Chronic pain after colon cancer surgery: Translation and validation of a scoring system.

OBJECTIVE: The aim of this study was to translate and validate the chronic pain score (CP score) in a cohort of colon cancer patients. Chronic pain following colon cancer surgery is still poorly understood, in particular the lack of a validated tool for measuring chronic pain is a major issue as such an instrument is critical for evaluating the incidence and risk factors. The CP score was created using data from Danish rectal cancer patients. METHODS: Danish colorectal cancer survivors diagnosed between 2001 and 2014 completed the CP score and two quality of life (QoL) measures. Clinical data were obtained from a national database. Convergent validity was investigated by testing the association of the CP score with a single ad hoc QoL item and the EORTC QLQ-C30, and discriminative validity was tested as the score's ability to differentiate between gender and age groups. Sensitivity and specificity were evaluated by determining the ability of the score to identify patients with a major impact of pain on QoL. RESULTS: Responses from 7127 colon cancer were included. Convergent validity was confirmed, as the score was associated with both QoL measures (p < 0.001). Moreover, the score could differentiate between males/females and older/younger patients (p < 0.001, respectively), reflecting high discriminative validity. Finally, the score was able to identify patients with a major impact on QoL, with a sensitivity of 87% and specificity of 82%. CONCLUSION: The CP score is a valid tool for measuring chronic pain after colon cancer surgery and should be used to homogenize outcomes in future studies.

Surviving rectal cancer at the cost of a colostomy: global survey of long-term health-related quality of life in 10 countries.

BACKGROUND: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries. METHOD: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems. RESULTS: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL. CONCLUSION: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life.

Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors.

PURPOSE: Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life. METHODS: In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life. RESULTS: The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]). CONCLUSION: In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

The impact of type 2 diabetes on long-term gastrointestinal sequelae after colorectal cancer surgery: national population-based study.

BACKGROUND: Long-term gastrointestinal sequelae are common after colorectal cancer surgery, but the impact of type 2 diabetes (T2D) is unknown. METHODS: In a cross-sectional design, questionnaires regarding bowel function and quality of life (QoL) were sent to all Danish colorectal cancer survivors, who had undergone surgery between 2001 and 2014 and had more than 2 years follow-up without relapse. The prevalence of long-term gastrointestinal sequelae among colorectal cancer survivors with and without T2D were compared while stratifying for type of surgical resection and adjusting for age, sex, and time since surgery. RESULTS: A total of 8747 out of 14 488 colorectal cancer survivors answered the questionnaire (response rate 60 per cent), consisting of 3116 right-sided colonic, 2861 sigmoid, and 2770 rectal resections. Of these, 690 (7.9 per cent) had a diagnosis of T2D before surgery. Survivors with T2D following rectal resection had a 15 per cent (95 per cent c.i. 7.8 to 22) higher absolute risk of major low anterior resection syndrome, whereas survivors with T2D following right-sided and sigmoid resection had an 8 per cent higher risk of constipation (P < 0.001) but otherwise nearly the same long-term risk of bowel symptoms as those without T2D. For all types of colorectal cancer resections, T2D was associated with a 6-10 per cent higher risk of severe pain (P < 0.035) and a 4-8 per cent higher risk of impaired QoL. CONCLUSION: T2D at time of surgery was associated with a higher risk of long-term bowel dysfunction after rectal resection, but not after colon resection excluding a higher risk of constipation. T2D was associated with a slightly higher frequency of severe pain and inferior QoL after both rectal and colonic cancer resection.

Labor Market Attachment 2 Years After Colorectal Cancer Surgery: A Population-based Study.

