Beyond survival: a comprehensive review of quality of life in rectal cancer patients

Won Beom Jung

doi:10.3393/ac.2024.00745.0106

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Review Colorectal cancer Beyond survival: a comprehensive review of quality of life in rectal cancer patients: Won Beom Jung; Annals of Coloproctology 2024;40(6):527-537.
DOI: https://doi.org/10.3393/ac.2024.00745.0106
Published online: December 20, 2024

Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Correspondence to: Won Beom Jung, MD. Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 48108, Korea Email: H00388@paik.ac.kr

• Received: October 17, 2024 • Revised: October 29, 2024 • Accepted: November 7, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
QoL ASSESSMENT TOOL
KEY FACTORS IMPACTING QoL: WHAT AFFECTS OUR WELL-BEING
EFFORTS AIMED AT IMPROVING PATIENTS’ QoL
CONCLUSION
ARTICLE INFORMATION
REFERENCES

Abstract

Rectal cancer is one of the most common carcinomas and a leading cause of cancer-related mortality. Although significant advancements have been made in the treatment of rectal cancer, the deterioration of quality of life (QoL) remains a challenging issue. Various tools have been developed to assess QoL, including the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) scale, the QLQ-C30 and QLQ-CR29 by the European Organization for Research and Treatment of Cancer (EORTC), and the 36-Item Short Form Health Survey (SF-36). Factors such as the lower location of the tumor, radiation therapy, chemoradiotherapy, and chemotherapy are associated with a decline in QoL. Furthermore, anastomotic leakage following rectal cancer resection is an important risk factor affecting QoL. With the development of novel treatment approaches, including neoadjuvant therapies such as chemoradiotherapy and total neoadjuvant therapy, the rate of clinical complete remission has increased, leading to the emergence of organ-preserving strategies. Both local excision and the “watch-and-wait” approach following neoadjuvant therapy improved functional outcomes and QoL. Efforts to improve QoL after rectal cancer surgery are ongoing in surgical techniques for rectal cancer. Since QoL is determined by a complex interplay of factors, including the patient's physical condition, surgical techniques, and psychological and social elements, a comprehensive approach is necessary to understand and enhance it. This review aims to describe the methods for measuring QoL in rectal cancer patients after surgery, the key risk factors involved, and various strategies and efforts to improve QoL outcomes.
Keywords: Quality of life; Chemoradiotherapy; Rectal neoplasms; Low anterior resection syndrome

INTRODUCTION

Colorectal cancer (CRC) is one of the most commonly diagnosed cancers worldwide and remains a major cause of cancer-related mortality [1–3]. However, with the advancements in treatment, particularly for rectal cancer, survival rates have significantly improved [2, 3]. For patients with advanced rectal cancer without systemic metastasis, the standard treatment approach, which includes total mesorectal excision (TME) and may involve concurrent chemoradiotherapy (CRT) administered preoperatively or postoperatively, followed by adjuvant chemotherapy, has greatly enhanced patient outcomes [4–7].

Over the past few decades, significant advancements in rectal cancer treatment—such as intersphincteric resection (ISR), transanal approach, multidisciplinary approaches, and total neoadjuvant treatment—have led to higher sphincter preservation rates [5–8]. However, patients who undergo sphincter-preserving resection (SPR) including low anterior resection (LAR) frequently experience postoperative symptoms like fecal urgency, frequent bowel movements, bowel fragmentation, and incontinence, collectively known as LAR syndrome (LARS) [7–9]. To alleviate LARS, various surgical techniques have been explored, and for select patients following neoadjuvant therapy, organ preservation has been proposed as a strategy to improve quality of life (QoL) [4, 9, 10]. However, a larger proportion of patients underwent sphincter-preserving radical resection, and LARS remains an important factor that considerably affects QoL after surgery. In addition, risk of nerve injury during radical surgery is one of the factors influence on postsurgical QoL. As survival rates have improved, there has been a growing emphasis on patients' QoL after treatment, regardless of whether surgery is involved. This review aims to examine the significance of QoL in rectal cancer patients, outline the methods used for its assessment, and highlight current efforts to enhance it alongside achieving oncological remission.

