Background: Most rectal cancer patients experience bowel symptoms after restorative proctectomy (RP). The prevalence of mental health disorders post-RP and its association with bowel symptoms are ...unknown. The objectives of our study were to describe the prevalence of mental health disorders in patients who underwent RP for rectal cancer and to study the association between postoperative functional impairment and mental health disorders. Methods: This was a retrospective cohort study using 2 linked databases: Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). Adult patients who underwent RP for rectal neoplasm between 1998 and 2018 were included. The main exposures were postoperative bowel, sexual, and urinary symptoms. The primary outcome was postoperative mental health disorders, defined using diagnosis and medication codes for depression, anxiety, psychosis, sleep, and substance use disorder. The associations between postoperative bowel, sexual, and urinary dysfunction and mental health disorders were studied using Cox proportional hazard regression models. Results: In total, 2197 patients who underwent RP and were ostomy-free were identified. During 8138 person-years follow-up, there were 910 patients with postoperative mental health disorders (rate 11.2 per 100 person-year). On Cox proportional hazards regression model, older age (70-79 yr, adjusted hazard ratio aHR 1.20, 95% confidence interval CI 1.02-1.42), female gender (aHR 1.35, 95% CI 1.18-1.54), postoperative bowel (aHR 1.26, 95% CI 1.06-1.51), and urinary dysfunction (aHR 1.54, 95% CI 1.21-1.96) were significantly associated with mental health disorders post-RP. Among a select cohort of patients (n = 1056) with no preoperative functional impairment or psychiatric history, 466 (32.0%) patients developed de novo mental health disorders. Bowel (aHR 1.41, 95% CI 1.12-1.76) and urinary dysfunction (aHR 1.57, 95% CI 1.16-2.14) post-RP were associated with developing incident mental health disorders. Conclusion: A significant proportion of patients experience postoperative mental health disorders following RP for rectal cancer. The presence of bowel and urinary dysfunction increases the risk of poor psychological outcomes among rectal cancer survivors.
Background: Many rectal cancer patients are frail and the majority experience low anterior resection syndrome (LARS) after restorative proctectomy (RP). Association between frailty and LARS is ...unknown. We hypothesized that frailty, rather than older age, is associated with LARS. Methods: This was a retrospective cohort study with cross-sectional follow-up at a single tertiary care hospital. Patients over age 65 years who underwent RP for rectal cancer between 2007 and 2020 were included. Frailty was measured using the Targeted Geriatric Assessment, a multidimensional questionnaire that assesses function, mobility, social support, cognitive performance, depression, polypharmacy, and nutritional status. Global quality of life (QoL) was measured by the European Organization for Research and Treatment of Cancer-QoL Questionnaire-C30 (EORTC-QLQ-C30). The association between LARS, frailty, and QoL was then assessed using multiple linear regression. Results: Of 126 eligible rectal cancer survivors who were contacted, 52 completed the questionnaires (response rate 41.3%) at a median follow-up of 8.3 (interquartile range 5.1-10.9) years after RP. Ten (19.2%) individuals were classified as frail. Frail individuals were more likely to have major LARS (40.0% v. 23.8%, p = 0.52) when compared with nonfrail individuals. Individuals with major LARS had a higher mean frailty score (0.27 ± 0.11 v. 0.17 ± 0.12, p = 0.019) compared with those with minor/ no LARS. On multiple linear regression, younger age (ß = -0.80, p = 0.002), female gender (ß = 6.56, p = 0.002), and a higher frailty score (ß = 3.84, p = 0.005) were independently associated with worse LARS. Furthermore, after adjusting for age, gender, LARS, and time from surgery, frailty score alone also predicted a lower global QoL (ß = -5.50, p = 0.003). Conclusion: Frailty, rather than older age, is an independent predictor of LARS and QoL among rectal cancer survivors after RP. Assessment of frailty and interventions to improve frailty status perioperatively have the potential to improve long-term functional and QoL outcomes among rectal cancer patients.
Background: Studying low anterior resection syndrome (LARS) in the general population can help better interpret to what extent the severity of bowel dysfunction in rectal cancer patients is related ...to the disease and/or treatment. Currently, North American LARS normative data do not exist. The aim of this study was to describe the prevalence of bowel dysfunction as measured by LARS score and quality of life (QoL) in a reference North American population, and to identify any associations between participant characteristics and LARS. Methods: This was a single-institution cross-sectional study of adults who underwent screening colonoscopies between 2018 and 2021 with no or benign endoscopic findings. Exclusion criteria were personal history of colorectal cancer, radiotherapy or inflammatory bowel disease. Outcomes were LARS and QoL. Multivariable linear regression accounting for a priori clinical factors associated with bowel and pelvic floor dysfunction was performed. Results: Of 1004 eligible adults, 502 (50.0%) participated, and 135 (26.9%) had major/minor LARS. A greater proportion of females lived with major/minor LARS compared with males. Participants with LARS were more likely to have depression (18.5% v. 9.0%, p < 0.05). On multiple linear regression, female gender (β = 2.15, 95% confidence interval CI 0.30 to 4.00); younger age (β = -0.10, 95% CI -0.18 to -0.03); white ethnicity (β = 2.45, 95% CI 0.15 to 4.74); and presence of at least 1 of diabetes, depression, neurologic disorder, or cholecystectomy (β = 3.54, 95% CI 1.57 to 5.51) were independently associated with higher LARS score. Individuals with LARS had lower global QoL, functional subscales and various symptom subscales scores. Conclusion: Our study identified important risk factors for LARS, which should be taken into account when counselling patients regarding rectal cancer treatment strategies and long-term outcomes. These normative data will allow for more accurate interpretation of ongoing studies on LARS in North American rectal cancer patients.
Background: Rectal cancer patients treated with restorative proctectomy (RP) are at risk of experiencing bowel dysfunction, which is associated with emotional distress and social isolation. The ...objective of this study was to conduct a systematic review and meta-analysis on mental health outcomes following RP for rectal cancer during the postoperative recovery phase. Methods: MEDLINE, Embase, and the Cochrane library were systematically searched until May 2021 to identify studies reporting on the evolution of mental health outcomes over time, as measured by validated assessment tools selected a priori. Two independent reviewers extracted data and assessed risk of bias. Average scores for mental health outcome were pooled across studies at each time point using a random-effects model. Fourteen prospective cohort studies and 7 randomized controlled trials were included in the systematic review. Sixteen studies provided average and variance of mental health outcome using the Emotional Function subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30-EF) or the Mental Health Component Summary Scores of the Short Form-36 (SF-36-MCS) and were included in the meta-analysis. Results: A significant improvement in mental health outcome was detected over time from baseline to 3 years after RP (R2 = 0.76, p = 0.02) as measured by pooled scores of the EORTCQLQ-C30-EF. No significant trend in SF-36-MCS (R2 = 0.55, p = 0.15) was observed from baseline to 2 years. Nine studies examined changes in mental health outcome scores over time using a statistical analysis, of which 6 studies showed improvement in EORTC-QLQ-C30-EF score, with statistically significant improvements observed as of 6 months. Conclusion: Rectal cancer patients experience significant changes in mental health outcomes post-RP. Improvement in mental health is observed as of 6 months posttreatment. Future studies evaluating the effectiveness of perioperative support interventions in this period will further provide solutions to improve mental health outcomes.
