Quality of Life of Colorectal Cancer patients and its association with Anxiety and Depression: Cross sectional study at a tertiary care hospital in low-middle income country

doi:10.21203/rs.3.rs-3138703/v1

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Research Article

Quality of Life of Colorectal Cancer patients and its association with Anxiety and Depression: Cross sectional study at a tertiary care hospital in low-middle income country

https://doi.org/10.21203/rs.3.rs-3138703/v1

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published 31 Aug, 2024

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Background: Colorectal cancer (CRC) and its therapy have an enormous impact on the health related quality of life (QoL) of cancer patients. The emotional distress like anxiety & depression also negatively affect wellbeing of such patients. This study aims to evaluate the QoL, anxiety & depression in CRC patients and their association with clinic-pathological features at a tertiary care hospital in Karachi Pakistan, a low middle income country (LMIC).

Methods: An analytical cross sectional study was conducted on adult patients with CRC presenting to Aga Khan University Hospital, Karachi, Pakistan. The European Organization for Research and Treatment of Cancer, QoL questionnaire C30 and CR29 were used to assess the QoL; while Hospital Anxiety & Depression Score (HADS) was utilized to evaluate the anxiety and depression. Data were analyzed using STATA version 12. Multivariable linear and MANOVA were performed to analyze the correlation between independent factors and the global QoL as well as the item specific QoL scores, respectively. A p value of <0.05 was considered as significant.

Results: A total of 127 CRC patients were included in this study with a mean age of 53±15 years. Majority were male (70%), married (83.5%), and living in combined family system (52.7%). Mean Global QoL score in our patients was 69.08±1.78. Among symptoms scales, stoma care problem, dry mouth and urinary frequency were 3 worst symptoms respectively. Among functional scales, sexual interest (women > men) was the most significantly affected aspect. Anxiety and Depression were seen in 26 (20.9%) and 24 (18.9%) patients, respectively. On multivariable linear regression adjusted for covariates, lower global QoL was significantly associated with depression (Adjusted Beta Coefficient: -25.33 [95% Confidence Interval: −34.4, −16.23]), patients on adjuvant treatment (−15.14 [−21.84, −8.44]), and those who received neo adjuvant treatment (-11.75 [-19.84, -3.65]).

Conclusions: This is the first study to assess the QoL in CRC patients in Pakistan. Depression was found to be significantly associated with poor quality of life. Numerous factors were identified which correlated with QoL indicating the need to develop local guidelines to help our patients cope with the psychological distress.

Quality of life

colorectal cancer

anxiety

depression

Low Middle Income Country

Colorectal cancer (CRC) is the 3rd most common cancer and 2nd most common reason for cancer related mortality worldwide (1). The diagnosis of cancer may result in significant physical, social and psychological trauma; since it is not just the disease itself, but also the treatment which may have serious adverse consequences (2–3). Chemotherapy induced nausea and vomiting, surgery related prolonged diarrhea or fecal incontinence, social and emotional trauma due to stoma bag and radiation induced sexual dysfunction are few of the common sufferings of CRC patients.

The concept of patient self-reported consequences and wellbeing have become popular amongst healthcare professionals to measure the quality of life (QoL) of cancer patients. In addition to the conventional outcome measures like morbidity or mortality, a variety of tools have been developed to measure important outcome variables, particularly the self-administered QoL questionnaires (4–5). The European Organization of Research and Treatment of Cancer (EORTC) has developed a core cancer quality of life questionnaire (QLQ) C30, along-with the site specific tools. The EORTC-QLQ-CR29 is a colorectal cancer specific module supplementary to EORTC-QLQ-C30 (6). Similarly, the Hospital Anxiety and Depression Scale (HADS) is the most extensively studied tool to measure the frequency of anxiety and depression (7).

In addition to the disease related issues, multiple other factors influence the quality of life of colorectal cancer patients including the age, personality type, physical fitness, physical activity, social support, economic status and presence of comorbidities (7–9). The emotional distress like anxiety and depression may also negatively affect the quality of life that ultimately affect the treatment compliance (9). Cancer survivors are more prone to develop depression due to multiple factors, including the disease related morbidity, huge cost of treatment and the fear of recurrence. High frequency of depression (58–70%) has been reported in cancer patients of Pakistan (10–11). However, the association of anxiety and depression with quality of life in colorectal cancer group has not been studied in a Low Middle Income Country (LMIC), like Pakistan.

