Patient Perspectives on Consequences of Resectable Colorectal Cancer Treatment: a Qualitative Study

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Kooten, Bianca A.M. Schutte, Dorine J. Staalduinen, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2427813/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Colorectal cancer is diagnosed in approximately 500,000 patients each year in Europe, leading to a high number of patients having to cope with the consequences of resectable colorectal cancer treatment. As treatment options tend to grow, more information on these treatments’ effects is needed to properly engage in shared decision-making. This study aims to explore the impact of resectable colorectal cancer treatment on patients’ daily life. Methods: Patients (≥18 years) who underwent an oncological colorectal resection between 2018 and 2021 were selected. Purposeful sampling was used to include patients who differ in age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence. Semi-structured interviews were conducted, guided by a topic guide. Interviews were fully transcribed and subsequently thematically analyzed using the framework approach. Analyses were done by using the predefined themes: 1) daily life and activities, 2) psychological functioning, 3) social functioning, 4) sexual functioning and 5) healthcare experiences. Results: Sixteen patients with a follow-up between 0.6 and 4.4 years after surgery were included in this study. Participants reported several challenges they experience due to poor bowel functioning, stoma presence, chemotherapy-induced neuropathy, fear of recurrence and sexual dysfunction, however, they were reported not to interfere much with daily life. Conclusion: Colorectal cancer treatment leads to several challenges and treatment-related health deficits. This is often not recognized by generic patient-reported outcome measures, but the findings on treatment-related health deficits presented in this study, contain valuable insights which might contribute to improving colorectal cancer care, shared decision making and value based healthcare. Colorectal cancer Quality of life Cancer Survivorship Qualitative study Value Based Healthcare Introduction In Europe, colorectal cancer is diagnosed in approximately 500,000 patients each year, leading to a high number of patients that has to live with the consequences of colorectal cancer treatment [ 1 ]. The cornerstone of colorectal cancer treatment is surgical resection, which encompasses invasive and high-risk procedures with a total complication rate of up to 30% and 30-day mortality of about 2% [ 2 – 4 ]. Currently, patient psychological and functional outcomes next to oncological outcomes after resectable colorectal cancer treatment are gaining more interest, due to increased overall survival, improved oncological care and more awareness of the sequelae of cancer survivorship [ 5 , 6 ]. Together with an increasing trend towards shared decision-making, (recurrence-free) survival is not the only important factor taken into account during treatment planning and patient counseling, but also the anticipated quality of life after treatment [ 7 ]. Since this post-treatment quality of life should also be part of the decision-making process regarding treatment options, treatment decisions may be impacted. Therefore, treatment options such as, “watch and wait” after clinical complete response to neoadjuvant therapy may be preferred [ 8 ]. To adequately engage in shared decision-making, information on how surgical treatment of colorectal cancer affects daily life and quality of life after colorectal cancer surgery is essential. Colorectal cancer surgery may lead to a decreased quality of life, as well as decreased daily functioning and decreased physical functioning [ 9 ]. However, a previous study of our group showed that quality of life returns to a level similar to the preoperative level one-year after surgery, which seems paradoxical since various treatment-related health deficits may arise [ 10 ]. Earlier studies have shown that coping mechanisms in patients with malignant diseases might be leading to a relative underestimation of the effect of treatment-related health deficits on patient-reported quality of life [ 11 , 12 ]. Insight into long-term consequences of colorectal cancer treatment for daily life and explicit patient consideration on treatment decisions might positively influence the long-term quality of life and lead to a higher acceptance of possible consequences. Additionally, rehabilitation programs might be more focused on these consequences [ 13 ]. This study aims to explore the impact of resectable colorectal cancer treatment on patients’ daily life. With a qualitative approach more in-depth information on patients’ perspectives might be obtained. The major themes from the cancer-specific European Organization for Research and Treatment of Cancer (EORTC) qlq-C30 questionnaire are studied [ 14 ]. These themes are often affected by colorectal cancer treatment. Furthermore, the findings of this explorative study could expose outcomes with a high burden on patients’ daily life. Ultimately, this information can be used for patient information, shared-decision making and treatment planning. Also, the knowledge gained by this study may provide leads for the optimization of long-term postoperative care and rehabilitation programs in colorectal cancer patients. Methods Setting A purposive sample was retrieved from a cohort of patients who underwent surgery for colorectal cancer between 2018 and 2021 at the Leiden University Medical Center (LUMC), a tertiary teaching hospital in the Netherlands. Purposeful sampling was used to include patients of a different age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence. Participants Patients (≥ 18 years) after curative intended colorectal resection for primary carcinoma were approached during follow-up appointments. To be eligible, participants had to understand and speak Dutch. Patients were included until no further pertinent information and themes were forthcoming from at least three interviews, suggesting that data saturation was reached [ 15 , 16 ]. Ethics approval The Medical Ethics Committee Leiden Den Haag Delft assessed the study protocol for this study (ref. no. N21.168) and concluded that no formal review was needed, as this study was not conducted under the Medical Research Involving Human Subjects Act (WMO). All study participants were given verbal and written information about the study and signed an informed consent form. Semi-structured interviews To learn more about the perspectives of patients towards the effects of oncological colorectal treatment on their daily functioning, a qualitative approach was used [ 17 – 19 ]. For the semi-structured interviews, a topic guide was developed. The topics were based on the cancer- EORTC qlq-C30 questionnaire and an expert-opinion; 1) daily life and activities, 2) psychological functioning, 3) social functioning, 4) sexual functioning and 5) healthcare experiences [ 14 ]. Semi-structured interviews were selected as a method, because it offers flexibility to gather in-depth perspectives and leads to rich thematically-structured narratives with participants [ 18 ]. The interviews were conducted online via Zoom by one investigator, a trained medical doctor involved in surgical oncology (RTK). Analysis The interviews were fully audio-taped and manually transcribed. A theoretical thematic analysis of the transcripts was performed together by two researchers (RTK, BAMS) to identify patterns in the data[ 17 ]. The analysis was done by using the framework approach, and followed the following sequential steps: (1) familiarizing with the data, (2) developing a coding scheme, based on the aforementioned themes, using ATLAS.ti 9, (3) coding of the transcripts, the coding scheme was applied independently by two coders and discussed until an agreement was reached, (4) summarizing the data for data interpretation [ 19 ]. The researchers met regularly and discussed the coding scheme as it developed during data analysis. Results Participants In total, 16 patients participated in this study, 9 were male and ages ranged from 54 to 79, (Table 1 ). Patients were interviewed between 0.6 and 4.4 years after surgery. Six participants had a primary tumor located in the colon and 10 had a rectum-located tumor. Six participants received neo-adjuvant therapy and 3 received adjuvant chemotherapy. A stoma was constructed in 7 participants of which 3 were closed at time of the interview. Major complications, requiring a reoperation, occurred in 6 participants of which 3 experienced an anastomotic leakage. Table 1 – Study participant characteristics. * At time of the interview ID Age* (years) Gender Comorbidities Tumor stage Time since surgery * (years) Type of Surgery Stoma Postoperative complications Reoperation (Neo-) adjuvant therapy P1 69 Male Hypertension, Obesity, Hypercholesteremia cT3bN0/ ypT2N1M0 2.1 Laparoscopic abdominoperineal resection Colostoma Urinary retention No Neo-adjuvant chemotherapy and radiotherapy P2 56 Female Abdominal surgery pT4aN2b 3.5 Laparoscopic sigmoid resection - - No Adjuvant chemotherapy P3 54 Female Orofacial surgery pT3N0 1.1 Laparoscopic low-anterior resection Colostoma Anastomotic leakage, Pulmonary embolism Yes - P4 68 Female - cT2N1M0/ ypT0N0 3.9 Laparoscopic low-anterior resection - - No Neoadjuvant brachytherapy P5 75 Male Diabetes Mellitus type II, Hypertension, Hypercholesterolemia pT3N1b 2.5 Laparoscopic sigmoïd resection - - No Adjuvant chemotherapy P6 69 Female Cataract surgery pT3N0 3.0 Laparoscopic low-anterior resection Colostoma Anastomotic leakage, abdominal abscess, SIADH Yes - P7 57 Male - pT2N1M0 0.7 Laparoscopic hemicolectomy left - - No Adjuvant chemotherapy P8 62 Female COPD, Hypertension pT3N0 4.2 Open transverse colectomy Colostoma (reversed after 1 year) Hemorrhage Yes - P9 77 Male Urolithiasis pT2N0 4.4 Laparoscopic Hemicolectomy right - - No - P10 67 Female Appendectomy pT1N0 3.2 Laparoscopic low-anterior resection - - No - P11 79 Male Nephrectomy, multinodular goiter pT2N0 0.6 Laparoscopic sigmoid resection - - No - P12 74 Male Cystoprostatectomy pT2N1b 0.6 Open abdominoperineal resection Colostoma Small bowel perforation Yes - P13 54 Male - cT3N1/ ypT1N0 3.2 Laparoscopic low-anterior resection - - No Neo-adjuvant chemotherapy and radiotherapy P14 57 Female Hypertension cT3N1/ ypT2N0 3.3 Laparoscopic low-anterior resection - - No Neo-adjuvant radiotherapy P15 70 Male Diabetes Mellitus type II, Hypertension, Peripheral venous insufficiency cT3N1/ ypT3N1c 2.6 Laparoscopic low-anterior resection Ileostoma (reversed after 3 months) Ureter perforation Yes Neo-adjuvant chemotherapy and radiotherapy P16 63 Male Hypertension cT3aN2M0/ ypT2N0 4.2 Laparoscopic low-anterior resection Ileostoma (reversed after 6 months) Anastomotic leakage, Urinary retention Yes Neo-adjuvant chemotherapy and radiotherapy Daily life and activities Multiple participants reported to have poor bowel functioning with increased stool frequencies: “ I have stool at least 10 times a day ” (P16). This influences their daily life, for example their work and their mobility: “ I visit other companies for work and you prefer not to go to the toilet there, but I often have to go ” (P16) and “ When I'm on the road, I always think: am I nearby or can I be at a toilet within ten minutes? ” (P4) and “ Two hours is really the maximum that I can walk, because then I have to go to the toilet. ” (P2) To avoid these unwanted situations, some participants reported that they pay extra attention to their diet: “ When I eat a lot of legumes and herbs, then it gets really wrong. ” (P4) and “ I have to be careful with oil ” (P14). Having a stoma is also reported to present certain challenges in daily life. It took a while for most participants to get used to. In the beginning, they felt unsecure and had several problems, such as uncontrollable flatus and stoma bag leakages. Fortunately, at the time of the interviews, most patients reported to experience almost no stoma-related fecal leakage, but still have a fear of getting a stoma bag leakages. Furthermore, participants reported that they did not want to be dependent on nurses or family “ you can tell me how to do it, because I want to do it myself; I have to accept it and I have to deal with it ” (P3). Participants reported that they learned to cope with a stoma: “ I always say, it never makes you happy, that you have it, but I can deal with it quite well ” (P6) and “ Sometimes I even forget that I have a stoma ” (P1). Additionally, some participants complain about chemotherapy-induced neuropathy in their feet, which greatly influences their ability to walk: “ It's mainly my right foot. Because of that foot I will probably also walk slightly different, which causes problems in my knees and my back ” (P2). Furthermore, chemotherapy-induced neuropathy of the hands is reported not only to cause pain, but also to affect activities in daily life: “ Before I get my hands on small objects, I sometimes have to make multiple attempts, because I don’t feel it well ” (P7). Most participants reported that it took a while before they were fully recovered from surgery “ The surgery itself was not such a problem for me, because I thought: that's part of it, but in the end it took quite a while before I was fully recovered ” (P10). After full recovery most participants reported that not much has changed in daily life: “ In the end nothing has really changed in my daily life ” (P15). Although almost all of the patients face some negative influences of the treatment on their daily lives, in some cases it did positively change their general perspective on life: “ I look at what I can do, there is a solution for everything ” (P4) and “I can still live and be a happy person” (P5). Psychological functioning The interviews showed that colorectal cancer treatment may have an impact on a patient’s psychological functioning. Multiple participants reported that, after colorectal cancer treatment, the fear of cancer recurrence plays a major role in their daily living, “ Once you are diagnosed with rectal cancer, the fear of recurrence is always on the back of your mind ” (P12). Consequently, as part of this fear, participants are more aware of anything they feel within their bodies: “ You are more aware of things you feel, this makes you worry more ” (P8). Also, their confidence in their own body and physical health is sometimes decreased “ When I feel something in my body I keep wondering if this is normal or if I should visit the doctor ” (P2). Not only do participants experience fear towards their own bodies, the follow-up hospital visits are also reported as frightening events: “Every time I have a CT scan or blood test, it is still exciting for me” (P8). Some participants also reported changes in their mindset after the treatment, for instance: participants are more consciously enjoying their lives, are better in dealing with work-related issues and are more aware of their goals in life: “ I do not make a big fuss about some things anymore, for example at work ” (P16) and “ I have more plans, I want to get more out of life now ” (P15). Additionally, participants reported changes in their perspectives towards themselves: “ I have learned a lot about myself, you can do more than you think ” (P6) and “ I am more aware of my own body ” (P8). Furthermore, postoperative complications, such as hemorrhage and anastomotic leakage, have been reported by the participants as influential on their mental health: “ Especially with an emergency reoperation, you are upset for a while. That has had quite a big influence, but it is now going great again ” (P12) and “ I still suffer from flashbacks, for instance when I have to go to the toilet at 2am I remember that was the moment when the bleeding started back then ” (P8). It was also reported that some participants do cope differently with their disease, for example some are hesitant to speak about their colorectal cancer treatment: “ I do not really like to speak about my colon cancer, because I do not feel the need to discuss this with other people, since they always have an ‘irrelevant’ story about someone else with cancer ” (P12). Others say it helps them to talk about it “ I'd like to talk about it because it relieves me ” (P13). Participants with a stoma reported that they are usually open about having a stoma: “ I'm not ashamed of it at all, but I don't want to confront people with it ” (P1). Social functioning A few participants reported that the diagnoses of colorectal cancer and treatment had no influence on their social functioning: “ Actually, little has changed in that respect ” (P4). Some participants report that they felt supported: “ You discover how many dear friends and people you have around you ” (P2) and “ I knew he would always be there for me. He did a fantastic job ” (P8). Some relationships were deepened seeing another side of each other “ The bond with my children has definitely deepened after treatment ” (P6), and some reported that this was even more with people who also had to deal with cancer: “ They know a bit more about what I went through, than people who have never had to deal with it ” (P13). Stoma may lead to specific challenges, as participants with a stoma reported that the fear of stoma-related stool leakage or uncontrollable flatulence does influence social functioning “ During social appointments I am sometimes afraid that the stoma will leak, then you are not relaxed ” (P3). Sexual functioning Participants, male and female, reported several challenges regarding sexual functioning as a consequence of their colorectal cancer treatment, while some were not sexually active anymore. Erectile dysfunction and being unable to ejaculate was reported as a major issue “I do not get a good erection anymore and ejaculation is not possible at all. I do have medication for this, but it is not the same as it was before surgery” (P1). As medication for erectile dysfunction might offer some solution, several participants reported that the loss of the ability to spontaneously engage in sexual activities is a burden on their sexual functioning. Furthermore, bowel functioning might interfere with sexual functioning “ I am a bit more hesitant, because I am afraid of losing stool ” (P10), along these lines a stoma might have a negative impact as well “ In the beginning, the stoma frightened us ” (P8). Abdominal scars after laparotomy is also reported to be of influence on sexual functioning. When issues arise, participants stated that talking about this with their partners was very helpful “ We talk well about sexuality, therefore it has not become a problem ” (P15). Contrastingly, some other participants do report not to experience any difficulties or changes regarding sexuality: “ nothing really changed ” (P7). Healthcare and treatment experiences Participants reported several factors which they consider as important during colorectal cancer treatment, and which might impact daily life during treatment, and follow-up. Good explanation about the surgical treatment and perioperative care is reported as very important: “ The explanations by the doctors about the surgery were good, luckily because I like to know everything ” (P3), “ Whenever I had a question it was answered ” (P7) and “ Before surgery, I knew what was going to happen and the possible consequences ” (P11). Additionally, involvement and openness of medical personal was reported as important: “ You can call the stoma nurses at any time to solve some issues that might occur ” (P1) and “ The enormous concern and dedication of the surgeon helped me a lot and felt very supportive ” (P6). Others reported to find it difficult to find answers to their questions: “ I would like to know if the symptoms I experience are normal ” (P9). Conversely, also negative experiences regarding doctor-patient communication after complications have been reported: “ The surgeon who operated on me the first time never spoke to me after the complication, which I thought was a pity ” (P16). Furthermore, the way of communication might affect patient-doctor communication: “ Due to COVID-19 most of the appointments were by phone, therefore you cannot really discuss all your questions ” (P2). Waiting on results is reported as a factor on mental health: “ I have been waiting for 3 months on the results of genetic tests, which was quite long which bothered me ” (P2). Other negative factors that have been reported were: “ Usually I can sleep anywhere, but in the hospital, it was very bad ” (P12) and “ I had a pulmonary embolism which was detected quite