Long term effect of surgery and radiotherapy for colorectal cancer on defecatory function and quality of life

Treatment patterns in metastatic early-onset rectal cancer

BACKGROUND

Early onset rectal cancer (EORC) is increasing internationally. While EORC cancer presents with some distinct clinical features, there is currently insufficient evidence that age of onset should alter treatment. This study examines treatment patterns for EO versus late-onset (LO) metastatic rectal cancer in Canterbury, New Zealand, to better understand appropriate treatment strategies and there effect on patient outcomes.

METHODS

A retrospective study on all patients diagnosed with stage 4 rectal adenocarcinoma in Canterbury from 2010 to 2021 was undertaken. Patients under 50 were compared to a control group aged 60-74, analysing treatment patterns, hospital stays, and survival outcomes.

RESULTS

Between 2010 and 2021, there were 949 rectal cancer diagnoses in Canterbury, of which 23 were EO and 64 were LO with stage 4 cancer. Survival analysis revealed a significant difference in median survival times between EORC (47.9 months) and LORC patients (26.5 months; P = 0.03). There was no significant difference in the surgical or oncological management between age groups (P > 0.05). Mean admissions per 100 days of life was 0.45 in LORC and 0.44 in EORC (P = 0.9119). There was no significant difference in the median proportion of time spent in hospital between EO and LO groups (2.5 vs. 2.2 days for every 100 days of life, P = 0.88).

CONCLUSION

Surgical and oncological treatments were similar for both EORC and LORC groups. The EO group exhibited better survival, with hospitalization burdens comparable for both. These findings underline the importance of maintaining an approach to metastatic RC balancing survival and quality of life.

Efficacy of Neoadjuvant Hypofractionated Chemoradiotherapy in Elderly Patients with Locally Advanced Rectal Cancer: A Single-Center Retrospective Analysis

Background/Objectives: The application of long-course chemoradiotherapy (LCRT) in elderly patients with locally advanced rectal cancer (LARC) can be challenging due to increased risks of complications associated with comorbidities and reduced functional status. This study aimed to assess the efficacy of neoadjuvant hypofractionated chemoradiotherapy (HCRT) in elderly patients with mid-to-low LARC. Methods: We performed a retrospective review of patients diagnosed with LARC from January 2013 to December 2020 and included those aged 70 years or older. Patients were categorized into three groups based on their treatment strategies: neoadjuvant HCRT (33 or 35 Gy in 10 fractions), neoadjuvant LCRT, and upfront surgery. Comparative analyses were performed on clinicopathological characteristics, short-term outcomes, and long-term survival outcomes among these groups. Results: Among the 296 patients included, 30 (10.1%) received HCRT, 195 (65.9%) underwent standard LCRT, and 71 (24.0%) underwent upfront surgery. The baseline characteristics showed that the HCRT group had a higher American Society of Anesthesiologists (ASA) score (ASA score 3 or 4, HCRT 43.3% vs. LCRT 16.9% vs. upfront surgery 15.5%, p = 0.002). The HCRT group showed a significantly lower incidence of radiotherapy-related complications than the LCRT group (16.7% vs. 48.7%, p = 0.001). However, the rate of pathological complete response was significantly lower in the HCRT group (10.0% vs. 15.4%, p = 0.002). The 3-year relapse-free survival (83.0% vs. 77.2% vs. 83.2%; p = 0.411), 3-year local recurrence-free survival (93.1% vs. 93.2% vs. 93.5%; p = 0.464), and 5-year overall survival (65.1% vs. 67.0% vs. 67.7%; p = 0.682) were not significantly different between the three groups. Multivariate analysis also showed that the treatment strategy was not associated with survival outcomes. Conclusions: Neoadjuvant HCRT demonstrated reduced radiotherapy-related complications and acceptable long-term oncologic outcomes. Therefore, neoadjuvant HCRT may be considered as a viable alternative for elderly patients with LARC.

Omission of Chemoradiation in Locally Advanced Rectal Adenocarcinoma: Evaluation of PROSPECT in a National Database

BACKGROUND AND OBJECTIVES

The PROSPECT trial showed noninferiority of neoadjuvant chemotherapy (NAC) with selective chemoradiation (CRT) versus CRT alone. However, trial results are often difficult to reproduce with real-world data. Pathologic outcomes and overall survival (OS) were evaluated by neoadjuvant strategy in locally advanced rectal adenocarcinoma patients in a national database.

METHODS

The 2012-2020 National Cancer Database was queried for clinical T2N1 and T3N0-1 rectal adenocarcinoma patients with definitive resection. Patients were categorized by neoadjuvant treatment with CRT alone, NAC alone, and NAC with CRT. Outcomes included R0 resection, pathologic complete response (PCR), and OS.

RESULTS

Of 18 892 patients, 16 126 (85.4%) received CRT, 1018 (5.4%) NAC, and 1748 (9.3%) NAC with CRT. Patients with NAC alone or NAC with CRT were more likely to have stage-III disease, private insurance, and academic facility treatment (all p < 0.001). NAC alone had lower adjusted odds of an R0 resection (OR 0.72; 95%CI 0.54-0.95) and PCR (OR 0.77; 95%CI 0.64-0.93). NAC with CRT demonstrated improved OS (HR 0.71; 95%CI 0.61-0.82), with no difference between NAC and CRT alone. Among patients who received adjuvant chemotherapy, no differences in OS were seen.

CONCLUSIONS

Patients who received NAC alone had worse pathologic outcomes. NAC had similar OS to CRT and NAC with CRT showed improved OS.

