Health-related quality of life in rectal cancer patients undergoing neoadjuvant chemoradiation with delayed surgery versus short-course radiotherapy with immediate surgery: a propensity score-matched cohort study

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Evaluation of Depression, Anxiety, and Sexual Function in Rectal Cancer Patients Before and After Neoadjuvant Chemoradiotherapy

OBJECTIVE

The association of treatment-related side effects and tumor characteristics with sexual function, depression, and anxiety were investigated in patients with locally advanced rectum cancer (LARC) receiving neoadjuvant chemoradiotherapy (CRT).

MATERIAL AND METHODS

Thirty-two patients who received neoadjuvant CRT with LARC were included. The Arizona Sexual Experiences (ASEX) Scale was used to determine the sexual function status whereas the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were used to evaluate the depression and anxiety status of the patient, respectively. The patients were asked to fill these scales before and at least 4 weeks after the neoadjuvant CRT. T-test and Mann-Whitney U test were used for the comparison of values.

RESULTS

Median age was 52.5 years (range: 33-76). Twenty-six patients were male, and 6 patients were female. At presentation, the tumor was located mostly in lower third rectum (72%), and 69% of the patients had T3 tumors. There was a statistically significant deterioration in the sexual functions of the patients (p < 0.001), a statistically significant decrease in their anxiety level after CRT (p: 0.037). Depression level was changed from mild to minimal during this process (p: 0.17). A significant deterioration in the ASEX scale was observed especially in patients with grade 2 and above gastrointestinal side effects (p: 0.01).

CONCLUSION

This prospective study showed that the patient's anxiety and depression levels had decreased during the treatment process probably due to the decrease in the patient's symptoms. However, deterioration of the sexual function status which might be correlated to increased gastrointestinal side effects during CRT has been observed. So, clinical and psychiatric support including therapies for sexual dysfunctions is needed for LARC patients during and after the neoadjuvant CRT.

Short-course radiotherapy for rectal cancer: real-world evidence in Argentina

Background

Short-course radiotherapy (SCRT) of 25 Gy in five daily fractions is a recommended strategy in the neoadjuvant setting for resectable locally advanced rectal cancer (LARC), as well as in cases of metastatic disease for local control. There is scarce information regarding the use of SCRT for patients who have received nonoperative management.

Objectives

To describe the characteristics of patients who received treatment with SCRT for LARC and metastatic rectal cancer, toxicity, and the approach after radiation treatment.

Methods

This is a retrospective analysis of all patients who underwent SCRT for rectal cancer at the Alexander Fleming Institute from March 2014 to June 2022.

Results

In total, 44 patients were treated with SCRT. The majority were male (29, 66%), with a median age of 59 years (interquartile range 46-73). Most patients had stage IV disease (26, 59.1%), followed by LARC (18, 40.9%). Most lesions were located in the middle rectum (30, 68%). The majority of LARC patients underwent SCRT followed by consolidation chemotherapy (ChT) (16/18, 89%), while most patients with metastatic disease underwent SCRT followed by consolidation ChT (14/26, 53.8%). A clinical complete response (cCR) was documented in 8/44, 18.2% of patients. Most patients with LARC and cCR were managed by a watch and wait approach (5/18, 27.7%). Local recurrence was observed in LARC cases (2/18, 11.1%). Patients who underwent SCRT following consolidation ChT were more likely to have adverse events (AEs) than those undergoing induction ChT following SCRT (11/30, 36.7% versus 3/12, 25%, p = 0.02).

Conclusion

In a subgroup of patients diagnosed with LARC and treated with SCRT followed by ChT, surgical treatment could be omitted after they achieved a cCR. Local recurrence was similar to that reported in a previous study. SCRT is a reasonable option for local disease control in stage IV disease, yielding low toxicity rates. Therefore, decisions must be made by a multidisciplinary team. Prospective studies are necessary to reach further conclusions.

The Quality of Life of Patients with Surgically Treated Colorectal Cancer: A Narrative Review

INTRODUCTION

Quality of life is a topic increasingly being addressed by researchers. Due to the increasing incidence of colorectal cancer, this issue is particularly relevant. Despite the increasing number of publications on this topic each year, it still requires further research. The aim of this study was to analyze the available literature from the past 10 years, addressing the topic of QoL in patients with colorectal cancer which has been treated surgically.

