Late Side Effects and Quality of Life After Radiotherapy for Rectal Cancer

doi:10.1016/j.ijrobp.2009.03.010

International Journal of Radiation OncologyBiologyPhysics

Volume 76, Issue 4, 15 March 2010, Pages 1005-1011

https://doi.org/10.1016/j.ijrobp.2009.03.010 Get rights and content

Purpose

There is little knowledge on long-term morbidity after radiotherapy (50 Gy) and total mesorectal excision for rectal cancer. Therefore, late effects on bowel, anorectal, and urinary function, and health-related quality of life (QoL), were studied in a national cohort (n = 535).

Methods and Materials

All Norwegian patients who received pre- or postoperative (chemo-)radiotherapy for rectal cancer from 1993 to 2003 were identified. Patients treated with surgery alone served as controls. Patients were without recurrence or metastases. Bowel and urinary function was scored with the LENT SOMA scale and the St. Marks Score for fecal incontinence and QoL with the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30).

Results

Median time since surgery was 4.8 years. Radiation-treated (RT+) patients (n = 199) had increased bowel frequency compared with non–radiation-treated (RT−) patients (n = 336); 19% vs. 6% had more than eight daily bowel movements (p < 0.001). In patients without stoma, a higher proportion of RT+ (n = 69) compared with RT− patients (n = 240), were incontinent for liquid stools (49% vs. 15%, p < 0.001), needed a sanitary pad (52% vs. 13%, p < 0.001), and lacked the ability to defer defecation (44% vs. 16%, p < 0.001). Daily urinary incontinence occurred more frequently after radiotherapy (9% vs. 2%, p = 0.001). Radiation-treated patients had worse social function than RT− patients, and patients with fecal or urinary incontinence had impaired scores for global quality of life and social function (p < 0.001).

Conclusions

Radiotherapy for rectal cancer is associated with considerable long-term effects on anorectal function, especially in terms of bowel frequency and fecal incontinence. RT+ patients have worse social function, and fecal incontinence has a negative impact on QoL.

Introduction

With the introduction of total mesorectal excision (TME) in the treatment of rectal cancer, local recurrence and survival rates have improved substantially 1, 2. Additional reduction in local recurrence has been achieved with preoperative radiotherapy 3, 4. Improved long-term survival has augmented the awareness of late effects from radiotherapy, as major surgery combined with radiotherapy may lead to considerable morbidity with a negative impact on functional outcome and health-related quality of life (QoL) 5, 6, 7, 8 .

Current knowledge of late adverse effects of radiotherapy for rectal cancer is mainly based on trials of short-course preoperative radiotherapy (5 Gy × 5) (9). There are few reports on long-term morbidity after long-course radiotherapy (2 Gy × 25 or 1.8 Gy × 28) and TME. A German trial compared toxicity after pre- or postoperative radiotherapy (50 Gy), and found more long-term morbidity after postoperative radiation; however, the study did not assess anorectal function or QoL (10). Deteriorated anorectal function in radiation-treated (RT+) patients was reported in a Danish study in which patients (n = 28) with a follow-up of 15 to 20 years had been randomized to either long-course postoperative radiotherapy or conventional surgery alone (11). Other studies on functional outcome and QoL after long-course radiotherapy and TME have mainly been small, single-institution series with relatively short follow-up time 12, 13.

Information on QoL in long-term survivors after radiotherapy for rectal cancer is scarce. Few studies have used cancer-specific questionnaires, and the impact of anorectal and urogenital dysfunction on QoL is infrequently reported (9). In our previous study, subgroup analysis showed that RT+ patients had worse rectal function in terms of frequency, urgency, and incontinence (14). We therefore aimed to examine the patient-reported anorectal and urinary function in a national cohort. We expected patients treated with radiotherapy (50 Gy) and TME to have worse functional outcome than patients treated with TME alone. Furthermore, we aimed to assess whether anorectal or bladder dysfunction had negative impact on social function and global health perception.

Section snippets

Methods and Materials

Patients were sampled from a national database, the Norwegian Rectal Cancer Registry (NRCR), which is part of the Cancer Registry of Norway, and includes all patients with rectal cancer diagnosed since November 1993. The NRCR contains data on tumor characteristics, primary treatment, and information about recurrences and metastases reported from all hospitals in Norway treating rectal cancer.

Patients

RT+ (n = 382) and non–radiation-treated (RT−) (n = 778) patients were identified from the NRCR. Of these, 129 were noneligible because of local excision (n = 70), inability to give informed consent or emigration (n = 19), or death (n = 40). Another 19 were excluded after the interview because of total radiation dose being <42 Gy (n = 7), recent diagnosis of metastatic disease or local recurrence (n = 6), pelvic radiotherapy for other malignancy (n = 5), and no resection (n = 1). Thus, a total

Discussion

The present study demonstrates that radiotherapy for rectal cancer is associated with considerable late side effects on bowel and anorectal function, especially in terms of bowel frequency, urgency, and fecal incontinence. Our study also shows that RT+ patients have impaired social function compared with RT− patients, and that patients with frequent fecal incontinence have impaired quality of life.

Among patients <70 years of age, 72% of invited patients agreed to participate in the study, a

Acknowledgments

This work was supported by a research grant from the Eastern Norway Health Authority and with support and good collaboration with the Norwegian Rectal Cancer Registry. The authors thank the patients who contributed to this study and to Mette Wallin and Cathrine Knudsen for their assistance with the data collection.

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Clinical InvestigationLate Side Effects and Quality of Life After Radiotherapy for Rectal Cancer

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Methods and Materials

Patients

Discussion

Acknowledgments

Lancet

Radiother Oncol

Eur J Surg Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Clin Oncol (R Coll Radiol)

Nationwide quality assurance of rectal cancer treatment

Colorectal Dis

The TME trial after a median follow-up of 6 years: Increased local control but no survival benefit in radiation-treated patients with resectable rectal carcinoma

Ann Surg

Impact of radiotherapy on local recurrence of rectal cancer in Norway

Br J Surg

Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: Report of a multicenter randomized trial

J Clin Oncol

Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: Increased bowel dysfunction in radiation-treated patients—a Dutch colorectal cancer group study

J Clin Oncol

Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer

Br J Surg

Late adverse effects of radiation therapy for rectal cancer—a systematic overview

Acta Oncol

Preoperative versus postoperative chemoradiotherapy for rectal cancer

N Engl J Med

Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer

Dis Colon Rectum

Clinical Investigation
Late Side Effects and Quality of Life After Radiotherapy for Rectal Cancer