Download Rachel Haigh - Bowel Cancer UK

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 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
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)
[email protected]
Rachel Haigh (Research nurse)
[email protected]