MATERIAL AND METHODS

This review is based on 93 articles published between 2012 and 2022. It analyzes the impact of socioeconomic factors, the location and stage of the tumor, stoma and the method of surgical treatment on patients' QoL and sexual functioning.

RESULTS

CRC has a negative impact on patients' financial status, social functioning, pain and physical functioning. Patients with stage II or III cancer have an overall lower QoL than patients with stage I. The more proximally the lesion is located to the sphincters, the greater the negative impact on the QoL. There was a significant difference in favor of laparoscopic surgery compared with open surgery. In patients with a stoma, the QoL is lower compared with patients with preserved gastrointestinal tract continuity. The more time has passed since surgery, the more the presence of a stoma has a negative impact on QoL. Surgery for CRC negatively affects patients' sex lives, especially in younger people and among men.

CONCLUSIONS

This study may contribute to the identification of the factors that affect the QoL of patients with surgically treated colorectal cancer. This will allow even more effective and complete treatment, facilitating patients' return to normal physical, mental and social functioning.

Prospective Evaluation of the Quality of Life of Patients after Surgical Treatment of Rectal Cancer: A 12-Month Cohort Observation

This study constitutes a prospective, three-stage evaluation of quality of life among patients receiving surgical treatment for colorectal cancer depending on the type of surgery performed (open anterior resection, laparoscopic anterior resection, abdominoperineal resection, or Hartmann’s procedure). The study included 82 patients treated at the Surgical Oncology Outpatient Department of the Oncology Center in Bydgoszcz from June 2019 to August 2021. The study tools consisted of diagnostic surveys and analyses of medical records. The standardized study tools were the surveys EORTC QLQ-C30 and QLQ-CR29. In addition, a proprietary questionnaire was developed to collect demographic data. Quality of life was measured at three time-points: the day before the surgery and 6 and 12 months post-surgery. Statistically significant differences (p < 0.05) were observed in the domains of role functioning (III, p = 0.030), body image (II, p < 0.001; III, p < 0.001), sexual functioning (II, p = 0.037), buttocks/anal area/rectum pain (III, p = 0.031), and embarrassment (II, p = 0.022; III, p = 0.010). Statistically significant differences in the functional and symptom scale scores were also observed within each group at different stages of cancer treatment. As shown by our study, the quality of life of patients treated for colorectal cancer is determined not only by the operating technique but also by sociodemographic and clinical factors. The use of minimally invasive surgical techniques enables patients to return to their social roles more quickly and improves their self-assessment of body image.

Prospective multicentre observational cohort to assess quality of life, functional outcomes and cost-effectiveness following minimally invasive surgical techniques for rectal cancer in 'dedicated centres' in the Netherlands (VANTAGE trial): a protocol

INTRODUCTION

Total mesorectal excision is the standard of care for rectal cancer, which can be performed using open, laparoscopic, robot-assisted and transanal technique. Large prospective (randomised controlled) trials comparing these techniques are lacking, do not take into account the learning curve and have short-term or long-term oncological results as their primary endpoint, without addressing quality of life, functional outcomes and cost-effectiveness. Comparative data with regard to these outcomes are necessary to identify the optimal minimally invasive technique and provide guidelines for clinical application.

METHODS AND ANALYSIS

This trial will be a prospective observational multicentre cohort trial, aiming to compare laparoscopic, robot-assisted and transanal total mesorectal excision in adult patients with rectal cancer performed by experienced surgeons in dedicated centres. Data collection will be performed in collaboration with the prospective Dutch ColoRectal Audit and the Prospective Dutch ColoRectal Cancer Cohort. Quality of life at 1 year postoperatively will be the primary outcome. Functional outcomes, cost-effectiveness, short-term outcomes and long-term oncological outcomes will be the secondary outcomes. In total, 1200 patients will be enrolled over a period of 2 years in 26 dedicated centres in the Netherlands. The study is registered at https://www.trialregister.nl/9734 (NL9734).