QoL ASSESSMENT TOOL

In the medical field, QoL is one of several important outcomes and should be assessed alongside other clinical factors, rather than on its own. Epstein [11] proposed a widely recognized classification system that distinguishes between traditional clinical outcomes (e.g., mortality, readmission, and complications) and emerging outcomes (e.g., functional status, emotional health, social interaction, cognitive function, and degree of disability) in medical care.

A 33-item general cancer QoL measure, known as Functional Assessment of Cancer Therapy (FACT) scale, was developed to evaluate cancer patients. This tool assesses physical, functional, social, and emotional well-being, as well as satisfaction with the treatment [12].

Subsequently, Ward et al. [13] and Cella et al. [12] devised the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) scale, which was developed as the CRC-specific QoL assessment module within the Functional Assessment of Chronic Illness Therapy (FACIT) that combines FACT-General with the Colorectal Cancer Subscale (CCS). FACIT evaluates areas such as physical well-being, social/family well-being, relationship with the doctor, and emotional well-being. FACT-C address additional concerns specific to CRC patients, including abdominal pain, weight loss, bowel habits, digestion, diarrhea, appetite, self-esteem of appearance, and concerns about ostomy.

The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group also developed a modular approach for assessing QoL in cancer patients [14, 15]. Their revised questionnaire, QLQ-C30, consists of 30 items, including 9 scales: 6 functional scales (physical, role, cognitive, emotional, and social functioning, and global QoL) and 3 symptom scales (fatigue, nausea and vomiting, and pain). It also includes 6 individual items assessing sleep disturbance, constipation, diarrhea, appetite loss, dyspnea, and the financial impact of the disease and treatment. Later, CRC-specific module (EORTC QLQ-C38) was added, which was eventually refined into the 29-item EORTC QLQ-CR29 [16–18]. This module focuses on sexual function, urinary and bowel function, body image, pain, bloating, dry mouth, hair loss, appetite, anxiety, weight, flatulence, skin pain, and ostomy-related problems. The 36-Item Short Form Health Survey (SF-36) is another effective tool, which assesses physical activity, social activity, role limitations due to physical and emotional problems, bodily pain, mental health, vitality, and general health perception [19]. It is widely acknowledged that QoL encompasses an individual’s subjective perception of well-being across 3 key domains: physical (intensity and frequency of symptoms and functional status), psychological (anxiety, depression, and positive experiences), and social (family life, employment, and sexuality) [19].

In addition, a Bowel Function Instrument was proposed, adapted from the Fecal Incontinence Quality of Life (FIQL) scale and the EORTC QLQ-C30 and QLQ-CR38 questionnaires [20]. The FIQL consists of 29 items, categorized into 4 domains: lifestyle (10 items), coping/behavior (9 items), depression/self-perception (7 items), and embarrassment (3 items) [21].

In addition to general QoL assessment tools, specific instruments are available to evaluate key aspects of patient well-being. The Wexner score, also known as the Cleveland Clinic Fecal Incontinence Score (CCFIS) is widely used to measure the severity of fecal incontinence [22], while the International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI) assess male and female sexual function, respectively [23, 24].

Due to the wide range of bowel changes that occur after rectal cancer surgery, the LARS score was developed to assess key symptoms beyond just fecal incontinence. Compared to the CCFIS, the LARS score has the advantage of reflecting a broader spectrum of postoperative changes. It has also been validated in multiple languages, making it widely applicable [8, 25].

Recently, patient-reported outcome measures (PROMs) have gained increasing importance in evaluating treatment outcomes, as they provide direct insights into the patients’ perspective on their QoL and functional status. PROMs are valuable because they capture subjective experiences, such as symptom burden and daily functioning, which may not be fully reflected in clinical or physician-reported data [7, 26]. This shift emphasizes patient-centered care, making PROMs a key component in assessing the overall effectiveness of treatments, especially in conditions like rectal cancer where long-term QoL is a major concern.

Commonly used QoL measurement tool for colorectal cancer is summarized in Table 1 [8, 13, 18, 19, 25].

KEY FACTORS IMPACTING QoL: WHAT AFFECTS OUR WELL-BEING

Multiple factors would involve in determining QoL in rectal cancer patients after surgery or treatment (Fig. 1).