late, this was a pity because, in hindsight, as I understood the symptoms were very clear ” (P3). Discussion This study aimed to explore and gain insights into patient perspectives on the consequences of colorectal cancer treatment for their daily life. Health deficits as consequence of colorectal cancer treatment that were reported were poor bowel functioning, the presence of a stoma, chemotherapy-induced neuropathy of hands and feet due to chemotherapy, sexual dysfunction and fear of recurrence. Poor bowel functioning impacted daily life and activities, since patients reported to use the bathroom more frequently and had to pay more attention to their diet. Whereas, patients with a stoma reported to be afraid of stoma-related fecal leakage and uncontrollable flatus from their stoma in social situations. Patients who suffered from chemotherapy-induced neuropathy in hands and feet reported altered sensory functioning and pain during activities. Sexual dysfunction is reported to be a result of erectile function loss or ejaculation function loss. Also, the presence of a stoma or abdominal scars affected sexual functioning. Some patients reported to have an increased fear of recurrence when their follow-up appointment is coming up, and some reported that they trust their body less than before the diagnosis. Furthermore, social functioning is rarely affected. Also, coping style mechanisms seem to be different between patients: some patients do feel the need to talk about their situation, whereas others prefer not to speak about their colorectal cancer. However, overall, patients reported that daily life remains fairly unaffected by colorectal cancer treatment, since patients experience only minor interference with daily life. These findings suggest that various coping mechanisms are in place. As witnessed from a prior conducted study by our group, patients report that over time their quality of life seems to be returning to preoperative levels, suggesting that they face no or minor challenges or treatment-related health deficits [ 10 ]. However, as also shown in the current study and other literature, patients who underwent colorectal cancer treatment may still experience various challenges and health deficits. These challenges and health deficits differ based on the treatment they received [ 20 – 23 ]. The findings of this study suggest that most challenges that are frequently reported after colorectal surgery are bowel related. The functional bowel complaints which these patients reported, were similar to the ones that are described in literature as low-anterior resection syndrome (LARS). However, the LARS-score was not formally determined in this study [ 24 , 25 ]. It has been shown that quality of life in patients reporting LARS is significantly impaired [ 26 , 27 ]. Still, patients with a stoma also reported specific stoma-related challenges, such as worrying about stool leakages and uncontrollable flatulence, which is consistent with previous literature [ 28 ]. In line with a prior study, postoperative complications can in some cases affect the doctor-patient relationship. This urges, amongst other reasons, preoperative counseling of patients with information of the risks of surgery [ 29 ]. A noticeable complaint that was frequently reported by patients in our study that underwent (neo-)adjuvant chemotherapy, was peripheral neuropathy. In accordance with existing literature, patients reported that symptoms decrease over time, but a large proportion of patients keeps experiencing complaints [ 30 – 32 ]. These complaints of chemotherapy-induced peripheral neuropathy do, however, not affect global health status, but impair physical- and role functioning [ 31 ]. Another domain that is reported to be affected in this study, and in accordance with literature, is sexual functioning, which may be decreased as a result of colorectal cancer treatment [ 22 ]. As previously studied, sexual dysfunction may be caused by both surgery and radiotherapy. Additionally, the presence of a stoma is also described to negatively affect sexual activity in this study as well as in previous research [ 33 – 35 ]. Furthermore, previous studies have shown that coping strategies, to cope with treatment-related health deficits and challenges, differ between patients. This is similar to what was witnessed under the psychological functioning theme in this study [ 36 ]. Previous studies in both patients with ovarian carcinoma and colorectal carcinoma showed that patient may have various coping strategies, and that coping might even be enhanced as result of cancer survivorship [ 11 , 12 , 37 ]. The coping style that is used by patients might explain the underestimation of the effect of treatment-related health deficits (e.g., poor bowel function, chemotherapy-induced neuropathy) on quality of life, since patients are able to live a modified life with the use of various strategies and self-management techniques to maintain their quality of life [ 38 ]. Additionally, there is considerable individual variation between patients on how these self-management strategies are undertaken [ 39 ]. The knowledge acquired by this study on challenges that patients face after treatment could be taken in to account by making treatment decisions and by implementation of new treatment strategies [ 40 , 41 ].For example, recently, studies have reported a complete mesocolic excision as a new surgical technique for right-sided colon cancer, which entails a more extensive procedure to ensure adequate lymphatic resection [ 42 ]. While an alternative strategy might be to make the colonic resection more precise and potentially less extensive by performing a sentinel node procedure instead of a complete mesocolic excision [ 43 ]. In theory, a less extensive resection might lead to a lower rate of postoperative complications and better functional bowel outcome [ 44 ]. Additionally, in case multiple treatment options exist, information on postoperative consequences of the treatment on quality of life and the associated treatment-related health deficits may entail important information for patients during shared decision-making. Furthermore, as shown in this study, some patients reported that good preoperative education on the consequences of colorectal cancer treatment is important to them. Explicit patient consideration of their treatment and certain trade-offs are shown to have a positive effect on long-term quality of life, as it leads to increased acceptance of treatments’ consequences [ 13 , 26 ]. As shown in this study, after colorectal cancer treatment, patients may face various treatment-related health deficits in various domains (e.g., psychological, social, physical) [ 20 ]. In addition, these patients have an increased risk of other health issues, such as adverse effects of treatments and psychosocial challenges [ 45 , 46 ]. Therefore, optimizing post-treatment psychological-, sexual-, nutritional-, and cognitive functioning of colorectal cancer survivors could be an integral part of rehabilitation programs. However, some treatment-related health deficits may not be treatable, reliable outcome data on these sequelae may render important knowledge to incorporate in preoperative patient education and in shared decision-making. Value based-health care The insights of this study are important in light of the newly introduced management strategy value-based healthcare (VBHC). An important element of VBHC is measuring outcomes and costs for every patient [ 47 , 48 ]. To measure patient outcomes uniformly, a standard set of patient-centered outcomes was developed by The International Consortium for Health Outcomes Measurement (ICHOM), including survival and disease control, disutility of care, degree of health, and quality of death [ 49 ]. Using both generic and disease-specific questionnaires. Trying to streamline implementation of the patient-reported outcome measurements, some have suggested only to use generic quality of life assessment strategies. However, this study shows that one must be cautious in only using these generic patient-reported outcome sets and quality of life questionnaires, since these might give a too limited image of the actual quality of life of a patient. As this study shows, colorectal cancer patients might still experience challenges and treatment-induced health deficits, [ 37 , 50 ]. Strengths and limitations First, in this study, differences in complaints were witnessed between sub-groups. However, to study significant differences between sub-groups, a quantitative study design is more applicable. Despite this, this study gives valuable insights into the quality of life and influential factors on daily life after colorectal cancer treatment. A strength of this study is, due to the qualitative approach of this study, complementary and more in-depth insights are gathered that add to previous quantitative studies [ 51 ]. Second, this was a single-center study in an academic teaching hospital with relatively advanced/complex cases, which might affect the generalizability. To overcome this issue, purposeful sampling was used to include patients with a different age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence, therefore patient characteristics and complication rates are not representable for the general population. Third, interviews were held online and via Zoom, since interviews were partly conducted during the COVID-19 pandemic. This might have influenced the quality of the conversations with the participants. However, Shapka et al. showed no differences in quality between face-to-face and online conducted interviews [ 52 ]. Therefore, we expect that our method of interviewing did not majorly affect our results. Last, the sample size in this study is small, but data saturation was reached. This means that no more forthcoming information or themes were gained in the last three interviews, as described by Hennink et al [ 16 ]. Conclusion In conclusion, this explorative study shows that patients who underwent treatment for resectable colorectal cancer, face several challenges and treatment-related health deficits in the long-term, but that these challenges and health deficits lead to only minor interference with daily life. The reported minor interference might suggest coping mechanisms are in place. Frequently reported health deficits after