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

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

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

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

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.

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)

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

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)

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

Treatment Details

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

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)

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 (23/31 74.2%) and AR + SA (23/31 74.2%) On the whole, female participants did not answer questions relating to sexual function

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)

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

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

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

For further details please contact: Gillian Knowles (Principal Investigator) gillian.knowles@luht.scot.nhs.uk Rachel Haigh (Research nurse) rachel.haigh@luht.scot.nhs.uk

Western General Hospital, Edinburgh