Non-gastrointestinal symptom burden following colorectal cancer treatment-a systematic review

BACKGROUND

Colorectal cancer is one of the most common malignancies worldwide. Improvements in screening and treatment have allowed for earlier detection and longer survival. However, treatments, which may involve surgery, radiotherapy and/or chemotherapy, often lead to patients developing both gastrointestinal and non-gastrointestinal symptoms that can persist long term. This systematic review aims to understand better the non-gastrointestinal symptoms that patients develop after colorectal cancer treatment and how these are identified and assessed through the use of questionnaires.

METHOD

The review was conducted according to PRISMA guidelines. Scopus, PubMed, Web of Science, PsycINFO and Cochrane Library were searched. Eligible studies evaluated the non-gastrointestinal symptoms that patients had developed and continued to have at 12 months or longer after treatment. Studies that were performed on patients who were within 12 months of treatment, who had a recurrent or a secondary cancer, had stage 4 cancer/were palliative or that looked solely at gastro-intestinal symptoms were excluded. Articles were limited to studies on human subjects written in English published between February 2012 and July 2024.

RESULTS

The searches identified 3491 articles. Thirty-seven articles met the inclusion criteria, of which, 33 were quantitative, 2 were qualitative and 2 were mixed methods study designs. Nearly two-thirds (n = 22) were cross-sectional studies, whereas 14 were longitudinal. One study had both a cross-sectional and longitudinal component to it. Most studies were of medium to high quality based on the Newcastle Ottawa Scale (n = 23) and were conducted in 14 countries, the majority of which were performed in the Netherlands (n = 14). The majority of participants in the included studies (n = 30/37) were men. There were also three studies that were performed with only female participants and one study that was performed with male participants only. The age range of research participants across all the studies was 29 to 89 years. Forty-five different validated questionnaires containing 5-125 question items were used to collect information on the side effects and impact of colorectal cancer treatment. Completion rate for questionnaires varied from 30 to 100% (median 63.5%). These determined effects on quality of life, emotional/psychological distress, sexual and urinary dysfunction, neuropathy, fatigue and hip pain.

CONCLUSION

This systematic review highlighted a wide range of longer-term non-gastrointestinal symptoms that frequently adversely affect QoL following treatment. These studies included highlighting the importance of nutrition/diet, physical activity, spirituality and communication in managing these long-term side effects.

The Effect of Pelvic Floor Muscle Exercises on Bowel Evacuation and Quality of Life in Following Intestinal Ostomy Closure: Randomized Controlled Trial

PURPOSE

This purpose of this study was to evaluate the effect of pelvic floor muscle exercises (PFMEs) on bowel evacuation problems and health-related quality of life (HRQOL) following ostomy closure.

DESIGN

Randomized controlled trial.

SUBJECTS AND SETTING

Forty individuals following ostomy closure consented to participate in the study; 6 participants (15%) did not complete the trial (2 died and 2 required a second ostomy) yielding a study sample of 34. Participants were randomly allocated to an Exercise Group (EG, n = 17) and Control Group (CG, n = 17). The mean age of the EG was 55.7 (SD 12.6) years, whereas the mean age of the CG was 62.0 (SD 12.1) years. The study setting was the surgery clinic of 4 hospitals in Ankara, Turkey. Data were collected between December 2018 and May 2020.

METHODS

The study intervention, PFME training by a clinician, was administered to participants in the EG; CG participants received no information regarding PFME. Data were collected during face-to-face interviews on the day before discharge and by phone at the first, second, third, and sixth months after surgery. A questionnaire was used for data collection that queried a demographic and pertinent clinical questions, along with the Assessment Form for Bowel Evacuation Habits and Psychosocial Problems, Wexner Scale, and the Short Form (SF-36) Health-related Quality of Life Scale. Descriptive statistics and Mann-Whitney U test, t-test, Pearson-χ2 test, Fisher's Exact test, Friedman test, and Cochran-Q test statistical analysis according to normal distribution were used in data evaluation.

RESULTS

The number of defecations in the EG was statistically significantly lower than the CG at the second, third, and sixth months (P = .002, P = .002, P = .001, respectively). In addition, the number of individuals experiencing night defecation was statistically significantly less in the EG compared to the CG at the second-, third-, and sixth-month follow-ups (P = .001, P = .001, P = .028, respectively). HRQOL scores were also significantly higher in the EG.

CONCLUSION

Pelvic floor exercises applied after ostomy closure are effective in reducing bowel evacuation and increasing quality of life. Given these findings, PFMEs are recommended for patients after ostomy closure.

Patient-Reported Symptom Burden and Supportive Care Needs of Patients With Stage II-III Colorectal Cancer During and After Adjuvant Systemic Treatment: A Real-World Evidence Study

PURPOSE

Patients with colorectal cancer (CRC) experience a range of physical and psychologic symptoms, and supportive care needs throughout the illness trajectory. We used patient-reported outcomes and administrative health data to describe symptom burden and supportive care needs during and after adjuvant treatment and determine factors associated with changes to symptom burden.

METHODS

A retrospective population-based cohort study of patients who were newly diagnosed with stage II-III CRC in Alberta, Canada, between January 1, 2016, and January 31, 2019. Adults age 18 years or older who completed a patient-reported outcomes survey (Edmonton Symptom Assessment System) and supportive care needs (Canadian Problem Checklist) within 3 months after starting adjuvant treatment (during treatment) and > 7 months after starting treatment (after treatment) were included. Changes to symptom severity were stratified as stable, improved, or deteriorated. Multivariable logistic regression was used to evaluate factors associated with these changes.

