Change Toward Healthier Lifestyles Is Associated With Better Health-Related Quality of Life in Long-Term Colorectal Cancer Survivors

Authors:
Ruth Elisa Eyl-Armbruster Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;
Stuttgart Cancer Center—Tumorzentrum Eva Mayr-Stihl, Klinikum Stuttgart, Stuttgart, Germany;

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 PhD
,
Melissa S.Y. Thong Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;

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 PhD
,
Prudence R. Carr Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;
Division of Chronic Disease and Aging, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia;

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 PhD
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Lina Jansen Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;

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Jenny Chang-Claude Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany;
Cancer Epidemiology Group, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;

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Michael Hoffmeister Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;

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Hermann Brenner Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;
Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg, Germany; and
German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany.

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Volker Arndt Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany;

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Volume/Issue:
Volume 20: Issue 11
Online Publication Date:
Nov 2022
DOI:
https://doi.org/10.6004/jnccn.2022.7049
Full access

Background: Little is known about how changes in a constellation of lifestyle factors affect health-related quality of life (HRQoL) in colorectal cancer (CRC) survivors. Our study aimed to investigate the association between changes in healthy lifestyle and HRQoL over time in survivors of stage I–IV CRC. Methods: We included 2,283 long-term (≥5 years postdiagnosis) survivors. A healthy lifestyle score (HLS) comprising smoking, alcohol consumption, diet, physical activity, and body fatness was derived at diagnosis and 5-year follow-up (5YFU) and categorized as low, moderate, or high. We assessed HRQoL with the EORTC Quality of Life Questionnaire-Core 30 at 5YFU and 10-year follow-up. We used multivariable linear regression and linear mixed models to explore associations between changes in HLS and HRQoL over follow-up. Results: A low baseline HLS was associated with poorer functioning and global health/QoL and a higher symptom burden at 5YFU compared with a high baseline HLS. An improved HLS from baseline to 5YFU was associated with better functioning, higher global health/QoL, and fewer symptoms at 5YFU than a maintained-high HLS. In longitudinal analyses, improved HLS was associated with better functioning at follow-up. Survivors with a maintained-high or an improved HLS reported generally less fatigue, pain, and dyspnea at follow-ups compared with survivors with a maintained-low or decreased HLS. Conclusions: Change toward a healthier lifestyle since diagnosis was associated with better HRQoL in long-term CRC survivors. Our results support the importance of maintaining and/or promoting a healthier lifestyle among CRC survivors postdiagnosis.

Background

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer-related death worldwide.1 The number of CRC survivors is increasing due to the combined factors of improvements in early detection and treatment, and aging of the population.2 In Western countries, CRC survivors represent the third largest survivor group after breast and prostate cancer survivors.1

Many CRC survivors still experience detriments in health-related quality of life (HRQoL) years after diagnosis.3 Therefore, it is important to determine possibilities with potential to improve HRQoL among the growing population of long-term (≥5 years postdiagnosis) CRC survivors.

Individual lifestyle factors have been associated with HRQoL in CRC survivors. Physical activity4 and a healthy diet5 were positively associated with HRQoL, whereas obesity6 was negatively associated. Further, high alcohol consumption5,7 and smoking5,6,8 were negatively associated with HRQoL. Most epidemiologic studies to date have explored associations between individual health behaviors by treating other lifestyle factors as covariates in statistical models. However, in real life, it is uncommon that people practice isolated health behaviors. Studies that investigated a combination of lifestyle factors and HRQoL reported that better adherence to lifestyle guidelines (ie, a higher lifestyle score) was associated with better physical functioning,5,6,8 better role (eg, occupational and social aspects of relevance) and social functioning,6,8 and less fatigue5,6,8 in CRC survivors.

However, most studies used a cross-sectional study design, and to the best of our knowledge, no study has investigated whether a change toward a healthier lifestyle after diagnosis is positively associated with HRQoL among CRC survivors.5,6,8 Therefore, our study aimed to investigate (1) the association between a combination of lifestyle factors (smoking, alcohol consumption, diet quality, physical activity, body mass index [BMI]) at diagnosis (baseline assessment) and HRQoL at 5-year follow-up (5YFU), and (2) the association between changes in lifestyle (from baseline to 5YFU) and HRQoL at 5YFU and 10-year follow-up (10YFU).

