Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer

Phase III trial of fluorouracil-based chemotherapy regimens plus radiotherapy in postoperative adjuvant rectal cancer: GI INT 0144

PURPOSE

Adjuvant chemoradiotherapy after or before resection of high-risk rectal cancer improves overall survival (OS) and pelvic control. We studied three postoperative fluorouracil (FU) radiochemotherapy regimens.

PATIENTS AND METHODS

After resection of T3-4, N0, M0 or T1-4, N1, 2M0 rectal adenocarcinoma, 1,917 patients were randomly assigned to arm 1, with bolus FU in two 5-day cycles every 28 days before and after radiotherapy (XRT) plus FU via protracted venous infusion (PVI) 225 mg/m2/d during XRT; arm 2 (PVI-only arm), with PVI 42 days before and 56 days after XRT + PVI; or arm 3 (bolus-only arm), with bolus FU + leucovorin (LV) in two 5-day cycles before and after XRT, plus bolus FU + LV (levamisole was administered each cycle before and after XRT). Patients were stratified by operation type, T and N stage, and time from surgery.

RESULTS

Median follow-up was 5.7 years. Lethal toxicity was less than 1%, with grade 3 to 4 hematologic toxicity in 49% to 55% of the bolus arms versus 4% in the PVI arm. No disease-free survival (DFS) or OS difference was detected (3-year DFS, 67% to 69% and 3-year OS, 81% to 83% in all arms). Locoregional failure (LRF) at first relapse was 8% in arm 1, 4.6% in arm 2, and 7% in arm 3. LRF in T1-2, N1-2, and T3, N0-2 primaries who received low anterior resection (those most suitable for primary resection) was 5% in arm 1, 3% in arm 2, and 5% in arm 3.

CONCLUSION

All arms provide similar relapse-free survival and OS, with different toxicity profiles and central catheter requirements. LRF with postoperative therapy is low, justifying initial resection for T1-2, N0-2 and T3, and N0-2 anterior resection candidates.

Sexual dysfunction after pelvic surgery

Pelvic surgeries are among the most common causes of organic sexual dysfunction in men and women. The impact of nerve-sparing surgery on potency has been well documented in radical prostatectomy. However, its impact on potency needs to be evaluated in other pelvic surgeries. Sexual dysfunction is highly prevalent even after multiple technical advances in the field of oncological surgeries. The prevalence varies from 8 to 82%, depending on the type of pelvic surgery. In females, sexual dysfunction has not been evaluated adequately using validated questionnaires. However, in subspecialized circles, treatment for female sexual dysfunction is becoming routine. Currently, physicians have several options for the treatment of erectile dysfunction (ED) in men. Since the introduction of oral PDE-5 inhibitors, oral therapy has become the first-line treatment option for ED, irrespective of etiology. Currently available treatment options for the female sexual dysfunction include estrogens, androgens, phosphodiesterase inhibitors, and dopamine receptor antagonists. Initial reports regarding the role of early rehabilitation are encouraging and may become the part of routine practice in the management of ED after pelvic surgery. In this article, we summarize the sexual dysfunction following pelvic surgeries and their management.

Women's sexual dysfunction: a review of the "surgical landscape"

OBJECTIVES

To assess the impact of urogynaecologic surgery for stress urinary incontinence, oncologic pelvic surgery, and hysterectomy on women's overall sexual health.

METHODS

We used Ovid and PubMed (updated January 2006) to conduct a literature electronic search on MEDLINE that included peer-reviewed English-language articles. We analysed all studies identified that provided any functional outcome data about urogynaecologic surgery for the treatment of stress urinary incontinence, radical cystectomy for bladder cancer, surgery for rectal cancer, and hysterectomy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data.

RESULTS

Most studies showed that either urogynaecologic or oncologic pelvic surgery may have a significant impact on women's sexual health. Epidemiology varied widely among the studies and reported either improvement or impairment of postoperative sexual functioning, due to different definitions, study designs, and small cohorts of patients. An increasing number of studies have prospectively examined this issue and have found often controversial findings about the role of pelvic and perineal surgery in women's sexual health.

