomies. The prospective Finnish real-life RAXO-study included 1086 any organ mCRC patients. We assessed repeated centralized resectability, overall survival (OS), and quality of life (QoL) using 15D and EORTC QLQ-C30/CR29. Older adults (>75 years; n = 181, 17%) had worse ECOG performance status than adults (<75 years, n = 905, 83%), and their metastases were less likely upfront resectable. The local hospitals underestimated resectability in 48% of older adults and in 34% of adults compared with the centralized multidisciplinary team (MDT) evaluation (p < 0.001). The older adults compared with adults were less likely to undergo curative-intent R0/1-resection (19% vs. 32%), but when resection was achieved, OS was not significantly different (HR 1.54 [CI 95% 0.9-2.6]; 5-year OS-rate 58% vs. 67%). 'Systemic therapy only' patients had no age-related survival differences. QoL was similar in older adults and adults during curative treatment phase (15D 0.882-0.959/0.872-0.907 [scale 0-1]; GHS 62-94/68-79 [scale 0-100], respectively). Complete curative-intent resection of mCRC leads to excellent survival and QoL even in older adults. Older adults with mCRC should be actively evaluated by a specialized MDT and offered surgical or local ablative treatment whenever possible.

Health-related quality-of-life trajectories during/after surgery and adjuvant chemotherapy in patients with colon cancer

PURPOSE

This study aims to evaluate quality of life trajectory during the first year after surgical treatment in patients with resectable primary colon cancer.

METHODS

Patients with resectable primary colon cancer diagnosed between 2013 and 2019 who received surgical treatment and adjuvant chemotherapy if indicated were selected from the Prospective Dutch ColoRectal Cancer cohort study (PLCRC). Health-related quality of life (HR-QoL) was assessed using EORTC-QLQ-C30 questionnaire before surgery, and three and twelve months after surgery. HR-QoL scores varied between 0 and 100 and outcomes were compared according to age (< 70 years, ≥ 70 years), comorbidity (yes, no) and treatment type (adjuvant chemotherapy, surgical treatment only). The extent of resilience, defined as a recovery of HR-QoL to baseline level after a clinically relevant decline in HR-QoL at months, was calculated twelve months post-surgery.

RESULTS

For all 458 patients, the mean age was 66.4 years (SD 9.5), 40% were aged 70 years and older and 68% were men. Baseline level of HR-QoL summary score was relatively high with a mean of 87.9 (SD 11.5), and did not significantly differ between older and younger patients. The strongest decline of HR-QoL compared to baseline was observed at three months with a gradual recovery over time. Fourteen percent of all patients were non-resilient or showed a late decline at twelve months post-surgery. Compared to younger patients, older patients who received adjuvant chemotherapy were less resilient (respectively, 53 and 32%, p = 0.07) and at risk of a late decline in HR-QoL 1 year post-surgery (respectively, 3% versus 16%, p = 0.02). Comorbidity status had no significant impact on the HR-QoL trajectory.

CONCLUSION

Colon cancer treatment was associated with a decline in HR-QoL three months post-surgery, but most patients return to baseline level within twelve months. Still, particularly older patients who received adjuvant chemotherapy were less resilient and at risk of a late decline in HR-QoL. These data could help in patients counselling regarding colon cancer treatment.

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.

Patient-Reported Symptom Burden and Supportive Care Needs of Patients With Stage II-III Colorectal Cancer During and After Adjuvant Systemic Treatment: A Real-World Evidence Study

PURPOSE

Patients with colorectal cancer (CRC) experience a range of physical and psychologic symptoms, and supportive care needs throughout the illness trajectory. We used patient-reported outcomes and administrative health data to describe symptom burden and supportive care needs during and after adjuvant treatment and determine factors associated with changes to symptom burden.

METHODS

A retrospective population-based cohort study of patients who were newly diagnosed with stage II-III CRC in Alberta, Canada, between January 1, 2016, and January 31, 2019. Adults age 18 years or older who completed a patient-reported outcomes survey (Edmonton Symptom Assessment System) and supportive care needs (Canadian Problem Checklist) within 3 months after starting adjuvant treatment (during treatment) and > 7 months after starting treatment (after treatment) were included. Changes to symptom severity were stratified as stable, improved, or deteriorated. Multivariable logistic regression was used to evaluate factors associated with these changes.

RESULTS

We included 303 patients (median age 60 years, 62% male, 84.5% stage III, 51.2% rectal v colon). Prevalent symptoms included tiredness (80.5%), pain (50.8%), and poor well-being (50%) during treatment, and tiredness (71.3%), pain (44.2%), and poor well-being (62.1%) after treatment. The results were heterogeneous with respect to improvements, stability, or deterioration. Pain worsened for 25% of the cohort, tiredness for 28%, and depression, anxiety, and well-being for 21%, 22%, and 31%, respectively. Deterioration of some symptoms was associated with older age, stage II, comorbidities, rural setting, and higher income.