RESULTS

We included 303 patients (median age 60 years, 62% male, 84.5% stage III, 51.2% rectal v colon). Prevalent symptoms included tiredness (80.5%), pain (50.8%), and poor well-being (50%) during treatment, and tiredness (71.3%), pain (44.2%), and poor well-being (62.1%) after treatment. The results were heterogeneous with respect to improvements, stability, or deterioration. Pain worsened for 25% of the cohort, tiredness for 28%, and depression, anxiety, and well-being for 21%, 22%, and 31%, respectively. Deterioration of some symptoms was associated with older age, stage II, comorbidities, rural setting, and higher income.

CONCLUSION

We demonstrated symptom severity was generally low and most symptoms remained stable or improved after treatment. Particular groups of patients were at greater risk for more severe and/or more persistent symptoms. Ongoing assessments and interventions to address physical and psychologic symptoms, and supportive care needs in patients with CRC during and after treatment are needed.

Quality of life and patient reported symptoms after colorectal cancer in a Swedish population

AIM

A proportion of patients treated for colorectal cancer have impaired quality of life (QoL) but it is uncertain if the level of QoL differs from the corresponding background population. This population-based cohort study aimed to evaluate health-related QoL in colorectal cancer patients and compare their QoL with that of a Swedish reference population.

METHODS

Patients who underwent surgery for colorectal cancer Stages I-III in the Stockholm-Gotland region in 2013-2015 received the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the QLQ-CR29 questionnaires and the low anterior resection syndrome score, 1 year after surgery. Patient and tumour data were collected from the Swedish Colorectal Cancer Registry. The patient cohort was matched to a Swedish reference population regarding EORTC QLQ-C30. Global QoL was compared to the reference population and a patient group with impaired QoL was defined. Detailed patient-reported outcomes were analysed in relation to global QoL in the patient cohort.

RESULTS

A total of 925 patients returned the questionnaires and 358 patients (38.70%) reported a clinically relevant impaired global QoL compared to the reference population. Patients with impaired QoL reported clinically relevant and statistically significantly more complaints regarding bowel habits, pain and anxiety. After adjustment for sex, age and stoma, anxiety was the strongest predictor for impaired QoL, with OR 6.797 (95% CI 4.677-9.879).

CONCLUSION

A substantial proportion of patients treated for colorectal cancer have impaired global QoL. This impairment is strongly associated with several physical symptoms and anxiety.

Prevalence vs impact: a mixed methods study of survivorship issues in colorectal cancer

Purpose

This study aims to explore the prevalence of CRC survivorship issues and their impact on survivors’ quality of life (QoL).

Methods

This study utilised a mixed methods sequential explanatory design. Adult CRC survivors between 6- and 60-months post-diagnosis (n = 304) were purposively recruited from three hospitals and twenty-one cancer support centres in Ireland. QoL was evaluated using the EuroQol and FACT-C questionnaires and results compared to population norms. 22 survey participants took part in semi-structured interviews exploring the impact of survivorship issues on their daily lives.

Results

While CRC survivors reported QoL outcomes comparable to or better than normative populations, 54% were dissatisfied with their QoL. The most common survivorship issues reported included negative body image (74%), fatigue (68%), sexual dysfunction (66%) and sleep disturbance (59%). Thematic analysis of the qualitative data illustrated survivors’ attempts to live with the impact of cancer and its treatment (loss, fear, impact) and striving to contextualise, reframe and understand the consequences of cancer and its treatment (control, vigilance, benefit). Within these themes, the cross-domain impact of less prevalent symptoms including bowel dysfunction (28–57%) and peripheral neuropathy (47%) were widely discussed.

Conclusions

Although cancer survivors report positive QoL outcomes, many experience distressing physical, psychological and social effects. The findings suggest less common and difficult to manage symptoms are the greatest source of distress and unmet need. Support and information must be tailored to address survivors’ individual needs and preferences for support, informed by holistic person-centred assessment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02975-2.

Ruthenium Complexes: An Alternative to Platinum Drugs in Colorectal Cancer Treatment

Colorectal cancer (CRC) is one of the intimidating causes of death around the world. CRC originated from mutations of tumor suppressor genes, proto-oncogenes and DNA repair genes. Though platinum (Pt)-based anticancer drugs have been widely used in the treatment of cancer, their toxicity and CRC cells' resistance to Pt drugs has piqued interest in the search for alternative metal-based drugs. Ruthenium (Ru)-based compounds displayed promising anticancer activity due to their unique chemical properties. Ru-complexes are reported to exert their anticancer activities in CRC cells by regulating different cell signaling pathways that are either directly or indirectly associated with cell growth, division, proliferation, and migration. Additionally, some Ru-based drug candidates showed higher potency compared to commercially available Pt-based anticancer drugs in CRC cell line models. Meanwhile Ru nanoparticles coupled with photosensitizers or anticancer agents have also shown theranostic potential towards CRC. Ru-nanoformulations improve drug efficacy, targeted drug delivery, immune activation, and biocompatibility, and therefore may be capable of overcoming some of the existing chemotherapeutic limitations. Among the potential Ru-based compounds, only Ru (III)-based drug NKP-1339 has undergone phase-Ib clinical trials in CRC treatment.

Long-term health-related quality of life following colorectal cancer surgery: patient-reported outcomes in a remote follow-up population

AIM

Remote follow-up (RFU) after colorectal cancer (CRC) surgery allows delivery of surveillance tests without the need for regular outpatient clinical appointments. However, little is known about health-related quality of life (HRQoL) in RFU patients. The main aim of this study was to quantify HRQoL in our RFU population to identify particular patient groups that may benefit from a more personalised approach to follow-up, including access to a survivorship clinic.

METHOD

EQ-5D, QLQ-C30 and QLQ-C29 questionnaires were distributed to CRC patients enrolled in a RFU programme. The primary outcome of HRQoL scores was analysed by year of RFU, demographics, operation type, stoma and adherence to RFU protocols.

