Temporal relationship between symptom cluster and quality of life in rectal cancer survivor

Temporal relationship between symptom cluster and quality of life in rectal cancer survivor | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Temporal relationship between symptom cluster and quality of life in rectal cancer survivor Chaoxiang You, Guiqiong Xie, Mengying Jia, Shuang Li, Yi Zhou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3933341/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2024 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Symptom cluster and quality of life are negatively associated, but the prospective inter-relationship between them were unknown,which may provide a mechanism insight for symptom cluster management. A longitudinal study was conducted among 140 patients who undergoing laparoscopic-assisted sphincter-preserving surgery for rectal cancer between 2021 to 2022. We investigated the longitudinal associations of the change of symptom cluster with the trajectories of quality of life. These patients were assessed for symptom clusters and quality of life at specific time points: 2 weeks (T1), 1 month (T2), 3 months (T3) ,and 6 months (T4) after their surgeries. In our Pearson correlation analysis, the quality of life within 6 months after surgery showed a moderate-to-strong strength correlation (r=0.27-0.66) between the quality of life within the first 6 months post-surgery. There was also a significantly negative correlation between each symptom cluster and the quality of life at all four time points. Our cross-lagged model revealed a unidirectional temporal relationship between quality of life and symptom cluster. the quality of life level at these four time points could significantly and negatively predict the severity of each symptom cluster, with no observed reverse path. Importantly, the cross-lagged path coefficient from quality of life to symptom cluster was notably greater than the coefficient from symptom cluster to quality of life. These findings provide evidence that lower quality of life precede higher symptom cluster severity in rectal cancer survivor. This temporal relationship begins early in the post-surgery period, highlighting the importance of early quality of life intervention to help patients improve their symptom clusters. Keywords:rectal neoplasm;symptom cluster;quality of life;bidirectional relationship Biological sciences/Cancer Health sciences/Gastroenterology Health sciences/Oncology rectal neoplasm symptom cluster quality of life bidirectional relationship Figures Figure 1 Figure 2 Figure 3 Introduction Rectal cancer (RC) is a cancer situated between the dentate line and the rectosigmoid junction,ranking as the second leading cause of cancer death-related mortality globally [1] . In recent years, the adoption of minimally invasive techniques and the growing desire for anus preservation have deriven laparoscopic anus preservation surgery to account for 62% to 85% of cases, emerging as the primary surgical approach for rectal cancer cure [2] . Despite its potential to maintain normal defecation function, sphincter-preserving surgery frequently subjects patients to a constellation of physical and psychological symptoms stemming from factors like anatomical and physiological alterations, sphincter damage, changes in colonic motility, surgical irritation, and postoperative radiotherapy and chemotherapy [3] . These symptoms often co-occur, forming symptom clusters that exhibit a reinforcing and cumulative impact, significantly impinging on patient's functional well-being and quality of life, and some times even reducing their survival prospects [4] . Symptom cluster was defined as the simultaneous occurrence of two or more interrelated symptoms, and it is not necessarily to have the same etiological mechanism in each symptom [4] .Previous studies have provided that colorectal cancer survivors will experience many symptoms, such as physical or psychological subjective signs, depression, body image changes, sexual dysfunction, etc. These symptoms are usually important feedback of abnormal states caused by disease or injury, which can cause survivor's functional status and quality of life decline throughout the survival period [5] .Although previous cross-sectional studies have shown there are a negative relationship between symptom clusters and quality of life, higher symptom cluster severity is a risk factor for lower quality of life [6] 。However, some research results still show that because cancer survivors have significant individual discrepency in perceived symptom clusters, priority symptom clusters, symptom duration, and the relationship between cluster symptoms, not all symptom clusters will have a clinical impact on quality of life. These results reflect a fact that the impact of symptom clusters on quality of life is limited and the temporal causal associations between them remain largely unknown. In an era marked by a rising incidence of rectal cancer among younger population, it is crucial to elucidate the direction and magnitude of the link between symptom clusters and quality of life. This understanding can inform the development and adaption of targeted preventive trategies, with a focus on early-satge patients. However, the interaction between symptom clusters and quality of life may be bidirectional, making it challenging to discern causal predictive relationships. The influence of quality of life on changes in the severity of symptom clusters has not been extensively documented. Quality of life encompasses various dimensions of an individual’s overall health, including physical functions,psychological well-being, social relationships, and more [7] . It is generally believed that symptoms occur simultaneously with clinically significant declines in physical, cognitive, and social functions [6] ,It can be seen that the decline in quality of life will inevitably lead to the occurrence of symptoms and changes in symptom frequency and severity. However,the impact of quality of life on symptom clusters is multidimensional. In terms of physical function dimensions, some studies have shown that the disease course and stage of digestive tract cancer survivors have a significant impact on the severity of symptom clusters [8] ，while others have indicated no significant relationship between them [9] . The impact of social relationships on symptom clusters is not direct generation. Previous research has shown that the diagnosis of cancer will change an individual's social network and reduce the patient's perception of the help provided by the social network during the illness. Social support, especially family support, can improve the symptoms of cancer survivors by strengthening psychological adjustment [10] . The role of the psychological function dimension is more complex. Some studies have shown that distress, sadness, and anxiety will lead to an increase in the severity of symptom clusters [8] ,while others have indicated no significant relationship between them [11] . This conflicting evidence suggests that improvements or decreases in aspects of quality of life may contribute positively or negatively to changes in symptom cluster severity. The available data on symptom clusters and quality of life are limited, and yield mixed results. It is crucial to elucidate the temporal characteristics of their relationship. This understanding will help determine whether a decrease in the level of quality of life leads to an increase in the severity of the symptom cluster or vice versa. To the best of our knowledge, no prior study has investigated changes in the symptom cluster and quality of life at multiple time points in patients following laparoscopic anus-preserving surgery for rectal cancer.This gap in knowledge hampers our ability to comprehend these temporal dynamics.Notably,previous longitudinal studies have relied on conventional longitudinal analysis models that do not specifically address temporal relationships.Consequently,this study examines symptom clusters and quality of life in patients within 6 months after laparoscopic anus-preserving surgery for rectal cancer.Utilizing a cross-lagged model,we introduce a temporal dimension to rigorously analyze the bidirectional correlation between them, providing valuable insights foe the identification of potential intervention strategies. Methods Study population The subjects of this longitudinal research were inpatients in the First Department of Gastrointestinal Surgery of the Affiliated Hospital of North Sichuan Medical College.They were included in the research if they met diagnostic criteria for rectal cancer, were ≥18 years old, and underwent laparoscopic-assisted anus-preserving surgery for rectal cancer.A total of 140 eligible patients were enrolled from November 2021 to April 2022.Among them, data related to symptom clusters and quality of life will be measured repeatedly at 4 time points, namely 2 weeks, 1 month, 3 months, and 6 months after surgery.Sociodemographic and disease-related data were collected for all participants during their hospitalizationExclusion from the study was determined by the following criteria during the investigation period: 1) Tumor recurrence or metastasis ; 2) Complications with severe systemic diseases; 3) Conversion to laparotomy; 4) Severe postoperative complications; 5) Voluntary withdrawal from the study; 6) Deceased; 7) Failure to complete entire follow-up.The calculation of the sample size utilized a foenula for single-group repeated measurement data,detailed results are shown in Table 1. Ethics declaration All methods were performed in accordance with the relevant guidelines and regulations and were in accordance with the Declaration of Helsinki.The study protocol was approved by the ethics committee of North SiChuan Medical college. All subjects participated in the study voluntarily and signed informed consent forms. Confirms informed consent was obtained to publish the information/image(s) in an online open access publication. Symptom cluster measure Symptom clusters were assessed using the Chinese version of the Anderson Gastrointestinal Cancer Symptom Assessment Scale.This scale is a universally applicable self-report scale for assessing multiple symptoms and was developed by Cleeland et al in 2000 at the University of Texas MD Anderson Cancer Center [12] . It has been translated into 29 languages,and specific modules tailored to patients with different cancer type have been adapted,In our study, we