Importance of patient reported and clinical outcomes for patients with locally advanced rectal cancer and their treating physicians. Do clinicians know what patients want?

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

[For Whom, How and to What End - Neoadjuvant Therapy for Rectal Cancer?]

Over the past few decades, considerable progress has been made in the treatment of rectal cancer, leading to a reduction in local recurrence rates and an improvement in prognosis. The current German S3 guideline on colorectal cancer recommends neoadjuvant therapy for UICC stage II and III tumours of the middle and lower rectum. Primary surgery is still recommended for UICC I tumours, although exceptions are being discussed for certain subgroups, such as cT1/2 tumours with questionable nodal involvement. Current trials are focusing on multimodality treatment concepts, in particular total neoadjuvant therapy (TNT), which has been examined in several phase II and phase III trials. Therapies with selective omission of neoadjuvant radiotherapy and organ-preserving approaches are also being investigated. This review provides a comprehensive overview of the current evidence on neoadjuvant treatment of rectal cancer, highlights new multimodal treatment approaches, and discusses future challenges and opportunities to optimise treatment according to stage and to provide patients with the best possible individualised treatment.

National implementation of Watch-and-Wait in patients with rectal cancer

INTRODUCTION

Most reports on the outcome of Watch-and-Wait (W&W) in rectal cancer come from expert centres. This study reports on a broad implementation in the Netherlands.

MATERIAL AND METHODS

The process of W&W implementation is described and the outcome of patients in a W&W registry between 2004 and 2022 analysed (regrowth, metastases, survival, and organ preservation). Three equally sized chronological cohorts were compared to capture any differences during implementation over time.

RESULTS

W&W was gradually implemented in 18 high-volume hospitals coordinated by a single expert centre. One thousand and eighty patients with a clinical good response after (chemo)radiotherapy were included, with a median follow-up of 42 months (95% c.i. 40 to 44). At first response evaluation, 45% had a clinical complete response (cCR) and 55% near-complete reponse (nCR). In patients with nCR, 75% eventually achieved cCR, 14% underwent local excision, 2% received additional contact X-ray brachytherapy, and 10% underwent total mesorectal excision (TME) for persistent residual disease. Three-year actuarial local regrowth incidence was 23%. Three-year organ preservation rate was 76%. The 3-year distant metastases rate and overall survival were 10% and 97%. There were no significant differences in 3-year local regrowth or distant metastases between the three consecutive cohorts. In the two more recent cohorts more patients underwent TME for residual disease (13% versus 3%), likely due to a more liberal inclusion of patients with nCR.

CONCLUSION

The results of W&W in rectal cancer patients in high-volume hospitals mirror those of expert centres.

Chemotherapy before or after preoperative chemoradiotherapy and surgery for locally advanced rectal cancer: 5-year results of the CAO/ARO/AIO-12 trial - a general pairwise comparison

BACKGROUND

Total neoadjuvant treatment (TNT) has been increasingly adopted for multimodal rectal cancer treatment. Here, we present the 5-year results of our CAO/ARO/AIO-12 randomized phase II trial that compared two TNT sequences.

PATIENTS AND METHODS

Patients were initially randomized 1 : 1 to arm A (induction chemotherapy followed by chemoradiotherapy) or arm B (chemoradiotherapy followed by consolidation chemotherapy) followed by total mesorectal excision surgery. This report on the 5-year results involved a general pairwise comparison (GPC) of the following parameters, ranked as indicated: overall survival, incidence of locoregional recurrence, incidence of distant metastasis, rate of pathological/clinical complete remission, long-term quality of life (at least 24 months after randomization) based on global health assessed by the European Organisation For Research And Treatment Of Cancer Quality of Life Questionnaire Core 30 questionnaire, and incidence of toxicity, ranked by grade, during follow-up.

RESULTS

A total of 306 patients were eligible for this analysis. After a median follow-up of 60 months (interquartile range 58-62 months), we found that long-term oncological outcome was comparable in both arms [e.g. 5-year overall survival 85.8% (95% confidence interval 80.2% to 91.8%) in arm A and 84.2% (95% confidence interval 78.2% to 90.5%) in arm B], regardless of whether patients received induction chemotherapy and chemoradiotherapy or chemoradiotherapy and consolidation chemotherapy. The GPC showed no clinically meaningful overall treatment benefit (-1.38%) or win ratio difference (0.97) between the two treatment sequences. The incidence of pathological or sustained clinical complete remission remained higher in patients treated with consolidation chemotherapy after adjusting for long-term outcome between both arms (11% versus 6.5%).

CONCLUSIONS

Our 5-year GPC confirmed the 3-year findings that chemoradiotherapy followed by consolidation chemotherapy resulted in higher rates of pathological complete remission without compromising oncological outcome, toxicity, or quality of life. The TNT sequence chemoradiotherapy/chemotherapy may be preferred for organ preservation strategies.

