Quality of Life in Patients With Colorectal Cancer 1 Year After Diagnosis Compared With the General Population: A Population-Based Study
Publication: Journal of Clinical Oncology
Abstract
Purpose
Quality of life (QOL) has become an important outcome measure for patients with cancer, but long-term results from population-based studies are rare. The objective of our study was to identify specific limitations of QOL in survivors of colorectal cancer in comparison with men and women from the general population 1 year after diagnosis when acute treatment effects are expected to have declined.
Patients and Methods
QOL was assessed 1 year after diagnosis in a population-based cohort of 439 patients with colorectal cancer from Saarland (Germany) using the EORTC-QLC30 questionnaire. Specific functional and symptom QOL scores were compared with published reference data from the general population.
Results
Of 439 patients, 378 of them survived the first year after tumor diagnosis (86.1%). Of these, 309 returned the questionnaire (response rate, 81.7%). Compared with the general population, colorectal cancer patients scored their physical, role, cognitive, and global health functioning only slightly worse. More severe limitations were observed for the emotional and social functioning scales and for the symptom subscales of fatigue, dyspnea, insomnia, constipation, diarrhea, and financial difficulties. The differences regarding functional and symptom scores were predominantly found in younger age groups whereas older cancer patients and controls rated their health and QOL similarly.
Conclusion
Deficits in emotional and social functioning and specific limitations like fatigue, dyspnea, insomnia, constipation, diarrhea, and financial difficulties are main factors hampering the QOL among colorectal cancer patients and seem to affect predominantly younger patients.
Introduction
Colorectal cancer is the second leading cause of cancer-related mortality and the fourth most prevalent malignant disease in many developed countries; it affects men and women almost equally. Almost 1 million new incident cases and 250,000 deaths occur worldwide each year.1 Survival rates have increased throughout the last decades because of earlier diagnosis, improved diagnostic tests, introduction of adjuvant therapy, and advances in the treatment of metastatic disease. Approximately 80% of patients now survive the first year after diagnosis, and approximately 62% survive 5 years and more.2
Besides disease-free and overall survival time, quality of life (QOL) has become an important outcome measure for cancer patients. The term quality of life refers to a multidimensional concept, which includes, at least, the dimensions of physical, emotional, and social functioning. In addition, 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.3
Colorectal cancer and its treatment can have an adverse effect on social functioning, including work and productive life; relationships with friends, relatives, and partners; and other social activities and interests. Patients with colorectal cancer, both stoma and nonstoma patients, are troubled by frequent or irregular bowel movements, diarrhea, flatulence, and fatigue, and often have to follow dietary restrictions.4,5 Comparisons between cancer survivors and healthy controls provide evidence that cancer survivors face ongoing problems related to the cancer disease6 including reduction in energy, weight loss, and psychological distress.7 Less is known, however, about how colorectal cancer patients rate their overall QOL and emotional and social functioning in comparison with healthy subjects and how they cope with the awareness of living with a chronic and potentially life-threatening disease. We, therefore, initiated a population-based study to describe the QOL of patients with colorectal cancer 1 year after diagnosis when acute treatment effects are expected to have declined. The major objective of this study was to identify specific limitations of QOL in cancer survivors in comparison with men and women from the general population.
Patients and Methods
Study Design and Study Population
We set up a population-based statewide cohort study of men and women (age range, 18 to 80 years) with newly diagnosed, invasive colorectal cancer in Saarland, a state with a population of about 1 million people, located in southwest Germany. Patients with colorectal cancer who were diagnosed between October 1, 1996, and February 28, 1998, were identified and reported to the study center located at the Saarland Cancer Registry. These patients were identified during first hospitalization by their treating physicians in the context of a study on patterns of the diagnostic process and prognosis among patients with various forms of cancer. Details of the design of the baseline examinations have been reported elsewhere.8,9 Overall, 439 colorectal cancer patients were recruited, representing 95.2% of those asked for participation by their doctors (eight patients died before the interview could be carried out, and 14 patients refused to participate) and approximately 60% of all new incident, invasive colorectal cancer cases during the study period, according to estimates from the population-based Saarland Cancer Registry. Data privacy regulations required that only patients who were identified and informed by their treating physicians could be recruited. It is likely that population-wide coverage of cancer patients would have been substantially higher if patients could have been contacted directly by the Saarland Cancer Registry, which has more than 95% completeness of incident cases.10 However, our study population was comparable with the population of all patients with colorectal cancer registered at the Saarland Cancer Registry during the recruitment period in terms of basic demographic and clinical characteristics, such as age, sex, tumor localization, tumor stage, and surgery. The study was approved by local and regional ethics committees, and all participants gave written informed consent.