Age and sex

Both sex and age contribute to the variability in QoL after rectal cancer surgery. Women often report more issues related to bowel function, sexual health, and body image, while men may face challenges in sexual function and urinary control [27, 28]. Age also plays a crucial role, with younger patients generally experiencing a stronger impact on social and emotional well-being, as they may find it harder to adjust to lifestyle changes. In contrast, older patients may have more physical limitations but may adapt better emotionally to these changes [29, 30].

Several studies have investigated how age and sex affect the QoL in rectal cancer patients. A retrospective study by Schmidt et al. [29] involving 519 patients who underwent rectal cancer surgery, found that individuals aged ≥70 years were more likely to experience impaired physical functioning, poor global health, and fatigue. However, while older patients experienced increased strain early postoperative period, their condition improved over time. In contrast, patients aged ≤69 years experienced greater strain, primarily due to impaired sexual function, though their physical and role functioning were better. A study involving 137 patients who underwent SPR showed that those aged <60 years experienced more sexual issues, and that their global health status/QoL was closely tied to emotional functioning and future outlook. Patients aged ≥60 years had more micturition problems, and their global health status/QoL was significantly influenced by cognitive functioning, as shown by Kinoshita et al. [30].

In a population-based study, Thong et al. [27] found that among 479 rectal cancer patients, those diagnosed under 50 years reported worse functioning and more symptom burden compared to older patients. Younger patients, especially women, also reported lower sexual interest than men of the same age group. Lastly, a matched cross-sectional study reported that female rectal cancer patients with an ostomy had significantly worse QoL and mental well-being compared to male patients. The impact of ostomy on physical well-being was greater in younger women (<75 years) than in older women, as demonstrated by Krouse et al. [28].

Tumor location

The location of rectal cancer is usually considered a crucial factor in determining QoL after surgery. Several studies have reported that lower tumor location in rectal cancer is associated with a higher risk of complications [9, 31, 32] which may negatively affect QoL [31, 33, 34]. Additionally, when the tumor is located lower in the rectum, partial resection of the internal sphincter during anastomosis or the need for abdominoperineal resection (APR) is often required, both of which can further impair QoL [35, 36].

Lower tumor location has been reported to make patients more vulnerable to developing LARS, and this risk can be compounded when neoadjuvant therapy is added due to the tumor’s position. Studies have identified low tumor levels and neoadjuvant CRT as significant risk factors for delayed bowel dysfunction, as seen in patients with upper or middle rectal cancer 2 years after tumor resection [37]. Additionally, the distance of the tumor from the anal verge is significantly associated with a higher risk of LARS [9].

Radical forms of sphincter-preserving surgery such as ISR for rectal cancer are associated with a decline in QoL, although it showed serial improvement. Zhang et al. [35] evaluated changes in QoL and functional outcomes in 102 patients who underwent ISR for ultra-low rectal cancer. Significant improvements were observed in the incontinence by 12 months post-ileostomy reversal, while LARS scores improved only at 24 months. Kinoshita et al. [38] demonstrated that patients who underwent ISR had significantly worse QoL scores than those who underwent LAR. Additionally, Sun et al. [39] reported that patients who underwent conformal SPR had shorter hospital stays and greater QoL satisfaction than those who underwent ISR.

Restorative vs. nonrestorative surgery

The creation of a permanent ostomy may pose significant concerns regarding the psychological, physical, and social aspects of QoL. Patients with colostomies are more likely to experience feelings of stigma and reduced participation in social activities [36, 40]. However, this conclusion remains complex.

According to meta-analyses [36, 40], APR adversely affects QoL in rectal cancer patients, particularly in social functioning and body image, compared to sphincter-sparing surgeries. On the contrary, APR patients initially reported worse body image and micturition complaints, but overall QoL became comparable to SPR patients after recovery, indicating mixed effects on QoL [41–43].

Digennaro et al. [42] and Dumont et al. [43] reported that QoL in patients who underwent coloanal anastomosis (CAA) was not superior to that in patients with permanent stomas. According to these studies, patients with APR had poorer sexual function, whereas those with CAA had more incontinence. A meta-analysis of 19 studies comparing outcomes in patients with low rectal cancer reported no significant differences in the overall QoL and pain levels between patients who underwent APR and those who underwent CAA [44]. A Cochrane review of 26 studies concluded that there was insufficient evidence to definitively determine whether the QoL of patients who underwent SPR was superior to that of patients who underwent APR [45].

