DOI:10.31557/APJCP.2022.23.4.

1301
Quality of Life Colorectal Cancer KSA

RESEARCH ARTICLE Editorial Process: Submission:10/23/2021 Acceptance:04/24/2022

Quality of Life and Psychological Wellbeing of Colorectal

Cancer Survivors in the KSA
Munir Abu-Helalah1,2*, Hani Mustafa3, Hussam Alshraideh4, Abdullah Ibrahim
Alsuhail5, Omar A Almousily6, Ruba Al-Abdallah7, Ashwaq Al Olayan8

Abstract
Introduction: Colorectal cancer (CRC) ranked first among cancers reported in males and ranked third amongst
females in Saudi Arabia. CRC cancer symptoms or symptoms secondary to treatment, such as diarrhea, constipation,
fatigue and loss of appetite are very common and has significant negative effects on the quality of life (QoL). Methods:
This project was a cross-sectional study of colorectal cancer survivors diagnosed between 1 January 2015 and May
2017. Assessment was performed using the European Organization for Research and Treatment of Cancer Quality of
Life Questionnaire (EORTC QLQ-C30), the colorectal cancer specific module (EORTC QLQ-CR 29) and the Hospital
Anxiety and Depression Scale (HADS). Data on potential predictors of scores were also collected. Results: 115 CRC
patients from Middle, Eastern and Western regions of the KSA participated in the study. Participants have unexpectedly
low global health score with a mean of 56.9±31.3. Physical functioning scale had the lowest score of 61.3±27.7.
Regarding the generic symptoms of cancer, fatigue was the worst symptom, followed by appetite loss. Psychological
wellbeing assessment utilizing HADS reveals alarming outcomes for survivors of CRC in the KSA with high proportion
of participants with moderate to severe depression (55%) and a good proportion of participants with moderate to high
anxiety (31%). Only 3.7% of participants reported receiving psychosocial support. Discussion: Results of this project
reveal an overall trend of low scores of quality of life amongst colorectal cancer patients in the KSA when compared
with regional or international figures. Consistent results for psychological wellbeing were reached. We recommend
routine screening for quality of life and psychological wellbeing and including the outcomes per individual patient
care. Psychological support is highly needed for cancer survivors.

Keywords: Colorectal cancer- quality of life- psychological wellbeing- Saudi Arabia

Asian Pac J Cancer Prev, 23 (4), 1301-1308

Introduction Colorectal cancer (CRC) in this paper refers to cases

of colon cancer, rectal cancer, or colorectal cancer. CRC
Cancer is a major public health problem in the KSA. It cancer symptoms or symptoms secondary to treatment,
is the second leading cause of death in the KSA. Colorectal such as diarrhea, constipation, fatigue, and loss of appetite
ranked first among cancers reported in males and ranked are very common and has significant negative effects on
third amongst females. The five-year overall survival for the quality of life (QoL) (Steginga et al., 2009; Gray et al.,
1994–2004 was 44.6% for patients with colorectal cancer 2011; Pan and Tsai, 2012). Consequently, CRC patients
(Al-Ahwal et al., 2013). In 2018, 4007 new colorectal have significantly poorer physical and mental quality of
cancer cases were diagnosed in the KSA, contributing to life scores when compared with the general population or
14.4% of all cancers (Who, 2018). with patients without cancer (Smith et al., 2008). Stage of
The overall Age-standardized Incidence Rate (ASR) cancer, site of the colorectal cancer, pathological coding,
was 13.9 per 100,000. ASR for males was 16.1 per age of the patient, cancer recurrence, type of surgery,
100,000, and for females was 10.9 per 100,000 (Who, radiation therapy, chemotherapy or adjuvant chemotherapy
2018). The highest ASR was in the Riyadh region at 15.7 regimen, and stoma use are the key determinants of the
per 100,000 (Who, 2018). quality of life and psychological wellbeing of colorectal