CONCLUSIONS

Although numerous controversies exist, data demonstrate an overall positive impact of the surgical repair for stress urinary incontinence on resolution of coital incontinence, coupled with an improvement of overall sexual life. In contrast, genitourinary and rectal cancers are commonly associated with treatment-related sexual dysfunction, but few studies rigorously assessed women's postoperative sexual function after major oncologic pelvic surgery. Data about the functional outcome after hysterectomy are often contradictory. Adequately powered prospective clinical trials are needed.

Gender differences in quality of life of patients with rectal cancer. A five-year prospective study

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

Adjuvant radiotherapy is associated with increased sexual dysfunction in male patients undergoing resection for rectal cancer: a predictive model

OBJECTIVES

The objectives of this study were to evaluate the effect of radiotherapy (RT) on sexual function in patients undergoing oncologic resection for rectal cancer, and to develop a mathematical model for quantifying the risk of sexual dysfunction through time for this group of patients.

METHODS

Data were prospectively collected on patients undergoing proctosigmoidectomy (group 1: n = 101) or adjuvant radiotherapy (40-50 Gy) and resection (group 2: n = 100) for rectal cancer at a tertiary referral center between December 1998 and July 2004. Study end points were recorded at 7 time intervals (preoperatively, 4 months, 8 months, 1 year, 2 years, 3 years, and 4 years after surgery) and included: 1) ability to have an erection, 2) maintain an erection, 3) attain orgasm, 4) dry orgasm, and 5) whether they were sexually active. Multilevel logistic regression analysis for repeated measures was used to identify factors associated with the sexual dysfunction. A predictive model was developed and internally validated by comparing observed and model-predicted outcomes.

RESULTS

Radiotherapy had an adverse effect on the ability to get an erection, maintain an erection, attain orgasm, and being sexually active in comparison with patients undergoing surgery alone (7.4%, 12.6%, 16.2%, and 13.7% reduction 8 months after surgery respectively; P < 0.05). The effect of sexual dysfunction deteriorated with age (odds ratio for erectile function, 0.40 per 10-year increase in age; 95% confidence interval, 0.29-0.49; P < 0.001). A significant variability in sexual function was present among the 7 time points with a maximal deterioration occurring at 8 months after surgery with subsequent slow but not complete recovery (P < 0.001). The predictive model showed adequate discrimination on 4 of the 5 domains of sexual dysfunction (area under the receiver operating characteristic curve >0.70).

CONCLUSIONS

Radiotherapy has an adverse effect on sexual function, the effect being maximal at 8 months after surgery. The risk of sexual dysfunction can be quantified preoperatively using the proposed index and can assist patients in making better informed choices on the type of treatment they receive.

Factors influencing sexual function in patients with rectal cancer

Only few studies have investigated the impact of surgery for rectal cancer on sexual function. Little of that research included quality of life (QoL) aspects and hardly any study analyzed the impact of age, gender and type of surgery on sexual function. The aim of the presented study was to address these issues. Over a 5 y period, EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12 and 24 months postoperatively. Comparisons were made between patients receiving abdominoperineal resection (APR), anterior resection (AR) with or without Pouch and Sigmoid resection. Furthermore, effects of surgery on female and male patients, and age groups were analyzed. A total of 819 patients participated in the study: 412 were males and 407 were females. The groups were comparable in terms of adjuvant treatment, tumor stage and histology. Patients after APR and AR with Pouch had worst sexual function. Men reported significantly more difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men that were worse than baseline levels in the early postoperative period. These problems tended to remain. Patients aged 69 y and younger scored higher for problems with loss of sexual function and sexuality-related strain than patients aged 70 y and older. The findings in this study confirm that QoL changes postsurgery and that factors like type of surgery, gender and age have tremendous impact on sexual function and sexual enjoyment. APR and AR with Pouch affect sexual function more than AR and resection of the lower sigmoid. Through impaired sexual enjoyment, men are put more under strain than women. Patients aged 69 y and younger experience more stress through deteriorated sexual function.

