This study demonstrated that patients undergoing APR for rectal cancer did not have worse HRQL than patients undergoing LAR and HRQL was not affected by the anatomic location of the rectal tumor. Younger patients in general had lower HRQL than older patients. This finding is similar ash other research in examining colorectal cancer patients [43
], rectal cancer patients [45
], breast cancer patients [47
]. Since younger patients may be more active, they may perceive cancer and surgery to be a larger burden than older patients. Of those receiving adjuvant therapy, only older patients with stage I disease had lower HRQL. Patients with stage I cancer may perceive adjuvant therapy to be a larger burden than those with higher stages of disease because they are not as ill. Older patients may perceive adjuvant therapy to be a larger burden than younger patients if health status at diagnosis is worse.
Consistent with our findings, several prior studies have found that patients have better or at least similar HRQL after organ-ablating surgery than after organ-sparing surgery [48
]. Our results are also similar to those reported from four Scottish hospitals that assessed 106 rectal cancer patients using the EORTC QLQ-C30 and QLQ-CR38 [53
]. HRQL is often independent of physical symptoms; indeed, patients with major physical limitations often have high HRQL [54
]. Additionally, an individual's expectation of symptoms and limitations affects the degree of distress experienced [55
]. For example, patients who expect to have a well-functioning sphincter, but do not, may have poorer HRQL than patients who have a well-functioning stoma [6
]. A well-designed, single institution study found that colorectal cancer patients with stomas had lower HRQL than those without stomas, but having realistic goals and expectations appeared to have an important effect on HRQL [56
]. Stoma patients may have better or similar HRQL because they receive detailed information on self-care for treatment-related problems, which sphincter-sparing patients do not receive [57
]. For example, Engle et al. found that patients who underwent APR had lower HRQL than patients who underwent LAR or high anterior resection but APR patients were poorly informed about stoma irrigation [9
]. In the larger cohort of both colon and rectal cancer patients from which our study sample was drawn, the presence of a stoma and crude tumor location (colon vs. rectum) did not predict HRQL [33
To our knowledge, this is the first study to examine the impact of location of tumor, type of surgery and adjuvant treatment for rectal cancer on HRQL using the FACT-C in a population-based cohort. The FACT-C is important because it is designed to detect clinically meaningful changes in scores in addition to clinically meaningful differences between groups of patients [58
]. Other research examining postoperative HRQL found that sphincter-ablating surgery was associated with worse HRQL than sphincter-sparing surgery [6
]. However, these studies were drawn from convenience samples at single institutions and most did not use validated, comprehensive HRQL instruments. Only one other study [9
] examined outcomes longer than 19 months after diagnosis. Patients selected in convenience series are vulnerable to the potential bias that physicians may only have invited ‘well-adjusted’ patients to participate [70
]. In addition, the results may not apply to other centers with different surgeons, and may not generalize to broader populations.
The majority of recent studies have measured HRQL with the European Organization for Research and Treatment of Cancer (EORTC) Core (C)-30 and Colorectal (CR)-38. The results of these studies are conflicting [9
]. Some researchers have questioned the sensitivity of EORTC-30 and CR-38 to detect differences in bowel function [13
]. To overcome limitations of interpreting HRQL based on a total score as was the focus in previous studies, we examined multiple domains simultaneously using MANOVA to account for correlations among the subscales, and we adjusted for multiple comparisons to reduce our type 1 error rate. Consequently, through our analysis using MANOVA, we defined quality of life in a broad, multidimensional manner, instead of focusing individual symptoms or total scores.
Other researchers have used instruments of questionable sensitivity in rectal cancer patients, such as the Short Form-36 Medical Outcomes Survey (SF-36) and the Gastrointestinal Quality of Life Index [14
]. General HRQL instruments, such as the SF-36, RAND's adaptation of the SF-36, and the Nottingham Health Profile, are designed to compare patients across many disease categories and may lead to equivocal results when a single disease is studied [69
Patients with higher stage of disease had lower HRQL in physical and functional scales [42
]. When we stratified our results by patient characteristics, there were no differences in HRQL by gender. Older patients with Stage I cancers receiving adjuvant treatment had worse physical well-being, emotional well-being, and colorectal concerns scores than 23 similar patients who were not receiving adjuvant therapy. These differences exceeded the threshold for a clinically important difference for FACT-C subscales, which has been estimated as 2-3 points [73
]. Since adjuvant treatment is not generally recommended for Stage I patients [28
], it is possible that those who received adjuvant treatment had some indication such as tumor behavior, which placed them at higher risk.
Receipt of chemotherapy was associated with lower HRQL, but we found that HRQL scores improved by approximately 19 months after diagnosis in patients completing both surveys, confirming others' finding that the adverse effects of adjuvant therapy on quality of life are relatively short-lived [9
]. Although tumor location was predictive of type of surgery in the present study, it was not associated with HRQL. Tumor location is a very important variable that is rarely available in population-based studies. It has been postulated to confound the relationship between type of surgery and quality of life in previous research [76
], but our study did not confirm this hypothesis.
In conclusion, we used a validated, multi-dimensional, cancer-specific instrument to assess postoperative HRQL in a population-based sample of patients with rectal cancer, and found neither statistically significant nor clinically meaningful differences based on tumor location or sphincter-sparing surgery. Future large studies should also assess the relation of HRQL to follow-up treatment, comorbid conditions, perceived quality of care, and evolving surgical techniques such as total mesorectal excision [77
]. Further research is also needed to address sexual functioning, because this domain is addressed with only one item in the FACT-C. These studies can help patients and physicians to choose between different treatment regimens, especially when the more aggressive approach does not have a clear survival advantage [81
]. Although this study does not report on data before patients were diagnosed with cancer, this research controls for stage of disease at diagnosis in the MANOVA, which should account for some of the unknown differences in HRQL due to disease rather than treatment. Studies of HRQL will help physicians and their patients to make more informed decisions regarding choice of treatment, based on realistic patient expectations of symptoms and limitations.