Determination of Quality of Life and Self-Care Agency in Patients Who Underwent Colorectal Cancer Surgery: A Prospective Descriptive Study

Cancer is a significant disease that causes serious problems in patients’ lives and affects their quality of life due to both the nature of the disease and the effects of treatment.¹ One of the most common types of cancer is colorectal cancer.² According to the 2018 data from the Global Cancer Observatory, colorectal cancer has the third highest incidence rate (10.2%) among all cancers worldwide for both sexes and has a mortality rate of 9.2%.^3,4 According to the Turkey Cancer Statistics 2016 data, colorectal cancer ranks third among the 10 most common cancers in both men and women.^5,6 

Patients with colorectal cancer are often treated with surgical intervention.⁷ In patients with colorectal cancer who have undergone surgery, factors such as loss of organ/function due to surgery, changes in lifestyle, treatments, complications, and cancer causes can lead patients to have many physical, psychological, and socioeconomic problems.^8–10 In addition, side effects of chemotherapy and radiation therapy include nausea, vomiting, fatigue, and insomnia, which negatively affect overall health.^10–12

Self-care agency is the skill to initiate or perform health activities to maintain one’s life, health, and well-being.¹³ According to Orem,¹³ an individual needs to have sufficient self-care agency to meet the requisites of self-care. Many studies have indicated that cancer negatively affects self-care agency.^14–16 In a descriptive and longitudinal study in which colorectal cancer patients with diarrhea evaluated symptom distress and self-care strategies for up to 3 months after surgery, Pan et al¹⁶ found that the self-care strategies of patients increased over time. In a study of the function of fatigue and illness perceptions as mediators between self-efficacy and health-related quality of life during the first year after surgery in people receiving colorectal cancer treatment, Johansson et al¹⁴ found that self-efficacy decreased in the first year compared with the third month after surgery. As can be understood from these studies, the long-term self-care agency of individuals who have undergone surgery due to colorectal cancer varies depending on many factors, including those mentioned above. There are other follow-up studies in the literature evaluating the postoperative quality of life in patients with colorectal cancer.^14,17–19 In addition, there are also studies evaluating the self-care experiences of patients with colorectal cancer as well as follow-up studies evaluating postoperative self-efficacy, self-care strategies, self-care information Access, and self-care needs in patients with colorectal cancer.^{14–16,19–21} However, the authors found no evidence of a follow-up study that examined quality of life and self-care together in patients with colorectal cancer in Turkey. The purpose of this study was to examine the correlation between quality of life and self-care agency of patients following surgery for colorectal cancer in Turkey. 

The study was conducted between October 5, 2017, and September 10, 2018, in the general surgical clinics of 2 training and research hospitals in a metropolitan city in Turkey. Using a prospective, descriptive design, all patients who met the the following inclusion criteria were enrolled; being an inpatient for surgery with a diagnosis of colorectal cancer, being willing to participate in the study, being older than 18 years of age, having no sensory loss such as vision or hearing, and being conscious and able to answer questions. Patients diagnosed with mental illness, mental disability, or impaired cognitive abilities were not eligible to participate. 

Patients were interviewed immediately after admission to the preoperative clinic. The purpose and method of the study, expectations of the patient, and data collection forms were explained to the patients, and informed consent was obtained. The patients were informed that they would participate in the study preoperatively and postoperatively; that is, they would answer the questions in the data collection form preoperatively and at 1, 3, and 6 months after surgery.

Data collection form. The data collection form consists of 4 parts: the Sociodemographic Data Form, the Quality of Life Scale for Cancer Patients (EORTC QLQ-C30) Turkish Version 3.0), the Quality of Life Scale for Colorectal Cancer Patients (EORTC QLQ-CR29), and the Self-Care Agency Scale.