Measures
Patients' sociodemographic characteristics such as age, sex, education level, and marital status, as well as medical history of previous and concurrent diseases were obtained from standardized in-person interviews, which were usually conducted during hospitalization a few days after recruitment at baseline. In addition, clinical variables such as stage and location of cancer at the time of diagnosis were obtained from hospital records.
One year after recruitment, all study participants were sent a letter with detailed information describing the purpose of the follow-up study together with a QOL questionnaire (details see below) and a stamped addressed return envelope. Nonrespondents were mailed up to two reminders and patients were contacted by phone if they did not respond after three mailings. If all these attempts did not result in any response, vital status of nonrespondents was obtained from the residents' registration office. More than 95% of all respondents returned the questionnaires within 3 months after first contact by mail.
QOL Questionnaire
QOL 1 year after diagnosis was assessed with the 30-item questionnaire (QLQ-C30 Version 2) of the European Organization for Research and Treatment of Cancer (EORTC).11 The QLQ-C30 is a validated, brief, self-reporting, cancer-specific measure of health-related QOL.12-14 The EORTC QLQ-C30 is composed of five multi-item functional scales that evaluate physical, role, emotional, cognitive, and social function, and one global health status/QOL scale. Three multi-item symptom scales measure fatigue, pain, and nausea/vomiting, and six single items assess symptoms such as dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties. High functional scores represent better functioning/QOL whereas a high symptom score indicates more severe symptoms. The time frame for all scales in the questionnaire is the last week.
Statistical Methods
The scoring of the EORTC QLQ-C30 items was performed according to the EORTC scoring manual.15 All scores were linearly transformed to a 0 to 100 scale. In case of missing items, multi-item scores were calculated as the mean of nonmissing items if at least half of the items from the corresponding scale had been completed.15
As in many other QOL studies16 the score distributions of most of the function and symptom scales among study participants were asymmetric. To be more precise, all functional scores (with the exception of “global health/QOL”) were negatively skewed (ie, scores bunched up on the high end of the scale), whereas all symptom scales were positively skewed. Nevertheless, we use mean scores as descriptive measure, to enable comparison of the results with published QLQ-C30 reference data from the German general population.17 The reference data, which were similarly skewed, were derived from a representative sample of the German adult population comprising 1,139 women and 889 men (age range, 16 to 92 years). The members of the reference population were selected by nationwide random-route technique and interviewed in their private homes by skilled interviewers in 1998. Age standardized reference QOL scores were calculated by weighting of the age-specific mean scores from the reference population according to the age structure of the cancer patients. Age-standardized and age-specific means were compared and interpreted in a descriptive way following the findings from Osoba et al18 and Michelson et al19 indicating that differences of more than 10 points are clinically meaningful. Statistical testing was not used as no information regarding the precision of the age-specific reference values was published.
Results
Baseline characteristics of the study population are presented in Table 1. Of the 439 patients with colorectal cancer at baseline, 60 (13.6%) died during the first year after diagnosis. Of the remaining 379, 309 (81.5%) participated in the follow-up survey and filled out the QOL questionnaire. Referring to the total baseline sample of 439 patients, 70.4% completed the QOL questionnaire. Respondents were better educated (P = .02) than nonrespondents and tended to live with a spouse (P = .12), but there were no major differences between both groups with respect to age, stage, and comorbidity. Almost all patients (432 of 439) had undergone some form of major surgery. A colostomy was reported by 20.1% at the time of follow-up and was more common among patients with rectal cancer (40.9%) than among patients with colorectal cancer (6.9%; data not shown). Of the 309 respondents, 152 (49.2%) had undergone adjuvant chemotherapy and/or radiotherapy.
Table 2 presents the mean scores for the QLQ-C30 subscales. The percentage of missing data both at the item level and at the score level was low, ranging from 1% to 5%. The mean score for the global health status and overall QOL was 62.8. Highest functional scores were observed for physical and cognitive functioning. Emotional functioning was scored lowest. Almost 80% of all patients reported limitations such as feeling depressed, irritable, tense, or worried.
