Colorectal cancer

Background[edit source]

The diagnosis and treatment of cancer presents a major and stressful life event that can reduce quality of life in the short and long term. Apart from the existential challenge faced by all patients with a life-threatening disease, patients with colorectal cancer have specific challenges.

Before their operation, people with colorectal cancer commonly experience fear, isolation and uncertainty, and have a high need for information and support.[1] Postoperatively, patients may experience physical, social and psychological challenges, especially if they have a new stoma.

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Overview of evidence (non-systematic literature review)[edit source]

No systematic reviews were undertaken for this topic. Practice points were based on selected evidence. Please see guideline development process for more information.

Physical challenges[edit source]

Postoperative physical challenges include bowel issues, such as frequent bowel movements, constipation and diarrhoea. Patients with stomas may face leakage, skin and stoma problems, and odour.[2][3]

Sexual dysfunction is also very common among people with colorectal cancer, with sexual dysfunction rates following rectal surgery ranging from 23% to 69% in men and 19% to 62% in women.[4] Problems with erectile function and ejaculation have been reported in men,[5] and women have experienced dyspareunia, vaginal dryness and pain interfering with sexual pleasure after surgery.[6] Some patients experience a disturbed body image,[7] which can lead to low self-esteem and exacerbate sexual dysfunction.

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Social challenges[edit source]

Patients who have undergone surgery for colorectal cancer (especially those with stomas) may avoid and fear social interactions, and experience disrupted intimate relationships due to body changes, changes in roles, social restrictions and sexual dysfunction.[7][8]

Psychological challenges[edit source]

Cognitive dysfunction[edit source]

The effects of chemotherapy on cognitive function have been assessed in patients with colorectal cancer, as for those with other cancers. A recent meta-analysis of 13 relevant studies[9] found evidence of impairment in executive function and memory in patients of all ages. Longer treatment duration, but not shorter time since treatment, was associated with worse impairment.[9]

Anxiety and depression[edit source]

Many patients with colorectal cancer experience moderate-to-severe anxiety and depression. In a population-based Australian sample of 1966 colorectal cancer survivors assessed at six time points from 5 months to 5 years post diagnosis,[10] the prevalence of high overall distress ranged between 44% and 32%. The study[10] identified four trajectories of distress – some declining, and others (38.5% of the sample) steadily increasing over time. Other studies have reported clinical levels of depression in 8–23% of people with colorectal cancer and anxiety in 16– 39%.[11][12][13][14]

Distress affects survival rates[edit source]

Patients’ distress is important, not only because of its impact on quality of life, but also its impact on survival. Quality of life has been reported to predict survival in patients with advanced colorectal cancer.[15] Depression has also been found to influence survival in a population-based sample of 1074 colorectal cancer survivors in the Netherlands.[16] In analyses adjusted for metastasis and other potential confounders, depressive symptoms significantly increased the risk of death among 1-year to 10-year colorectal cancer survivors (hazard ratio [HR] 1.88; 95 % CI, 1.24–2.83; p < 0.01) and even more in 1-year to 2-year colorectal cancer survivors (HR, 2.55; 95 % CI, 1.44–4.51; p < 0.001).[16] Thus depression has the highest negative effect on survival in the first 1-2 years, but this effect extends out to 10 years post-diagnosis.

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Who is more vulnerable to anxiety and depression?[edit source]

A number of studies have explored predictors of anxiety, depression and distress among people with colorectal cancer. However, a recent systematic review[17] noted that most studies were cross-sectional and psychosocial variables have been poorly studied.

Many of the factors associated with anxiety, depression and distress may be modified with appropriate intervention.

Factors that were associated with an increased risk of developing anxiety include:[14]

  • more, or more severe, symptoms such as poor self-reported cognitive functioning, dyspnoea and diarrhoea
  • financial difficulties.

Factors that were associated with an increased risk of developing depression include:[14]

  • neo-adjuvant radiotherapy
  • poor physical, cognitive or social functioning
  • difficulties with personal care and communicating with others.

