Health-related quality of life (HRQOL) of colorectal cancer survivors is a growing public health concern, alongside conventional outcome measures that are disease-centric such as mortality and survival rate. Despite being the third most common cancer and the fourth leading cause of cancer-related deaths worldwide, the survival rate of colorectal cancer continues to increase substantially over the past decades (Arnold, 2016 #52@@hidden;Arnold, 2016 #52)
In Malaysia, colorectal cancer is the second leading cancer, accounts for 13.2% of all cancers
Understanding the pattern of HRQOL as well as the complexity of factors, characteristics or conditions that predict HRQOL is a significant step towards identifying patients who are at risk of poor HRQOL. Previous studies that have investigated the role of socio-demographic, medical, lifestyle behaviour, health system and various intervention in predicting the HRQOL of colorectal cancer patients have been inconsistent
Therefore, we embarked on this study to assess patient’s perceived global health status and quality of life (GHS/QOL), functional outcomes and symptoms as measured by the Malaysian versions of Quality of Life Questionnaire core (QLQ-C30) and QLQ-CR29; and to determine factors among demographics, clinical factors, treatment and scales of the QLQ-C30/ QLQ-CR29 that were associated with of GHS/QOL in patients with colorectal cancer.
This was a cross-sectional study conducted at the University Malaya Medical Centre (UMMC), which is a tertiary hospital. Ethics approval was obtained from the Medical Research Ethics Committee (
Sample size was calculated based on previous literature by Neil W Scott et al., considering Malaysian colorectal patients had global health mean score of 10 points higher than the reference values of 60.7 (SD 23.4) as reported in the literature
Data collection was conducted between May and June 2013. Information on baseline socio-demographic and medical conditions, index cancer clinical features, treatment characteristic and the consequences of the disease and its treatments were obtained from the EMR system. While the functional scales, symptoms and single item scales of the EORTC QLQ-C30 and QLQ-CR29 questionnaires were obtained through the phone interviews. A total of four experienced research assistants were recruited, two for Malaysian national language and two for Malaysian Chinese language. During the phone interviews, patients were given detailed explanation on the purpose and methods of study, the right to participate or refuse and the language of preference for the questionnaire. Patients were requested to respond to the questionnaire themselves with no proxies allowed.
HRQOL scales were measured using locally validated questionnaire of the EORTC QLQ-C30 and CR-29. Validation of EORTC QLQ-C30 and QLQ-CR29 were necessary due to different cultural settings and languages in Malaysia. This has been translated into Malaysian national language
The QLQ-C30 is one of the most widely used questionnaire in clinical cancer research
All statistical analyses were conducted using SPSS version 22.0 for Windows (SPSS Inc., and Chicago, Illinois, USA). Exploratory analysis was performed to examine the accuracy and completeness of our data as well as to guide the choice of statistical methods. Raw scores from the QLQ-C30 and QLQ-CR29 were transformed into a scale of 0-100 according to the developer’s guidelines. The profile of patients’ HRQOL was presented using mean and standard deviation (±SD)
Univariate analysis was performed to compare the difference in patients’ GHS/QOL, functionality and symptoms experience according to patients’ characteristics, comorbidities and treatment modalities. Independent sample t-test and one-way analysis of variance (ANOVA) with Bonferroni post-hoc tests of contrasts were used. Chi-square test was used to compare proportions between categorical variables. Pearson correlations coefficient, Kruskal Wallis tests were used to compare mean in different HRQOL scales and correlation coefficient (
A total of 324 patients were recruited and included in the final analysis. Majority of them were of Chinese ethnicity (62.3%), followed by Malays (19.8%) and Indians (14.8%). They had a mean age (±SD) of 62.5 years (±13.6), with a mean duration of 62.8 months (±31.4) since diagnosis. Overall, 87% of our participants were diagnosed with colon cancer, up to 7-fold commoner than rectal cancer (13%). TNM staging at presentation to the hospital was as follows: Stage I (7.1%), Stage II (29.6%), Stage III (28.1%) and Stage IV (16.0%), while the remaining 19.1% was unknown. The most common treatment modality was surgery alone (42.9%). Stoma was present in about 10% of patients. The baseline characteristic of the overall patient cohort is shown in Table 1.