CONCLUSION

We demonstrated symptom severity was generally low and most symptoms remained stable or improved after treatment. Particular groups of patients were at greater risk for more severe and/or more persistent symptoms. Ongoing assessments and interventions to address physical and psychologic symptoms, and supportive care needs in patients with CRC during and after treatment are needed.

The impact of surgery and adjuvant chemotherapy on health-related quality of life in patients with colon cancer: Changes at group level versus individual level

OBJECTIVE

This study aims to evaluate changes in health-related quality of life (HR-QoL) 1 year after surgical treatment in patients with primary resectable colon cancer and to assess whether changes at group level differ from changes at individual level. In addition, we assess which characteristics are associated with a decline of HR-QoL.

METHODS

Patients with primary resectable colon cancer who received surgical treatment and adjuvant chemotherapy if indicated were selected from the Prospective Dutch ColoRectal Cancer cohort (PLCRC). HR-QoL was assessed using EORTC-QLQ-C30 questionnaire before surgery and 12 months post-surgery. Outcomes were assessed at group and individual levels. Logistic regression analysis was conducted to assess which socio-demographic and clinical characteristics were associated with a clinically relevant decline of HR-QoL at 12 months.

RESULTS

Of all 324 patients, the baseline level of HR-QoL summary score was relatively high with a mean of 88.1 (SD 11.4). On group level, the change of HR-QoL at 12 months varied between -2% for cognitive functioning and +9% for emotional functioning. On individual level, 15% of all patients experienced a clinically relevant decline in HR-QoL summary score at 12 months. Older age, comorbidity burden or the reception of adjuvant chemotherapy was independently associated with a decline of HR-QoL in one of the functional subscales of EORTC-QLQ-C30 at 12 months.

CONCLUSION

Only trivial changes of HR-QoL were observed after colon cancer treatment on group level, whereas on individual level, at least 1 out of 10 patients experienced a decline of HR-QoL 12 months post-surgery. It is important to consider individual differences while making a treatment decision.

Quality of life and health status in older adults (≥65 years) up to five years following colorectal cancer treatment: Findings from the ColoREctal Wellbeing (CREW) cohort study

Objective

Colorectal cancer (CRC) is common in older adults, with more than 70% of diagnoses in people aged ≥65 years. Despite this, there is a knowledge gap regarding longer-term outcomes in this population. Here, we identify those older people most at risk of poor quality of life (QoL) and health status in the five years following CRC treatment.

Materials and methods

CREW is a UK longitudinal cohort study investigating factors associated with health and wellbeing recovery following curative-intent CRC surgery. Participants completed self-report questionnaires pre-surgery, then at least annually up to five years. Longitudinal analyses explored the prevalence and pre-surgery risk factors of poor QoL (QLACS-GSS) and health status (EQ-5D: presence/absence of problems in five domains) in older (≥65 years) participants over five years.

Results

501 participants aged ≥65years completed questionnaires pre-surgery; 45% completed questionnaires five years later. Oldest-old participants (≥80 years) reported poorer QoL (18% higher QLACS-GSS) and 2–4 times higher odds of having problems with mobility or usual activities, compared with the youngest-old (65–69 years) over follow-up. Baseline higher self-efficacy was significantly associated with better QoL (10–30% lower QLACS-GSS scores compared to those with low self-efficacy) and lower odds of problems in all EQ-5D domains. Adequate social support was significantly associated with better QoL (8% lower QLACS-GSS) and lower odds of problems with usual activities (OR = 0.62) and anxiety/depression (OR = 0.56).

Conclusion

There are important differences in QoL and health status outcomes for the oldest-old during CRC recovery. CREW reveals pre-surgery risk factors that are amenable to intervention including self-efficacy and social support.

Persistent symptoms of fatigue, neuropathy and role-functioning impairment among indolent non-Hodgkin lymphoma survivors: A longitudinal PROFILES registry study

Little is known about the long-term health-related quality of life (HRQoL) and persistence of symptoms among patients with indolent non-Hodgkin lymphoma (iNHL). This large population-based longitudinal study therefore investigated the long-term HRQoL and persistence of symptoms and identified associated sociodemographic, clinical and psychological factors. Patients diagnosed between 1999 and 2014 and four or more months after diagnosis were invited to participate in a longitudinal survey. Sociodemographic and clinical data were obtained from the Netherlands Cancer Registry. The EORTC QLQ-C30 and CLL-16 were completed by 669 patients (74% response rate). Patients completed on average four questionnaires. Primary treatment was active surveillance (52%), systemic therapy (31%) or radiotherapy (13%). Respectively, 36% reported persistent fatigue, 33% persistent neuropathy and 25% persistent role-functioning impairment. This was 2-3 times higher than in the age- and sex-matched normative population. Up to 10 years after diagnosis, scores remained relatively stable without clinically relevant changes. Comorbidities, psychological distress, shorter time since diagnosis, systemic therapy, younger age, education level and having no partner were associated with worse outcomes (all ps < 0.05). Up to a third of patients with iNHL experience long-term persistent symptoms which do not improve over time. Early recognition of symptoms will help in providing tailored supportive care for those in need.