colorectal cancer treatment are the presence of a stoma, poor bowel function, chemotherapy-induced neuropathy, fear of tumor recurrence and sexual dysfunction. The results of this study offer in-depth insights into patient perspectives on the consequences of colorectal cancer treatment. These insights are important in appreciation of generic quality of life questionnaires, in which post-treatment health deficits may be less clearly noticeable and therefore may be underestimated. Abbreviations EORTC; European Organization for Research and Treatment of Cancer, ICHOM; International Consortium for Health Outcomes Measurement, LARS; Low-Anterior Resection Syndrome, VHBC; Value-Based Health Care Declarations ACKNOWLEDGEMENTS This study was supported by the Leiden University Medical Center (LUMC). Authors declare no conflict of interest. Special thanks are due to all the participants who have taken part in this study. FUNDING DECLARATION The authors received no financial support for the research, authorship, and/or publication of this article. CONFLICT OF INTEREST STATEMENT Authors declare no conflict of interest. AUTHOR’S CONTRIBUTIONS Study design : Robert T. van Kooten, Jetty H.L. Hoeksema, Rob A.E.M. Tollenaar, Michel W.J.M. Wouters, Koen C.M.J. Peeters Data acquisition : Robert T. van Kooten, Fabian A. Holman, Chantal van Dorp, Koen C.M.J. Peeters Quality control of data : Robert T. van Kooten, Bianca A.M. Schutte, Rob A.E.M. Tollenaar, Michel W.J.M. Wouters Data analysis and interpretation : Robert T. van Kooten, Bianca A.M. Schutte, Dorine J. van Staalduinen Manuscript preparation : Robert T. van Kooten, Bianca A.M. Schutte, Dorine J. van Staalduinen Manuscript editing : Robert T. van Kooten, Bianca A.M. Schutte, Dorine J. van Staalduinen Manuscript review : Jetty H.L. Hoeksema, Fabian A. Holman, Chantal van Dorp, Koen C.M.J. Peeters, Rob A.E.M. Tollenaar, Michel W.J.M. 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Qual Health Res, 2017. 27 (4): p. 591-608. Mays, N. and C. Pope, Quality in Qualitative Health Research , in Qualitative Research in Health Care . 2006. p. 82-101. Pope, C., S. Ziebland, and N. Mays, Qualitative research in health care. Analysing qualitative data. BMJ (Clinical research ed.), 2000. 320 (7227): p. 114-116. Pope, C., S. Ziebland, and N. Mays, Analysing Qualitative Data , in Qualitative Research in Health Care . 2006. p. 63-81. Arndt, V., et al., Quality of life in long-term and very long-term cancer survivors versus population controls in Germany. Acta Oncol, 2017. 56 (2): p. 190-197. Monastyrska, E., et al., Prospective assessment of the quality of life in patients treated surgically for rectal cancer with lower anterior resection and abdominoperineal resection. Eur J Surg Oncol, 2016. 42 (11): p. 1647-1653. Schmidt, C.E., et al., Ten-year historic cohort of quality of life and sexuality in patients with rectal cancer. Dis Colon Rectum, 2005. 48 (3): p. 483-92. Lim, C.Y.S., et al., The long haul: Lived experiences of survivors following different treatments for advanced colorectal cancer: A qualitative study. Eur J Oncol Nurs, 2022. 58 : p. 102123. Bryant, C.L., et al., Anterior resection syndrome. Lancet Oncol, 2012. 13 (9): p. e403-8. Keane, C., et al., International Consensus Definition of Low Anterior Resection Syndrome. Dis Colon Rectum, 2020. 63 (3): p. 274-284. Algie, J.P.A., et al., Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life. International Journal of Colorectal Disease, 2022. Pieniowski, E.H.A., et al., Low Anterior Resection Syndrome and Quality of Life After Sphincter-Sparing Rectal Cancer Surgery: A Long-term Longitudinal Follow-up. Dis Colon Rectum, 2019. 62 (1): p. 14-20. Vonk-Klaassen, S.M., et al., Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res, 2016. 25 (1): p. 125-33. Di Cristofaro, L., et al., Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship. Colorectal Dis, 2014. 16 (12): p. O407-19. Teng, C., et al., Systematic review of long-term chemotherapy-induced peripheral neuropathy (CIPN) following adjuvant oxaliplatin for colorectal cancer. Support Care Cancer, 2022. 30 (1): p. 33-47. Soveri, L.M., et al., Long-term neuropathy and quality of life in colorectal cancer patients treated with oxaliplatin containing adjuvant chemotherapy. Acta Oncol, 2019. 58 (4): p. 398-406. Wu, C.J., et al., Peripheral Neuropathy: Comparison of Symptoms and Severity Between Colorectal Cancer Survivors and Patients With Diabetes. Clin J Oncol Nurs, 2021. 25 (4): p. 395-403. Anaraki, F., et al., Quality of life outcomes in patients living with stoma. Indian J Palliat Care, 2012. 18 (3): p. 176-80. Lange, M.M., et al., Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer, 2009. 45 (9): p. 1578-88. Stephens, R.J., et al., Impact of short-course preoperative radiotherapy for rectal cancer on patients' quality of life: data from the Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 randomized clinical trial. J Clin Oncol, 2010. 28 (27): p. 4233-9. Lim, C.Y.S., et al., Fear of Cancer Progression and Death Anxiety in Survivors of Advanced Colorectal Cancer: A Qualitative Study Exploring Coping Strategies and Quality of Life. Omega (Westport), 2022: p. 302228221121493. Chirico, A., et al., A meta-analytic review of the relationship of cancer coping self-efficacy with distress and quality of life. Oncotarget, 2017. 8 (22): p. 36800-36811. Schulman-Green, D., et al., Processes of self-management in chronic illness. J Nurs Scholarsh, 2012. 44 (2): p. 136-44. Livneh, H. and R.F. Antonak. Psychosocial adaptation to chronic illness and disability . Aspen Publishers 1997. Stiggelbout, A.M., et al., Shared decision making: really putting patients at the centre of healthcare. Bmj, 2012. 344 : p. e256. Hirpara, D.H., et al., Understanding the complexities of shared decision-making in cancer: a qualitative study of the perspectives of patients undergoing colorectal surgery. Can J Surg, 2016. 59 (3): p. 197-204. Hohenberger, W., et al., Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome. Colorectal Disease, 2009. 11 (4): p. 354-364. Staniloaie, D., et al., In Vivo Sentinel Lymph Node Detection with Indocyanine Green in Colorectal Cancer. Maedica (Bucur), 2022. 17 (2): p. 264-270. Benz, S.R., et al., Complete mesocolic excision for right colonic cancer: prospective multicentre study. Br J Surg, 2022. Dal Maso, L., et al., Cancer Cure and Consequences on Survivorship Care: Position Paper from the Italian Alliance Against Cancer (ACC) Survivorship Care Working Group. Cancer Manag Res, 2022. 14 : p. 3105-3118. Shapiro, C.L., Cancer Survivorship. N Engl J Med, 2018. 379 (25): p. 2438-2450. M.E. Porter, E.O.T., Redefining Health Care . 2006: Harvard Business School Press. Massa, I., et al., Emilia-Romagna Surgical Colorectal Cancer Audit (ESCA): a value-based healthcare retro-prospective study to measure and improve the quality of surgical care in colorectal cancer. Int J Colorectal Dis, 2022. 37 (7): p. 1727-1738. Zerillo, J.A., et al., An International Collaborative Standardizing a Comprehensive Patient-Centered Outcomes Measurement Set for Colorectal Cancer. JAMA Oncol, 2017. 3 (5): p. 686-694. Macía, P., et al., Expression of resilience, coping and quality of life in people with cancer. PLoS One, 2020. 15 (7): p. e0236572. Allan, G., Qualitative research , in Handbook for research students in the social sciences . 2020, Routledge. p. 177-189. Shapka, J.D., et al., Online versus in-person interviews with adolescents: An exploration of data equivalence. Computers in Human Behavior, 2016. 58 : p. 361-367. Additional Declarations No competing interests reported. Supplementary Files SRQRReportingchecklistIJCD.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2427813","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":164425928,"identity":"6d712e0d-d8c8-4430-97bd-41118986d716","order_by":0,"name":"Robert T. Kooten","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDADCQhlIwOhC/CpZYZrYWxgYEjjgXANiNdymLAW8wb+A8w8NXcYJNubjz/4uOM8j8G1ww+YC/BokTnAzMDMc+wZgzTPscTGmWdu8xjcTjNgnoFHiwTQYYwz2A4zyEnkGDbztoG05AANIajlH1TL37ZzxGlh+Nh2mEEapIWx7QARWpiZDQ587DvMINlzLHFmb1syjyTQL4fxamFvfPgg4dthBonjzQc+/Gyzk+O7nfzwMU8Fbi0gdx0AUvUNyIIH8GgYBaNgFIyCUUAEAADcFEYxqVVWIAAAAABJRU5ErkJggg==","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Robert","middleName":"T.","lastName":"Kooten","suffix":""},{"id":164425929,"identity":"4f4744af-fcf4-41ac-9bf9-7d29c440a543","order_by":1,"name":"Bianca A.M. 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Holman","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"A.","lastName":"Holman","suffix":""},{"id":164425933,"identity":"a05ad121-a256-4985-ae61-991a54d62a6a","order_by":5,"name":"Chantal Dorp","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Chantal","middleName":"","lastName":"Dorp","suffix":""},{"id":164425934,"identity":"27cc9687-3ec9-461d-b6e6-a45685770dfb","order_by":6,"name":"Koen C.M.J. Peeters","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Koen","middleName":"C.M.J.","lastName":"Peeters","suffix":""},{"id":164425935,"identity":"117cd763-9a67-4432-8537-591d652c2584","order_by":7,"name":"Rob A.E.M. Tollenaar","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Rob","middleName":"A.E.M.","lastName":"Tollenaar","suffix":""},{"id":164425936,"identity":"063c17aa-4604-47c8-9ace-a85bf75422bf","order_by":8,"name":"Michel W.J.M. Wouters","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Michel","middleName":"W.J.M.","lastName":"Wouters","suffix":""}],"badges":[],"createdAt":"2022-12-30 08:59:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2427813/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2427813/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":31271868,"identity":"8174b75c-077b-4858-bde9-72150aae2fad","added_by":"auto","created_at":"2023-01-08 13:29:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":402588,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2427813/v1/d809b044-fd93-4ecc-afef-d35b3652304f.pdf"},{"id":31240136,"identity":"b8c971e1-2bbf-41e5-b479-cfe7e4f19a7c","added_by":"auto","created_at":"2023-01-06 20:33:19","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":38856,"visible":true,"origin":"","legend":"","description":"","filename":"SRQRReportingchecklistIJCD.