Treatment of Recurrent rectal Cancer

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Treatment of Recurrent rectal Cancer

• Dr. Beldholm/Dr Yeo
• Prince of Wales Surgical Journal Club

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Article
Pain and quality of life after treatment in
patients with locally recurrent rectal
cancer Esnaola NF. Cantor SB. Johnson ML. Mirza
AN. Miller AR. Curley SA. Crane CH. Cleeland CS.
Janjan NA. Skibber JM. Journal of Clinical
Oncology. 20(21)4361-7, 2002 Nov 1.
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BACKGROUND TO SUBJECT

• Difficult treatment area
• After primary resection of rectal tumours up to
  40 have recurrences usually distal. Around 8
  are locally recurrent2.
• The main argument for salvage surgery is that 50
  of patients with recurrent cancer after curative
  surgery have an isolated pelvic tumour.
• Even when the margins are negative after Locally
  recurrent tumours are resected the survival is
  poor. (30-40 5 year survival1,2.)

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BACKGROUND TO SUBJECT

• Patients with recurrent rectal cancer may
  experience
• intractable pelvic or sciatic pain
• bleeding
• cramping
• constipation caused by intestinal obstruction
• dysuria
• urinary tract dysfunction
• chronic pelvic sepsis
• The goal of treatment of locally recurrent rectal
  cancer are palliation of symptoms, good quality
  of life and if possible cure with low
  treatment-related complication rate.

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BACKGROUND TO SUBJECT

• Younger age, earlier stage of primary tumour and
  initial treatment by radical proctectomy with
  sphincter-saving procedure have been shown to do
  better in some studies.
• Curative intent surgery may have significant
  morbidity
• Treatment options in rectal cancer are more
  restrictive than more proximal bowel cancers.
• Palliative surgery have been shown in several
  studies not to improve survival compared to no
  surgery.

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BACKGROUND TO SUBJECT

• Endoscopic treatments for palliation of
  obstructive rectal cancer include
• Stents
• Dilatation
• NdYag laser photoablation
• Electrocoagulation
• Cryotherapy
• Photodynamic therapyphotodynamic therapy (PDT) -
  A form of treatment involving the systemic
  injection of a photosensitizing agent which
  collects in tumor tissue. Subsequently, a low
  power laser light is applied during an endoscopic
  procedure through the scope exposing the tumor to
  red light with resultant tumor necrosis due to
  the photochemical reaction.

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BACKGROUND TO ARTICLE

• LOCAL RECURRENCE occurs in up to one third of
  patients after curative resection of rectal
  cancer and is amenable to re-resection in
  approximately one third of these cases
• Although multimodality therapy for locally
  recurrent rectal cancer (LRRC) has resulted in
  5-year survival rates of 21 to 58, it is
  associated with significant morbidity and
  mortality
• Because many patients with LRRC present with
  disease involving adjacent viscera or bone,
  curative surgery often requires multivisceral
  resections, multiple ostomies, and bone
  resection.

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BACKGROUND TO ARTICLE

• Despite adequate surgical margins, the majority
  of patients eventually succumb to recurrent local
  or systemic disease.
• Because survival in patients with locally
  recurrent rectal cancer (LRRC) is limited, pain
  control and quality of life (QOL) are important
  parameters.

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BACKGROUND TO ARTICLE

• The stated purpose of this study was to assess
  the prevalence of post treatment pain and QOL of
  patients with LRRC treated with nonsurgical
  palliation verses resection
• The aim was also to identify predictors of poor
  outcome.

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STUDY DESIGN

• prospective study of pain management and QOL post
  treatment with either resection or palliation.
• Non randomised
• Observational using previously validated
  functional and pain assessment tools

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STUDY DESIGN- Patient selection

• Patients where enrolled between Dec 1999 and
  October 2000
• patients with LRRC observed at the
  Gastrointestinal Surgery Clinic at The University
  of Texas M.D. Anderson Cancer Center
• Prospective study of pain management and QOL
  after treatment
• Patients were eligible if a period of at least 3
  months had elapsed between treatment of their
  primary tumor and disease recurrence
• patients with concurrent distant disease were
  included

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STUDY DESIGN- Patient exclusions

• Nonadenocarcinoma pathology
• Concurrent nonrectal pelvic malignancies or a
  previous history of pelvic pain syndrome
• Chronic constipation

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STUDY DESIGN- Definitions

• Nonsurgical palliation was defined as treatment
  with supportive care alone, chemotherapy,
  radiation therapy, or chemoradiation without
  tumor resection.
• Patients were enrolled at various time points
  after recurrence, and serial assessments were
  performed at 3-month intervals. To perform a
  cross-sectional analysis of posttreatment pain
  and QOL, They based their study only on each
  patients first posttreatment assessment.

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STUDY DESIGN

• 51 of 52 patients who fulfilled eligibility
  criteria agreed to participate and completed
  informed consent.
• 6 patients with incomplete post-treatment
  assessments were excluded, leaving 45 patients
• In 5 patients who enrolled before treatment, the
  first posttreatment assessments (at approximately
  3 months) were used. In the remaining 40 patients
  who enrolled after the initiation of treatment,
  the assessment obtained at the time of study
  entry was used.