Objectives: To investigate the association between clinical/sociodemographic factors and labor market attachment, and to estimate employment probability 2 years after colorectal cancer (CRC) surgery. Background: A rising prevalence of younger CRC survivors commands a stronger focus on labor market attachment. The association between clinical factors like type of surgery and CRC survivors' labor market attachment remains poorly investigated. Methods: National registries provided information on employment status and clinical/sociodemographic variables for all 20- to 60-year-old CRC patients without previous cancer diagnosed in Denmark from 2001 to 2014, undergoing surgery and being attached to the labor market. Associations between clinical/sociodemographic factors and labor market attachment were investigated in multiple logistic regression analyses. Results: A total of 5755 CRC patients were included. Two years after surgery, 59.7% were working. Factors significantly associated with a higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower Union for International Cancer Control stage, and undergoing surgery in the most recent of four time-periods. Two years after undergoing surgery, the probability of working was significantly higher for left-sided than for right-sided colon resections, higher for low anterior resection (LAR)/high tumor than for LAR/low tumor, and higher for abdominoperineal resection than for Hartmann's procedure. Of the 4798 (86.8%) patients alive 2 years after surgery, 68.8% were working, 7.8% had retired, whereas 23.4% were on temporary benefits, sick leave, or disability pension. Conclusions: Clinical/sociodemographic factors were associated with the probability of working 2 years after surgery. This knowledge can be used to inform patients and target interventions towards patients with low post-CRC probability of working.

Prevalence of self-reported abdominal symptoms among 50-74-years-old men and women eligible for colorectal cancer screening -a cross-sectional study.

BACKGROUND: Screening is defined as the identification of unrecognized disease in an apparently healthy population. Symptomatic individuals are recommended to contact a physician instead of participating in screening. However, in colorectal cancer (CRC) screening this approach may be problematic as abdominal symptoms are nonspecific. This study aimed at identifying the prevalence of self-reported abdominal symptoms among screening-eligible men and women aged 50-74 years. METHODS: This cross-sectional survey study included 11,537 individuals aged 50-74 years invited for CRC screening from 9 to 23 September 2019. Descriptive statistics of responders experiencing alarm symptoms of CRC, Low Anterior Resection Syndrome Score (LARS) and the Patient Assessment of Constipation-Symptoms (PAC-SYM) were derived. The association between abdominal symptoms and demographic and socioeconomic variables were estimated by prevalence ratio (PR) using a Poisson regression model with robust variance. RESULTS: A total of 5488 respondents were included. The respondents were more likely women, of older age, Danish, cohabiting and had higher education and income level compared to non-respondents. Abdominal pain more than once a week was experienced by 12.0% of the respondents. Of these, 70.8% had been experiencing this symptom for >1 month. Fresh blood in the stool was experienced by 0.7% and of these 82.1% for >1 month. About one third of those experiencing alarm symptoms more than once a week for >1 month had not consulted a doctor. A total of 64.1% of the respondents had no LARS, 21.7% had minor LARS and 14.2% had major LARS. The median PAC-SYM score was 0.33 (Interquartile range (IQR): 0.17;0.75), the median abdominal score was 0.50 (IQR: 0.00;1.00), median rectal score 0.00 (IQR:0.00;0.33) and median stool score 0.40 (IQR: 0.00;0.80). Men and those aged 65-74 reported less symptoms than women and those aged 50-64 years, respectively. CONCLUSIONS: This study illustrated that abdominal symptoms were frequent among screening-eligible men and women. This should be taken into account when implementing and improving CRC screening strategies. A concerning high number of the respondents experiencing alarm symptoms had not consulted a doctor. This calls for attention to abdominal symptoms in general and how those with abdominal symptoms should participate in CRC screening.

Urinary dysfunction after colorectal cancer treatment and impact on quality of life-a national cross-sectional study in males.

