Sexual Function in Males After Radiotherapy for Rectal Cancer

Long-term Quality of Life and Functional Outcome of Patients With Rectal Cancer Following a Watch-and-Wait Approach

Importance

A watch-and-wait approach for patients with rectal cancer and a clinical complete response after neoadjuvant chemoradiotherapy or radiotherapy is associated with better quality of life and functional outcome. Nevertheless, prospective data on both parameters are scarce.

Objective

To prospectively evaluate quality of life and functional outcome, including bowel, urinary, and sexual function, of patients following a watch-and-wait approach.

Design, Setting, and Participants

A total of 278 patients with rectal cancer and a clinical complete response or near-complete response after neoadjuvant chemoradiotherapy or radiotherapy were included in 2 prospective cohort studies: a single-center study (March 2014 to October 2017) and an ongoing multicenter study (from September 2017). Patients were observed by a watch-and-wait approach. Additional local excision or total mesorectal excision was performed for residual disease or regrowth. Data were analyzed between April 1, 2021, and August 27, 2021, for patients with a minimum follow-up of 24 months.

Main Outcomes and Measures

Quality of life was evaluated with the European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-C30 (EORTC-QLQ-C30), EORTC-QLQ-CR38, or EORTC-QLQ-CR29 and 36-Item Short-Form Health Survey. The score for the questionnaires and 36-Item Short-Form Health Survey ranges from 0 to 100. For some scales, a high score indicates a high level of functioning, and for others it indicates a high level of complaints and symptomatology. Functional outcome was assessed by the Low Anterior Resection Syndrome score, Vaizey incontinence score, International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index.

Results

Of 278 patients included, 187 were male (67%), and the median age was 66 years (range, 34-85 years). In the first 24 months, 221 patients (80%) were observed by a watch-and-wait approach without requiring surgery, 18 patients (6%) underwent additional local excision, and 39 patients (14%) underwent total mesorectal excision. In general, patients observed by a watch-and-wait approach reported good quality of life, with limited variation over time. At 3 months, 56 of 221 patients (25.3%) reported major bowel dysfunction; at 12 months, 53 patients (24.0%) reported it; and at 24 months, 55 patients (24.9%) reported it. At 24 months, 48 of 151 male patients (31.8%) reported severe erectile dysfunction. For female patients, sexual satisfaction and overall sexual function decreased during follow-up. Patients who underwent local excision reported more major bowel dysfunction (10 of 18 patients [55.6%]) compared with those without additional surgery. Quality-of-life scores, however, were comparable. After total mesorectal excision, patients scored significantly worse on several quality-of-life subscales.

Conclusions and Relevance

Results of this study suggest that patients with rectal cancer who were observed by a watch-and-wait approach had good quality of life, with some patients reporting bowel and sexual dysfunction. Quality of life and functional outcome deteriorated when patients required surgery. These data will be useful in daily care to counsel patients on what to expect from a watch-and-wait approach.

Predictive biomarkers in radioresistant rectal cancer: a systematic review

BACKGROUND AND AIMS

The treatment of locally advanced rectal cancer often consists of neoadjuvant chemoradiotherapy followed by surgery. However, approximately 15% of patients show no response to this neoadjuvant chemoradiotherapy. This systematic review aimed to identify biomarkers of innate radioresistant rectal cancer.

METHOD

Through a systematic literature search, 125 papers were included and analyzed using ROBINS-I, a Cochrane risk of bias tool for non-randomized studies of interventions. Both statistically significant and nonsignificant biomarkers were identified. Biomarkers mentioned more than once in the results or biomarkers with a low or moderate risk of bias were included as the final results.

RESULTS

Thirteen unique biomarkers, three genetic signatures, one specific pathway, and two combinations of two or four biomarkers were identified. In particular, the connection between HMGCS2, COASY, and PI3K-pathway seems promising. Future scientific research should focus on further validating these genetic resistance markers.

Effect of Neoadjuvant Therapy on the Functional Outcome of Patients With Rectal Cancer: A Systematic Review and Meta-Analysis

AIMS

The impact of neoadjuvant therapy on the functional outcome of patients with resectable rectal cancer is still controversial. The aim of the present study was to explore the effects of neoadjuvant therapy on anorectal function (ARF), urinary function and sexual function in relevant patients.

MATERIALS AND METHODS

PubMed, Embase, Web of Science and the Cochrane Library were searched systematically. All English-language studies, published from January 2000 to July 2021, that explored the (postoperative) effects of neoadjuvant therapy versus upfront surgery on ARF, urinary function and sexual function of patients were included (PROSPERO 2021: CRD42021281617).

RESULTS

The data in this study were derived from 37 articles based on 33 studies; in total, 17 917 patients were enrolled. The meta-analysis revealed that the incidence of anorectal dysfunction in the neoadjuvant therapy group was significantly higher than that in the group of upfront surgery, which was manifested by a higher incidence of major low anterior resection syndrome (odds ratio = 3.09, 95% confidence interval = 2.48, 3.84; P < 0.001), reduction of mean squeeze pressure and mean resting pressure, and other manifestations, including clustering of stools, incontinence, urgency and use of pads. With the extension of follow-up time, the adverse effects of neoadjuvant therapy on major low anterior resection syndrome existed. Compared with patients undergoing upfront surgery, neoadjuvant therapy increased the risk of urinary incontinence (odds ratio = 1.31, 95% confidence interval = 1.00, 1.72; P = 0.05) and erectile dysfunction (odds ratio = 1.77, 95% confidence interval = 1.27, 2.45; P < 0.001).

CONCLUSION

Compared with upfront surgery, neoadjuvant therapy is not only associated with impairment of ARF, but also with increased incidence of urinary incontinence and male erectile dysfunction. However, the influence of confounding factors (e.g. surgical method, tumour stage) needs to be considered.

Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection

BACKGROUND

Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear.

OBJECTIVE

The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome.

DESIGN

Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires.

SETTING

Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage.

PATIENTS

Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants.

RESULTS

The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003).

LIMITATIONS

The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms.

CONCLUSIONS

In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 .

SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO

ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).

[Radiation-induced sexual toxicity]

Oncosexuality has recently become a new supportive care mission. Sexual morbidity is, routinely, underestimated and must be questioned. We report here the most frequent disorders for men and for women, how to prevent them and how to treat them.

Quality of Life in Patients With Severe Skin Reactions in Course of First-Generation Epidermal Growth Factor Receptor Inhibitors Monoclonal Antibodies (Our Experience With Cetuximab)

Background

Metastatic colorectal cancer (mCRC) with wild type expression of RAS and RAF genes can be treated with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, such as cetuximab, in combination with chemotherapy. Skin toxicity represents the most serious and frequent side effect in these patients. Skin manifestations occur in approximately 80% of patients. In this study, we investigated the consequences on body image and quality of life (QoL) of patients with severe skin toxicity.