Methods

Setting and Participants

We used data from the population-based DACHS study conducted in Southwest Germany. Eligible patients with a histologically confirmed diagnosis of primary CRC (ICD-10 codes C18–C20) were identified by their treating clinician during their hospital stay or were contacted by mail shortly after discharge by clinicians or clinical cancer registries. Further details of the study have been described elsewhere.9 All respondents to the baseline assessment who were alive were eligible for assessment of HRQoL at 5YFU and 10YFU. The current study reports on participants diagnosed with stage I–IV CRC between 2003 and 2013 who completed a lifestyle survey at baseline, 5YFU, and possibly 10YFU between 2009 and 2018 (supplemental eFigure 1, available with this article at JNCCN.org). The ethics committee of the University of Heidelberg and the state medical boards of Baden-Wuerttemberg and Rhineland-Palatinate approved the DACHS study. All participants gave written informed consent.

Data Collection

At baseline, trained interviewers obtained sociodemographic information, medical history, and lifestyle history using a standardized questionnaire. At 3-year follow-up, attending physicians provided detailed information about participants’ treatment, other diseases, and recurrence via a standardized questionnaire. Among participants alive at 5YFU and 10YFU, 81% and 86%, respectively, completed a mailed questionnaire that included information on lifestyle, medical or recurrence history, and HRQoL. Attending physicians verified participant reports on recurrence, other diseases, and new cancers. Participants’ vital status was regularly updated through population registries. We combined relevant data from baseline, 3-year follow-up, 5YFU, and 10YFU for this analysis.

Lifestyle Factors Assessment

Extensive information on lifestyle behaviors was collected at baseline and 5YFU. Further details on the assessment and availability of the individual factors are outlined in supplemental eAppendix 1.

Healthy Lifestyle Score

Using data from the DACHS study, Carr et al10 previously developed a healthy lifestyle score (HLS) and assessed its association with CRC risk. The HLS was created by dichotomizing 5 modifiable lifestyle factors based on a priori knowledge of CRC risk factors.

In brief, participants were assigned 1 point for the following lifestyle behaviors:

  • Nonsmoking (never-smoker or former smoker [<30 pack-years])

  • Moderate alcohol consumption (adherent to the World Cancer Research Fund/American Institute for Cancer Research recommendations11: ≤24 g/d for men, ≤12 g/d for women)

  • Healthy diet (diet quality score ≥34, top 40%)

  • Adequate physical activity (meeting the WHO Global Recommendations on Physical Activity for Health12: minimum 150 minutes of moderate-intensity or 75 minutes of vigorous physical activity/week),

  • Healthy weight (BMI ≥18.5 to <25 kg/m2)

Adherence to individual lifestyle guidelines were determined at baseline (using baseline lifestyle data) and at 5YFU (using 5YFU lifestyle data). To assess change in adherence for each lifestyle factor, we compared the baseline and 5YFU scores. Four categories were determined: met/maintained adherence, improved adherence, maintained nonadherence, and decreased adherence (supplemental eFigure 2).

To create the HLS, points for the 5 lifestyle factors were summed, with totals ranging from 0 (least healthy) to 5 (most healthy). This HLS was used as the basis for the current analyses, and we derived an HLS for each participant at baseline (using baseline lifestyle data) and at 5YFU (using 5YFU lifestyle data). To facilitate clinical interpretation, the HLS was categorized into 3 categories: low (HLS ≤2), moderate (HLS = 3), and high (HLS ≥4).

Change in HLS

To determine change in HLS (ΔHLS) over time, we derived 4 categories by comparing the categoric baseline HLS with the categoric 5YFU HLS: no change–moderate/high (HLS remained ≥3), improved (baseline HLS < 5YFU HLS), no change-low (HLS remained ≤2), or decreased (baseline HLS > 5YFU HLS).

Health-Related QoL

At 5YFU and 10YFU, HRQoL was measured with the EORTC Quality of Life Questionnaire-Core 30,13 which comprises 5 functional scales, 1 global health/QoL scale, 3 symptom scales, and 6 single items. All scores were linearly transformed to a 0 to 100-point scale according to the EORTC scoring manual.14 Higher functioning and global health/QoL scores imply better functioning and health/QoL; higher symptom and financial difficulties scores imply greater symptom severity and financial problems.

