Editorial

 

Morbidity associated with the management of rectal cancer and its impact on patient quality of life

 

Around 75% of patients with rectal cancer may be surgically treated with an intention to cure. The goal of curative surgery in rectal cancer is tumor resection with adequate margins, which is addressed by performing a wide excision of the underlying soft tissue and associated lymph nodes. This implies an extension of tumor resection margins to at least 5 cm around the involved area. The surgical approach to rectal cancer considers the neoplasm's location -upper (12 to 16 cm), middle (7.5 to 12 cm) or lower and anal canal (less than 7.5 cm); the distance from the tumor's lower border to the linea dentata is the most significant factor when it comes to the selection of a procedure type. The standard management of this type of cancer is radical resection, either lower anterior resection or abdominoperineal amputation, depending on the tumor's upper-mid location or lower-mid location, respectively (1).

In the past few years significant improvements in surgical technique and technology itself have been made mostly regarding the development of suturing devices, which allowed a greater number of procedures with sphincter preservation, ultralow colorectal anastomosis, and coloanal anastomosis. A number of low tumors still require abdominoperineal amputation, however. Despite the aforementioned advances, rectal cancer surgery is burdened with the fact that these techniques are associated with high morbidity even in experienced hands, which results from anastomotic dehiscence, genitourinary dysfunction, fecal incontinence, permanent colostomy, etc. In addition, local recurrence develops in 15-50% of patients after conventional surgery, even following complete resection (2). Local recurrence is associated with positive resection margins, histologic differentiation grade, rectal wall invasion (T), and nodal infiltration (N).

Therefore we envisage two interrelated groups of difficulties deriving from curative-intent surgery for rectal cancer: the morbidity arising from surgical techniques, which directly affects quality of life, and the potential for local recurrence of disease, which clearly relates to patient survival and, through therapies intended to prevent such recurrence, to morbidity and quality of life involving these subjects.

Health is currently understood as a complete state of physical, mental, and social well-being, rather than merely an absence of disease (3). The fact of suffering from disease results in a multidimensional involvement of life, with changes in the personal, familiar, and social spheres. Thus, not only objective data such as mortality rate should be considered when assesing a disorder's impact, but we should rather take into account the impact of disease on the subject's self-perceived health, that is, on the subject's quality of life. Quality of life is considered a subjective and dynamic characteristic of individuals, and is assessed by using various techniques such as personal interviewing and questionnaires. Measuring quality of life allows an assessment of procedure outcomes, of the personal, familiar, and social impact of disease, and of quality of life; it also allows to improve our understanding of disease, to identify health-care needs, etc. (4).

In this issue of the Revista Española de Enfermedades Digestivas, Pérez FJ et al. (5) discuss the results of a study on the factors influencing quality of life in patients with locally advanced rectal cancer undergoing surgery. For their assessment they used the Nottingham Health Profile, a generic questionnaire, and QLQ-CR 38, a validated questionnaire specific for patients with colorectal cancer that was modified from the QLQ-CR 30 questionnaire, which is administered to patients with cancer in general. This questionnaire includes two modules -functional and symptomatic.

From the study of the factors included in these questionnaires Pérez FJ et al. concluded that women, patients with mid-third rectal tumors, and patients undergoing lower anterior resection perceived their quality of life as more negatively changed following rectal cancer surgery. The latter two factors are clearly interrelated, since this type of resection is commonly applied for tumors in this location. The authors report that surgical technique is the only factor that may be modified in order to improve quality of life for this group of patients. Abdominoperineal amputation includes a resection of the whole rectum and anal canal, the mesorectum, most anus-raising muscles, ischiorectal fat, upper hemorrhoidal and lower mesenteric vessels, and the corresponding left colon and mesocolon portion. With this surgical technique, rectal dissection may damage the pelvic autonomic plexus, and thus impair sexual and urinary functions. During lower anterior resection sphincters may be preserved and permanent colostomy avoided, thus decreasing the potential development of impotence, impaired ejaculation, urine retention, etc. Notwithstanding, trauma to the anal sphincter as induced upon stapler introduction may result in incontinence, defecatory urgency, etc.

The authors report that expectations also differ amongst patients, which may have influenced results obtained: in abdominoperineal amputation, patients assume their need for colostomy and become psychologically adapted to it once they check their activity remains unrestricted; patients undergoing lower anterior resection expect that their usual intestinal and sphincter function will be preserved, and feel deeply let down when difficulties regarding fecal incontinence arise. To avoid this, thoroughly informing patients on either technique seems relevant enough prior to surgery.