The Sociodemographic Data form was developed based on the literature and both researchers’ experience.^2,22–24 The Sociodemographic Data Form consists of 5 questions about sociodemographic characteristics (age, sex, marital status, education level, and employment status) and 3 questions about postoperative health characteristics (a person to assist with activities of daily living, meeting daily needs [eg, eating, dressing, and bathing], and stoma type). 

The EORTC QLQ-C30 was developed by the European Organisation for Research and Treatment of Cancer (EORTC) in 1987 as a cancer-specific quality of life scale, and the content validity and reliability study of the scale was conducted by Beser and Öz.²⁵ The EORTC QLQ-C30 consists of 30 questions and evaluates 3 areas: general well-being, functional status, and symptom control. The Cronbach alpha coefficient of the scale is 0.9014. In this study, the Cronbach alpha coefficient of the scale was 0.865.

The EORTC QLQ-CR29 was developed specifically for colorectal cancer, and the Turkish validity and reliability study was conducted by Akduran.² According to the Turkish validity and reliability results, the EORTC QLQ-CR29 has 4 dimensions: general health problems, urinary system pleasure, excretory system pleasure, and drug side effects. Low scores indicate an increased quality of life. The Cronbach alpha coefficient of the scale is 0.762 for the 31st through 47th items of EORTC QLQ-CR29, 0.738 for those with a stoma bag, 0.738 for those without a stoma bag, –1.178 (the value is negative due to negative mean covariance among the items) for EORTC QLQ-CR29 male sexuality, and 0.879 for EORTC QLQ-CR29 female sexuality. In this study, the Cronbach alpha coefficient of the EORTC QLQ-CR29 scale was 0.812. The coefficient was found to be 0.851 for general health problems, 0.797 for urinary system pleasure, 0.797 for excretory system pleasure, and 0.777 for drug side effects.

The Self-Care Agency Scale was developed by Kearney and Fleischer²⁶ in English and consists of 43 items. The scale was adapted for use in Turkish adolescents by Nahcivan,²⁷ and the number of items was reduced to 35. It is frequently used in current research in Turkey. The scale focuses on the self-assessment of self-care actions. It is a 5-point Likert-type scale, and each item is scored from 0 to 4 points. A high score obtained from the scale indicates a high self-care agency or self-care ability. The maximum score is 140. There is no cut-off value. The Cronbach alpha coefficient of the scale adapted by Nahcivan is 0.89. In this study, the Cronbach alpha coefficient of the scale was 0.927.

Ethical considerations. Written permission was obtained from the relevant institutions (number 41303261-799 E147, date: October 18, 2017, and number E148844, date: October 19, 2017). Ethics committee approval (number E.165232, November 20, 2017) was also obtained. In addition, written informed consent was obtained from the patients who participated in the study. 

Implementation of research. The aim and method of the study were explained to the patients who met the research criteria during a face-to-face interview at the hospital by 1 of the researchers the day before the surgery and the Sociodemographic Data Form, quality of life scales (EORTC QLQ-C30 and EORTC QLQ-CR29), and Self-Care Agency Scale were completed. Patients completed the EORTC QLQ-C30, EORTC QLQ-CR29, and Self-Care Agency Scale face-to-face at the hospital within 1 month after surgery (on the fifth to seventh day and just before discharge), and via telephone at the third and sixth postoperative months. It took approximately 20 to 25 minutes to complete the data collection forms on paper. 

Data management and analysis. Statistical analyses were conducted by a statistician using the SPSS 24.0 (IBM SPSS) software. Tables of frequency and descriptive statistics were used to interpret the findings. The independent sample t test, repeated measures test, Mann-Whitney U-test, and Friedman test were used.

Power analysis was performed using the Gpower, 3.1 program. The target sample size was calculated as 45 with 5% margin of error and 90% power. Five (5) patients withdrew from the study because they did not feel well during the follow-up period, and 3 patients died. Therefore, 37 patients who met the inclusion criteria participated in the study. When the target sample size could not be reached, power analysis was performed using the Gpower, 3.1 program to calculate the power of the study; calculated power should be at least 80%. As a result of the power analysis performed to eliminate doubts about the adequacy of the sample size, the power of the study was found to be 80, which is sufficient with a 5% margin of error.

