Top

Published in:

01-06-2013 | Colorectal Cancer

Effect of Preoperative Radio(chemo)therapy on Long-term Functional Outcome in Rectal Cancer Patients: A Systematic Review and Meta-analysis

Authors: Martin Loos, MD, Philipp Quentmeier, MD, Tibor Schuster, PhD, Ulrich Nitsche, MD, Ralf Gertler, MD, Andreas Keerl, MD, Thomas Kocher, MD, Helmut Friess, MD, Robert Rosenberg, MD

Published in: Annals of Surgical Oncology | Issue 6/2013

Abstract

Background

Preoperative radio(chemo)therapy (pR(C)T) significantly reduces the local recurrence risk and is therefore recommended in stage II/III rectal cancer. However, this multimodal treatment approach may be associated with late adverse effects. To determine the impact of pR(C)T on long-term anorectal, sexual, and urinary function, we performed a systematic review and meta-analysis.

Methods

PubMed, Embase, and the Cochrane Library were systematically searched for studies reporting on long-term functional outcome after rectal cancer resection with pR(C)T. Only studies that reported anorectal, sexual, and/or urinary function after rectal cancer resection in TME-technique with pR(C)T were eligible for inclusion.

Results

Twenty-five studies, including 6,548 patients, were identified. Methodological quality of the eligible studies was low. The majority of studies reported higher rates of anorectal (14/18 studies) and male sexual dysfunction (9/10 studies) after pR(C)T. Few studies examined female sexual dysfunction (n = 4). Meta-analysis revealed that stool incontinence occurred more often in irradiated patients (risk ratio (RR) = 1.67; 95 % confidence interval (CI), 1.36, 2.05; p < 0.0001) and manometric results were significantly worse after pR(C)T (mean resting pressures (weighted mean difference (WMD) = 15.04; 95 % CI, 0.77, 29.31; p = 0.04) and maximum squeeze pressures (WMD = 30.39; 95 % CI, 21.48, 39.3; p < 0.0001)). Meta-analysis of erectile dysfunction revealed no statistical significance (RR = 1.41; 95 % CI, 0.74, 2.72; p = 0.3). Six of eight studies and meta-analysis demonstrated no negative effect of pR(C)T on urinary function (RR = 1.05; 95 % CI, 0.67, 1.65; p = 0.82).

Conclusions

Although quality of studies on long-term functional outcome is limited, current evidence demonstrates that pR(C)T negatively affects anorectal function after TME.

Cunningham D, Atkin W, Lenz HJ, Lynch HT, Minsky B, Nordlinger B, Starling N. Colorectal cancer. Lancet. 2010;375:1030–47.PubMedCrossRef

Cecil TD, Sexton R, Moran BJ, Heald RJ. Total mesorectal excision results in low local recurrence rates in lymph node-positive rectal cancer. Dis Colon Rectum. 2004;47:1145–9.PubMedCrossRef

Engstrom PF, Arnoletti JP, Benson AB III, et al. NCCN Clinical Practice Guidelines in Oncology: rectal cancer. J Natl Compr Canc Netw. 2009;7:838–81.PubMed

Valentini V, Aristei C, Glimelius B, et al. Multidisciplinary rectal cancer management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2). Radiother Oncol. 2009;92:148–63.PubMedCrossRef

Schmiegel W, Reinacher-Schick A, Arnold D, et al. [Update S3-guideline “colorectal cancer” 2008]. Z Gastroenterol. 2008;46:799–840.PubMedCrossRef

Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.PubMedCrossRef

Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.PubMedCrossRef

Bujko K, Kepka L, Michalski W, Nowacki MP. Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials. Radiother Oncol. 2006;80:4–12.PubMedCrossRef

Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med. 2006;355:1114–23.PubMedCrossRef

10.

Peeters KC, Marijnen CA, Nagtegaal ID, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.PubMedCrossRef

11.

Desnoo L, Faithfull S. A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery. Eur J Cancer Care (Engl). 2006;15:244–51.CrossRef

12.

Wallner C, Lange MM, Bonsing BA, et al. Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial. J Clin Oncol. 2008;26:4466–72.PubMedCrossRef

13.

Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P, Guillou PJ. Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg. 2005;92:1124–32.PubMedCrossRef

14.

Pietrangeli A, Pugliese P, Perrone M, Sperduti I, Cosimelli M, Jandolo B. Sexual dysfunction following surgery for rectal cancer: a clinical and neurophysiological study. J Exp Clin Cancer Res. 2009;28:128.PubMedCrossRef

15.

Banerjee AK. Sexual dysfunction after surgery for rectal cancer. Lancet. 1999;353:1900–2.PubMedCrossRef

16.

Platell CF, Thompson PJ, Makin GB. Sexual health in women following pelvic surgery for rectal cancer. Br J Surg. 2004;91:465–8.PubMedCrossRef

17.

Maas CP, Moriya Y, Steup WH, Kiebert GM, Kranenbarg WM, van de Velde CJ. Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome. Br J Surg. 1998;85:92–7.PubMedCrossRef

18.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med. 2009;3:e123–30.PubMed

19.

Lange MM, den Dulk M, Bossema ER, et al. Risk factors for faecal incontinence after rectal cancer treatment. Br J Surg. 2007;94:1278–84.PubMedCrossRef

20.

Lange MM, Maas CP, Marijnen CA, Wiggers T, Rutten HJ, Kranenbarg EK, van de Velde CJ. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg. 2008;95:1020–8.PubMedCrossRef

21.

Lange MM, Marijnen CA, Maas CP, et al. Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer. 2009;45:1578–88.PubMedCrossRef

22.

Marijnen CA, van de Velde CJ, Putter H, et al. 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. 2005;23:1847–58.PubMedCrossRef

23.

Peeters KC, van de Velde CJ, Leer JW, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients–a Dutch colorectal cancer group study. J Clin Oncol. 2005;23:6199–206.PubMedCrossRef

24.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.PubMedCrossRef

25.

Parc Y, Zutshi M, Zalinski S, Ruppert R, Furst A, Fazio VW. Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer. Dis Colon Rectum. 2009;52:2004–14.PubMedCrossRef

26.

Fichera A, Michelassi F. Long-term prospective assessment of functional results after proctectomy with coloanal anastomosis. J Gastrointest Surg. 2001;5:153–7.PubMedCrossRef

27.

van Duijvendijk P, Slors JF, Taat CW, van Tets WF, van Tienhoven G, Obertop H, Boeckxstaens GE. Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy. Am J Gastroenterol. 2002;97:2282–9.PubMedCrossRef

28.

Ammann K, Kirchmayr W, Klaus A, et al. Impact of neoadjuvant chemoradiation on anal sphincter function in patients with carcinoma of the midrectum and low rectum. Arch Surg. 2003;138:257–61.PubMedCrossRef

29.

Canda AE, Terzi C, Gorken IB, Oztop I, Sokmen S, Fuzun M. Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients. Int J Colorectal Dis. 2010;25:197–204.PubMedCrossRef

30.

Pietsch AP, Fietkau R, Klautke G, Foitzik T, Klar E. Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients. Int J Colorectal Dis. 2007;22:1311–7.PubMedCrossRef

31.

Amin AI, Hallbook O, Lee AJ, Sexton R, Moran BJ, Heald RJ. A 5-cm colonic J pouch colo-anal reconstruction following anterior resection for low rectal cancer results in acceptable evacuation and continence in the long term. Colorectal Dis. 2003;5:33–7.PubMedCrossRef

32.

Ito M, Saito N, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y. Analysis of clinical factors associated with anal function after intersphincteric resection for very low rectal cancer. Dis Colon Rectum. 2009;52:64–70.PubMedCrossRef

33.

Chamlou R, Parc Y, Simon T, Bennis M, Dehni N, Parc R, Tiret E. Long-term results of intersphincteric resection for low rectal cancer. Ann Surg. 2007;246:916–21.PubMedCrossRef

34.

Welsh FK, McFall M, Mitchell G, Miles WF, Woods WG. Pre-operative short-course radiotherapy is associated with fecal incontinence after anterior resection. Colorectal Dis. 2003;5:563–8.PubMedCrossRef

35.