Health-related quality of life among family caregivers of oesophageal cancer survivors one year after curative intended treatment - a nationwide population-based study

BACKGROUND

To investigate factors that might influence the quality of life of the family caregivers of oesophageal cancer patients.

MATERIAL AND METHODS

A cross-sectional study within a prospective, population-based nationwide cohort study including family caregivers to oesophageal cancer patients was conducted. The exposures were family caregivers' age, sex, education level and patients' tumour stage, postoperative complications, weight loss and comorbidities. The outcome was health-related quality of life (HRQL) one year after the patient's cancer surgery measured by the RAND-36. Multivariable linear regression analysis provided mean score differences (MSD) with 95% confidence intervals (CI).

RESULTS

In total 257 family caregivers were included. Family caregivers ≥65 years displayed lower physical function (MSD=-8.5; p = 0.001) but a higher level of energy (MSD = 9.2; p = 0.002). Those with a higher education level had less pain (MSD = 11.2; p = 0.01) and better physical function (MSD = 9.1; p = 0.006).Among the patient related exposures, postoperative complications were associated with family caregivers' physical function (MSD= -6.0; p = 0.01) and pain (MSD= -7.9; p = 0.01). Tumour stage and comorbidities were not associated with the HRQL of the family caregiver.

CONCLUSION

The study suggests that patients' complications and age and education level of the family caregivers are associated with family caregivers HRQL. This information provides guidance in the process of creating support for family caregivers of oesophageal cancer patients.

Effect of comorbidities on long-term outcomes of colorectal cancer patients

OBJECTIVE

The objective of this work is to evaluate the association of comorbidities with various outcomes in patients diagnosed with colon or rectal cancer.

METHODS

We conducted a prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery. Data were gathered on sociodemographic, clinical characteristics, disease course, and the EuroQol EQ-5D and EORTC QLQ-C30 scores, up to 5 years after surgery. The main outcomes of the study were mortality, complications, readmissions, reoperations, and changes in PROMs up to 5 years. Multivariable multilevel logistic regression models were used in the analyses.

RESULTS

Mortality at some point during the 5-year follow-up was related to cardiocerebrovascular, hemiplegia and/or stroke, chronic obstructive pulmonary disease (COPD), diabetes, cancer, and dementia. Similarly, complications were related to cardiovascular disease, COPD, diabetes, hepatitis, hepatic or renal pathologies, and dementia; readmissions to cardiovascular disease, COPD, and hepatic pathologies; and reoperations to cerebrovascular and diabetes. Finally, changes in EQ-5D scores at some point during follow-up were related to cardiocerebrovascular disease, COPD, diabetes, pre-existing cancer, hepatic and gastrointestinal pathologies, and changes in EORTC QLQ-C30 scores to cardiovascular disease, COPD, diabetes, and hepatic and gastrointestinal pathologies.

CONCLUSIONS

Optimising the management of the comorbidities most strongly related to adverse outcomes may help to reduce those events in these patients.

Disparities in quality of life, social distress and employment outcomes in Australian cancer survivors

PURPOSE

To examine how socio-demographic, comorbidities and information needs influence quality of life (QoL) outcomes of survivors of breast, colorectal, or prostate cancer, non-Hodgkin lymphoma or melanoma.

METHODS

Cross-sectional postal survey with eligible participants identified through a population-based cancer registry. QoL outcomes were assessed by EQ-5D-5L, social difficulties index (SDI) and, for those employed at diagnosis, current employment. Regression analyses explored associations between outcome variables and cancer type, age, time since diagnosis, residential location, socio-economic disadvantage, comorbidities and unmet information needs. Mediation analyses examined whether comorbidities and information needs explained relationships between outcome variables and socio-economic disadvantage.

RESULTS

2115 survivors participated. Mean EQ-5D-5L scores (mean = 0.84) were similar to population averages and SDI scores were low for the entire sample (mean = 3.80). In multivariate analyses, being aged over 80, greater socio-economic disadvantage, comorbidities and unmet information needs decreased EQ-5D-5L scores. Higher SDI scores were associated with socio-economic disadvantage, comorbidities and unmet information needs. Not being employed was associated with being aged over 50, more comorbidities and socio-economic disadvantage. Comorbidities but not information needs partially mediated the impact of socio-economic disadvantage on EQ-5D-5L and SDI accounting for 17% and 14% of the total effect of socio-economic disadvantage respectively. Neither comorbidities nor information needs mediated the association between socio-economic disadvantage and employment outcomes.

CONCLUSIONS

To improve quality of life, survivorship care should be better tailored to address the needs of individuals given their overall health and impact of comorbidities, their age and type of cancer and not simply time since diagnosis.

