Symptoms affecting quality of life after sphincter-saving rectal cancer surgery: A systematic review

The Frequency of Urination Dysfunction in Patients Operated on for Rectal Cancer: A Systematic Review with Meta-Analyses

The frequency of long-term urination dysfunction after surgery for rectal cancer remains unclear, yet it is essential to establish this to improve treatment strategies. Randomized controlled trials (RCTs), non-RCTs, and cohort studies were included with patients having undergone sphincter-preserving total (TME) or partial mesorectal excision (PME) for the treatment of primary rectal cancer in this review. The outcome was urination dysfunction reported at least three months postoperatively, both overall urination dysfunction and subdivided into specific symptoms. The online databases PubMed, Embase, and Cochrane CENTRAL were searched, bias was assessed using the Newcastle-Ottawa scale, and results were synthesized using one-group frequency meta-analyses. A total of 55 studies with 15,072 adults were included. The median follow-up was 29 months (range 3-180). The pooled overall urination dysfunction was 21% (95% confidence interval (CI) 12%-30%) 3-11 months postoperatively and 25% (95% CI 19%-32%) ≥12 months postoperatively. Retention and incontinence were common 3-11 months postoperatively, with pooled frequencies of 11% and 14%, respectively. Increased urinary frequency, retention, and incontinence seemed even more common ≥12 months postoperatively, with pooled frequencies of 37%, 20%, and 23%, respectively. In conclusion, one in five patients experienced urination dysfunction more than a year following an operation for rectal cancer.

Patients' experiences of living with low anterior resection syndrome three to six months after colorectal cancer surgery: A phenomenological study

BACKGROUND

Increased use of sphincter-preserving surgery following colorectal cancer has led to more people living with low anterior resection syndrome (LARS), a disordered bowel function that significantly impacts quality of life. Little is known about how patients experience the first months following sphincter-preserving surgery and having LARS.

OBJECTIVE

To shed light on what it means to live with LARS in the first three to six months after colorectal cancer sphincter-preserving surgery.

METHOD

A qualitative study with a phenomenological approach constitutes the study design. Semi-structured interviews were conducted with five participants from September 2022 to January 2023. The transcribed interviews were analysed using Giorgi's phenomenological method.

RESULTS

Five themes emerged from the analysis: bowel emptying becomes all-consuming and affects both daily life and working life, you hear what they're saying, but don't understand what it means until your body goes through it, low anterior resection syndrome may impact sexual life, leaving feelings of guilt, it doesn't matter what the circumstances are, but rather how one deals with them, and support and follow-up from healthcare professionals, employers, family and friends are crucial for living a good life with LARS.

CONCLUSION

Participants described struggles living with major LARS in the early period following hospital discharge. However, few months later, they had developed strategies enabling them to control their everyday life. Support and follow-up from healthcare professionals, employers, family, and friends were crucial when learning to live with major LARS. Participants expressed desire for a systematic and proactive follow-up from healthcare professionals and contact with peer-support groups.

Quantifying societal burden of radiation-induced small bowel toxicity in patients with rectal cancer

Introduction

Advancements in rectal cancer (RC) treatment not only led to an increase in lives saved but also improved quality of life (QoL). Notwithstanding these benefits, RC treatment comes at the price of gastrointestinal morbidity in many patients. Health economic modelling poses an opportunity to explore the societal burden of such side-effects. This study aims to quantify radiation-induced late small bowel (SB) toxicity in survivors of RC for Three-Dimensional Conformal Radiation Therapy (3D-CRT), Intensity Modulated Radiation Therapy (IMRT) and Intensity Modulated Radiation Therapy - Image Guided Radiation Therapy (IMRT/IGRT).

Materials and methods

Materials and A model-based health economic evaluation was performed. The theoretical cohort consists of a case-mix of survivors of RC aged 25-99 years according to Belgian age-specific incidence rates. A societal perspective was adopted. The base case analysis was complemented with one-way deterministic analyses, deterministic scenario analyses and probabilistic sensitivity analysis (1,000 iterations). Results were presented as mean lifetime incremental cost (€) and utility (QALYs) per patient.

Results

The analyses showed that the use of innovative radiotherapy (RT) improves lifetime QoL in survivors of RC by 0.11 QALYs and 0.05 QALYs by preferring IMRT/IGRT and IMRT over 3D-CRT, respectively. The use of IMRT/IGRT and IMRT results in an incremental cost-saving of €3,820 and €1,863 per patient, solely by radiation-induced SB toxicity, compared to 3D-CRT.

