Quality of life outcomes in colorectal cancer survivors: insights from an observational study at a tertiary cancer center

Colorectal cancer (CRC) poses significant health challenges globally and remains a predominant cancer type in Portugal, where it is the second leading cause of cancer-related deaths [1]. Advancements in medical science have improved survival rates, however survivors’ long-term quality of life (QoL) has not received comparable attention, despite its paramount importance [2‐5]. The impact of CRC and its treatments on QoL is highly variable, influenced by factors such as tumor location, the stage at diagnosis, and the chosen treatment strategies [2‐6].

CRC management includes a wide range of treatment modalities such as surgery, chemotherapy, and radiotherapy, each carrying a distinct physical and psychological impact. Especially when applied in combination, they significantly influence patients’ daily functioning and overall well-being [2, 7]. The scope of these effects highlights the need for a thorough assessment of the multidimensional aspects of QoL in CRC survivors [4]. Such evaluations are essential for understanding their recovery trajectories and long-term health outcomes, which could guide the selection and design of targeted interventions, as well as survivorship care plans [7, 8].

Patients with CRC may experience diminished physical functioning and daily life quality due to numerous disease- and treatment-related symptoms, such as pain, change in bowel movements, blood loss and anemia, weight loss, and fatigue. Additionally, their psychological, emotional, social, and role functioning may suffer due to fear, anxiety, sleep disturbances, and depression [6].

Colon cancer patients often report more favorable QoL outcomes compared to those with rectal cancer, who tend to endure more severe symptoms including pelvic pain and complications related to defecation, sexual, and urinary functions [2, 6, 7, 9]. The sphincter-preserving procedures preferred in rectal cancer are associated with their own set of challenges. Approximately 70% of patients undergoing these procedures develop some form of low anterior resection syndrome (LARS), which significantly deteriorates their long-term QoL [10]. Furthermore, although the impact of a stoma on QoL remains a subject of debate in well-designed systematic reviews [11], most recent studies indicate a decline in overall QoL for these patients, particularly in physical and role functioning, and body image [5, 12‐14].

Laparoscopic techniques provide several short-term advantages over traditional open surgery, including reduced blood loss, less pain, and shorter recovery times. In the short term, patients undergoing laparoscopic sphincter-preserving procedures report higher QoL scores, including better physical functioning, improved body image, reduced pain, and fewer bowel dysfunction symptoms, compared to those undergoing open surgery [7, 15]. However, a systematic review suggested that differences in QoL may diminish over time as patients who underwent open surgery gradually recover, eventually reaching similar levels of QoL in the long term [15]. Since this review did not include a meta-analysis due to the heterogeneity of the studies analyzed, further investigation is needed to determine whether long-term QoL outcomes truly differ by surgical approach.

Radiotherapy, employed in both neoadjuvant and adjuvant settings for treating rectal cancer, is strongly associated with the development of LARS, as well as urinary and sexual dysfunctions, which significantly reduce QoL [16, 17]. Meanwhile, chemotherapy, generally well tolerated, can lead to adverse effects like neutropenia, diarrhea, skin toxicity, and sensory neuropathy which markedly impair QoL. While most of these side effects resolve after the cessation of treatment, some may persist over the long-term [18, 19].

Remarkably, long-term survivors of CRC often undergo significant psychological adjustments, such as response shift and reframing, that can profoundly influence their perceived QoL, bringing it closer to that of the general population, despite past or ongoing physical and emotional challenges [4‐7].

This study aims to assess the QoL of CRC patients treated with curative intent at a tertiary cancer center over a decade. Our secondary objectives include comparing the QoL outcomes to the Portuguese general population, between patients with colon and rectal cancer, patients receiving radiotherapy and those who did not, patients receiving chemotherapy and those who did not, patients with a stoma and those without, and exploring which sociodemographic and clinical variables may influence these outcomes. We intend to improve the understanding of CRC treatment effects, thereby informing future clinical practices and enhancing support mechanisms for patients.

This study assessed the quality of life (QoL) experienced by mid to long-term survivors of colorectal cancer who received curative treatment at a tertiary cancer center over a decade-long period. We conducted QoL evaluations once for each patient, using a comprehensive set of questionnaires, and strategically selecting individuals at four stages of their follow-up pathway.

Out of the invited cohort, 179 individuals (55.2%) participated in our study. While acknowledging the modest response rate, our figures align with those of similar studies in colorectal cancer [29, 30]. They indicate a consistent pattern of engagement across different follow-up intervals, apart from the ten-year cohort who presented a 40% response rate.