Self-management by older people living with cancer and multi-morbidity: a qualitative study

PURPOSE

Over half of individuals diagnosed with cancer are aged over 70 years, and more than 75% of those with cancer report at least one other medical condition. Having multiple conditions alongside cancer in old age may lower functional status, greater likelihood of treatment complications and less favourable prognoses. This qualitative study explored how older people with long-term chronic conditions manage their health and meet their health-related goals after they have completed treatment for cancer.

METHODS

One-to-one face-to-face qualitative interviews were conducted with 8 older people and 2 informal caregivers based in the UK. Older adults were eligible to participate if they were over 70 and had completed primary cancer treatment with curative intent and had at least one other chronic health condition. A semi-structured interview schedule developed a priori based on Shippee's cumulative complexity model was used. We aimed to explore experiences that could influence self-management, utilisation of healthcare services and health outcomes. A framework analysis was used to describe and interpret the data.

RESULTS

Four overarching themes were identified in the analysis. These themes related to factors that influenced the everyday health-related workload and capacity of the participants. These factors included their health, resources, and opportunities, as well their motivation and sense of perceived control over their lives.

CONCLUSIONS

Fragmented healthcare systems and relationships with healthcare professionals also influenced the participants' self-management of their health. Our findings highlight the interaction between an individuals' needs, capacity, treatment burden, and the services and resources available to them. These findings support calls to promote person-centred care to better support older adults to manage their health.

Impact of Tumor Location on Survival in Patients With Colorectal Cancer: A Retrospective Cohort Study Based on Taiwan’s Cancer Registry Database

Background:

Colorectal cancer is one of the leading cancers worldwide. This study aimed to investigate the mortality differences between 2 primary tumor locations, the proximal/distal colon and rectosigmoid junction (RSJ)/rectum, after adjusting for comorbidities.

Methods:

The Taiwan Cancer Registry linked with Taiwan’s National Health Insurance Research Database was used to estimate the 5-year mortality rate among patients with colorectal cancer. A total of 73 769 individuals were enrolled in the study, which included 44 234 patients with proximal and distal colon cancers and 29 535 patients with RSJ and rectal cancers. Potential mortality risk was calculated using Cox regression analysis.

Results:

The mortality rates due to the location of the cancer in the proximal/distal colon and RSJ/rectum were 45.27% and 42.20%, respectively. After adjustment for age, sex, comorbidities, and clinical stages, the proximal/distal colon had a 1.03-fold higher 5-year overall mortality rate than RSJ/rectal cancer (95% confidence interval = 1.00–1.05). Proximal and distal colon cancers had a worse prognosis and survival than RSJ and rectal colon cancers in women and older patients (⩾70 years). Comorbidities had different effects on mortality in the proximal/distal colon and RSJ/rectum.

Conclusions:

Tumor location is associated with the prognosis of patients with colorectal cancer. It is important to treat patients beyond their cancer treatment, and to manage their comorbidities.

Comorbidities, Rather Than Older Age, Are Strongly Associated With Higher Utilization of Healthcare in Colorectal Cancer Survivors

BACKGROUND

Colorectal cancer (CRC) survivors generally have a higher healthcare utilization (HCU) than the general population due to cancer burden. However, it is unclear which factors are associated with this increased uptake. Our study aimed to (1) compare CRC-related and non-CRC visits to general practitioners (GPs) and medical specialists (MSs) by comorbidities, and (2) assess whether HCU differs by demographic, clinical, and psychological factors.

METHODS

We used data from a German population-based cohort of 1,718 survivors of stage I-III CRC diagnosed in 2003 through 2010 who provided information on HCU at 5-year follow-up. Multivariable linear regression was used to calculate least-square means of CRC-related and non-CRC HCU according to the Charlson comorbidity index and comorbidity cluster, adjusting for relevant demographic, clinical, and psychological characteristics.

RESULTS

A higher comorbidity level was associated with more CRC-related MS visits and non-CRC GP visits. In addition to being strongly associated with non-CRC GP visits, comorbidity clusters were associated with CRC-related GP and MS visits, but their association varied by specific cardiometabolic comorbidities. HCU was less dependent on prognostic factors for CRC, such as age and tumor stage, but was strongly associated with disease recurrence, depression, and emotional functioning.

CONCLUSIONS

Comorbidities, rather than age or tumor stage, were related to HCU, suggesting that CRC survivors use healthcare mainly for reasons other than cancer 5 years postdiagnosis. Improved communication between primary and tertiary healthcare providers could enhance the medical care of cancer survivors with complex health needs and thereby also reduce healthcare costs.

Prevalence and determinants of depression up to 5 years after colorectal cancer surgery: results from the ColoREctal Wellbeing (CREW) study

AIM

Depression experienced by people with colorectal cancer (CRC) is an important clinical problem affecting quality of life. Recognition of depression at key points in the pathway enables timely referral to support. This study aimed to examine depression before and 5 years after surgery to examine its prevalence and identify determinants.

