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10.1245/s10434-006-9283-6
Annals of Surgical Oncology 14:1727-1734 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Can Differences in Bowel Function After Surgery for Rectal Cancer Be Identified by the European Organization for Research and Treatment of Cancer Quality of Life Instrument?

Heather B. Neuman, MD1, Deborah Schrag, MD2,3, Cynthia Cabral, MD1, Martin R. Weiser, MD1, Philip B. Paty, MD1, Jose G. Guillem, MD1, Bruce D. Minsky, MD4, W. Douglas Wong, MD1 and Larissa K. Temple, MD, FACS1

1 Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, New York 10021, USA
2 Department of Biostatistics and Health Outcomes Research, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, New York 10021, USA
3 Department of Medical Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, New York 10021, USA
4 Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, New York 10021, USA

Correspondence: Address correspondence and reprint requests to: Larissa K. Temple, MD, FACS; E-mail: templel{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Bowel function is an important outcome after rectal cancer surgery that affects quality of life (QOL). Postoperative bowel function is often assessed with QOL instruments, but their ability to detect functional differences has not been evaluated. This study evaluated the efficacy of the European Organization for the Research and Treatment of Cancer (EORTC) Core (C)-30 and Colorectal (CR)-38 QOL instruments in identifying functional differences among patients undergoing sphincter-preserving surgery, grouped by clinical and treatment-related factors known to be associated with bowel function.

Methods: A total of 123 patients who underwent sphincter-preserving surgery for stage I to III rectal cancer completed the EORTC C-30 and CR-38 a median of 22.9 months after restoration of bowel continuity. The global QOL, Social and Physical Function subscales of the EORTC C-30, and Gastrointestinal (GI) Symptom and Defecation subscales of the EORTC CR-38 were hypothesized to be affected by bowel function. Known factors associated with function (age, sex, radiation, procedure, rectal reconstruction) were used to group patients. Differences in the QOL scores between patient groups were evaluated (t-test or analysis of variance).

Results: The global QOL was high, with a mean score of 76.84 ± 18.6. The Defecation subscale detected differences in patients grouped by age (P = .002), use of radiation (P = .04), and procedure type (P = .05). However, the remaining subscales failed to identify any differences.

Conclusions: We found neither the EORTC C-30 nor CR-38 to be sensitive instruments in delineating differences in bowel function. The use of a validated instrument designed to assess function in patients with rectal cancer will more effectively and efficiently identify those patients with poor postoperative function.

Key Words: Bowel function • Quality of life • EORTC • Sphincter-preserving surgery • Rectal cancer


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Postoperative bowel function is an important outcome in patients undergoing surgery for rectal cancer, one that greatly affects quality of life (QOL).1–7 Two recent studies evaluating the impact of surgery on postoperative QOL for patients with rectal cancer reported that global QOL was better for those patients who had undergone a high anterior resection than for those with a lower anastomosis.2,3 Both studies hypothesized that the worse QOL observed in association with a low anastomosis was due to impaired postoperative bowel function. Although these findings have not been consistently seen in all studies,1,7 it is evident that an association between QOL and postoperative bowel function exists.

In current clinical practice, the use of preoperative radiation8–10 and advanced surgical techniques such as intersphincteric dissection11,12 have made sphincter preservation possible in the setting of low rectal tumors that would previously have required an abdominoperineal resection and permanent ostomy. Unfortunately, bowel function after these sphincter-sparing procedures may be greatly altered. Additionally, clinical factors such as patient age13,14 and sex,15 and treatment-related factors such as the type of anastomosis,16,17 level of the anastomosis,17–19 and type of rectal reconstruction (i.e., colonic J pouch or coloplasty)17,20–22 have been reported to affect postoperative bowel function (Table 1Go).


