Fatigue 5 years after treatment for rectal cancer – results from the QoLiRECT study
DOI:
https://doi.org/10.2340/1651-226X.2026.46460Keywords:
Rectal neoplasms/surgery, rectal neoplasms, therapy, fatigue, quality of life, risk factors, surveys and questionnaires, Sweden/epidemiology, Denmark/epidemiologyAbstract
Background and purpose: Fatigue affects colorectal cancer survivors and has a significant impact on overall quality of life (QoL) and possibly overall survival. Fatigue, with focus on patients with rectal cancer, is less studied. The aim of this study was to investigate fatigue prevalence at 5 years after rectal cancer
surgery.
Patient/material and methods: Data were collected from the Quality of Life in RECTal cancer study, a prospective longitudinal multicenter study of patients with rectal cancer, also using data from Swedish and Danish colorectal cancer registries. Baseline characteristics and treatment-related factors were investigated as potential predictors for fatigue measured with the Piper Fatigue Scale (PFS). Patients were included at diagnosis and answered questionnaires at baseline and at 5 years after diagnosis.
Results: The cohort consisted of 1024 patients who underwent surgery for rectal cancer. Five hundred and ninety three patients responded to the 5-year follow-up questionnaire. At 5 years, 52.4% of patients experienced fatigue. Moderate-severe fatigue (PFS ≥ 4) was reported by 172 patients (29%). Higher Body mass index (BMI) at baseline was associated with PFS ≥ 4 (Odds ratio [OR] 1.07, 95% Confidence interval [CI] 1.02–1.11, p = 0.004) in the univariate analysis, with similar results in multivariate analysis. A significant
association was found between pain and moderate-to-severe fatigue in univariate analysis, OR 4.34 (p < 0.0001, 95% CI 2.91–6.49), but not in multivariate analysis, 2.8 (p < 0.0001, 95% CI 1.79–4.58). Higher QoL was negatively correlated with PFS ≥ 4 in both uni- and multivariate analyses (OR 0.37, 95% CI 0.30–0.46, p < 0.0001; OR 0.34, 95% CI 0.27–0.44 p < 0.0001). Major low-anterior resection syndrome (OR 2.17, 95% CI 1.09–4.34, p = 0.028) and permanent stoma (OR 1.92, 95% CI 1.06–3.47, p = 0.032) were associated with PFS ≥ 4 in the univariate, but not in the multivariate, analysis.
Interpretation: Moderate-severe fatigue is prevalent in rectal cancer survivors. Targeted prevention of fatigue might be of interest in long-term rehabilitation of rectal cancer survivors.
Downloads
References
Patel SG, Karlitz JJ, Yen T, Lieu CH, Boland CR. The rising tide of early-onset colorectal cancer: a comprehensive review of epidemiology, clinical features, biology, risk factors, prevention, and early detection. Lancet Gastroenterol Hepatol. 2022;7(3):262–74. DOI: https://doi.org/10.1016/S2468-1253(21)00426-X
Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR. Cancer-related fatigue: the scale of the problem. Oncologist. 2007;12(Suppl. 1):4–10. DOI: https://doi.org/10.1634/theoncologist.12-S1-4
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: cancer-related fatigue [Internet]. Plymouth Meeting, PA: NCCN; 2024. [Cited 2026 Sep 9]. Available from: https://www.cancer.gov/about-cancer/treatment/side-effects/fatigue/fatigue-hp-pdq
Yoon JH, Park NH, Kang YE, Ahn YC, Lee EJ, Son CG. The demographic features of fatigue in the general population worldwide: a systematic review and meta-analysis. Front Public Health. 2023;11:1192121. DOI: https://doi.org/10.3389/fpubh.2023.1192121