utilized the Chinese version of the Anderson Symptom Assessment Scale’s gastrointestinal tumor-specific assessment module designed for patients with gastrointestinal cancer [13] . The scale conprises two parts. The first part includes 13 core symptoms and 5 gastrointestinal tumor-specific symptoms that are most commonly or severely experienced by patients with various cancers. A total of 18 symptoms are used to gauge symptom severity over past 24 hours. Each item in this section is rated on a scale from 0 to 10, with 0 indicating an absence of symptoms and 10 signifying the most severe possible symptom. The second part assesses the extent to which the aforementioned symptom interfere with six aspects of daily life, such as work, mood, and mobility. Each item is scored on a scale of 0-10, where 0 denotes no interference and 10 represents complete interference. The Cronbach's alpha coefficients for the two section of the scale are 0.84 and 0.90 respectively, indicating strong reliability and validity [14] . In our study, the measured Cronbach's alpha coefficient range from 0.701 to 0.813. Quality of life measure Quality of life was evaluated using the Colorectal Cancer Patients Quality of Life Measurement Scale, a quality of life assessment tool designed for cancer patients with Chinese cultural characteristics,which was developed by Yang Zheng et al in 2008 [15] .This scale encompasses general modules applicable to cancer patients and specific modules tailored for colorectal cancer patients. It comprises five domains: physical function, psychological function, social function, common symptoms and side effects, and colorectal cancer-specific modules, totaling 46 items. Each item is rated on a five point scale: not at all, a little, somewhat, quite a bit, and very much. For scoring ,forward items are directly assigned values from 1 to 5 points, while reverse items are scored reversely. This scale exhibits robust reliability and validity, with Cronbach's alpha coefficients of 0.63 and 0.66 in the common symptoms and side effects domain and the social function domain,respectively. For other domains and common modules, Cronbach's alpha values consistently exceed 0.85. In our study,the measured Cronbach's alpha ranged from 0.776 to 0.830. Higher scores on this scale correspond to better quality of life, whereas lower scores indicate lower quality of life. Data analysis IBM SPSS statistical software for Windows (version 26.0) was employed to calculate the differences between demographic characteristics and study variables. Descriptive statistics were utilized to present the baseline characteristics of the study sample. The included reporting frequencies and percentages for categorical variables and means and standard deviations for continuous variables. To assess the longitudinal changes in quality of life scores at the four time points, repeated measures analysis of variance was conducted. Furthermore,the Friedman test was applied to evaluate the longitudinal changes in symptom cluster severity scores at the four time points, with significance level set at 0.05. Subsequently,exploratory factor analysis was utilized to identify symptom cluster, Symptom with an incidence rate of ≥15% at different time points were included in the factor analysis [16] .The following principles guide the extraction of symptom clusters: ① initial eigenvalue ≥1; ② factor loading >0.5; ③ factors comforming to Cartel’s ″steep order‶ test principle; ④ factors consisting of at least two items. Factors were named based on clinical expertise. To explore the correlation between symptom clusters and quality of life,Pearson correlation analysis was employed. In the next step, to examine the relationship between symptom clusters and quality of life, a cross-lagged model was conducted and analyzed using Mplus8.0. In this analysis,covariates were included based on previous data that demonstrated associations with predictor or outcome variables. There covariates encompassed age, drinking history, distance from the lower edge of the tumor to the anal verge, marital status, medical expense burden, treatment method, T stage, and surgical method, The cross-lagged model, a structural model assessing interaction and longitudinal relationships between variables,was established. Four models were constructed to elucidate the causal predictive relationship between symptom cluster and quality of life: (1) Model 1 a stability model with symptom clusters and quality of life, devoid of cross-labeled structural paths. (2) Model 2 building on Model 1,it incorporates a cross-lagged path from symptom clusters to quality of life. (3) Model 3 an extension of Model 2,it adds a cross-lagged path from quality of life to symptom cluster. (4) Model 4 includes all autoregressive and cross-lagged paths from Model 1-3. These measures were repeated while exploring the bidirectional temporal relationship between each symptom cluster and quality of life. Standardized beta coefficients were employed to determine and compare the strength of associations. Model fitting effectiveness was evaluated using the following criteria: Comparative Fit Index(CFI) ≥ 0.95, Tucker-Lewis Index(TLI) ≥ 0.95, Standardized Root Mean Square Residual (SRMR) ≤ 0.08, and Root Mean Square Error of Approximation (RMSEA) ≤ 0.06. A significance level of P ＜ 0.05 was considered statistically significant. Chi-square difference tests were conducted to compare difference between nested models. It is noteworthy that previous literature recommended including more than 100 participants in any Mplus model,sand this study exceeded this requirement at all four time points. Results Characteristics of study participants. The present study included those participants with complete sociodemographic information and health related factors at four survey time point.Depicted in table 1. Table 1.Sample characteristics for those individuals included in the present analyses Characteristic Follow-up 2weeks(n=140) Follow-up 1month(n=138) Follow-up 3months(n=134) Follow-up 6months(n=128) Age,years 63.94(12.07) 64.22(11.92) 64.43(12.01) 64.36(12.20) Sex,n(%) male 94(67%) 92(66%) 89(66%) 85(66%) female 46(33%) 46(32%) 45(34) 43(34%) BMI,Kg/m 2 22.51(2.93) 22.39(3.46) 22.60(2.95) 22.61(2.97) Smoking,n(%) No 89(64%) 87(63%) 83(62%) 78(61%) Yes 51(36%) 51(37%) 51(38%) 50(39%) Drinking,n(%) No 97(69%) 95(68%) 93(69%) 89(70%) Yes 43(31%) 43(32%) 41(31%) 39(30%) operation mode，n(%) Single-incision laparoscopic surgery 55(39%) 55(40%) 52(39%) 50(39%) Conventional laparoscopic surgery 85(61%) 83(60%) 82(61%) 78(61%) distance from lower margin of tumor to anal margin，n(%) ＜5cm 14(10%) 14(10%) 14(10%) 14(10%) 5-10cm 77(55%) 76(55%) 72(54%) 66(52%) ＞10cm 49(35%) 48(35%) 48(36%) 48(38%) sickness symptom cluster 0.95(0.87) 0.95(0.87) 0.94(0.87) 0.95(0.88) gastrointestinal symptom cluster 2.01(1.25) 2.02(1.26) 1.99(1.25) 1.97(1.27) psychological-sleep symptom cluster ─ 1.79(1.54) 1.79(1.54) 1.75(1.54) Quality of life 73.54(5.01) 82.79(7.04) 70.46(6.41) 87.96(5.63) Correlation analysis Pearson correlation analysis showed that there was a negative correlation between symptom cluster and quality of life in each survey wave (Table 1). The quality of life at four survey wave showed a significant moderate to strong correlation (correlation range from -0.369( P ＜0.01) to -0.661( P ＜0.01)). The correlation between gastrointestinal symptom cluster and quality of life was strongest at 2 weeks and 1 month after surgery (at 2 weeks after surgery r=-0.658 ( P <0.01) , at 1 month after surgery r=-0.658( P <0.01)). The correlation between psychological-sleep symptom cluster and quality of life is strongest at 3 months and 6 months after surgery (at 3 months after surgery r=-0.638 ( P <0.01) , at 6 months after operation r=-0.547 ( P <0.01)) . Importantly, gastrointestinal symptoms had a significant negative correlation with quality of life in all four wave(correlation range from r=-0.252 ( P <0.01) to -0.658 ( P <0.01)), while other symptom cluster were not observed(Table 2). Table2.Correlation analysis between symptom cluster and quality of life(*：＜0.05，**：＜0.01,T1:time1;T2:time2;T3time3;T4:time4;SSC:sickness symptom cluster;GSC:gastrointestinal symptom cluster;PSSC:psychological-sleep symptom cluster) Variable M(SD) T1QOL T2QOL T3QOL T4QOL T1SSC T2SSC T3SSC T4SSC T1GSC T2GSC T3GSC T4GSC T2PSSC T3PSSC T4PSSC T1QOL 74.32(4.88) 1 T2QOL 84.48(6.94) .661 ** 1 T3QOL 72.30(7.05) .389 ** .577 ** 1 T4QOL 88.85(5.75) .479 ** .354 ** .369 ** 1 T1SSC 1.00(1.05) -.533 ** -.357 ** -.108 -.447 ** 1 T2SSC 0.80(0.88) -.492 ** -.541 ** -.255 ** -.245 ** .604 ** 1 T3SSC 0.00(1.30) -.303 ** -.427 ** -.530 ** -.186 * .128 .240 ** 1 T4SSC 0.00(0.64) -.263 ** -.151 -.275 ** -.530 ** .319 ** .277 ** .369 ** 1 T1GSC 3.00(1.27) -.658 ** -.474 ** -.252 ** -.302 ** .485 ** .294 ** .161 .193 * 1 T2GSC 1.84(1.26) -.582 ** -.628 ** -.328 ** -.209 * .390 ** .389 ** .308 ** .025 .668 ** 1 T3GSC 1.50(0.98) -.365 ** -.281 ** -.388 ** -.364 ** .234 ** .230 ** .184 * .170 .387 ** .396 ** 1 T4GSC 1.00(0.89) -.207 * -.179 * -.142 -.369 ** .174 * -.055 -.032 .152 .296 ** .298 ** .256 ** 1 T2PSSC 1.67(1.54) -.308 ** -.393 ** -.272 ** -.237 ** .343 ** .408 ** .121 .128 .268 ** .285 ** .124 .139 1 T3PSSC 1.00(1.03) -.351 ** -.568 ** -.638 ** -.327 ** .238 ** .329 ** .605 ** .437 ** .306 ** .446 ** .320 ** .296 ** .468 ** 1 T4PSSC 0.67(1.16) -.261 ** -.269 ** -.331 ** -.547 ** .293 ** .322 ** .340 ** .641 ** .136 .114 .244 ** .159 .323 ** .473 ** 1 Temparal relationship Building upon the findings of the correlation analysis, We constructed a cross-lagged model to analyze the magnitude and directionality of the relationship between symptom cluster and quality of life. Cross-lagged path coefficients showed a negative relationship between quality of life and each symptom cluster. We observed that quality of life at each survey wave statistically significantly predicted symptom clusters at the next wave (standardized path coefficients from -0.111 ( P <0.05) to -0.237 ( P <0.001)). The same pattern occurred for repeated measures of quality of life and gastrointestinal symptom clusters over time (standardized path coefficients from -0.051 ( P <0.05) to -0.252 ( P <0.01)), and these coefficients were higher than Illness symptom cluster. However, only the quality of life from 3 months to 6 months after surgery could statistically significantly predict the psychological-sleep symptom cluster in the next wave (standardized path coefficient was -0.540 ( P <0.001)). In addition, all three models show that the effect of quality of life on symptom clusters is stronger than the effect of symptom clusters on quality of life. Cross-lagged path effects are critical to our study hypotheses, it suggests that the deterioration in quality of life may be associated with the heightened severity of symptom clusters. The temporal stability of gastrointestinal symptom cluster is higher than that of sickness symptom cluster and psychological-sleep symptom cluster(Figure1．