Meanwhile, a Korean group recently conducted a prospective multicenter trial (ASPIRE) regarding QoL after SPR or APR for low rectal cancer [46]. The study demonstrated no differences in the overall QoL between the 2 groups, although they recommended SPR over APR because of its association with improved sexual and urinary function. Patients without ostomies may also experience physical impairments, including altered bowel habits and psychological distress related to impaired sexual function, following SPRs.

Although APR is associated with risk of high sexual and urinary dysfunction, and impaired body image, but SPR is not universally recommended over APR in terms of QoL according to comprehensive evaluation. Patient-related, tumor-related, and social factors need to be considered to select type of surgery for rectal cancer.

Radiation therapy and chemotherapy

The introduction of chemotherapy and radiotherapy (RT) in the treatment of rectal cancer has significantly contributed to reducing recurrence rates and improving survival rates [4, 47, 48]. Recently, there has been a rapid increase in attempts to administer these treatments before considering surgery, aiming to diversify treatment approaches, improve patient compliance, and address potential distant metastases early on [4, 47, 48]. However, concerns have been consistently raised about the potential negative impact of these treatments on QoL although there are still controversies [48–51]. The Dutch TME trial revealed that TME with preoperative RT significantly reduced local recurrence but was associated with impaired bowel function, which affected QoL [48]. Radiation-induced early toxicity primarily includes diarrhea, cystitis, and perineal dermatitis, whereas late toxicity is characterized by bowel dysfunction, fecal incontinence, bleeding, perforation, and genitourinary dysfunction [50]. Although CRT demonstrates superiority over RT in terms of local control, it has been associated with a greater decline in QoL mainly caused by decline of bowel function than RT alone [37, 51].

A meta-analysis by Birgisson et al. [52] showed that late toxicities from RT, such as radiation-induced bowel obstruction and bowel dysfunction—which include symptoms like fecal incontinence to gas, loose or solid stools, and sexual dysfunction—play a significant role in reducing QoL. Similarly, a long-term study by Bruheim et al. [53] reported that patients who received RT and CRT groups had more frequent bowel movements (more than 8 per day), higher rated of urinary and fecal incontinence, greater reliance on sanitary pads, and a more difficulty controlling the urge to defecate compared to those who did not receive RT. The study also noted that the CRT and RT groups had lower global QoL and social functioning. Kinoshita et al. [54] conducted a prospective questionnaire-based study on patients who had surgery for lower rectal cancer. They found that those who receive chemotherapy had significantly lower physical and social functioning scores 12 months after surgery compared to those who did not. It is widely agreed that RT, CRT, and chemotherapy negatively impact although it is still controversial [49]. To improve outcomes, recommendations include using short-course RT, reducing irradiated area, applying advanced irradiation techniques, and tailoring chemotherapy regimens to individual patients instead of using standardized treatment [55]. Interestingly, Wagner et al. [56] reported that two-thirds of patients anticipated a curative outcome from their RT despite only one-third receiving RT with curative intent. Patients with higher expectations of recovery reported better QoL than those with lower expectations. These findings suggest that, while the actual effects of RT may not always meet patients’ expectations, the anticipation of a positive outcome appears to enhance QoL. Therefore, it is crucial to balance between providing realistic information about the effectiveness of RT and offering optimistic explanations to improve patients’ QoL.

Anastomotic leakage

Anastomotic leakage (AL) is a serious complication that can occur after rectal resection and is also known to be associated with functional decline and impairment of QoL [9, 34, 57–59]. Re et al. [34] conducted a retrospective audit that revealed an association between AL and elevated long-term fecal incontinence scores. Mongin et al. [59] demonstrated that patients with AL following laparoscopic SPR for mid and low rectal cancer exhibited significantly impaired physical activity, self-respect, and wear pad scores, as well as blood/mucus in the stool. However, no significant differences were observed in the overall Wexner scores. According to the retrospective cross-sectional study from Australia including 224 patients who underwent minimally invasive restorative rectal surgery with a low pelvic colorectal anastomosis, 11% of patients experienced AL and had worse LARS scores than those who did not have AL (P=0.028) [60].