ETHICS AND DISSEMINATION

Data will be collected through collaborating parties, who already obtained approval by their medical ethical committee. Participants will be included in the trial after having signed informed consent. Results of this study will be disseminated to participating centres, patient organisations, (inter)national society meetings and peer-reviewed journals.

Systematic Review of Cognitive Impairment in Colorectal Cancer Survivors Who Received Chemotherapy

PROBLEM IDENTIFICATION

Cognitive impairment is a common and troublesome side effect experienced by many cancer survivors. It can have a significant impact on survivors' ability to function and enjoy a high quality of life. However, most cognitive impairment research has focused on breast cancer survivors, despite the high rates of colorectal cancer and the toxicity of treatment agents in some colorectal cancer chemotherapeutic regimens, which have been linked to cognitive impairment. This review provides a novel synthesis of what is known about cognitive impairment in colorectal cancer survivors.

LITERATURE SEARCH

CINAHL®, Cochrane Library, Embase®, PsycINFO®, and PubMed® were systematically searched by a health sciences librarian.

DATA EVALUATION

Data were extracted across studies; findings about the prevalence, severity, and correlates of cognitive impairment were synthesized.

SYNTHESIS

Across findings from 26 articles representing 24 independent studies, 13%-57% of participants had cognitive impairment. Potential demographic, physiologic, and psychological correlates of cognitive impairment were identified.

IMPLICATIONS FOR PRACTICE

Findings indicate a need to focus research and patient assessments on early identification of risk factors, assessing for existing cognitive deficits and testing interventions to decrease cognitive impairment in colorectal cancer survivors.

Trajectories of health-related quality of life and psychological distress in patients with colorectal cancer: A population-based study

BACKGROUND

The aim of this nationwide cohort study was to examine the course of symptoms and trajectories of health-related quality of life (HR-QoL) and psychological distress during follow-up and to identify vulnerable patients.

METHODS

Patients with pathological stage I-III colorectal cancer (CRC) between 2013 and 2018 were included. Baseline characteristics were collected from the Netherlands Cancer Registry, and patients completed the European Organisation for Research and Treatment of Cancer QLQ-C30/CR29, Hospital Anxiety and Depression Scale and low anterior resection syndrome (LARS) questionnaires at the baseline and subsequently at 3, 6, 12, 18 and 24 months. Latent class growth and multinomial logistic regression analyses were performed to outline 24-month trajectories in HR-QoL and distress and to identify predictive factors.

RESULTS

A total of 1535 patients with colon cancer or rectal cancer were included. Trajectory analysis of HR-QoL identified three patient classes: high HR-QoL (62.7%), improving HR-QoL (29.0%) and low HR-QoL (8.3%). The following patient groups were identified with having low distress (64.0%), moderate distress (26.9%) and high distress (9.1%). Around 13% of the total cohort had either persistent low HR-QoL or high psychological distress throughout follow-up. Patients belonging to this vulnerable group were significantly more likely to be female, to be younger aged, to have lower education, to have disease stage II-III or to have major LARS.

CONCLUSIONS

Although most patients treated for stage I-III CRC fared well, a small but significant proportion of around 13% did not recover during follow-up and reported low HR-QoL and/or high psychological distress levels throughout. This study's findings should be taken into account when organising and selecting patients for tailored follow-up.

Impact of dose-escalated chemoradiation on quality of life in patients with locally advanced rectal cancer: two year follow-up of the randomized RECTAL-BOOST trial

BACKGROUND

Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer (LARC) did not result in higher complete response rates, but initiated more tumor regression in the randomized XXXXX trial (Clinicaltrials.gov XXXXX). This study compared patient reported outcomes (PROs) between patients who received dose-escalated CRT (5 × 3Gy boost + CRT) or standard CRT for two years following randomization.

METHODS

Patients with LARC, participating in the XXXXX trial, filled out EORTC QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18 and 24 months following start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test.

RESULTS

Patients treated with dose-escalated CRT (boost group, n=51) experienced a significantly stronger decline in global health at 3 and 6 months (ES -0,4 and ES -0,4), physical functioning at 6 months (ES -1,1), role functioning at 3 and 6 months (ES -0,8 and ES -0,6) and social functioning at 6 months (ES -0,6) compared to patients treated with standard CRT (control group, n=64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs. 66% resp. 89% vs. 76%), pain at 3 and 6 months (67% vs. 36% resp. 80% vs. 44%) and diarrhea at 3 months (45% vs. 29%) compared to the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group.