Methods

One hundred patients were enrolled with mCRC. All patients signed informed consent and completed questionnaires to assess QoL and body discomfort. Toxicity was assessed on Common Terminology Criteria for Adverse Events (CTCAEs).

Results

The greatest impact on QoL was represented by difficulties in managing skin rash-related side effects. Data showed a significant impact in psychological sphere and social relationships.

Conclusions

Skin side effects, particularly rash, influence QoL and social relationships, compromising therapeutic compliance.

Prevalence of erectile dysfunction in male survivors of cancer: a systematic review and meta-analysis of cross-sectional studies

Background

Prevalence of erectile dysfunction (ED) in male survivors of cancer across cancer types has not been systematically analysed.

Aim

To estimate the prevalence of ED in all types of cancer and identify characteristics associated with ED in survivors of cancer.

Design and setting

Systematic review and meta-analysis (MA) of cross-sectional studies.

Method

MEDLINE, CINAHL, PsycINFO, and EMBASE were searched, targeting reports published from inception to 1 February 2020. All retrospective or prospective studies reporting prevalence of ED in male patients with cancer and using a validated tool for detection of ED were included. A random-effects MA model was used to pool prevalence of ED as absolute estimates at three different stages, that is, ‘healthy’, ‘at diagnosis’, and ‘after treatment’. A univariate MA regression including the three-level group variable as the only independent variable was used to assess the difference in ED prevalence across the three groups. Further MAs were conducted for studies involving patients at diagnosis and after treatment, and statistical inferences were made with setting for multiple testing controlling for a false discovery rate (FDR) <0.05.

Results

In total, 1301 studies were assessed for inclusion. Of these, 141 were potentially eligible and subsequently scrutinised in full text. Finally, 43 studies were included with a total of 13 148 participants. Overall, pooled data of the included studies showed an ED prevalence of 40.72% (95% confidence interval [CI] = 31.80 to 50.29) in patients with cancer, with prevalences of 28.60% (95% CI = 12.10 to 53.83) at time of diagnosis and 42.70% (95% CI = 32.97 to 53.03) after treatment, with significant difference between these two stages and across cancer locations, controlling for an FDR <0.05.

Conclusion

Erectile dysfunction was particularly high in male survivors of cancer and was associated with cancer treatment, cancer site, and age.

Robotic versus transanal total mesorectal excision in sexual, anorectal, and urinary function: a multicenter, prospective, observational study

PURPOSE

Improved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study.

METHODS

One hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence-Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%.

RESULTS

RoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score - 0.3 ± 1.0 vs. - 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME - 13.4 ± 2.7 vs. TaTME - 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function.

CONCLUSION

After adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.

The power of empirical data; lessons from the clinical registry initiatives in Scandinavian cancer care

BACKGROUND

In Scandinavia, there is a strong tradition for research and quality monitoring based on registry data. In Denmark, Norway and Sweden, 63 clinical registries collect data on disease characteristics, treatment and outcome of various cancer diagnoses and groups based on process-related and outcome-related variables.

AIM

We describe the cancer-related clinical registries, compare organizational structures and quality indicators and provide examples of how these registries have been used to monitor clinical performance, develop prediction models, assess outcome and provide quality benchmarks. Further, we define unmet needs such as inclusion of patient-reported outcome variables, harmonization of variables and barriers for data sharing.

RESULTS AND CONCLUSIONS

The clinical registry framework provides an empirical basis for evidence-based development of high-quality and equitable cancer care. The registries can be used to follow implementation of new treatment principles and monitor patterns of care across geographical areas and patient groups. At the same time, the lessons learnt suggest that further developments and coordination are needed to utilize the full potential of the registry initiative in cancer care.

Effects of neoadjuvant chemotherapy with or without intensity-modulated radiotherapy for patients with rectal cancer

Neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision and adjuvant chemotherapy is the standard regimen for patients with locally advanced rectal cancer (LARC). However, whether and to which extent neoadjuvant radiotherapy could be removed from nCRT for patients with LARC is still unclear. This was a multicenter, retrospectively recruited, prospectively maintained cohort study. A propensity score matching model was employed to minimize potential confounding factors between subgroup patients treated with neoadjuvant chemotherapy (nCT) or nCRT. Overall survival (OS), disease‐free survival (DFS), local recurrence‐free survival (LRFS), and distant metastasis‐free survival (DMFS) were assessed between subgroup patients by Kaplan‐Meier analysis, log‐rank test, and Cox regression model. In total, 3233 consecutive patients, consist of 571 nCT and 2662 nCRT‐treated cases, were included. After propensity score matching (1:4), 565 nCT‐treated patients were matched to 1852 nCRT‐treated patients. Compared with nCT, nCRT treatment indeed decreased 3‐y local recurrence (10.0% vs 6.6%, P = .026), but had no impact on OS, DFS and DMFS (all P > .05) for LARC. Stratified analysis further confirmed that nCRT treatment was associated with higher 3‐y LRFS and 3‐y DFS than nCT treatment for baseline high‐risk subgroup (cT4, cN+, and cIII stage) patients (all P < .05). Conversely, for the baseline low‐risk subgroup patients (cT3, cN0, and cII stage), nCRT and nCT treatment had similar 3‐y OS, LRFS, DFS, and DMFS (all P > .05). The administration of neoadjuvant radiotherapy for LARC patients might be determined by baseline risk classification, the high‐risk individuals could be delivered while low‐risk patients might be omitted.

Preparing Patients for Sexual Dysfunction After Radiation for Anorectal Cancers: A Systematic Review

PURPOSE

Successful multimodality treatment of anorectal cancers has led to increased numbers of survivors who experience permanent, life-changing side effects of treatment. Little is known about sexual dysfunction (SD) in this population. The etiology of SD after anorectal cancer treatment is complex and multifactorial. However, pelvic radiation plays a significant negative role in anatomic, hormonal, and physiological aspects of sexual function.

METHODS AND MATERIALS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. Information was organized by key concepts useful for patient education, including (1) rates of SD after pelvic radiation for rectal cancer, (2) rates of SD after pelvic radiation for anal cancer, (3) mechanisms of SD and methods to reduce rates of SD, and (4) issues and opportunities related to patient education and discussion of SD after pelvic radiation.

RESULTS

SD after pelvic radiation for anorectal cancers is common in both men and women. Higher radiation doses may increase the risk for vaginal stenosis; however, it is unclear whether there are similar dose-volume relationships for men. Vaginal dilators and advanced radiation techniques can reduce the radiation dose to sexual organs at risk. Improvement is needed regarding counseling and education of patients about SD.