Anyway, considering the benefits and shortcomings of both techniques, the goal of surgery is to ensure oncologic safety besides modifying factors apt to negatively influence quality of life following the procedure. As previously mentioned, we have been witness to a great technical advance in the surgery of rectal cancer, but issues regarding surgical technique remain that require refinement in order to reduce morbidity and hence improve quality of life for operated patients. A surgical option for rectal cancer that is associated with decreased morbidity is transanal endoscopic surgery, which allows the preservation of sexual, vesical, and anal functions. This curative-intent local resection technique is indicated for patients with well- or moderately-differentiated tumors confined to the rectal wall, not extending beyond the muscularis layer, and lacking nodal involvement (T0-T1, N0) (6,7). In carefully selected patients, recurrence and survival rates with this therapeutic modality are similar to those of radical surgery (8). Success with this surgical technique definitely depends on patient triage, and a thorough preoperative study including endorectal endoscopy is therefore mandatory.

Alternatively, regarding local rectal cancer recurrence, Garay M et al. (9) studied the morbidity of postoperative radiotherapy in operated individuals. These authors encountered that postoperative radiotherapy decreased the potential for local recurrence in rectal cancer, but at the expense of increased acute and late morbidity. As goals for rectal cancer management, they claim that not only an increase in total and free-of-disease survival, and a reduction in local recurrence and postoperative complications should be considered, but also that these criteria are met while preserving the best quality of life for patients. In view of their results, they suggested a reassessment of postoperative radiotherapy, which has a negative impact on patient quality of life, and a consideration of other similarly highly effective options to reduce local recurrence rates in rectal cancer with less morbidity: total mesorectal excision and preoperative chemoradiotherapy.

The mesorectum consists of fatty, lymphovascular, and neural tissues around the rectum, and its significance in rectal cancer results from its potential neoplastic involvement, either from direct extension or lymph node infiltration, or in the form of isolated implants away from the primary tumor. Distant metastases develop in the mesorectum in 4 to 20% of patients. A close relationship exists between the extent of mesorectal involvement and prognosis following surgery. Thus, total mesorectal excision is postulated in curative-intent surgery for rectal cancer, especially for mid- to lower-third neoplasms. In expert hands, total mesorectal excision allows a reduction of local recurrence rates to levels below 10%, as well as an improvement in survival for patients with this neoplasm (10). Some authors consider that total mesorectal excision may adequately decrease local recurrence rates, so that preoperative radiotherapy would be rendered unnecessary for a high number of patients (11). However, other studies have drawn differing conclusions.

The preoperative use of chemoradiotherapy followed by total mesorectal excision is currently accepted as the treatment of choice for patients with mid- and lower-third rectal cancer in whom mesorectal and/or nodal infiltration is suspected in the extension study. The benefits of preoperative radiotherapy include easier tumoral resection, decreased risk for tumor cell spread from surgical management, increased potential for anal sphincter preservation, and lower morbidity versus postoperative radiotherapy (small intestinal loop radiation is avoided to prevent fixation following surgery), with higher tumoral radiosensitivity (vascular changes occur during surgery, which may entail poorer tumoral oxygenation). Preoperative radiotherapy provides additional benefits when administered to patients undergoing adequate mesorectal resection, and significantly reduces local recurrence rates when compared to conventional surgery alone (12).

To conclude, radical surgery techniques for rectal cancer currently result in reduced quality of life for patients. Local resection using transanal endoscopic surgery may be considered a therapeutic modality with less morbidity, and its success directly depends upon a careful triage of patients with early-stage tumors. The prevention of local recurrence in rectal cancer using preoperative chemoradiotherapy plus mesorectal excision during surgery is more effective than postoperative radiotherapy and impairs patient quality of life to a lesser extent.

M. L. Manzano Alonso

Service of Digestive Diseases. Hospital 12 de Octubre. Madrid, Spain

 

References

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8. Winde G, Nottberg H, Keller R, Schmid K, Buuml;nte H. Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs anterior resection. Dis Colon Rectum 1996; 39: 969-76.

9. Garay Burdeos M, García-Botella M, Viciano Pascual V, Torregrosa Macías MD, Aguiló Lucía J, Ata M, et al. Morbilidad de la radioterapia postoperatoria en el cáncer de recto. Rev Esp Enferm Dig 2004; 96 (11): 765-72

10. Pera M. Cáncer de recto: valor de la resección del mesorrecto en el pronóstico de la enfermedad. Gastroenterol Hepatol 2003; 26: 159-60.

11. Simunovic M, Sexton R, Rempel E, Moran BJ, Heald RJ. Optimal preoperative assessment and surgery for rectal cancer may greatly limit the need for radiotherapy. Br J Surg 2003; 90: 999-1003.

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