Background: Rectal cancer 5-year survival has increased from 58% of those diagnosed in 1987-1989 to 68% of those diagnosed in 2003-2009. Rectal cancer patients commonly receive one of two surgical treatments: permanent ostomy (a resection of tumor following by a stoma) or anastomosis (a resection followed by a reconnection with or without a prior temporary ostomy). The multifaceted consequences of both types of surgery potentially can affect both long-term psychological well-being and financial concerns of patients and their families. The overall goal of this dissertation is to increase the understanding of the impact of depression on the quality of life of rectal cancer survivors. Methods: The research data were based on a quality of life survey conducted in 2010-2011 among long-term survivors (≥ 5 years post-diagnosis) of rectal cancer. Participants were identified through the Kaiser Permanente (KP) health systems in Northern California and Southwest Washington/Oregon. Data included both the 2010/2011 survey data and KP electronic medical records (EMRs). Results: 1) The 24.7% prevalence of self-reported current depression among long-term rectal survivors was observed with a higher prevalence of 31% among those with permanent ostomies. Although average perceived financial burden level was low in this population of insured cancer survivors, 20% still reported moderate-to-high burden. Perceived financial burden was especially high among those who recalled having depression immediately after surgery and reported depression at the time of survey.2) All self-reported measures showed low sensitivity varying from 26% to 56% and high specificity from 77% to 82.7% against either diagnostic scheme from EMRs. Using either diagnostic scheme, the MCS-12 measure, a Mental Composite Summary (MCS) score from the 12-item Short-Form Health Survey with a cut-off point of≤45.6 for a self-reported depression, performed better as compared to the other two self-reported measures. 3) Approximately one in six rectal cancer survivors experienced depression after their surgery of sufficient severity to result in a depression diagnosis. Among survivors with recurrent depression diagnoses, those with a permanent ostomy reported significantly lower psychological well-being than those with an anastomosis. Conclusions: Depression burden is elevated after receiving surgery and remains a problem long after cancer diagnosis and treatment. Types of rectal cancer surgery received and gender of survivors may complicate the extent of depression burden. Among long-term rectal cancer survivors, having depression is associated with higher perceived financial burden. Chronic or recurrent course of depression may exist in this group of rectal cancer survivors and has significant impact on long-term psychological well-being. Self-reported measures for depression, such as MCS-12 measure with a cutoff point≤45.6, have the potential to be utilized for epidemiological studies when common screening instruments, electronic medical records, or administrative databases are not available. Implications: These findings underline the significance of depression assessments after surgery for this population of rectal cancer survivors and the importance of symptoms monitoring throughout the cancer survivorship continuum. Depressive symptoms should be monitored and managed as early as after cancer diagnosis and surgery to optimize survivors' long-term emotional well-being. In addition, depression screening and treatment as well as discussion of financial issues may have important roles in long-term survivorship care planning, particularly for those with permanent ostomies.