CONCLUSION

In patients with LARC, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months following start of treatment compared to standard CRT. From 12 months onwards, the impact of dose-escalated CRT on QoL largely resolved.

Evaluating the longitudinal effect of colorectal surgery on health-related quality of life in patients with colorectal cancer

Background and Objectives

Surgery for colorectal cancer (CRC) negatively affects health‐related quality of life (HRQoL). Addressing shortcomings in literature, the purpose of this study was to evaluate the impact of surgery for CRC on the course of HRQoL from baseline up to 2 years after diagnosis.

Methods

In this prospective, population‐based study patients with newly diagnosed CRC were included between 2016 and 2019. HRQoL was assessed by the EORTC QLQ‐C30 questionnaire over time both between and within subgroups of patients that underwent right‐sided colonic, left‐sided colonic, and rectal resection using linear mixed model analyses.

Results

The study included 415 patients of whom 148 patients underwent right‐sided colonic (36%), 147 left‐sided colonic (35%), and 120 rectal resection (29%). Overall, HRQoL scores restored to baseline level 1 year after diagnosis. Impact of surgery seems to be more prominent in patients who underwent rectal resection, as they experienced more pain and had worse role and social functioning scores 4 weeks after surgery. Finally, among patients who underwent left‐sided and rectal resection, physical functioning did not return to baseline level during follow‐up.

Conclusion

This study shows several differences (between‐group and within‐group) in HRQoL according to surgery type and offers perspective which patients may need additional support in the care pathway.

Follow-up practice and healthcare utilisation of colorectal cancer survivors

OBJECTIVE

To examine healthcare utilisation and adherence to colorectal cancer (CRC) follow-up guidelines.

METHODS

A total of 2450 out of 3025 stage I-III CRC survivors diagnosed between 2000 and 2009 completed the Hospital Anxiety and Depression Scale, SF-12, EORTC QLQ-CR38 and Fatigue Assessment Score questionnaires, in December 2010. Multivariable regression analyses were performed to identify predictors for increased follow-up care (>1 visit than recommended by guidelines).

RESULTS

In the first follow-up year, the average number of cancer-related visits to the general practitioner and medical specialist was 1.7 and 4.2, respectively. More than 80% of the CRC survivors was comfortable with their follow-up schedule, and 49-72% of them received follow-up according to the guidelines. Around 29-47% was followed more than recommended. Simultaneously, around 4-14% of the CRC survivors received less follow-up care than recommended. Survivors of stage III disease treated with chemotherapy received the most follow-up care. In addition, lower socio-economic status stoma and fatigue were associated with increased follow-up care.

CONCLUSION

CRC survivors were predominantly followed according to national guidelines. Increased follow-up care is driven by advanced disease stage, chemotherapy, SES, stoma and fatigue. Future studies should investigate how increased follow-up care use can be reduced, while still addressing patients' needs.

Immunity, immunotherapy, and rectal cancer: A clinical and translational science review

Rectal cancer remains a challenging disease to treat. Therapy for locally advanced rectal cancer (LARC), the most frequent presentation, has evolved to include a multimodal approach of radiation, chemotherapy, and surgery. While this approach improves local disease control, the distant recurrence rate is nearly 30% and treatment-related morbidity is substantial, thus underscoring the need for new therapeutic approaches with better efficacy and lower side effects. Immunotherapy could potentially fill this need, but its promise is not yet realized in rectal cancer. In this translational science review, we address what is known about how cytotoxic therapies shape rectal cancer immunity and potentially prime the tumor microenvironment for response to immune checkpoint inhibitors and other immunotherapies. We also address the role of current immunotherapies in colorectal cancer and highlight where novel immunotherapy approaches are currently being evaluated in LARC. Finally, we address important future directions in LARC immunotherapy including the need to define optimal therapeutic sequencing, predictive biomarkers, strategies to limit treatment-related side effects and the potential of gut microbiome manipulation to improve outcomes. In summary, this review provides a framework to guide future research and inform immunotherapy trial design so as to advance rectal cancer care.