CONCLUSIONS

This review provides information from previously published studies that clinicians may use in their discussions with patients embarking on pelvic radiation for anorectal cancers. More modern, standardized, and complete data are needed to quantify the risk of SD after treatment. Some methods of sexual toxicity reduction have been studied, but further study into interventions aimed at treating postradiation sexual function are needed.

Sexual Function, Quality of Life, and Mood After Radiation Therapy in Patients with Anal Cancer

PURPOSE/OBJECTIVE(S)

Definitive chemoradiation (CRT) results in high cure rates of anal cancer, with advanced radiation (RT) techniques improving toxicity. However, there is limited data regarding these patients' sexual function (SF), quality of life (QOL), and mood. We hypothesized that anal cancer treatment would result in detrimental effects on SF, QOL, and mood.

MATERIALS/METHODS

We prospectively surveyed patients with anal cancer treated with definitive CRT. We assessed SF for women with the Female Sexual Function Index (FSFI) and for men with the International Index of Erectile Function (IIEF). For all patients, we assessed QOL using EORTC QLQ-C30 and CR29 and mood using the Hospital Anxiety and Depression Scale (HADS). We reported descriptive statistics for SF, QOL, and mood and used univariate analysis to evaluate predictors of SF for women.

RESULTS

Of 50 eligible patients, 84% completed the surveys. Median time from RT until survey was 36 months (1-97 months). Women (n = 34) reported poor SF overall (mean FSFI score = 15, scale 2-36, standard deviation (SD) 10.4). Most women reported poor SF related to satisfaction, desire, orgasm, arousal, pain, and lubrication. Men (n = 8) also had poor overall satisfaction (mean IIEF score = 6.1, scale 2-10, SD 3.6). Men reported poor erectile function and lower satisfaction with intercourse. Mean QLQ-C30 QOL score was 86.5 (SD 16.3). Results from EORTC QLQ-CR-20 demonstrated patients experienced poor sexual interest. Per HADS, 2.5% reported depression and 18% anxiety.

CONCLUSION

Patients with anal cancer experience sexual dysfunction after RT, with QOL and mood symptoms similar to patients with other cancers. Our data support the need for ongoing efforts to understand and address issues with SF, QOL, and mood following RT for these patients.

Sexual health in colon cancer patients: A systematic review

OBJECTIVE

Despite the impact that diagnosis and treatment can have on patients' sexual health, very little research has been conducted on the impact of colon cancer on sexual health. The aim of this systematic review was to assess the prevalence of sexual dysfunctions in colon cancer and describe the sociodemographic, clinical, and psychological correlates of sexual dysfunction.

METHODS

Four electronic databases (PsycINFO, PubMed, AcademicSearchPremier, Cochrane Library) were searched for studies reporting sexual adjustment outcomes for colorectal cancer patients from January 1990 to July 2019.

RESULTS

Of the 380 articles screened, 14 were included in this review. Sexual function is affected by colon cancer: patients' sexual satisfaction decreases significantly, as does the frequency of sexual intercourse. There is an increase in sexual problems (desire, excitement, or pleasure disorders). Male gender, advanced age, distress, and the comorbidities increase sexual disorders. In addition, it appears that partner distress negatively affects patients' sexual health. Taking such difficulties into account appears key for these patients and their partners. They could benefit from better care throughout treatment and in remission.

CONCLUSION

The results of this systematic review highlight the importance of taking an interest in the sexual health of patients with colon cancer.

Dose-time fractionation schedules of preoperative radiotherapy and timing to surgery for rectal cancer

Chemoradiotherapy (CRT) is extensively used prior to surgery for rectal cancer to provide significantly better local control, but the radiotherapy (RT), as the other component of CRT, has been subject to less interest than the drug component in recent years. With considerable developments in RT, the use of advanced techniques, such as intensity-modulated radiotherapy (IMRT) in rectal cancer, is garnering more attention nowadays. The radiation dose can be better conformed to the target volumes with possibilities for synchronous integrated boost without increased complications in normal tissue. Hopefully, both local recurrence and toxicities can be further reduced. Although those seem to be of interest, many issues remain unresolved. There is no international consensus regarding the radiation schedule for preoperative RT for rectal cancer. Moreover, an enormous disparity exists regarding the RT delivery. With the advent of IMRT, variations will likely increase. Moreover, time to surgery is also quite variable, as it depends upon the indication for RT/CRT in the clinical practices. In this review, we discuss the options and problems related to both the dose-time fractionation schedule and time to surgery; furthermore, it addresses the research questions that need answering in the future.

Do radiation oncologists talk about sexual health and dysfunction with their cancer patients? Results of the igls-vienna-sexmed-survey

Background and purpose

The aim of this survey was to invite radiation oncologists to self-assess whether sexual health care and sexual dysfunction are an issue in daily routine.

Materials and Methods

At the annual congress of the Austrian Society of Radiation Oncology in 2017 doctors were asked about their care for sexual health in cancer patients by using questionnaires. No exclusion criteria were employed. Forty-one questionnaires were answered and statistically analysed so 44.5% of doctors participated.

Results

Only 4.9% of the participants self-assessed to routinely explore sexual health issues in 61-80% of their patients. Thirty-one point seven percent of the doctors suspected sexual problems in about half of their patients but did not raise the issue. The most common reason for not raising sexual issues by the patients was assumed by the doctors "other problems are more important" (73.2%), followed by "lack of time" (36.6%). Participants were also asked about additional medical qualifications: none of the physicians had training in sexual medicine.

Conclusion

The main reason for not talking about sexual problems was the impression of the participating doctors that other problems were more important for the patients. Another reason for not bringing up the topic of sexual issues by the patients was assumed by the doctors: lack of time. As doctor shortage is a problem in the observed country other kind of networks and counselling possibilities should be evaluated. An interesting finding was that survey participants show a higher awareness for male sexual problems than for female issues.

High symptom burden is associated with impaired quality of life in colorectal cancer patients during chemotherapy:A prospective longitudinal study

PURPOSE

Multiple symptoms can have a negative impact on quality of life (QoL), but there is little information about the impact of multiple symptoms on QoL of patients with colorectal cancer (CRC) during outpatient chemotherapy. Therefore, the purpose was to assess the physical and mental QoL in CRC patients over six months of chemotherapy, to evaluate the association of QoL with the presence of multiple symptoms, and to determine which demographic and clinical characteristics are associated with physical and mental QoL scores.