RESULTS

A total of 428 respondents were included, with a mean age of 71 years (SD 10.1 years) and a median RFU time of 2.6 years [interquartile range (IQR) 1.6-4.8 years]. 'Perfect health' was reported by 26.6% of patients. The median EQ-5D index score was 0.785 (IQR 0.671-1) and the median QLQ-C30 Global HRQoL score was 75 (IQR 58.3-83.3). Women had a significantly lower EQ-5D median score of 0.767 (IQR 0.666-0.879, P = 0.0088). Lower QLQ-C30 HRQoL scores were seen in stoma patients (median 66.6, IQR 58.3-83.3, P = 0.0029). Erectile dysfunction (P = 0.0006) and poor body image (P = 0.001) were also reported more frequently in stoma patients. Patients undergoing right-sided resection reported a lower median EQ-5D score of 0.765 (IQR 0.666-0.879, P = 0.028) and higher pain severity (P = 0.0367) compared with left-sided resections. There were 128 (29.4%) patients who breached RFU protocol and were seen in ad hoc colorectal clinics. However, there was no statistical difference in HRQoL between patients who adhered to or breached RFU protocols.

CONCLUSION

Overall HRQoL in patients in RFU is good, with no difference in those strictly followed up remotely. However, women, patients with right-sided resection and patients with a stoma may require additional clinical reviews.

Investigating the nutritional advice and support given to colorectal cancer survivors in the UK: is it fit for purpose and does it address their needs?

BACKGROUND

The present study assessed the quantity and quality of nutritional advice and support given to colorectal cancer survivors in the UK.

METHODS

A descriptive cross-sectional survey was completed by 75 colorectal cancer survivors recruited through social media and bowel cancer support groups in the UK. The survey consisted of open-ended and closed questions that aimed to explore the nutritional needs, nutritional advice given and other sources of information accessed by colorectal cancer survivors.

RESULTS

Sixty-nine percent of respondents reported that they did not receive any nutritional advice or support from their healthcare team throughout diagnosis, treatment and post-treatment. Colorectal cancer survivors accessed nutritional advice from a variety of sources, mainly cancer charity websites. Respondents expressed their desire for individualised advice relating to their nutritional problems.

CONCLUSIONS

The results obtained in the present study indicate that a high proportion of colorectal cancer patients are not receiving the nutritional support that they need to overcome nutritional difficulties. There is an urgent need to improve clinical practice to ensure colorectal patients receive nutritional advice that is both consistent between healthcare professionals and personalised throughout each stage of diagnosis, treatment and post-treatment.

AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region. PERSPECTIVE: Using AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.

The impact of surviving bowel cancer on occupation: A scoping review

Introduction

The number of people surviving bowel cancer is increasing globally, with many of those affected living with long-term psychological and physical sequelae that potentially disrupt occupations.

Method

A scoping review – guided by Arksey and O’Malley’s methodological framework – was conducted to provide an overview of what is known about the impact of having had bowel cancer on occupations, and to reveal the potential role of occupational therapy. A systematic search of four databases and a grey literature repository generated 244 results. Applying inclusion and exclusion criteria, 33 items addressing bowel cancer and occupations were selected and thematically analysed.

Results

Researchers have identified six domains of occupation that are impacted by bowel cancer (social activity, physical activity, sexual activity, employment and role functioning, physical functioning, and self-care) but survivors report a distinct lack of health professional support after completion of medical treatment and being left to devise self-management strategies to accommodate the long-term effects of their cancer.

Conclusion

The sequelae of bowel cancer can have a significant impact on occupational participation. There is scope for increasing and improving occupational therapy input to assist people with cancer-related loss of function to re-engage in valued occupations and improve wellbeing.

Synthesis of a Clay-Based Nanoagent for Photonanomedicine

Photo-induced cancer therapies, mainly including photothermal therapy (PTT) and photodynamic therapy (PDT), have attracted numerous attentions owing to the high selectivity, convenience, and few side effects. However, single PTT usually requires high laser power density, and single PDT usually needs a high photosensitizer dosage. Herein, a kind of composite nanocarrier based on clay (laponite)-polypyrrole (LP) nanodisks was synthesized via the in situ polymerization of pyrrole in the interlayer space of laponite. LP composite nanodisks were then coated with polyvinylpyrrolidone (PVP) to form the LP-PVP (LPP) composite nanodisks which show an excellent colloidal stability and in vitro and in vivo biocompatibility. The interlayer space of LPP can be further used for the loading of Chlorin e6 (Ce6), with an ultrahigh loading capacity of about 89.2%. Furthermore, the LPP nanocarrier can enhance the PDT effect of Ce6 under the irradiation of a 660 nm laser, through enhancing its solubility and cellular uptake amount. Besides, it was found that LPP nanodisks exhibit a more outstanding photothermal performance under a 980 nm near-infrared laser (NIR) than a 808 nm NIR laser, with the photothermal conversion efficiency of 45.7 and 27.7%, respectively. The in vitro and in vivo tumor therapy results evidently confirm that the Ce6-loaded LPP nanodisks have a combined tumor PTT and PDT effect, which can significantly suppress the tumor malignant proliferation.

An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study

PURPOSE

To investigate the feasibility of conducting a rehabilitation program for patients following surgery for abdomino-pelvic cancer.

