"I Wish There had been Resources": A Photo-Elicitation Study of Rectal Cancer Survivorship Care Needs.

BACKGROUND: Rectal cancer survivors experience unique, prolonged posttherapy symptoms. Previous data indicate that providers are not skilled at identifying the most pertinent rectal cancer survivorship issues. Consequently, survivorship care is incomplete with the majority of rectal cancer survivors reporting at least one unmet posttherapy need. METHODS: This photo-elicitation study combines participant-submitted photographs and minimally structured qualitative interviews to explore one's lived experiences. Twenty rectal cancer survivors from a single tertiary canter provided photographs representative of their life after rectal cancer therapy. The iterative steps informed by inductive thematic analysis were used to analyze the transcribed interviews. RESULTS: Rectal cancer survivors had several recommendations to improve their survivorship care, which fell into three major themes: (1) informational needs (e.g., more details about posttherapy side effects); (2) continued multidisciplinary follow up care (e.g., dietary support); and (3) suggestions for support services (e.g., subsidized bowel altering medications and ostomy supplies). CONCLUSIONS: Rectal cancer survivors desired more detailed and individualized information, access to longitudinal multidisciplinary follow-up care, and resources to ease the burdens of daily life. These needs may be met through the restructuring of rectal cancer survivorship care to include disease surveillance, symptom management, and support services. As screening and therapy continues to improve, providers must continue to screen and to provide services that address the physical and psychosocial needs of rectal cancer survivors.

Parastomal Hernia Rates and Exercise After Ostomy Surgery.

BACKGROUND: Parastomal hernias are common and negatively affect patient's lives. We hypothesized that physical activity (or lack thereof) might be associated with the presence of parastomal hernia. If so, this might be an actionable target for prevention. OBJECTIVE: The objective was to determine rates of and risk factors for parastomal hernias in patients with a permanent ostomy. DESIGN: This was a retrospective cohort and survey study. Postal survey included questions about parastomal hernia, symptoms, lifestyle, and validated instruments to measure stoma quality of life and physical activity. Medical record abstraction was conducted for clinical comorbidities. SETTINGS: This study was conducted in a single large academic medical center. PATIENTS: Patients who underwent operations that included a permanent urostomy, colostomy, and/or ileostomy between 2014 and 2018 were included. MAIN OUTCOME MEASURES: Parastomal hernia (self-reported) and physical activity, measured in total metabolic equivalent-minutes/week, were our main outcome measures. RESULTS: A total of 443 of 724 patients responded (response rate, 61.2%). Two hundred twelve patients (47.9%) had urostomies, 160 (36.1%) had colostomies, and 99 (22.3%) had ileostomies. One hundred twenty-eight patients (29.7%) had a parastomal hernia, with rates of 27.1% for urostomy, 40.0% for colostomy, and 23.7% for ileostomy. There was a statistically significant association between less exercise and higher incidence of parastomal hernia (median, 579 metabolic equivalent-minutes/week for those with parastomal hernias vs 1689 metabolic equivalent-minutes/week for those without; p = 0.001). LIMITATIONS: The association between physical activity and parastomal hernia may be confounded by obesity or the possibility that patients with parastomal hernia may be limited physically by their hernia. CONCLUSIONS: Parastomal hernia rates remain high in modern surgical practice. This study shows an association between patients' physical activity and the presence of a parastomal hernia, with a higher rate among patients who exercise less. See Video Abstract at http://links.lww.com/DCR/B910 . TASAS DE HERNIA PARAESTOMAL Y EJERCICIO DESPUS DE LA CIRUGA DE OSTOMA: ANTECEDENTES:Las hernias paraostomales son complicaciones comunes después de la cirugía de ostomía y afectan la calidad de vida de los pacientes. Nuestra hipótesis es que la actividad física de los pacientes (o la falta de ella) podría estar asociada con la presencia de hernia paraostomal. Si es así, este podría ser un objetivo utilizable para la prevención.OBJETIVO:Determinar las tasas y los factores de riesgo de las hernias paraostomales en pacientes que se sometieron a una cirugía que resultó en una ostomía permanente.DISEÑO:Estudio retrospectivo de cohorte y encuesta. La encuesta postal incluyó preguntas sobre hernia paraostomal, síntomas, estilo de vida e instrumentos validados para medir la calidad de vida del paciente ostomizado y la actividad física. Se realizó la confección de gráficos para las comorbilidades clínicas.ESCENARIO:Centro médico académico de gran tamañoPACIENTES:Pacientes que se sometieron a operaciones que incluyeron una urostomía permanente, colostomía y/o ileostomía entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:La hernia paraostomal (autoinformada) y la actividad física, medidas en equivalente metabólico de actividad total-minutos/semana, fueron nuestras principales medidas de resultado. También se evaluó la calidad de vida.RESULTADOS:Un total de 443 de 724 pacientes respondieron a la encuesta (tasa de respuesta 61,2%). 212 pacientes (47,9%) tenían urostomías, 160 (36,1%) colostomías y 99 (22,3%) ileostomías. 128 pacientes (29,7%) tenían hernia paraostomal, con tasas de 27,1% para urostomía, 40,0% para colostomía y 23,7% para ileostomía. Hubo una asociación estadísticamente significativa entre menos ejercicio y una mayor incidencia de hernia paraostomal (mediana: 579 equivalentes metabólicos - minutos/semana para aquellos con hernias paraostomales versus 1689 para aquellos sin hernias; p = 0,001).LIMITACIONES:La asociación entre la actividad física y la hernia paraostomal puede confundirse con la obesidad o con el hecho de que los pacientes con hernia paraostomal pueden tener menos actividad física debido a su hernia.CONCLUSIONES:Las tasas de hernia paraostomal siguen siendo altas en la práctica quirúrgica moderna y las hernias se asocian con una peor calidad de vida. Este estudio muestra una asociación entre la actividad física de los pacientes y la presencia de una hernia paraostomal, con una tasa más alta entre los pacientes que hacen menos ejercicio. Consulte Video Resumen en http://links.lww.com/DCR/B910 . (Traducción-Dr. Felipe Bellolio ).

