Electroacupuncture improves psychosocial outcomes in rectal cancer patients with bowel dysfunction

Table 1 Baseline characteristics of patients with low anterior resection syndrome undergoing electroacupuncture or standard postoperative care (n = 100), mean ± SD/n (%)

Characteristics	Electroacupuncture group (n = 50)	Control group (n = 50)	Test statistic1	P value2
Demographic variables
Age, years	61.2 ± 8.5	62.1 ± 7.9	t = 0.641	0.523
Sex			χ2 = 0.168	0.682
Male	30 (60)	28 (56)
Female	20 (40)	22 (44)
Body mass index, kg/m2	23.7 ± 3.2	24.1 ± 3.5	t = 0.685	0.497
Education level ≥ high school	38 (76)	36 (72)	χ2 = 0.202	0.653
Employment status			χ2 = 0.158	0.691
Employed	29 (58)	27 (54)
Unemployed	21 (42)	23 (46)
Comorbidities
Hypertension	17 (34)	19 (38)	χ2 = 0.164	0.685
Diabetes mellitus	10 (20)	9 (18)	χ2 = 0.072	0.791
Smoking history	12 (24)	14 (28)	χ2 = 0.214	0.644
Surgical and oncological characteristics
TNM stage			χ2 = 0.410	0.815
Stage I	8 (16)	7 (14)
Stage II	26 (52)	24 (48)
Stage III	16 (32)	19 (38)
Time since surgery, months	10.3 ± 4.1	10.8 ± 4.4	t = 0.567	0.571
Anastomosis level from anal verge, cm	5.1 ± 0.8	5.2 ± 0.9	t = 0.779	0.438
Type of surgery			χ2 = 0.319	0.573
Laparoscopic	43 (86)	41 (82)
Open	7 (14)	9 (18)
Neoadjuvant radiotherapy	18 (36)	20 (40)	χ2 = 0.170	0.684
Functional status
LARS score (0-42)	32.4 ± 5.6	31.9 ± 5.9	t = 0.426	0.672
LARS severity category			χ2 = 0.040	0.842
Moderate (21-29)	22 (44)	21 (42)
Severe (≥ 30)	28 (56)	29 (58)
Baseline quality of life (EORTC QLQ-C30 total)	56.3 ± 8.9	57.0 ± 9.1	t = 0.437	0.664
Psychological characteristics
Anxiety score (HADS-A, 0-21)	8.1 ± 3.2	8.5 ± 3.5	t = 0.610	0.544
Depression score (HADS-D, 0-21)	7.6 ± 3.4	7.9 ± 3.7	t = 0.427	0.671
General self-efficacy (GSES, 10-40)	28.2 ± 4.5	27.6 ± 5.1	t = 0.692	0.493
Perceived social support (PSSS, 12-84)	59.4 ± 8.9	58.1 ± 9.5	t = 0.796	0.428
Coping strategy score (Brief COPE, 14-56)	38.5 ± 6.1	37.9 ± 6.4	t = 0.561	0.577
Body image disturbance (BIS, 0-30)	12.7 ± 4.3	13.1 ± 4.7	t = 0.460	0.649

¹Independent-sample t test for continuous variables; χ² for categorical variables, test statistics are rounded to three significant digits.

²P < 0.05 considered statistically significant.

TNM: Tumor-nodes-metastasis; LARS: Low anterior resection syndrome; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; GSES: General Self-Efficacy Scale; PSSS: Perceived Social Support Scale; COPE: Coping Orientation to Problems Experienced; BIS: Body Image Scale.

Table 2 Temporal changes in psychological outcomes between groups during the 4-week intervention period, mean ± SD

