INTRODUCTION
1. Necessity of Research
With the active treatment of cancer and the development of medical technology, cancer is recognized as a chronic disease, and the direction of treatment is not only to prolong the survival period but also to improve the quality of life after the treatment is completed [1,2]. The relative survival rate of colorectal cancer has always been higher than all cancers, with 74.3% from 2015 to 2019, and more than half of colorectal cancer patients survive for more than 5 years [3]. This means that more attention should be paid to the quality of life of patients with colorectal cancer due to the increased length of illness until they are cured. Quality of life refers to the physical, social, emotional, and functional well-being of patients with a general health condition or course of treatment of a disease [4]. Quality of life is used in clinical practice as an important indicator of treatment effectiveness because it reflects the well-being of colorectal cancer patients and can predict length of stay and healthcare costs [5].
With the exception of stage 1 and 2, most patients with colorectal cancer receive chemotherapy according to the guidelines for colorectal cancer treatment set forth by the National Comprehensive Cancer Network (NCCN), with some stages 2 and 3 as postoperative adjuvant therapy and stage 4 with the aim of relieving symptoms and prolonging life [6]. Chemotherapy used in patients with colorectal cancer is a treatment that prevents recurrence and increa-ses survival, but it also causes a variety of side effects [5]. In particular, they experience physical symptoms such as peripheral neuropathy, fatigue and gastrointestinal symptoms such as nausea, vomiting, diarrhea, constipation, numbness in the hands and feet and paresthesias caused by certain medications [1,2,4]. Some of these symptoms leave sequelae in patients even after some time has passed since the end of chemotherapy [7]. In addition, they ex-hibit various psychosocial distress such as anxiety, depression, fear, and hopelessness due to uncertainty about cancer treatment and prognosis. Colorectal cancer patients’ experience of physical symptoms and psychosocial distress due to chemotherapy side effects reduces their quality of life [1,8]. Therefore, interventions are required to improve the quality of life of patients with colorectal cancer undergoing chemotherapy, and for this, a variety of approaches to quality-of-life factors are needed.
Disease perception refers to the subject's knowledge of the definition, characteristics, and health threats asso-ciated with the disease, and the more positive the perception of a disease such as cancer, the more positive it is on psychological well-being, social functioning, and vitality, and the more actively they engage in treatment [9]. On the other hand, negative disease perceptions cause psychological distress to patients and negatively affect their disease status, which also affects their quality of life [10]. As disease perception can have various effects on the treatment process and adaptation patterns of cancer patients, it is necessary to form a positive disease perception of patients with colorectal cancer undergoing chemotherapy who require an active will for treatment.
Health-related stigma is a personal experience of alien-ation, rejection, blame, and devaluation due to one's current illness, which can adversely affect the patient's health status, such as guilt, shame, anxiety, and depression, re-sulting in a decrease in the quality of life [11]. Previous studies have reported that cancer patients feel stigma as-sociated with dysentery, physical squalor, grief, and de-creased social activity [12], and the greater the stigma, the higher the distress and symptoms, and the lower the quality of life and function [13]. In a recent study of several cancer patients, the degree of stigma in patients with colorectal cancer was found to be the highest [14], and further research is needed to manage stigma in patients with colorectal cancer.
Distress is a collective term for psychological, social, and spiritual unpleasant experiences that interfere with the ability to cope effectively with cancer and cancer-related physical symptoms and treatments [15]. NCCN [6] recommended that distress in cancer patients is a condition in which various emotional reactions such as shock, denial of reality, anger, fear, anxiety, depression, self-blame, and loneliness affect the treatment process, and that continu-ous screening is recommended. A significant number of cancer patients are experiencing distress, but adequate measures have not been taken against them [16]. Other prior studies in patients with various cancers [16,17] in-dicate that patients receiving anti-cancer drugs suffer from higher levels of distress, and distress appears to be a factor affecting quality of life; thus, early detection and aggres-sive treatment of distress are important. However, there has not yet been a distress study on patients with colorectal cancer, so research is needed.