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2427813/v1/a1c01af7b477134d116ee54e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Perspectives on Consequences of Resectable Colorectal Cancer Treatment: a Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn Europe, colorectal cancer is diagnosed in approximately 500,000 patients each year, leading to a high number of patients that has to live with the consequences of colorectal cancer treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The cornerstone of colorectal cancer treatment is surgical resection, which encompasses invasive and high-risk procedures with a total complication rate of up to 30% and 30-day mortality of about 2% [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Currently, patient psychological and functional outcomes next to oncological outcomes after resectable colorectal cancer treatment are gaining more interest, due to increased overall survival, improved oncological care and more awareness of the sequelae of cancer survivorship [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Together with an increasing trend towards shared decision-making, (recurrence-free) survival is not the only important factor taken into account during treatment planning and patient counseling, but also the anticipated quality of life after treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Since this post-treatment quality of life should also be part of the decision-making process regarding treatment options, treatment decisions may be impacted. Therefore, treatment options such as, “watch and wait” after clinical complete response to neoadjuvant therapy may be preferred [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To adequately engage in shared decision-making, information on how surgical treatment of colorectal cancer affects daily life and quality of life after colorectal cancer surgery is essential. Colorectal cancer surgery may lead to a decreased quality of life, as well as decreased daily functioning and decreased physical functioning [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, a previous study of our group showed that quality of life returns to a level similar to the preoperative level one-year after surgery, which seems paradoxical since various treatment-related health deficits may arise [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarlier studies have shown that coping mechanisms in patients with malignant diseases might be leading to a relative underestimation of the effect of treatment-related health deficits on patient-reported quality of life [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Insight into long-term consequences of colorectal cancer treatment for daily life and explicit patient consideration on treatment decisions might positively influence the long-term quality of life and lead to a higher acceptance of possible consequences. Additionally, rehabilitation programs might be more focused on these consequences [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to explore the impact of resectable colorectal cancer treatment on patients’ daily life. With a qualitative approach more in-depth information on patients’ perspectives might be obtained. The major themes from the cancer-specific European Organization for Research and Treatment of Cancer (EORTC) qlq-C30 questionnaire are studied [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These themes are often affected by colorectal cancer treatment. Furthermore, the findings of this explorative study could expose outcomes with a high burden on patients’ daily life. Ultimately, this information can be used for patient information, shared-decision making and treatment planning. Also, the knowledge gained by this study may provide leads for the optimization of long-term postoperative care and rehabilitation programs in colorectal cancer patients.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003cdiv id=\"Sec3\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eSetting\u003c/h2\u003e\u003cp\u003eA purposive sample was retrieved from a cohort of patients who underwent surgery for colorectal cancer between 2018 and 2021 at the Leiden University Medical Center (LUMC), a tertiary teaching hospital in the Netherlands. Purposeful sampling was used to include patients of a different age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence.\u003c/p\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003ePatients (≥ 18 years) after curative intended colorectal resection for primary carcinoma were approached during follow-up appointments. To be eligible, participants had to understand and speak Dutch. Patients were included until no further pertinent information and themes were forthcoming from at least three interviews, suggesting that data saturation was reached [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003e The Medical Ethics Committee Leiden Den Haag Delft assessed the study protocol for this study (ref. no. N21.168) and concluded that no formal review was needed, as this study was not conducted under the Medical Research Involving Human Subjects Act (WMO). All study participants were given verbal and written information about the study and signed an informed consent form.\u003c/p\u003e\u003ch2\u003eSemi-structured interviews\u003c/h2\u003e\u003cp\u003eTo learn more about the perspectives of patients towards the effects of oncological colorectal treatment on their daily functioning, a qualitative approach was used [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e–\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For the semi-structured interviews, a topic guide was developed. The topics were based on the cancer- EORTC qlq-C30 questionnaire and an expert-opinion; 1) daily life and activities, 2) psychological functioning, 3) social functioning, 4) sexual functioning and 5) healthcare experiences [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Semi-structured interviews were selected as a method, because it offers flexibility to gather in-depth perspectives and leads to rich thematically-structured narratives with participants [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The interviews were conducted online via Zoom by one investigator, a trained medical doctor involved in surgical oncology (RTK).\u003c/p\u003e\u003ch2\u003eAnalysis\u003c/h2\u003e\u003cp\u003eThe interviews were fully audio-taped and manually transcribed. A theoretical thematic analysis of the transcripts was performed together by two researchers (RTK, BAMS) to identify patterns in the data[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The analysis was done by using the framework approach, and followed the following sequential steps: (1) familiarizing with the data, (2) developing a coding scheme, based on the aforementioned themes, using ATLAS.ti 9, (3) coding of the transcripts, the coding scheme was applied independently by two coders and discussed until an agreement was reached, (4) summarizing the data for data interpretation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The researchers met regularly and discussed the coding scheme as it developed during data analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eIn total, 16 patients participated in this study, 9 were male and ages ranged from 54 to 79, (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were interviewed between 0.6 and 4.4 years after surgery. Six participants had a primary tumor located in the colon and 10 had a rectum-located tumor. Six participants received neo-adjuvant therapy and 3 received adjuvant chemotherapy. A stoma was constructed in 7 participants of which 3 were closed at time of the interview. Major complications, requiring a reoperation, occurred in 6 participants of which 3 experienced an anastomotic leakage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e Study participant characteristics. * At time of the interview\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge*\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTumor stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime since surgery * (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eType of Surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(Neo-) adjuvant therapy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHypertension, Obesity, Hypercholesteremia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT3bN0/\u003c/p\u003e \u003cp\u003eypT2N1M0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic abdominoperineal resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColostoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeo-adjuvant chemotherapy and radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbdominal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT4aN2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic sigmoid resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrofacial surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT3N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColostoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnastomotic leakage, Pulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT2N1M0/\u003c/p\u003e \u003cp\u003eypT0N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeoadjuvant brachytherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiabetes Mellitus type II, Hypertension, Hypercholesterolemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT3N1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic sigmo\u0026iuml;d resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCataract surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT3N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColostoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnastomotic leakage, abdominal abscess, SIADH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT2N1M0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic hemicolectomy left\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCOPD, Hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT3N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOpen transverse colectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColostoma (reversed after 1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUrolithiasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT2N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic Hemicolectomy right\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAppendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT1N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNephrectomy, multinodular