Consequences of Treatment for Rectal Cancer

1. Consequences of Treatment for Rectal Cancer Gillian Knowles, Rachel Haigh, Catriona McLean, Hamish Phillips, Malcolm Dunlop, Farhat Din

2. 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

3. 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

4. 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

5. 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.

6. 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)

7. Recruitment • Overall response 381/667 patients (57%) • Rectal cancer 138/193 – 72% response • Colon cancer 243/474 – 51% response

8. 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)

9. Results- Demographic Details

10. Treatment Details

11. 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

12. 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)

13. 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

14. 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)

15. Overall global health status was good in both rectal and colon groups

16. 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

17. 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

18. 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

19. 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

20. 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