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  		TABLE 1. Clinical factors and EORTC subscales associated with bowel function
 
Clearly, bowel function is an important patient-centered outcome for surgeons to measure. Knowledge of the anticipated functional outcome will aid surgeons in relaying accurate information regarding postoperative bowel function to patients during the preoperative consultation. Most studies measuring postoperative bowel function in patients with rectal cancer have used QOL instruments with subscales relevant to function, rather than instruments specifically designed to measure postoperative bowel function. Of the QOL instruments used, the European Organization for Research and Treatment of Cancer (EORTC) Core (C)-30 and Colorectal (CR)-38 are the most common.23

The EORTC C-30 is a questionnaire designed to evaluate overall QOL in patients undergoing treatment for cancer. It consists of a number of function and symptom subscales. Supplemental disease-specific modules have been developed for use as adjuncts to the EORTC C-30; the CR-38, a colorectal cancer-specific module, supplements information obtained through the EORTC C-30 by assessing factors thought to be especially pertinent to the colorectal cancer population.24 Although many studies have used the EORTC C-30 and CR-38 to compare functional outcomes of sphincter-preserving surgery with functional outcomes of abdominoperineal resection,1–3,7 the ability of these instruments to detect functional differences among patients undergoing sphincter-preserving surgery has never been fully evaluated. Therefore, the purpose of this study was to evaluate the efficacy of the EORTC C-30 and CR-38 in identifying differences in bowel function among patients undergoing sphincter-preserving surgery.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
This study was approved by the Memorial Sloan-Kettering Cancer Center Institutional Review Board as part of a study designed to develop a tool to assess bowel function,17 and was supported by a Limited Project Grant from the American Society of Colon and Rectal Surgeons.

Patient Population
Patients who underwent sphincter-preserving surgery for rectal cancer at Memorial Sloan-Kettering Cancer Center (MSKCC) from 1997 to 2001 were identified by querying the Colorectal Service and Disease Management Team databases. Patients were eligible for inclusion if they were older than 18 years, had bowel continuity at the time of the survey, and spoke English. Patients currently receiving chemotherapy or radiation and patients with stage IV disease were excluded.

Questionnaire
The survey was distributed to patients at the time of their clinic visit to MSKCC or through the mail by a modified Dillman method.

Patients were asked to complete the EORTC C-3023 and CR-38.24 The EORTC C-30 is a validated QOL instrument designed to assess QOL in cancer patients, regardless of cancer type. It comprises a global QOL scale, as well as five function and nine symptom subscales designed to evaluate different factors contributing to QOL. The EORTC CR-38 was developed for use alone or in conjunction with the EORTC C-30 to assess disease-specific factors relevant to patients being treated for colorectal cancer; it comprises four function and eight symptom subscales. Each of the EORTC C-30 and CR-38 subscales are scored from 0 to 100. A higher score on a function scale correlates to a better level of functioning; a higher score on a symptom scale is associated with worse symptoms.

We hypothesized that the EORTC C-30 Global QOL, Physical Function, and Social Function scores, and the EORTC CR-38 Defecation and Gastrointestinal (GI) Symptoms scores could be affected by bowel function (Table 1Go).

Chart Extraction
A number of clinical and treatment-related factors, previously shown to be associated with postoperative bowel function, were identified a priori (Table 1Go).3,13–22,25,26 Clinically relevant data was extracted from the patient record, and patients were grouped according to these clinical and treatment-related factors.

Statistical Analyses
Missing values within the EORTC C-30 and CR-38 questionnaire were imputed in multi-item scales if at least half of the items from the scale had been answered in accordance with EORTC guidelines.23 Normative values for the EORTC C-30 were previously collected through administration of the instrument to a randomly selected sample of the population.27 In the initial analysis, comparison was made between the mean EORTC C-30 scores of the MSKCC population and the norm reference population scores.27 A difference of more than 10 points was considered important.28,29

Differences in scores of the select subscales of the EORTC C-30 and CR-38 among patients grouped by the clinical and treatment-related factors associated with bowel function were evaluated by Student’s t-test. For groupings with more than two variables, analysis of variance was used. Because this was exploratory, P values less than .05 were considered statistically significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of 184 eligible patients with stages I to III rectal cancer at MSKCC, 124 (67%) completed the EORTC C-30 and CR-38. One patient had missing values on most of the questions and was excluded from the analysis. Data are shown for the remaining 123 patients. Surveys were completed a median of 22.9 months (range, 1.3–60.1 months) after restoration of bowel continuity. Characteristics of patients completing the questionnaire are listed in Table 2Go.