What To Do With Suspected Nodal Regrowth on MRI During Follow-Up in an Organ Preservation Approach for Rectal Cancer?

BACKGROUND

For nodal regrowth in patients with rectal cancer following watch-and-wait, standardized protocols on diagnostic procedures and subsequent treatment are lacking.

OBJECTIVE

To evaluate the diagnosis and treatment of suspected nodal regrowth following an organ preservation approach.

SETTINGS

Patients were included from national and institutional watch-and-wait databases.

DESIGN

Thirty-five rectal cancer patients with suspected nodal regrowth on MRI were retrospectively identified during watch-and-wait follow-up.

PATIENTS

Twenty-seven of 35 patients followed the watch-and-wait schedule after neoadjuvant (chemo)radiotherapy and 8 of 35 patients followed the watch-and-wait schedule after local excision for early rectal cancer.

MAIN OUTCOME MEASURES

Diagnostic procedures, treatment, and histopathological outcome.

RESULTS

The median follow-up was 34 months. The median time from the end of (chemo)radiotherapy or local excision to the first detection of suspected nodal regrowth on MRI following watch-and-wait was 9 and 10 months. After the first detection, 17 of 35 patients underwent immediate treatment without further diagnostics, of whom 7 also had luminal regrowth. In 18 of 35 patients, additional diagnostic procedures were performed. In 4 of 18 patients, PET-CT or endorectal ultrasound-guided biopsy was performed, and treatment was initiated on the basis of increased nodal regrowth suspicion. In 14 of 18 patients, MRI was repeated after 8 to 12 weeks: growth of suspected lymph nodes was the most decisive factor to proceed to treatment. In 8 patients, repeated MRI was combined with PET-CT and/or endorectal ultrasound-guided biopsy: in half of them, it contributed to treatment initiation. In total, 34 of 35 patients were treated: 9 received (re-)irradiation and 33 underwent total mesorectal excision. In 27 of 33 patients, nodal regrowth was pathologically confirmed in the total mesorectal excision-resection specimen; 5 of 6 patients without nodal involvement had pathologically confirmed luminal regrowth.

LIMITATIONS

Highly selected study population.

CONCLUSIONS

During watch-and-wait follow-up of patients with rectal cancer in an organ preservation strategy, MRI plays an important role in the diagnosis of nodal regrowth. Repeated MRI after an interval can be helpful in making treatment decisions, and the role of PET-CT and endorectal ultrasound-guided biopsy appears limited. See Video Abstract .

QU HACER ANTE LA SOSPECHA DE UN NUEVO CRECIMIENTO GANGLIONAR EN LA RESONANCIA MAGNTICA DURANTE EL SEGUIMIENTO EN UN ENFOQUE DE PRESERVACIN DE RGANOS PARA EL CNCER DE RECTO

ANTECEDENTES:Para el recrecimiento ganglionar en pacientes con cáncer de recto posterior a watch-and-wait (W&W), faltan protocolos estandarizados de sobre procedimientos de diagnóstico y tratamiento subsecuente.OBJETIVO:Evaluar el diagnóstico y tratamiento de sospecha de recrecimiento ganglionar posterior a tratamiento de preservación del órgano.ENTORNO CLINICO:Se incluyeron pacientes de la base de datos W&W nacionales e institucionales.DISEÑO:Se identificaron retrospectivamente 35 pacientes con cáncer de recto con sospecha de recrecimiento ganglionar en la resonancia magnética durante el seguimiento de W&W.PACIENTES:27 de 35 pacientes siguieron el programa W&W después de (quimio)radioterapia neoadyuvante y 8 de 35 siguieron el programa W&W después de la escisión local en cáncer rectal temprano.PRINCIPALES MEDIDAS DE RESULTADO:Procedimientos de diagnóstico, tratamiento y resultado histopatológico.RESULTADOS:La mediana de seguimiento fue de 34 meses. La mediana de tiempo desde el final de la (quimio)radioterapia o la escisión local hasta la primera detección de un presunto recrecimiento ganglionar en la resonancia magnética después de W&W fue de 9 y 10 meses. Después de la primera detección, 17 de 35 pacientes fueron sometidos a tratamiento inmediato sin diagnóstico adicional, de los cuales 7 también tuvieron un nuevo crecimiento luminal. En 18 de 35 pacientes se realizaron procedimientos de diagnóstico adicionales. En 4 de 18 pacientes se realizó PET-CT o biopsia guiada por ecografía endorrectal (ERUS) y se inició tratamiento en base a una mayor sospecha de recrecimiento ganglionar. En 14 de 18 pacientes, la resonancia magnética se repitió después de 8 a 12 semanas: el crecimiento de los ganglios linfáticos sospechosos fue el factor más decisivo para proceder al tratamiento. En 8 pacientes, la resonancia magnética repetida se combinó con PET-CT y/o biopsia guiada por ERUS: en la mitad de ellos contribuyó al inicio del tratamiento. En total, se trataron 34 de 35 pacientes: 9 recibieron (re)irradiación y 33 se sometieron a escisión total de mesorrecto. En 27 de 33 pacientes se confirmó patológicamente el recrecimiento ganglionar en la muestra de escisión total de mesorrecto; 5 de 6 pacientes sin afectación ganglionar tuvieron un recrecimiento luminal patológicamente confirmado.LIMITACIONES:Población de estudio altamente seleccionada.CONCLUSIONES:Durante el seguimiento de W&W de pacientes con cáncer de recto en estrategia de preservación de órganos, la resonancia magnética juega un papel importante en el diagnóstico del recrecimiento ganglionar. La repetición de la resonancia magnética después de un intervalo puede ser útil para tomar decisiones de tratamiento, y el papel de la PET-CT y la biopsia guiada por ERUS parece limitado. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Short-term outcomes after primary total mesorectal excision (TME) versus local excision followed by completion TME for early rectal cancer: population-based propensity-matched study