1
Associate Professor of Epidemiology and Preventive Medicine, Department of Public Health, Faculty of Medicine, Mutah
University, Kerak, Jordan. 2Adjunct Associate Professor of Epidemiology and Preventive Medicine, Faculty of Medicine, Alfaisal
University, KSA. 3Internal Medicine Department, King Abdulaziz Medical City, AlAhsa, Kingdom of Saudi Arabia. 4Industrial
Engineering Department, Jordan University of Science and Technology, Irbid, Jordan. 5Comprehensive Cancer Center, King Fahad
Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia. 6King Fahad Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia.
7
MENA Center for Researchand Development And Internship, Amman, Jordan. 8Department of Oncology Center, King Abdulaziz
Medical City, AlAhsa, kingdom of Saudi Arabia. *For Correspondence: mabuhelalah@yahoo.co.uk
Asian Pacific Journal of Cancer Prevention, Vol 23 1301
Munir Abu-Helalah et al

cancer patients (Schmidt et al., 2005; Paika et al., 2010; showed the results. This study also showed that pain,
Cardin et al., 2012). Studies have shown that QoL score are fatigue, and insomnia were the most stressful symptoms
worse in rectal as compared to colon cancer survivors. This (Younis, 2019).
association could be justified by differences in symptoms, The main limitations of published studies from the
treatment modalities particularly need for stoma, and KSA on the quality of life of colorectal cancer patients
therapy duration (El Alami et al., 2021). is that they were conducted at one site, and quality
A study showed that diarrhea, fecal control and of life was limited to caner general domain without
constipation were the most important symptoms that affect including Colorectal cancer domain and a more specific
quality of life scores of colorectal cancer patients, while questionnaires for the psychological wellbeing. Therefore,
other studies showed that fatigue and loss of appetite were it was proposed to conduct a cross-sectional study on a
the most important predictors (Caravati-Jouvenceaux et representative sample of colorectal cancer patients at 12
al., 2011; Tsunoda et al., 2007). to 36 months after initial diagnosis. This would allow
Treatment modalities of colorectal cancer include assessing intermediate and long-term consequences of
surgery, chemotherapy, and radiation therapy. Adverse colorectal cancer like pain, coping with a stoma, sexual
events due to chemotherapy such as nausea, vomiting, problems, and psychosocial dysfunction. This study
and neutropenia leads to deteriorations in quality of life focuses on intermediate survivors and provides important
(QoL) (Kim, 2009). Chemotherapy induced peripheral data for cancer care providers and decision makers in the
neuropathy is another common adverse effect associated field in the KSA.
with poorer QoL. Therefore, with proper management
of chemotherapy associated toxicities, such as dosage Materials and Methods
reduction or supportive treatment for adverse effects can
improve the quality of life of colorectal cancer survivors This project was a cross-sectional study conducted
(Mols et al., 2013). among colorectal cancer patients diagnosed in the period
Impotence, dyspareunia, dysuria and fecal incontinence from cancers survivors diagnosed between 1 January 2015
were other reported complications from radiation therapy. and May 2017, with the assessment conducted at 12 to 36
Some patients develop hemorrhagic cystitis secondary to months after initial diagnosis. This would allow assessing
radiotherapy (Andriole et al., 1987; Chong et al., 2005) intermediate and long-term consequences of colorectal
Patients who were current stoma users had worst scores cancer like pain, coping with a stoma, sexual problems,
than non-users or ex-users in sore skin, embarrassment, and psychosocial dysfunction. This study was not studying
while the ex-users had worst fecal incontinence means the immediate post-treatment effects of colorectal cancer
score, when compared with the remaining participants. management.
Stoma early complications prevalence varies from 13.1% This study was conducted in three regions in the KSA:
to 69.4% (Kann, 2008), while the prevalence rates of Central, Eastern, and Western. Research sites include
overall late complications vary from a low of 6% to highs three large tertiary Ministry of Health Hospitals and two
exceeding 76% in selected series (Husain and Cataldo, National Guard Health Affairs hospitals. The sample
2008). There are several approaches to reduce such high in this study is expected to represent colorectal cancer
complications rates (Husain and Cataldo, 2008; Kann, survivors in the KSA to a large extent.
2008). Therefore, preventive measures should be applied
and patients’ counseling should focus on control of feeling Eligibility Criteria
of embarrassment. Inclusion criteria:
The impact of colorectal cancer diagnosis, - Colon or rectal cancer patients between 1 January
complications or the disease or management has been 2010 and 31 December 2011
associated with negative psychological impact. In a - Age range 18 to 65
study from the US, investigators used the Brief Symptom - Lives permanently in the KSA
Inventory as a screening tool for anxiety and depression. - No history of other cancers
Results of this study showed a prevalence rates of 35% - Not receiving current therapy for a minimum of six
for distress, 24% anxiety and 19% depression (Zabora et months prior to recruitment
al., 2001). Results from Jordan using Hospital Anxiety
and Depression scaled revealed that a large proportion Exclusion criteria:
of colorectal cancer survivors have high rate of moderate - Inability to attend the interview
to severe anxiety and depression with a large proportion - Have a medical condition that limits her ability to
of undiagnosed and uncounseled patients (Abu-Helalah complete interview
et al., 2014) .
A cross-sectional study was conducted in Saudi Study Outcomes
Arabia assessed quality of life in a cohort of colorectal Primary endpoints:
cancer patients at one center in Riyadh using European • The European Organization for Research and
Organization for Research and Treatment of Cancer Treatment of Cancer Quality of Life Questionnaire
Quality of Life Questionnaires—Core30 (EORTC (EORTC QLQ-C30) and Colorectal module (QLQ-CR29)
QLQ-C30) showed a good global score. The lowest The most widely used instrument is the European
scores were reported for the emotional scales (Almutairi Organization for Research and Treatment of Cancer
et al., 2016). Another study was in Tabuk, Saudi Arabia Quality of Life Questionnaire-Core 30 (EORTC
1302 Asian Pacific Journal of Cancer Prevention, Vol 23
 DOI:10.31557/APJCP.2022.23.4.1301
Quality of Life Colorectal Cancer KSA
QLQ-C30), which has been developed to assess the Sample size calculation and data analysis
health-related quality of life of cancer patients (European According to the Kish formula (1965) for survey
Organization for Research and Treatment of Cancer). sampling (Al-Subaihi, 2003), 112 is the estimated sample
This questionnaire was translated and validated in size with a margin error of 5%, which was representative
different languages, including the Arabic language (Awad of the estimated reported cases (1347) diagnosed in the
et al., 2008). Moreover, few instruments have been KSA in 2014 (MoH, 2014).
specifically developed and validated for the assessment
of the HRQL of colorectal cancer patients. the EORTC Plan for statistical analysis
colorectal cancer-specific quality of life questionnaire Analysis was conducted using STATA 10 software. As
module (QLQ-CR29) is one of the most widely used and shown in the study outcomes section, in addition to the
validated tools specific for colorectal cancer (Whistance calculation of quality-of-life scores, data on predictors
et al., 2009). of quality-of-life scores or confounding factors were
collected through a standardized interview questionnaire
General psychological wellbeing using Hospital Anxiety and chart review form. These two questionnaires covered
and Depression Scale (HADS) sociodemographic variables, pathology, stage, grade
Hospital Anxiety and Depression Scale (HADS) treatment, other medical conditions.
is a self-administered questionnaire to detect minor Student’s t tests was used to compare means of