Study participants generally reported favorable QoL outcomes, characterized by good global health, high functional scores, and low symptom scores. Remarkably, these results are comparable to, and in some aspects even better than those of the Portuguese general population, underscoring the resilience and adaptability of cancer survivors. This positive outlook may be influenced by psychological adaptations such as ‘response shift’ and ‘reframing’, where individuals adjust their internal standards of well-being, and ‘rejoice’, a profound sense of gratitude that could significantly enhance QoL perceptions [4, 6, 7].

Distinct variations in QoL were noted between colon and rectal cancer patients. Those with rectal cancer reported lower scores across various domains, including global health, role and social functioning, body image; and specific symptoms such as buttock pain, blood and mucus in stool, flatulence, fecal incontinence, and impotence. These outcomes are consistent with previous research and may be attributed to the aggressive nature of treatments. Irradiation and surgical dissection of the pelvic structures can result in impaired bowel, urinary and sexual functions [2, 6‐8].

In a subgroup analysis of rectal cancer patients, those who received radiotherapy reported lower QoL, consistent with previous research [16, 17]. Specifically, radiotherapy was associated with increased complaints of diarrhea, bloating, and impotence.

Patients who received chemotherapy reported lower global health and functional scores, along with higher symptom scores, compared to those who did not receive chemotherapy. These results align with previous research [18, 19], indicating that chemotherapy may negatively impact both overall quality of life and specific aspects such as emotional well-being, body image, and physical symptoms.

The presence of a stoma at the time of QoL assessment was associated with poorer outcomes in our subgroup analysis, affecting both functional and symptom scales. This finding underscores the significant impact of stoma management on patients’ daily lives and overall well-being [12‐14].

In a further subgroup analysis, survivors at long-term follow-up intervals (5- and 10-years) reported reduced physical functioning compared to those at mid-term intervals (1- and 3-years). This difference in physical functioning is likely attributable to the older age at which QoL was assessed in the long-term group. Such findings suggest that age-related declines in physical capabilities may have contributed to the diminished QoL reported by these patients.

Our multivariate analysis revealed that women, patients undergoing open surgery, and those receiving chemotherapy reported lower QoL. Previous studies have similarly identified female gender as a predictor of poorer QoL outcomes in colorectal cancer survivors, though the underlying causes are not fully understood [31, 32]. It should be noted that during the period of this study, open surgery was mainly reserved for patients presenting with more extensive locoregional tumor spread, while laparoscopic surgery was preferred in our unit. Additionally, a specific group of patients who underwent chemotherapy reported persistent side effects, especially those associated with neurotoxicity, which may explain the worse QoL outcomes [18‐19].

Educational level, employment status, and marital status are commonly used as proxies for socioeconomic status in QoL studies [33‐35]. However, in our analysis, none of these factors was significantly associated with the QLQ-C30 summary score. This suggests that socioeconomic status, as measured by these proxies, may not strongly influence QoL outcomes in our cohort. Nevertheless, other socioeconomic factors not assessed in our study, such as income, social support, or access to healthcare, could still play a role and warrant further investigation.

To accurately capture the impact of CRC on survivors, QoL assessments should employ a multi-layered set of instruments that include generic, condition-specific, and disease-specific measures [4, 23, 34]. This comprehensive methodology allowed us to reveal differences not only by tumor location and administration of radiotherapy or chemotherapy but also between patients with and without a stoma, highlighting the value of tailored assessments in uncovering unique patient challenges.

The study is not without limitations. Its cross-sectional design limits our ability to infer causality or track changes in QoL over time. Additionally, the single-center nature of the study may restrict the applicability of our findings to other demographic and clinical settings. A notable concern is the modest response rate; although no statistically significant differences were detected in the characteristics of respondents versus non-respondents, the potential exclusion of more frail individuals– who may have been less willing to participate– could introduce bias into our results. Moreover, the exclusion of patients with metastatic disease at diagnosis or those experiencing recurrence during follow-up may diminish the comprehensiveness of our findings, limiting the integration of QoL assessments with broader oncological outcomes. Finally, the EORTC QLQ-C30 and QLQ-CR29 may not capture all aspects of HRQOL specific to long-term survivors. Future studies could benefit from incorporating the computerized adaptive testing (CAT) version of the EORTC QLQ-C30 [37] once it becomes available in European Portuguese, or the EORTC survivorship core questionnaire [38] once its development is complete, and it has been widely validated for this population.

In summary, this research highlights the importance of a multi-tiered QoL assessment approach in colorectal cancer survivors, revealing differences that can inform tailored support strategies. The findings advocate for less invasive treatment modalities and the implementation of comprehensive rehabilitation programs to address the QoL challenges identified. Future research should consider a longitudinal, multicentric design that includes a wider spectrum of patients, particularly those with metastatic disease or recurrence, enhancing the applicability and depth of understanding in QoL dynamics among colorectal cancer survivors.