AIM: Despite advances in the treatment of colorectal cancer, postoperative urogenital dysfunction is still a problem although its exact extent remains unclear. The aim of this study was to identify the prevalence and patterns of urinary dysfunction in men following treatment for colorectal cancer and the impact of urinary dysfunction on quality of life. METHOD: A retrospective national Danish cross-sectional study was performed in patients treated for colorectal cancer between 2001 and 2014. Patients answered questionnaires on urinary function and quality of life including the International Consultation on Incontinence Modular Questionnaire-Male Lower Urinary Tract Symptoms measuring voiding and incontinence. Results were analysed based on data on demographics and treatment-related factors obtained from the Danish Colorectal Cancer Group database. RESULTS: A total of 5710 patients responded to the questionnaire (response rate 52.8%). In both crude analysis and after adjusting for patient-related factors (age, time since surgery and American Society of Anesthesiologists score), both voiding (P < 0.0001) and incontinence scores (P < 0.0001) were significantly higher after rectal cancer than after colon cancer. In the rectal cancer group, abdominoperineal excision was found to be a significant risk factor for both voiding (P < 0.0001) and incontinence (P = 0.011), while radiotherapy only impaired continence (P = 0.014). Significant correlations between high voiding and incontinence scores and impaired quality of life were found in both groups. CONCLUSION: We found a high prevalence of urinary dysfunction following treatment for colorectal cancer, especially in the rectal cancer group. Abdominoperineal excision was the most significant risk factor for both voiding and incontinence. Urinary dysfunction significantly impairs patients' quality of life.

Urinary dysfunction after colorectal cancer treatment and its impact on quality of life - a national cross-sectional study in women.

AIM: The aim of this study was to investigate urinary dysfunction and its impact on the quality of life of colorectal cancer survivors. We also wanted to identify the risk factors for impaired urinary function. METHOD: A national cross-sectional study was performed including patients treated for colorectal cancer between 2001 and 2014. Patients answered questionnaires regarding urinary function and quality of life, including the International Consultation on Incontinence Questionnaire - Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), measuring filling, voiding and incontinence. Data were compared with data on demographics and treatment-related factors from the Danish Colorectal Cancer Group (DCCG) database. RESULTS: We found that rectal cancer treatment significantly impaired urinary function compared with colon cancer treatment (filling score p = 0.003, voiding p < 0.0001, incontinence p = 0.0001). Radiotherapy was the single most influential risk factor for high filling (p = 0.0043), voiding (p < 0.0001) and incontinence (p < 0.0001) scores, whereas type of rectal resection was only significant in crude analysis. Urinary dysfunction was strongly associated with an impaired quality of life. CONCLUSION: Urinary dysfunction is common after treatment for colorectal cancer, particularly if the treatment includes radiotherapy. All patients must be informed of the risk before cancer treatment, and functional outcome should be routinely assessed at follow-up.

Comparative analysis of the Memorial Sloan Kettering Bowel Function Instrument and the Low Anterior Resection Syndrome Questionnaire for assessment of bowel dysfunction in rectal cancer patients after low anterior resection.

AIM: Neoadjuvant therapy and total mesorectal excision (TME) for rectal cancer are associated with bowel dysfunction symptoms known as low anterior resection syndrome (LARS). Our study compared the only two validated instruments-the LARS Questionnaire (LARS-Q) and the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI)-in rectal cancer patients undergoing sphincter-preserving TME. METHODS: One hundred and ninety patients undergoing sphincter-preserving TME for Stage I-III rectal cancer completed the MSK-BFI and LARS-Q simultaneously at a median time of 12 (range 1-43) months after restoration of bowel continuity. Associations between the MSK-BFI total/subscale scores and the LARS-Q score were investigated using Spearman rank correlation (r s ). Discriminant validity for the two questionnaires was assessed, and the questionnaires were compared with the European Quality of Life Instrument. RESULTS: Major LARS was identified in 62% of patients. The median MSK-BFI scores for no LARS, minor LARS and major LARS were 76.5, 70 and 57, respectively. We found a strong association between MSK-BFI and LARS-Q (r s -0.79). The urgency/soilage subscale (r s -0.7) and the frequency subscale (rs -0.68) of MSK-BFI strongly correlated with LARS-Q. Low correlation was observed between the MSK-BFI diet subscale and LARS-Q (r s -0.39). On multivariate analysis, both questionnaires showed worse bowel function in patients with distal tumours. A low to moderate correlation with the European Quality of Life Instrument was observed for both questionnaires. CONCLUSIONS: The MSK-BFI and LARS-Q showed good correlation and similar discriminant validity. As the LARS-Q is easier to complete, it may be considered the preferred tool to screen for bowel dysfunction.

Male erectile function after treatment for colorectal cancer: a population-based cross-sectional study.