psychiatric impairment. This scale is a validated screening continuous variables for two groups, and one-way analysis
instrument for anxiety and depression that has been of variance was used to compare means of continuous
validated in different settings for the general population variables for three or more groups. For data that did not
and patients with a wide range of medical conditions. follow a Gaussian distribution, nonparametric tests was
A score of 0 to 7 is categorized as normal, a score of 8 used (Bland, 2000).
to 10 suggests possible anxiety or depressive disorder, Pearson correlation coefficients was used for
and a score of 11 or above indicates probable anxiety or investigating the relationship between two quantitative
depressive disorder (Zigmond and Snalth, 1983). continuous variables. Chi-square tests was used to compare
The hospital Anxiety and Depression Scale (HADS) categorical measures, and a one-way analysis of variance
has been validated on patients with colorectal cancer was used to compare means of continuous measures across
(Tsunoda et al., 2005). It has also been validated on Arabic the groups. For the analyses that involved adjusting for
speaking patients (El-Rufaie and Absood, 1987). covariates, forward stepwise logistic regression was used
for dichotomous outcomes, and analysis of covariance will
Secondary Outcomes be used for continuous outcomes.
• Interview questionnaire: This includes
sociodemographic variables (age, age at diagnosis, time Results
since last treatment, marital status, living status, average
monthly household income, medical insurance, job, The colorectal cancer is based on the results of 115
husband’s job, education, husband’s education, smoking participants. The mean age was 53.3±11.6, while the mean
status. age at diagnosis was 52.6±11.8.
• Chart Review Form: This includes medical history, 55.8% of the participants are females. Other
cancer treatment and diagnosis information: stage, grade, sociodemographic features are shown in supplementary
morphology, treatment, including categories for surgical Table 1.
treatment, systemic adjuvant therapy (chemotherapy, Table 1 shows selected clinical indicators such as site,
hormonal therapy), and radiation therapy. Menopausal metastasis, treatment modalities ...etc.
status, other comorbidities, medication history, family 67.8% of cases had colon cancer, 18.3% had rectal
history of cancer. cancer, while 13.9% had rectosigmoid cancer. 95% of
the participants had the first episode of colorectal cancer,
Methodology while 5% had recurrent colorectal cancer.
Data were collected through a face-to-face interview This project showed alarming figures of low overall
and thorough chart review forms. quality of life and impairment in the psychological
Eligible participants were interviewed alone by a wellbeing for intermediate colorectal cancer survivors
research assistant unless they preferred to be accompanied (One to three years post-diagnosis) in KSA. The majority
by a friend or family member. of the study participants had unexpectedly low global
For illiterate patients, a third party such as a family health score with a mean of 56.9±31.3SD, with 22.34% of
member or a friend of the participant must be available participants scoring less than 33.3%. More than half of the
when consenting sample had moderate to severe undiagnosed depression,
and one third had moderate to severe anxiety. Only 3.7%
Scientific and ethics committees’ approvals of the sample received psychosocial support.
Scientific and Ethical approvals were obtained from Results of the quality-of-life scores are shown in
the Ethics Committee of the Ministry of National Guard Tables 2 and 3. The QLQ-C30 questionnaires show that
Health Affairs through King Abdullah International participants have unexpectedly low global health score
Medical Research Office. All participants signed an with a mean of 56.9±31.3. The physical functioning scale
informed consent form prior to being interviewed. had the lowest score of 61.3±27.7, while social functioning
Asian Pacific Journal of Cancer Prevention, Vol 23 1303
Munir Abu-Helalah et al