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62.45 (±13.64) | ||
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0.437 | ||
| ≤ 60 | 131 (40.4) | 73.79 (±15.09) | |
| ≥ 61 | 193 (59.6) | 72.80 (±13.51) | |
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0.198 | ||
| Male | 163 (50.3) | 73.16 (±14.64) | |
| Female | 161 (49.7) | 73.29 (±13.76) | |
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22.35 (±4.99) | ||
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| Normal weight (<25) | 140 (43.2) | 72.32 (±14.87) | 0.427 |
| Overweight (25-30) | 176 (54.3) | 74.10 (±13.70) | |
| Obese (>30) | 8 (2.5) | 69.79 (±12.55) | |
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| Chinese | 202 (62.3) | 70.13 (±14.14) | < 0.001 |
| Malays | 63 (19.8) | 77.73 (±10.61) | |
| Indians | 48 (14.8) | 78.65 (±15.56) | |
| Others | 10 (3.1) | 80.83 (±11.15) | |
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62.78 (±31.36) | ||
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0.053 | ||
| ≤ 60 | 158 (48.5) | 73.26 (±14.45) | |
| ≥ 61 | 166 (51.5) | 73.19 (±13.98) | |
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0.234 | ||
| Yes | 86 (26.5) | 73.06 (±13.33) | |
| No | 238 (73.5) | 73.28 (±14.51) | |
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0.753 | ||
| Yes | 51 (15.7) | 73.86 (±13.02) | |
| No | 273 (84.3) | 73.11 (±14.42) | |
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0.713 | ||
| Colon | 282 (87.0) | 73.20 (±14.39) | |
| Rectum | 42 (13.0) | 73.41 (±12.91) | |
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0.746 | ||
| I | 23 (7.1) | 73.55 (±11.95) | |
| II | 96 (29.6) | 72.92 (±14.20) | |
| III | 91 (28.1) | 74.54 (±14.18) | |
| IV | 52 (16.0) | 71.15 (±12.18) | |
| Unknown | 62 (19.1) | 73.39 (±15.52) | |
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0.085 | ||
| Surgery alone | 139 (42.9) | 73.02 (±12.91) | |
| Surgery and chemo or radiotherapy |
123 (38.0) |
74.33 (±15.37) |
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| Surgery and chemo and radiotherapy | 10 (3.1) | 78.33 (±11.25) | |
| Chemo and/or radiotherapy | 20 (6.2) | 75.00 (±11.15) | |
| Palliative | 32 (9.9) | 67.19 (±16.11) | |
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0.044 | ||
| Yes | 31 (9.6) | 69.35 (±13.16) | |
| No | 293 (90.4) | 73.63 (±14.25) |
In general, majority of patients rated their HRQOL measures as high. About 89% of patients and 87% of patients rated their global health status (GHS) and overall quality of life (QOL) between score of 5 and 7 respectively on a scale of 1 to 7 (from ‘very poor’ to ‘excellent’). After linear transformation from raw scores to a scale of 0-100, the mean score for GHS/QOL was 73.23.
A better functioning is represented by a higher score in functioning scales. With respect to the
Most patients were satisfied with their body image (mean= 94.27) as it scored the highest among the functioning scales covered in colorectal cancer specific
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73.23 (±14.19) |
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| Physical | 84.34 (±16.58) |
| Emotional | 88.17 (±17.32) |
| Role | 83.02 (±20.23) |
| Cognitive | 83.90 (±19.99) |
| Social/ family | 88.01 (±18.30) |
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| Fatigue | 22.29 (±17.40) |
| Nausea/ vomiting | 7.30 (±13.43) |
| Pain | 13.79 (±18.23) |
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| Dyspnoea | 10.70 (±18.79) |
| Sleep loss | 18.42 (±23.32) |
| Appetite loss | 13.07 (±20.08) |
| Constipation | 15.02 (±22.43) |
| Diarrhoea | 11.01 (±17.95) |
| Financial difficulty | 11.32 (±17.26) |
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| Body image | 94.27 (±12.59) |
| Anxiety | 82.41 (±20.38) |
| Weight | 91.05 (±16.76) |
| Sexual dysfunction in men | 33.14 (±28.87) |
| Sexual dysfunction in women | 17.56 (±25.59) |
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| Urinary frequency | 22.96 (±24.22) |
| Blood and mucus | 1.03 (±5.92) |
| Stool frequency | 5.14 (±15.04) |
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| Urinary incontinence | 4.63 (±13.97) |
| Dysuria | 2.98 (±11.49) |
| Abdominal pain | 4.63 (±13.21) |
| Buttock pain | 1.85 (±8.89) |
| Bloated feeling | 10.49 (±17.58) |
| Dry mouth | 13.37 (±20.13) |
| Hair loss | 14.19 (±23.96) |
| Trouble with taste | 7.61 (±15.19) |
| Flatulence | 16.87 (±21.71) |
| Faecal incontinence | 3.60 (±14.03) |
| Sore skin | 2.78 (±12.68) |
| Embarrassment | 2.37 (±12.21) |
| Stoma care-related problem | 20.00 (±31.91) |
| Impotence | 18.49 (±26.74) |
| Dyspareunia | 3.82 (±12.15) |
*Abbreviation: GHS/QOL: global health status/quality of life; EORTC: European Organisation for Research and Treatment of Cancer **Values are expressed in mean (±standard deviation)
On univariate analysis, presence of stoma and ethnicity were significantly associated with health-related quality of life among colorectal cancer patients. The mean score of GHS/QOL is significantly lower in Chinese (mean=70.13) than Malays (mean=77.73), Indians (mean= 78.65) and others (mean=80.83). Besides, there was significantly higher mean score observed among patients with stoma (mean= 73.63) than those without stoma (mean= 69.35). Results are shown in Table 1
Variables with p-value of less than 0.25 were included in multivariate analysis. Factors included were gender, ethnicity, duration since diagnosis, hypertension, presence of stoma and treatment modality. Of these, ethnicity was the only independent predictor of GHS/QOL (95% confidence interval, 2.589 to 6.139, p<0.001). Further post-hoc analysis revealed that Indians and Malays had significantly higher scores compared to Chinese. Age, gender, body mass index (BMI), duration of diagnosis, comorbidities, anatomic site of tumour, TNM’s staging, treatment modality and presence of stoma were not associated with GHS/QOL. Results are shown in Table 3.