METHOD

The ColoREctal Wellbeing (CREW) study is a prospective UK cohort study involving 872 adults with nonmetastatic CRC recruited before surgery with curative intent. Questionnaires completed before surgery and 3, 9, 15, 24, 36, 48 and 60 months after surgery captured socio-demographics and assessed depression (Centre for Epidemiologic Studies Depression Scale, CES-D) and other psychosocial factors. Clinical details were also gathered. We present the prevalence of clinically significant depression (CES-D ≥ 20) over time and its predictors assessed before and 2 years after surgery.

RESULTS

Before surgery, 21.0% of the cohort reported CES-D ≥ 20 reducing to 14.7% 5 years after surgery. Presurgery risk factors predicting subsequent depression were clinically significant depression and anxiety, previous mental health service use, low self-efficacy, poor health, having neoadjuvant treatment and low social support. Postsurgery risk factors at 2 years predicting subsequent depression were clinically significant depression, negative affect, cognitive dysfunction, accommodation type and poor health.

CONCLUSION

Depression is highly pervasive in people with CRC, exceeding prevalence in the general population across follow-up. Our findings emphasize the need to screen and treat depression across the pathway. Our novel data highlight key risk factors of later depression at important and opportune time points: before surgery and at the end of routine surveillance. Early recognition and timely referral to appropriate support is vital to improve long-term psychological outcomes.

An exploration of the sociodemographic and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults

OBJECTIVE

To identify sociodemographic factors and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Participants were recruited via investigator networks and an online panel provider with an established nationwide panel of Aboriginal and Torres Strait Islander adults. Those interested were invited to complete a survey that included an assessment of wellbeing using a visual analogue scale. Data was collected from October-November 2019 and August-September 2020. Exploratory analyses were conducted to ascertain factors associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults.

RESULTS

Having more than enough money to last until next pay day, full-time employment, completion of grade 12, having a partner, and living with others were significantly associated with higher wellbeing among Aboriginal and Torres Strait Islander adults. A self-reported history of depression, anxiety, other mental health conditions, heart disease, or disability were associated with lower self-rated wellbeing scores. Our findings indicate a need for further investigation among these socioeconomic and patient groups to identify how to improve and support the wellbeing of Aboriginal and Torres Strait Islander adults.

Influence of albumin and physical activity on postoperative recovery in patients with colorectal cancer: An observational study

PURPOSE

The study explores the influences of nutrition-related factors (albumin, hemoglobin, and obesity) and lifestyles (physical activity, fruit and vegetable intake, smoking, and drinking) on the length of hospital stay in postoperative colorectal cancer patients.

METHODS

This study is a cross-sectional design. A convenience sample of 106 preoperative colorectal cancer patients was recruited from a medical center in Taiwan. Data were collected using self-reported questionnaires and from patients' medical records.

RESULTS

The median length of hospital stay was ten days with an interquartile range (IQR) of 8-11.25 days. The results of the log-link Gamma generalized linear model showed that albumin (B = -0.16, p = 0.007) and physical activity (B = -0.14, p = 0.001) were significant predictors of the length of hospital stay after controlling for demographics and disease characteristics. The influences of anemia, obesity, fruit and vegetable intake, smoking, and drinking on the length of hospital stay were insignificant.

CONCLUSIONS

Patients with hypoalbuminemia and a low level of physical activity undergo a more extended postoperative hospital stay. The study findings inform clinicians of the influencing factor of the patients' recovery and provide a foundation for developing interventions to decrease hospital stay length.

Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement

BACKGROUND

The incidence of incisional hernia after major abdominal surgery via a midline laparotomy is 20-41 per cent with short-term follow-up, and over 50 per cent in those surviving an abdominal catastrophe. Abdominal wall reconstruction (AWR) requires complex operations, often involving mesh resection, management of scarred skin, fistula takedown, component separation or flap reconstruction. Patients tend to have more complex conditions, with multiple co-morbidities predisposing them to a vicious cycle of complications and, subsequently, hernia recurrence. Currently there appears to be variance in perioperative practice and minimal guidance globally. The aim of this Delphi consensus was to provide a clear benchmark of care for the preoperative assessment and perioperative optimization of patients undergoing AWR.

METHODS

The Delphi method was used to achieve consensus from invited experts in the field of AWR. Thirty-two hernia surgeons from recognized hernia societies globally took part. The process included two rounds of anonymous web-based voting with response analysis and formal feedback, concluding with a live round of voting followed by discussion at an international conference. Consensus for a strong recommendation was achieved with 80 per cent agreement, and a weak recommendation with 75 per cent agreement.

RESULTS

Consensus was obtained on 52 statements including surgical assessment, preoperative assessment, perioperative optimization, multidisciplinary team and decision-making, and quality-of-life assessment. Forty-six achieved over 80 per cent agreement; 14 statements achieved over 95 per cent agreement.

