Effect of timing on baseline quality of life scores among surgical cancer patients
Steffens et al. BMC Res Notes
Effect of timing on baseline quality of life scores among surgical cancer patients
Daniel Steffens 0 2
Michael Solomon 0 1 2
Kenneth Vuong 0
Lyndal Alchin 0
Rachael Roberts 0
Cherry Koh 0
Jane Young 0 1 2
0 Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH) , PO Box M157, Missenden Road, Sydney, NSW 2050 , Australia
1 Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital , Sydney , Australia
2 Sydney Medical School, The University of Sydney , Sydney , Australia
Objectives: To investigate differences between quality of life (QoL) scores obtained preoperatively or recalled in the early postoperative period amongst patients undergoing major cancer surgery. Results: Of the 283 patients included, 133 completed their baseline QoL questionnaire preoperatively and 150 postoperatively. Patient groups were broadly comparable in terms of age however the preoperative group had a lower proportion of patients from non-English speaking backgrounds. There were important and statistically significant differences between mean scores for physical health (overall physical health, physical functioning and role physical domains) and mental health (overall mental health and mental health domains) between pre- and postoperative groups. There were no differences for other domain-specific scores (bodily pain, general health, vitality, social functioning and role emotional).
Quality of life; Preoperative; Postoperative; Surgery; SF-36; Cancer
Improvements in patient selection, surgical skills,
technology, and multidisciplinary care have led to dramatic
improvements in survival rates for patients undergoing
major cancer surgery [
]. For this reason, more patients
will live with permanent consequences of the disease and
treatment, including pain, bowel and sexual dysfunction,
psychological distress, faecal, urinary incontinence and
body issues; resulting in drastic changes in their lifestyle
and impacting their health-related quality of life (QoL)
Longitudinal studies that assess patient-reported
outcomes such as QoL provide valuable information
about the impact of treatment-related consequences on
patients’ daily life. In such longitudinal research, baseline
pre-intervention assessment of QoL provides the
reference level from which improvements or deterioration can
be assessed. Additionally, preoperative QoL is considered
a prognostic factor for many conditions, and has been
shown to correlate with surgical outcomes and long-term
In some circumstances however, it is not always
possible to collect baseline data preoperatively for
surgical patients, particularly those admitted as emergency
cases. For elective admissions, the trend towards patient
admission on the day of surgery leaves little time for
QoL assessment prior to the procedure. This combined
with multiple medical, surgical, nursing and allied health
assessments make the time for QoL assessments limited.
In longitudinal studies that investigate changes in QoL
over time, statistical imputation methods can be used for
missing follow-up data [
]. However, it is extremely
difficult to accurately impute missing baseline data, which
could potentially weaken the validity of the results and
An alternative and pragmatic approach to obtain
‘missed’ preoperative QoL information is to ask patients
in the early postoperative period to recall their health and
well-being in the week before surgery, and to complete
the baseline questionnaire based on this recall.
However, the reliability of scores collected at these two-time
points is uncertain. Therefore, this study was conducted
to compare baseline QoL scores collected either
preoperatively or postoperatively within a cohort of patients who
underwent major cancer surgery by comparing the mean
differences via large cohort of prospective exenteration
patients whose baseline measurements are recorded
situationally at the different time points.
This study used data from a prospectively maintained
clinical and QoL database [
]. The database is
maintained through REDCap, and is managed by the Surgical
Outcomes Research Centre (SOuRCe). Patients’ clinical
information and QoL data is collected at baseline (for
this study either preoperatively or postoperatively) and
then at 6, 12, 18, 24, 30, 36, 48 and 60 months
postoperative. In brief, participants for this study included patients
with advanced primary or recurrent rectal cancer who
underwent pelvic exenteration at the Royal Prince Alfred
Hospital (RPAH) Sydney, between 2008 and 2016.
Ethics approval for the QoL study was granted by the Royal
Prince Alfred Research Human Research Ethics
Committee (Approval Number X16-0272).