Discussion and conclusion

It is important to consider late toxicity effects in decisions regarding investments and reimbursement as our analysis highlighted the potential long-term cost-savings and improved QoL of novel RT techniques in patients with rectal cancer.

Treatment trajectories of individuals diagnosed with rectal cancer: an interpretative phenomenological study

Rectal cancer affects almost every aspect of an individual's daily life. However, there are gaps in understanding the complete spectrum of experiences spanning from diagnosis to recovery. Therefore, the aim of this study was to explore the treatment trajectories of individuals diagnosed with rectal cancer. Adopting an interpretative phenomenological approach, seven participants were recruited using purposive sampling. Data were collected using semi-structured, in-depth interviews that were digitally recorded, transcribed and analysed using thematic analysis. Study rigour was established following the four-dimension criteria of credibility, dependability, transferability and confirmability. Four prominent themes emerged from the participants' experiences of undergoing rectal cancer treatment: uncovering the inner battles; navigating the physical challenges; anchors of support and conquering the summit. These findings contribute to knowledge and practice by highlighting the importance of providing a comprehensive and individualised treatment plan for individuals that takes account of the physical and psycho-emotional implications of rectal cancer treatment.

Patient Reported Outcomes following Cancer of the Rectum (PROCaRe): protocol of a prospective multicentre international study

PURPOSE

Rectal cancer surgery presents challenges in achieving good oncological results and preserving functional outcomes. Different surgical approaches, including open, laparoscopic, robotic and transanal techniques, have been employed, but there is a lack of consensus on the optimal approach, particularly in terms of functional results. This study aims to assess bowel function and to compare outcomes of patients that had undergone surgery for mid-low rectal cancer across different surgical approaches.

METHOD

This is an international, multicentre, prospective cohort study. Inclusion criteria are patients diagnosed with rectal cancer below the peritoneal reflection, eligible for different surgical approaches for total mesorectal excision (TME). Data will be collected using validated questionnaires assessing bowel, sexual and urinary function, and quality of life (QOL). Secondary outcomes include short-term postoperative results. Data will be collected at baseline and 6, 12 and 24 months after index surgery or stoma reversal surgery.

CONCLUSION

This study will provide insights into the impact of different approaches for TME on bowel, sexual and urinary function, and overall QOL of patients undergoing rectal cancer surgery. The findings will provide important information to optimise the surgical strategy and to improve patient care in this population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04936581 (registered 23 June 2021).

Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet?

Rectal cancer is a common cancer and shows an increased incidence with older age. Although the gold standard treatment is surgical excision, minimally invasive approaches are increasingly used and organ preservation is becoming a reasonable approach. The conservative treatment approach includes local excision, external beam radiotherapy and brachytherapy. However, these all carry a risk of side-effects. It is crucial to provide patients with information to quantify the improvement or detriment in quality of life with their cancer treatment. This can only be done with patient-reported outcome measures (PROMs) as tools within current and future trials. Colorectal cancer has numerous publications with specific PROMs. However, PROMs reporting in rectal cancer is more sparse; PROMs are generally extrapolated from colorectal cancer. Rectal PROMs trials hold small population samples and PROMs as an end point is scarce. We present a review of recent literature based on the PROMs reporting of quality of life for rectal cancer patients and introduce the CITRuS trial as an innovative feasibility study related to electronic PROMs data collection.

Does the Low Anterior Resection Syndrome Score Accurately Represent the Impact of Bowel Dysfunction on Health-Related Quality of Life?

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, but its effect on health-related quality of life (HRQOL) is complex. Objective measures of bowel function may not be a good representation on the actual impact on HRQOL. Therefore, the objective of this study is to determine whether there are differences between patient-reported bowel-related impairment versus a standardized measure of bowel dysfunction on HRQOL.

METHODS

A prospective database starting in September 2018 of adult patients who had undergone sphincter preserving rectal cancer surgery up to October 2021 was queried. Patients were excluded if they had local recurrence, metastasis, persistent stoma, or had less than 1-year follow-up. Patients were administered the study instruments at their standard surveillance visit: patient-reported bowel-related quality of life(BQOL) impairment, HRQOL using the Short Form-36 (SF-36), and bowel dysfunction using the low anterior resection syndrome(LARS) score.