The mean age of the 37 patients participating in the study was 59.49 ± 10.84 years (range, 18–79); 22 (59.5%) were male, 33 (89.2%) were married, 21(56.8%) were primary school graduates (4 years of schooling), and 31 (83.2%) were unemployed (Table 1). The majority of patients (25 [67%]) did not have a stoma postoperatively (Table 2); of the 12 patients who did, 1 had an ileostomy and 2 had a colostomy preoperatively. 

Thirty-six (36) patients (97.3%) in the first month, 35 patients (94.6%) in the third month, and 35 patients (94.6%) in the sixth month postoperatively needed a person to assist with activities of daily living (Table 2). Twenty-two (22) patients (59.5%) in the first month, 33 patients (89.2%) in the third month, and 34 patients (91.9%) in the sixth month postoperatively met their daily needs independently.

General well-being scores decreased in the postoperative first month, increased significantly in the third and sixth months, and reached a significantly higher score compared with the preoperative period (58.3 vs 75.0 and 83.3; P = .000) (Table 3). Functional scores decreased at postoperative 1 month but increased statistically significantly at 3 and 6 months after surgery (75.6 vs 84.4 and 91.1; P = .000). Likewise, physical function scores decreased in the postoperative first month and increased in the third and sixth months after the surgery (60.0 vs 73.3 and 80.0; P = .000). Whereas role performance scores decreased in the first postoperative month, they reached the preoperative level in the sixth month (83.3 vs 100.0; P = .000). Preoperative emotional status scores increased in the sixth month postoperatively (83.3 vs 100.0; P = .003). Social status scores decreased in the first postoperative month but reached the preoperative level at the sixth month (66.7 vs 100.0; P = .005). Symptom control scores were highest at 1 month postoperatively but decreased at 6 months (17.9 vs 7.7; P = .000). Likewise, although fatigue scores were higher in the first month postoperatively compared with the preoperative period, they decreased significantly in the sixth month postoperatively (44.4 vs 11.1; P = .000). In addition, preoperative pain scores significantly decreased in the sixth month (16.7 vs 0.0; P = .000) (Table 3). Preoperative excretory system scores decreased significantly in the third and sixth month postoperatively (1.7 vs 1.0; P = .001) (Table 4). 

A statistically significant difference was found in Self-Care Agency scores over time; the scores were higher at the sixth month than at the first month postoperatively (109.62 ± 11.62 vs 115.19 ± 14.22; P = .006) (Table 5). Table 6 shows that the relationship between the preoperative Self-Care Agency scores and the physical function scores of the EORTC QLQ-C30 scale was positive and weak (P = .033). The correlation between preoperative Self-Care Agency scores and the EORTC QLQ-C30 scores for symptom control was negative and weak (P = .033), as was the correlation between preoperative Self-Care Agency scores and the EORTC QLQ-C30 scores for pain (P = .024) and the EORTC QLQ-C30 scores for loss of appetite (P =.003).

The relationship between Self-Care Agency scores and functional status scores of the EORTC QLQ-C30 scale was positive and moderate at 3 months postoperatively (P = .000). In addition, the relationship between Self-Care Agency Scale scores and global health status scores of the EORTC QLQ-C30 scale was positive and weak at 3 months postoperatively (P = .007), as was the relationship between Self-Care Agency Scale scores and emotional state scores of the EORTC QLQ-C30 scale (P = .045) and the social status scores of the EORTC QLQ-C30 (P = .015). The relationship between the Self-Care Agency Scale scores at 3 months postoperatively and the EORTC QLQ-C30 fatigue scores was negative and weak (P = .050).