Close distal margin is associated with locoregional rectal cancer recurrence: A multicenter study.

BACKGROUND AND OBJECTIVES: The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk. METHODS: This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018. RESULTS: Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035). CONCLUSIONS: Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.

"Their Whole Lives Are Going To Change": A Photo-Elicitation Study of Rectal Cancer Survivorship.

BACKGROUND: Rectal cancer survivors experience persistent symptoms, which may lead to unmet needs. OBJECTIVE: This study aimed to explore the rectal cancer survivor experience and identify the impacts of treatment using photo-elicitation. DESIGN: This was a novel study in which patients were instructed to take photographs that showed aspects of life that have been challenging to deal with since undergoing treatment. Participants underwent subsequent qualitative interviews using the photographs as prompts. SETTING: The study was conducted in a cancer center in a tertiary medical center. PATIENTS: Twenty patients were included who underwent curative-intent rectal cancer treatment. MAIN OUTCOME MEASURES: Interviews were designed to explore the lived experiences of patients with rectal cancer after treatment. RESULTS: Three major themes with regard to life after rectal cancer and its treatments emerged: physical symptoms, lifestyle changes, and changes over time. Physical symptoms encompassed GI issues, ostomy difficulties, and genitourinary symptoms. Lifestyle changes included those relating to diet, social life, and hobbies as well as major life changes and finances. Finally, patients spoke of improvement during the time of symptoms and impact on daily life. LIMITATIONS: There may be bias because of the homogeneity of our study population, which may not represent the experiences of younger patients, those of lower socioeconomic status, or those who chose not to participate. Our sample was also overrepresented by patients with a complete pathologic response after neoadjuvant chemotherapy and excluded individuals with recurrence. Finally, single interviews with each individual at different points from their treatment may have resulted in recall bias. CONCLUSIONS: This photo-elicitation study provided rectal cancer survivors with a unique opportunity to share how rectal cancer treatment has impacted their lives beyond traditional metrics such as postoperative complications and long-term survival. In addition to improving preoperative counseling and expectation setting, future efforts should focus on postoperative symptom surveillance and appropriate referral when needed. See Video Abstract at http://links.lww.com/DCR/C7. SUS VIDAS ENTERAS VAN A CAMBIAR UN ESTUDIO DE OBTENCIN DE IMGENES SOBRE LA SUPERVIVENCIA AL CNCER DE RECTO: ANTECEDENTES:Los sobrevivientes de cáncer de recto experimentan síntomas persistentes, lo que puede dar lugar a necesidades no satisfechas.OBJETIVO:Explorar la experiencia de los sobrevivientes de cáncer de recto e identificar los impactos del tratamiento mediante el uso de fotoestimulación.DISEÑO:En este nuevo estudio, se instruyó a los pacientes para que tomaran fotografías que mostraran aspectos de la vida que han sido difíciles de manejar desde que se sometieron al tratamiento. Los participantes se sometieron posteriormente a entrevistas cualitativas utilizando las fotografías como estimuladores.ESCENARIO:Centro oncológico en un centro médico terciario.PARTICIPANTES:Veinte pacientes que se sometieron a tratamiento de cáncer de recto con intención curativa.PRINCIPALES MEDIDAS DE RESULTADO:Las entrevistas se diseñaron para explorar las experiencias