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Abstract & Commentary
Synopsis: Longitudinal quality of life (QoL) was compared for 50 rectal cancer patients subjected to anterior resection (AR) vs. 23 patients treated with abdominoperineal extirpation (APE). Analysis revealed consistent trends toward lower QoL for AR patients than for APE patients, despite lack of permanent colostomy in those patients treated by AR. Both groups exhibited a similar reduction in body image scores over time. Patients with a low AR (anastomosis within 5 cm of the anal verge) experienced a significant and pronounced decrease in total QoL and function, possibly associated with compromise of fecal continence. Ultimately, the decision to perform a sphincter sparing procedure for rectal cancer must incorporate individual QoL issues, as well as clinical efficacy, in order to achieve optimal quality of care.
Source: Grumann MM, et al. Ann Surg. 2001;233(2):
Among selected rectal cancer patients
undergoing curative surgery, sphincter-sparing procedures such as anterior resection (AR) have progressively replaced rectal amputation with permanent colostomy, also known as abdominoperineal extirpation (APE), as the standard of care. This gradual shift has been based upon data indicating equivalent cancer-related outcomes.1-3 Dissent persists, however, regarding patient quality of life (QoL) after low-rectal anastomosis vs. permanent colostomy. Others contend that colostomy results in diminished self-image and psychosocial function and, furthermore, that patients undergoing APE have higher rates of impaired urinary and sexual function due to adjacent nerve injury.4,5 Conversely, cross-sectional studies using validated QoL questionnaires have shown no significant functional difference.6,7 Because QoL is increasingly recognized as a crucial component of the quality of care and because few studies exploring this issue have incorporated a rigorous methodology, Grumann and colleagues undertook a prospective longitudinal cohort study to measure QoL in patients treated with AR vs. APE over time.8
Grumann et al used the European Organization for Research and Treatment of Cancer (EORTC) questionnaire, QLQ C30, with its complementary colorectal module, CR 38. Questionnaires were applied during the preoperative phase of disease, then at 6-9 months post-op, and again at 12-15 months post-op. Inclusion criteria mandated that patients undergo R0 resection (surgery for cure), remain recurrence-free for 15 months postresection, and provide complete clinical and QoL data for each of the 3 measurement periods. Data were analyzed using multivariate ANOVA; multiple analysis in a time-by-group design was used to assess the 2 groups at 3 time points.
Twenty-three APE patients and 50 AR patients were selected. No differences in age, stage of disease, neoadjuvant treatment, or postoperative morbidity were found between groups.
The QLQ C30 and CR 38 feature a functional subscale, wherein higher scores indicate better functioning, and a symptoms subscale, for which higher scores represent greater distress. Most results on both scales revealed no significant difference between groups at all 3 assessment points. However, except for body image (on the functional scale), and micturition (on the symptoms scale), APE patients showed a consistent trend toward "better" scores (ie, higher and lower, respectively) than the AR patients. Evaluating the effect of time alone revealed that both groups experienced a similar and significant decrease in body image from the second to the third assessment and a similar and significant increase in emotional function and future perspective over both time intervals. In evaluating time-by-group, the AR group revealed significantly better role function than the APE group for the first 2 assessment periods, but, by the third assessment, APE patients actually had a significantly better role-function scores than AR patients. Lastly, examining the data by group alone, the sole significant finding was increased sleeplessness and distress due to diarrhea and constipation among AR patients.
Within the AR group, 15 patients had an anastomosis < 5 cm from the anal verge; 35 patients had a higher anastomosis. Both low-AR and high-AR patients experienced similar and significant decreases in role function and body image over time and both groups showed significantly better future perspective over time. Predictably, the low-AR patients consistently scored significantly more poorly on the functional subscale than high-AR patients.
Grumann et al conclude that, contrary to the current wisdom, APE patients enjoyed a consistently superior overall QoL than AR patients. They note that APE and AR patients experience a similar decline in body image over time, and that patients with low AR experienced the greatest decline in body image score. Although most scores were not significantly different, AR patients had significantly increased defecation-related problems and sleeplessness, and low-AR patients were the most severely impaired. Thus, Grumann et al warn that routine replacement of APE with AR may not actually achieve the desired QoL benefits, and that individual patient needs and conditions must be considered.
Comment by Arden Morris, MD
As the topic of quality of care has become an established fixture in US health care priorities, QoL has increasingly been recognized as an important component of care. Cancer patient survival, in particular, has improved so markedly over the past 30 years that QoL is a logical addition to traditionally measured treatment outcomes, such as morbidity and survival time. Acknowledging this, a host of recent studies have focused on QoL among rectal cancer patients, as summarized in a large recent review.8 However, while nearly all of these studies generally recognized that QoL "refers to patients’ appraisal of and satisfaction with their current level of functioning compared to what they perceive to be possible or ideal," most were not based upon formally validated instruments and may be criticized for reporting potentially misleading data.9
Efforts to create reliable questionnaires that address QoL in health status have recognized the enormous and complex role played by individual patient perspectives and expectations. In order to address these confounders, several excellent QoL instruments have been developed incorporating physical, functional, social, and emotional dimensions.9 One of these, the EORTC QLQ30, is a well-validated general cancer questionnaire with several submodules tailored to specific malignancy categories, including the CR 38 for colorectal cancer.10
As part of a larger prospective quality-of-care study, Grumann et al identified QoL among the outcomes of interest, and sought to identify specific QoL values affected by rectal cancer surgery, using the QLQ30 and CR 38. They used a longitudinal cohort design in order to assess differences between APE- and AR-treated groups over time, which should control for individual baseline variation. Twenty-three APE patients and 50 AR patients were selected based upon 3 rigorous inclusion criteria: the requirement that they undergo curative surgery, remain recurrence-free, and complete all clinical and QoL portions of the study over 3 time intervals. The 1:2 APE to AR ratio is consistent with other cohort studies and with the larger rectal cancer cohort from which they were drawn; however, no information was available regarding how operations were chosen nor was quantitative exclusion data reported.
The trend toward better global QoL and function among APE patients compared to AR patients was unexpected, but has been supported by prospective studies using validated QoL instruments.6,7 A number of hypotheses may be proposed to explain this. The rigid inclusion criteria may have led to a selection bias in which more optimistic patients were included, leading to a more positive perspective overall. Moreover, the mean subject age was 61 years and it has been suggested that older patients deem body image a lower priority, which may have a more positive impact on QoL.4 Alternatively, patient expectations of colostomy may have been so negative at baseline that the reality of living with a stoma seemed positive by contrast. Low-AR patients’ experiences may have been just the opposite; defecation-related issues, such as fecal incontinence, could present a most unpleasant surprise, leading to the more profound decline in body image. These contrasts may have ultimately resulted in relative decrease in QoL for all AR patients as compared with APE patients.
In summary, Grumann et al have provided interesting and relevant data supporting individualized decisions regarding the best QoL choice for rectal cancer excision. Further investigation might include a larger and more varied patient database, with more detailed exclusion information, in order to be generalizable to the rectal cancer population at large. Additional fruitful study might include finding ways to enhance realistic patient expectations of outcome.
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