The primary objectives of our study were to assess the quality of life (QoL), and measure the frequency of anxiety and depression in patients with CRC presenting to our hospital. The secondary objectives included evaluation of factors associated with the quality of life and determine association between anxiety, depression and quality of life. Evaluation of quality of life in CRC patients is essential in order to take appropriate steps towards their optimum care and wellbeing.

An analytical cross sectional study was conducted on patients with CRC presenting to the Aga Khan University Hospital (AKUH), Karachi, Pakistan, from November 2020 to October 2021. Adult CRC patients who received any form of treatment at AKUH and were beyond 30 day of surgical intervention were included in the study. Patients with a prior history of malignancy other than CRC, patients with diagnosed psychiatric disorders or on medication prescribed by a psychiatrist, patients with physical disability and those who were unable to understand English or Urdu were excluded. CRC patients were identified by their hospital medical record numbers and were approached by the research team on the day of their appointment in clinic. A written and informed consent was taken from eligible patients without any coercion. A purposive sampling technique was used to select the participants and an approval was taken from the institutional Ethical Review Committee (ERC) before starting the data collection.

Each participant or caregiver were provided with 4 self-filled questionnaires:

A self-designed questionnaire measuring the socio-demographic and other factors associated with QoL; including age, gender, education, marital status, disease status and treatment received.

EORTC QLQ-C30: Validated Urdu (Pakistan) version for core cancer QoL.

EORTC QLQ-CR29: This tool is specific to assess QoL of colorectal cancer patients. The tool was translating into Urdu using guidelines of EORTC QoL. Content validation (for relevance and clarity) was done by 6 experts of the disease. A pilot study was conducted on 10 patients to identify its validity and feasibility before using in the study.

The Hospital Anxiety and Depression Scale (HADS): Validated Urdu version for anxiety and depression assessment.

Time consumed by participants to complete the forms was between 20 to 30 minutes. Research team, trained by a psychologist, were available all the time to provide any assistance and the participants who were considered as clinically depressed were counseled on spot and referred to a psychiatrist. Data confidentiality was strictly maintained and no personal identifiers were disclosed.

The data was analyzed on STATA version 15. Continuous variables were reported as mean ± standard deviation (SD) or median with inter-quartile range (IQR); while categorical variables were reported as frequency and percentages. General Linear Model (GLM) multivariate analysis of variance (MANOVA) was used to determine the relationship between the independent variables and the dependent variables (QLQ-C30 and QLQ CR29). Initially, a one-factor model was used to identify independent variable with a p < 0.20. These variables were then assessed on a multi-factor model. Unadjusted and adjusted beta coefficients with 95% confidence intervals (CI) were reported to determine the factors associated independently with QoL by using linear regression. The variables with a p < 0.20 on univariate regression were considered as significant for inclusion into the multivariable regression model. A p < 0.05 was considered as significant.

A total of 127 CRC patients were included in this study. Table 1 represents the demographic profile of participants. Mean age of the study participants was 53 ± 15 years. Majority were male 89 (70%), married 106 (83.5%), and living in the combined family system 67 (52.7%); while only 55 (43.3%) participants were employed. Literacy status revealed that 68 (53.5%) participants were graduates, while 13 (10%) were either illiterate or just able to write their names. Urdu (n = 45, 35.4%) was the most commonly speaking language in study participants followed by Sindhi (n = 36, 28.3%).