Figure2．Figure3．) Sensitivity analysis In order to evaluate the stability of bidirectional temporal relationship between symptom cluster and quality of life and eliminate the effects of confounding variable. we included gender, age, distance between the lower edge of the tumor and the anal verge, surgical method, treatment method, and clinical T stage as covariates in the above three models, there was no significant difference between the standardized regression coefficients. It shows that after controlling for more confounding variables, quality of life can still significantly and negatively predict symptom clusters, while symptom clusters do not significantly predict quality of life. Discussion In the present longitudinal study,we construct a cross-lagged model to investigate the bidirectional temporal relationship between symptom cluster and quality of life and explore the direction and magnitude.The results revealed a consistent pattern that the effect of quality of life on symptom clusters was stronger than the effect of symptom clusters on quality of life, with lower quality of life levels among rectal cancer survivors being associated with subsequent increases in symptom cluster severity.However, data from any survey wave were unable to demonstrate that symptom clusters predict quality of life. A significant and noteworthy discovery from this study is the negative prediction of symptom cluster severity by the level of quality of life. This implies that a decline in quality of life precedes an increase in the severity of each symptom cluster, which serves as an expression of the quality of life. The reason may be that the huge pain caused by symptom cluster to patients is generated by the superposition of multiple symptoms, and the impact of this superposition on patients increases exponentially, and the quality of life can clearly reflect the degree to which patients are affected by symptom clusters [17] .Secondly, it is reflected from the cross-lagged path coefficient that symptom clusters still have a partial impact on quality of life. Even if its impact is very weak, their association still exists. This indicates that the decline in quality of life may be related to the increase in the severity of symptom clusters, which is consistent with previous research results [10, 18] .These findings suggest that the gastrointestinal symptom cluster, psychological-sleep symptom cluster, and sickness symptom cluster may play an important role in the development trajectory of postoperative quality of life of rectal cancer survivors, and therefore may be part of the treatment strategy to intervene in the quality of life of such patients. The results of our study are contradictory to existing research results. Previous studies believed that symptom clusters are factors affecting quality of life, and the decline in quality of life is due to the increase in the severity of symptom clusters [10, 18, 19] .Several explanations are plausible for these different findings. First, some studies only conducted correlation analysis between them [19, 20] ,and could not determine the causal relationship. Although some studies have performed regression analysis on them [10, 21] ,their cross-sectional nature limits the time dimension and cannot verify the potential causal effect mechanism of the them, that is, appropriate temporal order is a necessary prerequisite for causality [17] . The results of this study show that changes in the severity of gastrointestinal symptom clusters, psychological-sleep symptom clusters, and sickness symptom clusters do not significantly predict quality of life. The reason may be that quality of life is a multi-dimensional evaluation of patients’ physical functions, psychological functions, social relationships, etc., and is a key indicator for evaluating clinical treatment and rehabilitation effects [22] .The main determinants of the postoperative quality of life of patients with rectal cancer are the patient's disease process and treatment effect. However, the symptom cluster is only a reflection of part of the body's functional status and cannot accurately evaluate the quality of life. Secondly, the symptom clusters are diverse. Affected by the cancer itself and its treatment, the number and type of symptom clusters show longitudinal stability and transverse variability over time. Another possible explanation is that there is a longitudinal mediating effect that affects their influencing mechanisms. For example, in a study of 175 patients with atrial fibrillation, Chohee Bang et al found that symptoms of atrial fibrillation increased patients' depression and anxiety and further affected their quality of life [23] . Our study currently has some limitations. First, we only used self-reported measures to assess symptom cluster severity and quality of life levels. These are not exact clinical diagnoses, and there is a lack of objective measurement data. Therefore, there is a certain measurement deviation. Secondly, although we adjusted for a wide range of potential confounding variables, we cannot rule out that other variables and conditions (e.g., previous illness, physical activity, medication intake, time of measurement) may also influence the revealed effects. Third, our sample size is small, and responses to the relationship may lack representativeness. Fourth, our measurement period was short, only 6 months. Our study also has several strengths. Notably, we employed a powerful analytical approach that offers several important advantages over traditional multiple regression techniques, first by maximizing sample size reduction by avoiding missing data at a single time point. Maximizes the utility of large sample sizes. Secondly, they enable testing of the temporal direction of association, a prerequisite for investigating potential causal associations. A key strength of this study is our four-band longitudinal study design, which provides the opportunity to accurately assess the actual relationship. Declarations Author Contribution Z.Y,Z.X.X,W.X.F,performed the measurements. Y.C.X ,X.G.Q and K.H.Y designed the model. Y.C.X and K.H.Y designed the computational framework and analysed the data. Y.C.X,J.M.Y and L.S conceived the original project. K.H.Y and X.G.Q supervised the project. J.M.Y and Y.C.X pre-analysed and prepared the heart rate data and contributed to the interpretation of the findings.Y.C.X and X.G.Q took the lead in writing the manuscript. All authors discussed the results and contributed to the final version of the manuscript. Data Availability The raw data are not publicly available due to the participant’s privacy, but derived data supporting the findings are available from the corresponding author by reasonable request. References Xi Y, Xu P. Global colorectal cancer burden in 2020 and projections to 2040[J]. Transl Oncol, 2021,14(10): 101174. Shahjehan F, Kasi P M, Habermann E, et al. Trends and outcomes of sphincter-preserving surgery for rectal cancer: a national cancer database study[J]. Int J Colorectal Dis, 2019,34(2): 239–245. Li C, Tang H, Zhang Y, et al. Experiences of bowel symptoms in patients with rectal cancer after sphincter-preserving surgery: a qualitative meta-synthesis[J]. Support Care Cancer, 2022,31(1): 23. Harris C S, Dodd M, Kober K M, et al. Advances in Conceptual and Methodological Issues in Symptom Cluster Research: A 20-Year Perspective[J]. ANS Adv Nurs Sci, 2022,45(4): 309–322. Sheikh-wu S F, Anglade D, Gattamorta K A, et al. Symptom Occurrence, Frequency, and Severity During Acute Colorectal Cancer Survivorship[J]. Oncol Nurs Forum, 2022,49(5): 421–431. Potosky A L, Graves K D, Lin L, et al. The prevalence and risk of symptom and function clusters in colorectal cancer survivors[J]. J Cancer Surviv, 2022,16(6): 1449–1460. Haraldstad K, Wahl A, Andenaes R, et al. A systematic review of quality of life research in medicine and health sciences[J]. Qual Life Res, 2019,28(10): 2641–2650. Poon M, Dennis K, Deangelis C, et al. Symptom clusters of gastrointestinal cancer patients undergoing radiotherapy using the Functional Living Index-Emesis (FLIE) quality-of-life tool[J]. Support Care Cancer, 2015,23(9): 2589–2598. Adams S V, Ceballos R, Newcomb P A. Quality of Life and Mortality of Long-Term Colorectal Cancer Survivors in the Seattle Colorectal Cancer Family Registry[J]. PLoS One, 2016,11(6): e156534. Wang Y, Xie Z, Liu Y, et al. Symptom clusters and impact on quality of life in esophageal cancer patients[J]. Health Qual Life Outcomes, 2022,20(1): 168. Rha S Y, Lee J. Symptom clusters during palliative chemotherapy and their influence on functioning and quality of life[J]. Supportive Care in Cancer, 2017,25(5): 1519–1527. Cleeland C S, Mendoza T R, WANG X S, et al. Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory[J]. Cancer, 2000,89(7): 1634–1646. Wang X S, Williams L A, ENG C, et al. Validation and application of a module of the M. D. Anderson Symptom Inventory for measuring multiple symptoms in patients with gastrointestinal cancer (the MDASI-GI)[J]. Cancer, 2010,116(8): 2053–2063. Wang X S, Wang Y, Guo H, et al. Chinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients[J]. Cancer, 2004,101(8): 1890–1901. Yan Z,Lu Y B, Wan C H,et al.Development of the system of quality of life instrumentsfor cancer patients:colorectal cancer(QLICP-GR)[J]. Cancer, 2008,27(1): 96–100. Li N N,Wu J,Xu M,et al. analysis of symptom groups and influencing factors for patients with lung cancer chemothera[J]. J Nurses Train, 2018,33(22): 2029–2032. Aaltonen S, Latvala A, ROSE R J, et al. Leisure-Time Physical Activity and Academic Performance: Cross-Lagged Associations from Adolescence to Young Adulthood[J]. Sci Rep, 2016,6: 39215. Zhang L, Wang J, Chen T, et al. Symptom Clusters and Quality of Life in Cervical Cancer Patients Receiving Concurrent Chemoradiotherapy: The Mediating Role of Illness Perceptions[J]. Front Psychiatry, 2021,12: 807974. Chen F, Leng Y, Ni J, et al. Symptom clusters and quality of life in ambulatory patients with multiple myeloma[J]. Support Care Cancer, 2022,30(6): 4961–4970. Rodgers C C, Hooke M C, Taylor O A, et al. Childhood Cancer Symptom Cluster: Leukemia and Health-Related Quality of Life[J]. Oncol Nurs Forum, 2019,46(2): 228–237. Fu L, Feng X, Jin Y, et al. Symptom Clusters and Quality of Life in Gastric Cancer Patients Receiving Chemotherapy[J]. J Pain Symptom Manage, 2022,63(2): 230–243. Ocalewski J, Jankowski M, Zegarski W, et al. The Role of Health Behaviors in Quality of Life: A Longitudinal Study of Patients with Colorectal Cancer[J]. Int J Environ Res Public Health, 2023,20(7). Bang C, Park S. Symptom Clusters, Psychological Distress, and Quality of Life in Patients with Atrial Fibrillation[J]. Healthcare (Basel), 2023,11(9). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 01 Nov, 2024 Reviews received at journal 28 Oct, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviews received at journal 22 Jul, 2024 Reviewers agreed at journal 08 Jul, 2024 Reviewers invited by journal 24 Apr, 2024 Editor assigned by journal 15 Apr, 2024 Editor invited by journal 18 Mar, 2024 Submission checks completed at journal 18 Mar, 2024 First submitted to journal 06 Feb, 2024 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. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guiqiong","middleName":"","lastName":"Xie","suffix":""},{"id":281151410,"identity":"9263c969-0cf0-4e28-a7c6-2e18d0ec0044","order_by":2,"name":"Mengying Jia","email":"","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Mengying","middleName":"","lastName":"Jia","suffix":""},{"id":281151411,"identity":"0f6b9ac3-d217-415c-97bc-060ee7939dc7","order_by":3,"name":"Shuang Li","email":"","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Li","suffix":""},{"id":281151412,"identity":"d6cad86f-43c5-403c-82e8-4c6c3e390b7e","order_by":4,"name":"Yi Zhou","email":"","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Zhou","suffix":""},{"id":281151413,"identity":"514f47ab-f3dd-46a6-8db6-c488f6197cba","order_by":5,"name":"Xiaoxuan Zhang","email":"","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxuan","middleName":"","lastName":"Zhang","suffix":""},{"id":281151414,"identity":"2cc7ae9b-b504-4852-bbf1-b17a83f31f32","order_by":6,"name":"Xiufei Wu","email":"","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiufei","middleName":"","lastName":"Wu","suffix":""},{"id":281151415,"identity":"afa76e55-c1da-4377-bc9c-60a75ed76ae2","order_by":7,"name":"Hongyan Kou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBAC+4bDBx98qPjHbD//8AHitBgwHks2nHHmALuBBFsCkVqYz6hJ87Yd4DeQ4DEgTos52xkGyRln7kibS/d8vPGGwU5Ot4GAFsueswcMPlQ8M7acc3az5RyGZGOzA4SsuXEuIXHGGeZkhgO526R5GA4kbiOo5f4bg8O8bcz1DQdynhGnxeDAGcNm3rbDzAY3ctiI0yLZcCyZccaZNGbJnmNA/xgQ4Rd+hsPHf3yosGHmZ29+eONNhZ0cYe8jA6KjBlkLqTpGwSgYBaNgRAAA5VtMtyjhEGwAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Hospital of North Sichuan Medical College","correspondingAuthor":true,"prefix":"","firstName":"Hongyan","middleName":"","lastName":"Kou","suffix":""}],"badges":[],"createdAt":"2024-02-06 09:00:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3933341/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3933341/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-83755-z","type":"published","date":"2024-12-30T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53188044,"identity":"189afe13-4ac9-4370-a6ab-13e9f259967b","added_by":"auto","created_at":"2024-03-21 16:47:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56767,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCross-lagged Path Analysis\u003c/strong\u003e \u003cstrong\u003eof Sickness Symptom Cluster and Quality of Life.\u003c/strong\u003e (QOL:quality of life,SSC:Sickness Symptom Cluster,β\u003csub\u003e1\u003c/sub\u003e,β\u003csub\u003e2\u003c/sub\u003e =cross-lagged path coefficients;r\u003csub\u003e1\u003c/sub\u003e =synchronous correlations;r\u003csub\u003e2\u003c/sub\u003e, r\u003csub\u003e3\u003c/sub\u003e=tracking correlations;Significance levels are indicated by asterisk (*\u003cem\u003eP\u003c/em\u003e＜0.05；**\u003cem\u003eP\u003c/em\u003e＜0.01；**\u003cem\u003eP\u003c/em\u003e＜0.001)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure1.CrossLaggedPathAnalysisofSicknessSymptomClusterandQualityofLife.png","url":"https://assets-eu.researchsquare.com/files/rs-3933341/v1/1a5fe1b187f51aacc475bb44.png"},{"id":53188042,"identity":"40f8a8b4-98ad-4021-8399-466753e9285d","added_by":"auto","created_at":"2024-03-21 16:47:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54964,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCross-Lagged Path Analysis of Sickness Symptom Cluster and Quality of Life.\u003c/strong\u003e(QOL:quality of life,SSC:Sickness Symptom Cluster,β1,β2 =cross-lagged path coefficients;r1 =synchronous correlations;r2, r3=tracking correlations;Significance levels are indicated by asterisk (*P＜0.05；**P＜0.01；**P＜0.001)\u003c/p\u003e","description":"","filename":"Figure2.CrossLaggedPathAnalysisofGastrointestinalSymptomClusterandQualityofLife.png","url":"https://assets-eu.researchsquare.com/files/rs-3933341/v1/c4c657ca5e57b32147c15ede.png"},{"id":53188043,"identity":"dbffcb17-d969-4d4c-a3a8-d8761a6edba2","added_by":"auto","created_at":"2024-03-21 16:47:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40475,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCross-Lagged Path Analysis of Psychological-Sleep Symptom Cluster and Quality of Life.\u003c/strong\u003e(QOL:quality of life,SSC:Sickness Symptom Cluster,β1,β2 =cross-lagged path coefficients;r1 =synchronous correlations;r2, r3=tracking correlations;Significance levels are indicated by asterisk (*P＜0.05；**P＜0.01；**P＜0.001)\u003c/p\u003e","description":"","filename":"Figure3.CrossLaggedPathAnalysisofPsychologicalSleepSymptomClusterandQualityofLife.png","url":"https://assets-eu.researchsquare.com/files/rs-3933341/v1/9394f522b46eecd6d16c1149.png"},{"id":73093313,"identity":"1e11964d-0bcd-488f-ad7b-1eb53ec73498","added_by":"auto","created_at":"2025-01-06 16:13:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":693611,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3933341/v1/b4ae3199-dde8-410d-b48c-39679811a69b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTemporal relationship between symptom cluster and quality of life in rectal cancer survivor\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRectal cancer (RC) is a cancer situated between the dentate line and the rectosigmoid junction,ranking as the second leading cause of cancer death-related mortality globally\u003csup\u003e[1]\u003c/sup\u003e.\u0026nbsp;In recent years, the adoption of minimally invasive techniques and the growing desire for anus preservation have deriven laparoscopic anus preservation surgery to account for 62% to 85% of cases, emerging as the primary surgical approach for rectal cancer cure\u003csup\u003e[2]\u003c/sup\u003e.\u0026nbsp;Despite its potential to maintain normal\u0026nbsp;\u0026nbsp;defecation function, sphincter-preserving surgery frequently subjects patients to a constellation of physical and psychological symptoms stemming from factors like \u0026nbsp;anatomical and physiological alterations, sphincter damage, changes in colonic motility, surgical irritation, and postoperative radiotherapy and chemotherapy\u003csup\u003e[3]\u003c/sup\u003e. These symptoms often co-occur, forming symptom clusters that exhibit a reinforcing and cumulative impact, significantly impinging on patient\u0026apos;s functional well-being and quality of life, and some times even reducing their survival prospects\u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSymptom cluster was defined as the simultaneous occurrence of two or more interrelated symptoms, and it is not necessarily to have the same etiological mechanism in each symptom\u003csup\u003e[4]\u003c/sup\u003e.Previous studies have provided that colorectal cancer survivors will experience many symptoms, such as physical or psychological subjective signs, depression, body image changes, sexual dysfunction, etc. These symptoms are usually important feedback of abnormal states caused by disease or injury, which can cause survivor\u0026apos;s functional status and quality of life decline throughout the survival period\u003csup\u003e[5]\u003c/sup\u003e.Although previous cross-sectional studies have shown there are a negative relationship between symptom clusters and quality of life, higher symptom cluster severity is a risk factor for lower quality of life\u003csup\u003e[6]\u003c/sup\u003e。However, some research results still show that because cancer survivors have significant individual discrepency in perceived symptom clusters, priority symptom clusters, symptom duration, and the relationship between cluster symptoms, not all symptom clusters will have a clinical impact on quality of life.\u0026nbsp;These results reflect a fact that the impact of symptom clusters on quality of life is limited and the temporal causal associations between them remain largely unknown.\u0026nbsp;In an era marked by a rising incidence of rectal cancer among younger population, it is crucial to elucidate the direction and magnitude of the link between symptom clusters and quality of life. This understanding can inform the development and adaption of targeted preventive trategies, with a focus on early-satge patients.\u0026nbsp;However, the interaction between symptom clusters and quality of life may be bidirectional, making it challenging to discern causal predictive relationships.\u003c/p\u003e\n\u003cp\u003eThe influence of quality of life on changes in the severity of symptom clusters has not been extensively documented. Quality of life encompasses various dimensions of an individual\u0026rsquo;s overall health, including physical functions,psychological well-being, social relationships, and more\u003csup\u003e[7]\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;It is generally believed that symptoms occur simultaneously with clinically significant declines in physical, cognitive, and social functions\u003csup\u003e[6]\u003c/sup\u003e,It can be seen that the decline in quality of life will inevitably lead to the occurrence of symptoms and changes in symptom frequency and severity. However,the impact of quality of life on symptom clusters is multidimensional. In\u0026nbsp;terms of physical function dimensions, some studies have shown that the disease course and stage of digestive tract cancer survivors have a significant impact on the severity of symptom clusters\u003csup\u003e[8]\u003c/sup\u003e，while others have indicated no significant relationship between them\u003csup\u003e[9]\u003c/sup\u003e.