Table 1. Clinical Indicators for 115 Participants with Table 2: QLQ-C30 Scores for Participants with CRC
Colorectal Cancer Cancer (n=115)
Number Valid Percent Scale Mean Standard Percent less Percent
deviation than 33.3% more than
Cancer Site 66.7%
Colon 78 67.8 Global health status
Rectal 21 18.3 Global health 56.91 31.32 22.34 36.17
Rectosigmoid 16 13.9 status/QoL (QL2)
Functional scales
Recurrent or first episode
Physical 61.33 27.71 10.62 36.28
First episode 109 95 functioning (PF2)
Recurrent cancer 6 5 Role functioning 74.84 28.66 5.66 53.77
Presence of metastasis (RF2)
Emotional 74.97 29.51 10.09 60.55
Distant metastasis 41 35.71
functioning (EF)
Local 55 47.96 Cognitive 75.45 28.44 6.36 58.18
Regional 19 16.33 functioning (CF)

Type of surgery: Social 79.32 26.46 2.78 60.19

functioning (SF)
Local excision or simple 7 5.97
Symptom scales
polypectomy.
Fatigue (FA) 37.02 30.39 39.82 12.39
Resection and anastomosis. 53 46.27
Nausea and 23.3 30.34 61.06 7.96
Resection and anastomosis 31 26.87 vomiting (NV)
followed by chemotherapy. Pain (PA) 30.24 29.76 50.44 8.85
Resection with or without 10 8.96 Dyspnea (DY) 20.91 29.9 59.09 6.36
anastomosis.
Insomnia (SL) 34.56 35.98 41.28 14.68
Surgery to remove parts of 14 11.94 Appetite loss 36.11 35.63 37.96 14.81
other organs, such as the liver, (AP)
lungs, and ovaries, where cancer
Constipation 25.38 32.99 52.29 11.01
may have recurred or spread. (CO)
Chemotherapy therapy Diarrhea (DI) 22.94 33.24 58.72 11.01
No 12 10.78 Financial 16.01 28.81 70.59 5.88
difficulties (FI)
Yes 103 89.22
Radiation therapy
No 89 77.78 means less than 50. The proportion of participants with
Yes 26 22.22 score percentage more than 66.7% was the highest
for Impotence Symptom (16.9%) and Embarrassment
Palliative Radiation therapy
(15.6%), followed by Urinary frequency (13.8%)
No 111 96.88 Psychological wellbeing assessment utilizing HADS
Yes 4 3.12 reveals alarming outcomes for survivors of CRC in
Palliative chemotherapy the KSA, as shown in Figure 1. A high proportion of
No 102 88.3 participants with moderate to severe depression (55%)
and a good proportion of participants with moderate to
Yes 13 11.7
high anxiety (31%). Only 3.7% of participants reported
Stoma receiving psychosocial support.
Currently present 17 14.94
Not used 81 70.11 Regression analysis
Used but removed 17 14.94 There were no statistically significant predictors for
the global quality of life scores through the stepwise
had the best scores with a mean of 79.3±26.5. Regarding regression analysis. Regression analysis for predictors
the generic symptoms of cancer, fatigue was the worst of HADS score showed that the statistically significant
symptom, followed by appetite loss. predictor for the HADS depression score was living status;
The colorectal cancer module results are shown in for patients who live with husband or spouse had a lower
Table 3. showed that body image had the best and highest depression scale than those living alone or with a family
score, with a mean of 74.4±27.9. The worst score within member. For anxiety score, the statistically significant
functional scales was weight for females and sexual predictor was the presence of metastasis; patients with
interest for males, while the worst reported symptom metastasis have a higher anxiety score than those with
within the QLQ-C30 questionnaire was fatigue (mean local or regional disease.
score= 37.02) then appetite loss (mean score= 36.11).
Symptom scale did not show a significant prevalence
of symptoms amongst the study population, with all

