| Abstract |
Colorectal cancer (CRC) is the third most common cancer in men and second in women,
globally, with the highest incidence of 44% in people over 75 years of age, and survival rates
around 60% for 10 years or more for rectal cancer alone. Rectal cancer (RC) is an important
subgroup of colorectal cancer (CRC): it may result from different gene alterations and its
treatment is surgically more challenging. The “gold standard” of RC treatment is total
mesorectal excision (TME) by either low anterior resection (LAR) or by abdominoperineal
resection (APR) of the rectum with temporary ileostomy or a permanent stoma, respectively.
An alternative to TME is the minimally invasive transanal endoscopic microsurgery
(TEMS), which was introduced by Buess in the early 1980s for selected early rectal cancers
(ERC). The advantages of TEMS, apart from preserving the sphincters and the rectal function,
are fast recovery and a shorter hospitalization (average 2 days) with much lower morbidity and
mortality than LAR and APR.
The TEMS technique for ERC was shown to be safe with low local recurrence, high
survival rates and equal oncological results with radical surgery. Hence, the decision regarding
treatments that are similar in clinical and oncological outcomes rely on patient experience and
QoL following treatment. Furthermore, in older and frail patients the surgical trauma should be
kept to a minimum with organ preservation, aiming for functional advantages and better QoL.
Only few studies have addressed the QoL after TEMS with small samples and followup
up to one year in most cases. Nonetheless, it is not clear what QoL patients have after TEMS,
and to which extend it justifies their treatment decision. Patient involvement in treatment
decisions is fundamental in modern health care and known to be beneficial to patient
experience. To the best of our knowledge, there is no literature regarding factors influencing
patient decision making towards the TEMS option against radical surgery.
Objective: To explore the factors affecting patients’ decision-making concerning the choice of surgical
treatment as well as to measure the Quality of Life (QoL) post-Transanal endoscopic
microsurgery (TEMS)
Design: Cross-sectional study
Setting: Colorectal Department, King’s College Hospital, regional referral centre for TEMS.
Patients and Methods: Patients with rectal cancer stage T1/T2 -N0-M0 that underwent TEMS were studied. The
questionnaires used included the Short Form SF12v2, Wexner Score (CCF-FIS) and the Sexual
Function Questionnaire (SFQ). The patients’ views on experience and treatment decision were
obtained with a custom-designed questionnaire. Questionnaires were completed at a mean of
6.9 years following treatment.
Outcome measures: Quality of Life, patients’ experience of TEMS therapy, patients’ views on decision-making on
TEMs choice.
Results: The factors that influenced the patients’ decisions were experience satisfaction (p=0.003),
postoperative bowel function (p<0.001), lower incontinence score (p=0.020) and the agreement
of TEMS experience with preoperative information (p=0.049). Treatment experience
satisfaction was associated with family support (p=0.034) and the agreement with preoperative
information (p=0.047); it correlated with bowel function (p=0.026) and mental QoL (MCS)
(p=0.003) as well. Both physical and mental QoL were similar to the general population and
were inversely associated with the level of continence Wexner score (r=-0.40 p=0.019 and r=-
0.38 p=0.025), respectively. Continence level (Wexner score) was good with mean equal to
3.97 (SD=3.89). Sexual functioning overall was correlated with better physical QoL (p=0.014)
and in reverse with increasing age (p=0.006). Patients reported less problems when having
better mental QoL (p=0.030). Postoperative pain was rated low with mean 3.1 (3.3) on a scale
0-10, whilst less postoperative pain was associated with family support (p=0.009).
Conclusion: Factors important to patients, when reflecting on treatment experience, are adequate and
reliable information, a good QoL, and the presence of family support. Clinicians should
incorporate those parameters in their practice when assisting patients in making a surgical
treatment choice and provide informed consent on TEMS for rectal cancer.
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