Inclusion and exclusion criteria
Patients eligible for the study was adults aged 18 years
and over with non-metastatic curable locally advanced or
locally recurrent cancer arising from the pelvis. Although
the type of cancer is not restricted, what these cancers
have in common is the need for radical multivisceral en
bloc resection. Patients were also excluded if they had
cognitive impairment such that they are unable to give
informed consent or inadequate English to complete
selfreported outcome measures.
Pelvic exenteration was defined as en bloc resection of
at least three major pelvic structures which may
comprise of a major pelvic organ (e.g. rectum, uterus, bladder
etc.) and/or pelvic neurovascular structure, soft tissue or
bony structure (e.g. iliac vessels, obturator internus,
sciatic nerve roots, sacrum etc.).
Patient characteristics and quality of life measurements
Data collection at study enrolment included patient
demographics, relevant clinical information as well as
QoL data. For logistical reasons described above, some
patients did not complete the QoL measures prior to
surgery. This group of patients then completed QoL
measures in the early postoperative period. Patients were
specifically instructed to answer the questionnaires based
on their recollection of their preoperative QoL status.
The QoL questionnaire used at preoperative or
postoperative was identical (i.e. same instruments were used).
The SF-36 was used to evaluate health related
]. It is a broad measure compared with other
patient-reported outcome measures, which are either
disease-, treatment- or symptom-specific, and provides
two summary scales (physical and mental component
summary scales) plus eight domain-specific subscales
(vitality; physical functioning; bodily pain; general health
perceptions; physical role functioning; emotional role
functioning; social role functioning; and mental health).
QoL data was scored for the preoperative and
postoperative groups using SF-36 Scoring Software. Higher SF-36
scores indicate better QoL.
Baseline pre- and postoperative demographics,
clinical characteristics and QoL scores were summarised as
mean ± standard deviation for continuous outcomes or
as frequencies (percentage) for dichotomous outcomes.
Differences between the pre- and postoperative group
scores were assessed using Chi squared tests
(dichotomous outcomes) or T tests (continuous outcomes) with
P < 0.05 considered statistically significant. All analyses
were performed using SPSS version 22 (SPSS, inc.,
From January 2008 to December 2016, 446 patients
underwent pelvic exenteration at RPAH. Of these a
total of 283 (63.5%) patients were eligible and recruited
into the study. The baseline self-reported questionnaire
was completed by 133 patients preoperatively and by
150 patients postoperatively (recalled as preoperative)
during this study period. The demographic and clinical
characteristics of the included patients are described in
Table 1. The mean age was 59.5 (SD 12.13) years. Most
demographic and clinical characteristics were
comparable between the pre- and postoperative groups, except for
country of birth (P = 0.027) and language spoken at home
(P = 0.020) (Table 1).
Comparison of baseline QoL scores collected
preand postoperatively are summarised in Table 2 and
Fig. 1. There were statistically significant differences
between baselines QoL scores collected pre- and
postoperatively on the physical health (mean ± SD
preoperative = 42.79 ± 10.25 vs postoperative = 39.29 ± 11.3;
P = 0.045) and mental health components
(mean ± SD preoperative = 43.19 ± 11.67 vs
postoperative = 46.00 ± 11.38; P = 0.008). On the QoL
domainspecific subscales, differences were noted in physical
functioning (mean ± SD preoperative = 64.94 ± 28.17 vs
postoperative = 56.47 ± 32.74; P = 0.022), role
physical (mean ± SD preoperative = 48.80 ± 34.78 vs
postoperative = 38.68 ± 41.00; P = 0.030), and mental health
domains (mean ± SD preoperative = 63.57 ± 20.45 vs
postoperative = 69.36 ± 20.26; P = 0.019).
domain-specific scores were similar.