Understanding the specific condition of colorectal cancer patients undergoing chemotherapy with increasing disease duration and understanding their lives is an important factor in the development of nursing interventions for patients with colorectal cancer. Nonetheless, so far, quality of life studies in colorectal cancer patients have been limited to the fragmentary associations of peripheral neuropathy, symptom experience, depression and symptoms, fatigue, mood status, social support, and symptom experience with each related variable [1,4,7,18-20]. Thus, there is a need for a comprehensive study that expands the various physical and mental symptoms experienced by colorectal cancer patients undergoing chemotherapy and psychosocial problems such as pain and stigma, as well as their relationship with attitudes toward diseases and quality of life.
Therefore, this study aims to identify the patterns of disease perception, stigma, distress, physical symptom experience, and quality of life in patients with colorectal cancer undergoing chemotherapy, and to suggest the relationship between them and the factors influencing quality of life. These results could be useful as a basis for developing intervention programs to improve the quality of life of patients with colorectal cancer undergoing chemotherapy.
2. Aims
This study aimed to explore the degree of disease perception, stigma, distress, and physical symptom experience in colorectal cancer patients undergoing chemotherapy, and to determine the impact of these variables on quality of life. More specifically, it aimed to 1) describe the general characteristics and disease-related characteristics of the subject, 2) determine the subjects degree of disease perception, stigma, distress, experience of physical symptoms, and quality of life, 3) examine the differences in quality of life according to the general characteristics of the subjects and disease-related characteristics, 4) identify the correlations between subjects' disease perceptions, stigma, distress and physical symptom experiences and quality of life, 5) determine the effects of subjects' disease perceptions, stigma, distress, and physical symptom experiences on quality of life.
METHODS
1. Study Design
This study is a descriptive correlation study to identify the effects of disease perception, stigma, distress, and physical symptom experience on quality of life in colorectal cancer patients undergoing chemotherapy.
2. Study Participants
The participants of this study are patients who have ma-lignant tumors in the colon and rectum at C General Hospital located in City I, and are diagnosed with colorectal cancer and are undergoing adjuvant or palliative chemotherapy. According to the NCCN guidelines [6], the study included adults aged 19 and older who were able to communicate and were receiving at least one of the following intensive treatment drugs for colorectal cancer: Oxaliplatin, 5-Fluorouracil, Irinotecan, Capecitabine, Ce-tuximab, or Bevacizumab. Excluded individuals are; 1) those who have been receiving neoadjuvant chemotherapy, those who have received the above drugs but have been recommended for hospice treatment due to the in-effectiveness of further chemotherapy, 2) those who have a history of psychiatry or are currently taking psychiatric medications, and 3) those who do not have cognitive ability (perception of time, place, and people).
Sample size was calculated using the G*Power 3.1.9.7 program. Based on 12 predictors, a significance level of .05, a median effect size of .15, and a power of .80 [4], the minimum number of participants required for multiple regression analysis was 127. In this study, the dropout rate was set at 5% because the researcher was asked to directly read the questionnaire to the participants, and after col-lecting the questionnaire, the missing items were checked on the spot. In consideration of this, questionnaires were distributed to 134 people, of which 127 copies were recov-ered were included in the final analysis.
3. Data Collection and Research Procedure
The data collection period was from June 1 to November 10, 2023. Data were collected using a self-report questionnaire from patients who were diagnosed with colorectal cancer at C General Hospital in City I, were admitted to the ward for chemotherapy, or visited the outpatient de-partment during chemotherapy, after explaining the purpose of the study and submitting a consent form. The par-ticipant's cancer stage was examined through their medical records. The survey took about 30 minutes, and the completed questionnaire was collected on site. After com-pleting the questionnaire, all survey participants were given a small return gift.
4. Measurements
1) Disease perception
For the disease perception of patients with colorectal cancer undergoing chemotherapy, the Brief Illness Perception Questionnaire (B-IPQ) developed by Broadbent et al. [21] was translated into Korean by Min et al. [22] after obtaining the author's consent. In order to verify the content validity of the tool, the CVI measurement value of the expert group consisting of 1 oncology nurse specialist and two nursing professors was confirmed to be .96. This tool has a total of 9 questions and consists of 3 subdomains: cognitive representation, emotional representation, and causal representation. The contents of the questions were Identity, Timeline, Consequence, Personal control, Treatment control, Concern, Coherence, Emotional representation, and Causes, and one of the questions was a descriptive question about the cause of the disease, and it was not included in the total score. With the exception of open-ended questions, each item is on a Likert scale ranging from 0 (no affect) to 10 (severely affecting), with higher scores indicating a negative perception of the disease. At the time of tool development, its reliability was Cronbach's ⍺=.77, and in this study, Cronbach's ⍺=.69. Al-though the reliability in this study was somewhat lower, it is considered to be at an acceptable level according to sug-gestions from previous studies [23].