goiter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT2N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic sigmoid resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCystoprostatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epT2N1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOpen abdominoperineal resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColostoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSmall bowel perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT3N1/\u003c/p\u003e \u003cp\u003eypT1N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeo-adjuvant chemotherapy and radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT3N1/ ypT2N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeo-adjuvant radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiabetes Mellitus type II, Hypertension, Peripheral venous insufficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT3N1/\u003c/p\u003e \u003cp\u003eypT3N1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIleostoma (reversed after 3 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUreter perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeo-adjuvant chemotherapy and radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecT3aN2M0/\u003c/p\u003e \u003cp\u003eypT2N0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLaparoscopic low-anterior resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIleostoma (reversed after 6 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnastomotic leakage, Urinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNeo-adjuvant chemotherapy and radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eDaily life and activities\u003c/h2\u003e \u003cp\u003eMultiple participants reported to have poor bowel functioning with increased stool frequencies: \u0026ldquo;\u003cem\u003eI have stool at least 10 times a day\u003c/em\u003e\u0026rdquo; (P16). This influences their daily life, for example their work and their mobility: \u0026ldquo;\u003cem\u003eI visit other companies for work and you prefer not to go to the toilet there, but I often have to go\u003c/em\u003e\u0026rdquo; (P16) and \u0026ldquo;\u003cem\u003eWhen I'm on the road, I always think: am I nearby or can I be at a toilet within ten minutes?\u003c/em\u003e\u0026rdquo; (P4) and \u0026ldquo;\u003cem\u003eTwo hours is really the maximum that I can walk, because then I have to go to the toilet.\u003c/em\u003e\u0026rdquo; (P2) To avoid these unwanted situations, some participants reported that they pay extra attention to their diet: \u0026ldquo;\u003cem\u003eWhen I eat a lot of legumes and herbs, then it gets really wrong.\u003c/em\u003e\u0026rdquo; (P4) and \u0026ldquo;\u003cem\u003eI have to be careful with oil\u003c/em\u003e\u0026rdquo; (P14).\u003c/p\u003e \u003cp\u003eHaving a stoma is also reported to present certain challenges in daily life. It took a while for most participants to get used to. In the beginning, they felt unsecure and had several problems, such as uncontrollable flatus and stoma bag leakages. Fortunately, at the time of the interviews, most patients reported to experience almost no stoma-related fecal leakage, but still have a fear of getting a stoma bag leakages. Furthermore, participants reported that they did not want to be dependent on nurses or family \u0026ldquo;\u003cem\u003eyou can tell me how to do it, because I want to do it myself; I have to accept it and I have to deal with it\u003c/em\u003e\u0026rdquo; (P3). Participants reported that they learned to cope with a stoma: \u0026ldquo;\u003cem\u003eI always say, it never makes you happy, that you have it, but I can deal with it quite well\u003c/em\u003e\u0026rdquo; (P6) and \u0026ldquo;\u003cem\u003eSometimes I even forget that I have a stoma\u003c/em\u003e\u0026rdquo; (P1).\u003c/p\u003e \u003cp\u003eAdditionally, some participants complain about chemotherapy-induced neuropathy in their feet, which greatly influences their ability to walk: \u0026ldquo;\u003cem\u003eIt's mainly my right foot. Because of that foot I will probably also walk slightly different, which causes problems in my knees and my back\u003c/em\u003e\u0026rdquo; (P2). Furthermore, chemotherapy-induced neuropathy of the hands is reported not only to cause pain, but also to affect activities in daily life: \u0026ldquo;\u003cem\u003eBefore I get my hands on small objects, I sometimes have to make multiple attempts, because I don\u0026rsquo;t feel it well\u003c/em\u003e\u0026rdquo; (P7).\u003c/p\u003e \u003cp\u003eMost participants reported that it took a while before they were fully recovered from surgery \u0026ldquo;\u003cem\u003eThe surgery itself was not such a problem for me, because I thought: that's part of it, but in the end it took quite a while before I was fully recovered\u003c/em\u003e\u0026rdquo; (P10). After full recovery most participants reported that not much has changed in daily life: \u0026ldquo;\u003cem\u003eIn the end nothing has really changed in my daily life\u003c/em\u003e\u0026rdquo; (P15). Although almost all of the patients face some negative influences of the treatment on their daily lives, in some cases it did positively change their general perspective on life: \u0026ldquo;\u003cem\u003eI look at what I can do, there is a solution for everything\u003c/em\u003e\u0026rdquo; (P4) and \u003cem\u003e\u0026ldquo;I can still live and be a happy person\u0026rdquo;\u003c/em\u003e (P5).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003ePsychological functioning\u003c/h2\u003e \u003cp\u003eThe interviews showed that colorectal cancer treatment may have an impact on a patient\u0026rsquo;s psychological functioning. Multiple participants reported that, after colorectal cancer treatment, the fear of cancer recurrence plays a major role in their daily living, \u0026ldquo;\u003cem\u003eOnce you are diagnosed with rectal cancer, the fear of recurrence is always on the back of your mind\u003c/em\u003e\u0026rdquo; (P12). Consequently, as part of this fear, participants are more aware of anything they feel within their bodies: \u0026ldquo;\u003cem\u003eYou are more aware of things you feel, this makes you worry more\u003c/em\u003e\u0026rdquo; (P8). Also, their confidence in their own body and physical health is sometimes decreased \u0026ldquo;\u003cem\u003eWhen I feel something in my body I keep wondering if this is normal or if I should visit the doctor\u003c/em\u003e\u0026rdquo; (P2). Not only do participants experience fear towards their own bodies, the follow-up hospital visits are also reported as frightening events: \u003cem\u003e\u0026ldquo;Every time I have a CT scan or blood test, it is still exciting for me\u0026rdquo;\u003c/em\u003e (P8).\u003c/p\u003e \u003cp\u003eSome participants also reported changes in their mindset after the treatment, for instance: participants are more consciously enjoying their lives, are better in dealing with work-related issues and are more aware of their goals in life: \u0026ldquo;\u003cem\u003eI do not make a big fuss about some things anymore, for example at work\u003c/em\u003e\u0026rdquo; (P16) and \u0026ldquo;\u003cem\u003eI have more plans, I want to get more out of life now\u003c/em\u003e\u0026rdquo; (P15). Additionally, participants reported changes in their perspectives towards themselves: \u0026ldquo;\u003cem\u003eI have learned a lot about myself, you can do more than you think\u003c/em\u003e\u0026rdquo; (P6) and \u0026ldquo;\u003cem\u003eI am more aware of my own body\u003c/em\u003e\u0026rdquo; (P8).\u003c/p\u003e \u003cp\u003eFurthermore, postoperative complications, such as hemorrhage and anastomotic leakage, have been reported by the participants as influential on their mental health: \u0026ldquo;\u003cem\u003eEspecially with an emergency reoperation, you are upset for a while. That has had quite a big influence, but it is now going great again\u003c/em\u003e\u0026rdquo; (P12) and \u0026ldquo;\u003cem\u003eI still suffer from flashbacks, for instance when I have to go to the toilet at 2am I remember that was the moment when the bleeding started back then\u003c/em\u003e\u0026rdquo; (P8).\u003c/p\u003e \u003cp\u003eIt was also reported that some participants do cope differently with their disease, for example some are hesitant to speak about their colorectal cancer treatment: \u0026ldquo;\u003cem\u003eI do not really like to speak about my colon cancer, because I do not feel the need to discuss this with other people, since they always have an \u0026lsquo;irrelevant\u0026rsquo; story about someone else with cancer\u003c/em\u003e\u0026rdquo; (P12). Others say it helps them to talk about it \u0026ldquo;\u003cem\u003eI'd like to talk about it because it relieves me\u003c/em\u003e\u0026rdquo; (P13). Participants with a stoma reported that they are usually open about having a stoma: \u0026ldquo;\u003cem\u003eI'm not ashamed of it at all, but I don't want to confront people with it\u003c/em\u003e\u0026rdquo; (P1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eSocial functioning\u003c/h2\u003e \u003cp\u003eA few participants reported that the diagnoses of colorectal cancer and treatment had no influence on their social functioning: \u0026ldquo;\u003cem\u003eActually, little has changed in that respect\u003c/em\u003e\u0026rdquo; (P4). Some participants report that they felt supported: \u0026ldquo;\u003cem\u003eYou discover how many dear friends and people you have around you\u003c/em\u003e\u0026rdquo; (P2) and \u0026ldquo;\u003cem\u003eI knew he would always be there for me. He did a fantastic job\u003c/em\u003e\u0026rdquo; (P8). Some relationships were deepened seeing another side of each other \u0026ldquo;\u003cem\u003eThe bond with my children has definitely deepened after treatment\u003c/em\u003e\u0026rdquo; (P6), and some reported that this was even more with people who also had to deal with cancer: \u0026ldquo;\u003cem\u003eThey know a bit more about what I went through, than people who have never had to deal with it\u003c/em\u003e\u0026rdquo; (P13).