Table 1

Demographic profile of CRC patients
Characteristics		Frequency	Percent
	Total	127
Age	Mean ± SD	53 ± 15
Gender	Male	89	70
Gender	Female	38	30
Educational status	Illiterate	4	3
	Can write name	9	7
	Primary	10	8
	Matriculation	11	8.7
	Intermediate	25	19.7
	Graduate or beyond	68	53.5
Marital Status	Unmarried	12	9.4
	Married	106	83.5
	Divorced/widowed	9	7
Family type	Nuclear	60	47.3
Family type	Combined	67	52.7
Employment status	Employed	55	43.3
	Employed but unable to work due to disease	10	8
	Retired	36	28.3
	Homemaker	20	15.7
	Not reported	6	4.7

Table 2 summarizes the clinical characteristics and treatment received by the study participants. Sigmoid colon was the most common site (n = 27, 21.3%) followed by recto-sigmoid junction (n = 23, 18%). Majority of the tumors were stage III at presentation (n = 75, 59%) and moderately differentiated (n = 74, 58.3%). Surgical intervention was performed in all patients, out of which 59 (46.5%) had a stoma. A total of 30 (23.6%) patients received neo-adjuvant treatment and 104 (65.8%) received adjuvant treatment, amongst them 67 (52.7%) were on adjuvant treatment at the time of participation in the study.

Table 2: Clinical characteristics and Treatment received

Characteristics		Frequency	Percent
Site of tumor	Appendix	1	0.7
	Caecum	14	11
	Ascending colon	22	17.3
	Transverse colon	7	5.5
	Descending colon	13	10
	Sigmoid colon	27	21.3
	Recto-sigmoid junction	23	18
	Rectum	19	15
	Multiple	1	0.7
Stage of THE Disease	I	3	2.4
	II	42	33
	III	75	59
	IV	7	5.5
CURRENTLY UNDER treatment		67	52.7
NeoAdjuvant TREATMENT		30	23.6
Surgical intervention		127	100
Adjuvant TREATMENT		104	65.8
Stoma bag created		59	46.5
Type of Stoma	Ileostomy	37	29.13
Type of Stoma	Colostomy	22	17.3
Nature of stoma	Temporary	46	36.2
Nature of stoma	Permanent	13	10.2
Recurrence		17	13.4
Comorbids	Hypertension	49	38.6
	Diabetes Mellitus	34	26.8
	Ischemic Heart Disease	12	9.4
	Chronic Kidney Disease	4	3
	Hepatitis	4	3
Smoking status	Never	83	65.4
	Ex-Smoker	37	29
	Active smoker	6	4.7
BMI category	Underweight	5	4
	Normal	50	39.4
	Over weight	40	31.5
	Obese	31	24.4
BMI	Mean ± SD	26.43 ± 5.74
Functional CLass (ECOG)	Fully active	90	71
	Active with some difficulty	17	13.4
	Able to self-care	9	7
	Needs Assistance in self-care	7	5.5
	Totally dependent	3	2.4
	Not reported	1	0.8

The generalized overall global QoL score was 69.08 ± 1.78 in our patients. Individual domain scores of form C30 are presented in Table 3 with threshold for clinical importance (TCI) scores for comparison. It was observed that among functioning scales; physical functioning was found to be below TCI whereas among symptom scores; nausea/vomiting and financial impact were found to be above TCI. Using colorectal cancer specific questionnaire QLQ CR 29, it was evident that amongst symptom scales the three worst symptoms reported were stoma care problem (32.53 ± 5.26), dry mouth (22.83 ± 2.51) and urinary frequency (21.65 ± 2.29). Amongst functional scales, sexual interest was worst in our CRC patients and females (7.89 ± 2.64) were more severely affected as compared to males (27.34 ± 2.35). Anxiety and Depression were noticeable in 26 (20.9%) and 24 (18.9%) patients and the median scores for anxiety and depression were 3(IQR 6) and 3(IQR 5), respectively. Twelve (9.4%) patients were found to be in abnormal range for anxiety and 5 (3.9%) were diagnosed with depression (Table 4).

Table 3

Generalized QOL score (C30) in CRC patients and comparison with threshold of clinical significance (TCI)
Domains		Mean score	SD	TCI
Global		69.08	1.78
Functioning Scale	Physical	78.72	2.05	83
	Social	79.1	2.18	58
	Role	84.54	2.23	58
	Cognitive	86.8	1.66	75
	Emotional	80.95	2	71
Symptom Scale	Fatigue	26.13	2.28	39
	Nausea/Vomiting	10	1.67	8
	Pain	17.73	2.38	25
	Dyspnea	11.64	1.89	17
	Sleep disturbance	24.33	2.61	50
	Appetite loss	18.25	2.5	50
	Constipation	23.54	2.88	50
	Diarrhea	13.22	2.31	17
	Financial impact	53.6	3.29	17