BACKGROUND

Colorectal cancer screening programmes have led to a shift towards early-stage colorectal cancer, which, in selected cases, can be treated using local excision. However, local excision followed by completion total mesorectal excision (two-stage approach) may be associated with less favourable outcomes than primary total mesorectal excision (one-stage approach). The aim of this population study was to determine the distribution of treatment strategies for early rectal cancer in the Netherlands and to compare the short-term outcomes of primary total mesorectal excision with those of local excision followed by completion total mesorectal excision.

METHODS

Short-term data for patients with cT1-2 N0xM0 rectal cancer who underwent local excision only, primary total mesorectal excision, or local excision followed by completion total mesorectal excision between 2012 and 2020 in the Netherlands were collected from the Dutch Colorectal Audit. Patients were categorized according to treatment groups and logistic regressions were performed after multiple imputation and propensity score matching. The primary outcome was the end-ostomy rate.

RESULTS

From 2015 to 2020, the proportion for the two-stage approach increased from 22.3% to 43.9%. After matching, 1062 patients were included. The end-ostomy rate was 16.8% for the primary total mesorectal excision group versus 29.6% for the local excision followed by completion total mesorectal excision group (P < 0.001). The primary total mesorectal excision group had a higher re-intervention rate than the local excision followed by completion total mesorectal excision group (16.7% versus 11.8%; P = 0.048). No differences were observed with regard to complications, conversion, diverting ostomies, radical resections, readmissions, and death.

CONCLUSION

This study shows that, over time, cT1-2 rectal cancer has increasingly been treated using the two-stage approach. However, local excision followed by completion total mesorectal excision seems to be associated with an elevated end-ostomy rate. It is important that clinicians and patients are aware of this risk during shared decision-making.

Point/Counterpoint #2: Current Clinical Considerations With Nonoperative Management of Rectal Cancer

ABSTRACT

Locally advanced rectal cancer has historically been treated with multimodal therapy consisting of radiation therapy, chemotherapy, and total mesorectal excision. However, recent prospective trials and registry studies have demonstrated similar disease outcomes with nonoperative management for patients who experience an excellent clinical response to radiation and chemotherapy. This article reviews data regarding nonoperative management for rectal cancer, and highlights current challenges and limitations in a point-counterpoint format, in the context of two clinical cases.

Optimisation of Organ Preservation treatment strategies in patients with rectal cancer with a good clinical response after neoadjuvant (chemo)radiotherapy: Additional contact X-ray brachytherapy versus eXtending the observation period and local excision (OPAXX) - protocol for two multicentre, parallel, single-arm, phase II studies

INTRODUCTION

Standard treatment for patients with intermediate or locally advanced rectal cancer is (chemo)radiotherapy followed by total mesorectal excision (TME) surgery. In recent years, organ preservation aiming at improving quality of life has been explored. Patients with a complete clinical response to (chemo)radiotherapy can be managed safely with a watch-and-wait approach. However, the optimal organ-preserving treatment strategy for patients with a good, but not complete clinical response remains unclear. The aim of the OPAXX study is to determine the rate of organ preservation that can be achieved in patients with rectal cancer with a good clinical response after neoadjuvant (chemo)radiotherapy by additional local treatment options.