Statistical Analysis

We assessed the distributions of demographic and clinical characteristics by baseline HLS and by ΔHLS. Differences were tested for statistical significance using ANOVA for continuous variables and a chi-square test for categorical variables.

We used multivariable linear regression models to explore the association between baseline HLS and HRQoL at 5YFU and the association between ΔHLS from baseline to 5YFU and HRQoL at 5YFU. All linear regression models included a comprehensive adjustment of covariates, such as baseline HLS, age at survey, sex, comorbidity cluster, cancer type (colon vs rectum), cancer stage, radiotherapy, and chemotherapy, where appropriate. Comorbidity clusters were defined as cardiovascular diseases (CVD; myocardial infarction, chronic heart failure, coronary heart disease, peripheral vascular disease, stroke ± hemiplegia, pulmonary embolism), metabolic diseases (diabetes mellitus, chronic renal disease, liver disease), other diseases (depression, dementia, chronic obstructive pulmonary disease [COPD], non-CRC cancers, peptic ulcer, rheumatoid disease), and multiple (>1 comorbidity cluster).

We used linear mixed models to investigate the longitudinal associations between ΔHLS and HRQoL at 5YFU to 10YFU. We used an unstructured covariance matrix structure and maximum likelihood estimation. Time was analyzed as a categorical predictor with 2 levels. For adjustment, we included time-invariant covariates (sex, cancer type, cancer stage, chemotherapy, and radiotherapy) and time-variant covariates (age, comorbidity cluster, and disease recurrence).

We conducted 2 sensitivity analyses on the linear regression models. The first sensitivity analysis excluded survivors with disease recurrence. Because the number of respondents who completed 5YFU and 10YFU was fewer than that of respondents who completed only a 5YFU, we conducted the second sensitivity analysis to explore the association of ΔHLS and HRQoL at 5YFU by number of follow-ups (ie, to compare the HRQoL at 5YFU of those who completed only 1 follow-up and those who completed 2 follow-ups).

All analyses were conducted using SAS 9.4 (SAS Institute Inc.). Statistical significance was determined at P<.05 (2-sided). The P values were not adjusted for multiple testing and referred to the individual tests rather than a global test for differences.

Results

In total, 3,151 survivors were contacted at 5YFU, of whom 2,455 (78%) responded (supplemental eFigure 1 and eTable 1). Respondents at 5YFU were more likely to be younger and male, have localized disease with a distal location, receive treatment in a high-volume hospital, and have received chemotherapy compared with nonrespondents or those who had died. At 10YFU, 918 (83%) survivors responded and returned a completed questionnaire. Respondents at 10YFU were more likely to be younger and to have received treatment at a high-volume hospital compared with nonrespondents or those who had died.

Of the 2,455 respondents who completed an HRQoL survey at 5YFU, 172 were excluded for missing HLS (baseline: n=43; 5YFU: n=83) or having a BMI <18.5 (n=46) (supplemental eFigure 1). In total, 2,283 respondents were included in the current analysis, of whom 1,429 completed 1 follow-up (5YFU only) and 854 completed 2 follow-ups (5YFU and 10YFU). Participants who completed 2 follow-ups were younger at age of diagnosis and were less likely to have stage IV disease, disease recurrence, a stoma, or comorbid conditions (supplemental eTable 2).

Proportion of Individual Lifestyle Factors That Met Guidelines

At baseline and 5YFU, respectively, a majority of survivors met the guidelines mentioned previously for smoking (78%/91%), alcohol consumption (72%/83%), and physical activity (99%/81%) (supplemental eFigure 2). In contrast, a smaller proportion of survivors met the guidelines for diet (36%/45%) and BMI (31%/30%) at baseline and 5YFU, respectively. Improvements in adherence between baseline and 5YFU were noted for smoking (14%), alcohol consumption (18%), and diet (20%). On the contrary, improvements in adherence to physical activity were noted only for 1% of survivors, and improvements in BMI were noted for only 7%.

