International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationLate Side Effects and Quality of Life After Radiotherapy for Rectal Cancer
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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Conflict of interest: none.