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| By
Joel B. Finkelstein |
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Complex surgical techniques
have been developed to preserve bowel function in patients with
advanced rectal cancers. However, the impact on quality-of-life of
these surgeries may leave many patients disappointed.
Even
for cancers located very low down in the rectum,
surgeons have procedures for removing the tumors while leaving
intact a patient’s sphincter,
the muscle responsible for controlling bowel movements (see a related
story). But many patients with advanced disease who are also
getting high doses of radiation may still have poor bowel control
after these surgeries, according to a small study conducted by David
Shibata, M.D., formerly of Memorial Sloan-Kettering Cancer Center in
New York.
“We may have the technical ability to preserve
sphincter function in patients with very large or recurrent rectal
cancers, but they may not always be happy with the result,” said
Jose G. Guillem, M.D., one of the study investigators at Memorial
Sloan-Kettering. The poor result in these patients is likely due to
the combination of a large cumulative dose of radiation and surgery
very low in the rectum, he said.
The researchers reported on
their survey of 18 patients who had undergone sphincter-preserving
procedures during which radiation was delivered directly to the site
of disease an average of 26 months earlier. Only one patient
reported having excellent bowel function, while 10 patients reported
fair to poor function, including urgency, soilage, and incontinence.
A third of the patients reported more than four bowel movements a
day, and many patients required medication to control diarrhea.
A quality-of-life survey showed that these problems
restricted their social life and traveling. The patients reported
that the unpredictability and spontaneity inherent in these
activities conflicted with their need to have a bathroom readily
available at all times. Sexual function was also affected in both
men and women, according to the study, published in the June issue
of Diseases of the Colon and Rectum.
More than half of the
patients said they were dissatisfied or very dissatisfied with their
quality of life in relation to bowel function.
“In all
possible cases you try to preserve the sphincter,” said Matthew
Kulke, M.D., an instructor of medicine in the department of
gastrointestinal oncology at the Dana-Farber
Cancer Institute in
Boston, explaining that people don’t want a colostomy,
which involves attaching a removable bag to the end of the colon
threaded through the wall of the abdomen.
“This study points out that, in fact, some of these patients
may have been happier with a colostomy,” he said. It is unlikely,
however, that such a small study will change current practices,
especially since it cannot be determined whether the poor
functioning was a result of the surgical approach, the radiation or
the interaction between the two.
The study does highlight
the need to make the decision to perform sphincter-preserving
surgery based on the individual patient’s disease and lifestyle.
Although patients may not like the idea of having to wear a
colostomy bag, some may ultimately find it more convenient than
always trying to find a bathroom.
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