METHODS

Outpatients with CRC (N = 120) completed the Medical Outcomes Study Short Form (SF-12) and Memorial Symptom Assessment Scale (MSAS) at eight time points during six months of chemotherapy. Linear mixed models for repeated measures were used to analyse QoL over time; and its association with demographic and clinical characteristics; and with the presence of multiple symptoms (e.g., 'numbness/tingling' and 'problems with sexual interest').

RESULTS

The CRC patients had worse physical and mental QoL scores than the general population at all time points. Impaired physical QoL was significantly associated with psychological symptom burden (p < 0.001) and numbness/tingling (p < 0.027). Impaired mental QoL was associated with physical symptom burden (p < 0.001), with being female (p < 0.009), younger age (p < 0.024), and having problems with sexual interest (p < 0.009).

CONCLUSIONS

Impaired QoL was associated with symptoms in CRC outpatients. This information about the symptoms and characteristics associated with worse QoL during chemotherapy may help clinicians identify and inform at-risk patients.

Prognostic Impact of Ventral Versus Dorsal Tumor Location After Total Mesorectal Excision of Rectal Cancer

BACKGROUND

Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy.

METHODS

We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses.

RESULTS

Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001).

CONCLUSIONS

Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.

Long-term Outcomes After Surgery Involving the Pelvic Floor in Rectal Cancer: Physical Activity, Quality of Life, and Health Status

PURPOSE

This study has aimed to evaluate the effects of surgery on physical activity (PA), quality of life (QoL), and disease-specific health status, by analyzing the differences between sphincter-preserving surgery (low anterior resection (LAR)) and abdominoperineal resection (APR) among rectal cancer survivors.

METHODS

Individuals who were diagnosed with rectal cancer and who underwent an APR or a LAR between 2000 and 2009 were included. The different questionnaires on QoL, disease-specific health status, and physical activity began their surveys in 2010. Differences in QoL, health status, and physical activity were analyzed between the APR group and the LAR group.

RESULTS

The study included 905 rectal cancer survivors (LAR, 632; APR, 273). Besides a higher rate of radiotherapy treatment in the APR group (94% vs. 75%, p < 0.001), there were no differences in clinical characteristics or in comorbid conditions between the LAR group and APR group. No significant differences were found in PA level between the patients who had undergone an APR vs. a LAR. Regarding QoL, APR patients did report a worse physical (p = 0.009) and role functioning (p = 0.03), as well as a worse body image (p = 0.001), compared to patients who had undergone a LAR. However, they reported fewer constipation (p = 0.02) and gastrointestinal problems (p = 0.009). Finally, compared to patients who had undergone a LAR with a permanent ostomy, APR patients reported a better body image (p = 0.048) and less stoma-related problems (p = 0.001).

CONCLUSIONS

This study showed no differences in PA level among the patients who had undergone an APR versus a LAR. With respect to their QoL, their physical and role functioning seemed to be worse in the APR patients. However, these differences in outcomes resolved when comparing the APR group with patients after a LAR with a permanent ostomy.

Local recurrence rate in a national Danish patient cohort after curative treatment for rectal cancer

AIM

Several trials have shown that preoperative (chemo)radiotherapy (CRT) reduces local recurrence rates (LRRs) in rectal cancer (RC). The use of CRT varies greatly between countries. It is unknown whether the restrictive use of CRT in Denmark results in a higher LRR relative to other countries. The aim was to evaluate the LRR in a national Danish consecutive cohort of patients with RC.

METHODS

All data from patients with RC in Denmark in 2009-2010 who were operated on with curative intent were retrieved from the Danish Colorectal Cancer Group database. Patients with metastases at the time of diagnosis, patients with synchronous colon cancer, and patients, in whom only local surgical procedures were performed, were excluded. In total, 1633 patients met the inclusion criteria. Clinical follow-up was at least five years with a cut-off date of 31 December 2015.

RESULTS

Clinical follow-up was 5.4 years (median) with an interquartile range of 4.5-6.1 years. Of all included patients, 479 (29%) were treated with preoperative long-course CRT. Local recurrence was found in 68 patients, resulting in an LRR of 4.2%, and 182 (11%) patients developed distant metastases. Five-year overall survival was 74% (95% CI: 71.64-75.91).

CONCLUSIONS

Five-year follow-up of curatively treated patients with RC in Denmark revealed a low LRR. This figure is identical to those reported in other Nordic countries, despite Denmark's considerably stricter guidelines for CRT. The obtained results justify the currently adopted restrictive use of preoperative CRT in Denmark.

Urogenital function 3 years after abdominoperineal excision for rectal cancer

AIM

The aim of this study was to explore urogenital dysfunction and associated risk factors after treatment of rectal cancer, in a large national cohort of patients 3 years after abdominoperineal excision, and to compare outcomes with a reference population and a cohort of patients operated for prostate cancer.

METHOD

Patients treated with abdominoperineal excision in 2007-2009 were identified using the Swedish Colorectal Cancer Registry. All consenting patients received a questionnaire. A sample of the Swedish population was contacted and completed a questionnaire. Patients undergoing radical prostatectomy in a prospective multicentre trial received questionnaires 24 months after surgery.

RESULTS

In the abdominoperineal excision, reference and radical prostatectomy populations 72%, 51% and 91% of the questionnaires were returned. Within the abdominoperineal excision group 36% of the men and 57% of the women were incontinent postoperatively. Fifteen per cent and 37% of men and women in the reference group were incontinent. Two years after radical prostatectomy 49% were incontinent. Seventy-four per cent of the men had erectile dysfunction after abdominoperineal excision. Nineteen per cent of the women experienced reduced ability to reach orgasm. Fewer men and women experienced their present sex life as satisfying after abdominoperineal excision for rectal cancer compared with the reference population.

CONCLUSION

A large proportion of patients endure persistent urogenital dysfunction after abdominoperineal excision for rectal cancer as do men after radical prostatectomy. Effects on sexual and urinary function should be part of preoperative information and after surgery patients should be asked about function in order to identify those in need of further assistance.