Engberg I, Segerstedt J, Waller G, Wennberg P, Eliasson M. Fatigue in the general population: associations to age, sex, socioeconomic status, physical activity, sitting time and self-rated health. BMC Public Health. 2017;17(1):654. DOI: https://doi.org/10.1186/s12889-017-4623-y
Bower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol. 2000;18(4):743–53. DOI: https://doi.org/10.1200/JCO.2000.18.4.743
Quinten C, Maringwa J, Gotay CC, Martinelli F, Coens C, Reeve BB, et al. Patient self-reports of symptoms and clinician ratings as predictors of overall cancer survival. J Natl Cancer Inst. 2011;103(24):1851–8. DOI: https://doi.org/10.1093/jnci/djr485
Thong MSY, Doege D, Koch-Gallenkamp L, Bertram H, Eberle A, Holleczek B, et al. Fatigue in long-term cancer survivors: prevalence, associated factors, and mortality. Br J Cancer. 2025;133(6):831–43. DOI: https://doi.org/10.1038/s41416-025-03116-z
Husson O, Mols F, van de Poll-Franse L, de Vries J, Schep G, Thong MS. Variation in fatigue among 6011 (long-term) cancer survivors and a normative population: a study from the population-based PROFILES registry. Support Care Cancer. 2015;23(7):2165–74. DOI: https://doi.org/10.1007/s00520-014-2577-5
Romero-Elias M, Alvarez-Bustos A, Mendez M, Sanchez A, Gutierrez L, Cebolla-Boado H, et al. Correlates of cancer-related fatigue in colorectal cancer patients at the time of diagnosis. Support Care Cancer. 2025;33(4):338. DOI: https://doi.org/10.1007/s00520-025-09386-w
Kastelein A, Mols F, Kervezee L, Chavannes NH, Gelderblom H, Neefjes J, et al. The impact of chemotherapy and body mass index on cancer-related fatigue in colon cancer patients: a PROFILES-registry study. Cancer Med. 2025;14(1):e70536. DOI: https://doi.org/10.1002/cam4.70536
Jacobs L, van der Vlies E, Ten Bokkel Huinink D, Bloemendal H, Intven M, Smits AB, et al. Tolerability, safety, and outcomes of neoadjuvant chemoradiotherapy with capecitabine for patients aged ≥ 70 years with locally advanced rectal cancer. Clin Colorectal Cancer. 2018;17(3):179–86. DOI: https://doi.org/10.1016/j.clcc.2018.03.004
Ansari N, Solomon MJ, Fisher RJ, Mackay J, Burmeister B, Ackland S, et al. Acute adverse events and postoperative complications in a randomized trial of preoperative short-course radiotherapy versus long-course chemoradiotherapy for T3 adenocarcinoma of the rectum: Trans-Tasman Radiation Oncology Group Trial (TROG 01.04). Ann Surg. 2017;265(5):882–8. DOI: https://doi.org/10.1097/SLA.0000000000001987
Kim HJ, Choi GS, Park JS, Park SY, Yang CS, Lee HJ. The impact of robotic surgery on quality of life, urinary and sexual function following total mesorectal excision for rectal cancer: a propensity score-matched analysis with laparoscopic surgery. Colorectal Dis. 2018;20(5):O103–13. DOI: https://doi.org/10.1111/codi.14051
Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE, et al. Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon Rectum. 2014;57(5):585–91. DOI: https://doi.org/10.1097/DCR.0000000000000116
Afshari K, Onerup A, Li Y, Angenete E, Ehrencrona C, Wedin A, Haglind E. Effects of prehabilitation by physical activity on fatigue after surgery for colorectal cancer. Results from secondary analyses in the randomized controlled trial PHYSSURG-C. Cancer Med. 2026;15(8):e72142. DOI: https://doi.org/10.1002/cam4.72142
Oppong I, Naemi R, Gossett RT. The effects of aerobic and resistance training across eight cancer types: a systematic review. Support Care Cancer. 2026;34(2):149. DOI: https://doi.org/10.1007/s00520-026-10363-0
Asplund D, Heath J, Gonzalez E, Ekelund J, Rosenberg J, Haglind E, et al. Self-reported quality of life and functional outcome in patients with rectal cancer – QoLiRECT. Dan Med J. 2014;61(5):A4841.
Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM. The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum. 1998;25(4):677–84. DOI: https://doi.org/10.1037/t18854-000
Ostlund U, Gustavsson P, Furst CJ. Translation and cultural adaptation of the Piper Fatigue Scale for use in Sweden. Eur J Oncol Nurs. 2007;11(2):133–40. DOI: https://doi.org/10.1016/j.ejon.2006.04.034
Sandberg S, Asplund D, Bisgaard T, Bock D, Gonzalez E, Karlsson L, et al. Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study. Colorectal Dis. 2020;22(10):1367–78. DOI: https://doi.org/10.1111/codi.15095
Carmichael C, Gousset C, Burns D, Miller J, Van Tomme S, Kitchen H, et al. Fatigue experience in oncology: a targeted qualitative literature review and novel patient-centric conceptual model. Adv Ther. 2025;42(11):5380–96. DOI: https://doi.org/10.1007/s12325-025-03330-4
Andersson J, Angenete E, Gellerstedt M, Haglind E. Developing a multivariable prediction of global health-related quality of life in patients treated for rectal cancer: a prospective study in five countries. Int J Colorectal Dis. 2024;39(1):35. DOI: https://doi.org/10.1007/s00384-024-04605-y
Zeng Y, Zhang JW, Yang J. Attention to cancer-related physical and mental fatigue: breaking the vicious cycle. World J Psychiatry. 2025;15(3):99037. DOI: https://doi.org/10.5498/wjp.v15.i3.99037
Walming S, Block M, Bock D, Angenete E. Timely access to care in the treatment of rectal cancer and the effect on quality of life. Colorectal Dis. 2018;20(2):126–33. DOI: https://doi.org/10.1111/codi.13836
Pape E, Pattyn P, Van Hecke A, Somers N, Van de Putte D, Ceelen W, et al. Impact of low anterior resection syndrome (LARS) on the quality of life and treatment options of LARS: a cross-sectional study. Eur J Oncol Nurs. 2021;50:101878. DOI: https://doi.org/10.1016/j.ejon.2020.101878
Oggesen BT, Hamberg MLS, Rosenberg J. Practical management algorithms for late complications after colorectal and anal cancer – basic treatment of late complications. Med Adv. 2023;1(3):260–9. DOI: https://doi.org/10.1002/med4.32
van der Heijden JAG, Thomas G, Caers F, van Dijk WA, Slooter GD, Maaskant-Braat AJG. What you should know about the low anterior resection syndrome: clinical recommendations from a patient perspective. Eur J Surg Oncol. 2018;44(9):1331–7. DOI: https://doi.org/10.1016/j.ejso.2018.05.010
Boyle H, Fullbrook A, Wills A, Veal I, Peat N, Al-Noor Z, et al. Multimodal prehabilitation service for patients with colorectal cancer: the challenges of implementation. BMJ Open Qual. 2023;12(2):e002064. DOI: https://doi.org/10.1136/bmjoq-2022-002064
Brandenbarg D, Korsten J, Berger MY, Berendsen AJ. The effect of physical activity on fatigue among survivors of colorectal cancer: a systematic review and meta-analysis. Support Care Cancer. 2018;26(2):393–403. DOI: https://doi.org/10.1007/s00520-017-3920-4
Eyl RE, Thong MSY, Carr PR, Jansen L, Koch-Gallenkamp L, Hoffmeister M, et al. Physical activity and long-term fatigue among colorectal cancer survivors: a population-based prospective study. BMC Cancer. 2020;20(1):438. DOI: https://doi.org/10.1186/s12885-020-06918-x
Vgontzas AN, Bixler EO, Chrousos GP. Obesity-related sleepiness and fatigue: the role of the stress system and cytokines. Ann N Y Acad Sci. 2006;1083:329–44. DOI: https://doi.org/10.1196/annals.1367.023
Tran CG, Dornbush C, Jensen BS, Mott SL, Fannon EEH, Stark AC, et al. Obesity, survival, and chemotherapy outcomes in stage IV colorectal cancer: a retrospective study. BMC Cancer. 2026;26(1):331. DOI: https://doi.org/10.1186/s12885-026-15653-8
Revesz D, Bours MJL, Wegdam JA, Keulen ETP, Breukink SO, Slooter GD, et al. Associations between alcohol consumption and anxiety, depression, and health-related quality of life in colorectal cancer survivors. J Cancer Surviv. 2022;16(5):988–97. DOI: https://doi.org/10.1007/s11764-021-01090-y
Grbic A, Causevic M, Brodaric S, Birk M, Oblak I. Gender impact on quality of life in colorectal cancer survivors. Radiol Oncol. 2025;59(3):457–65. DOI: https://doi.org/10.2478/raon-2025-0023
Published
How to Cite
Issue
Section
Categories
License
Copyright (c) 2026 Johan Ekstrand, Rode Grönkvist, Carolina Ehrencrona, Elisabeth Gonzalez, Jacob Rosenberg, Eva Haglind, Eva Angenete
This work is licensed under a Creative Commons Attribution 4.0 International License.