Chatwin NA, Ribordy M, Givel JC. Clinical outcomes and quality of life after low anterior resection for rectal cancer. Eur J Surg. 2002;168:297–301.PubMedCrossRef

36.

Murata A, Brown CJ, Raval M, Phang PT. Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer. Am J Surg. 2008;195:611–5.PubMedCrossRef

37.

Prabhudesai AG, Cornes P, Glees JP, Kumar D. Long-term morbidity following short-course, preoperative radiotherapy and total mesorectal excision for rectal cancer. Surgeon. 2005;3:347–51.PubMedCrossRef

38.

Nathanson DR, Espat NJ, Nash GM, et al. Evaluation of preoperative and postoperative radiotherapy on long-term functional results of straight coloanal anastomosis. Dis Colon Rectum. 2003;46:888–94.PubMedCrossRef

39.

Temple LK, Bacik J, Savatta SG, et al. The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer. Dis Colon Rectum. 2005;48:1353–65.PubMedCrossRef

40.

Varpe P, Huhtinen H, Rantala A, Salminen P, Rautava P, Hurme S, Gronroos J. Quality of life after surgery for rectal cancer with special reference to pelvic floor dysfunction. Colorectal Dis. 2009;13:399–405.CrossRef

41.

Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E. Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum. 2011;54:963–968.PubMedCrossRef

42.

Bonnel C, Parc YR, Pocard M, Dehni N, Caplin S, Parc R, Tiret E. Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis Colon Rectum. 2002;45:934–9.PubMedCrossRef

43.

Song PH, Yun SM, Kim JH, Moon KH. Comparison of the erectile function in male patients with rectal cancer treated by preoperative radiotherapy followed by surgery and surgery alone. Int J Colorectal Dis. 2010;25:619–24.PubMedCrossRef

44.

Zugor V, Miskovic I, Lausen B, et al. Sexual dysfunction after rectal surgery: a retrospective study of men without disease recurrence. J Sex Med. 2010;7:3199–205.PubMedCrossRef

45.

Selvindos PB, Ho YH. Multimedia article. Laparoscopic ultralow anterior resection with colonic J-pouch-anal anastomosis. Dis Colon Rectum. 2008;51:1710–1.PubMedCrossRef

46.

Morino M, Parini U, Allaix ME, Monasterolo G, Brachet Contul R, Garrone C. Male sexual and urinary function after laparoscopic total mesorectal excision. Surg Endosc. 2009;23:1233–40.PubMedCrossRef

47.

Garlipp B, Ptok H, Schmidt U, Meyer F, Gastinger I, Lippert H. Neoadjuvant chemoradiotherapy for rectal carcinoma: effects on anastomotic leak rate and postoperative bladder dysfunction after non-emergency sphincter-preserving anterior rectal resection. Results of the Quality Assurance in Rectal Cancer Surgery multicenter observational trial. Langenbecks Arch Surg. 2010;395:1031–8.PubMedCrossRef

Title: Effect of Preoperative Radio(chemo)therapy on Long-term Functional Outcome in Rectal Cancer Patients: A Systematic Review and Meta-analysis
Authors: Martin Loos, MD
Philipp Quentmeier, MD
Tibor Schuster, PhD
Ulrich Nitsche, MD
Ralf Gertler, MD
Andreas Keerl, MD
Thomas Kocher, MD
Helmut Friess, MD
Robert Rosenberg, MD
Publication date: 01-06-2013
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 6/2013
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-012-2827-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Effect of Preoperative Radio(chemo)therapy on Long-term Functional Outcome in Rectal Cancer Patients: A Systematic Review and Meta-analysis

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2013

Comprehensive Databases: A Cautionary Note

Longitudinal Changes in Function, Symptom Burden, and Quality of Life in Patients with Early-Stage Lung Cancer

How Often do Level III Nodes Bear Melanoma Metastases and does it Affect Patient Outcomes?

Effects of Metallothionein-1 Genetic Polymorphism and Cigarette Smoking on the Development of Hepatocellular Carcinoma

Assessment and Comparison of Recovery after Open and Minimally Invasive Esophagectomy for Cancer: An Exploratory Study in Two Centers

Role of Major Vascular Resection in Patients with Intrahepatic Cholangiocarcinoma