With respect to symptoms, QOL among patients with colorectal cancer was most severely affected by “fatigue” and “insomnia.” Almost 80% reported problems with fatigue, such as “feeling tired,” “feeling weak,” or “need a rest.” Almost 55% reported symptoms referring to insomnia, such as having trouble sleeping.
Population controls and patients with colorectal cancer reported almost identical mean scores of global health/QOL and physical functioning (Fig 1). In contrast, deficits among patients with colorectal cancer seem to exist with respect to emotional (Δ = 10.1) and social functioning (Δ = 12.6). Minor but also potentially meaningful differences were observed for cognitive (Δ = 8.1) and role functioning (Δ = 6.8).
With the exception of pain, all other symptom scores were higher in the colorectal cancer group than in the general population, indicating more frequent and/or more severe symptoms among colorectal cancer patients 1 year after diagnosis (Fig 2). The differences were most pronounced in the subscales of fatigue (mean, 35.4 v 23.8), constipation (mean, 16.9 v 5.7), diarrhea (mean, 17.6 v 2.7), and financial difficulties (mean, 20.9 v 9.0).
Age-Specific Scores
Figure 3 shows the mean functional scores of the colorectal cancer patients and of the reference group within different age groups. Age-specific comparisons revealed an almost uniform pattern with largest differences between colorectal cancer patients and population controls among the youngest age groups (< 60 years) and virtually no differences among the elderly. The graph also indicates that the associations between age and some functional scores differ between patients with colorectal cancer and population controls. For example, role and social functioning decreased with older age among the population controls whereas the corresponding mean scores among colorectal cancer patients tended to increase with older age.
With respect to symptoms, most age-specific comparisons showed a similar pattern (data not shown). In particular, differences regarding fatigue, insomnia, diarrhea, and financial difficulties were highest among youngest age groups and decreased with older age.
Other Factors
On average, stoma patients reported lower scores than nonstoma cancer patients on many functional scales (Fig 4). The difference was largest regarding social functioning whereas cognitive functioning did not seem to differ between stoma and nonstoma cancer patients. Differences between these two patient groups also seem to exist for specific symptoms such as fatigue, nausea/vomiting, pain, insomnia, and appetite loss, whereas both groups were comparable with respect to problems caused by frequent or irregular bowel movements (data not shown). Further adjustment for tumor stage only slightly reduced the observed differences indicating that the differences are only partly explained by differences in tumor stage. The pattern did not change when we restricted the comparison between stoma and nonstoma cancer patients and patients with rectal cancer only.
Patients with colorectal cancer who underwent adjuvant therapy and patients whose tumor was removed by surgery alone reported similar responses with respect to most functional scores but role and social functioning seem to be more affected in patients with adjuvant chemotherapy and/or radiotherapy (data not shown). Also, patients with adjuvant therapy reported more problems with diarrhea (mean score, 23.9) than patients with surgery alone (mean score, 12.1).
Additional analyses indicted no relevant differences between patients with colon and rectal cancer with respect to health-related QOL (data not shown). Finally, stratification by sex revealed neither differences between male and female colorectal cancer patients nor sex-specific differences in the pattern of major limitations when cancer patients were compared with population controls (data not shown). Also, patients living with a spouse and patients living alone reported similar QOL scores. In contrast, patients who had been working at time of diagnosis reported better role functioning (mean score, 84.2) than age- and sex-matched patients who were not working (mean score, 75.6).
Discussion
This first large population-based study from Germany comparing QOL among colorectal cancer survivors 1 year after diagnosis with controls from the general population suggests that overall QOL and physical functioning of patients with colorectal cancer 1 year after diagnosis is comparable to population norms. However, deficits in emotional and social functioning and specific limitations like fatigue, dyspnea, insomnia, constipation, diarrhea, and financial difficulties represent main factors that continue to hamper the QOL among colorectal cancer patients even in the long run and that predominantly younger patients are affected.