Value of endorectal ultrasonography in measuring the extent of mesorectal invasion and substaging of T3 stage rectal cancer

The present study aimed to determine the value of endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) for T3 rectal cancer, and substaging of T3 rectal cancer by measuring the extent of mesorectal invasion (EMI). The clinical data of patients with rectal cancer who were admitted to the general surgical department of Peking Union Medical College Hospital (Beijing, China) were reviewed and analyzed. Two ultrasound practitioners independently measured the EMI on ERUS, and a radiologist measured the EMI on MRI. The consistency of ERUS measurements between the two doctors was assessed using intraclass consistency (ICC) analysis. T3 stages were subdivided into T3a (EMI ≤5 mm) and uT3b (EMI >5 mm). The accuracy of MRI and ERUS in T3 rectal cancer, and T3 substaging of rectal cancer was assessed and compared according to the pathological results. The Bland-Altman scatter plot demonstrated good consistency between the ERUS measurement and pathology measurement. Furthermore, the consistency of the ERUS measurement between the two doctors was good (ICC, 0.9344; 95% confidence interval, 0.8789-0.9645). The diagnostic accuracies for T3 rectal cancer, for the two ultrasound doctors and for MRI were 86.9% (53/61), 85.2% (52/61), and 90.2% (55/61), respectively. The accuracy, sensitivity and specificity for the two individual ultrasound doctors in the substaging of T3 tumors were 79.1% (34/43), 66.7% (10/15), and 85.7% (24/28), compared with 67.4% (31/43), 60% (9/15), and 82.1% (23/28), respectively. The accuracy of MRI in the substaging of T3 tumors was 86.0% (37/43), which was not statistically higher compared with those of ERUS (P>0.05). In conclusion, ERUS is a valuable tool for measuring the EMI and substaging T3 rectal cancer, and thus, can be complementary to MRI in selecting the appropriate treatment for rectal cancer.

Sexual Function and Health-Related Quality of Life in Long-Term Rectal Cancer Survivors

INTRODUCTION

Sexual dysfunction is a treatment sequela in survivors of rectal cancer (RC). Differences in health-related quality of life (HRQOL) can occur based on ostomy status (permanent ostomy vs anastomosis).

AIM

To describe alterations in sexual function and HRQOL based on ostomy status in long-term (≥5 years) survivors of RC.

METHODS

Survivors of RC with an ostomy (n = 181) or anastomosis (n = 394) were surveyed using validated HRQOL and functional status tools. We compared sexuality outcomes between the ostomy and anastomosis groups and reported differences adjusted for clinical and demographic characteristics. Qualitative data from one open-ended question on survivors' greatest challenges since their surgery were analyzed to explore sexuality, symptoms, and relationships.

MAIN OUTCOME MEASURES

Whether sexually active, satisfaction with sexual activity, and select sexual dysfunction items from the Modified City of Hope Quality of Life-Colorectal.

RESULTS

Survivors with a permanent ostomy were more likely to have been sexually inactive after surgery if it occurred before 2000 and experience dissatisfaction with appearance, interference with personal relationships and intimacy, and lower overall HRQOL. Female survivors of RC with an ostomy were more likely to have problems with vaginal strictures and vaginal pain after surgery that persisted at the time of the survey (≥5 years later). Radiation treatment, tumor stage, soilage of garments in bed, and higher Charlson-Deyo comorbidity scores were negatively associated with outcomes. Six qualitative themes emerged: loss of and decreased sexual activity, psychological issues with sexual activity, physical issues with sexual activity, partner rejection, ostomy interference with sexual activity, and positive experiences with sexuality.

CONCLUSION

Sexual dysfunction is a common long-term sequela of RC treatment, with more problems observed in survivors with a permanent ostomy. This warrants widespread implementation of targeted interventions to manage sexual dysfunction and improve HRQOL for these survivors.

Genito-urinary sequelae after carcinological rectal resection: What to tell patients in 2017

Although we have seen revolutionary changes with multi-disciplinary management of patients with rectal cancer, the evaluation of genito-urinary sequelae remains of great concern. Precise pre-operative evaluation with validated scores allows detection of urinary disorders in 16 to 23% of patients, and sexual disorders in nearly 35% of men and 50% of women. Regardless of the surgical approach, it is fundamental to respect the autonomic innervation during total mesorectal excision in order to prevent these sequelae. Identification of these nerves can be facilitated by intra-operative neuro-stimulation. In spite of these precautions, de novo urinary sequelae are observed in nearly 33% of patients and bladder evacuation disorders in 25% of patients. Advanced age, pre-operative urinary disorders, female gender, and abdomino-perineal resection are independent risk factors for urinary sequelae. Early post-operative urodynamic abnormalities might be predictive of these sequelae and justify early physiotherapy. Likewise, sexual sequelae such as erectile and/or ejaculatory disorders, dyspareunia and lubrication deficits result in de novo cessation of sexual activity in 28% of men and 18% of women. Advanced age, neo-adjuvant radiation therapy, and abdomino-perineal resection are independent risk factors for sexual dysfunction. Pharmacotherapy with sildenafil has proven useful in the treatment of erectile disorders. Genito-urinary and ano-rectal sequelae occur concomitantly in more than one of ten patients, suggesting a potential common pathophysiology.

Diffusion Kurtosis Imaging Study of Rectal Adenocarcinoma Associated with Histopathologic Prognostic Factors: Preliminary Findings

Purpose To determine the correlation between diffusion kurtosis imaging (DKI)-derived parameters and prognostic factors for rectal adenocarcinoma. Materials and Methods This study was approved by the local institute review board, and written informed consent was obtained from each patient. Data from 56 patients (median age, 59.5 years; age range, 31-86 years) with rectal adenocarcinoma between April 2014 and September 2015 were involved in this prospective study. DKI (b = 0, 700, 1400, and 2100 sec/mm²) and conventional diffusion-weighted imaging (b = 0, 1000 sec/mm²) were performed. Kurtosis and diffusivity from DKI and apparent diffusion coefficients (ADCs) from diffusion-weighted imaging were measured by two radiologists. Student t test, receiver operating characteristic curves, and Spearman correlation were used for statistical analysis. Results Kurtosis was significantly higher in high-grade than in low-grade rectal adenocarcinomas on the basis of both the number of poorly differentiated clusters (PDCs) (1.136 ± 0.086 vs 0.988 ± 0.060, P < .05) and World Health Organization (WHO) grades (1.103 ± 0.086 [standard deviation] vs 1.034 ± 0.103, P < .05). In PDC grading, the diffusivity and ADC were significantly lower in high-grade tumors than in low-grade tumors (1.187 ± 0.150 vs 1.306 ± 0.129 and 1.020 ± 0.113 vs 1.108 ± 0.097, respectively; P < .05) and showed similar correlations with histologic grades (r = -0.486 and r = -0.406, respectively; P > .05). Compared with both diffusivity and ADC, kurtosis showed significantly higher sensitivity (83.3% [20 of 24] vs 70.8% [17 of 24] and 70.8% [17 of 24], respectively) and specificity (96.8% [31 of 32] vs 84.4% [24 of 32] and 81.3% [26 of 32], respectively). Kurtosis showed a better correlation with PDC grades than with WHO grades (r = 0.797 vs r = 0.293, P < .05). Kurtosis was significantly higher in pN1-2 than in pN0 tumors (1.086 ± 0.103 vs 1.009 ± 0.086, P < .05). Conclusion Kurtosis derived from DKI demonstrated a higher correlation with histologic grades compared with diffusivity and ADC. It also showed better performance in differentiating between high- and low-grade rectal adenocarcinomas and between pN1-2 and pN0 tumors. ^© RSNA, 2016.