AIM: The aim of this work was to determine the knowledge gap in the field of erectile function (EF) after colorectal cancer surgery and investigate and compare long-term male EF in colon and rectal cancer survivors in a national population. METHOD: Danish male patients alive without evidence of recurrence who were treated for colon or rectal cancer between May 2001 and December 2014 were invited to participate. Using the International Index of Erectile Function (IIEF) score the derived dichotomized erectile dysfunction (ED) was defined as moderate/severe or no/mild. Patients were grouped based on type of surgery [colon resection, rectal resection (RR) or local resection] and stratified for stoma, preoperative radiotherapy (RT), age and American Society of Anesthesiologists (ASA) score. RESULTS: Of 10 037 eligible patients, 4334 responded (43.18%). The EF score was significantly lower for RR (mean 12.14) compared with both colon resection (mean 15.82) and local resection (mean 14.81) (p < 0.0001). No significant difference between colon resection and local resection was found (p = 0.29). Both a stoma and the use of RT were independent risk factors for ED. After excluding patients with stoma and RT and adjusting for age and ASA score, RR still had a higher risk of ED (OR 1.42, CI 1.20-1.67) compared with colon resection. CONCLUSION: RR has a negative affect on EF. No difference between patients who underwent colon resection and local resection was found. RT and stoma were independent risk factors for ED.

Normative Data for the Low Anterior Resection Syndrome Score (LARS Score).

OBJECTIVE: To provide normative data for the Low Anterior Resection Syndrome (LARS) score. BACKGROUND: The LARS score is a validated and frequently used tool measuring bowel dysfunction after sphincter sparing surgery for rectal cancer. The interpretation of LARS score results has previously been limited by the lack of normative data. METHODS: An age and sex-stratified random sample of 3440 citizens from the general population was drawn from the Danish civil registration system (age range 20-89 years, 50% females). A brief questionnaire including the LARS score and health-related items were distributed electronically or by post. RESULTS: A total of 1875 (54.5%) responded, 54.0% were females. In the age group 50 to 79 years, relevant for most rectal cancer studies, the response rate was 70.5% (n = 807). In this specific age group, 18.8% of the females and 9.6% of the males had a LARS score ≥30, corresponding to the LARS score category "major LARS" (P = 0.001), and the median (interquartile range) LARS score was 16 (7-26) and 11 (4-22), respectively (P < 0.001). Responders with physical disease had a statistically significant higher risk of a LARS score ≥30, compared with responders without any physical disease (odds ratio 2.2, 95% confidence interval 1.6-2.9, P < 0.001). CONCLUSIONS: A LARS score ≥30 (major LARS) is common in the general population, especially in the age group 50 to 79 years. Normative data for the LARS score are now available and can be taken into account when interpreting LARS score results in scientific studies of bowel function after rectal cancer treatment.

Low Anterior Resection Syndrome and Quality of Life After Sphincter-Sparing Rectal Cancer Surgery: A Long-term Longitudinal Follow-up.

BACKGROUND: Despite low anterior resection syndrome being a well-known consequence of sphincter-preserving rectal cancer surgery, the long-term effect on bowel function and quality of life is not fully understood. OBJECTIVE: This study aimed to elucidate whether symptoms of low anterior resection syndrome change over time and if the correlation to quality of life is equivalent when measured at 2 time points. DESIGN: This prospective cohort study included measurements at 2 time points (5 years between; range, 7.1-16.1 years from surgery to second follow-up). SETTINGS: This multicenter study included patients from Sweden and Denmark. PATIENTS: Patients were included if they were ≥18 years of age and underwent curative rectal cancer surgery with either total or partial mesorectal excision. MAIN OUTCOME MEASURES: Outcomes were measured with the low anterior resection syndrome questionnaire including a question assessing the impact of bowel function on quality of life and with the validated quality-of-life questionnaire EORTC QLQ-C30. RESULTS: In total, 282 patients were included and there were no statistically significant differences in the distribution among the 3 groups (no, minor, and major low anterior resection syndrome) when comparing time points follow-up 1 with follow-up 2 (p = 0.455). At follow-up 2, 138 patients (49%) still experienced major impairment. No both statistically and clinically significant differences were seen in the mean score of EORTC QLQ-C30 when comparing the same low anterior resection syndrome group at follow-up 1 and follow-up 2, and the impact on quality of life was comparable. Global health status/quality of life was impaired in the major low anterior resection syndrome group at both follow-up 1 (p < 0.001) and follow-up 2 (p < 0.001). LIMITATIONS: The study design prevents an evaluation of causality. CONCLUSIONS: Difficulties with low anterior resection syndrome and the impact on patients' quality of life persist over time. See Video Abstract at http://links.lww.com/DCR/A762.