Sample Characteristics by Baseline HLS

At baseline, 577 (25%) survivors had a low HLS, 862 (38%) had a moderate HLS, and 844 (37%) had a high HLS (supplemental eTable 3). More survivors with a low baseline HLS were younger and male, had stage II CRC, had distal tumor, had received radiotherapy, and had comorbid conditions compared with those with a high baseline HLS. Survivors with a high baseline HLS were more likely to have colon cancer and had more years of education.

Sample Characteristics According to ΔHLS

Between baseline and 5YFU, 947 (41%) survivors maintained a moderate/high HLS, 661 (29%) had an improved HLS, 208 (9%) maintained a low HLS, and 467 (20%) had a decrease in HLS (Table 1). Survivors who maintained a moderate/high HLS had more years of education. Survivors with an improved HLS at 5YFU were more likely to have rectal cancer and to have had disease recurrence. Survivors who maintained a low HLS were more likely to be younger and male, have distal tumor, have received radiotherapy, have a stoma, and have comorbid conditions.

Table 1.

Demographic and Clinical Characteristics of Survivors According to Change in HLS From Baseline to 5YFU
Table 1.

Baseline HLS and HRQoL at 5YFU

Compared with survivors with a high baseline HLS, survivors with low baseline HLS had significantly lower functioning (physical, role, and emotional) and poorer global health/QoL (Figure 1). Concerning symptom burden, survivors with low baseline HLS were more likely to have more problems with sleep, fatigue, pain, dyspnea, constipation, diarrhea, appetite loss, and finances than those with high baseline HLS. Survivors with moderate baseline HLS reported significantly lower physical functioning and higher levels of pain, dyspnea, and financial difficulties compared with survivors with high baseline HLS.

Figure 1.
Figure 1.

Difference in mean EORTC QLQ-C30 scores at 5YFU, according to baseline HLS.

High HLS is the reference group used to derive the differences in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.

Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7049

ΔHLS and HRQoL at 5YFU

When compared with survivors who maintained a moderate/high HLS, survivors who had an improved HLS from baseline to 5YFU reported significantly better functioning (physical, role, emotional), higher global health/QoL, and lower symptom burden (fatigue, dyspnea) at 5YFU (Figure 2). Survivors with decreased HLS reported having poorer functioning and global health/QoL and more problems with fatigue, pain, dyspnea, diarrhea, appetite loss, nausea/vomiting, and finances compared with survivors who maintained a moderate/high HLS.

Figure 2.
Figure 2.

Difference in mean EORTC QLQ-C30 scores at 5YFU, according to change in HLS between baseline and 5YFU.

No change–moderate/high HLS is the reference group used to derive the changes in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.

Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7049

Longitudinal Analyses

Of the 854 survivors who completed HRQoL questionnaires at 5YFU and 10YFU, results from the linear mixed models showed that survivors who maintained a high HLS or had an improved HLS from baseline to 5YFU reported the highest levels of physical and role functioning at 5YFU and 10YFU (Figure 3). An association with time was noted for physical functioning, which decreased between 5YFU and 10YFU, notably for the survivors who maintained a high HLS (Meandifference 2.11; 95% CI, 0.06–4.17) or had an improved HLS (Meandifference 3.49; 95% CI, 1.05–5.92) (data not shown). Regarding symptoms, survivors who maintained a high HLS or had an improved HLS generally reported lower symptom scores (Figure 4), notably on fatigue, pain, dyspnea, constipation, appetite loss, and nausea/vomiting (Meandifference range, 5.19–12.57; data not shown) compared with survivors who maintained a low HLS or had a decreased HLS. An association with time was noted for diarrhea (Meandifference 5.71; 95% CI, 1.04–10.38) and appetite loss (Meandifference 4.25; 95% CI, 0.07–7.79) among survivors with a decreased HLS (data not shown).

Figure 3.
Figure 3.

Longitudinal assessment of mean EORTC QLQ-C30 functioning scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate better functioning. Error bars indicate the 95% confidence interval.

Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low; QoL, quality of life.

Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7049

Figure 4.
Figure 4.

Longitudinal assessment of mean EORTC QLQ-C30 symptom and financial difficulties scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate higher symptom burden and more financial difficulty. Error bars indicate the 95% confidence interval.

Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low.

Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7049

Sensitivity Analyses

Among disease-free survivors, the associations between baseline HLS and HRQoL at 5YFU generally did not alter with the exception that differences found in emotional functioning, fatigue, constipation, and diarrhea were no longer significant between the 3 groups (data not shown).

