1. Long Term Effects of Surgery and Radiotherapy for Colorectal Cancer on Bowel Function and Quality of Life
Gillian Knowles, Rachel Haigh, Catriona McLean, Hamish Phillips, Malcolm Dunlop, Farhat Din

2. Background
People can experience distressing symptoms following treatment for rectal cancer
Emerging evidence about the long-term impact on health-related quality of life
Survival is increasing
People are living longer with consequences of treatment

3. Background
Study Aim:
To evaluate the long term bowel, urinary and sexual function in patients who have undergone pelvic surgery for rectal cancer with or without radiotherapy
Health Service Research Funding (1yr)
Ethical approval granted

4. Study Questions
What is the prevalence of long term bowel, urinary and sexual dysfunction in patients with rectal cancer (+/- XRT) and in patients having abdominal surgery for colon cancer?
What is the prevalence of dysfunction and reduced quality of life in each of these groups?
To what degree does pelvic XRT add to pelvic dysfunction

5. Sample
All patients who had undergone pelvic dissection (+/- pelvic XRT) for a primary rectal cancer (Dukes A, B & C) within NHS Lothian
Time period January 2002 to December 2006
In addition, patients who underwent abdominal surgery without pelvic dissection for a primary colon cancer during the same period.
Study was conducted at the Western General Hospital, Edinburgh, Scotland, U.K.

6. Study Tools Demographic assessment
EORTC QLQ C30 (Aaronson et al 1993) and QLQ-CR38 (Sprangers et al 1999)
MSKCC Bowel Function Instrument (Temple et al 2005)

7. Recruitment Overall response 381/667 patients (57%)
Rectal cancer 138/193 – 72% response
Colon cancer 243/474 – 51% response

8. Results- Demographic details
Patients who responded to the study were younger than non-responders (p<0.001)
No association found between gender, Dukes Stage or TNM classification & participation in the study
Median length of time from surgery to completing questionnaires was 53 months (interquartile range 38 to 68 months)

9. Results- Demographic Details
Rectal n=138
Colon n=243
Median Age
66.7yrs (58, 72.9)
68yrs (60.5, 75)
Male
85 (61.6%)
139 (57.2%)
Female
53 (38.4%)
104 (42.8%)
Dukes Staging A
31 (22.5%)
26 (10.6%) B
58 (42%)
146 (60.1%) C
49 (35.5%)
71 (29.2%)
AJCC Staging
Stage I
Stage IIA
54 (39.1%)
112 (46%)
Stage IIB/C
4 (2.9%)
34 (13.9%)
Stage III

10. Treatment Details

11. Results- Bowel Function (MSKCC)
In a sub-set of patients with rectal cancer
16% documented persistent problems with leakage of stool ‘always’ or ‘most of the time’
17% ‘always’ had to wear a protective pad
31% reported incomplete emptying
32% experienced difficulty in controlling flatus
9% ‘always’ had to alter their daily activities
30% required to modify their diet
Increase in total number of bowel movements in a 24hour period (p<0.001)
Patients who received radiotherapy experienced poorer functional outcomes in all three subscales than those who did not have radiotherapy

12. Results- EORTC QLQ-C30/CR38
Patients who underwent pelvic dissection were more likely to experience:
Diarrhoea (p=0.001) & increased defecation (p=0.000) & gastrointestinal problems (p=0.000)
Financial difficulties (p=0.024)
Reduced body image perception (p=0.002)
Reduced social functioning (p<0.001)
Reduced role functioning (p=0.038)
Altered bowel function was found to impact significantly on overall QOL (p<0.001)
Patients with an anastomotic level of ≤6cm were more likely to experience increased gastrointestinal problems (p=0.05)

13. Results- EORTC QLQ-CR38 Sexual function:
Men who underwent pelvic dissection were found to have greater sexual problems (p=0.009)
Sexual function problems were more frequently reported in men who had undergone APR (13/13 100%), low AR + colopouch (23/ %) and AR + SA (23/ %)
On the whole, female participants did not answer questions relating to sexual function

14. Results- EORTC QLQ-C30/CR38 radiotherapy and no radiotherapy pelvic dissection patients
Rectal cancer patients who received pre-operative radiotherapy had:
Increased defecation problems (p=0.005)
Reduced social functioning (p=0.048)
Greater financial difficulties (p=0.049)
There was no association between long or short course XRT and sexual dysfunction in men responding to sexual function questions (p=1.000)

15. Overall global health status was good in both rectal and colon groups

16. Summary points:
Sub-set of patients with rectal cancer document persistent bowel function difficulties
Altered bowel function impacts on overall quality of life
Pre-op radiotherapy and low anastomotic join is associated with increased defecation problems
Increased sexual function difficulties noted in men who underwent pelvic dissection
Patients treated for rectal cancer report reduced role and social function, body image perception and greater financial difficulties compared to patients with colon cancer
Few women completed the sexual function questions
Urinary difficulties were not found to be of significance in this study

17. Future developments
Introduce more systematic assessment of bowel function in rectal cancer patients using validated assessment tool
Need for an evaluation of earlier pre-emptive interventions
Need for identification of ‘at risk groups’ and those ‘at risk’ of developing late effects
Development of existing Nurse-led follow up services

18. For further details please contact:
Gillian Knowles (Principal Investigator)
Rachel Haigh (Research nurse)

19. Western General Hospital, Edinburgh