METHODS

A non-randomised controlled before-and-after study. Patients who had undergone surgery for stage I-III abdomino-pelvic cancer (colorectal, gynaecological or prostate cancer) were recruited. The rehabilitation group (n = 84) received an 8-week, bi-weekly education and exercise program conducted by a physiotherapist, exercise physiologist, health psychologist and dietician, supplemented by exercise diaries and telephone coaching sessions. The comparator group (n = 104) completed postal questionnaires only. Feasibility measures, functional exercise capacity, muscle strength, physical activity levels, pelvic floor symptoms, anxiety and depression, health-related quality of life (HRQoL) and self-efficacy were measured at baseline (time 1), immediately post-intervention (time 2) and at 6 months post-baseline (time 3) and compared within- and between-groups.

RESULTS

The consent rate to the rehabilitation program was 24%. Eighty-one percent of the rehabilitation group attended 85-100% of 16 scheduled sessions. Overall satisfaction with the program was 96%. Functional exercise capacity, handgrip strength in males, bowel symptoms, physical activity levels, depression and HRQoL were significantly improved in the rehabilitation group (p < 0.05) at time 2. The improvements in all these outcomes were sustained at time 3. The rehabilitation group had significantly improved physical activity levels, depression and HRQoL compared with the comparator group at times 2 and 3 (p < 0.05).

CONCLUSION

Recruitment to this oncology rehabilitation program was more difficult than expected; however, attendance and patient satisfaction were high. This program had positive effects on several important clinical outcomes in patients following abdomino-pelvic cancer treatment.

TRIAL REGISTRATION

ANZCTR 12614000580673.

Diet and Behavior Modifications by Long-term Rectal Cancer Survivors to Manage Bowel Dysfunction-Associated Symptoms

BACKGROUND

Rectal cancer (RC) survivors experience significant bowel function issues after treatment. We aimed to describe self-reported dietary and behavioral modifications among long-term (≥5 yr) RC survivors to manage bowel dysfunction.

METHODS

RC survivors from Kaiser Permanente Northern California and Northwest regions completed surveys either via postage-paid return mail or telephone. Summary statistics on diet/behavioral modifications data were tabulated by proportion of responses. Modifications and frequency of bowel symptoms cited and were compared by ostomy status.

RESULTS

A total of 575 respondents were included (overall response rate = 60.5%). Fruits and vegetables were troublesome for symptoms, but was also helpful in mitigating constipation, obstruction, and frequency, as well as improving predictability. Many respondents attributed red meat (17.7%), fried foods (13.9%), spicy foods (13.1%), carbonated beverages (8.0%), and sweets (7.6%) to increased diarrhea, gas, and urgency. Common behavioral modifications included controlling meal portions (50.6%), timing regularity (25.3%), and refraining from late night eating (13.8%). Permanent ostomy survivors were more likely to report symptoms of obstruction, while anastomosis survivors were more likely to report urgency.

CONCLUSION

Multiple modifications were attempted by RC survivors to manage bowel symptoms. Identifying diet changes among RC survivors can improve symptom management and survivorship care.

Colorectal cancer survivors: an investigation of symptom burden and influencing factors

Background

Colorectal cancer is a significant issue internationally, with over 1.3 million people diagnosed annually. Survival rates are increasing as treatments improve, although physical symptoms can persist despite eradication of the tumour. In order to optimize survivorship care, further research is warranted in relation to symptom burden. Therefore, the objectives of this study are to (i) investigate frequency of physical symptoms in colorectal cancer survivors (ii) identify which symptoms occur together (iii) examine the associations between demographic and clinical variables, and symptoms.

Methods

Participants nine months to three years post diagnosis were identified from the population-based National Cancer Registry Ireland. Respondents completed the EORTC QLQ-C30 and EORTC QLQ-CR29. Reported physical symptom frequencies were transformed into continuous scale variables, which were then analysed using one way analysis of variance, general linear modelling and Spearman rank correlations.

Results

There were 496 participants. Fatigue, insomnia and flatulence were the most frequent symptoms, with ≥20% of respondents reporting these to be often present in the previous week. Eight other symptoms were experienced often by 10–20% of respondents. At least one of these eleven most common symptoms was experienced frequently by almost every respondent (99%). 66% of respondents experienced at least two of these symptoms together, and 16% experienced five or more together. Current stoma was the single most common variable associated with increased symptom scores, although statistically significant relationships (p ≤ 0.05) between symptom frequency scores and clinical/demographic variables were generally weak (R-sq value ≤0.08).

Conclusion

Findings may inform targeted interventions during the nine month to three year post diagnosis timeframe, which would enable supported self-management of symptoms.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4923-3) contains supplementary material, which is available to authorized users.

Comorbid conditions and health-related quality of life in long-term cancer survivors-associations with demographic and medical characteristics

PURPOSE

Our study provides a detailed overview of comorbid conditions and health-related quality of life of long-term cancer survivors and analyses the impact of demographic, disease- and treatment-related characteristics.

METHODS

We present data obtained from 1000 survivors across mixed tumour entities 5 and 10 years after cancer diagnosis in a cross-sectional study. We analyse the prevalence of physical symptoms and health conditions via self-report and health-related quality of life using the EORTC QLQ-C30 in comparison to gender- and age-matched reference values of the general population.

RESULTS

Cancer survivors reported on average 5 comorbidities; 23% had 7 or more comorbid conditions. Cancer survivors reported higher physical symptom burden than the population-especially fatigue, insomnia and pain. Type and prevalence of long-term and late effects differ with disease-related factors (e.g. cancer type, treatment) and characteristics of the patient. Cancer survivors also reported lower quality of life than the population, especially in everyday activities, social life, psychological well-being and financial difficulties. There was a positive association between high quality of life and a low level of morbidity.

CONCLUSIONS

The specific knowledge about physical long-term consequences for the individual types of cancer could raise awareness in health care professionals for high-risk patients and help to develop adequate prevention and survivorship-programs.