1304 Asian Pacific Journal of Cancer Prevention, Vol 23

 DOI:10.31557/APJCP.2022.23.4.1301
Quality of Life Colorectal Cancer KSA

(a), Depression score (b), Anxiety Score

Figure 1. Hospital Depression and Anxiety Score

Discussion different and lower than that reported in regional and

international figures; the mean global score in a study
This project showed alarming figures of low overall from Egypt was 64.5±11.9 SD (Hokkam et al., 2013),
quality of life and impairment in the psychological from Jordan (79.7±23.3 SD), (Abu-Helalah et al., 2014),
wellbeing for intermediate colorectal cancer survivors and from Germany 62.8±22.4 SD (Arndt et al., 2004).18
(One to three years post-diagnosis) in KSA. The mean Also, the mean global score in our study is worse than
global score of the QLQ-C30 (56.9±31.3SD) is slightly figures from recent two studies from the KSA with mean
global scores of 67.1± 23.78SD (Almutairi et al., 2016)
Table 3. Colon Cancer Module CR-29 for Colorectal and 68.65±11.34SD (Younis, 2019).
Cancer Patients (n=115) The mean ages of participants in Egypt and Germany
Scale Mean Standard Percent Percent studies were 61.6±8.2 SD (Hokkam et al., 2013) and
deviation less than more than 65.0±9.9 SD (Arndt et al., 2004), respectively. While
33.3% 66.7%
the Jordanian study that followed the same protocol of
Functional scales
ours, the mean age of 53.3±11.6SD to close to that for
Body Image (BI) 74.41 27.89 8.26 58.72
our sample, although the quality of life in our study
Anxiety (ANX) 58.65 38.72 20.19 37.5
showed much worse scores when compared with the
Weight (WEI) 62.31 37.22 17.76 38.32 results from Jordan (Abu-Helalah et al., 2014). There are
Sexual interest men 55.22 32.07 13.43 20.9 slight differences between the Jordan study and our study
(SEXM)
in the stage of the disease (Abu-Helalah et al., 2014).
Sexual interest 65.77 27.76 5.41 27.03
women (SEXW) The proportions of patients distant metastasis is higher
Symptom scales
in this study, when compared with the Jordanian study.
The proportion of cases with local, regional, and distant
Urinary frequency 40.83 30.47 26.61 13.76
(UI) stages in the Jordan study were 47.4%, 40.5%, and 12.1%,
Blood and mucus in 15.12 24.7 72.22 2.78 respectively, while in our study, the rates were 47.96%,
the stool (BMS) 16.33%, 35.71%, respectively. These differences could
Stool frequency (SF) 23.92 28.89 56.45 6.45 justify the worse scores amongst the Saudi population
Urinary incontinence 12.96 24.89 74.07 2.78 and indicates the need for early detection campaigns in
(UI) the KSA.
Dysuria (DY) 18.69 29.02 63.55 5.61 The physical functioning scale had the lowest score,
Abdominal pain (AP) 31.46 33.9 43.93 10.28 while social functioning had the best scores with a mean
Buttock pain (BP) 25.62 32.1 52.78 7.41 of, similar scores were reported from a German study
Bloating (BF) 25.96 31.14 49.04 7.69 (Arndt et al., 2004). Another single site study from the
Dry mouth (DM) 28.7 31.06 43.52 7.41 KSA showed that cognitive functioning was rated the
Hair loss (HL) 35.58 36.36 39.42 16.35 highest with the mean value of 77.01±5.60, whereas
Taste (TA) 30.5 33.21 44.34 9.43 emotional functioning scored the lowest with the mean
Flatulence (FL) 18.69 28.72 65.15 3.03
value of 60.35±12.47, followed by social functioning
Faecal incontinence 20 30.51 63.08 6.15
62.44±10.32SD (Almutairi et al., 2016).
(FI) In our study, the worst reported symptom within
Sore skin (SS) 20.9 32.22 64.18 7.46 the QLQ-C30 questionnaire was fatigue then appetite
Embarrassment 25 38.49 65.62 15.62 loss Fatigue score is similar to that reported for German
(EMB) patients (35.4) (Arndt et al., 2004) but different in appetite
Stoma care problems 18.42 31.67 68.42 7.89 loss score (9.8). For KSA patients, the mean score of the
(STO)
fatigue scale was (39.3) while the mean score of the loss
Impotence (IMP) 41.03 35.24 29.23 16.92 of appetite scale was (29.13) (Younis, 2019). The mean
Dyspareunia (DYS) 35.19 29.76 27.78 8.33 score of the financial difficulties scale is better than that
Asian Pacific Journal of Cancer Prevention, Vol 23 1305
Munir Abu-Helalah et al

