Patient Reported Outcomes Following Cancer of the Rectum — PROCaRe  

Rectal Cancer Clinical Trial

Official title: Patient Reported Outcomes Following Cancer of the Rectum

Status Enrolling by invitation

Clinical Trial Summary

The surgical management of rectal cancer includes a Total Mesorectal Exicison (TME). TME can be performed by open, laparoscopic, robotic or transanal approaches, as long as the oncological principles for the resection are achieved. Unfortunately, up to 90% of these patients will present a change in bowel habit, ranging from an increased frequency of bowel movements to the degree of fecal incontinence or evacuation dysfunction. Of these patients, 25-50% will have a severe alteration in the quality of life. This wide spectrum of symptoms has been called "low anterior resection syndrome" (LARS). Other collateral damage is the change in sexual and urinary function, due to hypogastric plexus injury. There is a significant lack of multicenter prospective studies that provide evidence, and that reveal the functional results and quality of life of these techniques available to date for the management of rectal cancer.

The study is set up as a prospective multicentre observational study. Inclusion criteria are:

1) patients over 18 years old, 2) diagnosed with rectal cancer located below the peritoneal reflection, defined by pereoperative MRI, 3) undergoing Open, laparoscopic, robotic or Transanal Total Mesorectal Excision (taTME) approaches, 4) with/withou derivative stoma and 5) with/without neoadjuvant treatment. Exclusion criteria are: 1) Upper rectal cancer, located above the peritoneal reflection, 2) previous radical prostatectomy, 3) previous pelvic radiotherapy, 4) rectal resection without primary anastomosis, 5) intraoperative findings of peritoneal carcinomatosis, 6) stage IV disease, 7) multivisceral or en-bloc resection, which includes uterus, prostate, vagina or bladder, 8) rectal resection due to a benign condition, 9) rectal resection due to a recurrence of rectal cancer (previous anterior resection or another pimary neoplasm), 10) rectal resection following a 'watch & wait' program, 11) emergency surgery, 12) previous derivative colostomy 13) inflammatory bowel disease.

Accepting an alpha risk of 0.05 and a beta risk of 0.2 in a two-sided test, 45 subjects are necessary in first group and 45 in the second to recognize as statistically significant a difference greater than or equal to 2 units. The common standard deviation is assumed to be

3. It has been anticipated a drop-out rate of 20% Primary outcomes are LARS and Vaizey score. Secondary outcomes included are QLQ C30 and CR29, sexual function questionnaire (female/male), urinary function questionnaire and postoperative complications (Clavien-Dindo classification) Data will be collected in an online secure and protected repository (Castor edc). The planned study period is 2 years (September 2021 - September 2023).

It is essential to have a validated instrument that allows us to assess sphincter function and the different aspects of quality of life in operated patients, since increased survival in this pathology has led to greater importance in the evaluation functional outcome and quality of life; Furthermore, there are recent studies that speak of the direct relationship between these factors.

Clinical Trial Description

The rectum is located in a narrow space, limited by the bone and surrounded tissues, in a very complex and narrow pelvic space. It necessarily implies greater difficulty in achieving tumour-free margins3, and preserving sexual, urinary and fecal continence functions. Depending on the height of the tumor, the difficulty of preserving the anal sphincter arises, being able to perform a low anterior resection (LAR), an ultra-low anterior resection (RAUB) or an intersphincteric ultra-low anterior resection (ISR). Finally, if it is not impossible to preserve the sphincters or to make an anastomosis, an abdominoperineal resection (APR) is needed, being the gold standard in this particular situation.

In order to perform a correct surgery, all the previous alternatives must follow the principle of Total Mesorectal Excision (TME) described by Heald in 1982. There is no consensus nowadays regarding the ideal approach for this procedure, and it can be performed using open or minimally invasive surgery, including laparoscopy, transanal approach (taTME), and robotic surgery.

Laparoscopic surgery has shown great advantages over open surgery, such as less postoperative pain, shorter hospital stay and early recovery. However, this approach has some technical difficulties, especially when it comes to tumours located at the mid-low rectum, in male and obese patients, which leads to a higher conversion rate for this subgroup of patients. This is why this laparoscopic procedure is considered highly demanding, and the 'European Society of Coloproctology' published in a cross-sectional study only 20% of laparoscopic surgery in such cases.

Robotic surgery then emerged with the idea of overcoming these technical difficulties. It has shown better results in terms of conversion to open surgery, despite an increase in operative time and higher economic costs. Some studies showed an improvement in erectile function after robotic surgery compared to laparoscopy, as well as a trend towards better functional results. However, its adoption worldwide is slow due to a lack of availability in most of centers.

Due to this controversy, a new approach that combines laparoscopic abdominal and transanal dissection has emerged in the last decade, the taTME. To date, several retrospective and prospective studies have been published, which show similar short and long-term results between techniques. However, after ensuring oncological results, surgeons must also focus on sphincter and bowel function, and patients' quality of life after surgery.

Anal sphincter sparing surgery is currently the most commonly performed in rectal cancer patients. Unfortunately, up to 90% of these patients will present a change in bowel habit, ranging from an increased frequency of bowel movements to the degree of fecal incontinence or evacuation dysfunction, after rectal resection and reconstruction. Of these patients, 25-50% will have severe changes in quality of life. This wide spectrum of symptoms has been called 'Low Anterior Resection Syndrome' (LARS). Another collateral damage caused during surgery affects to sexual and urinary function, due to hypogastric nerves damage. There is an important lack of multicenter prospective studies providing evidence, and showing pateints' functional results and quality of life after all these techniques available for the management of rectal cancer.

RATIONALE For these reasons, it is essential to have a validated instrument that allows us to assess sphincter function and the different aspects of quality of life in patients undergoing surgery for rectal cancer, since increased survival in this pathology has led to greater importance in the evaluation functional outcome and quality of life. Moreover, there are some recent studies showing a direct relation between these factors. ;

Related Conditions & MeSH terms

• Functional Bowel Disorder
• Intestinal Diseases
• PROM
• Rectal Cancer
• Rectal Neoplasms

• NCT number: NCT06290960
• Study type: Observational
• Source: Hospital Central de la Defensa Gómez Ulla
• Status: Enrolling by invitation
• Start date: September 1, 2021
• Completion date: December 2027