Chronic leakage also influences on QoL. The institutional database-based study including long study period (1995–2019) analyzed the prevalence and factors influencing chronic AL after LAR for rectal cancer, with a focus on treatment of persistent presacral sinus and its impact on OoL [61]. Among 71 patients, 54.9% developed a chronic presacral sinus, and neoadjuvant therapies significantly influenced AL formation. While multiple therapies and surgical revisions negatively affected bowel continuity, stoma reversal notably improved long-term survival, bowel function, and pain relief, thereby enhancing patients' overall QoL. The study emphasizes that tailored surgical treatment and stoma reversal can significantly improve QoL for patients with chronic AL.

EFFORTS AIMED AT IMPROVING PATIENTS’ QoL

SPR and the W&W approach

There has been a shift in treatment strategies from previous studies focusing solely on complete resection of the tumor with TME and oncological outcomes toward an approach that also emphasizes treatment-related morbidity and QoL of patients [4, 62–64]. As part of this, there is an emerging strategy in the management of rectal cancer as an approach to “organ preservation,” such as local excision or the watch-and-wait (W&W) approach [62–64]. These approaches yield oncological outcomes comparable to those of TME, potentially enhancing QoL. In the management of early rectal cancer, local excision techniques such as transanal excision or transanal minimally invasive surgery are viable alternatives to TME [65–67], although prospective studies reported that fecal incontinence was more prevalent in patients who underwent CRT followed by local excision 1 year after surgery [66] and long surgery time is a risk factor of functional disorder [67]. Increasing evidence supports an observational approach, known as W&W strategy, which omits rectal resection after clinical complete remission following CRT or total neoadjuvant treatment since Habr-Gama et al. [68] pioneered a nonoperative management for rectal cancer patients who respond well to CRT. Several studies, including a retrospective analysis of the Memorial Sloan Kettering experience [10, 69], showed that rectal cancer patients using the W&W strategy had better functional outcomes compared to those who had surgery, though pelvic radiation did cause symptoms of major LARS in about one-third of W&W patients. However, the oncologic outcomes of the W&W strategy are still being evaluated to determine its reliability and proper selection of patients in the International Watch & Wait Database (IWWD) of 880 patients with clinical complete response, the 2-year cumulative incidence of local regrowth was 25.2%, the incidence of distant metastasis was 8%, and the 5-year overall survival rate was 85% [64]. Additionally, São Julião et al. [70] reported that patients in the W&W group who experienced local regrowth had a reduced distant metastases-free survival rate compared to those who underwent conventional TME after CRT from the time of local recurrence. Therefore, efforts should be made by applying stricter criteria for determining clinical complete response and shortening follow-up intervals.

Reducing toxicity of RT

In efforts to reduce the toxicity associated with RT for rectal cancer, several strategies have been developed to customize treatment and improve patient QoL and not compromising oncologic outcomes.

The use of short-course radiation therapy, which delivers a higher dose of radiation over a shorter period, can minimize the duration of treatment and reduce long-term side effects while maintaining comparable efficacy compared to conventional long-course radiation [71, 72], Another customization in RT is the reduction of irradiated volumes. By using advanced imaging techniques, RT can be more precisely targeted to the tumor, sparing healthy surrounding tissues such as the bladder and small bowel. This precision leads to fewer complications and reduced toxicity [73].

Advanced irradiation techniques have also played an important role in minimizing toxicity. Intensity-modulated radiation therapy (IMRT) allows for precise dose distribution around the tumor while minimizing exposure to nearby organs. Studies show that IMRT can significantly reduce gastrointestinal and genitourinary side effects in rectal cancer patients compared to conventional techniques [74]. Volumetric modulated arc therapy (VMAT), which delivers radiation in a continuous arc around the patient, offers similar benefits but with shorter treatment times, further improving patient comfort and reducing radiation exposure [75].

Lowering radiation doses or modifying the fractionation schedule (how radiation is divided across treatment sessions) can also reduce toxicity, particularly in patients at high risk for side effects. Tailoring the dose based on patient-specific factors, such as age or co-existing health conditions, can balance efficacy and toxicity more effectively. Bowel-sparing techniques are another way to reduce the toxic effects of radiation. Approaches such as prone positioning (where the patient lies face down) or the use of belly boards help to move the small bowel away from the radiation field, minimizing the risk of bowel toxicity [76].