The relationship between the Self-Care Agency Scale scores and the functional status scores of the EORTC QLQ-C30 scale was positive and moderate at 6 months postoperatively (P = .000). The relationship between Self-Care Agency Scale and general well-being scores of the EORTC QLQ-C30 scale was positive and weak  at 6 months postoperatively (P= .010), as was the relationship between Self-Care Agency Scale and the physical function, emotional function scores of the EORTC QLQ-C30 (P = .005). The relationship between Self-Care Agency and EORTC QLQ-C30 scale fatigue scores was negative and weak at 6 months postoperatively (P = .002) (Table 6). 

The relationship between the postoperative first-month Self-Care Agency scores and the general health problems scores of the EORTC QLQ-CR29 scale was negative and weak (P = .024). Relationships were also negative and weak between the postoperative third-month Self-Care Agency scores and the general health problems scores of the EORTC QLQ-CR29 (P = .031) as well as the postoperative sixth-month Self-Care Agency scores and the general health problems scores of the EORTC QLQ-CR29 (P = .009) (Table 7).

Change in quality of life according to time. In this study, EORTC QLQ-C30 subdimension scores decreased in the first month postoperatively but significantly increased in the third and sixth months (Table 3). Gervaz et al²⁸ conducted a follow-up study with 20 patients with rectal cancer after abdominoperineal resection surgery; 1-year (first month, sixth month, and 12th month) evaluations of quality of life using EORTC QLQ-C30 and EORTC QLQ-CR38 found that there was a significant increase in general health perception, physical function, and role function subdimension scores over time. In a follow-up study conducted by Carlsson et al¹⁸ with 57 patients with rectal cancer using the SF36 quality of life scale, the scores on 6 (except general health and mental health) of 8 subdimensions (physical function, role constraint-physical, pain, vitality/fatigue, social function, role constraint-emotional, mental health, and general health perception) decreased significantly; however, it was found that there was a significant increase in the scores in the sixth month after ostomy surgery. 

In a 1-year follow-up study (preoperative period and postoperative second, sixth, and 12th months) conducted by Ito et al¹⁷ using the SF36 Quality of Life Scale in 18 patients with rectal cancer who underwent surgery, it was found that the SF36 scores decreased in the second month after colostomy surgery; however, the scores increased to the preoperative level in the sixth and 12th months. In addition, Ito et al¹⁷ also reported all the following results. There was a significant improvement in mental health, pain, and fitness subdimensions in the sixth and 12th months, and the scores reached a level higher than that in the preoperative period. Role function subdimension scores of 7 patients who participated in all 4 periods of that study was 25.6 ± 16.8 in the postoperative second month and increased to 42.1 ± 10.3 in the postoperative 12th month. Patients’ score from the pain subdimension of the SF36 scale was 43.7 ± 14.0 in the preoperative period and significantly (P = .02) increased to 49.9 ± 11.3 in the sixth month and to 51.2 ± 11.8 in the 12th month. In addition, scores from the cognitive function subdimension were 43.8 ± 15.5 in the postoperative second month and increased to 51.0 ± 12.0 in the sixth month and to 55.1 ± 9.4 in the 12th month.

The findings of the current study are similar to the results in the above-mentioned studies. However, Johansson et al¹⁴ found dissimilar results. That prospective and longitudinal study sought to determine the effect of changes in quality of life, fatigue, illness perception, and self-efficacy within 1 year after colorectal cancer surgery. It also evaluated self-efficacy, fatigue, and illness perception in the third and 12th months postoperatively. The study was carried out with 39 patients with colorectal cancer using the EORTC QLQ-C30 Revised Illness Perception Questionnaire and Maintain Function Scale. It was found that the self-efficacy of patients decreased in the 12th month compared with the third month; however, there was no significant change in quality of life.