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  		TABLE 2. Patient characteristics
 
Overall, MSKCC patients completing the EORTC C-30 questionnaire reported a high QOL, with a Global QOL score slightly higher than the published population norm (Fig. 1aGo). No differences were observed between the MSKCC patients and the reference population scores with regards to Physical Function, Social Function, Role Function, Emotional Function, or Cognitive Function. However, in the symptom subscales, differences were noted in Constipation, Diarrhea, and Financial Difficulties (Fig. 1bGo). As would be anticipated, patients who had undergone surgery for rectal cancer reported more symptoms related to constipation and diarrhea than did the reference population. Greater financial difficulty was also reported.


Figure 1
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  		FIG. 1. (a) Memorial Sloan-Kettering Cancer Center (MSKCC) European Organization for the Research and Treatment of Cancer (EORTC) Core (C)-30 function scores. (b) MSKCC EORTC C-30 symptom scores.

 
No differences in the EORTC C-30 Global QOL score were observed between patients grouped by clinical and treatment-related factors associated with bowel function (Table 3Go). However, differences were observed in the scores of other subscales in the EO-RTC C-30, including a difference in the Physical Function score between male and female subjects (P = .01) and the Social Function score between patients with an anastomosis > 6 cm or < 6 cm from the anal verge (P = .03). The remainder of the EORTC C-30 subscales were not associated with differences in bowel function.


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  		TABLE 3. Discrimination of factors associated with bowel function by the EORTC C-30 and CR-38 subscales
 
When evaluating the ability of the EORTC CR-38 (the colorectal cancer–specific module) to detect differences in bowel function, the two subscales hypothesized to be associated with bowel function did detect some difference between the patient groups (Table 3Go). The GI Symptoms subscale detected differences between patients grouped by age (P = .04) and sex (P = .02) but did not detect any differences between patients grouped by treatment-related factors, such as radiotherapy or surgical technique. The Defecation subscale was the most sensitive in detecting functional differences between patient groups, identifying differences by age (P = .002), type of surgical procedure (P = .05), and whether radiotherapy was received (P = .04). However, functional differences by type of anastomosis, level of anastomosis, and method of reconstruction were not distinguished by the Defecation subscale. No single question included in the Defecation subscale was most predictive of function, with two questions ("Did you have frequent bowel movements during the day?" and "Did you feel the urge to move your bowels without actually producing any stools?") failing to identify any differences between treatment groups.