METHODS AND ANALYSIS

The OPAXX study is a Dutch multicentre study that investigates the efficacy of two additional local treatments aiming at organ preservation in patients with a good, but not complete response to neoadjuvant treatment (ie near-complete response or a small residual tumour mass <3 cm). The sample size will be 168 patients in total. Patients will be randomised (1:1) between two parallel single-arm phase II studies: study arm 1 involves additional contact X-ray brachytherapy (an intraluminal radiation boost), while in study arm 2 the observation period is extended followed by a second response evaluation and optional transanal local excision. The primary endpoint of the study is the rate of successful organ preservation at 1 year following randomisation. Secondary endpoints include toxicity, morbidity, oncological and functional outcomes at 1 and 2 years of follow-up. Finally, an observational cohort study for patients who are not eligible for randomisation is conducted.

ETHICS AND DISSEMINATION

The trial protocol has been approved by the medical ethics committee of the Netherlands Cancer Institute (METC20.1276/M20PAX). Informed consent will be obtained from all participants. The trial results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05772923.

Patients' perspectives and the perceptions of healthcare providers in the treatment of early rectal cancer; a qualitative study

BACKGROUND

Shared decision-making has become of increased importance in choosing the most suitable treatment strategy for early rectal cancer, however, clinical decision-making is still primarily based on physicians' perspectives. Balancing quality of life and oncological outcomes is difficult, and guidance on patients' involvement in this subject in early rectal cancer is limited. Therefore, this study aimed to explore preferences and priorities of patients as well as physicians' perspectives in treatment for early rectal cancer.

METHODS

In this qualitative study, semi-structured interviews were performed with early rectal cancer patients (n = 10) and healthcare providers (n = 10). Participants were asked which factors influenced their preferences and how important these factors were. Thematic analyses were performed. In addition, participants were asked to rank the discussed factors according to importance to gain additional insights.

RESULTS

Patients addressed the following relevant factors: the risk of an ostomy, risk of poor bowel function and treatment related complications. Healthcare providers emphasized oncological outcomes as tumour recurrence, risk of an ostomy and poor bowel function. Patients perceived absolute risks of adverse outcome to be lower than healthcare providers and were quite willing undergo organ preservation to achieve a better prospect of quality of life.

CONCLUSION

Patients' preferences in treatment of early rectal cancer vary between patients and frequently differ from assumptions of preferences by healthcare providers. To optimize future shared decision-making, healthcare providers should be aware of these differences and should invite patients to explore and address their priorities more explicitly during consultation. Factors deemed important by both physicians and patients should be expressed during consultation to decide on a tailored treatment strategy.

Validated Pretreatment Prediction Models for Response to Neoadjuvant Therapy in Patients with Rectal Cancer: A Systematic Review and Critical Appraisal

Pretreatment response prediction is crucial to select those patients with rectal cancer who will benefit from organ preservation strategies following (intensified) neoadjuvant therapy and to avoid unnecessary toxicity in those who will not. The combination of individual predictors in multivariable prediction models might improve predictive accuracy. The aim of this systematic review was to summarize and critically appraise validated pretreatment prediction models (other than radiomics-based models or image-based deep learning models) for response to neoadjuvant therapy in patients with rectal cancer and provide evidence-based recommendations for future research. MEDLINE via Ovid, Embase.com, and Scopus were searched for eligible studies published up to November 2022. A total of 5006 studies were screened and 16 were included for data extraction and risk of bias assessment using Prediction model Risk Of Bias Assessment Tool (PROBAST). All selected models were unique and grouped into five predictor categories: clinical, combined, genetics, metabolites, and pathology. Studies generally included patients with intermediate or advanced tumor stages who were treated with neoadjuvant chemoradiotherapy. Evaluated outcomes were pathological complete response and pathological tumor response. All studies were considered to have a high risk of bias and none of the models were externally validated in an independent study. Discriminative performances, estimated with the area under the curve (AUC), ranged per predictor category from 0.60 to 0.70 (clinical), 0.78 to 0.81 (combined), 0.66 to 0.91 (genetics), 0.54 to 0.80 (metabolites), and 0.71 to 0.91 (pathology). Model calibration outcomes were reported in five studies. Two collagen feature-based models showed the best predictive performance (AUCs 0.83-0.91 and good calibration). In conclusion, some pretreatment models for response prediction in rectal cancer show encouraging predictive potential but, given the high risk of bias in these studies, their value should be evaluated in future, well-designed studies.

Patient perspectives on consequences of resection for colorectal cancer: A qualitative study

BACKGROUND

Colorectal cancer is diagnosed in approximately 500,000 patients each year in Europe, leading to a high number of patients having to cope with the consequences of resection for colorectal cancer. As treatment options tend to grow, more information on the effects of these treatments is needed to engage in shared decision-making. This study aims to explore the impact of resection for colorectal cancer on patients' daily life.