Psychological measure	Time point	Electroacupuncture group (n = 50)	Control group (n = 50)	Test statistic1	P value2
Anxiety (HADS-A, 0-21)	Baseline	8.1 ± 3.2	8.5 ± 3.5	U = 1189.0	0.547
	Week 1	6.7 ± 3.1	8.1 ± 3.4	U = 941.0	0.042
	Week 2	5.5 ± 2.8	7.7 ± 3.1	U = 778.5	< 0.001
	Week 4	4.8 ± 2.6	7.3 ± 3.0	U = 658.0	< 0.001
Depression (HADS-D, 0-21)	Baseline	7.6 ± 3.4	7.9 ± 3.7	U = 1202.5	0.671
	Week 1	6.4 ± 3.2	7.5 ± 3.6	U = 1021.0	0.102
	Week 2	5.3 ± 3.0	7.1 ± 3.4	U = 854.0	0.005
	Week 4	4.7 ± 2.7	6.8 ± 3.1	U = 722.0	< 0.001
Body image disturbance (BIS, 0-30)	Baseline	12.7 ± 4.3	13.1 ± 4.7	U = 1224.5	0.649
	Week 1	11.2 ± 4.1	12.8 ± 4.5	U = 1034.0	0.078
	Week 2	9.8 ± 3.9	12.3 ± 4.4	U = 876.0	0.003
	Week 4	8.7 ± 3.6	11.9 ± 4.2	U = 725.5	< 0.001
Coping strategy (Brief COPE, 14-56)	Baseline	38.5 ± 6.1	37.9 ± 6.4	t = 0.561	0.577
	Week 1	39.3 ± 6.2	37.6 ± 6.3	t = 1.390	0.169
	Week 2	41.5 ± 5.8	38.0 ± 6.1	t = 3.067	0.003
	Week 4	43.1 ± 5.7	38.4 ± 6.2	t = 4.114	< 0.001
Social support (PSSS, 12-84)	Baseline	59.4 ± 8.9	58.1 ± 9.5	t = 0.796	0.428
	Week 1	60.2 ± 9.1	58.3 ± 9.3	t = 1.007	0.316
	Week 2	63.5 ± 8.6	58.9 ± 9.2	t = 2.642	0.010
	Week 4	65.7 ± 8.3	59.2 ± 9.1	t = 3.584	< 0.001

¹Between-group comparisons were performed using: Mann-Whitney U test for non-normally distributed psychological scales (Hospital Anxiety and Depression Scale-Anxiety subscale, Hospital Anxiety and Depression Scale-Depression subscale, Body Image Scale). Independent-sample t test for normally distributed scales (Coping Orientation to Problems Experienced, Perceived Social Support Scale).

²P value < 0.05 were considered statistically significant.

HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; BIS: Body Image Scale; COPE: Coping Orientation to Problems Experienced; PSSS: Perceived Social Support Scale.

Table 3 Changes in low anterior resection syndrome scores over time in patients receiving electroacupuncture vs control care (n = 100), mean ± SD

Time point	Electroacupuncture group (n = 50)	Control group (n = 50)	Test statistic (t)	P value
Baseline	32.4 ± 5.6	31.9 ± 5.9	0.43	0.672
Week 1 after treatment	27.5 ± 5.2a	30.8 ± 5.5	2.44	0.018
Week 2 after treatment	23.9 ± 5.3a	29.7 ± 5.4	5.19	< 0.001
Week 4 after treatment	20.6 ± 5.1a	27.8 ± 5.7	6.79	< 0.001

^aP < 0.05 vs pretreatment and between groups (electroacupuncture vs control).

Test statistics calculated using the independent-sample t test. Lower scores indicate better bowel function.

Table 4 Changes in quality of life in patients receiving electroacupuncture vs control care (n = 100), mean ± SD

Time point	Domain	Electroacupuncture group	Control group	t value	P value
Baseline	Global health status	56.3 ± 8.9	57.0 ± 9.1	0.44	0.664
	Emotional functioning	61.2 ± 10.3	60.4 ± 9.7	-0.38	0.702
	Social functioning	58.0 ± 11.2	57.4 ± 10.9	-0.24	0.813
Week 1	Global health status	63.4 ± 9.0a	58.2 ± 9.5	-2.49	0.015
	Emotional functioning	68.7 ± 9.5a	61.3 ± 9.6	-2.84	0.006
	Social functioning	65.2 ± 10.1a	58.6 ± 10.4	-2.72	0.009
Week 2	Global health status	68.1 ± 8.8a	60.0 ± 9.7	-4.17	< 0.001
	Emotional functioning	73.5 ± 8.4a	63.2 ± 9.2	-5.67	< 0.001
	Social functioning	71.4 ± 9.6a	61.1 ± 10.2	-5.02	< 0.001
Week 4	Global health status	72.3 ± 8.1a	62.5 ± 9.4	-5.66	< 0.001
	Emotional functioning	78.2 ± 7.9a	66.4 ± 8.7	-6.90	< 0.001
	Social functioning	76.1 ± 8.3a	64.2 ± 9.1	-6.73	< 0.001

^aP < 0.05 vs baseline and between groups (electroacupuncture vs control).

Scores are based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (version 3.0) questionnaire and range from 0 to 100; higher scores indicate better function or quality of life. P values were calculated using the independent-sample t test.