CONCLUSION

Clear consensus recommendations from a global group of experts in the AWR field are presented in this study. These should be used as a baseline for surgeons and centres managing abdominal wall hernias and performing complex AWR.

Comorbidity, lifestyle factors, and sexual satisfaction among Chinese cancer survivors

Objectives

This study aims to explore the prevalence of sexual satisfaction among Chinese cancer survivors, and explore the association of sexual satisfaction with comorbidity and lifestyle factors.

Methods

A cross‐sectional study was performed among 3996 Chinese cancer survivors recruited at Shanghai Cancer Rehabilitation Club from March to April 2017. Data were collected through self‐reported questionnaires. The questionnaire includes information about demographic, cancer characteristics, comorbidities, lifestyle factors, and sexual satisfaction. Sexual satisfaction was measured by a single‐item scale. The distribution of sexual satisfaction among different demographic and cancer characteristics was compared using the chi‐squared test. Logistic regression models were conducted to assess the effects of lifestyle factors, comorbidities on sexual satisfaction after adjustment for demographic and cancer characteristics.

Results

More than 40% of male and female cancer survivors reported no sexual satisfaction. Sexual satisfaction of cancer survivors is significantly associated with both the number and the type of comorbidities. Heart disease, musculoskeletal system disease, diabetes, and hyperlipidemia are the comorbidities significantly associated with sexual satisfaction of cancer survivors. Lifestyle factors other than smoking, including exercise or fitness, drinking alcohol, and eating fruits and vegetables are significantly correlated with sexual satisfaction. Besides, all of the above associations show gender differences. In addition, demographic characteristics include sex, age, marital status, living status, and average monthly income are also significantly associated with sexual satisfaction of cancer survivors.

Conclusion

Comorbidity and lifestyle factors are associated with sexual satisfaction of cancer survivors, and the associations show gender differences. Improving the lifestyles of cancer survivors, and controlling and reducing their comorbidities are important for improving their sexual satisfaction.

This study aims to investigate the prevalence of sexual satisfaction among Chinese cancer survivors, and explore the association of sexual satisfaction with comorbidity and lifestyle factors. Comorbidity and lifestyle factors are associated with sexual satisfaction of cancer survivors, and the associations show gender differences. Improving the lifestyles of cancer survivors, and controlling and reducing their comorbidities are important for improving their sexual satisfaction.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.

Racial differences in lifestyle, demographic, and health factors associated with quality of life (QoL) in midlife women

Previously, quality of life (Qol) has been defined as an individual's evaluation of a satisfactory life as a whole (i.e. physically, mentally, psychologically, and socially). Only a few studies have examined the racial differences between QoL and risk factors associated with health, demographics, and lifestyle in midlife women. Thus, the purpose of our study was to determine racial differences in QoL in menopausal women due to lifestyle, demographic, and health related risk factors. A stratified ordinal logistic regression model was applied to self-reported questionnaire data from the Midlife Women's Health Study (MWHS) to determine risk factors associated with QoL differences between White and Black women during the menopausal transition. In multivariable models, our results showed Black women who had 3 or 4 comorbidities were about 4 times as likely to have higher QoL compared to women who had 0 to 2 comorbidities (95% CI: 1.65,10.78). However, the number of comorbidities was not significantly associated with QoL in White women in univariate or multiple regression. Further, body mass index and income were not significant factors in QoL in Black women but were in White women. Overall, our results illustrate that differences in health, demographic, and lifestyle factors are associated with QoL during menopause. Also, we suggest that future studies evaluate stratified models between racial groups to determine race-specific risk factors related to quality of life.

Examination of individual and multiple comorbid conditions and health-related quality of life in older cancer survivors

PURPOSE

Older cancer survivors (≥ 65 years at diagnosis) are at high-risk for multimorbidity (2 + comorbid conditions). However, few studies have utilized a generalizable sample of older cancer survivors to understand how individual comorbid conditions, as opposed to total comorbidity burden, are associated with health-related quality of life (HRQOL). We examined associations between HRQOL outcomes (pain, fatigue, physical function), individual comorbidities (cardiovascular disease [CVD], lung disease, diabetes, arthritis) and total comorbidity (cancer-only, cancer + 1 condition, cancer + 2 or more conditions).

METHODS

Utilizing a population-based sample of 2019 older cancer survivors, we tested associations between comorbid conditions and the HRQOL outcomes using generalized linear models. HRQOL domains were assessed using Patient-Reported Outcome Measurement Information System^® (PROMIS^®) measures. Comorbidity was assessed via self-report.

RESULTS

Cancer survivors with lung disease reported significantly worse physical functioning (β = - 4.96, p < 0.001), survivors with arthritis reported significantly higher pain (β = 4.37, p < 0.001), and survivors with CVD reported significantly higher fatigue (β = 3.45, p < 0.001) compared to survivors without each condition. Having cancer + 1 condition was not as strongly associated with all outcomes as when individual conditions were tested (e.g. pain: β = 3.09, p < 0.001). Having 2+ comorbidities had a stronger association with all outcomes (e.g. physical function: β = - 7.51, p < 0.001) than examining conditions individually.