Two patient subgroups classified by treatment-related factors were hypothesized to be associated with function. The ability of the EORTC C-30 and CR-38 to detect differences in bowel function in these patient subgroups was evaluated. In the first subgroup, functional differences between patients with coloanal anastomosis who did (n = 25) and did not (n = 45) receive radiotherapy were analyzed. It was hypothesized that functional outcome in patients with very low coloanal anastomosis would be sensitive to the effects of radiation, and that the functional difference would be reflected in the EORTC C-30 and CR-38 subscale scores; however, no differences in any of the EORTC C-30 and CR-38 subscales were observed. In the second subgroup, we evaluated patients who had stapled (n = 60) versus handsewn (n = 13) anastomosis. We hypothesized that a handsewn coloanal anastomosis, as a surrogate for an "ultralow" anastomosis, would have poorer function when compared with a stapled anastomosis. No differences in function were discerned by any of the EORTC C-30 and CR-38 subscales.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The current study evaluated the ability of the EORTC C-30 and CR-38 QOL instruments to detect differences in functional outcomes among patients undergoing sphincter-preserving surgery, who were grouped by clinical and treatment-related factors known to be associated with bowel function. Overall, the patients included in this study experienced good QOL after surgery for rectal cancer, as measured by the EORTC C-30. Although no differences were observed in the EORTC C-30 Global QOL scores between the patient groups evaluated within our study, differences were observed in the EORTC C-30 Physical Function and Social Function scores. However, the clinical significance of these observations is not clear. For example, the difference seen in the EORTC C-30 Physical Function score of male and female subjects is unlikely to be solely attributable to a difference in bowel function, as no other differences in Physical Function scores between patients grouped by clinical and treatment-related factors were discerned. Similarly, the noted difference in the EORTC C-30 Social Function score between patients with an anastomosis > 6 cm or < 6 cm from the anal verge is difficult to attribute to functional outcomes alone. Although we had initially hypothesized that patients with worse function might have lower Social Function scores, we expected that a difference in Social Function scores attributable to poorer function would have been observed in association with clinical and treatment-related factors other than the level of anastomosis alone. Overall, we found the EORTC C-30 to be an insensitive means in the patient population studied of identifying functional differences after surgery for rectal cancer.

As predicted, we found the EORTC CR-38 to be more sensitive than the EORTC C-30 in identifying functional differences. Although the GI Symptoms subscale failed to identify clinically consistent differences in function between patient groups, the Defecation subscale detected differences by age, type of surgical procedure, and whether radiotherapy was received. However, the more technical aspects of rectal surgery that may be predictive of functional outcome and are therefore of interest to surgeons—such as type of anastomosis, level of anastomosis, and method of reconstruction—were not discriminated by the Defecation subscale, limiting the utility of this instrument in measuring postoperative functional differences for patients with rectal cancer.

The limited ability of the EORTC QOL instruments to discern differences in postoperative bowel function in patients with rectal cancer may be the result of the instruments’ original purpose and method of development. First, the EORTC C-30 is a global QOL instrument designed to assess QOL during cancer treatment in patients with all types of cancer. Because the EORTC C-30 is specifically designed for cancer patients undergoing treatment, one would hope that differences in bowel function that might occur as a result of treatment for colorectal cancer and affect QOL would be reflected as differences in the Global QOL and various Function sub-scale scores comprising the EORTC C-30. However, as this was not observed in our study, it may be that the EORTC C-30, as an overall cancer QOL instrument, is too insensitive to reflect the impact of differences in posttreatment bowel function on QOL for patients with rectal cancer alone. As patients adjust to the functional changes that occur as a result of sphincter-preserving surgery, their perception of QOL as measured by the EORTC C-30 might shift, and might not accurately reflect postoperative functional differences.30 Regardless, the data suggest that in the patient population studied, the EORTC C-30 is not an effective method for assessing QOL as it relates to function.

One would expect that the colorectal cancer–specific module, the EORTC CR-38, would capture functional outcomes occurring as a result of treatment. Because bowel function is an important outcome, one might expect that differences in function would be reflected by differences in subscale scores within the EORTC CR-38 when patients, grouped by various clinical and treatment-related factors known to be associated with bowel function, are compared. However, like the EORTC C-30, the EORTC CR-38 seems relatively insensitive to issues related to surgical treatment in the patient population studied. This may be because a large proportion of patients with metastatic disease and/or patients receiving adjuvant therapy were used in the development of this instrument. The EORTC CR-38 may be biased toward reflecting medical issues; therefore, it may not be sensitive enough to detect functional differences after surgical treatment.

