Identifying associations between quality of life outcomes and healthcare-related variables among colorectal cancer survivors: A cross-sectional survey study

https://doi.org/10.1016/j.ijnurstu.2019.103434Get rights and content

Abstract

Background

Follow-up care and surveillance are essential components of colorectal cancer survivorship. However, the relative contribution of healthcare experiences to quality of life in cancer survivorship is poorly understood.

Objectives

This study explores associations between colorectal cancer survivors’ healthcare experiences and quality of life.

Design

Cross-sectional survey study.

Settings

Participants were recruited from medical oncology and colorectal cancer surgery departments in three hospitals, and twenty-one cancer support centres providing psycho-social care to cancer patients and survivors in Ireland.

Participants

304 colorectal cancer survivors between 6 and 60 months post-diagnosis.

Methods

Participants completed a cross-sectional questionnaire, including the Functional Assessment of Therapy–Colorectal Cancer Survey and the Patient Continuity of Care Questionnaire. Multivariate logistic regression analysis was undertaken to identify associations between quality of life outcomes and healthcare-related variables including continuity of care, access to care, information needs and perceptions of support from health and advocacy services.

Results

Most participants (80%) had access to a named healthcare professional and were more frequently satisfied with support received in hospital (95%) compared to primary care (76%) or community (61%) settings. More than two-thirds of participants reported unmet information needs (68%) or social difficulties (66%). 40% reported some dissatisfaction with continuity of care. Greater social difficulty was consistently associated with poorer quality of life in all domains (OR range: 2.9–9.7). Lower satisfaction with continuity of care predicted poorer physical (OR=2.6), social (OR=2.1), functional (OR=2.9) and overall quality of life (OR=2.0). Unmet information needs (OR=2.9) and absence of access to a named nurse (OR=3.8) were associated with lower levels of emotional well-being. Survivors who were living with active malignant disease (OR=3.8), had undergone reversal of a temporary ostomy (OR=4.0) or had accessed advocacy-led cancer support were more likely to experience lower quality of life overall (OR=2.6).

Conclusions

Colorectal cancer survivors relied on oncology professionals for cancer-related support and experienced quality of life issues and unmet needs, which were not addressed by oncology, primary care or advocacy professionals. This study suggests there is scope to optimise the contribution of primary care, community care and advocacy services to cancer survivorship care; these services were often overlooked or provided insufficient support when accessed by survivors. The recurring associations between quality of life outcomes and continuity of care and social difficulties suggest these may be meaningful variables to target in the development of interventions to improve survivors’ quality of life in the context of healthcare.

Section snippets

What is already known about the topic?

  • •

    Fragmentation of follow-up care may exacerbate cancer survivors’ unmet needs and psychological distress.

  • •

    Insufficient continuity of care, informational insecurity and difficulties accessing cancer-related support contribute to survivors’ difficulties with healthcare navigation and may lead to survivors experiencing isolation and a loss of confidence in healthcare providers.

  • •

    While quality of life has been identified as a predictor of continuity of care in primary care-led models of cancer

What this paper adds

  • •

    Healthcare variables are significantly associated with colorectal cancer survivors’ quality of life in multiple domains.

  • •

    Poorer continuity of care, difficulties accessing information and support and greater social difficulty were associated with lower quality of life in several domains.

  • •

    Hospital-based professionals were the most common source of information and support for colorectal cancer survivors.

  • •

    Fewer participants expressed satisfaction with support from primary care and community care

Design and participants

This cross-sectional survey study forms part of The Cost of Survival Study, a sequential explanatory mixed methods study. The point at which one becomes a cancer survivor has been widely debated and varies internationally (Doyle, 2008; Drury et al., 2017; Khan et al., 2012; Leigh, 2007; Mullen, 1985; Reuben, 2004; Rowland et al., 2013). The most consistent and accepted definition of cancer survivorship begins at the point of diagnosis, as the challenges of survivorship persist for the duration

Sample characteristics

Of 404 colorectal cancer survivors invited to participate in the study, 304 questionnaires were returned (response rate=75.6%). Participants were predominantly White Irish, ranging in age from 25 to 96 years (x¯=67.2 years, SD=11.4) and diagnosed on average, 3.1 years prior to participation in the study (SD=1.4) (Table 2). Most were diagnosed with colon cancer (64.1%, n = 191) and had no active disease at the time of the survey (82.9%, n = 228). Almost half held private health insurance (48.3%,

Discussion

This paper suggests that healthcare-related variables are consistently associated with colorectal cancer survivors’ quality of life in all domains of the FACT-C, aligning with the Ashing-Giwa (2005) Contextual Model of Health-Related Quality of Life. The finding that greater social difficulty and absence of private health insurance are associated with poorer quality of life in multiple domains adds to the body of evidence highlighting the relationship between healthcare disparities, greater

Conclusions

This study advances the utility of the Ashing-Giwa (2005) Contextual Model of Health-Related Quality of Life with heterogeneous populations of cancer survivors. This study highlights the potential importance of healthcare experiences for colorectal cancer survivors’ quality of life outcomes. Greater social difficulty, lower satisfaction with continuity of care and health insurance status were the factors most consistently associated with poorer quality of life. While colorectal cancer survivors

Funding

This research was funded by the Health Research Board Research Training Fellowship 2014 (grant number HPF.2014.715). The Health Research Board had no role in the design of the study, the collection, analysis or interpretation of data, nor the writing of this paper.

Conflict of interest

SP and AMB report no conflict of interest. AD's time was funded by the Health Research Board Research Training Fellowship at the School of Nursing and Midwifery Trinity College Dublin. The authors alone are responsible for the content and writing of this paper.

Acknowledgements

The authors would like to thank the physicians, nurses and staff at the colorectal cancer Surgery and Medical Oncology Departments of the participating hospitals, and the voluntary cancer support services who facilitated data collection.

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