The impact of method of colorectal cancer surgery on quality of life of patients using the EORTC questionnaire

Introduction

The concept of a patient’s quality of life is a multidimensional concept that poses a challenge to scientists around the world [1]. As a subjective feeling of the patient, it is an extremely difficult aspect of life to investigate, requiring the implementation of advanced and precise research tools. Its level clearly affects the overall bio-psycho-social functioning of a person [2, 3].
Cancer diseases significantly affect the patient’s well-being. Colorectal cancer, as the most frequently diagnosed malignant tumor of the gastrointestinal tract, contributes to a decrease in the quality of life of patients [4]. Discomfort and reduced quality of life depend on a number of factors, such as the stage of development of the cancer process, its extent and location [5, 6].
The basic treatment methods for colorectal cancer include surgical removal of the lesion. It is also a necessary, inseparable, and sometimes the only stage of therapy [7]. Depending on the stage of the disease, it is possible to subject the patient to systemic treatment, which involves combining several therapeutic methods, including surgery, radiotherapy or chemotherapy [6, 7]. The expansion of therapeutic methods, despite scientifically proven effectiveness, significantly contributes to the reduction of patients’ quality of life [8].
Taking into account the concern for the patient’s good bio-psycho-social condition during the treatment process, efforts are made to eliminate determinants that reduce the quality of life [9].
Medical progress has made it possible to expand the possibilities of surgical tumor resection. Radical removal of colorectal cancer reduces the possibility of dissemination of cancer cells, and thus reduces the risk of recurrence [9–11]. Additionally, attention to the possible preservation of the continuity of the digestive tract significantly influences minimizing the decline in the quality of life [10]. The development of minimally invasive surgery makes it possible to select an appropriate surgical method while ensuring maximum patient safety [12]. Due to the great interest in modern technology, this method has gained many supporters [13]. However, considerations are still underway to make minimally invasive surgery of the large intestine the “gold standard of treatment”.
The aim of the study was to assess the impact of the surgical method of colorectal cancer on the quality of life of patients using the EORTC QLQ-C30 questionnaire.

Material and methods

The aim of the study was to assess the quality of life of patients after laparoscopic and conventional surgical treatment of colorectal cancer. The study used an analysis of available medical records and a research tool: the EORTC QLQ-C30 questionnaire.
The analysis included 269 consecutive patients diagnosed with colorectal cancer and undergoing surgery to remove the cancerous lesion between March 21, 2019 and December 31, 2021. The subjects were men and women aged 30–78.
The research was carried out in three time intervals – before the procedure, 7 days after the colon resection procedure, and one month after the operation.
In order to precisely assess the quality of life at work, a standardized questionnaire was used: EORTC-QLQ-C30 (version 3.0) for patients treated for cancer.
The EORTC QLQ-C30 questionnaire contains five subscales assessing physical functioning (PF: 1–5), functioning in life roles (RF: 6, 7), emotional functioning (EF: 21–24), cognitive functioning (CF: 20, 25), and social functioning (SF: 26, 27), as well as three scales assessing disease symptoms: fatigue (FA: 10, 12, 18), nausea and vomiting (NV: 14, 15), and pain (PA: 9, 19). It also includes a general health assessment scale (QL: 29, 30). Additionally, the scale has five more questions assessing disease symptoms, i.e. loss of appetite (AP: 13), shortness of breath (DY: 8), insomnia (SL: 11), constipation (CO: 16), diarrhea (DI: 17) and financial difficulties resulting from the disease (FI: 28).
The answers to the questions in the questionnaire are on a scale from 1 to 4 (1 means never, 2 – sometimes, 3 – often, 4 – very often) assessing the severity of the analyzed parameters. Patients completed the questionnaires on their own, and if they had difficulty understanding the questions, they sought help from a nurse, doctor or family member.
All calculations and graphs were made using the R statistical package, version 4.1.3.
In order to verify the internal consistency of the questionnaire construct used in this study, its reliability was analyzed using the Cronbach alpha reliability coefficient.
Reliability analysis of the QLQ-C30 questionnaire showed an acceptable level only in the case of the survey conducted one month after the procedure. One week after the procedure, the result was close to acceptable, and on the day of admission to the hospital the result was poor.

