Functional Assessment of Quality of Life Using EORTC QLQ-CR29 in Patients with Colon Cancer at University Hospital

Objective: Colorectal cancer is the third most common cancer in the world. Quality of life is important to achieve successful treatment outcomes. The aim of this study was to assess the functional quality of life of patients with newly diagnosed colorectal cancer in order to improve our understanding as physicians of how cancer therapy influences the patients’ lives, and how we can help patients improve the quality of life on a daily basis. Method: This was a cross-sectional study conducted between January-September 2013, of a sample of 40 patients newly diagnosed with colon cancer at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Participants completed the EROTIC QLQ-CR29 questionnaire, translated into Arabic and modified for a KSA population by three oncologists. Results: In total, 40 patients were included (males, 25; females, 15). Similar findings were reported between both genders in terms of body image, postoperative complications and stomas, and these were significant issues in a substantial number of respondents. Conclusion: The quality of life of patients with colorectal cancer in KSA is poor in general, as a result of both physician- and patient-specific factors. Further studies to assess this issue are recommended. Am understanding of the difficulties that patients face should encourage physicians to consider this vital aspect of their care, positively influencing the treatment course with the aim of creating the conditions for a peaceful and optimal psychological, as well as disease,


Introduction
Colorectal (including anal) cancer is the third most common cancer in the world, with an estimated incidence of 1.24 million worldwide within 5 years of diagnosis. It is also the second leading cause of death from cancer worldwide. In Saudi Arabia in particular, it is the most common cancer among men and the second most common among women [1]. The highest incidence rates have been reported in North America, Australia, Western Europe and Japan. The incidence tends to be low in Africa and Asia and intermediate in the southern parts of South America [2]. Patients with colorectal cancer, both stoma and non-stoma patients, experience frequent or irregular bowel movements, diarrhoea, flatulence, and fatigue, and often have dietary restrictions [3,4]. Furthermore, colorectal cancer and its treatment can have an adverse effect on social functioning, including work life and productivity, relationships with friends, relatives, and partners, and other social activities and interests.
Heath-related quality of life (QOL) has been an important object of interest in clinical practice, and there is particular emphasis on the assessment of treatment effects from a patient's point of view and the effect of the treatment on a daily basis [5]. The term "quality of life" is a multidimensional concept that covers physical, emotional, and social functioning, among other aspects, and QOL has become an important outcome measure in cancer patients, in addition to disease-free and overall survival. In addition, an assessment of QOL in patients with cancer may improve our understanding of how cancer and therapy influence the patients' lives and how to adapt treatment strategies to the needs of individual patients [6]. Studies on cancer survivors and healthy controls have shown that cancer survivors face ongoing problems related to the disease [7], including reduction in their energy levels, weight loss, and psychological distress [8]. Colorectal cancer in particular has been shown to have a negative impact on QOL due to its associated symptoms and the treatments administered to the patients (surgery, chemotherapy and radiotherapy) [9].
The QOL questionnaire (QLQ) of the European Organization for the Research and Treatment of Cancer (EORTC) is an internationally accepted as a tool for the assessment of the health-related QOL of cancer patients. The EORTC QLQ-CR29 was developed after modification of the original QLQ-CR38, which was developed specifically for assessing the QOL of colorectal cancer patients [10]. The validity and reliability of QLQ-CR29 as a supplement to QLQ-CR30 has been demonstrated with regards to assessing treatment outcomes in colorectal cancer patients in the clinical setting [11]. However, not much is known about the QOL of colorectal cancer patients in Saudi from the patient's perspective. Our literature search showed only one other very recent study which used QLQ-CR30 and CR29 to assess the patient-reported QOL among colorectal patients in Saudi Arabia [12]. Moreover, the present authors have also reported the impact of physiological symptoms and complications on the QOL of colorectal cancer patients from the same institution, using the self-reported FACT-C questionnaire [13]. In the present study, we have used QLQCR-29 to assess the self-reported QOL in a group of colorectal cancer patients treated at King Abdulaziz University Hospital. These qualitative findings will improve our understanding of QOL from the point of view of colorectal cancer patients in Arabia.

Study population
After obtaining the ethical approval of the Biomedical Ethics Committee of KAUH, a cross-sectional study was conducted on all patients with colorectal cancer who were treated at King Abdulaziz University Hospital between 15th January 2013 and 17th September 2013. A total of 40 patients who were diagnosed with colorectal cancer within the stipulated period were included.

Study tools
The EROTIC QLQ-CR29 questionnaire was used; it is one of the modules of EORTC QLQ-C15-PAL. The questionnaire was translated into Arabic by two experts and retranslated again into English to ensure that there were no errors in translation. It was finally revised by three oncologists at KAUH.

Statistical analysis
Statistical analyses were performed using SPSS (SPSS Inc., Chicago, IL, USA).