\u0026nbsp;The impact of social relationships on symptom clusters is not direct generation.\u0026nbsp;Previous research has shown that the diagnosis of cancer will change an individual\u0026apos;s social network and reduce the patient\u0026apos;s perception of the help provided by the social network during the illness.\u0026nbsp;Social support, especially family support, can improve the symptoms of cancer survivors by strengthening psychological adjustment\u003csup\u003e[10]\u003c/sup\u003e.\u0026nbsp;The role of the psychological function dimension is more complex. Some studies have shown that distress, sadness, and anxiety will lead to an increase in the severity of symptom clusters\u0026nbsp;\u003csup\u003e[8]\u003c/sup\u003e,while others have indicated no significant relationship between them\u003csup\u003e[11]\u003c/sup\u003e.\u0026nbsp;This conflicting evidence suggests that improvements or decreases in aspects of quality of life may contribute positively or negatively to changes in symptom cluster severity.\u003c/p\u003e\n\u003cp\u003eThe available data on symptom clusters and quality of life are limited, and yield \u0026nbsp;mixed results. It is crucial to elucidate the temporal characteristics of their relationship. This understanding will help determine whether a decrease in the level of quality of life leads to an increase in the severity of the symptom cluster or vice versa. To the best of our knowledge, no prior study has investigated changes in the symptom cluster and quality of life at multiple time points in patients following laparoscopic anus-preserving surgery for rectal cancer.This gap in knowledge hampers our ability to comprehend these temporal dynamics.Notably,previous longitudinal studies have relied on conventional longitudinal analysis models that do not specifically address temporal relationships.Consequently,this study examines symptom clusters and quality of life in patients within 6 months after laparoscopic anus-preserving surgery for rectal cancer.Utilizing a cross-lagged model,we introduce a temporal dimension to rigorously analyze the bidirectional correlation between them, providing valuable insights foe the identification of potential intervention strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u0026nbsp; The subjects of this longitudinal research were inpatients in the First Department of Gastrointestinal Surgery of the Affiliated Hospital of North Sichuan Medical College.They were included in the research if they met diagnostic criteria for rectal cancer, were \u0026ge;18 years old, and underwent laparoscopic-assisted anus-preserving surgery for rectal cancer.A total of 140 eligible patients were enrolled from November 2021 to April 2022.Among them, data related to symptom clusters and quality of life will be measured repeatedly at 4 time points, namely 2 weeks, 1 month, 3 months, and 6 months after surgery.Sociodemographic and disease-related data were collected for all participants during their hospitalizationExclusion from the study was determined by the following criteria during the investigation period: 1) Tumor recurrence or metastasis ; 2) Complications with severe systemic diseases; 3) Conversion to laparotomy; 4) Severe postoperative complications; 5) Voluntary withdrawal from the study; 6) Deceased; 7) Failure to complete entire follow-up.The calculation of the sample size utilized a foenula for single-group repeated measurement data,detailed results are shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e All methods were performed in accordance with the relevant guidelines and regulations and were in accordance with the Declaration of Helsinki.The study protocol was approved by the ethics committee of North SiChuan Medical college. All subjects participated in the study voluntarily and signed informed consent forms. Confirms informed consent was obtained to publish the information/image(s) in an online open access publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSymptom cluster measure\u003c/strong\u003e \u0026nbsp;Symptom clusters were assessed using the Chinese version of the Anderson Gastrointestinal Cancer Symptom Assessment Scale.This scale is a universally applicable self-report scale for assessing multiple symptoms and was developed by Cleeland et al in 2000 at the University of Texas MD Anderson Cancer Center\u003csup\u003e[12]\u003c/sup\u003e.\u0026nbsp;It has been translated into 29 languages,and specific modules tailored to patients with different cancer type have been adapted,In our study, we utilized the Chinese version of the Anderson Symptom Assessment Scale\u0026rsquo;s gastrointestinal tumor-specific assessment module designed for patients with gastrointestinal cancer\u003csup\u003e[13]\u003c/sup\u003e.\u0026nbsp;The scale conprises two parts. The first part includes 13 core symptoms and 5 gastrointestinal tumor-specific symptoms that are most commonly or severely experienced by patients with various cancers. \u0026nbsp;A total of 18 symptoms are used to gauge symptom severity over past 24 hours. \u0026nbsp;Each item in this section is rated on a scale from 0 to 10, with 0 indicating an absence of symptoms and 10 signifying the most severe possible symptom. The second part assesses the extent to which the aforementioned symptom interfere with six aspects of daily life, such as work, mood, and mobility. Each item is scored on a scale of 0-10, where 0 denotes no interference and 10 represents complete interference. \u0026nbsp;The Cronbach\u0026apos;s alpha coefficients for the two section of the scale are 0.84 and 0.90 respectively, indicating strong reliability and validity\u003csup\u003e[14]\u003c/sup\u003e.\u0026nbsp;In our study, the measured Cronbach\u0026apos;s alpha coefficient range from 0.701 to 0.813.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of life measure\u003c/strong\u003e \u0026nbsp;Quality of life was evaluated using the Colorectal Cancer Patients Quality of Life Measurement Scale, a quality of life assessment tool designed for cancer patients with Chinese cultural characteristics,which was developed by Yang Zheng et al in 2008\u003csup\u003e[15]\u003c/sup\u003e.This scale encompasses general modules applicable to cancer patients and specific modules tailored for colorectal cancer patients. It comprises five domains: physical function, psychological function, social function, common symptoms and side effects, and colorectal cancer-specific modules, totaling 46 items. \u0026nbsp;Each item is rated on a five point scale: not at all, a little, somewhat, quite a bit, and very much. \u0026nbsp;For scoring ,forward items are directly assigned values from 1 to 5 points, while reverse items are scored reversely. \u0026nbsp;This scale exhibits robust reliability and validity, with Cronbach\u0026apos;s alpha coefficients of 0.63 and 0.66 in the common symptoms and side effects domain and the social function domain,respectively. \u0026nbsp;For other domains and common modules, Cronbach\u0026apos;s alpha values consistently exceed 0.85. \u0026nbsp;In our study,the measured Cronbach\u0026apos;s alpha ranged from 0.776 to 0.830. Higher scores on this scale correspond to better quality of life, whereas lower scores indicate lower quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIBM SPSS statistical software for Windows (version 26.0) was employed to calculate the differences between demographic characteristics and study variables. Descriptive statistics were utilized to present the baseline characteristics of the study sample. The included reporting frequencies and percentages for categorical variables and means and standard deviations for continuous variables. \u0026nbsp;To assess the longitudinal changes in quality of life scores at the four time points, repeated measures analysis of variance was conducted. Furthermore,the Friedman test was applied to evaluate the longitudinal changes in symptom cluster severity scores at the four time points, with significance level set at 0.05. \u0026nbsp;Subsequently,exploratory factor analysis was utilized to identify symptom cluster, \u0026nbsp;Symptom with an incidence rate of \u0026ge;15% at different time points were included in the factor analysis\u003csup\u003e[16]\u003c/sup\u003e.The following principles guide the extraction of symptom clusters: ① initial eigenvalue \u0026ge;1; ② factor loading \u0026gt;0.5; ③ factors comforming to Cartel\u0026rsquo;s \u0026Prime;steep order‶ test principle; ④ factors consisting of at least two items. Factors were named based on clinical expertise.\u0026nbsp;To explore the correlation between symptom clusters and quality of life,Pearson correlation analysis was employed.\u003c/p\u003e\n\u003cp\u003eIn the next step, to examine the relationship between symptom clusters and quality of life, a cross-lagged model was conducted and analyzed using Mplus8.0. In this analysis,covariates were included based on previous data that demonstrated associations with predictor or outcome variables. There covariates encompassed age, drinking history, distance from the lower edge of the tumor to the anal verge, marital status, medical expense burden, treatment method, T stage, and surgical method, The cross-lagged model, a structural model assessing interaction and longitudinal relationships between variables,was established. Four models were constructed to elucidate the causal predictive relationship between symptom cluster and quality of life: (1) Model 1 a stability model with symptom clusters and quality of life, devoid of cross-labeled structural paths. \u0026nbsp;(2) Model 2 building on Model 1,it incorporates a cross-lagged path from symptom clusters to quality of life. (3) Model 3 an extension of Model 2,it adds a cross-lagged path from quality of life to symptom cluster. (4) Model 4 includes all autoregressive and cross-lagged paths from Model 1-3. \u0026nbsp;These measures were repeated while exploring the bidirectional temporal relationship between each symptom cluster and quality of life. Standardized beta coefficients were employed to determine and compare the strength of associations. \u0026nbsp;Model fitting effectiveness was evaluated using the following criteria: Comparative Fit Index(CFI) \u0026ge; 0.95, Tucker-Lewis Index(TLI) \u0026ge; 0.95, Standardized Root Mean Square Residual (SRMR) \u0026le; 0.08, and Root Mean Square Error of Approximation (RMSEA) \u0026le; 0.06. A significance level of \u003cem\u003eP\u0026nbsp;\u003c/em\u003e＜ 0.05 was considered statistically significant. Chi-square difference tests were conducted to compare difference between nested models. It is noteworthy that previous literature recommended including more than 100 participants in any Mplus model,sand this study exceeded this requirement at all four time points.