The ΔHLS and HRQoL at 5YFU of disease-free survivors were similar to the corresponding metrics of the whole sample of patients (data not shown), as was the course of HRQoL over time (data not shown).

Survivors who completed 2 follow-ups reported, in general, higher HRQoL and lower symptom scores at 5YFU than those who only completed 1 follow-up at 5YFU, irrespective of ΔHLS (supplemental eTable 4).

Discussion

To the best of our knowledge, this study is the largest and the first to investigate the association of change in lifestyle and HRQoL over time among CRC survivors. Survivors who improved their HLS from baseline to 5YFU reported better functioning and lower symptom burden at 5YFU. HRQoL in general remained stable over follow-ups between the groups.

In our study, a substantial proportion of survivors did not adhere to lifestyle guidelines or change their lifestyle after diagnosis, especially for BMI (∼70%) and diet (55%–64%). Yet these 2 factors could have the largest potential for improvement toward a healthier lifestyle.15,16 In our study, the metabolic equivalent of task hours per week reported at all time points were very high and almost all participants met pertinent physical activity recommendations. Other studies that assessed self-reported physical activity among CRC survivors reported comparably high levels of physical activity of 75% to 90%,8,16 suggesting that the high physical activity levels may be partly explained by use of self-reported measures.

Although most CRC survivors did not change their lifestyle after diagnosis, we found that those who made positive changes reported better HRQoL at 5YFU. Our results confirm previous findings among survivors with different cancer types. Prostate cancer survivors whose lifestyle improved over time reported better physical functioning and mental well-being.17,18 Similarly, CRC survivors who participated in intervention studies to improve lifestyle behaviors reported lower rates of functional decline and better general and mental health,19 along with improved physical HRQoL20 following intervention. However, comparability with these studies is limited because they had different methodological designs, included survivors with other cancer types, had small sample sizes, assessed different lifestyle factors, and used different HRQoL assessments.

Results from the linear mixed models showed a decrease in physical functioning over follow-ups in some subgroups, which may be attributable to the aging process and to comorbidities. Although we adjusted for age (in 5-year bands) and presence of comorbidity at survey, we cannot rule out possible residual confounding. Further, we did not assess comorbidity severity. Previous studies suggest that systemic changes associated with CVD or decline in pulmonary function in COPD could increase the likelihood of physical limitations over time.21,22 In our study, survivors with CVD or other comorbidities (eg, COPD) were more likely to report poorer physical functioning than those without these comorbid conditions (data not shown).

Public Health Relevance

CRC survivors experience persistent detriments in HRQoL years after their diagnosis.3 Our results suggest that lifestyle changes seem to provide potential for improving HRQoL of CRC survivors for years postdiagnosis. Previous studies have proposed that proximity to a cancer diagnosis may provide the teachable moment, given that recent cancer survivors were found to be more adherent to lifestyle recommendations compared with long-term survivors.23 However, our results suggest that improvements in lifestyle within 5 years postdiagnosis is associated with better HRQoL. It may be an encouraging message for CRC survivors that it is not too late to change their lifestyle after cancer diagnosis in order to improve their HRQoL. Furthermore, following a healthy lifestyle also has benefits for the prevention of chronic diseases such as CVD and diabetes, which occur more commonly in older populations that include long-term CRC survivors.24 Therefore, it is of great relevance to encourage CRC survivors to adopt a healthier lifestyle—in particular, a healthier diet and a lower BMI. In our sample, approximately one-third of survivors met the guidelines for diet and BMI at baseline. At 5YFU, only 20% of survivors reported improvements in diet and 7% reported a healthier BMI. Psychological distress is common among CRC survivors25 who are overweight or obese,26 and has been negatively associated with a healthy lifestyle.27 Therefore, promotion of a healthier lifestyle needs to consider CRC survivors’ psychological well-being, especially among those who are overweight or obese.28 Because it has been shown that cancer survivors are more likely to make healthier lifestyle changes under the counsel and guidance of oncology care providers,29 our results could reinforce the importance of tertiary prevention among CRC survivors postdiagnosis. Attention should also be given to better management of CRC survivors with comorbidities, because evidence suggests that lifestyle-related factors could help improve HRQoL for these individuals.30

Strengths and Limitations

This is the largest population-based study sample of long-term CRC survivors to investigate the association between lifestyle change and HRQoL. The comprehensive collection of medical, dietary, and lifestyle factors allowed us to include the most prevalent lifestyle factors convincingly linked to CRC. Further strengths of our study include the prospective study design, uniform follow-up, completeness of follow-up, and detailed investigations of differences in subgroups.