2) Stigma
Stigma in patients with colorectal cancer was evaluated using the Korean Cancer Stigma Scale (KCSS), which was modified and supplemented by So et al.[24], based on the Cataldo Lung Cancer Stigma Scale (CLCSS) developed for lung cancer patients by Cataldo et al.[11] after obtaining the author's consent. This tool consists of 24 questions, categorized into six subdomains: social isolation (5 items), avoidance (4 items), discrimination (4 items), guilt (5 items), attribution (3 items), and lack of support (3 items). Each item is on a Likert scale ranging from 1 (not at all) to 4(very much), with a minimum score of 24 and a maximum of 96, with higher scores indicating higher stigma levels. The reliability of the tool was Cronbach's ⍺=.89 in the study by So et al. [24] and Cronbach's ⍺=.90 in this study.
3) Distress
The distress of patients with colorectal cancer was assessed using the Distress Thermometer (DT) of the Distress Thermometer Screening Tool Version 2, developed by NCCN [6] in the United States and provided in Korean, excluding the list of questions related to symptom experience. The Distress Thermometer (DT) is a visual instrument that displays the degree of distress the patient felt in terms of mental, physical, social, or spiritual distress over the past week on a thermometer scale of 0 (no distress) to 10 (extreme distress), with higher scores indicating higher distress scores. The NCCN practice guidelines [6] for the management of distress recommends that a DT score of 4 or higher indicates moderate-to-severe distress. In this study, only distress thermometer scores were used because the items in the list of problems added to the DT were very similar to the symptom experience and quality of life details used in this study, and there was a concern that the results would be skewed.
4) Physical symptoms experience
The experience of physical symptoms of patients with colorectal cancer was assessed using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) developed by Chang et al. [25] and the tool adapted by Nho et al. [26] after obtaining the author's consent. This tool measures physical and psychological symptoms separately, in this study, only physical symptoms were used to measure them. Physical symptoms consist of 28 items, including pain, lack of energy, skin changes, dry mouth, nausea, drowsiness, numbness/numbness in the hands and feet, sleep disturbances, and difficulty concentrating, on a Likert scale ranging from 0 (not at all) to 4 (very much). Each symptom is measured on a scale of 0 to 4, with a higher score indicating the greater the severity and frequency of the symptom. At the time of tool development, the reliability was Cronbach's ⍺=.84, and in this study, Cronbach's ⍺=.85. To verify the content validity of the tool, the CVI measurement value of the expert group consisting of 1 oncology nurse specialist and two nursing professor was confirmed to be .93.
5) Quality of life
The quality of life of colorectal cancer patients undergoing chemotherapy was measured using the Functional Assessment of Cancer Therapy-Colorectal Version 4 (FACT-C), a tool developed by Ward et al. [5] to measure the quality of life of colorectal cancer patients after obtaining per-mission from FACIT (www.facit.org) to use the Korean version of the tool. This tool consists of 5 subdomains: physical wellbeing (7 items), social/family wellbeing (7 items), emotional wellbeing (6 items), functional well-being (7 items), and colorectal cancer-specific domain (7 items), for a total of 34 items. Each item is on a Likert scale ranging from 0 (not at all) to 4 (very much). The score was calculated as a total score by summing the scores of the 5 subdomains, with a minimum score of 0 and a high of 136, with higher scores indicating higher quality of life. At the time of tool development, the reliability was Cronbach's ⍺=.87, and in this study, Cronbach's ⍺=.94.
