This study examined the additional benefit of using the QLQ-CR29 as a supplement to the QLQ-C30 in patients with rectal cancer treated with different treatment protocols. Our study was conducted in a prospectively collected series of patients, and each patient was asked to complete the questionnaires at the time of the follow-up visit. The proportion of patients completing the questionnaires was 84.6%, which was similar to previous studies. To our knowledge, this is the first study focused on the QoL of treated patients with rectal cancer using the QLQ-CR29. Our study demonstrated that the QLQ-CR29 was able to provide additional information about patient outcomes in almost all kinds of rectal cancer patients who were curative treated. We also assessed the utility of the questionnaires in identifying differences in stoma and nonstoma patients. Since the meantime to QoL assessment were similar across all our groups our findings are unlikely to be due to differences in timing of the assessments. Similarly ensured that assessments only began after 6 months had elapsed from completion of all therapy. Previous studies have shown that most patient reported outcomes tend to have improved or stabilized by that time point. Our data only addresses the early impact at the end of the first year following treatment. Additional follow-up will be required to look for late effects of treatment on patients' QoL.
Local recurrence is one of the major problems in the treatment of rectal cancer. Radiotherapy or chemoradiotherapy was introduced into this field due to the reduction of local recurrence for locally advanced rectal cancer[1, 12]. However, the toxicity of radiotherapy has been criticized and the long-term results of the toxicity among different treatment regimens are seldom studied. Bowel functions, urinary incontinence, and sexual functions are the most-reported complaints that may affect the use of radiotherapy. Otherwise, infertility considerations and convenience to the facility of radiotherapy are other reasons that may reduce the use of radiotherapy for patients. We found that the responses of patients to the QLQ-C30 were broadly similar to previous studies[11, 13, 14]. Marijnen et al. found short-term preoperative radiotherapy resulted in more sexual dysfunction, slower recovery of bowel function, and impaired daily activity postoperatively. Pucciarelli et al ever reported that patients with preoperative radiotherapy had worse outcomes for bowel function, including constipation, diarrhea, stool fractionation, use of enema/laxative, urgency, and sensation of incomplete evacuation. But these impaired functions were compared with the general population, so the surgery-related issues could not be balanced, and the time spectrum of completing the questionnaires was not provided. In our series, a higher rate of diarrhea and faecal incontinence was also observed in patients with radiotherapy. However, the patients who received pre- or postoperative chemoradiation had more distal tumors, in which cases the surgery would have required a very low anastomosis and therefore may have resulted in worse sphincter function.
Sexual functions and symptoms are the most difficult scales from which to draw conclusions, as many patients are reluctant to complete the questions or give the truth to doctors. Some studies were unable to evaluate sexual functions due to too many missing values. Previous studies found total mesorectal excision or preoperative short-tem radiotherapy had a negative effect on sexual functioning in males and females. Although we found the symptom of dyspareunia was higher in patients with postoperative chemoradiotherapy, none of male or female sexual function was found significantly different between radiation group and non-radiation group. One explanation may be that patient with postoperative chemoradiotherapy have shorter times to recover from the radiotherapy, compared with patients whose radiotherapy were delivered preoperatively. Meanwhile, we also found that patient age was correlated to female sexual function and dyspareunia. Multivariate analysis wasn't reported in analyzing the impact of sexual function in patients with or without radiotherapy, so the interaction between demographic features and clinical features in patients with multimodality treatment is still unknown to us.
The extent of the difference between stoma and nonstoma patients in quality of life remain controversial, and have been tested in a variety of studies, mainly based on QLQ-C30 and CR38. Early studies found stoma patients suffered higher levels of psychologic distress and had more problems in social functioning, as well as the sexual functions. However, recently other studies found that the QoL in stoma patients was not inferior to nonstoma patients, and even better in some functional scales. Krouse et al found that both male and female cases with stoma had significantly worse social well-being compared with nonstoma cases, while only female cases reported significantly worse overall health-related QoL and psychological well-being. A meta-analysis reported by Cornish et al. revealed that no difference was found in globe health scores between the two groups, although stoma patients were inferior in physical function and sexual function, while the cognitive and emotional functions in stoma patients were superior to nonstoma patients. Other studies also found nonstoma patients had more gastrointestinal complaints, diarrhea, and constipation, and even had lower scores in global health status and future perspective[14, 15, 20]. In our study, as was expected; the embarrassment with bowel movement symptom of was more common in stoma patients. However, defaecation problem was more prominent in nonstoma patients. The existence of an anastomosis and surrounding chronic inflammation may attribute to this symptom.
Another impaired function scale found in stoma patients was the body image scale. Although the mean and median values of body image were similar between stoma and nonstoma patients, the distribution was significantly different between the two groups: 92.4% in nonstoma patients scored 100 in the body image function scale, compared with 80.8% in stoma patients. Similar results of undermining body image due to a permanent stoma were also reported in previous studies[13, 21–23]. However, the score in body image seems higher than the score in the published literature based on Caucasians[13, 20], and similar high scores were also observed in studies including patients in Hong Kong and Taiwan. Cultural differences and less obese populations may account for these disparate findings. Another possible reason may be that in our study, 98% of patients are married while less than 80% of married patients were reported in previous studies[5, 11, 14]. Similar to several recent studies[14, 25], no significantly difference was found for male and female sexual function and sexual related symptoms in our study.
However, as the current study mainly focused on the differences of quality of life among different treatment groups, a longitude assessment of QoL before and after treatment was not conducted for each patient. The relationship between the impaired functional results and preoperative status of individuals is unknown to us. Further study is needed to clarify this issue. Since quality of life is a relatively subjective variable, differences in human race, culture, education, religion and social environment, will have impacts on the results. International cooperation is needed to study the quality of life in patients with multiple cultural backgrounds.