Patient-centered outcomes in colorectal cancer screening and treatment
Outcomes research has been identified for all phases of colorectal cancer care. The reports that have been summarized reflect the variable quality and application of outcomes research to colorectal cancer screening and treatment. There were several articles that examined screening for colorectal cancer, and compliance with screening. In general, compliance with screening was associated with education level, socioeconomic status, belief in the efficacy of screening and treatment for colorectal cancer, and physician recommendation of screening tests. Economic analyses represented a substantial portion of the screening articles. There is general agreement among these articles that, compared to other screening programs such as breast cancer screening,6 colorectal cancer screening, regardless of the test employed, is cost-effective. Regarding surveillance of high-risk groups, compliance with follow-up among those with a history of resected colorectal cancer is greater among those whose surgery was performed with curative intent. In this group, mortality is associated with compliance and stage at time of diagnosis. For those with an inherited risk for colorectal cancer (e.g., hereditary nonpolyposis colorectal cancer (HNPCC), familial adenomatous polyposis (FAP)), genetic testing is more common among those who have increased anxiety about cancer, perceived increased risk, and a desire to plan for their own and their children's futures. Treatment for colorectal cancer was the subject of nearly half of the articles in this review. Quality of life was a focus of many of these articles. Methods for measuring quality of life were diverse and genetic for the most part. However, certain observations are noteworthy. Most studies found little correlation between HRQL and other disease outcomes such as survival or disease-free survival. While this may truly reflect that treatment for colorectal cancer, particularly chemotherapy, does not affect HRQL, an alternative explanation is that the largely generic measures used to assess it were insensitive to the quality of life concerns of patients undergoing treatment for colorectal cancer. Regarding care at the end of life, one study170 revealed that, although functional status remained high up to the last month on life, pain was a frequent symptom in the last 6 months of life. The articles for which the phase of care was unspecified examined a variety of topics including the testing of alternative methods for measuring quality of life, caregiver burden, impact of age on HRQL, and others. Their diversity reflects the diversity of patient and caregiver centered outcomes. Finally, the development of colorectal cancer-specific quality of life instruments in the latter part of the decade provides the opportunity to more adequately address patient-specific concerns related to colorectal cancer care. This review has considered patient centered outcomes of colorectal cancer screening and treatment. The last decade revealed a move towards incorporating these important outcomes into assessments of screening programs and treatment regimens. The lack of standardization of measures makes comparisons somewhat difficult, but the development of disease-specific instruments to measure quality of life provides an opportunity to standardize future measurements and study methods. Research that focuses on standard approaches to economic analysis and measurement of HRQL, and that addresses patient satisfaction and compliance with screening for colorectal cancer, may provide us with critical information about effective and cost-effective modalities to increase both length and quality of life.
Provenzale, D; Gray, RN; Fisher, DA; Schmidt, T
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