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCharacteristics of study participants.\u0026nbsp;The present study included those participants with complete sociodemographic information and health related factors at four survey time point.Depicted in table 1.\u003c/p\u003e\n\u003cp\u003eTable 1.Sample characteristics for those individuals included in the present analyses\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up 2weeks(n=140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up 1month(n=138)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up 3months(n=134)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up 6months(n=128)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eAge,years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e63.94(12.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e64.22(11.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e64.43(12.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e64.36(12.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eSex,n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e94(67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e92(66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e89(66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e85(66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e46(33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e46(32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e45(34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e43(34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eBMI,Kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e22.51(2.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e22.39(3.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e22.60(2.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e22.61(2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking,n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e89(64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e87(63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e83(62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e78(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e51(36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e51(37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e51(38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e50(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eDrinking,n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e97(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e95(68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e93(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e89(70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e43(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e43(32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e41(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e39(30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eoperation mode，n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eSingle-incision laparoscopic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e55(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e55(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e52(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e50(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eConventional laparoscopic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e85(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e83(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e82(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e78(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003edistance from lower margin of tumor to anal margin，n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003e＜5cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e14(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e14(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e14(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e14(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003e5-10cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e77(55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e76(55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e72(54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e66(52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003e＞10cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e49(35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e48(35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e48(36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e48(38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003esickness symptom cluster\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e0.95(0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e0.95(0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e0.94(0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e0.95(0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003egastrointestinal symptom cluster\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e2.01(1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e2.02(1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e1.99(1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e1.97(1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003epsychological-sleep symptom cluster\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e─\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e1.79(1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e1.79(1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e1.75(1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.704225352112676%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.781690140845072%\" valign=\"top\"\u003e\n \u003cp\u003e73.54(5.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e82.79(7.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e70.46(6.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.190140845070424%\" valign=\"top\"\u003e\n \u003cp\u003e87.96(5.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCorrelation analysis \u003cem\u003ePearson\u003c/em\u003e correlation analysis showed that there was a negative correlation between symptom cluster and quality of life in each survey wave (Table 1). The quality of life at four survey wave showed a significant moderate to strong correlation (correlation range from -0.369(\u003cem\u003eP\u003c/em\u003e＜0.01) to -0.661(\u003cem\u003eP\u003c/em\u003e＜0.01)). The correlation between gastrointestinal symptom cluster and quality of life was strongest at 2 weeks and 1 month after surgery (at 2 weeks after surgery r=-0.658 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01) , at 1 month after surgery r=-0.658(\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01)).\u0026nbsp;The correlation between psychological-sleep symptom cluster and quality of life is strongest at 3 months and 6 months after surgery (at 3 months after surgery r=-0.638 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01) , at 6 months after operation r=-0.547 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01)) .\u0026nbsp;Importantly, gastrointestinal symptoms had a significant negative correlation with quality of life in all four wave(correlation range from r=-0.252 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01) to -0.658 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01)), while other symptom cluster were not observed(Table 2).\u003c/p\u003e\n\u003cp\u003eTable2.Correlation analysis between symptom cluster and quality of life(*：＜0.05，**：＜0.01,T1:time1;T2:time2;T3time3;T4:time4;SSC:sickness symptom cluster;GSC:gastrointestinal symptom cluster;PSSC:psychological-sleep symptom cluster)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"931\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"bottom\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"bottom\"\u003e\n \u003cp\u003eT1QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"bottom\"\u003e\n \u003cp\u003eT2QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"bottom\"\u003e\n \u003cp\u003eT3QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"bottom\"\u003e\n \u003cp\u003eT4QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"bottom\"\u003e\n \u003cp\u003eT1SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"bottom\"\u003e\n \u003cp\u003eT2SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"bottom\"\u003e\n \u003cp\u003eT3SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"bottom\"\u003e\n \u003cp\u003eT4SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"bottom\"\u003e\n \u003cp\u003eT1GSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"bottom\"\u003e\n \u003cp\u003eT2GSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"bottom\"\u003e\n \u003cp\u003eT3GSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"bottom\"\u003e\n \u003cp\u003eT4GSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"bottom\"\u003e\n \u003cp\u003eT2PSSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"bottom\"\u003e\n \u003cp\u003eT3PSSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"bottom\"\u003e\n \u003cp\u003eT4PSSC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT1QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e74.32(4.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT2QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e84.48(6.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.661\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT3QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e72.30(7.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.389\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.577\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT4QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e88.85(5.