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Functional Deficits and Symptoms of Long-Term Survivors of Colorectal Cancer Treated by Multimodality Therapy Differ by Age at Diagnosis

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

With advances in multimodality therapy, colorectal cancer survivors are living longer. However, little is known about the quality of their long-term survival. We investigated the functional outcomes and symptoms among long-term survivors.

Methods

A cross-sectional study of 1,215 long-term (>5 years) colorectal cancer survivors was conducted using a validated disease-specific questionnaire. Younger onset survivors (18–50 years) were matched 1:2 to later onset survivors (>50 years). Standardized mean scores were compared using one-way ANOVA. Key patient and treatment factors that impact function and symptoms were assessed by multivariate linear regression.

Results

Eight hundred thirty survivors responded at an interval of 10.8 ± 3 years from diagnosis (68 % response rate). Younger onset survivors underwent more surgery (97.9 vs. 93.6 %, P < 0.001) and received more chemotherapy (86.1 vs. 77.7 %, P = 0.004). Anxiety, body image, sexual dysfunction, embarrassment by bowel movements, micturition problems, and impotence were significant concerns. Younger onset survivors reported worse anxiety, body image, and embarrassment with bowel movements, whereas later onset survivors highlighted sexual dysfunction, micturition problems, and impotence. Age at diagnosis was a key independent determinant of long-term function and symptoms.

Conclusion

Long-term survivors of CRC face ongoing functional deficits and symptoms, and their survivorship experience differs by age. Age at diagnosis should serve as a basis for tailored, personalized survivorship care plans.

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Acknowledgments

This work was supported in part by National Institutes of Health/National Cancer Institute Grant T32CA009599 (C.E.B.), the University of Texas MD Anderson Cancer Center Institutional Grant (Y.N.Y), G.S. Hogan Gastrointestinal Cancer Research Grant (Y.N.Y.), and University of Texas MD Anderson Cancer Center Core Support Grant P30 CA016672.

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Authors and Affiliations

  1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower, 1400 Pressler Street, Unit 1484, P.O. Box 301402, Houston, TX, 77230, USA

    Christina E. Bailey, Hop S. Tran Cao, Chung-Yuan Hu, George J. Chang, Barry W. Feig, Miguel A. Rodriguez-Bigas, Sa T. Nguyen, John M. Skibber & Y. Nancy You

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  1. Christina E. Bailey
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  2. Hop S. Tran Cao
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  3. Chung-Yuan Hu
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  4. George J. Chang
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  5. Barry W. Feig
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  6. Miguel A. Rodriguez-Bigas
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  7. Sa T. Nguyen
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  8. John M. Skibber
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  9. Y. Nancy You
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Correspondence to Y. Nancy You.

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Discussant

Dr. John R. Monson (Rochester, NY): Mr. Chairman, ladies and gentleman let me first thank the organizers for the invitation and honor to discuss this interesting presentation. I would also like to thank the authors for the opportunity to review their excellent manuscript.

For more than 100 years surgeons have debated and discussed the subtleties of colorectal cancer management and specifically surgical technique. For most of that time there was a belief that the only issue that mattered was removing the cancer and thereby curing the patient. What the patient looked like after that process was considered less important. This paper attempts to ask what the patient feels like—something that we now appreciate is often considered almost if not more important that actual survival rates. Quality of life is now recognized to be vitally important in survivorship programs—probably it should be noted not because the medical profession suddenly opened its eyes to the issues but rather, the patients themselves have developed a voice in these matters.

Today we heard the experience of a single large cancer center treating colorectal cancer centers of all types. Just over 1,200 patients long-term survivors were available to be questioned about their life using two well validated instruments—one dedicated to colorectal cancer. About two thirds responded to the questionnaires—a rate of 68 %. About one third were younger patients—less than 50 years old—with the remaining two thirds in the so-called older group.

As we heard this morning, younger patients were more anxious, more worried about body image and had better sexual function. In contrast, older patients were more afflicted by micturition problems and impotence. Now, one might simply say that these results would be the same for a general population inquiry—are these issues not part of the circle of life after all?

The manuscript does not tell us everything about these patients. For example, did they all receive their surgery in the center or not. I ask because it is well know that the pathway of care cancer patients follow before achieving their end point does impact their final psychological status. I am guessing they came from all over because I note the permanent stoma rate for the rectal cancer group seems to be over 30 %.

Two other smaller questions—do the authors plan to further investigate the relationship between psychological status and treatment choices. Finally, you have also suggested that these persisting functional effects should inform the care of colorectal cancer patients—my question is how?

Once again, many thanks for the opportunity to read the manuscript and discuss this excellent work.

Closing Discussant

Dr. Bailey: Dr. Monson, thank you for your excellent questions and insightful feedback.

In our study, younger patients reported better sexual function whereas, older patients complained of more problems with micturition and impotence. One would expect to observe similar trends in the general population, but it is important to pay attention to the proportion of patients affected in our study. For example, according to the National Institute of Health, approximately 5 % of men ≤40 years of age and 15 to 25 % of men ≥65 years of age complain of impotence. In comparison, 42 % of young adults and 63.2 % of older adults in our study complained of impotence, which is significantly higher than what is observed in the general population.

In looking back at our data, 36.8 % of patients did not undergo surgical resection at our facility. The facility at which a patient underwent surgical resection could impact functional status. We therefore compared functional and symptom scores for patients who did and did not undergo surgical resection at our facility. We only observed a statistically significant difference for impotence. Patients who underwent surgical resection at our facility complained of more impotence compared to patients who did not undergo resection at our facility (mean score 61.4 vs. 52.9; P value = 0.034). Based on these findings, we do not feel that the facility in which a patient underwent surgical resection significantly impacted our results.

Finally, our results demonstrate that colorectal cancer survivors experience long-term functional deficits and symptoms after treatment of their cancer that differs according to age at presentation. Surgeons play an important role in managing expectations of patients at the time of initial consultation. We suggest that our data allow patients of different age groups to be informed of long-term impact of surgery and multimodality therapy. We also suggest that specific problems be proactively solicited, because early referral and intervention are possible. For example, urodynamic studies and urologic referral may be appropriate for patients with micturition problems; behavioral intervention and cognitive therapy may be appropriate for those with body image concerns; and pain treatment can be actively initiated.

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Bailey, C.E., Cao, H.S.T., Hu, CY. et al. Functional Deficits and Symptoms of Long-Term Survivors of Colorectal Cancer Treated by Multimodality Therapy Differ by Age at Diagnosis. J Gastrointest Surg 19, 180–188 (2015). https://doi.org/10.1007/s11605-014-2645-7

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