METHODS

Patients (≥18 years of age) who underwent an oncological colorectal resection between 2018 and 2021 were selected. Purposeful sampling was used to include patients who differed in age, comorbidity conditions, types of (neo)adjuvant therapy, postoperative complications and the presence/absence of a stoma. Semi-structured interviews were conducted, guided by a topic guide. Interviews were fully transcribed and subsequently thematically analysed using the framework approach. Analyses were carried out using the following predefined themes: (1) daily life and activities; (2) psychological functioning; (3) social functioning; (4) sexual functioning; and (5) healthcare experiences.

RESULTS

Sixteen patients with a follow-up period of between 0.6 and 4.4 years after surgery were included in this study. Participants reported several challenges experienced because of poor bowel function, a stoma, chemotherapy-induced neuropathy, fear of recurrence and sexual dysfunction. However, they reported these as not interfering much with daily life.

CONCLUSION

Colorectal cancer treatment leads to several challenges and treatment-related health deficits. This is often not recognized by generic patient-reported outcome measures, but the findings on treatment-related health deficits presented in this study contain valuable insights which might contribute to improving colorectal cancer care, shared decision making and value-based health care.

Watch-and-Wait is an Option in Rectal Cancer Patients: From Controversy to Common Clinical Practice

Overview of the introduction of organ preservation in rectal cancer patients and future challenges.

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.

The Impact of Postoperative Complications on Short- and Long-Term Health-Related Quality of Life After Total Mesorectal Excision for Rectal Cancer

BACKGROUND

Survival for rectal cancer patients has improved over the past decades. In parallel, long-term health-related quality of life (HRQoL) is gaining interest. This study focuses on the effect of complications following rectal cancer surgery on HRQoL and survival.

METHODS

The TME-trial (1996-1999) randomized patients with operable rectal cancer between surgery with preoperative short-course radiotherapy and surgery. Questionnaires including the Rotterdam Symptom Checklist were sent at 6 time points within the first 24 months and after 14 years the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Differences in HRQoL and survival between patients with and without complications were analyzed.

RESULTS

A total of 1207 patients were included, of which 482 (39.9%) patients experienced complications, surgical complications occurred in 177 (14.6%) patients, non-surgical complications in 197 (16.3%) and 108 patients (8.9%) had a combination of both types of complications. Three months after surgery, patients with a combination of surgical- and non-surgical complications, especially patients with anastomotic leakage, had the worst HRQoL. Twelve months postoperative HRQoL returned to a similar level as before surgery, regardless of complications. In patients who survived 14 years, no significant differences in HRQoL were seen between patients with and without complications. However, patients with complications did have lower overall survival.

CONCLUSION

This study shows that survival and short-term HRQoL are negatively affected by complications. Twelve months after surgery HRQoL had returned to the preoperative level regardless, of complications. Also, in patients that survived 14 years, there was no effect of complications on HRQoL detected.

Patient choice in colorectal cancer treatment - A systematic review and narrative synthesis of attribute-based stated preference studies

AIM

The global burden of colorectal cancer (CRC) is set to increase by 60% by 2030. An aging population and increasing treatment complexity add difficulties for patients and clinicians in CRC management. Patient preferences can be investigated using attribute-based stated preference (AbSP) techniques to explore trade-offs between different treatments. These techniques include discrete-choice experiments (DCEs), conjoint analysis and time-trade off (TTO) methods. This systematic review with a narrative synthesis aimed to determine the use and design of AbSP studies in CRC treatment and to identify patient choice themes.

METHODS

The searches were performed using MEDLINE, Embase, PsycInfo and Cochrane Library in March 2021. All manuscripts featuring the use of AbSP techniques in CRC treatment were included. Data synthesis was performed using a narrative approach.

RESULTS

The search strategy returned 271 articles. Eighteen AbSP studies were included featuring 1890 patients and 296 clinicians. AbSP techniques compromised DCE (38.9%, n = 7), TTO (38.9%, n = 7) and conjoint analysis (22.2%, n = 4). Eleven studies (61.1%) involved piloting of tasks and the average task completion rate was 75%. CRC treatments included chemotherapy (33%, n = 6), combined treatments (33%, n = 6), surgery (17%, n = 3), targeted therapy (11%, n = 2) and radiotherapy (6%, n = 1). The most examined domain was physical health, investigated with 49 (59.8%) attributes.

CONCLUSIONS

Life expectancy was the main attribute in chemotherapy treatment. With surgery, patients were willing to trade life-expectancy to avoid adverse outcomes or a permanent stoma. Communication skills, treatment cost, and clinicians' views were important attributes for patients in cancer services. Further research in the elderly population, and other quality of life domains, are needed to deliver patient-centred CRC care.