No Differences in Symptom Burden Between Colorectal Cancer Patients Receiving Curative Versus Palliative Chemotherapy

CONTEXT

Colorectal cancer (CRC) is one of the most common cancers worldwide. Patients with CRC may have multiple cooccurring symptoms as a result of their disease or its treatment. Little is known about potential differences in symptom burden in CRC patients scheduled to receive curative versus palliative chemotherapy (CTX).

OBJECTIVES

The purposes of this study were to investigate the overall symptom burden of patients with CRC before their first CTX treatment or before the initiation of a new CTX regimen and to evaluate for differences in symptom occurrence, severity, and distress between patients with CRC who were scheduled to receive curative versus palliative CTX.

METHODS

Consecutive patients with CRC were recruited (n = 120), and symptoms were assessed using the Memorial Symptom Assessment Scale before the initiation of the CTX. The most common symptoms that occurred in ≥30% of the patients were evaluated. Differences in occurrence rates and severity and distress scores between the curative (n = 68) and palliative (n = 52) patient groups were evaluated using binary logistic regression and ordinal logistic regression analyses, respectively.

RESULTS

In both groups, patients reported an average of 10 cooccurring symptoms. Worrying (65%), lack of energy (59%), feeling drowsy (54%), feeling bloated (53%), pain (51%), and difficulty sleeping (50%) were the most prevalent symptoms. Problems with sexual interest had the highest severity and distress scores in both groups. For the 13 most common symptoms, no significant differences were found between the two patient groups on any of the Memorial Symptom Assessment Scale dimensions (i.e., occurrence, severity, distress).

CONCLUSION

Regardless of the reason for CTX, CRC patients experience a large number of cooccurring symptoms.

Erectile and urinary function in men with rectal cancer treated by neoadjuvant chemoradiotherapy and neoadjuvant chemotherapy alone: a randomized trial report

OBJECTIVE

The aim was to evaluate erectile and urinary function of male patients with rectal cancer treated by neoadjuvant (NA) chemoradiotherapy (CRT) or NA chemotherapy only.

METHODS

In this prospective randomized trial (ClinicalTrials.gov NCT01211210; "FOWARC"), we included 102 men who received NA therapy for stage II-III rectal cancer between January 2011 and June 2013. Before surgery, patients received either NA mFOLFOX6 chemotherapy with radiation (RCS group, n = 54) or NA mFOLFOX6 chemotherapy alone (CS group, n = 48). Erectile and urinary dysfunctions were assessed with the five-item International Index of Erectile Function (IIEF-5) scale and the International Prostatic Symptom Score (IPSS), respectively. Questionnaires were completed at baseline and at 3, 6, and 12 months (t0-t3, respectively) after surgery.

RESULTS

At t3, mean IIEF-5 score was significant higher in the CS group (15.3 ± 5.5) than in the RCS group (12.6 ± 5.7; P < 0.05). And score difference was statistically higher in RCS group compared with CS group at t2 and t3, especially t3 (9.3 ± 5.5 vs. 6.1 ± 5.1, P < 0.01). Univariate analysis of the RCS group's IIEF-5 scores associated age, stoma, location, and tumor size to erectile dysfunction. However, mean IPSS scores did not differ between the two groups at any point.

CONCLUSIONS

Compared with the CS group, erectile and urinary functions were significantly affected by NA CRT. Age, stoma, tumor location, and tumor size were also correlated with erectile dysfunction in the RCS group.

Male urinary and sexual function after robotic pelvic autonomic nerve-preserving surgery for rectal cancer

BACKGROUND

Urinary and sexual dysfunction is the potential complication of rectal cancer surgery. The aim of this study was to evaluate the urinary and sexual function in male patients with robotic surgery for rectal cancer.

METHODS

This prospective study included 137 of the 336 male patients who underwent surgery for rectal cancer. Urinary and male sexual function was studied by means of a questionnaire based on the International Prostatic Symptom Score and International Index of Erectile Function. All data were collected before surgery and 12 months after surgery.

RESULTS

Patients who underwent robotic surgery had significantly decreased incidence of partial or complete erectile dysfunction and sexual dysfunction than patients with laparoscopic surgery. The pre- and post-operative total IPSS scores in patients with robotic surgery were significantly less than that with laparoscopic surgeries.

CONCLUSIONS

Robotic surgery shows distinct advantages in protecting the pelvic autonomic nerves and relieving post-operative sexual dysfunction.

Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery

OBJECTIVE

The aim of this study was to express the effects of demographic characteristics, the type of the surgery, tumour characteristics and adjuvant therapy on urinary and sexual dysfunctions.

MATERIALS AND METHOD

Pre-operational urinary and sexual dysfunctions of the patients were evaluated by using the surveys prepared according to International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) in men and Index of Female Sexual Function (IFSF) in women.

FINDINGS

A total of 56 patients were included in the study; 20 of them were women and 36 of them were men. The mean age was 56. Abdominoperineal resection (APR) was performed on 11 patients, and low anterior resection (LAR) was performed on 45. The post-treatment IPSS classes were worsened at a rate of 12.7 % compared to the pre-treatment. The mean post-treatment sexual dysfunction score of both men and women were decreased by 27.5 and 17.8 %, respectively. Rectal tumours located in the lower part resulted in more sexual dysfunction.

CONCLUSION

The tumour in the 1/3 lower part of the rectal area was determined to be the most effective factor that caused both urinary and sexual dysfunction. Patients should be informed about the urinary and sexual dysfunctions in the pre-operative consultations.

A comprehensive longitudinal overview of health-related quality of life and symptoms after treatment for rectal cancer in the TME trial

BACKGROUND

Total mesorectal excision (TME) combined with preoperative short-term radiotherapy (PRT) reduces local recurrence rates in rectal cancer treatment. However, treatment with radiotherapy increased morbidity and did not result in a longer survival. The aim of this analysis is to provide a comprehensive longitudinal overview of the health-related quality of life (HRQL) and symptoms experienced by rectal cancer patients in the Dutch randomized TME trial from baseline until 14 years after treatment.

METHODS

Rectal cancer patients (n =1530) were randomly allocated to PRT (5 × 5 Gy) followed by TME or to TME alone. At baseline, 3, 6, 12, 18, and 24 months, 5 years and 14 years after treatment HRQL was evaluated in surviving patients (n =606, at 14 years after treatment).