Nevertheless, this study has limitations. Due to the lack of information on baseline HRQoL, we could not account for differences in HRQoL at baseline. For instance, it could be that survivors who had better HRQoL or socioeconomic resources (eg, higher education or better financial situation at baseline) were more likely to have or maintain a healthier lifestyle. Because of the observational and partly cross-sectional study design, the results should be interpreted with caution because lifestyle factors and HRQoL may mutually affect one another. Although we adjusted the models with a range of demographic and clinical covariates, we cannot rule out the possibility of residual confounding. Further, we must be mindful of possible selective survival. Survivors with an unhealthy lifestyle at baseline most likely had a lower chance of still being alive during follow-ups, and survivors still alive and participating in the 10YFU were younger and healthier even at 5YFU compared with survivors who participated in 5YFU only. Self-reported information on lifestyle factors may result in recall bias, desirability bias, or misclassification of exposures. In addition, the assessment of some HLS factors differed between baseline and follow-up. For instance, the physical activity questionnaires used at baseline assessed a wide range of different physical activity domains, whereas the International Physical Activity Questionnaire – Short Form31 used at 5YFU assessed fewer physical activity domains. These differences in assessment may affect comparability of HLS at baseline and follow-up. Because almost all CRC survivors reported meeting the physical activity recommendations at baseline, there was not much potential for improvement. The HLS was developed to assess, with success, CRC risk. However, it has not been tested for prognostic use. Nevertheless, the associations found between HLS and HRQoL suggest that the HLS can have prognostic value.

Conclusions

Change toward a healthier lifestyle since diagnosis was associated with better HRQoL in long-term CRC survivors. Our results reinforce the importance of maintaining and/or promoting a healthier lifestyle among CRC survivors following a cancer diagnosis.

Acknowledgments

The authors thank Ute Handte-Daub, Ansgar Brandhorst, and Petra Bächer for their excellent technical assistance. The authors thank the study participants and the interviewers who collected the data. The authors also thank the following hospitals and cooperating institutions that recruited patients for this study: Chirurgische Universitätsklinik Heidelberg, Klinik am Gesundbrunnen Heilbronn, St. Vincentiuskrankenhaus Speyer, St. Josefskrankenhaus Heidelberg, Chirurgische Universitätsklinik Mannheim, Diakonissenkrankenhaus Speyer, Krankenhaus Salem Heidelberg, Kreiskrankenhaus Schwetzingen, St. Marienkrankenhaus Ludwigshafen, Klinikum Ludwigshafen, Stadtklinik Frankenthal, Diakoniekrankenhaus Mannheim, Kreiskrankenhaus Sinsheim, Klinikum am Plattenwald Bad Friedrichshall, Kreiskrankenhaus Weinheim, Kreiskrankenhaus Eberbach, Kreiskrankenhaus Buchen, Kreiskrankenhaus Mosbach, Enddarmzentrum Mannheim, Kreiskrankenhaus Brackenheim, and the Cancer Registry of Rhineland-Palatinate, Mainz.

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    Hawkins NA, Smith T, Zhao L, et al. Health-related behavior change after cancer: results of the American cancer society’s studies of cancer survivors (SCS). J Cancer Surviv 2010;4:20–32.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.↑

    van Zutphen M, Boshuizen HC, Kok DE, et al. Colorectal cancer survivors only marginally change their overall lifestyle in the first 2 years following diagnosis. J Cancer Surviv 2019;13:956–967.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.↑

    Daubenmier JJ, Weidner G, Marlin R, et al. Lifestyle and health-related quality of life of men with prostate cancer managed with active surveillance. Urology 2006;67:125–130.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.↑

    Farris MS, Kopciuk KA, Courneya KS, et al. Associations of postdiagnosis physical activity and change from prediagnosis physical activity with quality of life in prostate cancer survivors. Cancer Epidemiol Biomarkers Prev 2017;26:179–187.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.↑

    Morey MC, Snyder DC, Sloane R, et al. Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. JAMA 2009;301:1883–1891.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.↑

    Hawkes AL, Chambers SK, Pakenham KI, et al. Effects of a telephone- delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes in survivors of colorectal cancer: a randomized controlled trial. J Clin Oncol 2013;31:2313–2321.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.↑

    Clarenbach CF, Sievi NA, Haile SR, et al. Determinants of annual change in physical activity in COPD. Respirology 2017;22:1133–1139.