5. Data Analysis
The data collected in this study were analyzed using the IBM SPSS/WINdows 26.0 Program. Participants’ general, disease-related characteristics, disease perception, stigma, distress, physical symptom experience, and quality of life were analyzed by descriptive statistics. The difference in quality of life according to the general characteristics and disease-related characteristics of the as was analyzed by t-test and ANOVA, and the post-hoc test was analyzed by Scheffé test. The correlation between disease perception, stigma, distress, physical symptom experience, and quality of life was performed using Pearson's correlation coef-ficient. The influencing factors on the quality of life were identified using hierarchical regression analysis.
6. Ethical Considerations
This study was conducted after receiving research ap-proval (OIRB-신20230414-001) after deliberation by the Institution Review Board (IRB) of a tertiary general hospital for the ethical protection of research participants. The researcher, who was familiar with the process, explained the purpose and content of the research, the decision to participate in the research, the possibility of withdrawing mid-term, the confidentiality of the collected data and the data management method, and distributed the questionnaire to the subjects who voluntarily agreed to participate in the research. The questionnaire was filled out by the subjects themselves, and those who could not fill it out by themselves were read by this researcher and filled out after listening to the answers. The researcher, who had worked in a cancer ward, observed the patient's condition during the survey to see if there were any difficulties in the survey. The collected data were given a serial number to anonymize the participants' information, and the PC con-taining the research information was set up with a pass-word to manage the data.
RESULTS
1. Participants’ Characteristics
Among the patients, 73 (57.5%) were male, and 42 (33.1%) were in their 40s∼50s and 60s, respectively. 103 (81.1%) were living with their families, and 91 (71.7%) had a high school diploma or less. Of the participants, 102 (80.3%) were unemployed, and 71 (55.9%) had no religious affiliation.
The time elapsed after cancer diagnosis was the most common in 81 patients (63.8%) in ‘ less than 12 months’, and stage 4 cancer was the most common with 77 patients (60.6%) (Table 1).
Table 1.
Characteristics of Participants (N=127)
2. Participants’ Level of Disease Perception, Stigma, Distress, Physical Symptoms Experience and Quality of Life
The patients’ disease perception score was 6.05±1.46 out of 10. Stigma scored 1.74±0.47 out of 4, and Stigma's subdomains were 2.18±0.76 out of 4 for social isolation, 2.12±0.69 for avoidance, 2.02±0.70 for lack of support, 1.49±065 for attribution, 1.40±0.53 for guilt, and 1.35± 0.54 for discrimination. The average score of the distress thermometer was 5.53±2.84 out of 10, 86 (67.6%) had a score of 4 or higher, and the symptom experience was 0.80±0.49 on a 4-point scale. The quality of life score was 2.15±0.73 out of 4, and the subdomains scored 2.46±1.06 for physical state and 2.30±1.08 for emotional state, which was higher than 2.10±0.89 for social/family status and 1.72±0.96 for functional status (Table 2).
Table 2.
Disease Perception, Stigma, Distress, Physical Symptom Experience, and Quality of Life (N=127)
3. Differences in Quality of Life by Participants’ General Characteristics
There was a significant difference in quality of life in terms of cohabitation status (t=-2.20, p=.030), education level (t=-3.08, p=.003), occupation status (t=5.34, p<.001), religious status (t=-3.44, p<.001), and current cancer stage (F=4.36, p=.020). The post-hoc analysis showed that patients with stage 2 cancer had a higher quality of life than those with stage 4 (Table 1).
4. Correlation between Participants’ Disease Perception, Stigma, Distress, Symptom Experience and Quality of Life
Quality of life was negatively correlated with disease perception (r=-.72, p<.001), stigma (r=-.60, p<.001), distress (r=-.80, p<.001), and physical symptom experience (r=-.57, p<.001). Disease perception was positively correlated with stigma (r=.50, p<.001), distress (r=.63, p<.001), and physical symptom experience (r=.46, p<.001), stigma was positively correlated with distress (r=.60, p<.001) and physical symptom experience (r=.39, p<.001), and distress was positively correlated with physical symptom experience (r=-.57, p<.001) (Table 3).
Table 3.