IMPLICATIONS FOR CANCER SURVIVORS

Limitations in the mental health area underlines the importance of psycho-oncological survivorship-care-plans, which go beyond the time of rehabilitation. Special attention should be given to the financial situation of patients in long-term follow-up care.

Assessment of bowel and anal sphincter function after neoadjuvant chemoradiotherapy in locally advanced rectal cancer

PURPOSE

To report long-term effects on anorectal function and bowel disorders and late toxicity rate of preoperative chemoradiotherapy in patients with locally advanced rectal cancer.

METHODS

Between 2000 and 2016, 201 patients treated with different neoadjuvant schedules of chemotherapy and radiotherapy doses were retrospectively analyzed. The Memorial Sloan-Kettering Cancer Center score was used for the evaluation of anal sphincter function.

RESULTS

The median follow-up time was 68 months (interquartile range 35-113 months). Radical resection was performed in 188 (93.5%) patients with a pathologic complete response rate of 26.4%. Overall sphincter function resulted excellent in 105 (52.2%) patients, good in 13 (6.5%), fair in 10 (5.0%), and poor (incontinence) in 40 (19.9%), with a persistent stoma rate of 16.4%. A further evaluation on 194 patients showed an improvement of sphincter function after 2 years in 11.9% of them. Seventy-three patients presenting stoma or poor sphincter function were re-evaluated for quality of life (QoL) indexes. Twenty-one (29%), 19 (26%), and 24 (33%) of them declared some variations concerning well-being, fatigue, and ability to perform daily activities. The 5-year overall survival, disease-free survival, and local recurrence rates were 88.0% ± 2.6%, 86.3% ± 2.5%, and 94.6% ± 1.9%, respectively.

CONCLUSIONS

In our study, neoadjuvant chemoradiotherapy was associated with good results in terms of sphincter function, late toxicities, and QoL indexes. A routine use of assessment scales could contribute to a better selection of patients with increased risk of developing functional disorders who could benefit from neoadjuvant therapy.

Pelvic floor symptoms, physical, and psychological outcomes of patients following surgery for colorectal cancer

BACKGROUND

Little has been published regarding general and pelvic floor-related health status in patients who have undergone surgery for colorectal cancer (CRC).

OBJECTIVE

The objective of the study was to assess changes in pelvic floor symptoms, physical activity levels, psychological status, and health-related quality of life (HRQoL) in patients with CRC from pre- to 6 months postoperatively.

METHODS

Pelvic floor symptoms, physical activity levels, anxiety and depression, and HRQoL of 30 participants who were undergoing surgery for stages I-III CRC were evaluated pre- and 6 months postoperatively.

RESULTS

Six months postoperatively, there were no significant changes in severity of pelvic floor symptoms, or other secondary outcomes (physical activity levels, depression, global HRQoL) compared to preoperative levels (p > 0.05). However, fecal incontinence (p = 0.03) and hair loss (p = 0.003) measured with the HRQoL instrument were significantly worse. Participants were engaged in low levels of physical activity before (42.3%) and after surgery (47.4%).

CONCLUSION

The findings of a high percentage of participants with persistent low physical activity levels and worse bowel symptoms after CRC surgery compared to preoperative levels suggest the need for health-care professionals to provide information about the benefits of physical activity and bowel management at postoperative follow-ups. Further investigation in larger studies is warranted.

The lived experiences of patients with post-operative rectal cancer who suffer from altered bowel function: A phenomenological study

PURPOSE

Altered bowel function is a common consequence of anal sphincter-saving surgery in rectal cancer patients, and bowel symptoms influence patients' daily life and psychosocial status. Patients have inadequate professional support because care specialists fail do fully appreciate the impact of the patients' symptoms. In-depth exploration of the individual's experience is essential to improve the quality of patient care. The purpose of this study was to explore the lived experiences of post-operative rectal cancer patients with altered bowel function.

METHODS

This Husserlian descriptive phenomenological study recruited 16 post-operative rectal cancer patients with altered bowel function. Data was collected through purposive sampling and one-on-one in-depth, semi-structured interviews. Narratives were analyzed thematically using Colaizzi's seven-step method.

RESULTS

Three themes emerged, namely: "living in the restroom", "never backward", and "rebalancing on a new road". "Living in the restroom" described how patients frequent the restroom due to post-operative physical changes. "Never backward" outlined that such changes disturbed their mood, interrupted their daily activities, and affected their family life. "Rebalancing on a new road" described the patients' coping strategies, which included spiritual reconstruction, a new excrement model, an adjusted lifestyle, and peer support.

CONCLUSIONS

Post-operative rectal cancer patients with altered bowel function frequent the restroom for prolonged periods, which disturbs their psychosocial status. However, they are forced to develop coping methods by themselves. Specialists can offer effective early post-operative interventions by thoroughly understanding each patient's symptomatic experience, symptom-related interferences, and primary concerns.

Predictors of Bowel Function in Long-term Rectal Cancer Survivors with Anastomosis

BACKGROUND

Bowel function in long-term rectal cancer survivors with anastomosis has not been characterized adequately. We hypothesized that bowel function is associated with patient, disease, and treatment characteristics.

METHODS

The cohort study included Kaiser Permanente members who were long-term (≥5 years) rectal cancer survivors with anastomosis. Bowel function was scored using the self-administered, 14-item Memorial Sloan-Kettering Cancer Center Bowel Function Index. Patient, cancer, and treatment variables were collected from the electronic medical chart. We used multiple regression to assess the relationship of patient- and treatment-related variables with the bowel function score.