There are several limitations to the current study. First, it is limited by its retrospective nature. In the patient population evaluated, the follow-up times at which patients completed the EORTC C-30 and CR-38 were not standardized. Because function varies as a factor of postoperative time, it is possible that differences between the evaluated patient groups did not exist because of the variations in postoperative time, and were therefore not discerned by the EORTC instruments. However, bowel function should begin to stabilize at the median follow-up time of 22.9 months, minimizing this concern. Additionally, the patient population evaluated was relatively heterogenous. It is possible that, in some patient groups, functional differences were present but were obscured by the remainder of the study population. However, when we evaluated two subgroups of patients, those with coloanal anastomosis treated with and without radiation and those with hand-sewn versus stapled anastomosis, no differences were discerned by the EORTC C-30 and CR-38 subscales, making the heterogeneity of the study population a less likely explanation for why few functional differences were identified by the subscales. A final limitation relates to the relatively small patient population in this study. The small sample size is especially apparent in the case of some subgroups, such as local excision and postoperative radiation, and may have affected the ability of the EORTC instrument to differentiate between patient groups. However, this study does suggest that alternative methods beyond the use of QOL instruments may be required for accurate measurement of postoperative bowel function.

Measurement of bowel function in patients who undergo sphincter-preserving surgery is important. A number of methods developed to assess function in a particular clinical setting have been reported in the literature.6,31–33 Most of the more rigorously developed instruments have focused on measuring continence in benign disease.34–36 Although authors have used the EORTC QOL instrument as a surrogate measure of function in patients with rectal cancer, we found that it is not a sensitive instrument for identifying differences in function. Of the 58 questions answered in the EORTC QOL instrument by patients with bowel continuity, only the seven questions in the Defecation subscale (from the EORTC CR-38) reflected differences between patients grouped by clinical and treatment-related factors known to be associated with function. Because the EORTC instrument is validated only when administered in its entirety,23 our study suggests that the EORTC C-30 and CR-38 are an inefficient means for surgeons to obtain functional outcome data. Additionally, although the Defecation subscale was able to detect differences in age, type of procedure performed, and whether radiation was received, it was insensitive to other surgically relevant treatment differences, such as method of reconstruction and level of anastomosis. Even if the Defecation subscale were to be administered independent of the complete EORTC instrument, its ability to differentiate between patient groups is limited. This suggests that the EORTC QOL instruments are an inefficient means of evaluating postoperative function.

Given the number of technical alternatives that now exist in rectal cancer surgery, it has become increasingly important for surgeons to accurately capture the impact of different surgical treatments and radiotherapy protocols on bowel function. It is important that clinicians be able to convey functional data pre-operatively to those patients who are candidates for sphincter preservation. Understanding the functional results of various treatment alternatives will help practitioners choose a surgical plan optimizing both oncologic outcome and function, and may help patients set realistic expectations for their postoperative function. More realistic expectations may, in turn, help patients adapt to functional alterations postoperatively, resulting in better QOL.37 Identifying efficient tools to assess function after surgery for rectal cancer remains an area of active research.

Although the EORTC C-30 and CR-38 are reasonable tools for obtaining a rough measure of differences in functional outcome in the context of a larger QOL study, they are not a sufficient means of determining optimal resection and reconstruction in the setting of rectal cancer. An instrument developed specifically to detect differences in functional outcomes after treatment for rectal cancer may be more effective and efficient. A number of nonvalidated instruments assessing functional outcomes in benign disease have been developed, but these do not adequately allow comparisons across patient groups, and they may not accurately capture functional outcomes that are specifically relevant to patients with rectal cancer. To obtain reliable data on functional outcomes and definitively identify those factors that most affect bowel function after treatment for rectal cancer, a validated, bowel function–specific instrument designed for patients with rectal cancer is necessary.


   ACKNOWLEDGMENTS
 
L.K.T. is supported in this project by a Career Development Award from the American Society of Clinical Oncology and by a Limited Project Grant from the American Society of Colon and Rectal Surgeons. H.N. is a research fellow of the Agency for Healthcare Quality and Research, supported by grant 5 T32 HS000066-13.

Received for publication July 27, 2006. Accepted for publication October 26, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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