Long-term Functional Outcome After Right-Sided Complete Mesocolic Excision Compared With Conventional Colon Cancer Surgery: A Population-Based Questionnaire Study.

BACKGROUND: Complete mesocolic excision improves the long-term outcome of colon cancer but might carry a risk of bowel dysfunction. OBJECTIVE: This study aimed to investigate whether right-sided complete mesocolic excision is associated with an increased risk of long-term bowel dysfunction and reduced quality of life compared with conventional colon cancer resections. DESIGN: Data were extracted from a population-based study comparing complete mesocolic excision and conventional colon cancer resections and from a national questionnaire survey regarding functional outcome. SETTINGS: Elective right-sided colon resections for stage I to III colon adenocarcinoma were performed at 4 university colorectal centers between June 2008 and December 2014. PATIENTS: Seven hundred sixty-two patients were eligible to receive the questionnaire in November 2015. MAIN OUTCOME MEASURES: The primary outcomes measured were the risk of diarrhea (Bristol stool scale score of 6-7), 4 or more bowel movements daily, and the impact of bowel function on quality of life. Secondary outcomes were other bowel symptoms, chronic pain, and quality of life measured by the European Organisation for Research and Treatment of Cancer QLQ-C30. RESULTS: One hundred forty-one (63.8%) and 324 (59.9%) patients undergoing complete mesocolic excision and conventional resections responded after a median of 3.99 (interquartile range, 2.11-5.32) and 4.11 (interquartile range, 3.01-5.53) years (p = 0.04). Complete mesocolic excision was not associated with increased risk of diarrhea (adjusted OR, 1.07; 95% CI, 0.57-1.95; p = 0.84), 4 or more bowel movements daily (adjusted OR, 1.16; 95% CI, 0.57-2.24; p = 0.68), or lower quality of life (adjusted OR, 0.84; 95% CI, 0.49-1.40; p = 0.50). Complete mesocolic excision was associated nonsignificantly with nocturnal bowel movements, but not associated with chronic pain or other secondary outcomes. LIMITATIONS: This study was limited by the retrospective design with unknown baseline symptoms. Responding patients were younger but without obvious selection bias. The outcome "diarrhea" seemed somehow sensitive to information bias. CONCLUSION: Right-sided complete mesocolic excision seems associated with neither bowel dysfunction nor impaired quality of life when compared with conventional surgery. See Video Abstract at http://links.lww.com/DCR/A665.

The Rectal Cancer Female Sexuality Score: Development and Validation of a Scoring System for Female Sexual Function After Rectal Cancer Surgery.

BACKGROUND: Sexual dysfunction and impaired quality of life is a potential side effect to rectal cancer treatment. OBJECTIVE: The objective of this study was to develop and validate a simple scoring system intended to evaluate sexual function in women treated for rectal cancer. DESIGN: This is a population-based cross-sectional study. SETTINGS: Female patients diagnosed with rectal cancer between 2001 and 2014 were identified by using the Danish Colorectal Cancer Group's database. Participants filled in the validated Sexual Function Vaginal Changes questionnaire. Women declared to be sexually active at follow-up were randomly assigned to 2 groups: one for development and one for validation. Logistic regression analyses identified items for the score, and multivariate analysis established a weighted-score value allocated to each item, adding up to the total score. The validity of the score was tested in the validation group. PATIENTS: Female patients with rectal cancer above the age of 18 who underwent abdominoperineal resection, Hartmann procedure, or total/partial mesorectal excision were selected. MAIN OUTCOME MEASURES: The primary outcome measured was the quality of life that was negatively affected because of sexual problems. RESULTS: A total of 466 sexually active women responded. The score includes 7 items with a range of 0 to 29 points. Score ≥9 indicates sexual dysfunction. The score has a sensitivity/specificity of 76%/75% detecting patients bothered by sexual dysfunction with a negative impact on quality of life. LIMITATIONS: This study was limited by the large amount of nonresponders. CONCLUSIONS: Living up to our demands for a short and easy-to-use validated tool, we have developed the Rectal Cancer Female Sexuality score. It captures, with high sensitivity, the essential problems of female sexuality seen from the perspective of a surviving rectal cancer patient. See Video Abstract at http://links.lww.com/DCR/A576.

Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score.

OBJECTIVE: Bowel dysfunction is common following a restorative rectal cancer resection, but symptom severity and the degree of quality of life impairment is highly variable. An internationally validated patient-reported outcome measure, Low Anterior Resection Syndrome (LARS) score, now enables these symptoms to be measured. The study purpose was: (1) to develop a model that predicts postoperative bowel function; (2) externally validate the model and (3) incorporate these findings into a nomogram and online tool in order to individualise patient counselling and aid preoperative consent. DESIGN: Patients more than 1 year after curative restorative anterior resection (UK, median 54 months; Denmark (DK), 56 months since surgery) were invited to complete The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 version3 (EORTC QLQ-C30 v3), LARS and Wexner incontinence scores. Demographics, tumour characteristics, preoperative/postoperative treatment and surgical procedures were recorded. Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, risk factors for bowel dysfunction were independently assessed by advanced linear regression shrinkage techniques for each dataset (UK:DK). RESULTS: Patients in the development (UK, n=463) and validation (DK, n=938) datasets reported mean (SD) LARS scores of 26 (11) and 24 (11), respectively. Key predictive factors for LARS were: age (at surgery); tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy, with satisfactory model calibration and a Mallow's Cp of 7.5 and 5.5, respectively. CONCLUSIONS: The Pre-Operative LARS score (POLARS) is the first nomogram and online tool to predict bowel dysfunction severity prior to anterior resection. Colorectal surgeons, gastroenterologist and nurse specialists may use POLARS to help patients understand their risk of bowel dysfunction and to preoperatively highlight patients who may require additional postoperative support.

Predicting the Risk of Bowel-Related Quality-of-Life Impairment After Restorative Resection for Rectal Cancer: A Multicenter Cross-Sectional Study.

BACKGROUND: Restorative anterior resection is considered the optimal procedure for most patients with rectal cancer and is frequently preceded by radiotherapy. Both surgery and preoperative radiotherapy impair bowel function, which adversely affects quality of life. OBJECTIVE: This study aimed to report symptoms associated with and key predictors for bowel-related quality-of-life impairment. DESIGN: The study included a cross-sectional cohort. SETTINGS: This was a multicenter study from 12 United Kingdom centers. PATIENTS: A total of 578 patients with rectal cancer underwent curative restorative anterior resection between 2001 and 2012 (median, 5.25 years postsurgery). MAIN OUTCOME MEASURES: Patients completed outcome measures that assessed bowel dysfunction (low anterior resection syndrome score), incontinence (Wexner score), and quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30), plus an anchor question: "Overall how does bowel function affect your quality of life?" RESULTS: The response rate was 80% (462/578). Overall, 85% (391/462) of patients reported bowel-related quality-of-life impairment, with 40% (187/462) reporting major impairment. A large difference in global quality of life (22 points; p < 0.001) was reported for "none" versus "major" impairment, with greatest symptom severity being diarrhea (25 points; p < 0.001), insomnia (24 points; p < 0.001), and fatigue (20 points; p < 0.001). Regression analysis identified major impairment in 60% and 45% of patients with low rectal cancer treated with and without preoperative radiotherapy compared with 47% and 33% of middle/upper rectal cancers with and without preoperative radiotherapy. LIMITATIONS: Advances in radiotherapy delivery and improvements in posttreatment symptom control, although currently of limited efficacy, imply that the content of this consent aid should be re-evaluated in 5 to 10 years. CONCLUSIONS: Before a restorative anterior resection, patients with rectal cancer should be informed that bowel-related quality-of-life impairment is common. The key risk factors are neoadjuvant therapy and a low tumor height. This study presents quality-of-life and functional outcome data, along with a consent aid, that will enhance this preoperative patient discussion.