RESULTS

The study included 381 anastomosis patients surveyed an average 12 years after their rectal cancer surgeries. The total bowel function score averaged 53 (standard deviation, 9; range, 31-70, higher scores represent better function). Independent factors associated with worse total bowel function score included receipt of radiation therapy (yes vs. no: 5.3-unit decrement, p < 0.0001), tumor distance from the anal verge (≤6 cm vs. >6 cm: 3.2-unit decrement, p < 0.01), and history of a temporary ostomy (yes vs. no: 4.0-unit decrement, p < 0.01). One factor measured at time of survey was also associated with worse total bowel function score: ever smoking (2.3-unit decrement, p < 0.05). The regression model explained 20% of the variation in the total bowel function score.

CONCLUSIONS

Low tumor location, radiation therapy, temporary ostomy during initial treatment, and history of smoking were linked with decreased long-term bowel function following an anastomosis. These results should improve decision-making about surgical options.

Anorectal functional outcome following laparoscopic low anterior resection for rectal cancer

Low anterior resection (LAR) with total mesorectal excision has been considered a standard treatment for patients with rectal cancer. However, the functional outcome and life quality of laparoscopic LAR (LLAR) in Chinese patients remain unclear. A cohort of 51 Chinese patients (22 men and 29 women) who had undergone LLAR was included in this study. Anorectal manometry combined with the Wexner scores questionnaire were applied to assess functional outcome preoperatively (1 week) and postoperatively (at 3, 6 and 9 months). The validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires were also used to assess the patients' quality of life at the indicated time points. The results demonstrated that the manometric parameters exhibited a temporary decrease at 3 months postoperatively, but a gradual increase at 6 and 9 months, while the Wexner scores exhibited an opposite trend. Furthermore, patients with high anastomoses had significantly higher manometric parameters, a lower frequency of incontinence and lower Wexner scores compared with those with low anastomoses at 9 months (all P<0.05). For the entire cohort, quality of life at 3 months postoperatively was worse compared with the preoperative level, but returned to normal by 9 months. Patients with high anastomoses exhibited significantly better role, emotional and social function, had a better body image and sexual function, fewer problems with defecation and lower frequency of diarrhea, as well as fewer chemotherapy-related side effects at 6 months postoperatively when compared with the low anastomosis group (all P<0.05). In conclusion, LLAR is generally acceptable for Chinese patients with rectal cancer, particularly for those with middle or high rectal cancer, in terms of functional outcome and quality of life.

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.

Investigation of body image as a mediator of the effects of bowel and GI symptoms on psychological distress in female survivors of rectal and anal cancer

PURPOSE

Treatment for rectal and anal cancer (RACa) can result in persistent bowel and gastrointestinal (GI) dysfunction. Body image problems may develop over time and exacerbate symptom-related distress. RACa survivors are an understudied group, however, and factors contributing to post-treatment well-being are not well understood. This study examined whether poorer body image explained the relation between symptom severity and psychological distress.

METHODS

Participants (N = 70) completed the baseline assessment of a sexual health intervention study. Bootstrap methods tested body image as a mediator between bowel and GI symptom severity and two indicators of psychological distress (depressive and anxiety symptoms), controlling for relevant covariates. Measures included the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-CR38) Diarrhea, GI Symptoms, and Body Image subscales and Brief Symptom Index Depression and Anxiety subscales.

RESULTS

Women averaged 55 years old (SD = 11.6), White (79 %), and were 4 years post-treatment. Greater Depression was related to poorer Body Image (r = -.61) and worse Diarrhea (r = .35) and GI Symptoms (r = .48). Greater Anxiety was related to poorer Body Image (r = -.42) and worse GI Symptoms (r = .45), but not Diarrhea (r = .20). Body Image mediated the effects of bowel and GI symptoms on Depression, but not on Anxiety.

CONCLUSIONS

Long-term bowel and GI dysfunction are distressing and affect how women perceive and relate to their bodies, exacerbating survivorship difficulties. Interventions to improve adjustment post-treatment should address treatment side effects, but also target body image problems to alleviate depressive symptoms. Reducing anxiety may require other strategies. Body image may be a key modifiable factor to improve well-being in this understudied population. Longitudinal research is needed to confirm findings.

Knowledge and awareness of long-term and late treatment consequences amongst colorectal cancer survivors: A qualitative study

PURPOSE

To describe patient knowledge and awareness of long-term and late onset treatment consequences amongst colorectal cancer survivors.

METHODS

Semi-structured qualitative interviews were conducted with 19 colorectal cancer survivors at least 12 months post-treatment. Interviews were audio-recorded, transcribed into NVivo 10 software and analysed using the framework method.

RESULTS

Participants were aware of disease recurrence but not many other treatment consequences; change in bowel habit and impact on diet were common and had significant impact, yet many felt they had not received 'warning', considering it a gap in both information and support. Participants expressed preference to know about possible consequences early on and were willing to engage in education and support if offered. Information overload, timing of information provision and unequipped health care professionals were considered barriers to awareness.

CONCLUSION

Improvement in information provision, management of expectations and support around bowel function would facilitate patient self-empowerment and could improve holistic management of health and well-being after cancer.

Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis

BACKGROUND

There is growing recognition for the consequences of rectal cancer treatment to maintain an adequate functional sphincter in the long-term rather than preserving the anal sphincter itself. This study aims to evaluate long-term effects of neoadjuvant chemoradiotherapy (nCRT) followed by sphincter-preserving resection on anal sphincter function in relation to quality of life (QoL) among locally advanced rectal cancer patients.

METHODS

Twenty-nine patients treated with nCRT followed by low anterior resection surgery were included in this study. Data on patient demographics, tumor location and symptoms of urgency and fecal soiling were recorded and evaluated with respect to Wexner Fecal Incontinence Scoring Scale, European Organization for Research and Cancer (EORTC) cancer-specific (EORTC QLQ-C30) and colorectal cancer-specific (EORTC QLQ-CR38) questionnaires and anorectal manometrical findings. Correlation of manometrical findings with Wexner Scale, EORTC QLQ-CR38 scores and EORTC QLQ-C30 scores was also evaluated.