CONCLUSIONS

Knowing the specific comorbid condition profile of an older cancer survivor provides insight into specific HRQOL outcomes that may be impaired in cancer survivorship, but understanding total comorbidity burden, regardless of the specific conditions, sheds light on survivors at-risk for multiple impairments in HRQOL. This information, taken together, can inform risk-stratified survivorship care.

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.

Therapeutic radiographers' delivery of health behaviour change advice to those living with and beyond cancer: a qualitative study

OBJECTIVES

Therapeutic radiographers (TRs) are well placed to deliver health behaviour change advice to those living with and beyond cancer (LWBC). However, there is limited research on the opinions of TRs around delivering such advice to those LWBC. This study aimed to explore TRs' practices and facilitators in delivering advice on physical activity, healthy eating, alcohol intake, smoking and weight management.

SETTING AND PARTICIPANTS

Fifteen UK-based TRs took part in a telephone interview using a semi-structured interview guide. Data was analysed using the framework analysis method.

RESULTS

Emergent themes highlighted that TRs are mainly aware of the benefits of healthy behaviours in managing radiotherapy treatment related side effects, with advice provision lowest for healthy eating and physical activity. Participants identified themselves as well placed to deliver advice on improving behaviours to those LWBC, however reported a lack of knowledge as a limiting factor to doing so. The TRs reported training and knowledge as key facilitators to the delivery of advice, with a preference for online training.

CONCLUSIONS

There is a need for education resources, clear referral pathways and in particular training for TRs on delivering physical activity and healthy eating advice to those LWBC.

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.

Do age and comorbidity impair recovery during two years after treatment for endometrial cancer?

BACKGROUND

A better understanding of the impact of age and comorbidity on health-related quality of life (HRQoL) may improve treatment decision-making in patients with endometrial cancer. We investigated whether either age or comorbidity is more strongly associated with changes in HRQoL over time.

METHODS

Endometrial cancer patients (n = 296) were invited to complete questionnaires after initial treatment and after 6, 12 and 24 months follow-up. Patients were divided into subgroups according to age (<60, 60-75 and ≥75 years) and according to comorbidity (0, 1, 2 or ≥3). HRQoL was measured with the five EORTC QLQ-C30 functioning scales. Linear mixed models were performed for the different subgroups to assess changes in HRQoL over time. HRQoL was also compared to longitudinal outcomes from an age- and gender-matched normative population.

RESULTS

The first questionnaire was returned by 221 patients (75%) of whom six were excluded due to progressive disease. Changes in HRQoL were mainly associated with cumulative comorbidity burden and not with age. Patients with comorbidity reported deterioration of physical and role functioning between 12 and 24 months. Compared to the normative population, patients initially scored higher on physical and role functioning, but at 24 months outcomes were no longer different.

CONCLUSION

Cumulative comorbidity burden was more strongly associated with deterioration of HRQoL than patient's age. Therefore, patients with endometrial cancer and multiple comorbid conditions require careful follow-up of HRQoL after treatment.

Quality of life in "chronic" cancer survivors: a meta-analysis

PURPOSE

Cancer survivors are now living longer giving rise to a new concept-chronic cancer as survivors continue to face long-term consequences of cancer and its treatment. For these survivors, QOL becomes a vital consideration in understanding their survivorship and the long-term impact of cancer and its treatment. The primary aim of this review is to describe QOL in cancer survivors two or more years from diagnosis.

METHODS

A meta-analysis was completed of relevant studies assessing QOL in long-term cancer survivorship using PubMed, CINHAL, and PsycINFO. A total of 64 articles met inclusion criteria and included in the analysis. Standardized effect sizes and errors were calculated using previously published standard QOL pass rates to compare QOL across measurement tools and calculate cumulative effect sizes (CES). Fixed-effect or random-effects models were used based on the presence of significant heterogeneity of ≤ 0.10.

RESULTS

Physical health (CES = - 0.894; CI, - 1.472, - 0.316), role-physical health (CES = - 2.039; CI, - 2.643, - 1.435), and mental health (CES = - 0.870; CI, - 1.447, - 0.292) had large, negative cumulative effect sizes signifying worse QOL compared with acceptable QOL rates. Tested moderators, cancer type, average age, country of origin, time since diagnosis, or decade of diagnosis, were not significant to explain heterogeneity between included studies.

CONCLUSION

QOL is significantly impacted 2 to 26 years after cancer diagnosis. More research is needed to determine possible moderators of QOL in long-term cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

QOL continues to be significantly impacted in long-term cancer survivorship. More research is needed to understand the impact of these findings on care needs for survivors with chronic cancer.