Factors that were associated with an increased risk of developing distress include:[10]

  • male sex
  • younger age
  • lower education
  • poor socioeconomic advantage
  • poor social support
  • late disease stage
  • pre-diagnosis anxiety, pessimism and a distressed personality style.[17]

The investigators of an Australian prospective survey of colorectal cancer survivors[10] concluded that, based on their higher levels of distress, men who are younger, and with low education and poor social support, should be a priority for targeted intervention.

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Family distress[edit source]

There is also evidence that families of people with colon cancer experience considerable distress, particularly if the person has metastatic disease.[18] In a large Australian study of patients with advanced cancer in the palliative care setting,[19] evidence of substantial psychological distress warranting specific support was identified in up to half of the patients (20% of whom had colorectal cancer), one-third of their spouses and one-quarter of their offspring. For people in palliative care, this distress reverberates through the family in such a way that both patient and family-centred models of care need to be adopted.

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Psychological care and treatments[edit source]

The importance of psychosocial care is recognised in the 2003 national guideline Clinical practice guidelines for the psychosocial care of adults with cancer.[20] This guideline is a useful evidence-based source for practising clinicians.

Persisting unmet need[edit source]

Despite widespread acceptance that psychosocial care is integral to quality cancer care, psychological morbidity is often undetected and underestimated in busy cancer services,[21] and people with cancer continue to experience high levels of unmet need for psychosocial care.[22] Colorectal cancer patients report many deficiencies in their supportive care.[23]

Screening for distress[edit source]

Because anxiety and depression are often under-detected, international guidelines recommend routine screening of all cancer patients for psychological distress, using validated, reliable, objective measures.[24] The International Psycho-Oncology Society (IPOS) and 68 affiliated organisations have set a standard of care involving monitoring distress as the ‘6th vital sign’. The authors of an Australian study that measured distress in colorectal cancer survivors[10] recommend that screening should occur not only at diagnosis, but also at key points of the illness trajectory and into survivorship, to ensure that late-onset distress is not missed. Recent Australian clinical guidelines for screening for, and managing, anxiety and depression in cancer patients[10] recommend the following tools to screen for distress: the 1-item “Distress Thermometer” (with 39 problem areas to tick)[24] and the 9-item ESAS (Edmonton Symptom Assessment Schedule).[25]

Psychological intervention[edit source]

There is now a large evidence base, summarised in meta-analyses and systematic reviews, demonstrating that interventions for distress in patients with cancer are effective in the short and long term.[26][27][28][29] A recent review of psychological interventions specifically in colorectal cancer,[30] which identified 11 studies meeting inclusion criteria, found that psychosocial interventions (including educational interventions, cognitive–behavioural therapy, relaxation training and supportive group therapy) for colorectal cancer patients reduced length of hospital stay, days to stoma proficiency, and anxiety and depression, and improved quality of life.

Relaxation-based therapies are greatly beneficial in reducing anxiety, treatment-related phobias, conditioned nausea and vomiting, and insomnias.[31] Both cognitive–behavioural and supportive–expressive therapies are effective in countering existential fears of dying, aloneness, meaninglessness and unrealistic fears about processes of treatment.[26] Early referral for specialist support from a clinical psychologist or liaison psychiatrist is worthwhile when symptoms of distress or high risk become evident. One study has also shown that peer support (face-to-face group or individual by phone) is feasible, acceptable and appreciated by colo-rectal patients, although efficacy of this intervention has not yet been evaluated.[32]

Randomised controlled trials of early versus late referral to palliative care services show strong evidence of the benefits of early referral in reducing time spent in hospital, enhancing symptom control, increasing family satisfaction, and permitting death to occur in the desired location.[33] Early referral to community-based domiciliary palliative care services support and information, where available, may have several benefits and enhance quality of life. Support can be provided by various health disciplines with appropriate training.

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Patients with colorectal cancer should be screened for psychological distress at diagnosis and key points in their disease trajectory.

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Psychological interventions should be a component of colorectal cancer care, as they can improve the quality of life for patients with cancer.