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.479\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.354\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e.369\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT1SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e1.00(1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.533\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.357\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.447\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT2SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e0.80(0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.492\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.541\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.255\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.245\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.604\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT3SSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e0.00(1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.303\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.427\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.530\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.186\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n 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valign=\"top\"\u003e\n \u003cp\u003e-.530\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.319\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.277\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.369\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n 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\u003cp\u003e.468\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.096774193548387%\" valign=\"top\"\u003e\n \u003cp\u003eT4PSSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.849462365591398%\"\u003e\n \u003cp\u003e0.67(1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.261\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.269\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.331\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698924731182796%\" valign=\"top\"\u003e\n \u003cp\u003e-.547\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.293\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.322\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.340\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e.641\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e.244\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.591397849462366%\" valign=\"top\"\u003e\n \u003cp\u003e.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e.323\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e.473\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.129032258064516%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTemparal relationship\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Building upon the findings of the correlation analysis, We constructed a cross-lagged model to analyze the magnitude and directionality of the relationship between symptom cluster and quality of life.\u003c/p\u003e\n\u003cp\u003eCross-lagged path coefficients showed a negative relationship between quality of life and each symptom cluster.\u0026nbsp;We observed that quality of life at each survey wave statistically significantly predicted symptom clusters at the next wave (standardized path coefficients from -0.111 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05) to -0.237 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001)).\u0026nbsp;The same pattern occurred for repeated measures of quality of life and gastrointestinal symptom clusters over time (standardized path coefficients from -0.051 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05) to -0.252 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01)), and these coefficients were higher than Illness symptom cluster.\u0026nbsp;However, only the quality of life from 3 months to 6 months after surgery could statistically significantly predict the psychological-sleep symptom cluster in the next wave (standardized path coefficient was -0.540 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001)).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, all three models show that the effect of quality of life on symptom clusters is stronger than the effect of symptom clusters on quality of life.\u003c/p\u003e\n\u003cp\u003eCross-lagged path effects are critical to our study hypotheses, it suggests that the deterioration in quality of life may be associated with the heightened severity of symptom clusters. The temporal stability of gastrointestinal symptom cluster is higher than that of sickness symptom cluster and psychological-sleep symptom cluster(Figure1．Figure2．Figure3．)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSensitivity analysis\u003c/strong\u003e\u0026nbsp; \u0026nbsp;In order to evaluate the stability of bidirectional temporal relationship between symptom cluster and quality of life and eliminate the effects of confounding variable. we included gender, age, distance between the lower edge of the tumor and the anal verge, surgical method, treatment method, and clinical T stage as covariates in the above three models, there was no significant difference between the standardized regression coefficients. It shows that after controlling for more confounding variables, quality of life can still significantly and negatively predict symptom clusters, while symptom clusters do not significantly predict quality of life.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present longitudinal study,we construct a cross-lagged model to investigate the bidirectional temporal relationship between symptom cluster and quality of life and explore the direction and magnitude.The results revealed a consistent pattern that \u0026nbsp;the effect of quality of life on symptom clusters was stronger than the effect of symptom clusters on quality of life, with lower quality of life levels among rectal cancer survivors being associated with subsequent increases in symptom cluster severity.However, data from any survey wave were unable to demonstrate that symptom clusters predict quality of life.\u003c/p\u003e\n\u003cp\u003eA significant and noteworthy discovery from this study is the negative prediction of symptom cluster severity by the level of quality of life. This implies that a decline in quality of life precedes an increase in the severity of each symptom cluster, which serves as an expression of the quality of life.\u0026nbsp;The reason may be that the huge pain caused by symptom cluster to patients is generated by the superposition of multiple symptoms, and the impact of this superposition on patients increases exponentially, and the quality of life can clearly reflect the degree to which patients are affected by symptom clusters\u003csup\u003e[17]\u003c/sup\u003e.Secondly, it is reflected from the cross-lagged path coefficient that symptom clusters still have a partial impact on quality of life. Even if its impact is very weak, their association still exists. This indicates that the decline in quality of life may be related to the increase in the severity of symptom clusters, which is consistent with previous research results\u0026nbsp;\u003csup\u003e[10, 18]\u003c/sup\u003e.These findings suggest that the gastrointestinal symptom cluster, psychological-sleep symptom cluster, and sickness symptom cluster may play an important role in the development trajectory of postoperative quality of life of rectal cancer survivors, and therefore may be part of the treatment strategy to intervene in the quality of life of such patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of our study are contradictory to existing research results.\u0026nbsp;Previous studies believed that symptom clusters are factors affecting quality of life, and the decline in quality of life is due to the increase in the severity of symptom clusters\u003csup\u003e[10, 18, 19]\u003c/sup\u003e.Several explanations are plausible for these different findings.\u0026nbsp;First, some studies only conducted correlation analysis between them\u003csup\u003e[19, 20]\u003c/sup\u003e,and could not determine the causal relationship.\u0026nbsp;Although some studies have performed regression analysis on them\u003csup\u003e[10, 21]\u003c/sup\u003e,their cross-sectional nature limits the time dimension and cannot verify the potential causal effect mechanism of the them, that is, appropriate temporal order is a necessary prerequisite for causality\u003csup\u003e[17]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The results of this study show that changes in the severity of gastrointestinal symptom clusters, psychological-sleep symptom clusters, and sickness symptom clusters do not significantly predict quality of life. The reason may be that quality of life is a multi-dimensional evaluation of patients\u0026rsquo;\u0026nbsp;physical functions, psychological functions, social relationships, etc., and is a key indicator for evaluating clinical treatment and rehabilitation effects\u003csup\u003e[22]\u003c/sup\u003e.The main determinants of the postoperative quality of life of patients with rectal cancer are the patient\u0026apos;s disease process and treatment effect.\u0026nbsp;However, the symptom cluster is only a reflection of part of the body\u0026apos;s functional status and cannot accurately evaluate the quality of life.\u0026nbsp;Secondly, the symptom clusters are diverse.\u0026nbsp;Affected by the cancer itself and its treatment, the number and type of symptom clusters show longitudinal stability and transverse variability over time.\u0026nbsp;Another possible explanation is that there is a longitudinal mediating effect that affects their influencing mechanisms.\u0026nbsp;For example, in a study of 175 patients with atrial fibrillation, Chohee Bang et al found that symptoms of atrial fibrillation increased patients\u0026apos; depression and anxiety and further affected their quality of life\u003csup\u003e[23]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOur study currently has some limitations. First, we only used self-reported measures to assess symptom cluster severity and quality of life levels. These are not exact clinical diagnoses, and there is a lack of objective measurement data. Therefore, there is a certain measurement deviation. Secondly, although we adjusted for a wide range of potential confounding variables, we cannot rule out that other variables and conditions (e.g., previous illness, physical activity, medication intake, time of measurement) may also influence the revealed effects. Third, our sample size is small, and responses to the relationship may lack representativeness. Fourth, our measurement period was short, only 6 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study also has several strengths. Notably, we employed a powerful analytical approach that offers several important advantages over traditional multiple regression techniques, first by maximizing sample size reduction by avoiding missing data at a single time point. Maximizes the utility of large sample sizes. Secondly, they enable testing of the temporal direction of association, a prerequisite for investigating potential causal associations. A key strength of this study is our four-band longitudinal study design, which provides the opportunity to accurately assess the actual relationship.