Studies from other countries have shown that most colorectal cancer patients report good health,5 but colorectal cancer patients may suffer long-lasting pain and reductions in functional and social well-being.20 In general, there seem to be minor differences with respect to broader measures such as general health and overall QOL,21 especially when no serious comorbidity or relapse is apparent,22,23 but specific physical symptoms, such as reduction in energy and weight loss, and psychosocial problems, like psychological distress and depressive symptoms, may persist throughout the years7 and remain a problem even among long-term survivors who achieve remission from colorectal cancer.22 In particular, diarrhea may prevent patients from leaving their home and may, therefore, lead to isolation and a decreased QOL.5
One explanation for the small difference in overall QOL and general health between colorectal cancer patients and general population might be that patients being treated for a malignancy expect a different concept of subjective well-being compared with healthy subjects and, as a result, may report a more optimistic assessment of their post-treatment QOL. This phenomenon has been referred to as “reframing” and is thought to be part of the patients' adaptation to their disease and its treatment.21 The subjective well-being of cancer patients may be based on the evaluation of other domains of life than the subjective well-being of noncancer patients.24 Another, nonexclusive explanation might be that technical innovations such as staplers have reduced the rate of definitive colostomies and a greater number of patients may undergo sphincter-saving procedure.25,26 Abdominoperineal resection with definitive colostomy is a mutilating procedure and deeply influences the patient25 and the effect of a colostomy on QOL has been extensively studied. According to a review by Sprangers et al,5 survivors with colostomy appliances report substantially more problems with physical, psychological, social, and sexual functioning than colorectal cancer patients with preserved anal sphincter function. In our sample, stoma patients reported lower health-related QOL scores than nonstoma cancer patients on many functional scales. In particular, social functioning was limited, which appears highly plausible, as “a colostomy bag is something a patient will never be happy to show.”25
The influence of age on burden of diseases is equivocal. Overall burden of disease may increase among the elderly, but younger age groups may report higher demands of illness.27 Our results indicate that, in particular, younger patients with colorectal cancer express psychosocial deficits and suffer from specific symptoms and financial problems. It has been hypothesized that younger cancer patients are a vulnerable group in terms of poorer survival and more severe psychosocial effects. Younger patients view cancer as greater threat to their lives and manifest poorer mental health than older patients.28,29 Also, younger patients may possess fewer coping strategies and resources needed to manage a life-threatening disease30 whereas older persons consider their physical health in a different reference frame and tend to assess their health in terms of their age peers.19 These findings imply that psychosocial support measures should be tailored to the specific needs of the patients and should take into account the sociodemographic background of the patient.
Another striking finding in our study was that more than 20% of the cancer patients reported financial problems due to the disease. This is even more noteworthy, taking into account the German social security system. Costs of diagnostic procedures and treatment are covered by public and private health insurance plans, where 98% of the German population is subscribed. Subsidies may be given for hiring a domestic aid or paying extra child-care, but it is likely that not all extra costs are fully covered. Similarly, alternative or complementary treatment options not covered by health insurance plans and loss of earnings, which selectively affects patients at preretirement age, also may account for some of the observed differences. The latter might explain that predominantly younger patients are affected by financial problems in case of a chronic disease, a finding that has also been reported by Mor et al,31 who found economic problems due to cancer in young patients compared with older cancer patients occurred twice as often in the United States.
Results from randomized clinical trials have shown that adjuvant therapy is able to extend disease-free and overall survival in case of advanced colorectal cancer.32 Although adjuvant chemotherapy and radiation often negatively affect QOL during the phase of treatment, modern adjuvant therapy is usually well tolerated,33 and QOL scores recover to pretreatment levels within a few months after completion of therapy.34 In our study, patients with adjuvant therapy reported similar QOL scores with respect to most scales but more limitations with respect to social and role functioning.
This is one of the largest population-based studies comparing QOL among colorectal cancer survivors 1 year after diagnosis with controls from the general population. The majority of the pertinent literature6,7,20-24,35,36 included patients with a wide range of time since diagnosis,21-23,35 or was based on selective samples of patients from one or few hospitals.6,21,36 Particular strengths of our study are the high overall response rate, the statewide recruitment of patients from a wide range of hospitals, and the application of a well-established instrument to assess health-related QOL. Follow-up participation rate did not depend on tumor stage. However, better educated patients and patients living with a spouse were more likely to respond. Therefore, our findings might describe a slightly too optimistic picture of the situation of colorectal cancer patients. Also, these findings do not reflect the situation of those patients who have died either during the follow-up period or even before the baseline interviews were conducted. Furthermore, a 1-year follow-up may be a too short period to draw definitive conclusions because the majority of all recurrences after curative resection of carcinoma of the colon and rectum occur between the first and fifth year.37 The long-term consequence will be addressed in further follow-up of the cohort, which is currently underway.