RESULTS

None of the general symptoms differed significantly between PRT + TME and TME. However, in both treatment arms the general symptoms were increased at the diagnosis of rectal cancer, after surgery and by aging. With PRT + TME bowel symptoms were increased, specifically more fecal incontinence was reported at all time points, resulting in more use of pads for fecal incontinence (PRT + TME vs. TME at 5 years 51.5% vs. 30.5%, respectively, and at 14 years 56.4% vs. 37.1%, respectively).

CONCLUSIONS

This longitudinal analysis shows that general symptoms in both groups are increased at the diagnosis of rectal cancer, after surgery and by aging, but not by RT. However, irradiated patients reported more bowel dysfunction at all time points.

Comparative Outcomes of Neoadjuvant Treatment Prior to Total Mesorectal Excision and Total Mesorectal Excision Alone in Selected Stage II/III Low and Mid Rectal Cancer

BACKGROUND

Current guidelines advocate that all rectal cancer patients with American Joint Committee on Cancer (AJCC) stages II and III disease should be subjected to neoadjuvant therapy. However, improvements in surgical technique have resulted in single-digit local recurrence rates with surgery only.

METHODS

Operative, postoperative, and oncological outcomes of patients with and without neoadjuvant therapy were compared between January 2002 and December 2013. For this purpose, all patients resected with low anterior rectal resection (LAR) and total mesorectal excision (TME) who had or had not been irradiated were identified from the authors' prospectively maintained database. Patients who were excluded were those with high rectal cancer or AJCC stage IV disease; in the surgery-only group, patients with AJCC stage I disease or with pT4Nx rectal cancer; and in the irradiated patients, patients with ypT4Nx or cT4Nx rectal cancer.

RESULTS

Overall, 454 consecutive patients were included. A total of 342 (75 %) patients were irradiated and 112 (25 %) were not irradiated. Median follow-up for all patients was 48 months. Among patients with and without irradiation, pathological circumferential resection margin positivity rates (2.9 vs. 1.8 %, p = 0.5) were not different. At 5 years, in irradiated patients compared with surgery-only patients, the incidence of local recurrence was decreased (4.5 vs. 3.8 %, p = 0.5); however, systemic recurrences occurred more frequently (10 vs. 17.8 %, p = 0.2). Irradiation did not affect overall or disease-free survival (neoadjuvant treatment vs. surgery-only: 84.9 vs. 88.2 %, p = 0.9; 76 vs. 79.1 %, p = 0.8).

CONCLUSIONS

The current study adds to the growing evidence that suggests a selective rather than generalized indication for neoadjuvant treatment in stages II and III rectal cancer.

Impact of anatomic location on locally recurrent rectal cancer: superior outcome for intraluminal tumour recurrence

BACKGROUND

Local recurrence of rectal cancer after curative surgery predicts patients' prognosis. The correlation between the exact anatomic location of tumour recurrence and patients' survival is still under debate. Thus, this study aimed to investigate the impact of the exact location of recurrent rectal cancer on post-operative morbidity and survival.

METHODS

This is a retrospective study including 90 patients with locally recurrent rectal cancer. The location of tumour recurrence was classified into intraluminal and extraluminal recurrence. Univariate and multivariable Cox regression analyses were used to determine the impact on post-operative morbidity and survival.

RESULTS

Patients' survival with intraluminal recurrence was significantly longer compared to patients with extraluminal recurrence (p = 0.027). Curative resection was associated with prolonged survival in univariate and multivariable analyses (p = 0.0001) and was more often achieved in patients with intraluminal recurrence (p = 0.024). Survival of curative resected patients with intraluminal recurrence was significantly longer compared to curatively resected patients with extraluminal recurrence (p = 0.0001). The rate of post-operative morbidity between intraluminal and extraluminal recurrence was not statistically different (p = 0.59).

CONCLUSION

Based on the present investigation, intraluminal recurrence is associated with superior outcome. Post-operative morbidity did not differ significantly between both groups.

Short- and Long-Term Quality of Life and Bowel Function in Patients With MRI-Defined, High-Risk, Locally Advanced Rectal Cancer Treated With an Intensified Neoadjuvant Strategy in the Randomized Phase 2 EXPERT-C Trial

OBJECTIVE

Intensified preoperative treatments have been increasingly investigated in locally advanced rectal cancer (LARC), but limited data are available for the impact of these regimens on quality of life (QoL) and bowel function (BF). We assessed these outcome measures in EXPERT-C, a randomized phase 2 trial of neoadjuvant capecitabine combined with oxaliplatin (CAPOX), followed by chemoradiation therapy (CRT), total mesorectal excision, and adjuvant CAPOX with or without cetuximab in magnetic resonance imaging-defined, high-risk LARC.

METHODS AND MATERIALS

QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires. Bowel incontinence was assessed using the modified Fecal Incontinence Severity Index questionnaire.

RESULTS

Compared to baseline, QoL scores during preoperative treatment were better for symptoms associated with the primary tumor in the rectum (blood and mucus in stool, constipation, diarrhea, stool frequency, buttock pain) but worse for global health status, role functioning, and symptoms related to the specific safety profile of each treatment modality. During follow-up, improved emotional functioning and lessened anxiety and insomnia were observed, but deterioration of body image, increased urinary incontinence, less sexual interest (men), and increased impotence and dyspareunia were observed. Cetuximab was associated with a deterioration of global health status during neoadjuvant chemotherapy but did not have any long-term detrimental effect. An improvement in bowel continence was observed after preoperative treatment and 3 years after sphincter-sparing surgery.

CONCLUSIONS

Intensifying neoadjuvant treatment by administering induction systemic chemotherapy before chemoradiation therapy improves tumor-related symptoms and does not appear to have a significantly detrimental effect on QoL and BF, in both the short and the long term.

Clinical results and toxicity for short-course preoperative radiotherapy and total mesorectal excision in rectal cancer patients

Short-course preoperative radiotherapy (SCPRT) is an alternative method to chemoirradiation for patients with Stage II and III rectal cancer when no downsizing is needed, but there is still widespread reluctance to use this method because of fear of side effects from high-fraction doses. This paper reports on a single institution patient cohort of operated rectal cancer patients after SCPRT, evaluated for chronic adverse effects, local control, progression-free survival and overall survival. Altogether, 257 patients were treated with SCPRT and surgery including total mesorectal excision (92% total mesorectal excision = TME) between 2002 and 2009. Local control and survival were analyzed. Chronic adverse effects for 154 patients without local relapse were evaluated according to the NCI-CTCAE version 4.0 classification, with a median follow-up of 48 months. We found a 5-year disease-free survival (DFS) and overall survival (OS) of 71%. The 5-year estimated local control (LC) rate was 94%. A positive resection margin was found in 4% of the patients and was significantly correlated with decreased DFS, OS and LC. Chronic adverse effects were reported by 58% of the patients, of which 10% were Grade 3 toxicities. The most frequent Grade 2 toxicity was stool incontinence (13%). Sexual dysfunction was found in 36% of the patients (31% Grade 1 or 2, and only 5% Grade 3). SCPRT combined with TME produced excellent LC rates together with a low rate of high-grade chronic adverse effects.