\u003c/p\u003e \u003cp\u003eStoma may lead to specific challenges, as participants with a stoma reported that the fear of stoma-related stool leakage or uncontrollable flatulence does influence social functioning \u0026ldquo;\u003cem\u003eDuring social appointments I am sometimes afraid that the stoma will leak, then you are not relaxed\u003c/em\u003e\u0026rdquo; (P3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eSexual functioning\u003c/h2\u003e \u003cp\u003eParticipants, male and female, reported several challenges regarding sexual functioning as a consequence of their colorectal cancer treatment, while some were not sexually active anymore. Erectile dysfunction and being unable to ejaculate was reported as a major issue \u003cem\u003e\u0026ldquo;I do not get a good erection anymore and ejaculation is not possible at all. I do have medication for this, but it is not the same as it was before surgery\u0026rdquo;\u003c/em\u003e (P1). As medication for erectile dysfunction might offer some solution, several participants reported that the loss of the ability to spontaneously engage in sexual activities is a burden on their sexual functioning. Furthermore, bowel functioning might interfere with sexual functioning \u0026ldquo;\u003cem\u003eI am a bit more hesitant, because I am afraid of losing stool\u003c/em\u003e\u0026rdquo; (P10), along these lines a stoma might have a negative impact as well \u0026ldquo;\u003cem\u003eIn the beginning, the stoma frightened us\u003c/em\u003e\u0026rdquo; (P8). Abdominal scars after laparotomy is also reported to be of influence on sexual functioning. When issues arise, participants stated that talking about this with their partners was very helpful \u0026ldquo;\u003cem\u003eWe talk well about sexuality, therefore it has not become a problem\u003c/em\u003e\u0026rdquo; (P15). Contrastingly, some other participants do report not to experience any difficulties or changes regarding sexuality: \u0026ldquo;\u003cem\u003enothing really changed\u003c/em\u003e\u0026rdquo; (P7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eHealthcare and treatment experiences\u003c/h2\u003e \u003cp\u003eParticipants reported several factors which they consider as important during colorectal cancer treatment, and which might impact daily life during treatment, and follow-up. Good explanation about the surgical treatment and perioperative care is reported as very important: \u0026ldquo;\u003cem\u003eThe explanations by the doctors about the surgery were good, luckily because I like to know everything\u003c/em\u003e\u0026rdquo; (P3), \u0026ldquo;\u003cem\u003eWhenever I had a question it was answered\u003c/em\u003e\u0026rdquo; (P7) and \u0026ldquo;\u003cem\u003eBefore surgery, I knew what was going to happen and the possible consequences\u003c/em\u003e\u0026rdquo; (P11). Additionally, involvement and openness of medical personal was reported as important: \u0026ldquo;\u003cem\u003eYou can call the stoma nurses at any time to solve some issues that might occur\u003c/em\u003e\u0026rdquo; (P1) and \u0026ldquo;\u003cem\u003eThe enormous concern and dedication of the surgeon helped me a lot and felt very supportive\u003c/em\u003e\u0026rdquo; (P6). Others reported to find it difficult to find answers to their questions: \u0026ldquo;\u003cem\u003eI would like to know if the symptoms I experience are normal\u003c/em\u003e\u0026rdquo; (P9).\u003c/p\u003e \u003cp\u003eConversely, also negative experiences regarding doctor-patient communication after complications have been reported: \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eThe surgeon who operated on me the first time never spoke to me after the complication, which I thought was a pity\u003c/em\u003e\u0026rdquo; (P16). Furthermore, the way of communication might affect patient-doctor communication: \u0026ldquo;\u003cem\u003eDue to COVID-19 most of the appointments were by phone, therefore you cannot really discuss all your questions\u003c/em\u003e\u0026rdquo; (P2). Waiting on results is reported as a factor on mental health: \u0026ldquo;\u003cem\u003eI have been waiting for 3 months on the results of genetic tests, which was quite long which bothered me\u003c/em\u003e\u0026rdquo; (P2). Other negative factors that have been reported were: \u0026ldquo;\u003cem\u003eUsually I can sleep anywhere, but in the hospital, it was very bad\u003c/em\u003e\u0026rdquo; (P12) and \u0026ldquo;\u003cem\u003eI had a pulmonary embolism which was detected quite late, this was a pity because, in hindsight, as I understood the symptoms were very clear\u003c/em\u003e\u0026rdquo; (P3).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore and gain insights into patient perspectives on the consequences of colorectal cancer treatment for their daily life. Health deficits as consequence of colorectal cancer treatment that were reported were poor bowel functioning, the presence of a stoma, chemotherapy-induced neuropathy of hands and feet due to chemotherapy, sexual dysfunction and fear of recurrence. Poor bowel functioning impacted daily life and activities, since patients reported to use the bathroom more frequently and had to pay more attention to their diet. Whereas, patients with a stoma reported to be afraid of stoma-related fecal leakage and uncontrollable flatus from their stoma in social situations. Patients who suffered from chemotherapy-induced neuropathy in hands and feet reported altered sensory functioning and pain during activities. Sexual dysfunction is reported to be a result of erectile function loss or ejaculation function loss. Also, the presence of a stoma or abdominal scars affected sexual functioning. Some patients reported to have an increased fear of recurrence when their follow-up appointment is coming up, and some reported that they trust their body less than before the diagnosis. Furthermore, social functioning is rarely affected. Also, coping style mechanisms seem to be different between patients: some patients do feel the need to talk about their situation, whereas others prefer not to speak about their colorectal cancer. However, overall, patients reported that daily life remains fairly unaffected by colorectal cancer treatment, since patients experience only minor interference with daily life. These findings suggest that various coping mechanisms are in place.\u003c/p\u003e \u003cp\u003eAs witnessed from a prior conducted study by our group, patients report that over time their quality of life seems to be returning to preoperative levels, suggesting that they face no or minor challenges or treatment-related health deficits [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, as also shown in the current study and other literature, patients who underwent colorectal cancer treatment may still experience various challenges and health deficits. These challenges and health deficits differ based on the treatment they received [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The findings of this study suggest that most challenges that are frequently reported after colorectal surgery are bowel related. The functional bowel complaints which these patients reported, were similar to the ones that are described in literature as low-anterior resection syndrome (LARS). However, the LARS-score was not formally determined in this study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It has been shown that quality of life in patients reporting LARS is significantly impaired [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Still, patients with a stoma also reported specific stoma-related challenges, such as worrying about stool leakages and uncontrollable flatulence, which is consistent with previous literature [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with a prior study, postoperative complications can in some cases affect the doctor-patient relationship. This urges, amongst other reasons, preoperative counseling of patients with information of the risks of surgery [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A noticeable complaint that was frequently reported by patients in our study that underwent (neo-)adjuvant chemotherapy, was peripheral neuropathy. In accordance with existing literature, patients reported that symptoms decrease over time, but a large proportion of patients keeps experiencing complaints [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These complaints of chemotherapy-induced peripheral neuropathy do, however, not affect global health status, but impair physical- and role functioning [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother domain that is reported to be affected in this study, and in accordance with literature, is sexual functioning, which may be decreased as a result of colorectal cancer treatment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As previously studied, sexual dysfunction may be caused by both surgery and radiotherapy. Additionally, the presence of a stoma is also described to negatively affect sexual activity in this study as well as in previous research [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, previous studies have shown that coping strategies, to cope with treatment-related health deficits and challenges, differ between patients. This is similar to what was witnessed under the psychological functioning theme in this study [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Previous studies in both patients with ovarian carcinoma and colorectal carcinoma showed that patient may have various coping strategies, and that coping might even be enhanced as result of cancer survivorship [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The coping style that is used by patients might explain the underestimation of the effect of treatment-related health deficits (e.g., poor bowel function, chemotherapy-induced neuropathy) on quality of life, since patients are able to live a modified life with the use of various strategies and self-management techniques to maintain their quality of life [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Additionally, there is considerable individual variation between patients on how these self-management strategies are undertaken [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe knowledge acquired by this study on challenges that patients face after treatment could be taken in to account by making treatment decisions and by implementation of new treatment strategies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].For example, recently, studies have reported a complete mesocolic excision as a new surgical technique for right-sided colon cancer, which entails