Transanal total mesorectal excision and low anterior resection syndrome

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR).

METHODS

Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression.

RESULTS

Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group.

CONCLUSIONS

TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.

Altered fractionation short-course radiotherapy for stage II-III rectal cancer: a retrospective study

Purpose

To report the long-term outcomes of neoadjuvant altered fractionation short-course radiotherapy in 271 consecutive patients with stage II-III rectal cancer.

Patients and Methods: This was a retrospective single institution study with median follow-up of 101 months (8.4 years). Patients who were alive at the time of analysis in 2018 were contacted to obtain functional outcome data (phone interview). Radiotherapy consisted of 25 Gy in 10 fractions of 2.5 Gy administered twice daily. Median time interval to surgery was 5 days.

Results

Local relapse was observed in 12 patients (4.4%) after a median of 28 months. Overall survival after 5 and 10 years was 73 and 55.5%, respectively (corresponding disease-free survival 65.5 and 51%). Of all patients without permanent stoma, 79% reported no low anterior resection syndrome (LARS; 0–20 points), 9% reported LARS with 21–29 points and 12% serious LARS (30–42 points).

Conclusion

The present radiotherapy regimen was feasible and resulted in low rates of local relapse. Most patients reported good functional outcomes.

The Effects of Neoadjuvant Treatment on the Tumor Microenvironment in Rectal Cancer: Implications for Immune Activation and Therapy Response

BACKGROUND

Because more than one neoadjuvant treatment is available for advanced rectal cancer, the aim of this study was to compare the differential clinical and pathologic effects of different combinations of chemoradiation regimens, treatment sequencing, and timing to surgery on patient outcomes.

PATIENTS AND METHODS

Between January 2015 and October 2018, 126 newly diagnosed patients with rectal cancer with magnetic resonance imaging-based cT3-4 or N+ rectal disease for curative-intent treatment received 1 of 4 neoadjuvant regimens, followed by immediate surgery or delayed surgery. Whole post-neoadjuvant surgical specimens were assessed by 3-dimensional digital whole-tumor microarray imaging and immunostaining in pathology to analyze the global tumor pathologic regression grades, residual tumor distribution patterns, the extent of lymphovascular permeation, lymph node positivity, and the overall density of lymphocyte infiltration in the tumor microenvironment. These factors were further examined to identify possible correlations with clinical outcomes.

RESULTS

Among the 4 neoadjuvant treatment groups, including 2 conventional regimens, we found a significant increase of stromal CD3+ and CD8+ immune infiltrates in the postneoadjuvant tumor microenvironment in the 3 groups with delayed surgery after different chemoradiation regimens compared with the group with immediate surgery after a short course of RT alone. Independent of neoadjuvant chemoradiation regimens, the post-induction high-intermediate-low stromal-infiltrating CD8+ T-cell densities corresponded to tumor regression grades, distant metastasis rates, and disease-free survival and were prognostic factors for the further stratification of patients with American Joint Committee on Cancer stage III rectal cancer into different risk groups after surgery.

CONCLUSION

The effectiveness of induction strategies on tumor remission and disease recurrence in advanced rectal cancer was significantly correlated with an enhanced cytotoxic immune response in the tumor microenvironment.

Quality of Life After Radiotherapy for Rectal and Anal Cancer

Purpose of Review

With advances in radiation therapy (RT) techniques for rectal and anal cancers allowing for the modulation of critical normal tissues, there has been an increased emphasis on improving the quality of life (QOL) of cancer survivors. Herein, we review the literature to examine the impact of RT on QOL and patient reported outcomes (PROs) to better inform providers about the challenges of survivorship.

Recent Findings

Large systematic reviews, recent studies and long-term follow-up of pivotal clinical trials have shown that RT impacts QOL, particularly fecal continence and sexual function. Modern preoperative RT techniques allow for decreased dose to organs-at-risk will likely improve QOL.

Summary

RT, though critical in the treatment of rectal and anal cancer, has a profound impact on QOL for some patients. Recent studies have included PROs and validated QOL metrics to better inform providers and patients.