Correlations among Disease Perception, Stigma, Distress, Physical Symptom Experience, and Quality of Life (N=127)
5. Factors Influencing the Quality of Life
This study used hierarchical multiple regression analysis to identify the factors influencing quality of life in colorectal cancer patients with chemotherapy. In Model I., cohabitation status, education level, occupation status, religious status, and current cancer stage were converted into dummy variables and inserted as control variables to determine the effect on quality of life. In Model II, the independent variables disease perception, stigma, distress, and physical symptom experience were additionally added to determine whether the independent variables affected quality of life even after exogenous variable control.
As a result of testing the assumptions of regression analysis, the Durbin-Watson test was 1.69 in Model I., II, which was close to the reference value 2, so there was no auto-correlation, the tolerance limit was 0.43∼0.93, and the variance inflation factor (VIF) was 1.08∼2.30, so there was no problem of multicollinearity. The regular P-P plot of the residuals showed linearity, and the scatter plot satisfied the assumption of normality and equivariance of the error term because the residual distribution was evenly spread around zero.
As a result of the regression analysis, in Model I, occupation (β=.25, p=.005) and religion (β=.18, p=.038) were found to be influencing factors on quality of life, with an explanatory power of 18.6%(F=5.80, p<.001). In Model II, religion (β=.11, p=.018), occupation (β=.14, p=.002), disease perception (β=-.24, p<.001), distress (β=-.44, p<.001), stigma (β=-.12, p=.028) and physical symptom experience (β=-.16, p=.004) were found to be factors affecting the quality of life, and the explanatory power was 77.7%, and the hierarchical regression model of this study was significant (F=80.28, p<.001). In other words, the more threatening the patient's perception of the disease, the higher the stigma and distress, and the higher the degree and frequency of pain of the symptoms, the lower the quality of life (Table 4).
Table 4.
Factors Influencing Quality of Life (N=127)
DISCUSSION
In this study, we attempted to identify disease perception, stigma, distress, physical symptom experience, and quality of life in colorectal cancer patients undergoing chemotherapy, and to identify factors affecting quality of life to provide basic data for developing nursing interventions to improve the quality of life of patients with colorectal cancer. Based on the results of this study, we would like to discuss the following.
As a result of the study, the total quality of life score of colorectal cancer patients undergoing chemotherapy was 73.12 out of 136. This was lower than the scores of 81.93[19] and the 88.78[4], from studies that measured the quality of life of colorectal cancer patients undergoing chemotherapy with the same tool as this study. This seems to be because the study by Lee and Park [4] included colorectal cancer patients with stage 2 and stage 3 cancer, but in this study, patients with stage 4 colorectal cancer, which has a high disease severity, were included as well as stage 2 and 3 cancer stages. This is supported by the results of this study, which showed that the quality of life was significantly higher in the stage 2 group than in the stage 4 group in the mean comparison according to the cancer stage. Therefore, it is thought that there is a need for a re-peat study that can subdivide the cancer diagnosis stage and compare the quality of life of the patients.
The disease perception of colorectal cancer in the participants of this study was 6.05 points out of 10, and higher than the 5.34 points [27] in thyroid cancer patients and 5.01[28] points in patients with metabolic syndrome using the same tool. This suggests that the disease perception of patients with colorectal cancer undergoing chemotherapy is relatively negative, and it is thought that colorectal cancer patients receiving chemotherapy have a greater sense of threat to the disease's course and burden of chemotherapy compared to patients with thyroid cancer and metabolic syndrome in previous studies.
The stigma score of patients with colorectal cancer was 1.74 out of 4. In previous studies using the same tool, the stigma score of cancer patients was 1.41 points, of which 1.6 points were scored in patients with colorectal cancer, 1.47 points in gastric cancer patients, 1.41 points in breast cancer patients [14], and 1.4 points in lung cancer patients [13], which was slightly higher in this study. This is because the participants of this study were cancer patients undergoing chemotherapy, and it is thought that there was an increase in stigma due to the addition of physical and psychological symptoms compared to previous studies of colorectal cancer patients who were not on chemotherapy. Hernemann et al. [29], who studied patients with breast, colorectal, lung, and prostate cancer, found that receiving chemotherapy alone had high stigma in patients, and Roicke et al. [12] found that pain experience increased stigma in cancer patients, and young childhood cancer cured patients experienced high social stigma [30]. These results show that various factors affect stigma in cancer patients, and there is a need to understand and manage stigma in cancer patients undergoing chemotherapy.