vividas por los pacientes con cáncer de recto después del tratamiento.RESULTADOS:Surgieron tres temas principales con respecto a la vida después del cáncer de recto y sus tratamientos: síntomas físicos; cambios en el estilo de vida; y cambios en el tiempo. Los síntomas físicos abarcaron problemas gastrointestinales, dificultades de las ostomías y síntomas genitourinarios. Los cambios en el estilo de vida incluyeron aquellos relacionados con la dieta, la vida social y los pasatiempos, así como cambios importantes en la vida y las finanzas. Por último, los pacientes hablaron de una mejoría con el tiempo de los síntomas y el impacto en la vida diaria.LIMITACIONES:Puede haber sesgo debido a la homogeneidad de nuestra población de estudio, que puede no representar las experiencias de los pacientes más jóvenes, los de nivel socioeconómico más bajo o los que optaron por no participar. Nuestra muestra también estuvo sobrerrepresentada por pacientes con una respuesta patológica completa después de la quimioterapia neoadyuvante y excluyó a los individuos con recurrencia. Finalmente, las entrevistas individuales con cada paciente en diferentes puntos de su tratamiento pueden dar lugar a que los participantes experimenten un sesgo de recuerdo.CONCLUSIONES:Este estudio de obtención de fotografías brinda a los sobrevivientes de cáncer de recto una oportunidad única de compartir cómo el tratamiento del cáncer de recto ha impactado sus vidas más allá de las métricas tradicionales, como las complicaciones posoperatorias y la supervivencia a largo plazo. Además de mejorar el asesoramiento preoperatorio y el establecimiento de expectativas, los esfuerzos futuros deben centrarse en la vigilancia de los síntomas posoperatorios y la derivación adecuada cuando sea necesario. Consulte Video Resumen en http://links.lww.com/DCR/C7.

Impact of Postoperative Complications on Oncologic Outcomes After Rectal Cancer Surgery: An Analysis of the US Rectal Cancer Consortium.

BACKGROUND: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not well studied. METHODS: The United States Rectal Cancer Consortium (2007-2017) was reviewed for primary rectal adenocarcinoma patients who underwent R0/R1 resection. Ninety-day POCs were categorized as major or minor and were grouped into infectious, cardiopulmonary, thromboembolic, renal, or intestinal dysmotility. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS: Among 1136 patients, the POC rate was 46% (n = 527), with 63% classified as minor and 32% classified as major. Of all POCs, infectious complications comprised 20%, cardiopulmonary 3%, thromboembolic 5%, renal 9%, and intestinal dysmotility 19%. Compared with minor or no POCs, major POCs were associated with both worse RFS and worse OS (both p < 0.01). Compared with no POCs, a single POC was associated with worse RFS (p < 0.01), while multiple POCs were associated with worse OS (p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (p < 0.01), while cardiopulmonary and thromboembolic POCs were associated with worse OS (both p < 0.01). Renal POCs were associated with both worse RFS (p < 0.001) and worse OS (p = 0.01). After accounting for pathologic stage, neoadjuvant therapy, and final margin status, Multivariable analysis (MVA) demonstrated worse outcomes with cardiopulmonary, thromboembolic, and renal POCs for OS (cardiopulmonary: hazard ratio [HR] 3.6, p = 0.01; thromboembolic: HR 19.4, p < 0.01; renal: HR 2.4, p = 0.01), and renal and infectious POCs for RFS (infectious: HR 2.1, p < 0.01; renal: HR 3.2, p < 0.01). CONCLUSIONS: Major complications after proctectomy for cancer are associated with decreased RFS and OS. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.