Recently, personalized treatment planning based on genetic markers, patient-specific anatomy, or prior treatment responses enables further customization of RT. Personalized plans can better minimize toxicity while still achieving high oncologic control [77].

These advanced techniques and approaches are essential for optimizing RT in rectal cancer, reducing treatment-related toxicity, and improving QoL while ensuring effective cancer control.

Operative techniques for preserving QoL

Various operative techniques have emerged to enhance QoL.

Minimally invasive surgery

Various approaches have been introduced to improve oncologic outcomes as well as QoL [78–80]. Various studies suggest that a robotic approach for rectal cancer better preserves urogenital function by providing a better visual field and ergonomic control system considering patients body habitus and disease status [78–80].

Low ligation of IMA

Whether high ligation of the inferior mesenteric artery (IMA) negatively impact on functional outcomes is still controversial. A randomized clinical trial (RCT) conducted by Mari et al. [81] (the HIGHLOW trial) reported that low ligation of IMA resulted in significantly better outcomes than high ligation in terms of urinary parameters, including urinary volume, postvoid residual volume, maximum urinary flow, and flow time. On the contrary, another RCT showed no difference in QoL between 2 groups [82]. The level of IMA ligation is not a definitive factor of worsening QoL. However, care must be taken to avoid injury of the parasympathetic nerve trunk during IMA ligation. High ligation is more associated with a greater susceptibility to traumatic or thermal injury compared to low ligation. However, more evidence is required to reach consensus whether the level of IMA ligation influence on functional outcomes.

Colonic pouch and coloplasty

There were effort to improve bowel function by increasing reservoir volume. Chen et al. [83] conducted a retrospective study involving 72 patients with low rectal cancer who underwent SPR with either end-to-end or colonic pouch anastomosis. This study demonstrated that patients with colonic pouch anastomosis had lower postoperative LARS scores than those with end-to-end anastomosis, indicating improved bowel function.

RCTs by Fazio et al. [84] and Hallböök et al. [85] compared the functional outcomes of coloplasty, colonic J-pouch, and straight anastomosis following the resection of lower rectal cancer. The studies found that patients who underwent colonic J-pouch anastomosis had fewer bowel movements, less clustering, reduced pad use, and a lower fecal incontinence severity index than the other procedure groups.

However, several studies did not find any significant difference in QoL between colonic J-pouch and straight colorectal reconstruction in long-term results [86–88]. Reservoir anastomosis approach may be beneficial for early bowel function recovery although long-term benefit is not clear.

CONCLUSION

Rectal cancer treatment has undergone rapid advancements over the past few decades owing to the development of various treatment modalities and multidisciplinary approaches. In this study, we reviewed the key indicators for assessing QoL, factors contributing to QoL deterioration, and efforts to improve QoL postoperatively in patients with rectal cancer. As different treatment approaches and strategies to enhance QoL have both benefits and limitations, it is essential to provide patients with comprehensive information and ensure that informed consent is obtained.

ARTICLE INFORMATION

Conflict of interest

Won Beom Jung is an Editorial Board member of Annals of Coloproctology, but was not involved in the reviewing or decision process of this manuscript. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Fig. 1.

Factors related with quality of life (QoL) after rectal cancer surgery. Multiple patient-related, disease-specific, and surgery-related factors involve in determining QoL. APR, abdominoperineal resection; SPR, sphincter-preserving resection.

Table 1.