QLQ Domains		Mean score	Standard Error
Symptom Scales	Urinary frequency	21.65	2.29
	Urinary incontinence	5.77	1.49
	Dysuria	7.61	1.75
	Abdominal pain	15.22	2.46
	Buttock pain	14.96	2.65
	Bloating	13.91	2.022
	Blood & mucus in stool	3.67	1.01
	Dry mouth	22.83	2.51
	Hair loss	16.66	2.24
	Taste	15.22	1.96
	Flatulence	15.82	2.67
	Fecal incontinence	9.71	1.90
	Sore skin	9.18	1.73
	Stool frequency	11.28	1.7
	Embarrassment	12.96	2.18
	Stoma care problems	32.53	5.26
	Impotence	20.59	3.82
	Dyspareunia	3.5	1.68
Functional Scales	Anxiety	60.36	3.02
	Weight	75.59	2.39
	Body image	84.56	1.78
	Sexual interest (male)	27.34	2.35
	Sexual interest (female)	7.89	2.64
Hads Domains		Median	IQR
Anxiety		3	6
Normal (score 0-7)	99 (78%)
Borderline (score 8-10)	14 (11%)
Abnormal (score 11-21)	12 (9.4%)
Depression		3	5
Normal (score o-7)	101 (79.5%)
Borderline (score 8-10)	19 (15%)
Abnormal (score 11-21)	5 (3.9%)

Table 5 shows the overall effect of the depression, socio-demographic and other factors on the QoL outcomes among colorectal cancer patients. A total of 4 variables were included in the multifactor model GLM-MANOVA with EORTC QLQ-C30 scales as the dependent variables. The variables significantly associated with EORTC QLQ-C30 scores on the multifactor model were functional status (ECOG), family history of cancer, recurrence of cancer and depression. However, a total of 5 variables included in the multifactor model GLM-MANOVA with EORTC QLQ-CRS 29 scales as the dependent variables. The variables significantly associated EORTC QLQ-CRS 29 scores on the multifactor model were age, female gender, functional status, recurrence of cancer and depression.

Table 5

GLM-MANOVA test of the overall effect of the depression, sociodemographic and other factors on the EORTC QLQ-C30 and CR29 scales
Variables		QLQ C30				QLQ CR29
		One factor model		Multifactor Model		One factor model		Multifactor Model
		Wilk λ	p value	Wilk λ	p value	Wilk λ	p value	Wilk λ	p value
Age (in years )		0.721	0.002*	NS	NS	0.569	< 0.001*	0.545	< 0.001**
Gender	Male (ref) vs female	NS	NS	NS	NS	0.68	0.01*	0.652	0.021**
Marital status	Unmarried (ref) vs married vs divorce vs widow	0.548	0.027*	NS	NS	0.54	0.073*	NS	NS
Total Monthly household income (in PKR)		0.728	0.121*	NS	NS	NS	NS	NS	NS
Functional Status (ECOG)	fully active (ref) vs active with difficulty vs self care vs need help in self care vs totally dependent	0.277	< 0.001*	0.215	< 0.001**	0.217	< 0.001*	0.191	< 0.001**
Past Surgical History	Yes vs no (ref)	0.818	0.115*	NS	NS	NS	NS	NS	NS
Family history of depression	Yes vs no (ref)	0.797	0.067*	NS	NS	0.603	0.0005*	NS	NS
Family history of cancer	Yes vs no (ref)	0.73	0.003*	0.69	0.006**	0.716	0.04*	NS	NS
Stoma	Yes vs no (ref)	0.741	0.005*	NS	NS	0.67	0.0074*	NS	NS
Neoadjuvant therapy	Yes vs no (ref)	0.781	< 0.03*	NS	NS	0.746	0.103*	NS	NS
Adjuvant thepary	Yes vs no (ref)	NS	NS	NS	NS	0.682	0.013*	NS	NS
Grade	Well differentiated (ref) vs moderately differentiated vs poorly differentiated	0.691	0.102*	NS	NS	NS	NS	NS	NS
On treatment	Yes vs no (ref)	0.64	< 0.001*	NS	NS	0.553	< 0.001*	NS	NS
Recurrence	Yes vs no (ref)	0.681	0.0013*	0.663	0.002**	0.659	0.026*	0.702	0.04**
Anxiety	No anxiety (ref) v borderline v abnormal	0.499	< 0.001*	NS	NS	0.485	< 0.001*	NS	NS
Depression	No depression(ref) v borderline v abnormal	0.41	< 0.001*	0.398	< 0.001**	0.361	< 0.001*	0.392	< 0.001**
* significant at p value < 0.25 ** significant at p value < 0.05