a more extensive procedure to ensure adequate lymphatic resection [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. While an alternative strategy might be to make the colonic resection more precise and potentially less extensive by performing a sentinel node procedure instead of a complete mesocolic excision [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In theory, a less extensive resection might lead to a lower rate of postoperative complications and better functional bowel outcome [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Additionally, in case multiple treatment options exist, information on postoperative consequences of the treatment on quality of life and the associated treatment-related health deficits may entail important information for patients during shared decision-making. Furthermore, as shown in this study, some patients reported that good preoperative education on the consequences of colorectal cancer treatment is important to them. Explicit patient consideration of their treatment and certain trade-offs are shown to have a positive effect on long-term quality of life, as it leads to increased acceptance of treatments\u0026rsquo; consequences [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. As shown in this study, after colorectal cancer treatment, patients may face various treatment-related health deficits in various domains (e.g., psychological, social, physical) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In addition, these patients have an increased risk of other health issues, such as adverse effects of treatments and psychosocial challenges [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Therefore, optimizing post-treatment psychological-, sexual-, nutritional-, and cognitive functioning of colorectal cancer survivors could be an integral part of rehabilitation programs. However, some treatment-related health deficits may not be treatable, reliable outcome data on these sequelae may render important knowledge to incorporate in preoperative patient education and in shared decision-making.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eValue based-health care\u003c/h2\u003e \u003cp\u003eThe insights of this study are important in light of the newly introduced management strategy value-based healthcare (VBHC). An important element of VBHC is measuring outcomes and costs for every patient [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. To measure patient outcomes uniformly, a standard set of patient-centered outcomes was developed by The International Consortium for Health Outcomes Measurement (ICHOM), including survival and disease control, disutility of care, degree of health, and quality of death [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Using both generic and disease-specific questionnaires. Trying to streamline implementation of the patient-reported outcome measurements, some have suggested only to use generic quality of life assessment strategies. However, this study shows that one must be cautious in only using these generic patient-reported outcome sets and quality of life questionnaires, since these might give a too limited image of the actual quality of life of a patient. As this study shows, colorectal cancer patients might still experience challenges and treatment-induced health deficits, [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eFirst, in this study, differences in complaints were witnessed between sub-groups. However, to study significant differences between sub-groups, a quantitative study design is more applicable. Despite this, this study gives valuable insights into the quality of life and influential factors on daily life after colorectal cancer treatment. A strength of this study is, due to the qualitative approach of this study, complementary and more in-depth insights are gathered that add to previous quantitative studies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Second, this was a single-center study in an academic teaching hospital with relatively advanced/complex cases, which might affect the generalizability. To overcome this issue, purposeful sampling was used to include patients with a different age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence, therefore patient characteristics and complication rates are not representable for the general population. Third, interviews were held online and via Zoom, since interviews were partly conducted during the COVID-19 pandemic. This might have influenced the quality of the conversations with the participants. However, Shapka et al. showed no differences in quality between face-to-face and online conducted interviews [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Therefore, we expect that our method of interviewing did not majorly affect our results. Last, the sample size in this study is small, but data saturation was reached. This means that no more forthcoming information or themes were gained in the last three interviews, as described by Hennink et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this explorative study shows that patients who underwent treatment for resectable colorectal cancer, face several challenges and treatment-related health deficits in the long-term, but that these challenges and health deficits lead to only minor interference with daily life. The reported minor interference might suggest coping mechanisms are in place. Frequently reported health deficits after colorectal cancer treatment are the presence of a stoma, poor bowel function, chemotherapy-induced neuropathy, fear of tumor recurrence and sexual dysfunction. The results of this study offer in-depth insights into patient perspectives on the consequences of colorectal cancer treatment. These insights are important in appreciation of generic quality of life questionnaires, in which post-treatment health deficits may be less clearly noticeable and therefore may be underestimated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEORTC; European Organization for Research and Treatment of Cancer, ICHOM; International Consortium for Health Outcomes Measurement, LARS; Low-Anterior Resection Syndrome, VHBC; Value-Based Health Care\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Leiden University Medical Center (LUMC). Authors declare no conflict of interest. Special thanks are due to all the participants who have taken part in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR\u0026rsquo;S CONTRIBUTIONS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Robert T. van Kooten,\u0026nbsp;Jetty H.L. Hoeksema,\u0026nbsp;Rob A.E.M. Tollenaar,\u0026nbsp;Michel W.J.M. Wouters, Koen C.M.J. Peeters\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData acquisition\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Robert T. van Kooten, Fabian A. Holman, Chantal van Dorp, Koen C.M.J. Peeters\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality control of data\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Robert T. van Kooten, Bianca A.M. Schutte, Rob A.E.M. Tollenaar,\u0026nbsp;Michel W.J.M. Wouters\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis and interpretation\u003c/strong\u003e: \u0026nbsp;\u0026nbsp;Robert T. van Kooten, Bianca A.M. Schutte, Dorine J. van Staalduinen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript preparation\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Robert T. van Kooten,\u0026nbsp;Bianca A.M. Schutte,\u0026nbsp;Dorine J. van Staalduinen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript editing\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Robert T. van Kooten, Bianca A.M. Schutte, Dorine J. van Staalduinen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript review\u003c/strong\u003e: \u0026nbsp; \u0026nbsp; \u0026nbsp;Jetty H.L. Hoeksema, Fabian A. Holman, Chantal van Dorp, Koen C.M.J. Peeters, Rob A.E.M. Tollenaar, Michel W.J.M. 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As treatment options tend to grow, more information on these treatments’ effects is needed to properly engage in shared decision-making. This study aims to explore the impact of resectable colorectal cancer treatment on patients’ daily life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003ePatients (≥18 years) who underwent an oncological colorectal resection between 2018 and 2021 were selected. Purposeful sampling was used to include patients who differ in age, comorbidity, (neo-)adjuvant therapy, postoperative complications and stoma presence. Semi-structured interviews were conducted, guided by a topic guide. Interviews were fully transcribed and subsequently thematically analyzed using the framework approach. Analyses were done by using the predefined themes: 1) daily life and activities, 2) psychological functioning, 3) social functioning, 4) sexual functioning and 5) healthcare experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eSixteen patients with a follow-up between 0.6 and 4.4 years after surgery were included in this study. Participants reported several challenges they experience due to poor bowel functioning, stoma presence, chemotherapy-induced neuropathy, fear of recurrence and sexual dysfunction, however, they were reported not to interfere much with daily life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Colorectal cancer treatment leads to several challenges and treatment-related health deficits. This is often not recognized by generic patient-reported outcome measures, but the findings on treatment-related health deficits presented in this study, contain valuable insights which might contribute to improving colorectal cancer care, shared decision making and value based healthcare.\u003c/p\u003e","manuscriptTitle":"Patient Perspectives on Consequences of Resectable Colorectal Cancer Treatment: a Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-06 20:33:15","doi":"10.21203/rs.3.rs-2427813/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4e4a6d4b-675b-477b-a1a0-ac880fd361d2","owner":[],"postedDate":"January 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-01-08T13:29:16+00:00","versionOfRecord":[],"versionCreatedAt":"2023-01-06 20:33:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2427813","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2427813","identity":"rs-2427813","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}