QOL and Psychosocial Issues

QOL, the subjective evaluation of one's personal satisfaction with overall health and well-being, is an important outcome of cancer survivorship that includes physical, functional, psychological, and social functioning.^[11] Most reports of survivor QOL have focused on mixed groups of cancer diagnoses, including CRC survivors. Mental and physical QOL was poorer for these mixed groups compared with age-matched individuals without cancer.^[12] The most prevalent concerns reported 1 year after diagnosis and treatment were fear of recurrence (68%), fatigue (67%), and sleep difficulties (48%).^[13] When evaluated 6 and 12 months after diagnosis, more than 8% of survivors experienced distress severe enough to require follow-up.^[14] Long-term adult survivors had more physical limitations in sustained activities such as shopping, sports, and social events than individuals without cancer (53% vs. 21%).^[15] Gastrointestinal cancer survivors, including those with CRC, were found to be at higher risk for unemployment than healthy adults (48.8% vs. 33.4%), whereas cancer survivors as a group had an almost threefold higher rate of disability causing unemployment compared with healthy controls.^[16]

Older adult cancer survivors were distinguished from older adults without cancer by more chronic conditions, poorer physical functioning, and poorer health ratings.^[17,18] Older female long-term survivors reported more limitations of physical functioning, such as inability to do housework, walk a half mile, or walk up and down stairs compared with an age-matched group without cancer.^[19] Age, low income, symptom severity, and comorbidities were predictive of poorer physical functioning, perhaps because of cancer diagnosis, age, or some other combination of factors.^{[12,15,18,20-24]}

Although elderly long-term survivors generally reported low levels of anxiety and depression overall, they had worse psychological outcomes and used more mental health services than individuals without cancer.^[24-27] Thus, issues of CRC survivorship may be complicated by advancing age, because the age-adjusted rate of CRC for individuals older than 65 years is more than 3 times higher than for persons aged 50 to 64 years.^[3]

In contrast to other disease-based survivor populations, some studies have shown that CRC survivors report fewer physical problems and concerns^[12,28-30] and that problems reported in the short-term generally improved within 3 years of diagnosis, with two thirds of survivors reporting no symptoms and fewer than 10% reporting more than 2 symptoms by 4 years after diagnosis.^[31,32] The most commonly reported symptoms were fatigue (23%) and physical discomfort (19%), whereas stomachache was more frequent for survivors treated with chemotherapy (11% vs. 3%), diarrhea more common after radiotherapy (24% vs. 10%), and pain and cramping more prominent in those with ostomies (17% vs. 5%).^[32] Matched for age, long-term CRC survivors did not differ from their healthy counterparts regarding physical functioning.^[15,33] However, within the group of CRC survivors, increased age and number of comorbid conditions was associated with lower levels of physical functioning.^[15]

A major limitation of research that includes both colon and rectal cancer survivor groups is that symptoms and problems averaged across groups with differences in diagnosis and treatment could lead to incorrect conclusions. For example, bowel symptoms tend to be more prominent for survivors of rectal rather than colon cancer because of surgical techniques and therapies with long-term effects. The prevalence of rectal cancer is also lower, so averaging across both diagnoses could mask the severity of problems experienced by rectal cancer survivors. Therefore, conclusions about symptom severity or QOL are limited by differences in diagnosis and treatment between the 2 sites.

In a cross-sectional study of older CRC survivors, cohorts that were less than 3 years from diagnosis had lower overall QOL than those diagnosed more than 3 years previously. In all groups, QOL varied substantially across disease stages.^[31] A trend for declining QOL was seen in stage IV disease. Low income was associated with higher pain levels, difficulty ambulating, and lower social and emotional well-being. Pain remained a substantial problem that did not improve with time in this population. This study population also had a high prevalence of comorbidities: 77% had 1 comorbid condition, 38% had 2, and 19% had 3. In another cross-sectional study of CRC survivors 5 or more years after diagnosis, a higher number of comorbid conditions was associated with poorer QOL.^[18] These results suggest that the physical and functional aspects of QOL improve 3 or more years after a CRC diagnosis for most survivors, but a small percentage continue to report distressing symptoms (Table 2 and Table 3).

Regarding emotional status, depressive symptoms (measured by the CES-Depression Scale) of CRC survivors were not especially high at diagnosis and improved over the course of the first year after treatment.^[24] Survivors with more limitations of daily social activities tended to be more depressed than those without limitations.^[24] Those with better social networks consisting of more close friends and relatives and who had more community involvement had better mental health outcomes.^[34] Despite low levels of depressive symptoms, 26% to 44% of long-term CRC survivors continued to worry about cancer recurrence, symptoms as cancer indicators, getting a second malignancy, or future diagnostic tests. Cancer-related health worries were associated with anxiety and depression, with 24% of the survivors reporting depression scores that were high enough to warrant evaluation for clinical depression.^[29] Thus, screening for psychological distress, depression, fatigue, and pain is warranted in all CRC survivors and may identify issues requiring intervention to improve their QOL after treatment.^[35]

The presence of a permanent stoma may also affect QOL. Survivors with a permanent stoma who had been treated with radiotherapy followed by surgery for locally advanced rectal cancer reported improved bowel symptoms, fatigue, and pain compared with pretreatment levels.^[36] However, the presence of a stoma has also been associated with diminished body image and increased financial worries, although global QOL was not affected.^[37,38] Four years after treatment, survivors with a stoma were more likely to report negative feelings about body appearance compared with non-stoma survivors (25% vs. 12%; P = .02).^[32] Although social functioning 1 year after diagnosis was negatively impacted by the presence of a stoma,^[37,39] follow-up over 2 years suggests that a permanent stoma does not have a durable impact on social functioning or activities of daily living.^[40,41]