Table 6 depicts univariate and multivariable analysis to assess the factors associated with low global QoL patients with CRC. On univariate analysis, the variables significantly associated with low global QoL included higher age (β 0.3 (CI:0.07,0.54), lower functional status i.e. active with difficulty (β -10.66 (CI:-20.9,-0.43) and need help for self-care (-20.27 (CI: -38.05,-2.5), family history of depression (β -14.28 (CI: -24.49, -4.07), presence of stoma (β -10.15 (CI: -17.05,3.26), patients currently on adjuvant treatment (β -15.14 (CI: -21.84, -8.44), patients who received neo-adjuvant therapy (β -11.75 (CI: -19.84,-3.65), patients on adjuvant therapy (β -9.13 (CI: -18.01,-0.24), patients with borderline anxiety (β -21.52 (CI: -32.27, -10.76) and anxiety (β -13.13 (CI: 24.28 to -1.99) and patients with borderline depression (β -25.33 (CI: -34.43 to -16.23) and depression (β-10.15 (CI: -26.42 to 6.12). On multivariable analysis after adjusting for covariates, it was observed that the global QoL scores of patients with borderline depression was 25 units lower as compared to those with no depression. Similarly QoL scores of patients with depression was 10 units lower as compared to those with no depression. Moreover, patients who were currently on treatment had their QoL scores 15 units lower as compared to those who are on surveillance, while patients who received neo-adjuvant therapy had their QoL scores 12 units lower as compared to their counterparts.

Table 6

Univariate and Multivariate Analysis for assessing factors associated with Global QOL in CRC patients
Variables		Coef.	Std. Err.	95% CI
Univariate
Age*		0.3	0.11	0.07 to 0.54
Functional Status (ECOG)* Fully active (ref)	Active with difficulty	-10.66	5.166	-20.9 to -0.43
	Self care only	-4.23	7.2	-18.5 to 10.03
	Need help in self care	-20.27	8.97	-38.05 to -2.5
	Totally dependent	-5.27	11.46	-27.98 to 17.42
Ischemic heart disease*		8.33	5.99	-3.54 to 20.21
Past surgical history*		7.139	3.55	0.1 to 14.16
Family history of depression*		-14.28	5.15	-24.49 to -4.07
Stoma*		-10.15	3.48	-17.05 to -3.26
Neo-Adjuvant Treatment*		-11.75	4.08	-19.84 to -3.65
On Treatment*		-15.14	3.38	-21.84 to -8.44
Adjuvant Treatment*		-9.13	4.48	-18.01 to -0.24
Grade of tumor* Well Differentiated (ref)	Moderately Differentiated	10.98	5.39	0.3 to 21.66
Grade of tumor* Well Differentiated (ref)	Poorly Differentiated	-2.45	5.84	-14.02 to 9.12
Anxiety* Normal (ref)	Borderline	-21.52	5.43	-32.27 to -10.76
Anxiety* Normal (ref)	Abnormal	-13.13	5.62	-24.28 to -1.99
Depression* Normal (ref)	Borderline	-25.33	4.59	-34.43 to -16.23
Depression* Normal (ref)	Abnormal	-10.15	8.21	-26.42 to 6.12
Multivariate Analysis
Depression** Normal (ref)	Borderline	-25.33	4.59	-34.43 to -16.23
Depression** Normal (ref)	Abnormal	-10.15	8.21	-26.42 to 6.12
Currently On treatment**		-15.14	3.38	-21.84 to -8.44
Received Neo-Adjuvant Rx**		-11.75	4.08	-19.84 to -3.65
* p value < 0.2 0n univariate analysis
** p value < 0.05 On multivariate analysis