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Information needs and decision aids[edit source]

Providing information to patients[edit source]

Surveys of patients with cancer repeatedly identify information provision as a major unmet need.[21] Research has shown that the provision of adequate information is related to increased psychological wellbeing.[34] Effective communication skills, which can be learned through facilitated communication skills training, ensure that this information is clearly explained and understood.[35]

Six main principles of information provision for cancer patients are relevant to the care of people with colorectal cancer patients:

  • Treatment options should be explained clearly, with realistic information about potential effectiveness and adverse effects.
  • Patients should be invited to guide the clinician to provide the level of detail they wish to receive and to enable their desired level of active involvement in decision making.[36]
  • Clinicians should review both the person’s understanding of the information, and their reactions to it, as a means of increasing integration and providing emotional support.
  • Written materials should be provided, and clinicans should consider offering audio recording of key consultations.[33] The involvement of a specialist nurse or counsellor, provision of a follow-up letter, and participation in psychoeducational programs may also assist in recall of information.[37][38]
  • Information should be made available over time and, if desired, review appointments that allow time for further integration of information should be scheduled.
  • Patients’ carers and families should also be kept well informed.

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The role of decision aids[edit source]

Some decisions in colorectal cancer are ‘preference sensitive’; that is, the optimal decision is one that is consistent with patient values and preferences. Shared decision making is a model that seeks to include both patients and their healthcare providers in the decision making process. It encourages patients to play an active role in decisions concerning their health, which is a goal of patient-centered care.[39]

Shared decision making can be facilitated by patient decision aids, which are defined as interventions designed to help people make specific and deliberative choices among options by providing information on the options and outcomes relevant to the patient’s health status.[40] The effectiveness of decision aids has been demonstrated in at least three separate systematic reviews.[35][41][42]

Decision aids have been shown to:[35][41][42]

  • improve patient knowledge
  • lower decisional conflict related to feeling uninformed and unclear about personal values
  • reduce the proportion of people who were passive in decision making post-intervention
  • improve agreement between patient values and health care option chosen.

Only a few decision aids have been developed and evaluated for colorectal cancer treatment. In an Australian-US collaboration,[43] a decision aid was developed for patients with advanced colorectal cancer who are considering first-line chemotherapy and reviewing treatment options, prognostic information, and toxicities. In a randomised controlled trial with 207 patients, patients receiving the decision aid demonstrated a greater increase in understanding of prognosis, options, and benefits, with higher overall understanding (P < .001), compared with patients who received a standard medical oncology consultation. Anxiety was similar between groups, and decisions were not affected; 74% chose chemotherapy, 7% supportive care alone, and 10% observation.

Another trial evaluating a decision aid for people with colorectal cancer has been registered, but has not yet reported results. The decision aid addresses the two surgical options for rectal cancer patients: low anterior resection with re-establishment of bowel continuity, and abdominoperineal resection with a permanent stoma. The decision aid is currently being piloted and a barriers analysis, exploring factors that might hinder introduction into routine care, is planned to follow. Further work on decision aid development for colorectal cancer treatment is required.

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The use of decision aids should be considered for preference-sensitive decisions about treatment for colorectal cancer.

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References[edit source]