We conclude that overall QOL of colorectal cancer patients 1 year after diagnosis is comparable with that of the general population, but that specific limitations exist that predominantly affect younger patients who might potentially benefit from specific psychosocial support measures.
Authors' Disclosures of Potential Conflicts of Interest
The authors indicated no potential conflicts of interest.
| Respondents (n = 309) | Nonrespondents (n = 70) | Deceased (n = 60) | Total (N = 439) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | |||||
| Sex | ||||||||||||
| Male | 174 | 56.3 | 38 | 54.3 | 40 | 66.7 | 252 | 57.4 | ||||
| Female | 135 | 43.7 | 32 | 45.7 | 20 | 33.3 | 187 | 42.6 | ||||
| Age at diagnosis, years | ||||||||||||
| < 60 | 79 | 25.6 | 16 | 22.9 | 20 | 33.3 | 115 | 26.2 | ||||
| 60-69 | 109 | 35.3 | 21 | 30.0 | 22 | 36.7 | 152 | 34.6 | ||||
| 70-80 | 121 | 39.2 | 33 | 47.1 | 18 | 30.0 | 172 | 39.2 | ||||
| Mean age | 65.1 | 66.0 | 63.0 | 65.0 | ||||||||
| SD | 9.4 | 11.6 | 10.6 | 9.9 | ||||||||
| Employment status | ||||||||||||
| Employed | 67 | 21.7 | 14 | 20.6 | 13 | 22.0 | 94 | 21.6 | ||||
| Not employed | 242 | 78.3 | 54 | 79.4 | 46 | 78.0 | 342 | 78.4 | ||||
| Education | ||||||||||||
| < 10 years | 237 | 76.9 | 60 | 89.6 | 45 | 76.3 | 342 | 78.8 | ||||
| ≥ 10 years | 71 | 23.1 | 7 | 10.4 | 14 | 23.7 | 92 | 21.2 | ||||
| Living with spouse | ||||||||||||
| Yes | 219 | 70.9 | 43 | 61.4 | 45 | 75.0 | 307 | 69.9 | ||||
| No | 90 | 29.1 | 27 | 38.6 | 15 | 25.0 | 132 | 30.1 | ||||
| Stage of disease* | ||||||||||||
| Local | 180 | 58.4 | 38 | 55.1 | 8 | 13.3 | 226 | 51.7 | ||||
| Regional | 98 | 31.8 | 27 | 39.1 | 13 | 23.7 | 138 | 31.6 | ||||
| Distant | 30 | 9.7 | 4 | 5.8 | 39 | 65.0 | 73 | 16.7 | ||||
| Tumor location | ||||||||||||
| Colon | 186 | 61.0 | 49 | 71.0 | 40 | 66.7 | 275 | 63.4 | ||||
| Rectum | 119 | 39.0 | 20 | 29.0 | 20 | 33.3 | 159 | 36.6 | ||||
| Comorbidity† | ||||||||||||
| Yes | 211 | 68.3 | 42 | 60.0 | 34 | 56.7 | 287 | 65.4 | ||||
| No | 98 | 31.7 | 28 | 40.0 | 26 | 43.3 | 152 | 34.6 | ||||
Abbreviation: SD, standard deviation.
*
Local, T1-T3 and N0/M0; regional, N1-N3/M0 or T4/N0/M0; distant, M1 and any T and any N.
†
Defined as reporting treatment for cardiovascular disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, other cancers, or arthritis during past year.