Patient-Related Functional Outcomes After Robotic-Assisted Rectal Surgery Compared With a Laparoscopic Approach: A Systematic Review and Meta-analysis

BACKGROUND

Robotic surgery has gained significant momentum in rectal cancer surgery. Most studies focus on short-term and oncological outcomes, showing similar outcomes to laparoscopic surgery. Increasing survivorship mandates greater emphasis on quality of life and long-term function.

OBJECTIVE

This study aimed to compare quality of life and urinary, sexual, and lower GI functions between robotic and laparoscopic rectal surgeries.

DATA SOURCES

A systematic search of Medline, PubMed, Embase, Clinical Trials Register, and Cochrane Library-identified articles comparing robotic with laparoscopic rectal resections was performed.

MAIN OUTCOME MEASURES

The outcome measures were quality of life and urinary, sexual, and GI functions between robotic and laparoscopic rectal resection patient groups. Where comparable data were available, results were pooled for analysis.

RESULTS

The initial search revealed 1777 papers; 101 were reviewed in full, and 14 studies were included for review. Eleven assessed male sexual function; 7 favored robotic surgery, and the remaining studies showed no significant difference. Pooled analysis of 5 studies reporting rates of male sexual dysfunction at 12 months showed significantly lower rates after robotic surgery (OR, 0.51; p = 0.043). Twelve studies compared urinary function. Six favored robotic surgery, but in 2 studies, a difference was seen at 6 months but not sustained at 12 months. Pooled analysis of 4 studies demonstrated significantly better urinary function scores at 12 months after robotic surgery (OR, 0.26; p = 0.016). Quality of life and GI function were equivalent, but very little data exist for these parameters.

LIMITATIONS

A small number of studies compare outcomes between these groups; only 2 are randomized. Different scoring systems limit comparisons and pooling of data.

CONCLUSIONS

The limited available data suggest that robotic rectal cancer resection improves male sexual and urinary functions when compared with laparoscopy, but there is no difference in quality of life or GI function. Future studies should report all facets of functional outcomes using standardized scoring systems.

How Do Treatment Preferences of Patients With Cancer Compare With Those of Oncologists and Family Members? Evidence From a Discrete Choice Experiment in China

OBJECTIVES

This study aimed to compare the treatment preference among oncologists, patients with lung cancer, and their family members in China.

METHODS

A face-to-face discrete choice experiment survey was conducted among oncologists, patients, and their family members. Participants completed 13 choice sets describing 6 key attributes, namely, overall survival time, risk of severe adverse effect, severity of pain, appetite, physical functioning status, and monthly cost. Mixed logit model and latent class analysis were used to estimate attribute level preference weights and the relative importance (RI) for attributes. The willingness to pay (WTP) and maximum acceptable risk (MAR) were also estimated. The RI, WTP, and MAR of oncologists, patients, and family members were compared.

RESULTS

A total of 121 oncologists and 161 dyads of patients and family members completed the survey. Overall survival time, physical functioning status, and pain were the 3 most important attributes across all 3 groups. Oncologists and family members had higher RI on overall survival time than patients (48% and 51% vs 38%). Patients had higher RI on physical functioning status and pain (23% and 14%) than oncologists (13% and 12%) and family members (16% and 11%). For extending survival, patients had the least WTP, and family members had the highest MAR. The latent class analysis identified 2 classes in the patient group and 3 classes in oncologist and family member groups.

CONCLUSIONS

There were differences in preferences for survival, risk, quality of life, and costs associated with cancer treatments among patients, oncologists, and family members. This finding highlights the need of involving patients in treatment decision making in China.

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.

Prognostic value of patient-reported outcomes in predicting 30 day all-cause readmission among older patients with heart failure

AIMS

Previous prediction studies for 30 day readmission in patients with heart failure were built mainly based on electronic medical records and rarely involved patient-reported outcomes. This study aims to develop and validate a nomogram including patient-reported outcomes to predict the possibility of 30 day all-cause readmission in older patients with heart failure and to explore the value of patient-reported outcomes in prediction model.

METHODS AND RESULTS

This was a prospective cohort study. The nomogram was developed and internally validated by Logistic regression analysis based on 381 patients in training group from March to December 2019. The nomogram was externally validated based on 170 patients from July to October 2020. Receiver operating characteristic curves, calibration plots and decision-curve analysis were used to evaluate the performance of the nomogram. A total of 381 patients' complete data were analysed in the training group and 170 patients were enrolled in the external validation group. In the training group, 14.4% (n = 55) patients were readmitted to hospitals within 30 days of discharge and 15.9% (n = 27) patients were readmitted in the external validation group. The nomogram included six factors: history of surgery, changing the type of medicine by oneself, information acquisition ability, subjective support, depression level, quality of life, all of which were significantly associated with 30 day readmission in older patients with heart failure. The areas under the receiver operating characteristic curves of nomogram were 0.949 (95% CI: 0.925, 0.973, sensitivity: 0.873, specificity: 0.883) and 0.804 (95% CI: 0.691, 0.917, sensitivity: 0.778, specificity: 0.832) respectively in the training and external validation groups, which indicated that the nomogram had better discrimination ability. The calibration plots demonstrated favourable coordination between predictive probability of 30 day readmission and observed probability. Decision-curve analysis showed that the net benefit of the nomogram was better between threshold probabilities of 0-85%.