This is the first study to assess the baseline QoL scores in CRC patients in a lower middle income country like Pakistan. We analyzed the global QoL using the EORTC core cancer QoL questionnaire QLQ-C30, which is already validated in Urdu and is the most widely used cancer questionnaire (12). CRC specific QoL was assessed with EORTC-QLQ-CR29, a CRC specific module supplementary to EORTC-QLQ-C30 and previously translated and validated in multiple Asian countries (6, 13–17). The global mean score of QoL in our population of 69.08 ± 1.78, which is comparable to the previously published studies including a study from Saudi Arabia where mean score was found to be 63.91 (18–21). CRC patients in our study had a better global QoL score when compared to a previous study published from our center on QoL of all gastrointestinal (GI) cancers where mean score was reported as 65.48 (22). The difference can be explained by the fact that the study included all GI cancers, including upper GI which usually present at advance stage (15% patients were at stage 4) whereas only 5.5% of our patients were at stage 4 (22). Our CRC patients also had better QoL score when compared to cancers other than GI tract in Pakistani population (23–25). The difference is due to the fact that our cohort was treated with curative intent while those patients were at different stages of their treatment including palliative care patients (23–25).

EORTC developed threshold for clinical importance (TCI) for QLQ C30, to increase the practicality of the questionnaire in real world (26). For functional scale, higher scores means better function and good QoL. For symptoms scale, higher scores means higher symptoms and poor QoL (26). TCI are not yet developed for CR29, so we relied on comparison to other published studies. Among functional scales of C30, only physical functioning (78.72) was found to be lower than TCI in our CRC patients and we found this similar to another study reported on all GI cancer in Pakistan (22). Physical functioning scores have been reported in a diverse range (62.9–90) in the published literature (14, 16, 18, 27). This high variability is likely due to the variable stage of disease and the location of tumor as treatment modalities and stoma have significant effect on physical functioning of CRC patients. Among functional scales of CR29, sexual interest (female > male) was the most problematic in our population, similar to the previously published studies (14, 16, 28, 29). Previous studies have also highlighted other significant problems, for example, body image issues was a bigger concern than sexual interest in males (18) and sexual interest in males was more effected than females (30).

Among symptoms scale combining C30 and CR29, the three worst symptoms reported in our study included the financial impact (53.6), stoma care problems (32.5) and fatigue (26.1). The highest score with financial impact in our part was expected, since majority of our patients pay out of their pockets and no healthcare uniformity exist for citizens from the government. These findings are in contrast to the internationally published literature, where finances impact score was less than our cohort (14, 16, 18). Care for stoma has remained a major concern, not only for the patients but also for care givers. Unlike us, stoma care issues is not one of the major issues for patients in the other countries (14, 16, 18, 28, 30, 31). Lack of support group discussion, non-availability of supreme quality appliances and lack of adequate counselling / understanding of patients and caregiver about stoma care may be some of the common reasons in our population and need further validation. Fatigue is reported to be the worst symptoms scale in many published studies, especially from the developed countries (14, 16, 18). On the contrary, our patients’ score of fatigue was in top three, yet below TCI.

Risk of psychological disorder is high and variable in CRC patients, irrespective of time lapse post treatment (20, 32, 33). Anxiety and Depression were reported in 26 (20.9%) and 24 (18.9%) our patients, respectively. Our results were found to be comparable to the recent literature (21, 34); but different when compared to the data published before 2010 (9, 20). We also identified relationship of patient reported QoL with anxiety and depression. Anxiety was found to be significantly affecting QoL in univariate analysis but was not found significant on multivariate analysis. Depression, on the other hand, was found to be significantly associated with worsening QoL in CRC patients in both univariate and multivariate analyses. The significant association with depression with poor QoL has been reported by many published studies (20, 21). Previous studies have also noticed decreased survival in CRC patients who demonstrate mental disorders and poor QoL (35–37). By improving QoL of CRC patients, probability of survival can be significantly increased (38). Our study did not focus on survival data and we suggest further work on the impact of psychological disorders, QoL and resilience on the survival outcomes to make any further recommendations.

