The present study presents utility values using the EQ-5D-5L index and cTTO values in patients with CRC under chemotherapy treatment and impacts of socio-demographic and clinical factors on utility values. However, the high incidence of CRC is a significant health burden and public health concern in developing countries, such as Iran. Utility is a multidimensional concept that can convey important information including physical, emotional, social and cognitive domains for assessing the overall burden of cancer and the effectiveness of interventions. In addition, the findings of utility values can be used in calculating quality-adjusted life years which is a key determinant of cost- effectiveness analyses.
The mean values of EQ-5D-5L index were lower than those of two studies that have ever assessed the utility values using EQ-5D-5L in patients with CRC in Iran and China (13, 16). Our study found that patients had significantly lower EQ-5D-5L values than those of the study by Yousefi et al, on patients with CRC in Iran (0.45 vs 0.71). The lower values of EQ-5D-5L obtained in this study compared to the results of the study by Yousefi et al. can be explained by differences in the socio-demographic profile of patients. Compared to the study by Yousefi et al, this study assessed utility in patients who were more female and older. Studies showed that utility scores in patients with CRC were lower in women than in men (18-20). The other reason for the lower mean utility values in this study in comparison with the study by Yousefi was higher mean age of patients (59 vs. 55). Aging often has a negative relationship with utility scores in patients with CRC in different contexts from countries (13, 21, 22). The reason of this relationship can be due to a higher prevalence of multiple comorbidities and physical functioning limitations in older patients(23). Our results showed that 67% of older patients had >=2 comorbidities (data not shown).
The mean EQ-5D-5L index values of 0.45 was also lower when compared to those of 0.61 in the study carried out in China(24). A significant part of this difference can be explained by using the different tariffs of EQ-5D-5L in two study. The Chinese EQ-5D-5L tariff was derived from preferences of the Chines general public that is different from Iranian general public in terms of culture, demographic backgrounds, etc. This difference are also revealed when comparing the results with those of other developed countries including Japan (0.842)(10) and the UK (0.79)(11).
The findings of this study support that the mean utility scores were lower than those in the developed countries. It may be partly explained by the fact that in the countries with better economic countries, patients are more supported, especially economically and socially. Majority of the patients reported having financial problems (0.90) and limitations of social support (69%). Previous studies evaluating utility values of patients with colorectal cancer found a direct association between income level and health utility scores (13, 25, 26). Another reason for the differences in mean utility scores between countries may be related to social supports. Sapp et al, demonstrated that social support lead to better scores of utility in patients with colon, especially in terms of mental health domain(27). In addition, Sultan et al. found that patients with CRC who were socially supported having approximately 6 –7 points higher in domain of mental health than those who have no social support available(19). The use of the different versions of the EQ-5D can explain a significant part of difference between the mean utility values among the countries. We used the EQ-5D-5L, while the other two studies used the EQ-5D-3L for calculating utility. Empirical evidence shows that the EQ-5D-3L generated higher values than EQ-5D-5L because ceiling effects in EQ-5D-3L are more common than those in EQ-5D-5L.
The mean cTTO values of 0.51 were higher than those of 0.41 in the only study that assessed utility using cTTO in patients with CRC (15). The main part of this difference can be attributed to the different years were considered for the current health state in cTTO task. The number of years of the current health state was considered 10 years in cTTO task for all stages of cancer in the present study, while that was 4, 3, 2, and 1 years for stage 1, 2, 3, and 4, respectively, in the other study. Less number of years of current health state might lead to more patients trading time for an increase in quality of life, because patients believe that this short time will not an increase their quality of life.
The problems reported by patients on each of the EQ‐5D dimensions showed that percentage of very severe problems reported (i.e., report “Level 5”) on dimension of anxiety (9.52%) was more than other dimensions. This frequency was consistent with the results of obtained from the emotional functioning scale of the EROTC QLQ-C30 in patients with CRC. Patients' performance on emotional functioning scale, which is theoretically very similar to the anxiety/depression of the EQ-5D, was worse among the scales of the EROTC QLQ-C30 in Germany(22) and Brazil(28). Hence, paying attention to the anxiety/depression is an important issue in management of the patients with cancer. In addition, this finding was consistent with that of the EQ-5D-5L in China(13). The distribution of problems also showed that majority of patients (76%) experienced pain, similar to that obtained from EQ-5D for patients with CRC in China(13), the UK and the Netherlands(29).
Univariate analyses showed that the difference between the mean utility scores obtained from EQ-5D-5L was significant for education level, income level, stage of cancer, and comorbidity number; and those obtained by cTTO were significant for age, income level, employment status, stage of cancer, and a number of comorbidities. The older patients had lower utility scores, similar to those reported in patients with CRC in other countries (13, 21, 22). Older patients often have more comorbidities and advanced stages of cancer, and having physical functions limitations, which impact on quality of life. Our results showed that low income was associated with low mean utility scores. Financial constraints usually limit individuals from seeking private services and make less opportunity for better healthcare(18). Most patients reported that the reason for choosing the public hospital was financial limitations. In this regard, the financial supports can help patients to have a free choice of service provider. The mean utility scores showed that higher level of education was associated with higher utility scores.
Higher education level increases patients' perceptions of their disease and treatment. This result was in line with findings reported in other studies(13, 18). The low level of education can often contribute to delay in the recognition of symptoms and search for care in health services. The difference between mean utility scores in variable of employment status was significant, and mean utility was higher in employed patients. The employed may lead to individuals earn more income, and subsequently, they had more opportunity for better healthcare. We also found that mean utility values in patients with advanced stage of cancer was lower than that of early stage of cancer. This finding with consistent with those reported in, Australia(30) China(13) and some European countries for patients with CRC(25, 31). Mean utility scores by number of comorbidities showed that patients with a greater number of comorbidities had significantly lower utility scores. There is strong evidence of indirect relationship between number of comorbidities and QoL in CRC (32).
The regression analysis showed that gender, age, stage and number of comorbidities were significant independent predictors for utility scores in this study. Aging and having a larger number of comorbidities and advanced stage of cancer were significantly associated with lower EQ-5D scores. These relationships were observed in other studies conducted among colorectal cancer (13, 25, 30-32).
The present study has some limitations that should be noted. The present study was carried out a cross-sectional survey of patients with CRC. The results from a cross-sectional survey do not all us to stablish a causal relationship between outcome variable (utility values) input variables (socio-demographic and clinical characteristics). A longitudinal study requires to be conducted for understanding how the effects of patients’ characteristics on utility values. The participants were recruited the Oncology Center in one province, who were not be perfectly representative of patients; hence, generalization of the results needs to be cautious.