The aim of this pooled analysis was to examine the impact stoma location may have on ostomy-related issues and HRQOL in cancer survivors. Our results suggest that cancer survivors with ostomies may experience different self-care events and may report varying severity of ostomy-specific QOL issues, depending on stoma location.
Overall, about half of our participants experienced clothing issues and changed their clothing style due to their ostomies. Clothing restrictions and adaptations were identified as common and persistent concerns for long-term colorectal cancer survivors with ostomies, with both male and female ostomates reporting the need to wear large, loose-fitting shirts and pants to accommodate their ostomies (20). Stoma location may further motivate clothing style changes because the ostomy bag extends past the stoma at varying lengths, which can result in skin irritation or discomfort. For example, the edges of the ostomy bag may scratch against the genitalia or inner thigh if the stoma is located on the lower half of the abdomen. As a result, an ostomate may wear different underwear or opt for smaller ostomy bags, but these choices can result in more frequent bag changes to prevent overflow and increased costs. Furthermore, as ostomies can cause permanent changes in perceived body image (3), clothing style adaptations may further exacerbate this negative impact, regardless of stoma location.
Our results revealed that a majority of our participants experienced weight change after their ostomy surgery, with about half of the participants gaining weight post-surgery. This may be due to behavioral adjustments to cope with the ostomy, such as avoidance of physical activity or changes in diet. BMI has been implicated as a significant risk factor for stomal and peristomal complications, such as increased retractions, skin irritation, and peristomal hernias (21–23). Weight change in particular was shown to be associated with an increased risk of ostomy-related issues in long-term colorectal cancer survivors (24). An increase in weight may displace the stoma location to a less ideal position, making self-care more time-consuming. In our study, over 60% of cancer survivors with ostomies on the lower right side of the abdomen experienced weight gain, and these survivors also reported a higher frequency of ostomy bag changes or emptying compared to the other three quadrants. This may imply that our population of cancer survivors with ostomies on the lower right side consumed comparatively more calories, resulting in higher stomal output and weight gain. Further research is needed to determine the mechanism behind weight loss and stoma location on the lower right side of the abdomen.
We found that cancer survivors with ostomies on the right side of the abdomen reported on average worse issues with the skin surrounding the ostomy compared to those with ostomies on the left side of the abdomen. Peristomal skin complications may be associated with the composition of the stoma effluent (25) or with ostomy leakage. For example, colostomies placed at the right colon have an output that is more dilute than colostomies at the left colon due to the physiology of the colon: the ascending (right) portion of the colon is responsible for a large majority of water and salt reabsorption compared to the descending (left) colon (26), so effluent from colostomies placed at the left colon would therefore have a lower water content and be less liquid. Additionally, ileostomies tend to have more caustic effluent due to a higher content of proteolytic enzymes and a more alkaline liquid output (25). Similarly, urostomies collect urine, which may cause skin irritation if there is ostomy leakage that exposes the skin to the stoma effluent. Skin complications are a frequent concern for individuals with ostomies (27), and our results suggest further counseling or guidance for proper skin care are needed for cancer survivors who receive ostomies on the right side of their abdomen.
To date, few studies have evaluated the relationship between stoma location and ostomy-related QOL. In colorectal cancer survivors with colostomies or ileostomies, stoma location on the left side of the abdomen was shown to be associated with higher cognitive and social function (28). Similarly, in our analysis, we found that cancer survivors with ostomies on the left side of the abdomen had significantly different scores for the ostomy’s interference with social activities compared to those with ostomies on the right side of the abdomen, but we did not find differences in overall social well-being. This discrepancy can once again be explained by the consistency of the stomal output, as there may be a more pronounced need for frequent ostomy bag changes for survivors with ostomies on the right side of the abdomen, resulting in anxiety of social activities and being out in public. Cancer survivors with ostomies on the right side of the abdomen also reported significantly different scores for sleep disruptions due to the ostomy. Ostomates have difficulty getting an appropriate amount of sleep due to leakage disruptions, sleep position issues, and the need to change ostomy bags (29), all of which may be further exacerbated by stomal output consistency. Overall, cancer survivors with ostomies reported low (< 7/10) scores for the ability to be intimate. Our results mirror prior reports about the negative effect of ostomy on sexuality and intimacy (5, 30, 31), suggesting that intimacy is a pervasive concern for survivors with ostomies regardless of stoma location.
This pooled analysis has a few limitations that should be noted. First, all three studies surveyed highly motivated cancer survivors with ostomies who were willing to respond to surveys (Study 1 and Study 2) or were willing to participate in an ostomy self-management intervention (Study 3). Therefore, our results may not be representative of the general population of cancer survivors with ostomies. Second, as our analysis was exploratory, we did not adjust for multiple comparisons, raising the possibility of false positives (Type I errors). Finally, due to the retrospective nature of our analysis, the timing of the surveys were not standardized across all three studies: participants in Study 3 were eligible after at least 6 weeks had passed after the ostomy surgery, and participants in the other two studies had to be long-term (≥ 5 years post-diagnosis) colorectal cancer survivors, but time since surgery was not specified or collected. Our weight change observations did not consider time since surgery. However, our objective was to begin to explore the relationship between stoma location and incidence of self-care events rather than delve into the minutiae of any one event. In the event that a pattern or association was observed, more rigorous methods can be utilized to further elucidate these observations.