Table 5 Univariate Cox regression analysis for time to emotional remission (Hospital Anxiety and Depression Scale-Anxiety subscale reduction ≥ 3)

Variable	β coefficient1	HR (95%CI)	P value
LARS score (per 5-point increase)	0.31	1.36 (0.87-2.14)	0.008
Body image disturbance (BIS, per 5-point increase)	0.24	1.27 (0.81-1.99)	0.034
Self-efficacy (GSES, per 5-point increase)	-0.18	0.84 (0.53-1.31)	0.061
Social support (PSSS, per 5-point increase)	-0.22	0.80 (0.51-1.26)	0.048
Time since surgery (≤ 12 months vs > 12 months)	0.12	1.13 (0.72-1.77)	0.290
Surgical approach (open vs laparoscopic)	-0.05	0.95 (0.61-1.47)	0.711
Age (per 10-year increase)	0.07	1.07 (0.69-1.67)	0.518
Sex (male vs female)	0.03	1.03 (0.65-1.65)	0.889
BMI (per 1 kg/m2 increase)	-0.04	0.96 (0.83-1.12)	0.634
HADS-D baseline (per 3-point increase)	0.16	1.17 (0.92-1.51)	0.141
Brief COPE (per 5-point increase)	-0.09	0.91 (0.71-1.17)	0.456
Educational level (high school or below vs college or above)	0.14	1.15 (0.73-1.81)	0.553
Employment status (unemployed vs employed)	-0.08	0.92 (0.58-1.47)	0.724

¹β coefficients were obtained from univariate Cox proportional hazards models.

LARS: Low anterior resection syndrome; BIS: Body Image Scale; GSES: General Self-Efficacy Scale; PSSS: Perceived Social Support Scale; BMI: Body mass index; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; COPE: Coping Orientation to Problems Experienced; HR: Hazard ratio; CI: Confidence interval.

Table 6 Multivariate Cox regression analysis for emotional remission (Hospital Anxiety and Depression Scale-Anxiety subscale reduction ≥ 3)

Model	LARS score (per 5-point increase)	Body image disturbance (BIS; per 5-point increase)	Self-efficacy (GSES; per 5-point increase)	Social support (PSSS; per 5-point increase)	Sex (male vs female)	Age (per 10-year increase)	BMI (per 1 kg/m2 increase)
Unadjusted
HR	1.36	1.27	0.84	0.80	1.03	1.07	0.96
95%CI	0.87-2.14	0.81-1.99	0.53-1.31	0.51-1.26	0.65-1.65	0.69-1.67	0.83-1.12
P value	0.008	0.034	0.061	0.048	0.889	0.518	0.634
Model 11
HR	1.33	1.24	0.83	0.79	1.05	1.06	0.97
95%CI	0.84-2.10	0.79-1.92	0.51-1.28	0.50-1.23	0.66-1.71	0.68-1.65	0.84-1.13
P value	0.012	0.039	0.066	0.054	0.851	0.525	0.619
Model 22
HR	1.41	1.31	0.85	0.81	1.04	1.08	0.95
95%CI	1.08-1.96	1.02-1.86	0.59-1.27	0.66-1.24	0.64-1.72	0.70-1.73	0.82-1.12
P value	0.016	0.037	0.436	0.294	0.841	0.701	0.593

¹Model 1: Adjusted for sex, age, body mass index.

²Model 2: Further adjusted for Body Image Scale, General Self-Efficacy Scale, Perceived Social Support Scale, and low anterior resection syndrome score.

HR: Hazard ratio; CI: Confidence interval; LARS: Low anterior resection syndrome; BIS: Body Image Scale; GSES: General Self-Efficacy Scale; PSSS: Perceived Social Support Scale; BMI: Body mass index.

Table 7 Subgroup and interaction analysis of electroacupuncture effect on emotional remission (Hospital Anxiety and Depression Scale-Anxiety subscale reduction ≥ 3)

Subgroup variable	Stratum	HR1 (95%CI)	P value for interaction2
Anxiety level (HADS-A baseline)	High (≥ 8)	2.12 (1.42-3.59)	0.021
	Low (< 8)	1.24 (0.78-2.02)
Body image disturbance (BIS)	High (≥ 12)	1.98 (1.31-3.17)	0.033
	Low (< 12)	1.15 (0.71-1.96)
Social support (PSSS)	Low (< 60)	2.03 (1.26-3.32)	0.017
	High (≥ 60)	1.18 (0.73-1.91)

¹Hazard ratio for emotional remission in electroacupuncture group vs control.

²P value for interaction derived from interaction term in Cox model.

HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; BIS: Body Image Scale; PSSS: Perceived Social Support Scale; HR: Hazard ratio; CI: Confidence interval.