Various assessment tools of QoL in rectal cancer patients

Assessment tool	Description	Score	Domain	Strength	Limitation
LARS score [8, 25]	Assess bowel function	Range, 0–42 points	Gas incontinence	Specific to bowel function	Limited to bowel function
		No LARS (0–20)	Liquid stool incontinence	Quick and simple to use	Does not address QoL
		Minor LARS (21–29)	Evacuation frequency
		Major LARS (30–42)	Fragmented evacuation
			Defecation urgency
FACT-C [13]	Multidimensional QoL tool with a CRC-specific subscale	Range, 0–136 points	Physical well-being	Comprehensive view of QoL in CRC	Lengthy
		Higher scores indicate better QoL	Social/family well-being		May require more training for accurate interpretation
		Total and domain-specific scores analysis	Emotional well-being
		Focus on changes over time to evaluate pretreatment and posttreatment QoL	Functional well-being
			CRC-specific concerns
EORTC QLQ-CR29 [18]	Evaluate CRC-related symptoms and functions	Range, 0–100 points (for each domain)	Body image	Tailored to CRC patients	Lengthy
		Function domain: higher scores indicate better function	Sexual function	Covers a wide range of symptom areas	May require healthcare professional assistance for accurate completion
		Symptom domain: higher scores indicate more severe symptoms or issues	Gastrointestinal symptoms (e.g., diarrhea, constipation, bloating)
		Interpreting domain-specific scores and changes over time	Urinary symptoms
			Treatment-related side effects
SF-36 [19]	Assess general health status	Range, 0–100 points (for each domain)	Physical functioning	Widely used and validated across various conditions	Not cancer-specific
		Higher scores in each domain indicate better health status	Role limitations due to physical health	Broad QoL coverage allows comparison across diseases
		Average scores and track changes over time	Role limitations due to emotional problems
			Energy/fatigue
			Emotional well-being
			Social functioning
			Pain
			General health perception

QoL, quality of life; LARS, low anterior resection syndrome; FACT-C, Functional Assessment of Cancer Therapy-Colorectal; CRC, colorectal cancer; EORTC, European Organization for Research and Treatment of Cancer; SF-36, 36-Item Short Form Health Survey.

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Beyond survival: a comprehensive review of quality of life in rectal cancer patients

Ann Coloproctol. 2024;40(6):527-537. Published online December 20, 2024

DOI: https://doi.org/10.3393/ac.2024.00745.0106

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Figure

Beyond survival: a comprehensive review of quality of life in rectal cancer patients

Fig. 1. Factors related with quality of life (QoL) after rectal cancer surgery. Multiple patient-related, disease-specific, and surgery-related factors involve in determining QoL. APR, abdominoperineal resection; SPR, sphincter-preserving resection.

Fig. 1.

Beyond survival: a comprehensive review of quality of life in rectal cancer patients

Assessment tool	Description	Score	Domain	Strength	Limitation
LARS score [8, 25]	Assess bowel function	Range, 0–42 points	Gas incontinence	Specific to bowel function	Limited to bowel function
		No LARS (0–20)	Liquid stool incontinence	Quick and simple to use	Does not address QoL
		Minor LARS (21–29)	Evacuation frequency
		Major LARS (30–42)	Fragmented evacuation
			Defecation urgency
FACT-C [13]	Multidimensional QoL tool with a CRC-specific subscale	Range, 0–136 points	Physical well-being	Comprehensive view of QoL in CRC	Lengthy
		Higher scores indicate better QoL	Social/family well-being		May require more training for accurate interpretation
		Total and domain-specific scores analysis	Emotional well-being
		Focus on changes over time to evaluate pretreatment and posttreatment QoL	Functional well-being
			CRC-specific concerns
EORTC QLQ-CR29 [18]	Evaluate CRC-related symptoms and functions	Range, 0–100 points (for each domain)	Body image	Tailored to CRC patients	Lengthy
		Function domain: higher scores indicate better function	Sexual function	Covers a wide range of symptom areas	May require healthcare professional assistance for accurate completion
		Symptom domain: higher scores indicate more severe symptoms or issues	Gastrointestinal symptoms (e.g., diarrhea, constipation, bloating)
		Interpreting domain-specific scores and changes over time	Urinary symptoms
			Treatment-related side effects
SF-36 [19]	Assess general health status	Range, 0–100 points (for each domain)	Physical functioning	Widely used and validated across various conditions	Not cancer-specific
		Higher scores in each domain indicate better health status	Role limitations due to physical health	Broad QoL coverage allows comparison across diseases
		Average scores and track changes over time	Role limitations due to emotional problems
			Energy/fatigue
			Emotional well-being
			Social functioning
			Pain
			General health perception

Table 1. Various assessment tools of QoL in rectal cancer patients