| Respondents (No.) | No. of Items | Patients Reporting Any Level of Concern (%) | Score* | |||
|---|---|---|---|---|---|---|
| Mean | SD | |||||
| Functional scales | ||||||
| Physical functioning | 296 | 5 | 51.7 | 79.5 | 24.0 | |
| Role functioning | 297 | 2 | 41.4 | 74.4 | 33.4 | |
| Emotional functioning | 305 | 4 | 78.7 | 67.0 | 28.2 | |
| Cognitive functioning | 304 | 2 | 55.9 | 78.5 | 26.6 | |
| Social functioning | 304 | 2 | 52.0 | 74.7 | 30.9 | |
| Global health status/QOL | 307 | 2 | NA | 62.8 | 22.4 | |
| Symptom scales | ||||||
| Fatigue | 297 | 3 | 77.8 | 35.4 | 29.2 | |
| Nausea and vomiting | 295 | 2 | 18.0 | 5.8 | 14.9 | |
| Pain | 297 | 2 | 43.1 | 20.4 | 28.9 | |
| Dyspnea | 296 | 1 | 44.6 | 23.1 | 29.4 | |
| Insomnia | 298 | 1 | 54.7 | 32.1 | 34.8 | |
| Appetite loss | 296 | 1 | 19.3 | 9.8 | 22.9 | |
| Constipation | 296 | 1 | 30.7 | 16.9 | 28.7 | |
| Diarrhea | 295 | 1 | 30.9 | 17.6 | 30.2 | |
| Financial difficulties | 303 | 1 | 36.6 | 20.9 | 31.7 | |
*
NOTE. Higher scores referring to Functional scales and Global health status/QOL indicate better functioning whereas higher scores referring to symptom scales indicate more/severe symptoms.
Abbreviations: SD, standard deviation; QOL, quality of life; NA, not applicable.
This study was supported by two grants of the German Cancer Foundation (Deutsche Krebshilfe), Project No. 70-1816, 70-2413.
Presented in part at the 24th Annual Meeting of the International Association of Cancer Registries, Tampere, Finland, June 25-27, 2002.
V.A. and H.M. equally contributed to the manuscript.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
References
1.
Ferlay J, Bray F, Pisani P, et al: GLOBOCAN 2000: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0, IARC CancerBase No . 5. Lyon, France, IARC Press, 2001
2.
Brenner H: Long-term survival rates of cancer patients achieved by the end of the 20th century: A period analysis. Lancet 360::1131,2002-1135,
3.
Conroy T, Bleiberg H, Glimelius B: Quality of life in patients with advanced colorectal cancer. What has been learnt? Eur J Cancer 39::287,2003-294,
4.
Sprangers MAG, de Velde A, Aaronson NK, et al: Quality of life following surgery for colorectal cancer. A literature review. Psychooncology 2::247,1993-259,
5.
Sprangers MA, Taal BG, Aaronson NK, et al: Quality of life in colorectal cancer. Stoma vs. nonstoma patients Dis Colon Rectum 38::361,1995-369,
6.
Forsberg C, Cedermark B: Well-being, general health and coping ability: 1-year follow-up of patients treated for colorectal and gastric cancer. Eur J Cancer Care 5::209,1996-216,
7.
Schag CA, Ganz PA, Wing DS, et al: Quality of life in adult survivors of lung, colon and prostate cancer. Qual Life Res 3::127,1994-141,
8.
Arndt V, Stürmer T, Stegmaier C, et al: Socio-demographic factors, health behavior and late-stage diagnosis of breast cancer in Germany: A population-based study. J Clin Epidemiol 54::719,2001-727,
9.
Brenner H, Arndt V, Stürmer T, et al: Long-lasting reduction of risk of colorectal cancer following screening endoscopy. Br J Cancer 85::972,2001-976,
10.
Brenner H, Stegmaier C, Ziegler H: Estimating completeness of cancer registration in Saarland/Germany with capture-recapture methods. Eur J Cancer 30A::1659,1994-1669,
11.
Aaronson NK, Ahmedzai S, Bergman B, et al: The European Organization for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85::365,1993-376,
12.
Groenvold M, Klee MC, Sprangers MA, et al: Validation of the EORTC QLQ-C30 quality of life questionnaire through combined qualitative and quantitative assessment of patient-observer agreement. J Clin Epidemiol 50::441,1997-450,
13.
Ringdal GI, Ringdal K: Testing the EORTC Quality of Life Questionnaire on cancer patients with heterogeneous diagnoses. Qual Life Res 2::129,1993-140,
14.
McLachlan SA, Devins GM, Goodwin PJ: Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) as a measure of psychosocial function in breast cancer patients. Eur J Cancer 34::510,1998-517,
15.
Fayers PM, Aaronson N, Bjordal K, et al: The EORTC QLQ-C30 Scoring Manual (ed 2) . Brussels, Belgium, European Organization for Research and Treatment of Cancer, 1999
16.