  • 22.↑

    Keeney T, Fox AB, Jette DU, et al. Functional trajectories of persons with cardiovascular disease in late life. J Am Geriatr Soc 2019;67:37–42.

  • 23.↑

    Tollosa DN, Tavener M, Hure A, et al. Adherence to multiple health behaviours in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv 2019;13:327–343.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.↑

    Hajat C, Stein E. The global burden of multiple chronic conditions: a narrative review. Prev Med Rep 2018;12:284–293.

  • 25.↑

    Peng YN, Huang ML, Kao CH. Prevalence of depression and anxiety in colorectal cancer patients: a literature review. Int J Environ Res Public Health 2019;16:411.

  • 26.↑

    Mannan M, Mamun A, Doi S, et al. Is there a bi-directional relationship between depression and obesity among adult men and women? Systematic review and bias-adjusted meta analysis. Asian J Psychiatr 2016;21:51–66.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.↑

    Trudel-Fitzgerald C, Tworoger SS, Poole EM, et al. Psychological symptoms and subsequent healthy lifestyle after a colorectal cancer diagnosis. Health Psychol 2018;37:207–217.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.↑

    Ramp D, Mols F, Ezendam N, et al. Psychological distress and lower health-related quality of life are associated with need for dietary support among colorectal cancer survivors with overweight or obesity. Support Care Cancer 2021;29:7659–7668.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.↑

    Demark-Wahnefried W, Aziz NM, Rowland JH, et al. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814–5830.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.↑

    Derksen TM, Bours MJ, Mols F, et al. Lifestyle-related factors in the self-management of chemotherapy-induced peripheral neuropathy in colorectal cancer: a systematic review. Evid Based Complement Alternat Med 2017;2017:7916031.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.↑

    Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381–1395.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Submitted January 25, 2022; final revision received June 26, 2022; accepted for publication June 28, 2022.

Author contributions: Conceptualization: Eyl-Armbruster, Thong, Carr, Arndt. Conceptualization of DACHS and IMPACT studies: Chang-Claude, Hoffmeister, Brenner. Formal analysis: Eyl-Armbruster, Thong. Data curation: Jansen. Funding acquisition: Chang-Claude, Hoffmeister, Brenner, Arndt. Writing—Original draft: Eyl-Armbruster, Thong. Writing—review and editing: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This study was funded by the German Research Council (BR 1704/6-1, BR 1704/6-3, BR 1704/6-4, CH 117/1-1) and the German Federal Ministry of Education and Research (01KH0404, 01ER0814, 01ER0815, 01ER1505A, 01ER1505B).

Disclaimer: The funding source was neither involved in the collection, interpretation, and analysis of the data nor involved in the decision for the writing and submission of this report for publication.

Correspondence: Melissa S.Y. Thong, PhD, Unit of Cancer Survivorship, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany. Email: m.thong@dkfz-heidelberg.de

Supplementary Materials

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  • Expand
  • Figure 1.
    View in gallery
    Figure 1.

    Difference in mean EORTC QLQ-C30 scores at 5YFU, according to baseline HLS.

    High HLS is the reference group used to derive the differences in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

    Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.

  • Figure 2.
    View in gallery
    Figure 2.

    Difference in mean EORTC QLQ-C30 scores at 5YFU, according to change in HLS between baseline and 5YFU.

    No change–moderate/high HLS is the reference group used to derive the changes in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

    Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.

  • Figure 3.
    View in gallery
    Figure 3.

    Longitudinal assessment of mean EORTC QLQ-C30 functioning scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate better functioning. Error bars indicate the 95% confidence interval.

    Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low; QoL, quality of life.

