Consequences of Treatment for Rectal Cancer

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 DetailsRectal n=138 Colon n=243

Median Age 66.7yrs (58, 72.9) 68yrs (60.5, 75)Male 85 (61.6%) 139 (57.2%)Female 53 (38.4%) 104 (42.8%)Dukes StagingA 31 (22.5%) 26 (10.6%)B 58 (42%) 146 (60.1%)C 49 (35.5%) 71 (29.2%)AJCC Staging

Stage I 31 (22.5%) 26 (10.6%)Stage IIA 54 (39.1%) 112 (46%)Stage IIB/C 4 (2.9%) 34 (13.9%)Stage III 49 (35.5%) 71 (29.2%)

Pelvic Dissection Abdominal Surgery (rectal cancers) (colon cancers) n= 138 (%) n= 243 (%)

Operation Extended/Right hemicolectomy 112 (46%) Left hemicolectomy/sigmoid colectomy 30 (12.3%) A.R. + straight anastomosis (+/- pouch) 64 (46.4%) 82 (33.7%) A.R. + S.A + temp ileostomy (+/- pouch) 42 (30.5%) 1 (0.4%) A.P.R 23 (16.7%) Proctocolectomy + ileoanal pouch 1 (0.7%) Total colectomy + ileorectal anastomosis 7 (2.9%) Hartmanns procedure 3 (2.2%) 2 (0.8%) Other (includes x2 pouches) 2 (1.5%) 9 (3.7%) Radiotherapy Pre-operative radiotherapy 50 (36.2%) [Male 37 (74%) Female 13 (26%)] Post operative radiotherapy 1 (0.7%) Post operative chemotherapy 44 (31.8%) 76 (31.3%)

Treatment Details

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

Telephone Follow Up Pilot

• Small scale pilot involving 14 patients treated for rectal cancer

• Telephone calls made at 6, 8 and 12 weeks post operatively

• Bowel function assessment using ICIQ-B (Cotterill et al 2008)

• Documented evidence of interventions• Patient satisfaction questionnaire

Results

• Improvement in bowel pattern, bowel control and quality of life scores

• One patient brought back to clinic for early review

• Systematic telephone assessment viewed as useful and valuable service by patients

• Need to consider most appropriate assessment tool

• Formal clinic template needed

For further details please contact:

Gillian Knowles (Principal Investigator)gillian.knowles@luht.scot.nhs.uk

Rachel Haigh (Research nurse)rachel.haigh@luht.scot.nhs.uk