Our study identified a number of factors significantly associated with QoL including age, functional status, stoma, depression, ongoing treatment and neo-adjuvant treatment. Most of these factors were also found significant in the previously published data (13–16, 31, 39, − 42). On the other hand and contrary to the previously published literature, many factors including gender, exercise, employment status, education status, tumor location, and malnutrition failed to show significant association with QoL in our study (43–47).

Improvement in mortality rate ultimately enhances the survival rates in cancer patients, therefore considering quality of life in survivors is essential in providing comprehensive and compassionate care (38). Healthcare providers and the governments in the lower middle income countries face challenges in providing high quality cancer care due to limited resources, inadequate infrastructure and shortage of trained health care professionals. This may result in delays in making a diagnosis and providing appropriate treatment leading to poor quality of life of survivors. To address these critical challenges, it is important for LMICs to have a better understanding of health related quality of life and its associated factors, especially psychological stress related to depression and anxiety. By increasing awareness, LMICs can reduce long term emotional and social burden of cancer. Further studies are required to enhance the knowledge and assessment of health care workers to improve the wellbeing and quality of life CRC patients. Such studies related to QoL are crucial to develop policies to facilitate targeted treatment in resource limited regions and achieving the goals. This may involve training healthcare providers to recognize and address the needs of colorectal survivors, promoting community based programs and investing in mental health infrastructure and resources.

This is the first study to assess the baseline QoL scores in CRC patients in a lower middle income country like Pakistan. Base line QoL scores were calculated and found to be comparable to the previously reported literature. Anxiety and Depression were seen in 26 (20.9%) and 24 (18.9%) patients, respectively, and depression was found to be significantly associated with poor QoL. Numerous factors were identified to have significant association with both QoL & depression in CRC patients in our community. Much efforts are needed to improve the mental health and QoL in our patients with special emphasis on older age population, poor performance status, patients with stoma, or those currently on treatment or those who received multimodal treatment. It is essential to develop local guidelines to help CRC patients cope with the psychological distress for their optimum care.

AKUH: Aga Khan University Hospital

CI: Confidence intervals

CRC: Colorectal cancer

EORTC: European Organization of Research and Treatment of Cancer

ERC: Ethical Review Committee

GI: Gastrointestinal

GLM: General Linear Model

HADS: Hospital Anxiety & Depression Score

IQR: Inter-quartile range

LMIC: Low middle income country

MANOVA: Multivariate analysis of variance

QoL: Quality of life

SD: Standard deviation

TCI: Threshold for clinical importance

Ethics approval and consent to participate

A written and informed consent was taken from eligible patients without any coercion. An approval was taken from the AKUH institutional ERC before starting the data collection (2020-5019-11484).

Consent for publication

Not Applicable

Availability of data and materials

The data and material are available from the corresponding author that will support the findings of the study. The data file will be provided upon request.

Competing interests

None of the authors have any potential competing interests

Funding

The study is not funded

Authors' contributions

MTHS^{1 α} conceived the study, participated in data collection, contributed in data analysis, drafted, revised, and critically reviewed the manuscript. FS²: Conceived the study, participated in data collection, drafted and critically reviewed the manuscript. MRK³: overlooked the study and critically reviewed the manuscript, NZ⁴: analyzed data, and critically reviewed the manuscript, SS⁵: Data collection and contributed in data analysis. All authors have contributed intellectually to this manuscript, and have read and approved the final manuscript.

Acknowledgements

We would like to acknowledge the study participants, our residents, nursing staffs to help us completing this study. We would also like to acknowledge the European Organization for Research and Treatment of Cancer for giving permission to translate and use their (EORCT) QoL tool.

Author details

¹Department of Surgery, Patel Hospital, Karachi, Pakistan. ² Department of Radiation Oncology, Patient Aid Foundation, Jinnah Post-Graduate Medical Center, Karachi, Pakistan. ³Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. ⁴Department of Oncology, Aga Khan University Hospital, Karachi, Pakistan.
^αCorresponding Author

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Quality of Life of Colorectal Cancer patients and its association with Anxiety and Depression: Cross sectional study at a tertiary care hospital in low-middle income country

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