The distress score of the participants in this study was an average of 5.53 out of 10. Considering that NCCN [6] in the United States classifies a distress thermometer with a score of 4 or higher as a group of moderate distress, the score of the subjects in this study corresponds to severe distress, and 86 of the participants (67.7%) experienced severe distress with a score of 4 or higher. It was higher than the results of previous studies on various cancer patients [2,14,17]. Among the participants of this study, 77 (60.6%) patients with stage 4 colorectal cancer undergoing chemotherapy accounted for the largest number, which is thought to have made the difference from previous studies. This supports the report of a previous study of cancer patients undergoing chemotherapy with a distress score of 5.13 and a 73% rate of severe distress of 4 or higher [31]. NCCN emphasizes the importance of distress as the sixth vital sign, and some cancer medical institutions are also making great efforts to manage distress in cancer patients by producing guidelines related to distress [2]. In actual clinical practice, distress is an indicator that has not yet been generalized, like other vital signs. Therefore, it is thought that it is necessary to identify differences in distress by age, gender, carcinoma, and diagnosis and treatment period of the subject by using distress as a clinical indicator that should be basically measured for cancer patients, and to provide appropriate nursing interventions.
The average score of colorectal cancer patients who experience physical symptoms reflects the degree or frequency of those symptoms. In this study, the physical symptom score was 0.80 out of 4, which is similar to the mean score of 0.89 found in other studies of colorectal cancer patients using the same tool [4]. The most distressing or frequent physical symptoms in this study were lack of energy (1.75 points), numbness or tingling in the hands and feet (1.57 points), and taste changes (1.27 points). A study of colorectal cancer patients by Rohrl et al. [8] also reported periodic symptoms such as lack of energy, numbness or tingling, and nausea, which are consistent with the findings of this study. According to NCCN [6], colorectal cancer patients also experience various physical symptoms due to chemotherapy because chemotherapy dam-ages not only cancer cells but also healthy cells during treatment [8], so it is necessary to improve self-manage-ment skills so that they can respond appropriately when symptoms occur through prior education about physical symptoms.
As a result of hierarchical multiple regression analysis to identify the factors affecting the quality of life of patients with colorectal cancer, it was confirmed that main variables such as disease perception, stigma, pain, and experience of physical symptoms, as well as the characteristics of the participants such as occupation and religion, were significant factors affecting the quality of life of patients with colorectal cancer undergoing chemotherapy.
Disease perception has been shown to be an influencing factor in the quality of life of colorectal cancer patients undergoing chemotherapy, and although it is difficult to make an accurate comparison due to the lack of studies related to disease perception among colorectal cancer patients in Korea, it supports the results of previous studies that it affects the quality of life of thyroid cancer patients [27]. Kim et al. [32] found that the lower the perceived threat of disease, the better the self-management and treatment behavior. On the other hand, if the perception of disease threat is high, the person may feel threatened by their illness and may not be able to treat it well or take care of themselves, which in turn leads to a decrease in quality of life [10]. Schoormans et al. [9] also reported that negative disease perceptions worsen fatigue and pain in cancer survivors and lead to a decrease in quality of life. Therefore, if the nurse assesses the patient's understanding and perception of the disease and provides nursing intervention to have a positive perception of the disease individually, it can be a strategy to improve the quality of life. Since the prevalence of cancer is not decreasing every year and is a steady trend, follow-up studies on disease perception by cancer type, not just colorectal cancer, are needed.
Stigma has been shown to be a factor influencing quality of life, which supports the results of studies in lung cancer patients that show that higher stigma leads to higher distress and lower quality of life [13]. Negative emotions such as stigma experienced by cancer patients have a negative impact on the prognosis and quality of life of cancer patients [30]. The study of stigma on patients with colorectal cancer in Korea is still insignificant, and this study was significant in that it confirmed the correlation between the degree of stigma and the quality of life only in patients with colorectal cancer undergoing chemotherapy. Therefore, it is believed that social efforts such as education and campaigns are needed to change the negative perception of cancer in patients diagnosed with cancer, individuals who work with them, and society.