CONCLUSIONS

A novel and easy-to-use nomogram is constructed and demonstrated which emphasizes the important role of patient-reported outcomes in predicting studies. The performance of the nomogram drops in the external validation cohort and the nomogram must be validated in a wide prospective cohort of HF patients before its clinical relevance can be demonstrated. All these findings in this study can assist professionals in identifying the needs of HF patients so as to reduce 30 day readmission.

Selected stage IV rectal cancer patients managed by the watch-and-wait approach after pelvic radiotherapy: a good alternative to total mesorectal excision surgery?

AIM

The aim of this study was to assess the clinical and oncological outcome of a selected group of stage IV rectal cancer patients managed by the watch-and-wait approach following a (near-)complete response of the primary rectal tumour after radiotherapy.

METHOD

Patients registered in the Dutch watch-and-wait registry since 2004 were selected when diagnosed with synchronous stage IV rectal cancer. Data on patient characteristics, treatment details, follow-up and survival were collected. The 2-year local regrowth rate, organ-preservation rate, colostomy-free rate, metastatic progression-free rate and 2- and 5-year overall survival were analysed.

RESULTS

After a median follow-up period of 35 months, local regrowth was observed in 17 patients (40.5%). Nine patients underwent subsequent total mesorectal excision, resulting in a permanent colostomy in four patients. The 2-year local regrowth rate was 39.9%, the 2-year organ-preservation rate was 77.1%, the 2-year colostomy-free rate was 88.1%, and the 2-year metastatic progression-free rate was 46.7%. The 2- and 5-year overall survival rates were 92.0% and 67.5%.

CONCLUSION

The watch-and-wait approach can be considered as an alternative to total mesorectal excision in a selected group of stage IV rectal cancer patients with a (near-)complete response following pelvic radiotherapy. Despite a relatively high regrowth rate, total mesorectal excision and a permanent colostomy can be avoided in the majority of these patients.

Patient Preferences for Treatment Outcomes in Oncology with a Focus on the Older Patient-A Systematic Review

Simple Summary

In oncology, treatment outcomes can be competing, which means that one treatment could benefit one outcome, like survival, and negatively influence another, like independence. The choice of treatment therefore depends on the patient’s preference for outcomes, which needs to be assessed explicitly. Especially in older patients, patient preferences are important. Our systematic review summarizes all studies that assessed patient preferences for various treatment outcome categories. A total of 28 studies with 4374 patients were included, of which only six studies included mostly older patients. Although quality of life was only included in half of the studies, overall quality of life (79%) was most frequently prioritized as highest or second highest, followed by overall survival (67%), progression- and disease-free survival (56%), absence of severe or persistent treatment side effects (54%), treatment response (50%), and absence of transient short-term side effects (16%). In shared decision-making, these results can be used by healthcare professionals to better tailor the information provision and treatment recommendations to the individual patient.

Abstract

For physicians, it is important to know which treatment outcomes are prioritized overall by older patients with cancer, since this will help them to tailor the amount of information and treatment recommendations. Older patients might prioritize other outcomes than younger patients. Our objective is to summarize which outcomes matter most to older patients with cancer. A systematic review was conducted, in which we searched Embase and Medline on 22 December 2020. Studies were eligible if they reported some form of prioritization of outcome categories relative to each other in patients with all types of cancer and if they included at least three outcome categories. Subsequently, for each study, the highest or second-highest outcome category was identified and presented in relation to the number of studies that included that outcome category. An adapted Newcastle–Ottawa Scale was used to assess the risk of bias. In total, 4374 patients were asked for their priorities in 28 studies that were included. Only six of these studies had a population with a median age above 70. Of all the studies, 79% identified quality of life as the highest or second-highest priority, followed by overall survival (67%), progression- and disease-free survival (56%), absence of severe or persistent treatment side effects (54%), and treatment response (50%). Absence of transient short-term side effects was prioritized in 16%. The studies were heterogeneous considering age, cancer type, and treatment settings. Overall, quality of life, overall survival, progression- and disease-free survival, and severe and persistent side effects of treatment are the outcomes that receive the highest priority on a group level when patients with cancer need to make trade-offs in oncologic treatment decisions.

Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life

BACKGROUND

Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis.