Results

Two hundred sixty-nine patients were included in the study. The average age of the respondents was 60.1 (±7.32) years, with the youngest person being 30 years old and the oldest being 78 years old. Men constituted 70.3% (n = 189) of all patients, while women constituted 29.6% (n = 80). More than half of the respondents (57.6%, n = 155) were city residents. In terms of education, the largest percentage consisted of people with secondary education (48%, n = 129). The majority of respondents described their marital status as married (56.5%, n = 152). The vast majority of people participating in the study lived with their family (68.8%, n = 185) (Table 1).
The most frequently performed type of surgery was left hemicolectomy (55%, n = 148). The procedures were performed using two methods, with the laparoscopic method used in 46.8% of cases and the classic method in 53.2%.
The most common cancer among the respondents was a malignant tumor of the sigmoid colon (46.8%, n = 126) and a malignant tumor of the ascending colon (35.3%, n = 95). In the microscopic image of the tumor, adenocarcinoma was identified in all subjects. The stage of cancer was most often determined as T3N1M0 (21.9%) or T3N0M0 (21.6%) (Table 2).
On the day of admission to the hospital, statistically significant differences were observed in the following subscales of the QLQ-C30 questionnaire in relation to the method of colon removal:
• physical functioning (PF2) – Mann-Whitney U test (p < 0.001),
• functioning in social roles and at work (RF2) – Mann-Whitney U test (p < 0.001),
• fatigue (FA) – Mann-Whitney U test (p < 0.001),
• pain (PA) – Mann-Whitney U test (p < 0.001),
• shortness of breath (DY) – Mann-Whitney U test (p < 0.01),
• insomnia (SL) – Mann-Whitney U test (p < 0.05),
• constipation (CO) – Mann-Whitney U test (p < 0.001),
• diarrhea (DI) – Mann-Whitney U test (p < 0.01).
Functioning subscales such as PF2 (physical functioning), RF2 (functioning in social roles and at work) and symptoms of CO (constipation) and DI (diarrhea) had significantly higher results in people who were to undergo laparoscopic removal of the large intestine than the classic method. The subjects who underwent laparoscopic surgery were more independent and in better overall physical condition than those scheduled for the classic surgical method.
Additionally, their contact in society and maintaining social roles were at a better level. Patients maintained constant contact with their families.
It was found that the laparoscopic method was chosen more often in subjects who had changes in the rhythm of discharge of varying intensity. In general, patients with symptoms of constipation and diarrhea were more often operated on laparoscopically.
However, in the case of symptom subscales such as FA (fatigue), PA (pain), DY (shortness of breath) and SL (insomnia), significantly lower results were obtained in people who were to undergo laparoscopic surgery. This means that patients scheduled for laparoscopic surgery had significantly less discomfort such as fatigue and shortness of breath. Moreover, their sleep quality was better than that of patients scheduled for conventional surgery.
Table 3 presents a precise comparison of the results of individual subscales of the QLQ-C30 questionnaire in relation to the method of removal of the large intestine, assessed on the day of the subject’s admission to the hospital.
Another assessment was performed on the 7^th day after the procedure. For obvious reasons, the following subscales were not measured: CO (constipation), DI (diarrhea) and FI (financial difficulties). In the case of the remaining subscales relating to functioning, significantly higher scores were obtained by people after laparoscopic surgery. They were characterized by better functioning and faster recovery to physical health.
However, in the case of the subscales FA (fatigue), NV (nausea and vomiting), PA (pain), DY (shortness of breath), SL (insomnia), and AP (loss of appetite), patients who used the classical method had significantly higher scores. This indicates a persistently high level of undesirable symptoms that worsen the patient’s quality of life. Additionally, the analysis of the results confirms that the classic surgery is more burdensome for the patient.
Table 4 presents a detailed comparative analysis of the subscale results of the QLQ-C30 questionnaire in relation to the method of colon removal assessed 7 days after surgery. A follow-up assessment of the patient’s quality of life was also performed one month after the procedure. No significant correlations were observed only between the NV (nausea and vomiting), CO (constipation) and FI (financial difficulties) subscales and the method of colon removal (p > 0.05).
The results of the functioning subscales were significantly higher in patients after laparoscopic surgery, while the results of the symptom subscales were significantly lower. This means more efficient recovery after surgery and a faster return to fitness. Moreover, the subjects operated on laparoscopically showed a lower level of symptoms that worsened the patients’ quality of life. One month after the procedure, patients after the classic surgical method had greater problems with functioning and had greater problems with symptoms.
Table 5 presents a detailed comparative analysis of the subscale results of the QLQ-C30 questionnaire in relation to the method of colon removal assessed one month after the procedure.

