# Patients refusing a permanent colostomy for rectal cancer: clinical outcome and psychological aspects

## TL;DR

Some rectal cancer patients refuse a permanent colostomy due to psychological concerns, risking their health.

## Contribution

This study explores the psychological and social reasons behind patients' refusal of APR surgery for rectal cancer.

## Key findings

- Six out of 11 recommended APR patients refused surgery due to social stigma and emotional distress.
- Depression and anxiety were significant factors in patients' decision to avoid colostomy.
- Two patients died during the study period, highlighting the risks of refusing treatment.

## Abstract

For locally advanced rectal tumors affecting the lower rectum, anal sphincter, or levator muscles, abdominoperineal resection (APR) is one of the surgical options. This involves extensive tissue removal and the creation of a permanent colostomy. However, colostomy is perceived by certain patients as a serious challenge, affecting multiple aspects of their lives. Thus, some refuse surgery and accept the risks of leaving the tumor untreated. Our study aims to explore refusal rates and reasons for declining surgery.

Patients who were recommended to undergo APR surgery as part of their rectal cancer treatment were evaluated. These patients were followed up and underwent interviews and completed three questionnaires: one to explore reasons for surgery refusal, another to assess depression (PHQ-9), and a third to evaluate coping strategies (COPE). A medical psychologist analyzed the questionnaire responses.

During the study period 96 patients were diagnosed with rectal cancer. Eighty-four patients had anterior resection, one patient had TAMIS, and 11 patients were recommended to undergo APR. Out of them, five completed the surgery, and six refused. They were the focus of our study. All patients received neoadjuvant therapy. Average follow up time was 27 months. Two patients died during the study. Primary reasons for rejecting colostomy included concerns about social stigma and feelings of shame, as well as struggles with depression and anxiety. Notably, one patient was diagnosed with moderate depression based on the PHQ-9 questionnaire.

A planed permanent colostomy presents a significant psychological and emotional hurdle for patients. The fear of the procedure is so intense that some patients choose to avoid it while risking their lives. It is imperative to implement various measures to aid patients in the peri-operative setting, such as establishing support groups and providing mentors who have experienced the same disease and treatment.