METHODS

All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up.

RESULTS

Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma.

CONCLUSION

This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.

Debating Pros and Cons of Total Neoadjuvant Therapy in Rectal Cancer

Simple Summary

Rectal cancers represent one third of all colorectal tumours. Patients diagnosed with localised colon cancer undergo surgery upfront, likely followed by adjuvant chemotherapy. Those diagnosed with localised rectal cancer, however, frequently benefit from neoadjuvant treatments with either radiotherapy or chemoradiotherapy before undergoing surgery. On the other hand, the benefit of adjuvant chemotherapy in this setting is more controversial. The main challenges in treating patients affected by rectal cancer encompass: decreasing the risks of local relapse and distant metastases, preserving the sphincter and minimising treatment-associated functional sequelae, and improving overall survival. Some of these fuelled the concept of total neoadjuvant therapy, namely giving all available treatments including radiotherapy and systemic chemotherapy before surgery. Here, we critically review the pros and cons of such a treatment strategy, but also discuss the biological rational to support neoadjuvant treatment intensification.

Abstract

Recently, two large, randomised phase III clinical trials of total neoadjuvant therapy (TNT) in locally advanced rectal cancer were published (RAPIDO and PRODIGE 23). These two trials compared short-course radiotherapy (SCRT) followed by chemotherapy with standard chemoradiotherapy (CRT) and chemotherapy followed by CRT with standard CRT, respectively. They showed improvement in some of the outcomes such as distant recurrence and pathological complete response (pCR). No improvement, however, was observed in local disease control or the de-escalation of surgical procedures. Although it seems lawful to integrate TNT within the treatment algorithm of localised stage II and III rectal cancer, many questions remain unanswered, including which are the optimal criteria to identify patients who are most likely to benefit from this intensive treatment. Instead of providing a sterile summary of trial results, we put these in perspective in a pros and cons manner. Moreover, we discuss some biological aspects of rectal cancer, which may provide some insights into the current decision-making process, and represent the basis for the future development of alternative, more effective treatment strategies.

International consensus recommendations on key outcome measures for organ preservation after (chemo)radiotherapy in patients with rectal cancer

Multimodal treatment strategies for patients with rectal cancer are increasingly including the possibility of organ preservation, through nonoperative management or local excision. Organ preservation strategies can enable patients with a complete response or near-complete clinical responses after radiotherapy with or without concomitant chemotherapy to safely avoid the morbidities associated with radical surgery, and thus to maintain anorectal function and quality of life. However, standardization of the key outcome measures of organ preservation strategies is currently lacking; this includes a lack of consensus of the optimal definitions and selection of primary end points according to the trial phase and design; the optimal time points for response assessment; response-based decision-making; follow-up schedules; use of specific anorectal function tests; and quality of life and patient-reported outcomes. Thus, a consensus statement on outcome measures is necessary to ensure consistency and facilitate more accurate comparisons of data from ongoing and future trials. Here, we have convened an international group of experts with extensive experience in the management of patients with rectal cancer, including organ preservation approaches, and used a Delphi process to establish the first international consensus recommendations for key outcome measures of organ preservation, in an attempt to standardize the reporting of data from both trials and routine practice in this emerging area.

Burden of disease experienced by patients following a watch-and-wait policy for locally advanced rectal cancer: A qualitative study

AIM

Patient-reported outcome measures (PROMs) are increasingly being used in routine cancer care to evaluate treatment and monitor symptoms, function and other aspects of quality of life (QoL). There is no suitable PROM for rectal cancer patients following a watch-and-wait (W&W) programme. Insight into patient experiences with this programme is an essential step in the development of a PROM. The aim of this qualitative study was to provide insights into the most important functional outcomes and QoL features experienced by patients during our W&W programme.

METHOD

Patients with locally advanced rectal cancer who are enrolled in the W&W programme in the Netherlands were interviewed by telephone using a semistructured interview guide. All interviews were digitally audio-recorded, transcribed verbatim and coded. A thematic approach was used to analyse the data and identify themes and subthemes of importance to patients.

RESULTS

Eighteen patients were interviewed (78% male, mean age 68 years, range 52-83 years). Physical complaints after treatment were present, most notably gastrointestinal problems, neuropathy and fatigue. Furthermore, patients were anxious about a possible recurrence, had a fear of surgery or a stoma, or were experiencing a general feeling of apprehension in daily life. Many patients had different coping mechanisms, such as acceptance, and there were few limitations in daily life.

CONCLUSION

We identified important functional outcomes, such as gastrointestinal complaints, fatigue and neuropathy, in patients who were enrolled in this W&W programme. Furthermore, an emotional burden and unmet needs were reported by these patients. These findings can be used to improve clinical practice and inform the development of a PROM.

Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review

Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.