RESULTS

Overall, 136 patients were included. There were 43% with no LARS, 22% with minor LARS, and 35% with major LARS. For the BQOL, 26% of subjects reported no impairment, 57% minor impairment, and 17% major impairment. There was a high proportion of discordance between BQOL and LARS, with 23% minor or major LARS in patients with no BQOL impairment, and 32% with no or minor LARS with major BQOL impairment. The BQOL was associated with more changes in SF-36 scores compared to the LARS score.

CONCLUSIONS

The patient-reported BQOL is likely to be a more relevant outcome of interest to patients than the objective LARS score. This has important implications for shared decision-making for rectal cancer treatments.

Experience and coping strategies of bowel dysfunction in postoperative patients with rectal cancer: a systematic review of qualitative evidence

Aim

Due to the changes of bowel physiological structure and functional disorders after rectal cancer surgery, patients will face many bowel dysfunction for a long time, which will greatly affect their quality of life. The purpose of this review is to integrate the qualitative research on the experience of bowel dysfunction and coping strategies in postoperative patients with rectal cancer.

Methods

Systematic retrieval of PubMed, EMbase, Cochrane Library, CINAHL, Web of Sciences, PsycINFO, Willey and other databases was carried out by using the method of subject words and keywords. The Critical Appraisal Skill Programme (CASP) Qualitative Studies Checklist was used for Qualitative assessment. The findings were extracted from the included study and synthesized into the final themes, which was evaluated strictly in accordance with the ConQual process.

Results

Nine studies involving 345 participants were included and two main themes were extracted: "Experience a series of changes caused by bowel dysfunction" and "nmet needs and coping strategies facing bowel dysfunction". The changes of rectal cancer patients who experience bowel dysfunction after operation mainly include three parts: bowel dysfunction is more than just a bowel reaction, which covers the bowel symptoms themselves and the subsequent body-related symptoms. The interruption of a normal life, mainly reflected in personal, family, and social life. Complex psychological reactions to bowel dysfunction, psychological changes have a dual nature, showing a positive and negative intertwined. There are two main aspects of unmet needs and coping strategies: the demand is mainly manifested in the need for information and support from medical professionals, while the coping strategy mainly includes diet, activity and drug management.

Conclusion

Rectal cancer patient often experience persistent bowel dysfunction after operation, which has a certain physical and mental effects. A series of new needs of postoperative patients are often not fully met, and patients often rely on their own empirical attempts to seek balance, less can get professional support. Future studies need to focus on how to provide continuous information support for postoperative rectal cancer patients, especially professional care from health care staff.

The impact of bowel dysfunction on health-related quality of life after rectal cancer surgery: a systematic review

BACKGROUND

Symptoms of bowel dysfunction after sphincter-preserving rectal cancer surgery have an important impact on health-related quality of life (HRQOL), but that relationship is complex. A better understanding of this relationship allows for better informed shared decision-making about surgery. Our objective was to perform a systematic review to determine which HRQOL domains are most affected by postoperative bowel dysfunction.

METHODS

A systematic review of the CINAHL, Cochrane Library, Embase, Medline, PsycInfo, PubMed, Web of Science, and Scopus databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies that evaluated bowel function after sphincter-preserving rectal cancer surgery and assessed HRQOL using a validated instrument. The quality of HRQOL analysis was assessed using an 11-item checklist. The main outcome was the impact bowel dysfunction had on global and domain specific quality-of-life indices. The impact was evaluated for clinical relevance using the Minimum Clinical Important Difference (MCID) for each specific HRQOL instrument.

RESULTS

Out of 952 unique citations, 103 studies were full-text reviews. Eighteen studies met the inclusion criteria (4 prospective cohorts and 9 cross-sectional studies). Of the 15 studies with long-term follow-up, the time to assessment after surgery ranged from 1.2 to 14.6 years. The low anterior resection syndrome score and European Organization for Research and Treatment core quality-of-life questionnaire (EORTC QLQ-C30) were the most commonly used instruments. Medium and large magnitudes in MCID were seen for global health, social functioning, emotional functioning, fatigue, diarrhea, and financial difficulties. Among included studies, the most consistently reported functional domains affected by bowel function were social functioning and emotional functioning.

