Influence of preoperative life satisfaction on recovery and outcomes after colorectal cancer surgery - a prospective pilot study

Surgery, particularly colorectal cancer surgery, has an important impact on a patient’s quality of life [1], and postoperative rehabilitation can be difficult to handle [2, 3]. The classic medical outcomes for surgical procedures are usually mortality, complications, recurrence rate and long-term survival. However, from the patient’s perspective, the length of the hospital stay, convalescence duration, subjective well-being, sensation of pain, and quality of sleep are just as important [4‐6]. In an attempt to improve patient management and health recovery, standardized multimodal perioperative care programmes were recently introduced, particularly in the framework of colorectal cancer [7]. These protocols, involving both the participants in the care and the patients themselves, were designed to achieve enhanced recovery after surgical (ERAS) procedures by maintaining organ function and reducing a profound stress response following surgery [7, 8]. ERAS protocols place the patient’s recovery in the centre of perioperative care and have led to considerable improvements in easily measurable outcomes such as complications (−40%) and hospital stays (−2.5 days) [8, 9].

However, little has been reported on actual recovery. The reason for this is that recovery is poorly defined and that the available scores can present with certain limitations, especially because a consensus is lacking on the available criteria [10].

To enhance the understanding of recovery after colorectal cancer, health-related quality of life has become a standard outcome measurement in clinical care and research. Attention to this parameter from both patients and surgeons has already led to surgical innovations that aim to preserve sphincters, mitigate faecal disorders and reduce the risk for sexual dysfunction [11]. However, an appropriate evaluation of health-related quality of life after surgery should take a wider range of markers into account [12] from both objective (i.e., physical activity) and subjective (i.e., psychological feelings) standpoints. Quality of life after surgery has been studied using different scales; after colorectal cancer, for example, the EORTC QLQ-C30 has been recommended to measure postoperative recovery [13]. However, in this type of questionnaire, concepts linked to environmental factors, one’s place in society, relationships, and, more broadly, general feelings of life satisfaction are neglected. Nevertheless, recent reports have described the relationship between psychological and emotional characteristics prior to a stressful event, such as surgery, and the ways in which individuals respond during the recovery period [14‐16]. Moreover, life satisfaction, which refers to human characteristics that are stable over time (and thus not to transient states), was shown to significantly impact the recovery process in a heterogeneous sample of patients [17].

Thus, in terms of clinical applications, the extent to which a patient’s satisfactory assessment of his/her well-being and quality of life before surgery will play a role in alleviating some postoperative outcomes appears to be important for further investigations. Notably, progress in this area may foster the optimization of ERAS protocols to better take into account a patient’s psychological care. Therefore, the aim of this pilot study, which focused on colorectal cancer patients, was to analyse the influence of subjective feelings on various areas of life on different objective and subjective outcomes after colorectal surgery, which was assessed as a global component of life satisfaction [18].

The final analysis included 112 consecutive colorectal patients. The participants (55% males) were aged from 18 to 90 years (M _age  = 63.79 years, SD _age  = 13.93).

First, it is important to note that the low-level life satisfaction group and the high-level one (median score: 3.09) can be considered as equivalent in regard to their individual characteristics; the results showed no difference in terms of age (p = 0.64), gender (p = 0.80), intervention (p = 0.45), or approach (Laparoscopy: p = .45; Open: p = 0.37; Conversion: p = 0.34). Not surprisingly, the results indicated that the patients with the high preoperative physical activity had a significantly higher life satisfaction score than those with the lower physical activity (p = 0.02) (see Table 2).

Recent literature has noted the importance of quality of life as a relevant factor of recovery after surgery. In a number of studies, health-related quality of life was mostly restricted to physical and medical outcomes after surgical procedures, such as mortality or complications [22‐27]. However, the influence of different personality or subjective feeling factors related to psychological well-being has recently been singled out [15‐17, 28]. Focusing on a sample of colorectal cancer patients, the aim of this pilot study was to evaluate how preoperative feelings of global life satisfaction can significantly influence recovery outcomes after surgery. To properly assess these outcomes, a set of both objective and subjective markers of recovery were taken into account [12]. We have shown that positive preoperative life satisfaction was a significant factor that was correlated with a better postoperative rehabilitation, namely, it was associated with a significantly decreased length of stay combined with a trend of reduced postoperative complications. Furthermore, preoperative life satisfaction was significantly related with the postoperative subjective marker of recovery, which combines well-being, quality of sleep and pain sensation. It also seems that preoperative life satisfaction appears to be a particularly good predictor of subjective well-being after surgery; at this point in our research, the positive effects more strongly appeared to be subjective indicators of recovery rather than objective ones.

Our results are in accordance with previous works showing that negative feelings and emotional distress constitute major barriers to recovery from cancer [29]. In the context of health schemes and of efforts to reduce morbidity and mortality, special attention is currently being paid to understand and improve the preoperative factors affecting postoperative recovery. As coping behaviour [17] and patient activation, i.e., one’s propensity to engage in positive health, have been identified as important modifiers of the recovery process [28], proactive approaches have now been put forward. In this same vein, some attempts at preoperative strategies that are based on cognitive-behavioural patient education, acceptance-based nursing intervention, exercise training or pre-habilitation have been initiated and described to help optimize postoperative recovery [30‐34]. Such research notes the importance of patients being provided with early psychological support and being helped to develop self-management skills to better cope with illness and surgical outcomes [35]. Insofar as preoperative life satisfaction may represent a key point in the fostering of health-related recovery, it would be interesting to implement appropriate interventions that are able to improve this parameter. This would provide a valuable resource to patients, especially those with negative mood and emotional distress, both of which present a greater post-surgical risk for continued physical disability [16]. In this context, mindfulness-based interventions (MBI) could be particularly effective [36]. Indeed, a growing number of studies concerning coping with cancer, have reported a broad spectrum of the positive effects of MBI, ranging from quality of life domains (emotional, social and physical functioning) to psychological improvements (reduced symptoms of depression, anxiety, insomnia…) and biological markers of health [11]. However, the MBI in these studies were mostly concerned with ongoing care patients, as well as with survivors of cancer. It would be interesting to test the effects of earlier mindfulness training, particularly on the improvement of the parameters of the feelings of life satisfaction in preoperative patients with colorectal cancer.

Our pilot study presented several limitations due to a modest and heterogeneous patient cohort and to the absence of a life satisfaction estimation in a safe patient cohort. In this exploratory research, we were not able to reflect the sublevels of the pathologies of the interventions. Moreover, our correlational perspective did not allow us to conclude cause-effect relationships. Furthermore, the subjective tools and scores deserve to be complemented by more objective measures and conventional scales. However, this is the first study, to our knowledge, in the field of colorectal cancer that correlated preoperative feelings of life satisfaction with objective and subjective postoperative factors.

We have highlighted the importance of positive preoperative subjective states and global feelings of life satisfaction as characteristics that are associated with improved subjective, as well as clinical, outcomes after colorectal surgery. Such parameters deserve to be taken into account to optimize multimodal ERAS care protocols that have been recently introduced to foster recovery. Notably, the strengthening of well-being and life satisfaction by early interventions, such as MBI, could be effective aides for patients to cope and thrive through the difficult challenge of colorectal cancer. The strategy to improve a patient’s chance of a successful outcome by providing more comprehensive perioperative care should be especially valuable in the context of health schemes. This area of research and clinical implications deserves to be further explored.