Outcome after the introduction of a multimodality treatment program for locally advanced rectal cancer

AIM

This prospective study reports the results of a multimodality treatment protocol in patients with locally advanced rectal cancer and assesses outcome after curative vs non-curative surgery and in relation to primary advanced vs locally recurrent cancer.

METHODS

Between 1991 and 2002, 122 patients completed the protocol. Fifty-eight had primary advanced and sixty-four had locally recurrent rectal cancer. Median follow up was 82 months (5-143).

RESULTS

A potentially curative resection was achieved in 59% of the patients with primary advanced and in 34% of patients with locally recurrent cancer. After curative resection, 53 and 59%, respectively, were free from recurrence during the observation time (median 82 months) and the overall 5-year survival was 34 and 40%. Overall 5-year survival in all patients with primary advanced cancer was 29 and 16% in all patients with locally recurrent rectal cancer.

CONCLUSION

Multimodality treatment may cure at least a third of patients with locally advanced rectal cancer provided a radical resection is performed. As the post-operative morbidity is high, an optimised patient selection for neo-adjuvant treatment and surgery is essential. However, palliative surgery may benefit the patient if local control is achieved. Future studies should focus on the problem of distant metastasis.

Testicular dose and hormonal changes after radiotherapy of rectal cancer

BACKGROUND AND PURPOSE

To measure the dose received by the testicles during radiotherapy for rectal cancer and to determine the contribution of each field of the pelvic box and the relevance for hormonal status.

MATERIALS AND METHODS

In 11 patients (mean age 55.2 years) testicular doses were measured with an ionisation chamber between 7 and 10 times during the course of pelvic radiotherapy (50 Gy) for rectal carcinoma. Before and several months after radiotherapy luteinizing hormone, follicle stimulating hormone and total testosterone serum levels were determined.

RESULTS

The mean cumulative radiation exposure to the testicles was 3.56 Gy (0.7-8.4 Gy; 7.1% of the prescribed dose). Seventy-three percent received more than 2 Gy to the testicles. Fifty-eight percent of the measured dose was contributed by the p.a. field, 30% by the a.p. field and 12% by the lateral fields. Mean LH and FSH levels were significantly increased after therapy (350%/185% of the pre-treatment values), testosterone levels decreased to 78%. No correlation could be found between changes of hormones and doses to the testis, probably due to the low number of evaluated patients.

CONCLUSIONS

Radiotherapy of rectal carcinoma causes significant damage to the testis, as shown by increased levels of gonadotropins after radiotherapy. Most of the gonadal dose is delivered by the p.a. field, due to the divergence of the p.a. beam towards the testicles. The reduction in testosterone level may be of clinical concern. Patients who will receive radiotherapy for rectal carcinoma must be instructed about a high risk of permanent infertility, and the risk of endocrine failure (hypogonadism). Larger studies are needed to establish the correlation between testicular radiation dose and hormonal changes in this group of patients.

Ten-year historic cohort of quality of life and sexuality in patients with rectal cancer

PURPOSE

In various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery.

METHODS

A total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure.

RESULTS

For patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery.

CONCLUSIONS

Assessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.

Impact of Age on Quality of Life in Patients with Rectal Cancer

Some studies indicate that age at the time of surgery has a general effect on outcomes. The impact of age on the quality of life (QOL) of patients with rectal cancer, however, has not been investigated. The present study was conducted to address this issue. Over a 5-year period the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, and at 3, 6, 12, and 24 months postoperatively. Comparisons were made between age groups. A total of 519 patients participated in the study. QOL data were available for 253 patients. Significant differences were observed only between patients aged 69 years and younger (< or =69 years) (169/253) and those aged 70 years and older (> or =70 years) (85/253). Physical and role functioning was better for patients < or =69 years; patients > or =70 years suffered from increased pain and fatigue. Younger patients had more difficulty with sexual enjoyment, and over time sexual strain was worse for patients aged > or =70 years during the early postoperative period but improved, whereas patients aged < or =69 years had increasing levels of strain over time. The findings in this study confirmed that QOL is dynamic over time and that age has an impact on QOL and sexuality. Patients aged > or =70 years are affected by impaired physical functioning, global health, and fatigue, whereas increased treatment strain during the early postoperative period improves over time. Patients aged < or =69 years experience increased strain because of impaired sexual function.

ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Clinical Biologic Pathophysiologies of Women's Sexual Dysfunction

INTRODUCTION

Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.

AIM

To gain knowledge of biologic pathophysiology of female sexual function. METHODS. To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.

RESULTS

Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.

CONCLUSIONS

Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

Surgery for locally recurrent rectal cancer

After the diagnosis of a locally recurrent rectal cancer, imaging is the first step to estimate the extent and location of the local tumour growth and the presence or absence of distant metastases. The aim of the treatment is a R0 resection (microscopically tumour free circumferential margin) by multimodality treatment consisting of pre-operative radiation, extended resection and intra-operative radiotherapy by either electron beam irradiation or with high dose rate brachytherapy. Filling the pelvic cavity with vital tissue such as an omentoplasty should considered carefully. With this treatment the overall three-year survival rate of a group of 33 patients was 60% with a local control rate of 73%. The combination of chemotherapy as a radiosensitizer resulted in an increase of R0 resections by 20%. Introduction of TME surgery and pre-operative radiotherapy has created a new situation with limited possibilities due to dose-accumulation toxicity of the radiotherapy and extensive scarring of the tissues making estimation of the extent of the tumour growth more difficult. The prevention of local recurrence by proper selection of primary cases, the training of experienced surgeons and the optimal use of pre-operative radiotherapy is the way forward to improve results.

Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer

PURPOSE

In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed.

METHODS AND MATERIALS

Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months).

RESULTS

The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients.

CONCLUSIONS

As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.

Intraoperative parasympathetic nerve stimulation with tumescence monitoring during total mesorectal excision for rectal cancer

BACKGROUND

Unilateral or bilateral division of the parasympathetic nerves during resection of rectal cancer may result in sexual erectile dysfunction. The purposes of this project were twofold: to determine the ability to demonstrate penile tumescence in response to parasympathetic nerve stimulation after rectal cancer resection and to correlate the nerve stimulation response with clinical sexual function 6 months after operation.

STUDY DESIGN

In 21 consecutive male patients with normal erectile function undergoing total mesorectal excision, cavernous nerve identification and integrity before and after pelvic dissection were assessed intraoperatively, both visually by an experienced surgeon and by using the CaverMap nerve stimulator. The minimal effective current necessary to produce a 2% increase in penile tumescence was recorded for both the left- and right-sided nerves, primarily the largest nerve trunk, S3. Postclearance stimulation data were then correlated with sexual function outcomes, specifically erection and orgasm at 6 months after surgery.

RESULTS

The operating surgeon's visual assessment of the pelvic autonomic nerve's integrity after pelvic dissection was deemed intact in 20 of the 21 patients (95.2%). Of the 20 patients who were evaluated with CaverMap after completion of total mesorectal excision, 17 (85%) had tumescence response after nerve stimulation on either side, and 3 patients (15%) had unilateral response only. Of the 19 patients evaluated for sexual function 6 months after surgery, 18 (94.7%) had normal function, including the 3 patients with only unilateral nerve stimulation tumescence response.

CONCLUSIONS

Intraoperative mapping of the parasympathetic nerve trunks with the CaverMap nerve stimulator may be a valuable aid to less experienced pelvic surgeons and may help in autonomic nerve preservation during total mesorectal excision clearance.

Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer

PURPOSE

Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics.

METHODS

Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996), and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy.

RESULTS

The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P < 0.001).

CONCLUSION

The outcome of patients with locally recurrent rectal cancer was improved after the introduction of intraoperative radiation therapy-multimodality treatment.