The EORTC QLQ-C30 symptom control, fatigue, and pain scores of patients included in the current study were high in the postoperative first month and decreased significantly in the sixth month (Table 3). Likewise, there was a significant decrease in EORTC QLQ-CR29 excretory system pleasure compared with the preoperative period (Table 4). In the 1-year follow-up study conducted by Gervaz et al,²⁸ there was a significant decrease in symptom scale scores, such as fatigue and sleep disorders, over time. These findings are consistent with current study findings. 

According to our study findings, the quality of life of patients with colorectal cancer generally decreased in the general well-being and functional status subdimensions in the first month after surgery and pain scores also increased. However, at 6 months after surgery, quality of life increased relatively with a decrease in symptoms, an increase in general well-being, and an increase in functional status.

Self-Care Agency Scale scores. Self-care agency scores were significantly higher at the sixth month after surgery compared with the first month (Table 5). Although self-care agency may be negatively affected by surgery and complications that may develop due to surgery, it can improve over time. In a 3-month follow-up study conducted by Pan et al,¹⁶ which conducted one-on-one interviews with 35 patients who underwent surgery due to colorectal cancer, it was found that patient self-care strategies increased over time. Unlike our current study results, in the 1-year follow-up study conducted by Johansson et al¹⁴ with 39 postoperative colorectal cancer patients using QLQ-C30 (illness perception and function scales), it was found that self-efficacy of the patients decreased in the postoperative 12th month compared to the third month. 

Correlation between Quality of Life and Self-Care Agency Scale scores. There was a positive correlation between the EORTC QLQ-C30 scale and the Self-Care Agency Scale scores in the current study; in addition, as self-care agency increased, quality of life increased as well and vice versa (Table 6). In the postoperative period, there was a negative correlation between the EORTC QLQ-CR29 general health problem scores and the Self-Care Agency Scale scores; as self-care agency increased, general health problems decreased (Table 7). In the study conducted by Altiparmak et al¹ with 84 patients with lung cancer using EORTC QLQ-30 and the Self-Care Agency Scale, there was a positive correlation between self-care agency and physical function, role function, and social function. In a study conducted by Su et al¹⁵ with 150 patients with ostomy using the Chinese version of the Stoma Self-Efficacy Scale, City of Hope-Quality of Life-Ostomy Questionnaire, and Perceived Social Support Scale, there was a positive correlation between self-efficacy and quality of life of patients at least 4 weeks after surgery. In summary, in this study, self-care agency affected patient quality of life.

The study was limited to 37 patients who underwent follow-up in the general surgery clinics of 2 hospitals in Ankara, Turkey, between October 5, 2017, and September 10, 2018. For these reasons, the study cannot be generalized. In addition, the number of patients with stoma was limited. Therefore, the effect of stoma could not be studied. 

In this study, in which the preoperative and postoperative quality of life and self-care agency of 37 patients with colorectal cancer was evaluated prospectively, quality of life generally decreased in the postoperative first month but increased in the third and especially the sixth month following surgery. Self-Care Agency Scale scores 6 months after surgery were higher than preoperative values. In addition, there was a correlation between self-care agency and quality of life scores; better self-care agency correlated with better quality of life.. This study sheds light on the changes in the quality of life and self-care agency of patients with colorectal cancer before and after surgery. Care strategies to improve the quality of life and self-care capabilities of patients should be developed. In this context, future studies of nursing care, education, rehabilitation, and counseling services that support the self-care agency and quality of life of patients are recommended. 

Ms. Aktaş is a nurse, Dişkapi Yildırim Beyazit Training and Research Hospital, Ankara, Turkey. Dr. Baykara is an associate professor, Gazi University, Faculty of Health Science, Department of Nursing, Ankara, Turkey. Address all correspondence to: Nurhan Aktaş, RN, Dişkapi Yildirim Beyazit Training and Research Hospital, Ziraat Mahallesi, Şehit Ömer Halisdemir Caddesi, Dışkapı, Ankara, Turkey 06110; email: nurhankutlu90@gmail.com.