Health-related quality of life and oncologic outcomes after surgery in older adults with colorectal cancer

PURPOSE

Data regarding changes in functional status and health-related quality of life (HRQOL) before and after surgery are lacking. We identified colorectal cancer patients from the SEER-Medicare Health Outcomes Survey (MHOS) linked database to evaluate the association between HRQOL and survival.

METHODS

HRQOL survey data captured physical/mental health, activities of daily living (ADLs), and medical comorbidities. Patients who underwent surgery with HRQOL surveys prior to cancer diagnosis and ≥ 1 year after diagnosis were selected. Patient, disease, and HRQOL measures were analyzed in regard to overall survival (OS), disease-specific survival (DSS), and non-DSS.

RESULTS

Of 590 patients included, 55% were female, 75% were Caucasian, and 83% had colonic primary. Disease extent was localized for 52%, regional for 41%, and distant for 7%. Median OS was 83 months. Decreased OS was independently associated with age ≥ 75 (HR 1.7, p < 0.0001), male sex (HR 1.4, p = 0.011), advanced disease (regional-HR 2.0, p < 0.0001; distant-HR 7.0, p < 0.0001), and decreased mental HRQOL (HR 1.4, p = 0.005). Decreased DSS was independently associated with advanced disease (regional-HR 4.1, p < 0.0001; distant-HR 16.5, p < 0.0001) and rectal primary (HR 1.6, p = 0.047). Decreased non-DSS was independently associated with age ≥ 75 (HR 2.2, p < 0.0001), male sex (HR 1.4, p = 0.03), decreased mental HRQOL (HR 1.4, p = 0.02), and increased comorbidities (HR 1.4, p = 0.04).

CONCLUSIONS

The potential overall survival benefit of oncologic surgery is diminished by declines in physical and mental health. Early identification of older surgical patients at risk for functional and HRQOL declines may improve survival following colorectal cancer surgery.

Cancer specialist nurses' perspectives of physical activity promotion and the potential role of physical activity apps in cancer care

PURPOSE

The purpose of this study was to understand breast, prostate and colorectal cancer clinical nurse specialists' (CNSs) perspectives on physical activity (PA) promotion and the role of smartphone apps to support PA promotion in cancer care.

METHODS

CNSs working in breast, prostate or colorectal cancer were recruited via advertisements distributed by professional organizations. In-depth semi-structured telephone interviews were conducted and analysed using thematic analysis.

RESULTS

Nineteen CNSs participated. The analysis resulted in 4 themes regarding CNSs' perspectives of PA promotion within cancer care: (i) policy changes in survivorship care have influenced CNSs' promotion of PA; (ii) CNSs recognize their role in supporting PA but sit within a wider system necessary for effective PA promotion; (iii) CNSs use several techniques to promote PA within their consultations; (iv) remaining challenges in PA promotion. The analysis resulted in 3 themes regarding CNSs' perspectives on the use of apps to promote PA within cancer care: (i) the influence of apps on access to PA support; (ii) the role of apps in self-directed PA; (iii) implementing apps in cancer care.

CONCLUSIONS

The results of this study provide valuable insight into the CNS role and provide a number of important considerations for the development and implementation of PA interventions within cancer care, with a specific focus on smartphone-based interventions.

IMPLICATIONS FOR CANCER SURVIVORS

CNSs play an important role in PA promotion in cancer care and this research can inform the development of PA interventions delivered via smartphone app for people affected by cancer.

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.

Renewed: Protocol for a randomised controlled trial of a digital intervention to support quality of life in cancer survivors

INTRODUCTION

Low quality of life is common in cancer survivors. Increasing physical activity, improving diet, supporting psychological well-being and weight loss can improve quality of life in several cancers and may limit relapse. The aim of the randomised controlled trial outlined in this protocol is to examine whether a digital intervention (Renewed), with or without human support, can improve quality of life in cancer survivors. Renewed provides support for increasing physical activity, managing difficult emotions, eating a healthier diet and weight management.

METHODS AND ANALYSIS

A randomised controlled trial is being conducted comparing usual care, access to Renewed or access to Renewed with brief human support. Cancer survivors who have had colorectal, breast or prostate cancer will be identified and invited through general practice searches and mail-outs. Participants are asked to complete baseline measures immediately after screening and will then be randomised to a study group; this is all completed on the Renewed website. The primary outcome is quality of life measured by the European Organization for Research and Treatment of Cancer QLQ-c30. Secondary outcomes include anxiety and depression, fear of cancer recurrence, general well-being, enablement and items relating to costs for a health economics analysis. Process measures include perceptions of human support, intervention usage and satisfaction, and adherence to behavioural changes. Qualitative process evaluations will be conducted with patients and healthcare staff providing support.

ETHICS AND DISSEMINATION

The trial has been approved by the NHS Research Ethics Committee (Reference 18/NW/0013). The results of this trial will be published in peer-reviewed journals and through conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN96374224; Pre-results.

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.