reported in Germany (20.9) (Arndt et al., 2004), but close symptoms scales did not show significant prevalence
to that reported in KSA, where the mean score was 17.2 amongst the study population, with all means less than
(Younis, 2019). 50. The proportion of participants with a score percentage
The striking result in our study is that few of the more than 66.7% was the highest for Impotence Symptom
participants participated in a psychosocial support (16.9%) and Embarrassment (15.6%), followed by Urinary
group. Different studies have provided a strong evidence frequency (13.8%). The worst scores for the QLQ-CR29
that psychosocial interventions are often efficacious in symptoms scales for this study were impotence followed
decreasing patients’ distress and improving their quality by urinary frequency, then hair loss and dyspareunia. The
of life (Yun et al., 2013). In addition, participation in worst scores for the QLQ-CR29 symptoms scales for the
psychosocial support programs can often lead to the saving Jordan study were flatulence, impotence, and stoma care
of resources (Lin et al., 2014). problems, the same results of the Egyptian study (Arndt
Unfortunately, we did not perform a follow-up study et al., 2004; Hokkam et al., 2013; Abu-Helalah et al.,
on patients after diagnosis to obtain a more comprehensive 2014). In the Chinese study, impotence was the worst
picture of the quality of life of colorectal cancer patients symptom, followed by fecal incontinence and dyspareunia
in KSA. According to a 2014 report of the Saudi cancer (Ramsey et al., 2000). Patients who received palliative
registry, 24.4% of colorectal cases were localized radiotherapy had a statistically significant worse dysuria
tumors, 39.2% were regional, 29.1% showed distant score when compared with patients who did not receive
metastasis, while the remaining 7.3% of the cases were it. The development of hemorrhagic cystitis secondary
labeled as unknown stage (MoH, 2014). This indicates to radiotherapy could justify these findings (Chong et
that our sample is not different from the distribution of al., 2005).
cases at diagnosis, and all stages are well represented in The material status was considered the only marginally
proportions relevant to this baseline distribution (Ramsey significant predictor in this study with (p-value= 0.057);
et al., 2000). this study showed that the married participant either
In KSA, there is no colorectal cancer control program, male or female had a better global quality of life score.
and initiatives for colorectal cancer early detection or Results from the UK showed that sex, stage of the disease,
screening are lacking. This could explain why around symptoms, beliefs about consequences, lower income, and
half of the study subjects had stage three or greater presence of other comorbidities were the main predictors
on TNM staging. This is consistent with results from for the quality of life scores (Gray et al., 2011).
other developing countries where such a program is not For psychological wellbeing assessment using
available (Safaee et al., 2012). depression, anxiety, and the total HADS scores, our
In our study, the worst reported symptom within the results show a high proportion of participants with
QLQ-C30 questionnaire was fatigue (mean score= 37.02) moderate to severe depression (55%) and a good
then appetite loss (mean score= 36.11). Fatigue score is proportion of participants with moderate to high anxiety
similar to that reported for German patients (35.4) (Arndt (31%). That is consistent with a recently published study
et al., 2004) but different in appetite loss score (9.8). from Jordan, where the proportion of participants with
For KSA patients, the mean score of the fatigue scale abnormal depression or anxiety scores was 18% and 23%,
was (39.3) while the mean score of the loss of appetite respectively (Abu-Helalah et al., 2014). In a study from
scale was (29.13) (Younis, 2019). The mean score of the United States, investigators used the Brief Symptom
the financial difficulties scale (16.1) is better than that Inventory as a screening tool for anxiety and depression.
reported in Germany (20.9) (Arndt et al., 2004), but close That study showed prevalence rates of 35% for distress,
to that reported in KSA, where the mean score was 17.2 24% for anxiety, and 19% for depression (Zabora et al.,
(Younis, 2019). Variations in the cost of cancer treatment 2001). A review of 15 studies published between June
and differences in the social security system might alter 1967 and June 2018 was conducted and showed that the
the outcomes of this scale. In KSA, cancer patients receive prevalence of depression among patients diagnosed with
free health insurance for cancer management. colorectal cancer ranged from 1.6%–57%, and those of
As a consistent trend with the above findings, financial anxiety ranged from 1.0%–47.2%, indicating that there
difficulties affected the global score and all physical scales is a high prevalence of both depression and anxiety in
of the QLQ-C30. Participants who were suffering from colorectal patients, and these symptoms can persist even