RESULTS

Median follow-up was 45.6 months (ranged 7.5-98 months. Higher scores for incontinence for gas (p = 0.001), liquid (p = 0.048) and solid (p = 0.019) stool, need to wear pad (p = 0.001) and alteration in life style (p = 0.004) in Wexner scale, while lower scores for future perspective (p = 0.010) and higher scores for defecation problems (p = 0.001) in EORTC QLQ-CR38 were noted in patients with than without urgency. Manometrical findings of resting pressure (mmHg) was positively correlated with body image (r = 0.435, p = 0.030) and sexual functioning (r = 0.479, p = 0.011) items of functional scale, while rectal sensory threshold (RST) volume (mL) was positively correlated with defecation problems (r = 0.424, p = 0.031) items of symptom scale in EORTC QLQ-CR38 and negatively correlated with social function domain (r = -0.479, p = 0.024) in EORTC QLQ-C30. RST volume was also positively correlated with Wexner scores including incontinence for liquid stool (r = 0.459, p = 0.024), need to wear pad (r = 0.466, p = 0.022) and alteration in lifestyle (r = 0.425, p = 0.038).

CONCLUSION

The high risk of developing functional anal impairment as well as the systematic registration of not only oncological but also functional and QoL related outcomes seem important in rectal cancer patients in the long-term disease follow-up.

Dietary and Behavioral Adjustments to Manage Bowel Dysfunction After Surgery in Long-Term Colorectal Cancer Survivors

BACKGROUND

Bowel dysfunction is a known complication of colorectal cancer (CRC) surgery. Poor bowel control has a detrimental impact on survivors' health-related quality of life (HRQOL). This analysis describes the dietary and behavioral adjustments used by CRC survivors to manage bowel dysfunction and compares adjustments used by survivors with permanent ostomy to those with anastomosis.

METHODS

This mixed-methods analysis included pooled data from several studies that assessed HRQOL in CRC survivors. In all studies, CRC survivors with or without permanent ostomies (N = 856) were surveyed using the City of Hope Quality of Life Colorectal Cancer tool. Dietary adjustments were compared by ostomy status and by overall HRQOL score (high vs. low). Qualitative data from 13 focus groups and 30 interviews were analyzed to explore specific strategies used by survivors to manage bowel dysfunction.

RESULTS

CRC survivors made substantial, permanent dietary, and behavioral adjustments after surgery, regardless of ostomy status. Survivors who took longer after surgery to become comfortable with their diet or regain their appetite were more likely to report worse HRQOL. Adjustments to control bowel function were divided into four major strategies: dietary adjustments, behavioral adjustments, exercise, and medication use.

CONCLUSIONS

CRC survivors struggled with unpredictable bowel function and may fail to find a set of management strategies to achieve regularity. Understanding the myriad adjustments used by CRC survivors may lead to evidence-based interventions to foster positive adjustments after surgery and through long-term survivorship.

Self-Reorientation Following Colorectal Cancer Treatment - A Grounded Theory Study

After colorectal cancer (CRC) treatment, people reorganize life in ways that are consistent with their understanding of the illness and their expectations for recovery. Incapacities and abilities that have been lost can initiate a need to reorient the self. To the best of our knowledge, no studies have explicitly focused on the concept of self-reorientation after CRC treatment. The aim of the present study was therefore to explore self-reorientation in the early recovery phase after CRC surgery. Grounded theory analysis was undertaken, using the method presented by Charmaz. The present results explained self-reorientation as the individual attempting to achieve congruence in self-perception. A congruent self-perception meant bringing together the perceived self and the self that was mirrored in the near environs. The results showed that societal beliefs and personal explanations are essential elements of self-reorientation, and that it is therefore important to make them visible.

Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into "regular life." This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of patients achieves optimal outcomes.

Impact of colorectal cancer diagnosis and treatment on health-related quality of life among older Americans: a population-based, case-control study

BACKGROUND

Data on health-related quality of life (HRQoL) changes among Americans aged ≥65 following colorectal cancer (CRC) diagnosis and treatment are limited. This study compared HRQoL changes among CRC patients across stages from before to after diagnosis with matched noncancer controls.

METHODS

This population-based study used the Surveillance, Epidemiology, and End Results Medicare Health Outcomes Survey (MHOS) data set (1998-2007). Medicare Advantage beneficiaries diagnosed with CRC between their baseline and follow-up MHOS (n = 349) were matched to noncancer controls (n = 1745) using propensity scores. Mixed-effects analysis of covariance models estimated changes in HRQoL (measured by the Medical Outcomes Study Short Form-36/Veterans RAND 12-item Survey) and the ability to perform 6 activities of daily living (ADLs) between baseline and follow-up. Logistic regression models estimated odds ratios for ADL impairments and major depressive disorder (MDD) risk.

RESULTS

Mean time between CRC diagnosis and follow-up MHOS was 12.3 ± 9.8 months. Compared with controls, CRC patients had significantly lower scores in all physical and mental health domains at follow-up. The greatest decrements were observed in physical health and were largely driven by declines in the 6 months postdiagnosis and in stage III and IV patients. At follow-up, CRC patients had greater overall ADL impairment and difficulty with dressing, eating, and getting in/out of chairs. CRC patients, particularly stage IV patients, had greater odds of being at risk for MDD relative to controls.

CONCLUSIONS

This study further underscores the adverse effects of CRC on physical health and the need to support older Americans' basic self-care needs, with attention to later-stage patients' increased debility.