  • Figure 4.
    View in gallery
    Figure 4.

    Longitudinal assessment of mean EORTC QLQ-C30 symptom and financial difficulties scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate higher symptom burden and more financial difficulty. Error bars indicate the 95% confidence interval.

    Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low.

Figure 1.

Difference in mean EORTC QLQ-C30 scores at 5YFU, according to baseline HLS.

High HLS is the reference group used to derive the differences in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.
Figure 2.

Difference in mean EORTC QLQ-C30 scores at 5YFU, according to change in HLS between baseline and 5YFU.

No change–moderate/high HLS is the reference group used to derive the changes in HRQoL scores with the other subgroups. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy.

Abbreviations: 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; HRQoL, health-related quality of life; QoL, quality of life.
Figure 3.

Longitudinal assessment of mean EORTC QLQ-C30 functioning scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate better functioning. Error bars indicate the 95% confidence interval.

Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low; QoL, quality of life.
Figure 4.

Longitudinal assessment of mean EORTC QLQ-C30 symptom and financial difficulties scores at 5YFU and 10YFU, according to change in HLS from baseline to 5YFU. Models are adjusted for age at survey, sex, comorbidity at survey, cancer type, cancer stage, disease recurrence at survey, chemotherapy, and radiotherapy. Higher scores indicate higher symptom burden and more financial difficulty. Error bars indicate the 95% confidence interval.

Abbreviations: ΔHLS, change in HLS; 10YFU, 10-year follow-up; 5YFU, 5-year follow-up; EORTC QLQ-C30, EORTC Quality of Life Questionnaire-Core 30; HLS, healthy lifestyle score; NC-high, no change–moderate/high; NC-low, no change–low.
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    • PubMed
    • Search Google Scholar
    • Export Citation
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    • PubMed
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    • Export Citation
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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Farris MS, Kopciuk KA, Courneya KS, et al. Associations of postdiagnosis physical activity and change from prediagnosis physical activity with quality of life in prostate cancer survivors. Cancer Epidemiol Biomarkers Prev 2017;26:179–187.

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Morey MC, Snyder DC, Sloane R, et al. Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. JAMA 2009;301:1883–1891.

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Hawkes AL, Chambers SK, Pakenham KI, et al. Effects of a telephone- delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes in survivors of colorectal cancer: a randomized controlled trial. J Clin Oncol 2013;31:2313–2321.

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Tollosa DN, Tavener M, Hure A, et al. Adherence to multiple health behaviours in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv 2019;13:327–343.

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Hajat C, Stein E. The global burden of multiple chronic conditions: a narrative review. Prev Med Rep 2018;12:284–293.

  • 25.

    Peng YN, Huang ML, Kao CH. Prevalence of depression and anxiety in colorectal cancer patients: a literature review. Int J Environ Res Public Health 2019;16:411.

  • 26.

    Mannan M, Mamun A, Doi S, et al. Is there a bi-directional relationship between depression and obesity among adult men and women? Systematic review and bias-adjusted meta analysis. Asian J Psychiatr 2016;21:51–66.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Trudel-Fitzgerald C, Tworoger SS, Poole EM, et al. Psychological symptoms and subsequent healthy lifestyle after a colorectal cancer diagnosis. Health Psychol 2018;37:207–217.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Ramp D, Mols F, Ezendam N, et al. Psychological distress and lower health-related quality of life are associated with need for dietary support among colorectal cancer survivors with overweight or obesity. Support Care Cancer 2021;29:7659–7668.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Demark-Wahnefried W, Aziz NM, Rowland JH, et al. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814–5830.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Derksen TM, Bours MJ, Mols F, et al. Lifestyle-related factors in the self-management of chemotherapy-induced peripheral neuropathy in colorectal cancer: a systematic review. Evid Based Complement Alternat Med 2017;2017:7916031.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381–1395.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
Copyright:
Copyright © 2022 by the National Comprehensive Cancer Network 2022
Article Category:
Research Article
Received:
25 Jan 2022
Accepted:
28 Jun 2022
Print Publication Date:
01 Nov 2022
Online Publication Date:
Nov 2022
Keywords:
healthy lifestyle; longitudinal; Colorectal Cancer; quality of life; long-term survivors
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