financial difficulties had worse scores in global health after cancer treatment is completed (Peng et al., 2019).
and all physical scales. These results are consistent with Living with husband or spouse had a lower depression
previous studies where patients with deprivation indicators scale than those living alone or with a family member.
had a poor quality of life (Loh et al., 2013). This was consistent with Jordan study (Abu-Helalah et
For the QLQ-CR29 questionnaire, the worst scores al., 2014).
within the functional scales were for sexual interest for Similar to the Jordan study, the result showed that
men (mean= 55.22). Patient education and counseling are anxiety scores were predicted by the following factors:
essential to improve the outcomes of this domain (Moriya, the extent of disease, presence of social problems causing
2006). Regarding sexual interest in men, the results from daily anxiety, low back pain, presence of other chronic
Egypt and Jordan are similar to ours (Arndt et al., 2004; diseases, reported diarrhea symptoms, hoarseness of
Hokkam et al., 2013; Abu-Helalah et al., 2014), while voice, and HADS total score (Abu-Helalah et al., 2014).
body image was the worst functional scale for Chinese A study conducted in the UK showed that patients with
patients (Peng et al., 2011). The scores for the QLQ-CR29 more advanced disease were more anxious and depressed,
1306 Asian Pacific Journal of Cancer Prevention, Vol 23
 DOI:10.31557/APJCP.2022.23.4.1301
Quality of Life Colorectal Cancer KSA
perceived their social support as lower, and had a worse Ethical Approval
quality of life with (P<0.01) (Simon et al., 2009). This project obtained an ethical approval from the
Central IRB Committee at the King Abdullah International
The Value Of This Research To Cancer Care In The KSA Medical Research Center, Ministry of National Guard
Results of this project reveal an overall trend of Health Affairs
low scores of quality of life amongst colorectal cancer
patients in the KSA when compared with regional or Conflict of Interest statement
international figures (Abu-Helalah et al., 2014; Arndt et al., All authors declare no conflict of interest in this
2004; Faisal, 2018). Consistent results for psychological project.
wellbeing were reached. There was a high prevalence of
moderate to severe depression and anxiety when compared References
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patients detected with advanced stage of CRC in the KSA factors and calculation strategies for survey research. Saudi
highlight the importance of CRC programs in the KSA. Med J, 24.
The results of this study will hopefully provide Almutairi KM, Alhelih E, Al-Ajlan AS, Vinluan JM (2016). A
valuable data for colorectal cancer care providers in order cross-sectional assessment of quality of life of colorectal
cancer patients in Saudi Arabia. Clin Transl Oncol, 18.
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help in the future management of colorectal cancer patients uroprotectant in patients with hemorrhagic cystitis receiving
and hopefully stimulate further research in this field. further oxazaphosphorine chemotherapy. J Clin Oncol, 5.
https://doi.org/10.1200/JCO.1987.5.5.799.
Author Contribution Statement Arndt V, Merx H, Stegmaier C, Ziegler H, Brenner H (2004).
Quality of life in patients with colorectal cancer 1 year
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A population-based study. J Clin Oncol, 22. https://doi.
questionnaires and chart review forms development,
org/10.1200/JCO.2004.02.018
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project proposal, contributes to questionnaires and chart Organization for Research and Treatment of Cancer quality
review forms development, data collection, review of of life questionnaires for Arabic-speaking populations. Ann
the scientific paper and project management. Hussam N Y Acad Sci, 1138. https://doi.org/10.1196/annals.1414.021
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Ibrahim Alsuhail: project local site PI, review the project edition. Oxford University Press.
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proposal, contributes to questionnaires and chart review Health-Related Quality of Life Among Long-Term Survivors
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Funding statement El-Rufaie OEFA, Absood G (1987). Validity study of the
Hospital Anxiety and Depression scale among a group of
This project was fully sponsored by King Abdullah
Saudi patients. Br J Psychiatry, 151, https://doi.org/10.1192/
International Medical Research Center, Ministry of bjp.151.5.687.
National Guard Health Affairs. El Alami Y, Essangri H, Majbar MA, et al (2021). Psychometric
validation of the Moroccan version of the EORTC QLQ-C30
Scientific Body Approval in colorectal Cancer patients: cross-sectional study and
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at the King Abdullah International Medical Research org/10.1186/s12885-021-07793-w.
Center, Eastern Region, Ministry of National Guard Faisal M (2018). Assessment of quality of life of colorectal
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