Designing and evaluating a patient decision aid for patients with locally advanced or locally recurrent rectal cancer: a national multicentre mixed methods study protocol

A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer

INTRODUCTION

Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer.

METHODS

A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded.

FINDINGS

A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months.

CONCLUSIONS

This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.

A Prospective Observational Cohort Study Comparing High-Complexity Against Conventional Pelvic Exenteration Surgery

Background: Conventional pelvic exenteration (PE) comprises the removal of all or most central pelvic organs and is established in clinical practise. Previously, tumours involving bone or lateral sidewall structures were deemed inoperable due to associated morbidity, mortality, and poor oncological outcomes. Recently however high-complexity PE is increasingly described and is defined as encompassing conventional PE with the additional resection of bone or pelvic sidewall structures. This observational cohort study aimed to assess surgical outcomes, health-related quality of life (HrQoL), decision regret, and costs of high-complexity PE for more advanced tumours not treatable with conventional PE. Methods: High-complexity PE data were retrieved from a prospectively maintained quaternary database. The primary outcome was overall survival. Secondary outcomes were perioperative mortality, disease control, major morbidity, HrQoL, and health resource use. For cost-utility analysis, a no-PE group was extrapolated from the literature. Results: In total, 319 cases were included, with 64 conventional and 255 high-complexity PE, and the overall survival was equivalent, with medians of 10.5 and 9.8 years (p = 0.52), respectively. Local control (p = 0.30); 90-day mortality (0.0% vs. 1.2%, p = 1.00); R0-resection rate (87% vs. 83%, p = 0.08); 12-month HrQoL (p = 0.51); and decision regret (p = 0.90) were comparable. High-complexity PE significantly increased overall major morbidity (16% vs. 31%, p = 0.02); and perioperative costs (GBP 37,271 vs. GBP 45,733, p < 0.001). When modelled against no surgery, both groups appeared cost-effective with incremental cost-effectiveness ratios of GBP 2446 and GBP 5061. Conclusions: High-complexity PE is safe and feasible, offering comparable survival outcomes and HrQoL to conventional PE, but with greater morbidity and resource use. Despite this, it appears cost-effective when compared to no surgery and palliation.

A matter of survival-patients' and carers' perspectives on the decision to undergo pelvic exenteration surgery for locally advanced and recurrent rectal cancer

AIM

Pelvic exenteration is the only potentially curative treatment for patients with locally advanced or recurrent rectal cancer. This study aimed to investigate how patients decide to undergo such radical surgery.

METHOD

This qualitative study employed an exploratory interpretive design informed by hermeneutic philosophy. During semi-structured interviews, individuals who had undergone pelvic exenteration at a specialised centre and their carers were asked to reflect on the decision-making process around surgery.

RESULTS

Thirty-eight interviews were conducted with 39 participants (34 patients and five carers). Four themes were identified. There really wasn't a choice-participants indicated that long-term survival was their absolute priority, with many feeling that there was no alternative. Only one participant expressed decision regret due to the consequences of surgery. Grappling with the magnitude of surgery-despite extensive preoperative education and counselling, the enormity of the surgery and recovery experience was incomprehensible to participants until they were 'in it', with many surprised by a slow and protracted recovery. A spectrum of psychological states and support needs-participants reflected on their psychological state prior to surgery, identifying family or professional pre-surgery counselling as sources of support. Understanding life after surgery-although most participants were willing to accept anything in order to survive, many identified the impact on bodily functions, body image and overall quality of life as important.

CONCLUSIONS

Long-term survival was the principal factor influencing the decision to undergo pelvic exenteration. Individualised preoperative counselling may improve patient preparedness for the consequences of surgery.