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STUDY DESIGN

• Assessment of pain
• Done by dedicated clinical research nurse
• blinded to clinicians
• BPI (Brief Pain Index)
• Self administered previously validated instrument
• Questions regarding location of pain worst pain
  pain on average pain right now
• Scale 0-10

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STUDY DESIGN

• Index of pain management
• 0, no analgesic drug 1, non-opioid 2, weak
  opioid and 3, strong opioid.
• level 0, no pain (score 0) level 1, mild pain
  (score 1 to 4) level 2, moderate pain (score 5
  to 6) and level 3, severe pain (score 7 to 10).
• The pain-management index was constructed by
  subtracting the pain level from the analgesic
  level and ranged from -3 (a patient in severe
  pain receiving no analgesics) to 3 (a patient
  receiving a strong opioid and reporting no pain).
• negative score indicated inadequate pain
  management, whereas a positive score was
  considered a conservative indicator of acceptable
  treatment.

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STUDY DESIGN

• Assessment of QOL
• Functional Assessment of Cancer
  Therapy-Colorectal (FACT-C) questionnaire
• self-administered instrument consists of 26 items
• covering four domains of global QOL physical
  well-being, social/family well-being, emotional
  well-being, and functional well-being
• Higher FACT-C scores indicate good QOL, whereas
  low scores indicate poor QOL
• The FACT-C is reliable and has been validated in
  patients with colorectal cancer

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There was an association between pelvic or
sciatic pain at presentation and the type of
treatment received
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• The majority of patients treated with nonsurgical
  palliation presented with disease involving the
  bony pelvis or multiple sites,
• Almost half of the resected patients presented
  with anastomotic or pelvic visceral recurrences

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77 or 23 patients had complete resection with
clear margins.
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BPIBrief Pain Inventory scale from 0 (no pain)
to 10 (pain as bad as you can imagine)
FACT-C Functional Assessment of Cancer
Therapy-Colorectal questionnaire Higher FACT-C
scores indicate good QOL
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• Patients treated with nonsurgical palliation
  reported moderate to severe pain beyond the first
  3 months of treatment, accompanied by worsening
  QOL during the same interval
• patients treated with resection reported mild to
  moderate pain during the first 3 years after
  treatment, with a slow improvement in QOL scores
  during this interval

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• Long-term survivors after resection (ie, beyond 3
  years), reported minimal pain (ie, median pain
  score of 0) and good QOL
• Pain-management index scores were comparable in
  the two groups, suggesting that these
  observations were not caused by differences in
  pain management.

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• Female sex was associated with worse pain and QOL
  scores after treatment (P .04) despite similar
  pain-management index scores
• Women reported significantly worse QOL after
  treatment than men

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• Pelvic or sciatic pain at presentation was a
  strong predictor of poor outcome
• 67 of the patients treated with nonsurgical
  palliation reported pain at presentation compared
  with 27 of the patients treated with resection
• pain at presentation had a negative effect on
  posttreatment pain and QOL even when controlling
  for treatment group.

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• 75 percent of the patients who underwent total
  pelvic exenteration reported moderate to severe
  pain after treatment compared with only 32 of
  patients treated with low anterior resection,
  abdominoperineal resection, or anterior
  exenteration.
• In addition, 63 of the patients who underwent
  bony resections reported moderate to severe pain
  after treatment compared with only 21 of their
  counterparts.
• The fact that all of the patients who underwent
  total pelvic exenterations also underwent bony
  resections, the independent effect of total
  pelvic exenteration versus bony resection in
  these patients could not be analyzed.

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DISCUSSION-Points authors make on article

• Posttreatment pain is a common problem in
  patients with LRRC treated with either
  nonsurgical palliation or resection.
• Pain has a significant negative impact on
  posttreatment QOL
• Predictor of worse pain after treatment.
• Female sex
• symptoms at presentation
• total pelvic exenteration
• bony resection

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DISCUSSION-Points authors make on article

• For patients with limited pelvic disease, radical
  resection can result in significant disease-free
  and overall survival.

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DISCUSSION-Points authors make on article

• Most of the patients received acceptable pain
  management after resection (based on
  pain-management index scores), but the majority
  of reported mild to moderate levels of pain
  during the first 3 years after surgery
• despite apparently acceptable pain management,
  post-treatment pain after resection may be more
  prevalent and prolonged than previously reported.
• Several patient, tumor, and treatment factors
  were predictive of poor outcome and could be used
  to identify candidates for more aggressive pain
  management

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DISCUSSION-Points authors make on article

• Patients who presented with symptoms
  (particularly pelvic or sciatic pain) were more
  likely to experience worse pain and QOL after
  treatment.
• These factors have been associated with
  incomplete resection and poor survival in several
  series, re-resection in these patients should be
  carefully considered, particularly if total
  pelvic exenteration or bony resection is
  anticipated

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DISCUSSION-limitaions of study

• Enrolled through the Gastrointestinal Surgery
  Clinic--selection bias
• In patients who enrolled several months after
  treatment, data regarding symptoms at
  presentation (particularly pain) could be subject
  to recall bias, particularly in patients who were
  doing poorly at the time of assessment

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DISCUSSION-limitaions of study

• Based on 45 patients, 20 of whom experienced the
  outcome of interest (moderate to severe
  posttreatment pain). As a result, some of the
  reported analyses (particularly those dealing
  with specific surgical subgroups or adjuvant
  therapies) may have failed to reach statistical
  significance because of sample-size limitations
  and type II error.

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DISCUSSION- Limitaions

• Who made the decision on surgery/palliation and
  on what basis.