Collecting QoL data in the preoperative setting can be
challenging. The purpose of this study was to determine
whether QoL measures collected in the early
postoperative period based on patients’ recall of their preoperative
QoL status are comparable with scores obtained
preoperatively. Unfortunately, this study found that QoL scores
based on postoperative recall were lower for physical
health but higher for mental health compared with scores
obtained from patients preoperatively.
Postoperatively, the perception of QoL physical scores,
including the overall physical health component, physical
functioning and role physical based on recall were worse
for the group assessed postoperatively than
preoperatively. Conversely, QoL mental health scores, including
the mental health component and mental health specific
domains were perceived better postoperatively when
compared to preoperatively. Other specific domains,
such as bodily pain, general health, vitality, social
functioning and role emotional were equally perceived by the
patients, independently of the time point.
To our knowledge this is the first study to investigate
whether the recall of preoperative QoL scores are
different postoperatively in patients undergoing major
cancer surgery. Interestingly, when the preoperative SF-36
scores are compared with postoperative (perceived
preoperative) scores it reveals that the overall physical and
mental health domains including the overall physical and
mental health scores were perceived differently. This may
suggest that cancer patients that undergo major surgery
are mentally better postoperatively than preoperatively,
due to the fact that they survived the fears of a major and
complex surgery and can potentially now see a long-term
a Scores are mean ± standard deviation (higher scores indicate better quality of life); MD mean difference (negative values favours preoperative group); CI confidence
survival. While on the other hand, in the postoperative
group, the physical components were perceived worse
than the preoperative group, this may be related to the
extreme physical limitations post operation,
including physical, bowel and sexual dysfunction, faecal and
urinary incontinence. While they were emphatically
asked to recall their preoperative state it is obvious the
postoperative state has confounded the perception
positively mentally and negatively physically. When
compared with other studies investigating QoL following
major cancer surgery, the preoperative overall scores of
the physical (mean ± SD = 43.7 ± 10.3) and mental health
(mean ± SD = 42.9 ± 11.6) components were similar to
our preoperative group scores [
]. This may suggest that
patients undergoing major surgery may perceive their
preoperative status differently postoperatively. Therefore,
our findings support the collection of baseline QoL data
preoperatively where possible. Our findings are limited
by the study design, differences in the characteristics of
the samples (i.e. country of birth and language spoken at
home), and lack of generalizability due to the very
specific type of cancer and surgery studied, as such, caution
should be taken when interpreting these results.
From the results of this explanatory study, it is clear
that continued research and the application of response
shift on major cancer surgical field and outcomes are
needed. In brief, future studies should consider
measuring changes in QoL by examining some of the
following research designs described: (i) pre-test/post-test [
]; (ii) then-test [
]; (iii) structural equation
]; (iv) anchoring vignettes [
12, 15, 17, 18
Furthermore, future studies should focus on the clinical
application of response shift measurement and how this
may be incorporated into clinical practice.
Patients undergoing major cancer surgery perceive their
preoperative physical and mental health scores of the
SF-36 QoL questionnaire differently pre- and
postoperatively. Future studies, collecting data preoperatively and
immediately after surgery are warranted to support our
This study consisted of a small sample of participants
undergoing a complex and rare cancer procedure and
therefore may not be generalised. Participants were
grouped according to the period they answer their
baseline questionnaire (i.e. preoperatively versus
postoperatively), potentially resulting in high risk of bias. Caution
should be taken when interpreting these results.
QoL: quality of life; RPAH: Royal Prince Alfred Hospital; SF-36: Short Form 36;
SD: standard deviation.
DS, MS, JY and CK made contributions to conception and design, and
analysed the data. DS, KV, LA, RR wrote the paper. All authors worked on the
manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
All data generated or analysed during this study are included in this published
Consent for publication
Ethics approval and consent to participate
Ethics approval for the study was granted by the Royal Prince Alfred Research
Human Research Ethics Committee (Approval Number X16-0272). Writing
informed consent was obtained from all individual participants included in
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