A national qualitative study of surgical coaching: Opportunities and barriers for colorectal surgeons.

BACKGROUND: Surgical coaching interventions have been recommended as a method of technological skills improvement for individual surgeons and lifelong occupational learning. Patient outcomes for laparoscopic colectomy vary significantly based on surgeon experience and case volume. As surgical coaching is an emerging area, little is known about how surgeons view coaching interventions. METHODS: Semistructured interviews with 68 colorectal surgeons from across the country who were e-mail recruited from the American Society of Colon and Rectal Surgeons focused on exploring the attitudes surrounding surgical coaching programs among colorectal surgeons. Interviews were performed via telephone, audio-recorded, and transcribed verbatim with redaction of identifying information. Interviews were analyzed by iterative steps informed by thematic analysis. RESULTS: Surgeons reported the desire to participate in coaching programs to improve patient outcomes through technical skill advancement, to keep pace with surgical innovation, and to fulfill a desire for lifelong learning. However, surgeons varied in their beliefs over who should be coached, who should coach, the format of coaching, and the topics addressed in coaching. Obstacles identified included time, financial and medicolegal concerns, balance with resident education, and vulnerability. CONCLUSION: Widespread enthusiasm for surgical coaching programs exists among colorectal surgeons. However, there is variability in what surgeons believe an ideal surgical coaching program would look like. Therefore, in alignment with adult learning theory, we recommend the creation of several different models of surgical coaching to allow each surgeon to benefit from this advancement in continuous professional development.

It's not fine: A photo-elicitation study of rectal cancer survivors' emotions and coping strategies.

BACKGROUND: Comprehensive cancer care includes supporting the psychological health of survivors who are at high risk of distress. However, little is known about the emotional experiences of rectal cancer survivors specifically. We sought to explore psychological well-being and coping strategies utilized by rectal cancer survivors. METHODS: Twenty rectal cancer survivors shared photographs of their post-treatment experiences. In follow-up interviews, participants discussed photographs' meanings and emotional experiences during their cancer journey. Transcribed interviews were analyzed using iterative steps of inductive thematic analysis. RESULTS: Emotions ranged from sadness to anxiety and fear of cancer recurrence. Coping mechanisms were grouped into 3 categories: (1) seeking support and information; (2) focus on attitudes and perspectives; and (3) distancing strategies. CONCLUSION: Our results highlight the persistent psychological impact of rectal cancer and need for additional support for survivors. Providers may help temper patients' fear of recurrence by explicitly discussing prognosis and risk of recurrence. Although multidisciplinary survivorship clinics are ideal, all cancer care providers and primary care physicians should feel empowered to screen for psychological distress and refer patients to appropriate resources when needed.

Colorectal surgery patient perspectives on healthcare during the CoVID-19 pandemic.

BACKGROUND: To focus on critical care needs of coronavirus patients, elective operations were postponed and selectively rescheduled. The effect of these measures on patients was unknown. We sought to understand patients' perspectives regarding surgical care during the CoVID-19 pandemic to improve future responses. METHODS: We performed qualitative interviews with patients whose operations were postponed. Interviews explored patient responses to: 1) surgery postponement; 2) experience of surgery; 3) impacts of rescheduling/postponement on emotional/physical health; 4) identifying areas of improvement. Interviews were recorded, transcribed, coded, and analyzed through an integrated approach. RESULTS: Patient perspectives fell within the following domains: 1) reactions to surgery postponement/rescheduling; 2) experience of surgery during CoVID-19 pandemic; 3) reflections on communication; 4) patient trust in surgeons and healthcare. CONCLUSIONS: We found no patient-reported barriers to rescheduling surgery. Several areas of care which could be improved (communication). There was an unexpected sense of trust in surgeons and the hospital.