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| GHS/QOL | Gender | .173 (1.529) | 0.113 | -2.836 | 3.181 |
| Ethnicity | 4.241 (.907) | <0.001 | 2.456 | 6.025 | |
| Duration since | .343 (1.635) | 0.834 | -2.874 | 3.561 | |
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| Hypertension | -.372 (1.750) | 0.832 | -3.815 | 3.071 | |
| Presence of stoma | -3.372 (2.759) | 0.222 | -8.800 | 2.055 | |
| Treatment modality | -.641 (.611) | 0.295 | -1.844 | 0.561 |
*Abbreviation: GHS/QOL: global health status/quality of life; SE: standard error
We further stratified the dimensions of HRQOL by the ethnicity. It was found that all the domains including functionalities and symptoms in QLQ-C30 were significantly associated with different ethnic groups whereas some domains in QLQ-CR29 were significantly associated with ethnic groups. Chinese had significantly poorer GHS/QOL in all domains of QLQ-C30 core module as compared to Malays, Indians and others. Besides, Chinese had poorer functionalities (excluding sexual dysfunction in men) and experienced worst symptoms such as urinary frequency, bloated feeling, dry mouth, trouble with taste, hair loss and stoma care related problems than other ethnic groups according to the QLQ-CR29 module.
Colorectal cancer and its temporal development in developing countries including Malaysia remains a significant health burden and public health concern. With increased post-treatment survival rate, research on the pattern of quality of life and its associated factors is crucial to guide physicians in choosing treatment options and to improve quality of life by giving proper intervention on modifiable factors
The demographic, clinical and treatment characteristics of our patients were generally similar to those reported by previous studies from Malaysia and other countries in the South East Asian region
Health-related quality of life among our patients was good with respect to the global health status and overall quality of life (GHS/QOL) with an overall mean score of 73. This is comparable with previous studies in which the reported mean score for global quality of life ranged from 60 to 75
Of note, sexual dysfunction is one of the main concern among our patients with low mean scores of 33 in men and 17 in women respectively. Similar results were demonstrated in which the post-treatment sexual functioning scores were low, ranged from 15 to 40
Despite good overall GHS/QOL and functionalities, some symptoms seem to persist among our patients. We found that our patients suffered from long-lasting physical symptoms such as fatigue and sleep loss, genitourinary symptoms such as urinary frequency as well as bowel symptoms such as constipation. Several studies also reported persistent physical symptoms in colorectal cancer survivors such as reduction in energy
Presence of stoma is likely to impair patients’ quality of life. The association between stoma and poorer quality of life have been studied and was further demonstrated when the quality of life improved consistently after reversal of stoma
To our surprise, ethnicity is the only independent predictor of health-related quality of life among colorectal cancer survivors. No association between ethnicity and quality of life were reported previously except that there is one study reported a trend for higher psychological quality of life among African American survivors than Caucasion survivors
This study demonstrated that the quality of life among our colorectal cancer survivors is comparable with other studies. However, there were several limitations that should be addressed while interpreting our results. Firstly, there may be sampling bias as the data were obtained from only one institution and therefore may not be generalised to the general population of colorectal cancer patients. Besides, as half of our patients survived more than five years, this may not reflect the situation for those who died before the five-year follow-up. On the other hand, the strength of our study includes the use of well-established instruments to assess HRQOL among colorectal cancer survivors,
In conclusion,
The authors thank the patients, research assistants, and members of the colorectal surgery units of the UMMC for the assistance they rendered towards the success of this study. We thank the staff of the European Organization for Research and Treatment of Cancer Quality of Life Department, Avenue Mounier, 83/11 1200 Brussels, Belgium for the support offered to us. We also wish to acknowledge the funders of this study. This study was fully funded by the University of Malaya postgraduate fund with the following reference numbers (UM-IPPP PS212/2010A and PV015-2011B) and partially supported by the STeMM Programme, the University of Malaya/Ministry of Higher Education (UM/MOHE) High Impact Research Grant (No: E000010-20001).
The authors declare no conflict of interest.