  1. Worster B, Holmes S. The preoperative experience of patients undergoing surgery for colorectal cancer: a phenomenological study. Eur J Oncol Nurs 2008 Dec;12(5):418-24 Available from:
  2. Black, P.. Coping with common stoma problems in care homes. Nursing & Residential Care 2011;13(3): 126-128.
  3. Burch J. The pre- and postoperative nursing care for patients with a stoma. Br J Nurs 2005 Mar;14(6):310-8 Available from:
  4. Ho VP, Lee Y, Stein SL, Temple LK. Sexual function after treatment for rectal cancer: a review. Dis Colon Rectum 2011 Jan;54(1):113-25 Available from:
  5. Pietrangeli, A. Bove, L. Innocenti, P. Pace, A. Tirelli, C. Santoro, E. Jandolo, B.. Neurophysiological evaluation of sexual dysfunction in patients operated for colorectal cancer. Clin Auton Res 1998;8(6): 353-35.
  6. Bambrick, M. Fazio, V. W. Hull, T. L. Pucel, G.. Sexual function following restorative proctocolectomy in women. Dis Colon Rectum 1996;39(6): 610-614.
  7. 7.0 7.1 Ross L, Abild-Nielsen AG, Thomsen BL, Karlsen RV, Boesen EH, Johansen C. Quality of life of Danish colorectal cancer patients with and without a stoma. Support Care Cancer 2007 May;15(5):505-13 Available from:
  8. Simmons KL, Smith JA, Bobb KA, Liles LL. Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships. J Adv Nurs 2007 Dec;60(6):627-35 Available from:
  9. 9.0 9.1 Hodgson KD, Hutchinson AD, Wilson CJ, Nettelbeck T. A meta-analysis of the effects of chemotherapy on cognition in patients with cancer. Cancer Treat Rev 2013 May;39(3):297-304 Available from:
  10. 10.0 10.1 10.2 10.3 10.4 10.5 Dunn J, Ng SK, Holland J, Aitken J, Youl P, Baade PD, et al. Trajectories of psychological distress after colorectal cancer. Psychooncology 2013 Aug;22(8):1759-65 Available from:
  11. Tsunoda A, Nakao K, Hiratsuka K, Yasuda N, Shibusawa M, Kusano M. Anxiety, depression and quality of life in colorectal cancer patients. Int J Clin Oncol 2005 Dec;10(6):411-7 Available from:
  12. Strong V, Waters R, Hibberd C, Rush R, Cargill A, Storey D, et al. Emotional distress in cancer patients: the Edinburgh Cancer Centre symptom study. Br J Cancer 2007 Mar 26;96(6):868-74 Available from:
  13. Medeiros M, Oshima CT, Forones NM. Depression and anxiety in colorectal cancer patients. J Gastrointest Cancer 2010 Sep;41(3):179-84 Available from:
  14. 14.0 14.1 14.2 Gray NM, Hall SJ, Browne S, Johnston M, Lee AJ, Macleod U, et al. Predictors of anxiety and depression in people with colorectal cancer. Support Care Cancer 2014 Feb;22(2):307-14 Available from:
  15. Maisey NR, Norman A, Watson M, Allen MJ, Hill ME, Cunningham D. Baseline quality of life predicts survival in patients with advanced colorectal cancer. Eur J Cancer 2002 Jul;38(10):1351-7 Available from:
  16. 16.0 16.1 Mols F, Husson O, Roukema JA, van de Poll-Franse LV. Depressive symptoms are a risk factor for all-cause mortality: results from a prospective population-based study among 3,080 cancer survivors from the PROFILES registry. J Cancer Surviv 2013 Sep;7(3):484-92 Available from:
  17. 17.0 17.1 Sales PM, Carvalho AF, McIntyre RS, Pavlidis N, Hyphantis TN. Psychosocial predictors of health outcomes in colorectal cancer: a comprehensive review. Cancer Treat Rev 2014 Jul;40(6):800-9 Available from:
  18. Northouse LL, Mood D, Templin T, Mellon S, George T. Couples' patterns of adjustment to colon cancer. Soc Sci Med 2000 Jan;50(2):271-84 Available from:
  19. Kissane, David W. Bloch, Sidney Burns, W. Ivon McKenzie, Dean Posterino, Maria. Psychological morbidity in the families of patients with cancer. Psychooncology 1994;3(1): 47-56.
  20. National Breast Cancer Centre, National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre 2003 Jan 1 Available from:
  21. 21.0 21.1 Newell S, Sanson-Fisher RW, Girgis A, Bonaventura A. How well do medical oncologists' perceptions reflect their patients' reported physical and psychosocial problems? Data from a survey of five oncologists. Cancer 1998 Oct 15;83(8):1640-51 Available from:
  22. Sanson-Fisher R, Girgis A, Boyes A, Bonevski B, Burton L, Cook P. The unmet supportive care needs of patients with cancer. Supportive Care Review Group. Cancer 2000 Jan 1;88(1):226-37 Available from:
