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Function problems after rectal cancer surgery Terry Phang St. Pauls Hospital University of British Columbia
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Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Oct 13, 2019

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Page 1: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Function problems after rectal cancer surgery

Terry Phang

St. Paul’s Hospital University of British Columbia

Page 2: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Low Anterior Resection Syndrome

•  Loss of rectal reservoir

•  Injury to pelvic autonomic nerves

Page 3: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Questions

•  What percentage of rectal cancer patients have fecal incontinence after preop radiation and low anterior resection?

•  What percentage of rectal cancer patients expect to have worsened anorectal function after treatments?

•  What percentage of rectal cancer patients remember any discussion of anorectal function disturbances from preop consultation and consenting?

Page 4: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Rectal Functionality – After radiation

•  After pelvic radiation at 1 yr (eg. GU cancer)

–  #BM’s/day: 2

– Urgency: 50%

– Clustering: 40%

– Fecal incontinence: 20%

Haddock M et al, J Clin Oncol 2007, 25: 1255

Page 5: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Rectal Functionality – After TME

•  After rectal cancer surgery at 1 yr (no rad)

–  #BM’s/day: 3-4

– Urgency: 90%

– Clustering: 84%

– Fecal incontinence: 46%

Fazio et al, Ann Surg 2007, 246: 481

Page 6: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Effect of TME + Radiation SPH 1999-2004 Fecal incontinence scores

NO RAD N = 10

RAD, 25GY N = 24

No. Daily BMs

2-3 3-4

Gas 70% 83%

Mucus 20% 46%

Liquid Stool 30% 50%

Solid Stool 30% 42%

Muriata, Am J Surg 2008

Page 7: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Rectal Functionality – After Rad + TME

•  After rad + rectal cancer surgery at 5 yr

–  #BM’s/day: 3-4

– Fecal incontinence: 62%

•  14% severe

Peeters K et al, J Clin Oncol 2005, 23: 6199

Page 8: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Rectal Functionality – After Rad + TME + ISR / coloanal

•  #BM’s/day: 2-3

•  After rad + rectal cancer surgery at 5 yr

– Fecal incontinence: 59%

•  24% severe

•  No patient requested colostomy

Chamlou R et al, Ann Surg 2007, 246: 916

Page 9: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Urinary Functionality

•  Urinary incontinence after rectal cancer surgery at 5 yr

– No radiation: 39%

– Radiation: 39%

Peeters K et al, J Clin Oncol 2005, 23: 6199

Page 10: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Sexual Functionality

•  Sexual activity decreased after rectal cancer surgery: –  Preop male and female: 80%

–  Postop male: 50% –  Postop female: 32%

•  Postop sexual problems –  Male: libido 47%, impotence 32%, orgasm 41% –  Female: libido 41%, lubrication 56%, orgasm 35%

Hendren S et al, Ann Surg 2005, 242: 212

Page 11: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Functionality – Summary

•  After radiation and LAR

–  39% urinary incontinence

–  40% sexual dysfunction

–  60% fecal incontinence

Page 12: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Patient Expectations on Function

Worse Same or Better

Bowel 36% 64%

Bladder 12% 88%

Sexual 18% 82%

Temple et al, MSKCC

Page 13: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Patient satisfaction

•  After TME at 5 yrs

– LAR satisfaction:

• Non-radiated: 60%

• Radiated: 50%

– Stoma satisfaction: 75%

Peeters K et al, J Clin Oncol 2005, 23: 6199

Page 14: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Patient satisfaction higher for stoma than LAR

•  Is poor satisfaction with LAR bowel function due to incontinence and decreased quality of life?

•  Is poor satisfaction with bowel function after LAR due to insufficient preop counseling?

Page 15: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

SPH rectal cancer treatments QOL at 1 year:

Mean functional scores of patients with rectal cancer measured by EORTC QLQ-C30. A higher score represents a higher level of functioning or global health status/QOL.

0

20

40

60

80

100

Global Health Status Physical Functioning Role functioning Emotional Functioning Cognitive Functioning Social Functioning

Values in the functional scales range from 0 (worst outcome) to 100 (best outcome).

Mea

n Fu

nctio

nal S

core

s

Baseline

Post radiation before surgery

One year after stoma closure

Mean QOL scores of rectal cancer patients measured by EORTC QLQ-C38

0

10

20

30

40

50

60

70

80

90

Body Image SexualEnjoyment

Micturiction Chemotherapyside effects

Stoma Function Female Sexual

Values in the functional scales range from 0 (worst outcome) to 100 (best outcome). Values in the symptom scales range from 0 (no symptoms) to 100 (most symptoms)

Mea

n Q

OL

Scor

es Baseline

Post radiation before surgery

One year after stoma closure

*

*

Future Perspective

*

Unchanged Improved

Improved Improved

Page 16: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Curative Rectal Cancer Treatments

•  Global quality of life unchanged

•  Emotional functioning and future perspective improved at 1 year

SPH 2012

Page 17: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Myth of informed consent in rectal cancer surgery: What do patients retain?

•  30 patients, 2009-2010

•  47% did not recall preop discussion of risks to bowel function

•  57% did not recall preop discussion of risks to urinary function

•  47% did not recall preop discussion of risks to sexual function

Scheer, DCR 2012; 55: 970

Page 18: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Patient expectations of post-treatment bowel function, 65% same or improved:

•  UNREALISTIC !

•  Need to improve patient satisfaction after radiation + LAR

•  Better patient counseling and education required

Page 19: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Questions

•  What percentage of rectal cancer patients have fecal incontinence after preop radiation and low anterior resection? 60%

•  What percentage of rectal cancer patients expect to have worsened anorectal function after treatments? 35%

•  What percentage of rectal cancer patients remember any discussion of anorectal function disturbances from preop consultation and consenting? 50%

Page 20: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection

Functionality – Take home

•  After radiation and LAR

–  60% fecal incontinence

•  Patients have overly optimistic expectations of post-treatment function

•  Improved patient education required

Page 21: Function problems after rectal cancer surgery · Function problems after rectal cancer surgery Terry Phang St. Paul’s Hospital University of British Columbia . Low Anterior Resection