In history, economics, and psychology, it’s a fundamental truth: Past events/performance/behavior predicts future events/performance/behavior. And that’s the lesson we can take from an important Australian study of colorectal cancer survivors in the journal Quality of Life Research (2012;21:1551-64).
As noted by the authors, well-designed prospective studies about the long-term adjustment of colorectal cancer survivors are few and far between. That’s why they set about prospectively following a population-based cohort of colorectal cancer patients from 5 months post diagnosis to 5 years post diagnosis, determining the trajectory of their adjustment and quality of life (QoL) from a sociodemographic, medical, and psychological perspective.
What did they find?
"Importantly," they wrote, "the strongest predictor for long-term outcomes was the baseline values of health-related and global quality of life soon after diagnosis."
In other words, patients who at 5 months post diagnosis were optimistic, euthymic, and secure financially and in their relationships, continued to do well at 5 years.
It makes sense.
But the data also held key lessons about identifying people most likely to take their diagnosis in stride, seek out and receive good care, and then rebound – versus individuals at the other end of the spectrum, who started out not coping well and failed to rally.
First, some details about the study. Led by Professor Suzanne K. Chambers, a health psychologist at Griffith University’s Gold Coast campus in Queensland, Australia, the research team mined the Queensland cancer registry to locate 1,825 adults who were diagnosed with colorectal cancer during 2003-2004 and had signed up for a longitudinal study shortly after diagnosis.
Five months into their treatment, participants filled out an extensive battery designed to measure demographic variables, disease stage, treatment, physical function, cancer threat appraisal (how the disease affected their sense of identity, relationships, and perceptions of the future), perceived social support, quality of life, and psychological distress (depression, anxiety, and somatization).
Five years later, 259 (21.2%) had died.
Others were not included in the study because they failed to complete follow-up paperwork; notably, these nonresponders tended to be male, younger, uninsured, and smokers, and tended to have more advanced cancer, a more negative view of the threat of their cancer, higher somatization, and lower FACT-C (Functional Assessment of Cancer Therapy – Colorectal) scores. In other words, this group was fairly reflective of those patients who had not fared well on follow-up – possibly suggesting that the study’s findings were underestimates of the impact of identified risk factors on future distress.
Extreme contrast in survival rates among patients with stage 0 disease (100% of whom survived 5 years) and stage IV disease (5-year survival rate, 18.5%) led the researchers to focus only on patients with stage I-III disease, a total of 763 patients.
Five years following diagnosis, the group overall showed significantly improved health-related and global QoL, leading the researchers to conclude, reassuringly, that in general, colorectal cancer patients "adjust well to their cancer experience."
Psychological distress, however, did not show the same healing trajectory.
Given a relatively low distress rate initially, a statistical "floor effect" might account for this. Nonetheless, the study revealed subgroups of patients who were quite distressed initially and did not improve over time.
What risk factors at 5 months post diagnosis predicted poorer quality of life and/or greater psychological distress 5 years post diagnosis? Here’s the breakdown:
| Protective Factors | Elevated Risk for Distress |
|---|---|
| Being female | Being single |
| Good social support | Low social support |
| Positive outlook on cancer’s threat | Negative appraisal of cancer’s threat |
| Having a pet | Lower initial QoL |
| Optimism | Low optimism |
| Private health insurance | Rectal cancer |
| Surgery and adjuvant therapy | Permanent stoma |
| Later-stage disease | |
| Being fatigued | |
| Being a smoker |
The lists paint a picture, do they not?
On one side, we have single, pessimistic people who were not surrounded by, and shored up by, a network of close friends and family during their initial cancer treatment. On the other, we have women who were predisposed to view life optimistically and graced as well by strong social networks, good insurance and treatment options, and, not trivially, the love of a pet.
Certainly, it would not be difficult to identify, early on, those on the elevated-risk list, and customize support aimed at building their comfort networks and personal resilience.
"Consistent with response shift theory, the antecedents of QoL after colorectal cancer are multifactorial and include predisposing sociodemographic, medical, and psychosocial variables," the authors concluded.
"Psychosocial interventions that target both social support and threat appraisal may be effective for this patient group."
Such interventions, they suggest, would include maximizing of social support, as well as cognitive behavioral therapy designed "to challenge unhelpful or unrealistically negative cognitions about cancer."