Quality of Life and Functional Results Following Pelvic Exenteration Erin Kennedy September 19, 2015

No conflicts of interest

Objectives Provide overview for QoL following pelvic exenteration –Assessment of QoL studies –Review QoL outcomes for primary rectal cancer –Compare these outcomes to QoL for locally advanced and recurrent rectal cancer

Assessing quality of life studies Validated instruments Prospectively collected data Baseline values (need pre-op scores) Sample size Missing data

Quality of Life Assessment 65 patients assessed prospectively 21 anterior resection 26 anterior resection plus ileostomy 18 APR 17 pre/post radiation Mean age 67 yrs EORTC QLQ C-30 and CR 38 Baseline (pre-op) and 3, 6, 9, 12 months after surgery Camilleri, Brennan, & Steele, BJS 2001

Overall QoL scores the same Profile of the individual domains change Global QL, emotional function and future prospective were significantly better post-operatively Role function, fatigue and pain were the same and remained relatively unchanged Gastrointestinal problems (abdo pain, bloating) and defecation problems improved but did not return to baseline Sexual enjoyment, male sexual problems, body image decreased and continued to decline Quality of Life Assessment Camilleri-Brennan and Steele, BJS 2001

Meta-analysis of QoL APR relative to AR 11 studies Overall QoL scores similar before and after surgery with APR and AR Specific “domains” likely more important than overall QoL scores Bowel function Sexual function Body image

QoL Studies for Pelvic Exenteration Design Scale NGroups Thaysen, 2013 Colorectal Disease LongitudinalEORTC80/48Beyond TME vs standard TME Palmer, 2008 Ann Surg Onc X-sectionalEORTC43/80Beyond TME vs Standard TME

QoL for Advanced and Recurrent Rectal Cancer Prospective longitudinal study 122 locally advanced or recurrent rectal cancers undergoing complex “beyond the TME plane” surgery 48 LAR or APR in the standard TME plane EORTC QLQ C-30 and EORTC CR 38 Baseline (pre-op) and 3, 6, 12, 18 and 24 months after surgery Thaysen, 2013 Colorectal Disease

Overall QoL similar between groups at 12 months Future prospective, Global health status, Emotional function and Role function significantly improved between 3 and 12 months post-operatively Body image declined and stabilized but did not return to baseline Pain – no change Results for micturition, gastrointestinal, defecation problems, stoma related problems and weight loss domains NOT reported Unable to perform analysis for Sexual function Results Thaysen, 2013 Colorectal Disease

QoL in Locally Advanced Cancer Cross sectional study 43 locally advanced or recurrent rectal cancer having complex “beyond TME plane” surgery 80 primary rectal cancer with standard surgery in TME plane EORTC QLQ C-30 and EORTC CR-38 Mean follow up in both groups ~ 4 years Mean age in both groups = 65 years Palmer, 2008 Ann Surg Onc

Trend towards decrease in overall QoL score in “beyond TME” (60 vs 69, p<0.05) Significantly lower scores for: Physical Role Social Fatigue Body Image Trend towards lower scores for : Nausea and vomiting Defecation problems Results Palmer, 2008, Ann Surg Onc

Extended Pelvic Resection All that is important is your health – happy to be alive Unanticipated morbidity (mobility, ADLs, sexual well being) Mistaken perception of cure Sacrectomy Life changing impact of surgery – leisure activities, return to work, social interactions, family dynamics, sexual well being Significant chronic pain Grateful to be alive Qualitative Assessment of Patient Experiences Wright, J of Surg Onc 2006 and 2010

Overall QoL similar/slightly decreased with “beyond TME” or pelvic exenteration Profiles of domains not well reported but seems to parallel primary rectal cancer –Body image, bowel and sexual function Qualitative studies very informative and support findings from quantitative studies Want the information even if limited treatment options Best time to discuss is after surgery Patient want to know about Summary

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