Quality of Life

Symptoms and side effects

EORTC QLQ-C30 (n. of items)

EORTC QLQ-CR38 (n. of items)

EORTC QLQ-CR29 (n. of items)

SF-36 (n. of items)

FACT-C (n. of items)

BPI (n. of items)

Pain

–

Dyspnea

–

Insomnia

–

Appetite loss

–

Nausea and vomiting

–

Fatigue

–

Diarrhoea

–

Bowel dysfunction

–

Stoma troubles

–

Urinary dysfunction

–

EORTC QLQ-C30/CR38/CR29, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30/CR38/CR29; SF-36, Short-Form (36) Health Survey; FACT-C, Functional Assessment of Cancer Therapy–Colorectal; BPI, Brief Pain Inventory

The most frequently evaluated symptoms are pain and gastrointestinal issues. Patients who undergo extra-anatomical surgery, which has negative effects on physical and emotional domains, frequently experience pain, which is reported by 40% of patients with LRRC. Its impact on daily function is evaluated by different scoring systems (EORTC QLQ-CR38/CR29, SF-36, BPI) and is higher in patients with LRRC compared with those with LARC and nonadvanced rectal cancer [29, 30, 32, 35]. When different treatments for LRRC were analyzed by You et al. the authors found no significant differences in pain intensity and severity among patients treated surgically with curative intent and those who underwent noncurative or nonsurgical treatments. However, even long-term survivors without disease recurrence reported elevated pain scores [6].

Bowel function is impaired in patients with LRRC [39]. HR-QoL following complex surgery is frequently worsened by the presence of a stoma (colostomy/ileostomy). The most widely used questionnaires to measure stoma-related QoL are the EORTC QLQ-CR38, Stoma-QoL, and FACT-C. Although the literature shows no significant difference in QoL between patients with stoma and patients with bowel dysfunction related to surgery (frequent bowel movements, fecal urgency, incontinence) [40], the presence of a stoma affects the patient’s lifestyle because of the risk of leakage from the stoma bag, the need for night time emptying, fear of odor, difficulties in managing the stoma, and peristoma skin irritation, all of which can negatively influence body image and social and sexual relationships.

Conflicting results are reported concerning fatigue: only two studies report a high level of fatigue in 44% of LRRC patients [32, 37].

Urinary dysfunctions were evaluated by Mannaerts et al. in a cohort of 79 patients treated for LRRC, and they found more pronounced postoperative urinary dysfunctions in female patients [41]. Guren et al. focused attention on a specific concern related to HR-QoL in the presence of urinary diversion using the EORTC QLQ-C30 and EORTC QLQ-CR38. The authors found no differences between patients with LRRC who did or did no undergo urostomy and reported that a single urostomy does not modify functional outcome after surgery. Conversely, patients who received a double urostomy had a worse QoL score [33].

Other symptoms, such as dyspnea, insomnia, appetite loss, nausea, and vomiting, were mostly investigated using EORTC QLQ-C30, EORTC QLQ-CR38, FACT-C, and SF-36 (see Table 12.1). Among these symptoms, dyspnea, insomnia, and appetite loss were worse in patients with LRRC compared with the healthy population, while no significant differences between LRRC and LARC/early rectal cancer were reported for nausea and vomiting [29, 32].

12.3.3 Financial and Occupational Impact

Impact on financial and occupational status was the focus of three studies that used the EORTC QLQ-C30 or ad hoc questions and showed a strong impact on this domain. According to these studies, 13% of patients with LRRC returned to light employment, and only 18% resumed their previous occupations [37].

12.4 12.4. Conclusions

The recurrence of rectal cancer is a catastrophic event in a patient’s life, creating a wide range of sad scenarios and throwing the patient into a deep depression. The physician, when leading the patient along this winding road, must keep in mind several aspects. Besides considering a surgical approach, which, when possible, should be oriented to curative surgery, physicians must consider the clinical outcome and some functional aspects. Data from the literature, even though limited and inaccurate, indicate that HR-QoL of patients with LRRC is impaired in many ways, and this should be taken into account when counseling patients preoperatively. In fact, treating LRRC should not only be directed at the physical aspect of the disease but also at its psychological and social implications.

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