What Are the Best Questionnaires To Capture Anorectal Function After Surgery in Rectal Cancer?

With enhanced surgical techniques and neoadjuvant therapy in rectal cancer, survivorship issues are at the forefront of clinical practice and research. More and more patients are living with altered bowel habits following rectal cancer surgery. Sound assessment of anorectal function after rectal cancer surgery is the foundation for the continuing effort to explore the adverse effects of such surgery on bowel function, as well as for working towards reducing these effects. The quality of the assessment is predominantly determined by the instrument administered. This article reviews various questionnaires for capturing anorectal function after surgery in rectal cancer, discussing their attributes and suitability for different evaluation contexts.

Development and validation of a scoring system for late anorectal side-effects in patients treated with radiotherapy for prostate cancer.

PURPOSE: To develop and validate a scoring system for evaluation of long term anorectal dysfunction following radiotherapy for prostate cancer. MATERIALS AND METHODS: Patients treated for prostate cancer with radiotherapy filled in questionnaires on anorectal function and quality of life. Items for the condensed anorectal dysfunction score (RT-ARD) were identified and weighted by binomial regression analysis. The score was tested in a separate patient material by receiver operating characteristic (ROC) analysis and correlations to quality of life domains. RESULTS: A total of 309 patients participated in the study. The items selected were "incontinence for solid stool", "ability to defer defecation", "unproductive call to stool", "clustering of stool", and "mucus in stool." Patients were grouped into three categories according to the RT-ARD score; 0-8 (no RT-ARD), 9-23 (minor RT-ARD), 24-45 (major RT-ARD). ROC analyses revealed high sensitivity (91%) and specificity (85%) for major RT-ARD. The prediction model demonstrated a perfect fit in 60%, moderate fit in 36% and no fit in 4%. There was good correlation between the RT-ARD score and quality of life. CONCLUSIONS: The RT-ARD score is a validated and simple instrument for evaluation of anorectal dysfunction following radiotherapy for prostate cancer, and the RT-ARD score correlates to the patient's quality of life.

Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.

OBJECTIVE: The aim of this study was to develop and validate a scoring system for bowel dysfunction after low anterior resection (LAR) for rectal cancer, on the basis of symptoms and impact on quality of life (QoL). BACKGROUND: LAR for rectal cancer often results in severe bowel dysfunction (LAR syndrome [LARS]) with incontinence, urgency, and frequent bowel movements. Several studies have investigated functional outcome, but the terminology is inconsistent hereby complicating comparison of results. METHODS: Questionnaires regarding bowel function was sent to all 1143 LAR patients eligible for inclusion identified in the national Colorectal Cancer Database. Associations between items and QoL were computed by binomial regression analyses. The important items were selected and regression analysis was performed to find the adjusted risk ratios. Individual score values were designated items to form the LARS score, which was divided into "no LARS," "minor LARS," and "major LARS." Validity was tested by receiver operating characteristic (ROC) curve and Spearman's rank correlation and discriminant validity was tested by Student t tests. RESULTS: A total of 961 patients returned completed questionnaires. The 5 most important items were "incontinence for flatus," "incontinence for liquid stools," "frequency," "clustering," and "urgency." The range (0-42) was divided into 0 to 20 (no LARS), 21 to 29 (minor LARS), and 30 to 42 (major LARS). The score showed good correlation and a high sensitivity (72.54%) and specificity (82.52%) for major LARS. Discriminant validity showed significant differences between groups with and without radiotherapy (P < 0.0001), tumor height more or less than 5 cm (P < 0.0001), and total mesorectal excision/partial mesorectal excision (P = 0.0163). CONCLUSIONS: We have constructed a valid and reliable LARS score correlated to QoL--a simple tool for quick clinical evaluation of the severity of LARS.