Intersphincteric resection and hand-sewn coloanal anastomosis for low rectal cancer: Short-term outcomes in the Indian setting

INTRODUCTION

The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario.

MATERIAL AND METHODS

All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay.

RESULTS

Thirty-three patients with low rectal cancer and a median age of 38 years underwent ISR during the defined study period. Twenty-three patients (70 %) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300 mL and 7 days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes.

CONCLUSIONS

Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

[Sexual functions after treatment for rectal cancer: impact of doses in autonomic pelvic nerves]

PURPOSE

Prospective evaluation of sexual function after treatment of rectal cancer and identification of predictive factors.

PATIENTS AND METHODS

Thirty-three patients were treated with curative intent by chemoradiation and surgery for localized rectal adenocarcinoma. Sexual toxicity was assessed four times (before treatment and at 2, 6 and 12 months) using validated questionnaires: QLQ C30 and EORTC CR38 for all, simplified IIEF for men and FSFI for women. A correlation was sought between the toxicity and clinical and dosimetric parameters by Fisher and Mann-Whitney tests.

RESULTS

In men, erections and sexual satisfaction decreased significantly from the acute phase and then stabilized (respective scores of 84.5 and 86/100 in the initial phase, 66 and 70.4 at the end of radiotherapy, 70 and 70 at 6 months and 68.5 and 70 at 12 months). For women, the changes were not significant. This study confirms some risk factors for sexual toxicity already mentioned (original function, age, tumor volume) and highlights new (dose to the seminal vesicles and above all, doses to pelvic autonomic plexus).

CONCLUSION

Sexual effects of combined treatment of rectal cancer have only recently been described but remain undervalued and poorly understood. The impact of the autonomic pelvic plexus doses is a completely new data that could be extended in the development of intensity-modulated radiotherapy.

Addressing sexual dysfunction in colorectal cancer survivorship care

Despite the high prevalence of sexual dysfunction in survivors of colorectal cancer, studies have shown that patients and providers rarely discuss how these symptoms may be influencing overall quality of life. The type and severity of symptoms of sexual dysfunction can vary greatly depending on the type of colorectal cancer and treatment, and assessment of sexual dysfunction is key to understanding how patients may be affected by these symptoms. Although patients would like to discuss these issues with their provider, they are often reluctant to ask questions about sexual functioning during appointments. Likewise, health care providers may hesitate to address sexual dysfunction due to time limitations or lack of knowledge regarding treatment of sexual problems. Health care providers can facilitate discussion of sexual dysfunction by (I) assessing sexual functioning throughout treatment; (II) initiating discussions about symptoms of sexual dysfunction at each appointment; and (III) maintaining adequate referral resources for treatment of sexual dysfunction.

Patient-reported outcomes after neoadjuvant therapy for rectal cancer: a systematic review

Neoadjuvant therapy followed by total mesorectal excision is standard of care for locally advanced rectal cancer. However, this approach has been previously shown to be associated with high rate of morbidity and it may have a negative effect on patients' reported outcomes (PROs). In order to summarize findings on the effect of the neoadjuvant approach on PROs, we systematically reviewed articles published in the last five years. Thirty-five articles met the inclusion criteria. Ten articles compared the effect of surgery with and without neoadjuvant therapy, six articles compared different neoadjuvant therapies, ten articles reported on patients who were all treated with neoadjuvant therapy, and nine articles examined the effect of neoadjuvant therapy in the analyses. The results are summarized by function investigated and critically commented.

Comparative analysis of late functional outcome following preoperative radiation therapy or chemoradiotherapy and surgery or surgery alone in rectal cancer

PURPOSE

This study evaluates the anorectal and genitourinary function of patients treated by preoperative short-term radiotherapy (RT) or chemoradiotherapy (CRT) followed by surgery and surgery alone for rectal cancer.

METHODS

For this study, a total of 613 patients, who were identified from a prospective rectal cancer database, underwent anterior resection of the rectum between October 2001 and December 2007. Standardized questionnaires were used to determine fecal incontinence, urinary, and sexual function. Relevant clinical variables were evaluated using univariate and multivariate analyses. Independent predictors of functional outcome were identified by a binary logistic regression analysis.

RESULTS

The data of 263 (43 %) patients were available for analysis. On multivariate analysis, neoadjuvant RT (P < 0.01) and low anterior resection (LAR) (P = 0.049) were associated with fecal incontinence. In univariate analysis, fecal incontinence was linked to preoperative neoadjuvant treatment (RT and/or CRT vs. LAR) (P < 0.01). The hazard ratio for developing fecal incontinence was 3.3 (1.6-6.8) for patients who received RT. One hundred twenty-five patients (51.2 %) experienced urinary incontinence following surgery, the majority of whom were female (P < 0.01). On univariate analysis, male sexual function was associated with age (P < 0.01), ASA class (P = 0.01) and LAR (P = 0.01).

CONCLUSION

Multimodal therapy of low rectal cancer increases the incidence of fecal incontinence and negatively affects sexual function. The potential benefits of RT or CRT need to be balanced against the risk of increased bowel dysfunction when determining the appropriate treatment for individual patients with rectal cancer.

Intraoperative monitoring of bladder and internal anal sphincter innervation: a predictor of erectile function following low anterior rectal resection for rectal cancer? Results of a prospective clinical study

BACKGROUND

The objective was to investigate whether two-dimensional intraoperative neuromonitoring (IONM) of pelvic autonomic nerves has the potential to predict erectile function (EF) following surgery for rectal cancer.

METHODS

A consecutive series of 17 sexually active male rectal cancer patients undergoing IONM-based nerve-sparing low anterior rectal resection were evaluated prospectively. IONM was performed by electric stimulation of the pelvic splanchnic nerves with concomitant electromyography of the internal anal sphincter and cystomanometry. Sexual function was assessed using a validated questionnaire.

RESULTS

The degree of agreement between electromyography-based and cystomanometry-based IONM with postoperative EF was moderate and good (κ = 0.43 and κ = 0.66). Combined assessment yielded the best agreement (κ = 0.76) with sensitivity of 90%, specificity of 86%, positive predictive value of 90%, negative predictive value of 86%, and overall accuracy of 88%, respectively, in terms of prediction of postoperative EF.

CONCLUSION

The method may be suitable to predict male EF following rectal resection.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.