Transcript No Slide Title

Long Term Effects of Surgery and
Radiotherapy for Colorectal Cancer on
Bowel Function and Quality of Life
Gillian Knowles, Rachel Haigh, Catriona McLean, Hamish
Phillips, Malcolm Dunlop, Farhat Din
Background
• People can experience distressing symptoms
following treatment for rectal cancer
• Emerging evidence about the long-term impact on
health-related quality of life
• Survival is increasing
• People are living longer with consequences of
treatment
Background
• Study Aim:
– To evaluate the long term bowel, urinary and
sexual function in patients who have
undergone pelvic surgery for rectal cancer with
or without radiotherapy
• Health Service Research Funding (1yr)
• Ethical approval granted
Study Questions
• What is the prevalence of long term bowel, urinary
and sexual dysfunction in patients with rectal cancer
(+/- XRT) and in patients having abdominal surgery
for colon cancer?
• What is the prevalence of dysfunction and reduced
quality of life in each of these groups?
• To what degree does pelvic XRT add to pelvic
dysfunction
Sample
• All patients who had undergone pelvic dissection (+/pelvic XRT) for a primary rectal cancer (Dukes A, B &
C) within NHS Lothian
• Time period January 2002 to December 2006
• In addition, patients who underwent abdominal
surgery without pelvic dissection for a primary colon
cancer during the same period.
• Study was conducted at the Western General
Hospital, Edinburgh, Scotland, U.K.
Study Tools
– Demographic assessment
– EORTC QLQ C30 (Aaronson et al 1993)
and QLQ-CR38 (Sprangers et al 1999)
– MSKCC Bowel Function Instrument
(Temple et al 2005)
Recruitment
• Overall response 381/667 patients (57%)
– Rectal cancer 138/193 – 72% response
– Colon cancer 243/474 – 51% response
Results- Demographic details
• Patients who responded to the study were
younger than non-responders (p<0.001)
• No association found between gender, Dukes
Stage or TNM classification & participation in the
study
• Median length of time from surgery to completing
questionnaires was 53 months (interquartile range
38 to 68 months)
Results- Demographic Details
Median Age
Male
Female
Dukes Staging
A
B
C
AJCC Staging
Stage I
Stage IIA
Stage IIB/C
Stage III
Rectal n=138
66.7yrs (58, 72.9)
85 (61.6%)
53 (38.4%)
Colon n=243
68yrs (60.5, 75)
139 (57.2%)
104 (42.8%)
31 (22.5%)
58 (42%)
49 (35.5%)
26 (10.6%)
146 (60.1%)
71 (29.2%)
31 (22.5%)
54 (39.1%)
4 (2.9%)
49 (35.5%)
26 (10.6%)
112 (46%)
34 (13.9%)
71 (29.2%)
Treatment Details
Pelvic Dissection
(rectal cancers)
n= 138 (%)
Operation
Extended/Right hemicolectomy
Left hemicolectomy/sigmoid colectomy
A.R. + straight anastomosis (+/- pouch)
A.R. + S.A + temp ileostomy (+/- pouch)
A.P.R
Proctocolectomy + ileoanal pouch
Total colectomy + ileorectal anastomosis
Hartmanns procedure
Other (includes x2 pouches)
Radiotherapy
Pre-operative radiotherapy
Post operative radiotherapy
Post operative chemotherapy
64 (46.4%)
42 (30.5%)
23 (16.7%)
1 (0.7%)
3 (2.2%)
2 (1.5%)
Abdominal Surgery
(colon cancers)
n= 243 (%)
112 (46%)
30 (12.3%)
82 (33.7%)
1 (0.4%)
7 (2.9%)
2 (0.8%)
9 (3.7%)
50 (36.2%) [Male 37 (74%) Female 13 (26%)]
1 (0.7%)
44 (31.8%)
76 (31.3%)
Results- Bowel Function (MSKCC)
• In a sub-set of patients with rectal cancer
– 16% documented persistent problems with leakage
of stool ‘always’ or ‘most of the time’
– 17% ‘always’ had to wear a protective pad
– 31% reported incomplete emptying
– 32% experienced difficulty in controlling flatus
– 9% ‘always’ had to alter their daily activities
– 30% required to modify their diet
– Increase in total number of bowel movements in a
24hour period (p<0.001)
• Patients who received radiotherapy experienced
poorer functional outcomes in all three subscales than
those who did not have radiotherapy
Results- EORTC QLQ-C30/CR38
• Patients who underwent pelvic dissection were more
likely to experience:
– Diarrhoea (p=0.001) & increased defecation (p=0.000)
& gastrointestinal problems (p=0.000)
– Financial difficulties (p=0.024)
– Reduced body image perception (p=0.002)
– Reduced social functioning (p<0.001)
– Reduced role functioning (p=0.038)
– Altered bowel function was found to impact
significantly on overall QOL (p<0.001)
• Patients with an anastomotic level of ≤6cm were more
likely to experience increased gastrointestinal problems
(p=0.05)
Results- EORTC QLQ-CR38
• Sexual function:
– Men who underwent pelvic dissection were found
to have greater sexual problems (p=0.009)
– Sexual function problems were more frequently
reported in men who had undergone APR (13/13
100%), low AR + colopouch (23/31 74.2%) and AR
+ SA (23/31 74.2%)
– On the whole, female participants did not answer
questions relating to sexual function
Results- EORTC QLQ-C30/CR38
radiotherapy and no radiotherapy pelvic
dissection patients
• Rectal cancer patients who received pre-operative
radiotherapy had:
–
–
–
–
Increased defecation problems (p=0.005)
Reduced social functioning (p=0.048)
Greater financial difficulties (p=0.049)
There was no association between long or short
course XRT and sexual dysfunction in men
responding to sexual function questions (p=1.000)
• Overall global health status was good in
both rectal and colon groups
Summary points:
• Sub-set of patients with rectal cancer document
persistent bowel function difficulties
• Altered bowel function impacts on overall quality of life
• Pre-op radiotherapy and low anastomotic join is
associated with increased defecation problems
• Increased sexual function difficulties noted in men
who underwent pelvic dissection
• Patients treated for rectal cancer report reduced role
and social function, body image perception and
greater financial difficulties compared to patients with
colon cancer
• Few women completed the sexual function questions
• Urinary difficulties were not found to be of significance
in this study
Future developments
• Introduce more systematic assessment of bowel
function in rectal cancer patients using validated
assessment tool
• Need for an evaluation of earlier pre-emptive
interventions
• Need for identification of ‘at risk groups’ and those
‘at risk’ of developing late effects
• Development of existing Nurse-led follow up
services
For further details please contact:
Gillian Knowles (Principal Investigator)
[email protected]
Rachel Haigh (Research nurse)
[email protected]
Western General Hospital, Edinburgh