Discussion

Colorectal cancer is one of the most common malignant tumors of the digestive tract. In order to achieve the longest possible survival, patients need monitoring and full compliance with the planned treatment.
According to the analysis conducted by the National Cancer Registry (KRN), as many as 10,271 cases out of 18,466 patients with colorectal cancer are men [14, 15]. In the study group of 269 patients, as many as 70.3% (n = 189) of cases occurred in men, which confirmed the results of the National Clinical Register.
Stjepanovic et al. identified a relationship between the incidence of colorectal cancer and the age of patients. Most cases of colorectal cancer occur in older people, over 65 years of age [16]. This was also corroborated by research conducted by Mik et al., who conducted a study on a research group of 1,744 people. The mean age of the patients was 65 (±12 years) [17]. However, in the present study it was found that the mean age of patients had decreased to 60.1 (±7.32) years, with the oldest being 78 years old. The literature also contains disturbing data regarding an increase in the disease among young people < 40 years of age [18, 19]. The analysis of our own research showed that as many as 3.7% (n = 10) of the respondents were patients < 40 years of age.
Surgical treatment is the primary treatment for colorectal cancer. Resection of the large intestine can be performed in two ways – using the classic or laparoscopic method.
Many scientists focus their research on the patient’s quality of life, trying to identify a treatment method that maintains the quality of life at the best possible level. The research makes it possible to understand the bio-psycho-social consequences of patients after using various therapeutic methods. Measuring the quality of life requires openness, work and a multidimensional approach from the researcher. For this purpose, specialized questionnaires dedicated to specific diseases are used [20]. A questionnaire created for cancer patients is the EORTC QLQ-C30. Laghousi et al. report that in addition to selecting a questionnaire, it is also necessary to assess the quality of life examined at several time intervals [21].
In the study by Thong et al. using EORTC questionnaires, no statistically significant differences were found for any of the EORTC QLQ-C30 and EORTC QLQ-CR29 subscales, with the exception of better body image in patients after laparoscopic surgery (87.1 vs. 81.0, p = 0.03) [22]. Different results were obtained in the present study. Several significant differences were found.
The analysis of the questionnaire results showed that individual scales of the patient’s functioning determine the level of quality of life. According to Laghousi et al., the reference values of the obtained tests were lower than those of EORTC. This means a lower quality of life, which the researchers attributed to the advanced disease state of their patients [21]. Another study conducted in Iran by Akhondi-Meybodi et al. [23] on the quality of life of patients after colon removal showed a better result of the patients’ quality of life than in the study by Laghousi et al. In our study, the average quality of life score examined on the 7^th day after surgery was also lower than the EORTC reference values, while in the assessment carried out one month after surgery, this value was equal to or slightly lower than the values determined by EORTC. A significantly higher quality of life was observed in patients operated on laparoscopically.
Research conducted by Laghousi et al. showed the most favorable results in the following subscales: cognitive functioning (69.36) and physical functioning (52.05) [21]. In the case of our research, 7 days after the procedure, the highest values were also obtained in the categories of physical functioning (45.8) and general health condition (34.67). However, the results change when quality of life is checked one month after surgery. One month after the procedure, the highest values of quality of life parameters were found in the areas of physical functioning (73.43), cognitive functioning (70.45) and social functioning (69.08). The remaining results were around 60 points. This proves a significant improvement in the quality of life.
Laghousi et al. also identified a major financial problem in patients after surgery (69.52) [21]. The benchmark provided by the EORTC is 13.6 [24]. However, a low value for financial difficulties was obtained in the study conducted by Abu-Helalah et al., less than 20.7% [25]. The result of our research was similar to that of Abu-Helalah et al., at 21.19 points. Analysis of the assessment at time intervals showed that this factor increased slightly in the assessment one month after the procedure. Reasons beyond the patient’s control, such as the need to quit or limit work, or low socioeconomic status, may have an impact on difficulties related to the financial stability of the respondents [25]. Research conducted on the Chinese population also showed that intestinal cancer had a negative impact not only on the financial status of patients, but also on social functioning, coexistence of pain and physical functioning [26]. The patient’s age has been found to be an important determinant of financial problems. The study by Scarpa et al. identified no difference in the quality of life of elderly people according to the method of colon removal. However, in younger respondents, the quality of life after undergoing laparoscopic surgery resulted in a better assessment of the financial sphere and a higher level of quality of life [27]. It is worth mentioning, however, that regardless of the level of functioning of patients and their level of fitness, the quality of life increases after surgery [28].
The study by Rønning et al. also showed a significant improvement in the emotional functioning of patients 3 months after removal of the large intestine [29]. Gameiro et al. observed that patients undergoing minimally invasive surgery had better emotional functioning parameters compared to the group undergoing open surgery [30]. Thong et al. also confirmed the greatest emotional burden in patients undergoing classical surgery. They were more likely to experience anxiety and mental discomfort related to the treatment (72% – classic method vs. 56% – laparoscopic method) and after completion of treatment (43% – classic method vs. 28% – laparoscopic method) [22]. Our research also showed a significant improvement in the quality of patients’ emotional functioning after the procedure. Improvement is visible already on the 7th day after the procedure, while a significant difference is visible one month after the procedure. Patients operated on laparoscopically have a higher quality of life.
Research by Andersson et al. emphasized the importance of minimally invasive surgery, demonstrating a significantly higher quality of life in patients operated on laparoscopically. Moreover, it was found that the quality of life returned to the baseline 12 months after the procedure [31]. Our research confirmed the results of Andersson et al. A significantly higher quality of life was found in patients who had the large intestine removed laparoscopically. The quality of life increases over time. Most of the subscales assessed are at a much higher level one month after the procedure than when the patient was admitted to the ward. The increasing trend is most visible in patients operated on using a minimally invasive method.
Most clinical studies demonstrate the superiority of minimally invasive surgery over open surgery. However, there are ongoing considerations regarding the validity of treating laparoscopy as the gold standard. The debate on large intestine resections seems to be justified due to, among other things, technical difficulties [32, 33].

Conclusions

The vast majority of patients operated on laparoscopically assessed their quality of life as higher than patients operated on using the classical method. There was a relationship between the quality of life and the study periods: assessment on the day of admission to hospital (before surgery), 7 days after surgery and one month after surgery (p < 0.001) divided into two methods of colon removal (LA and OA).

Disclosure

1. The study was approved by the Bioethics Committee. Approval number: PCN/CBN/0052/KB/180/22.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References