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.Y,Z.X.X,W.X.F,performed the measurements. Y.C.X ,X.G.Q and K.H.Y designed the model. Y.C.X and K.H.Y designed the computational framework and analysed the data. Y.C.X,J.M.Y and L.S conceived the original project. K.H.Y and X.G.Q supervised the project. J.M.Y and Y.C.X pre-analysed and prepared the heart rate data and contributed to the interpretation of the findings.Y.C.X and X.G.Q took the lead in writing the manuscript. All authors discussed the results and contributed to the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e \u003cp\u003eThe raw data are not publicly available due to the participant\u0026rsquo;s privacy, but derived data supporting the findings are available from the corresponding author by reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eXi Y, Xu P. Global colorectal cancer burden in 2020 and projections to 2040[J]. Transl Oncol, 2021,14(10): 101174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahjehan F, Kasi P M, Habermann E, et al. Trends and outcomes of sphincter-preserving surgery for rectal cancer: a national cancer database study[J]. Int J Colorectal Dis, 2019,34(2): 239\u0026ndash;245.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Tang H, Zhang Y, et al. Experiences of bowel symptoms in patients with rectal cancer after sphincter-preserving surgery: a qualitative meta-synthesis[J]. Support Care Cancer, 2022,31(1): 23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris C S, Dodd M, Kober K M, et al. Advances in Conceptual and Methodological Issues in Symptom Cluster Research: A 20-Year Perspective[J]. ANS Adv Nurs Sci, 2022,45(4): 309\u0026ndash;322.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikh-wu S F, Anglade D, Gattamorta K A, et al. Symptom Occurrence, Frequency, and Severity During Acute Colorectal Cancer Survivorship[J]. Oncol Nurs Forum, 2022,49(5): 421\u0026ndash;431.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePotosky A L, Graves K D, Lin L, et al. The prevalence and risk of symptom and function clusters in colorectal cancer survivors[J]. J Cancer Surviv, 2022,16(6): 1449\u0026ndash;1460.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaraldstad K, Wahl A, Andenaes R, et al. A systematic review of quality of life research in medicine and health sciences[J]. Qual Life Res, 2019,28(10): 2641\u0026ndash;2650.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoon M, Dennis K, Deangelis C, et al. Symptom clusters of gastrointestinal cancer patients undergoing radiotherapy using the Functional Living Index-Emesis (FLIE) quality-of-life tool[J]. Support Care Cancer, 2015,23(9): 2589\u0026ndash;2598.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams S V, Ceballos R, Newcomb P A. Quality of Life and Mortality of Long-Term Colorectal Cancer Survivors in the Seattle Colorectal Cancer Family Registry[J]. PLoS One, 2016,11(6): e156534.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Xie Z, Liu Y, et al. Symptom clusters and impact on quality of life in esophageal cancer patients[J]. Health Qual Life Outcomes, 2022,20(1): 168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRha S Y, Lee J. Symptom clusters during palliative chemotherapy and their influence on functioning and quality of life[J]. Supportive Care in Cancer, 2017,25(5): 1519\u0026ndash;1527.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleeland C S, Mendoza T R, WANG X S, et al. Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory[J]. Cancer, 2000,89(7): 1634\u0026ndash;1646.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X S, Williams L A, ENG C, et al. Validation and application of a module of the M. D. Anderson Symptom Inventory for measuring multiple symptoms in patients with gastrointestinal cancer (the MDASI-GI)[J]. Cancer, 2010,116(8): 2053\u0026ndash;2063.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X S, Wang Y, Guo H, et al. Chinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients[J]. Cancer, 2004,101(8): 1890\u0026ndash;1901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan Z,Lu Y B, Wan C H,et al.Development of the system of quality of life instrumentsfor cancer patients:colorectal cancer(QLICP-GR)[J]. Cancer, 2008,27(1): 96\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi N N,Wu J,Xu M,et al. analysis of symptom groups and influencing factors for patients with lung cancer chemothera[J]. J Nurses Train, 2018,33(22): 2029\u0026ndash;2032.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAaltonen S, Latvala A, ROSE R J, et al. Leisure-Time Physical Activity and Academic Performance: Cross-Lagged Associations from Adolescence to Young Adulthood[J]. Sci Rep, 2016,6: 39215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Wang J, Chen T, et al. Symptom Clusters and Quality of Life in Cervical Cancer Patients Receiving Concurrent Chemoradiotherapy: The Mediating Role of Illness Perceptions[J]. Front Psychiatry, 2021,12: 807974.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen F, Leng Y, Ni J, et al. Symptom clusters and quality of life in ambulatory patients with multiple myeloma[J]. Support Care Cancer, 2022,30(6): 4961\u0026ndash;4970.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodgers C C, Hooke M C, Taylor O A, et al. Childhood Cancer Symptom Cluster: Leukemia and Health-Related Quality of Life[J]. Oncol Nurs Forum, 2019,46(2): 228\u0026ndash;237.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu L, Feng X, Jin Y, et al. Symptom Clusters and Quality of Life in Gastric Cancer Patients Receiving Chemotherapy[J]. J Pain Symptom Manage, 2022,63(2): 230\u0026ndash;243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOcalewski J, Jankowski M, Zegarski W, et al. The Role of Health Behaviors in Quality of Life: A Longitudinal Study of Patients with Colorectal Cancer[J]. Int J Environ Res Public Health, 2023,20(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBang C, Park S. Symptom Clusters, Psychological Distress, and Quality of Life in Patients with Atrial Fibrillation[J]. Healthcare (Basel), 2023,11(9).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"rectal neoplasm, symptom cluster, quality of life, bidirectional relationship","lastPublishedDoi":"10.21203/rs.3.rs-3933341/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3933341/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSymptom cluster and quality of life are negatively associated, but the prospective inter-relationship between them were unknown,which may provide a mechanism insight for symptom cluster management. A longitudinal study was conducted among 140 patients who undergoing laparoscopic-assisted sphincter-preserving surgery for rectal cancer between 2021 to 2022. We investigated the longitudinal associations of the change of symptom cluster with the trajectories of quality of life. These patients were assessed for symptom clusters and quality of life at specific time points: 2 weeks (T1), 1 month (T2), 3 months (T3) ,and 6 months (T4) after their surgeries.\u0026nbsp; In our Pearson correlation analysis, the quality of life within 6 months after surgery showed a moderate-to-strong strength correlation (r=0.27-0.66) between the quality of life within the first 6 months post-surgery. There was also a significantly negative correlation between each symptom cluster and the quality of life at all four time points. Our cross-lagged model revealed a unidirectional temporal relationship between quality of life and symptom cluster. the quality of life level at these four time points could significantly and negatively predict the severity of each symptom cluster, with no observed reverse path. Importantly, the cross-lagged path coefficient from quality of life to symptom cluster was notably greater than the coefficient from symptom cluster to quality of life. These findings provide evidence that lower quality of life precede higher symptom cluster severity in rectal cancer survivor. This temporal \u0026nbsp;relationship begins early in the post-surgery period, highlighting the importance of early quality of life intervention to help patients improve their symptom clusters.\u0026nbsp; Keywords:rectal neoplasm;symptom cluster;quality of life;bidirectional relationship\u003c/p\u003e","manuscriptTitle":"Temporal relationship between symptom cluster and quality of life in rectal cancer survivor","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 16:46:55","doi":"10.21203/rs.3.rs-3933341/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-01T19:05:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-28T13:47:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137325595479196341115307660255919743142","date":"2024-10-17T11:01:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T07:49:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146478669385738987594261962862752398474","date":"2024-07-08T07:14:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-24T05:33:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-15T10:30:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-19T02:42:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-19T00:22:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-02-06T08:57:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8718c3d-250d-4591-bafc-fd9db43e5303","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":29732334,"name":"Biological sciences/Cancer"},{"id":29732335,"name":"Health sciences/Gastroenterology"},{"id":29732336,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2025-01-06T16:02:35+00:00","versionOfRecord":{"articleIdentity":"rs-3933341","link":"https://doi.org/10.1038/s41598-024-83755-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-12-30 15:57:37","publishedOnDateReadable":"December 30th, 2024"},"versionCreatedAt":"2024-03-21 16:46:55","video":"","vorDoi":"10.1038/s41598-024-83755-z","vorDoiUrl":"https://doi.org/10.1038/s41598-024-83755-z","workflowStages":[]},"version":"v1","identity":"rs-3933341","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3933341","identity":"rs-3933341","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}