CONCLUSIONS

Following sphincter-preserving rectal cancer surgery, poor bowel function mainly affects the social and emotional functional domains of HRQOL, which in turn impact global scores. This finding can help inform patients about expected changes in HRQOL after rectal cancer surgery and facilitate individualized treatment decisions.

The trajectory of hope and loneliness in rectal cancer survivors with major low anterior resection syndrome: A qualitative study

PURPOSE

Rectal cancer survivors are often confronted with long-term bowel function impairment, called low anterior resection syndrome. This has a large impact on patients' lives. The aim was to explore the experiences of patients with major low anterior resection syndrome with a specific focus on hope and loneliness.

METHODS

A grounded theory approach was used. Individual semi-structured interviews (n = 28) were performed between 2017 and 2019. Patients were recruited in three hospitals and a call was distributed in two patients' organizations. During data analysis, the constant comparative method and investigators' triangulation was used.

RESULTS

Hope was important at different stages in the trajectory. After treatment patients hoped to pick up their previous life. Confrontation with low anterior resection syndrome was unexpected and patients hoped to manage it through trial and error. They lost hope if further improvement was absent. At that turning point some tried to accept the new lifestyle, others pushed their boundaries and some opted for a permanent stoma. Loneliness presented itself in several layers. Patients experience loneliness due being toilet-bound, changes in their lives and activities outside their homes and the impact on their family life.

CONCLUSION

Assessment of the impact on patients' lives and tailored counselling is possible if healthcare professionals gain more insight into the different layers of loneliness and where the patient is located in the trajectory of hope.

Managing Bowel Symptoms After Sphincter-Saving Rectal Cancer Surgery: A Scoping Review

CONTEXT

Rectal cancer is common and it is often treated by surgery with or without chemoradiation. Cancer treatment frequently results in bowel symptoms.

OBJECTIVES

The review aim was to chart the management options for bowel symptoms following rectal cancer surgery.

METHODS

A scoping review was undertaken searching nine healthcare databases, using relevant search terms and Boolean operators following PRISMA-ScR guidance. Data were extracted into an Excel spreadsheet using headings from the United Kingdom Department of Health guidance and are reported narratively.

RESULTS

30 heterogeneous studies met the inclusion criteria, including 853 patients. The most commonly reported bowel symptom was fecal incontinence; the most frequent management strategy was sacral nerve stimulation. Most studies reported on a single management option, often used to manage more than one bowel symptom. Often failure to satisfactorily improve symptoms using options such as medication was needed prior to progressing to other management options. In some studies more than one management option was used, such as rehabilitation programmes.

CONCLUSION

It is likely that to effectively manage the bowel symptoms experienced after rectal cancer treatment, more than one management option may be used-. Additionally, different management options may need to be tried concurrently.

Assessment of defecation function after sphincter-saving resection for mid to low rectal cancer: A cross-sectional study

PURPOSE

Patients with mid-to low-rectal cancer can have various dysfunctions of defecation after sphincter-saving resection. Defecation dysfunction can manifest as incontinence, urgency, or frequent bowel movements, and is called low anterior resection syndrome (LARS). This study aimed to examine LARS score and objective anorectal function indices in Chinese patients receiving sphincter-saving surgery for mid-to low-rectal cancer.

METHOD

This was a single-center cross-sectional study of patients undergoing sphincter-saving resection for low- or mid-rectal cancer and had restoration of trans-anal defecation for at least 1 month seen between January 2019 and June 2020. Patients completed a questionnaire regarding clinical characteristics, and Low Anterior Resection Syndrome (LARS) score and high-resolution anorectal manometry (HR-ARM) were used to assess defecation function. Multivariable analysis was used to identify variables significantly associated with defecation dysfunction.

RESULTS

146 patients completed and returned the questionnaires. 25 healthy adults also participated as control group for the anorectal manometry. Approximately 76% of patients developed LARS after surgery, of which 35.6% had major LARS. In these patients, anorectal manometry indices including initial rectal sensory capacity and rectal fecal sensory capacity, were significantly lower than normal. Logistic regression analysis showed that preoperative chemo-radiotherapy and the tumor inferior margins being close to the dentate line, especially 2-5 cm, were independent risk factors for defecation dysfunction after surgery.

CONCLUSIONS

Defecation dysfunction is a frequent occurrence after sphincter-saving resection for mid- and low-rectal cancer. Preoperative chemo-radiotherapy and a shorter tumor inferior margins distance to the dentate line are independent factors for defecation dysfunction.