In addition, the distress of the participants in this study was found to be a significant influencing factor in quality of life, similar to the results of the previous study [2,17]. However, direct comparison was difficult because there were few previous studies targeting only colorectal cancer patients with the same tool. Psychological symptoms en-compassing distress are also reported to be a major factor affecting the quality of life of colorectal cancer patients undergoing chemotherapy in a previous study [4], which supports the results of this study. Distress that occurs during the treatment process, along with the psychological pressure of cancer disease, adversely affects the quality of life of patients with gastrointestinal cancer, which in-cludes colorectal cancer [2]. For colorectal cancer survivors, poor quality of life, especially due to increased symptom burden and emotional distress experiences, can make social interaction difficult [33]. Therefore, for colorectal cancer patients undergoing chemotherapy, psycho-educational interventions are required to increase understanding and awareness of psychological symptoms that occur during the treatment process and to effectively manage symptoms.
In this study, the experience of physical symptoms had a significant effect on quality of life. These results are consistent with previous studies showing that negative symptom experiences in cancer patients affect quality of life [1,2]. Colorectal cancer patients undergoing chemotherapy experience a variety of physical symptoms such as fatigue, pain, sleeplessness, nausea/vomiting, and dry mouth, and these symptoms reduce the quality of life of the patients [2]. A study of ovarian cancer patients in South Korea also supported this study by finding that the more symptoms and severe the symptoms that ovarian cancer patients experience, the worse their quality of life [34]. Therefore, the efforts of an expert on tumors to alleviate the physical symptoms of colorectal cancer patients undergoing chemotherapy should be continued.
In this study, job status had a significant effect on quality of life. This is in a similar vein to the results of a previous study [35] that showed that frustration about not being able to work as usual or not be able to help the house-hold finances affects the quality of life. There has been a lot of interest and effort to change the personal and social perception of cancer patients returning to work after chemotherapy, but it is still insufficient [35]. Therefore, it is thought that efforts should be made to improve awareness of cancer patients at the social level and to prepare measures to help them reintegrate into society. In other words, it is necessary for hospitals and workplaces to consider the treatment schedule so that patients can maintain and ad-just their economic activities as much as possible. However, it should be taken into account that there is a large difference between the number of counties with jobs and those without jobs, and there is a risk of expansive inter-pretation. On the other hand, religion was also found to be a significant influencing factor, and the results were differ-ent from those of the previous studies [1,4,7,18-20], which seems to reflect the situation in which most of the patients in this study were receiving treatment at religious-affili-ated university hospitals. In the future, the impact of religion on the quality of life needs to be examined.
This study was conducted on patients with colorectal cancer undergoing chemotherapy at one tertiary general hospital, so it is difficult to generalize the results of the study to all colorectal cancer patients undergoing chemotherapy. In addition, this study has the limitation that it is a cross-sectional survey study that identified symptoms and quality of life on a one-time basis regardless of the cycle of chemotherapy. Therefore, it is necessary to conduct repeated studies that expand the area and target in the future. In addition, considering the cycle from the start to the end of chemotherapy, a longitudinal study of the changes in the symptoms and quality of life of the subjects is required. Based on the results of this study, we propose a study to understand the disease and develop specific interventions to alleviate psychological and physical symptoms in order to improve the quality of life of colorectal cancer patients undergoing chemotherapy. It is necessary to develop a program that can periodically assess physical and psychological symptoms during chemotherapy, and to intervene appropriately. Simultaneously, a systematic approach should be prepared to manage them comprehensively.
CONCLUSION
This study is significant in that it identified the effects of disease perception, stigma, distress, and symptom experience on the quality of life of patients with colorectal cancer undergoing chemotherapy, and provided basic data for preparing interventions to improve the quality of life of colorectal cancer patients undergoing chemotherapy. The results of this study showed that job, religion, disease perception, stigma, distress, and physical symptom experience significantly affected the quality of life of patients with colorectal cancer undergoing chemotherapy. Based on the results of this study, we propose specific intervention development studies such as patient education and participation in psychological counseling programs about colorectal cancer and chemotherapy to understand the disease and overcome psychological and physical symptoms with the aim of improving the quality of life of colorectal cancer patients undergoing chemotherapy.
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