  23. van Ryn, M. Phelan, S. M. Arora, N. K. Haggstrom, D. A. Jackson, G. L. Zafar, S. Y. Griffin, J. M. Zullig, L. L. Provenzale, D. Yeazel, M. W. Jindal, R. M. Clauser, S. B.. Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System. J Clin Oncol 2014;32(8): 809-815.
  24. 24.0 24.1 Holland JC, Bultz BD, National comprehensive Cancer Network (NCCN). The NCCN guideline for distress management: a case for making distress the sixth vital sign. J Natl Compr Canc Netw 2007 Jan;5(1):3-7 Available from:
  25. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7(2):6-9 Available from:
  26. 26.0 26.1 Osborn RL, Demoncada AC, Feuerstein M. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses. Int J Psychiatry Med 2006;36(1):13-34 Available from:
  27. Hart SL, Hoyt MA, Diefenbach M, Anderson DR, Kilbourn KM, Craft LL, et al. Meta-analysis of efficacy of interventions for elevated depressive symptoms in adults diagnosed with cancer. J Natl Cancer Inst 2012 Jul 3;104(13):990-1004 Available from:
  28. Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and challenges. CA Cancer J Clin 2008 Jul;58(4):214-30 Available from:
  29. Subnis UB, Starkweather AR, McCain NL, Brown RF. Psychosocial therapies for patients with cancer: a current review of interventions using psychoneuroimmunology-based outcome measures. Integr Cancer Ther 2014 Mar;13(2):85-104 Available from:
  30. Chien CH, Liu KL, Chien HT, Liu HE. The effects of psychosocial strategies on anxiety and depression of patients diagnosed with prostate cancer: a systematic review. Int J Nurs Stud 2014 Jan;51(1):28-38 Available from:
  31. Hoon, L. S. Chi Sally, C. W. Hong-Gu, H.. Effect of psychosocial interventions on outcomes of patients with colorectal cancer: a review of the literature. Eur J Oncol Nurs 2013;17(6): 883-891.
  32. Ieropoli SC, White VM, Jefford M, Akkerman D. What models of peer support do people with colorectal cancer prefer? Eur J Cancer Care (Engl) 2011 Jul;20(4):455-65 Available from:
  33. 33.0 33.1 Cheung YL, Molassiotis A, Chang AM. The effect of progressive muscle relaxation training on anxiety and quality of life after stoma surgery in colorectal cancer patients. Psychooncology 2003 Apr;12(3):254-66 Available from:
  34. Higginson IJ, Wade AM, McCarthy M. Effectiveness of two palliative support teams. J Public Health Med 1992 Mar;14(1):50-6 Available from:
  35. 35.0 35.1 35.2 Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011 Oct 5;(10):CD001431 Available from:
  36. De Vries AM, de Roten Y, Meystre C, Passchier J, Despland JN, Stiefel F. Clinician characteristics, communication, and patient outcome in oncology: a systematic review. Psychooncology 2014 Apr;23(4):375-81 Available from:
  37. Singh S, Butow P, Charles M, Tattersall MH. Shared decision making in oncology: assessing oncologist behaviour in consultations in which adjuvant therapy is considered after primary surgical treatment. Health Expect 2010 Sep;13(3):244-57 Available from:
  38. Waller A, Forshaw K, Bryant J, Mair S. Interventions for preparing patients for chemotherapy and radiotherapy: a systematic review. Support Care Cancer 2014 Aug;22(8):2297-308 Available from:
  39. Damian D, Tattersall MH. Letters to patients: improving communication in cancer care. Lancet 1991 Oct 12;338(8772):923-5 Available from:
  40. Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med 2012 Mar 1;366(9):780-1 Available from:
  41. 41.0 41.1 O'Connor AM, Bennett C, Stacey D, Barry MJ, Col NF, Eden KB, et al. Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis. Med Decis Making 2007 Sep;27(5):554-74 Available from:
  42. 42.0 42.1 O'Brien MA, Whelan TJ, Villasis-Keever M, Gafni A, Charles C, Roberts R, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. J Clin Oncol 2009 Feb 20;27(6):974-85 Available from:
  43. Leighl NB, Shepherd HL, Butow PN, Clarke SJ, McJannett M, Beale PJ, et al. Supporting treatment decision making in advanced cancer: a randomized trial of a decision aid for patients with advanced colorectal cancer considering chemotherapy. J Clin Oncol 2011 May 20;29(15):2077-84 Available from:

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