Results
With regards to the place of residence of the patients, the majority (n = 14, 35%) were from the South of Jeddah; moreover, 6 (15%) were from the North, 5 (12.5%) were from the middle, 3 (7.5%) were from the East, and 12 (30%) were from other parts. There was no significant difference between male and female patients with regards to the place of residence. Further, as shown in Table 1, there was no significant difference between the male and female patients with regard to the type of treatment chemotherapy, radiotherapy, or surgery. However, surgical treatment was more common in males than in female patients. Table 2, there was no significant difference between the male and female patients with regard to the urinary complaints reported in the questionnaire. Of the total patients, 57.5% reported that they "sometimes" and "mostly" experienced frequent urination during the day; 52.5%, frequent urination during the night; 12.5%, episodes of involuntary urine leakage, and 12.5%, dysuria pain while urinating. Table 3, no significant difference was found between the male and female patients with regard to any of the abdominal problems listed in the questionnaire. Of the total patients, 50% reported that they "sometimes" and "mostly" experienced abdominal pain; 35%, pain around the anal area; 55%, bloated feeling around the abdomen; 30%, blood in their stool; 32.5%, mucus in their stool; and 52.5%, dryness of the mouth. Table 4, no significant difference was detected between the male and female patients with regards to the treatment complications mentioned in the questionnaire. Of the total patients, 25% reported that they "sometimes" and "mostly" experienced hair loss; 27.5%, a change in their sense of taste; 40%, worry about their future health; 35%, worry about their body weight; 22.5%, a feeling that that they were less attractive physically; and 30%, dissatisfaction with their body.  Mostly 2 (5%) 1 (2>5%) 3 (7.5%) *The difference was not significant.  As shown in Table 5, there was no significant difference between the number of male and female patients who underwent open bag surgery colostomy for colorectal cancer.

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As shown in Table 6, there was no significant difference between the male and female patients with regards to the bag-related questions. Of the total patients, 58.8% reported that they "sometimes" and "mostly" experienced involuntary release of gas from the stoma bag; 41.17%, involuntary release of stool from the bag; 29.4%, skin irritation around the stoma; 82.35%, frequent replacement of the stoma bag; 47%, embarrassment because of the stoma; and 35.29%, problems with caring for the stoma. In particular, 29.41% of the male patients reported that they were embarrassed by the stoma, as opposed to 17.6% of the female patients who reported that they were embarrassed.
As shown in Table 7, no significant difference was detected between the male and female patients with regard to the postoperative data. Of the total patients, 28% reported that they "sometimes" and "mostly" experienced unintentional release of gas; 12.4%, unintentional release of stool; 6.2%, skin irritation around the anus; 34.4%, frequent bowel movements during the day; 28.1%, frequent bowel movements during the night; and 15.55%, embarrassment as a result of the bowel sounds. Rarely 2 (5%) 1 (2.5%) 3 (7.5%) 0.313* Sometimes 2 (5%) 4 (10%) 6 (15%) Mostly 3 (7.5%) 3 (7.5%) 6 (15%) *The difference was not significant   The majority of the patients were from the South of Jeddah (35%), but this is probably related to the location of the hospital. No significant difference was detected between the male and female patients with regards to the type of treatment, although we did notice that surgical intervention was more common in male than in female patients. However, this is probably because the number of female patients is lower in the original sample. Another reason could be that female patients were more apprehensive about undergoing surgical procedures and the related complications.
With regard to urination, 37.5% of the patients reported that they urinated frequently during the day and night, 70% did not experience any involuntary urination, and 60% did not experience any pain during urination. This is probably because the size of the mass had not increased and it had not metastasized to the genitourinary tract. There was no significant difference between the male and female patients with regards to this set of data. Further, 24 patients out of a total of 32 had normally functioning bladders according to a urodynamic study and decreased bladder compliance was observed in 7 patients. Bladder hypersensitivity, involuntary detrusor contractions and incontinence were observed in two women. Flow symptoms occurred in 6%, urgency in 15% and control problems in 19%. Of all the women, 11% wore pads. Distress as a result of urinary symptoms was half as common as the prevalence of the symptoms [14].
In our study, 60% of the patients experienced abdominal pain, 72.5% experienced bloating symptoms, 17.5% had blood in their stool, and 57.5% had mucus in their stool. This could be due to the presence of metastatic lesions that obstructed the lumen of the gut. Moreover, these findings could indicate bad prognosis of the disease. We did not find any differences between male and female patients, but our previous  in Europe, this figure was 96%. The other similar study that used QLQ-CR29 in colorectal cancer patients in Saudi Arabia also showed a lack Sometimes 0 (0%) of interest in sexual activity, probably because of the same reason [12].
Mostly 1 (8.33%) However, we did find a Dutch study that reported impairment in sexual *The difference was not significant.
functioning and a lower quality of sex life preoperatively in colorectal study using the FACT-C questionnaire showed that male patients probably need to be explored further in the future.
There are a few limitations to this study. complained more about abdominal pain (13); this is probably related… With regard to pain in their buttock region, 62.5% of the patients In conclusion, the most common complaints in our population of patients with colorectal cancer were abdominal pain and bloating, pain had this problem: 42.5% were male and 20% were female. In compare in the rectal area, and dry mouth. Further, hair loss and a change in to other studies, only 40 % of the patients had this complain. Further, the sense of taste were the most commonly reported treatment-related 72.5% of the patients experienced dry mouth, with a significant complications. Among the patients who underwent colostomy, only a difference observed between male and female patients.
small percentage reported any problems with care, which is probably Hair loss is one of the main complications associated with related to the religious and cultural practices in Saudi Arabia. chemotherapy, as this treatment is known to affect cell division,