King MT: The interpretation of scores from the EORTC quality of life questionnaire QLQ-C30. Qual Life Res 5::555,1996-567,
17.
Schwarz R, Hinz A: Reference data for the quality of life questionnaire EORTC QLQ-C30 in the general German population. Eur J Cancer 37::1345,2001-1351,
18.
Osoba D, Rodrigues G, Myles J, et al: Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol 16::139,1998-144,
19.
Michelson H, Bolund C, Nilsson B, et al: Health-related quality of life measured by the EORTC QLQ-C30–reference values from a large sample of Swedish population. Acta Oncol 39::477,2000-484,
20.
Ramsey SD, Andersen MR, Etzioni R, et al: Quality of life in survivors of colorectal carcinoma. Cancer 88::1294,2000-1303,
21.
Anthony T, Jones C, Antoine J, et al: The effect of treatment for colorectal cancer on long-term health- related quality of life. Ann Surg Oncol 8::44,2001-49,
22.
Ramsey SD, Berry K, Moinpour C, et al: Quality of life in long term survivors of colorectal cancer. Am J Gastroenterol 97::1228,2002-1234,
23.
Mosconi P, Apolone G, Barni S, et al: Quality of life in breast and colon cancer long-term survivors: An assessment with the EORTC QLQ-C30 and SF-36 questionnaires. Tumori 88::110,2002-116,
24.
Rijken M, Komproe IH, Ros WJ, et al: Subjective well-being of elderly women: Conceptual differences between cancer patients, women suffering from chronic ailments and healthy women. Br J Clin Psychol 34::289,1995-300,
25.
Barbarisi A, Parisi V, Parmeggiani U, et al: Impact of surgical treatment on quality of life of patients with gastrointestinal tumors. Ann Oncol 12::S27,2001-S30,
26.
Renner K, Rosen HR, Novi G, et al: Quality of life after surgery for rectal cancer: Do we still need a permanent colostomy? Dis Colon Rectum 42::1160,1999-1167,
27.
Klemm P, Miller MA, Fernsler J: Demands of illness in people treated for colorectal cancer. Oncol Nurs Forum 27::633,2000-639,
28.
Ganz PA, Rowland JH, Desmond K, et al: Life after breast cancer: Understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16::501,1998-514,
29.
Vinokur AD, Threatt BA, Vinokur-Kaplan D, et al: The process of recovery from breast cancer for younger and older patients: Changes during the first year. Cancer 65::1242,1990-1254,
30.
Wenzel LB, Fairclough DL, Brady MJ, et al: Age-related differences in the quality of life of breast carcinoma patients after treatment. Cancer 86::1768,1999-1774,
31.
Mor V, Malin M, Allen S: Age differences in the psychosocial problems encountered by breast cancer patients. J Natl Cancer Inst Monogr 16::191,1994-197,
32.
Rougier P, Mitry E: Epidemiology, treatment and chemoprevention in colorectal cancer. Ann Oncol 14::3,2003-5,
33.
Zaniboni A, Labianca R, Marsoni S, et al: GIVIO-SITAC 01: A randomized trial of adjuvant 5-fluorouracil and folinic acid administered to patients with colon carcinoma—long term results and evaluation of the indicators of health-related quality of life. Gruppo Italiano Valutazione Interventi in Oncologia. Studio Italiano Terapia Adiuvante Colon. Cancer 82::2135,1998-2144,
34.
Guren MG, Dueland S, Skovlund E, et al: Quality of life during radiotherapy for rectal cancer. Eur J Cancer 39::587,2003-594,
35.
Allal AS, Sprangers MA, Laurencet F, et al: Assessment of long-term quality of life in patients with anal carcinomas treated by radiotherapy with or without chemotherapy. Br J Cancer 80::1588,1999-1594,
36.
Rauch P, Miny J, Conroy T, et al: Quality of life among disease-free survivors of rectal cancer. J Clin Oncol 22::354,2004-360,
37.
Galandiuk S, Wieand HS, Moertel CG, et al: Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet 174::27,1992-32,
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Published in print: December 01, 2004
Published online: September 21, 2016
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Quality of Life in Patients With Colorectal Cancer 1 Year After Diagnosis Compared With the General Population: A Population-Based Study. JCO 22, 4829-4836(2004).
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