Strahlentherapie und Onkologie

, Volume 189, Issue 6, pp 486–494 | Cite as

Chronic adverse events and quality of life after radiochemotherapy in anal cancer patients

A single institution experience and review of the literature
  • K. Fakhrian
  • T. Sauer
  • A. Dinkel
  • S. Klemm
  • T. Schuster
  • M. Molls
  • H. Geinitz
Original article
First Online:
Received:
Accepted:

Abstract

Purpose

To report on chronic adverse events (CAE) and quality of life (QOL) after radiochemotherapy (RCT) in patients with anal cancer (AC).

Patients and methods

Of 83 patients who had received RCT at our department between 1988 and 2011, 51 accepted the invitation to participate in this QOL study. CAE were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) v. 4.0 and QOL was assessed with the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) questionnaire.

Results

CAE could be evaluated in 49 patients. There was a tendency toward a higher rate of grade 3 CAE in female patients, i.e. 18 out of 37 (49 %) vs. 2 out of 12 (17 %) male patients (p = 0.089). The most common grade 3 CAE were dyspareunia and vaginal symptoms (itching, burning and dryness) in 35 and 22 % of female patients, respectively, followed by stool incontinence in 13 % of all patients (6 out of 49). Both FACT-C and CAE information were available for 42 patients, allowing evaluation of the impact of CAE on QOL. The median total FACT-C score was 110 (40–132) out of a possible maximum of 136. The absence of grade 3 CAE (115 vs. 94, p = 0.001); an interval of ≥ 67 months after the end of the treatment (111 vs. 107, p = 0.010), no stool incontinence vs. grade 3 stool incontinence (111 vs. 74, p = 0.009), higher education (114 vs. 107, p = 0.013) and no dyspareunia vs. grade 3 dyspareunia (116 vs. 93, p = 0.012) were significantly associated with a higher median FACT-C score.

Conclusion

The majority of AC patients treated with RCT have acceptable overall QOL scores, which are comparable to those of the normal population. Patients with grade 3 CAE—particularly dyspareunia and fecal incontinence—have a poorer QOL compared to patients without CAE. In order to improve long-term QOL, future strategies might aim at a reduction in dose to the genitalia and more intensive patient support measures.

Keywords

Chemotherapy Dyspareunia Fecal incontinence Toxicity Survival 

Chronische Nebenwirkungen und Lebensqualität nach Radiochemotherapie bei Analkarzinompatienten

Die Erfahrungen einer Klinik und ein Literaturüberblick

Zusammenfassung

Ziel

Bericht über chronische Nebenwirkungen (CAE) und die Lebensqualität (QOL) nach Radiochemotherapie (RCT) bei Patienten mit Analkarzinom (AC).

Patienten und Methode

Von 83 Patienten, die in unserer Klinik zwischen 1988 und 2011 mit einer RCT behandelt wurden, folgten 51 Patienten der Einladung zur QOL-Studienteilnahme. Die chronischen Nebenwirkungen wurden anhand der „Criteria for Adverse Events“ (CTCAE v4.0) und die Lebensqualität mit dem „Functional-Assessment-of-Cancer-Therapy-Colorectal“-(FACT-C-)Fragebogen erfasst.

Ergebnisse

Chronische Nebenwirkungen konnten bei 49 Patienten ausgewertet werden. Es bestand eine Tendenz zu einer höheren Grad-3-CAE-Rate bei weiblichen Patienten im Vergleich zu männlichen Patienten (18/37 vs. 2/12; 49% vs. 17%; p = 0,089). Die häufigsten Grad-3-CAEs waren Dyspareunie und vaginale Symptome (Jucken, Brennen, Trockenheit) bei jeweils 35% bzw. 22 % der Frauen, gefolgt von Stuhlinkontinenz bei 13% aller Patienten (6/49). Bei 42 Patienten lagen Daten zu FACT-C und CAE vor, so dass der Einfluss von CAE auf den QOL evaluiert werden konnte. Der mediane Gesamt-FACT-C-Score betrug 110 (40–132) bei einem maximal erreichbarem Wert von 136. Das Fehlen von chronischen Grad-3-Nebenwirkungen (115 vs. 94; p = 0,001), ein Zeitabstand von ≥ 67 Monaten nach Behandlungsende (111 vs. 107; p = 0,010) sowie fehlende Stuhlinkontinenz vs. Grad-3-Stuhlinkontinenz (111 vs. 74; p = 0,009), höhere Schulbildung (114 vs. 107; p = 0,013) und fehlende Dyspareunie vs. Grad-3-Dyspareunie (116 vs. 93; p = 0,012) waren signifikant mit einem höheren medianen FACT-C-Score assoziiert.

Schlussfolgerung

Die Mehrzahl der Analkarzinompatienten erreicht nach einer RCT eine akzeptable globale Lebensqualität, die jener der Normalbevölkerung entspricht. Patienten mit chronischen Grad-3-Nebenwirkungen – insbesondere Dyspareunie und Stuhlinkontinenz – haben eine schlechtere Lebensqualität als Patienten ohne chronische Nebenwirkungen. Zukünftige Strategien könnten auf eine Dosisreduktion bei den Genitalien und auf intensivere Supportivmaßnahmen abzielen, um die Langzeitlebensqualität zu verbessern.

Schlüsselwörter

Chemotherapie Dyspareunie Fäkale Inkontinenz Toxizität Überleben 
This is a preview of subscription content, log in to check access.

Notes

Author contributions

Dr. Fakhrian had full access to all of the data in this study and takes responsibility for the integrity of these and the accuracy of the data analysis.

Conflict of interest

On behalf of all authors, the corresponding author states that there are no conflicts of interest.

References

  1. 1.
    Uronis HE, Bendell JC (2007) Anal cancer: an overview. Oncologist 12:524–534PubMedCrossRefGoogle Scholar
  2. 2.
    Fakhrian K, Sauer T, Klemm S et al (2012) Radiotherapy with or without chemotherapy in the treatment of anal cancer: 20-year experience from a single institute. Strahlenther Onkol 188(6):464–470PubMedCrossRefGoogle Scholar
  3. 3.
    Vordermark D, Sailer M, Flentje M et al (1999) Curative-intent radiation therapy in anal carcinoma: quality of life and sphincter function. Radiother Oncol 52:239–243PubMedCrossRefGoogle Scholar
  4. 4.
    Allal AS, Sprangers MA, Laurencet F et al (1999) Assessment of long-term quality of life in patients with anal carcinomas treated by radiotherapy with or without chemotherapy. Br J Cancer 80(10):1588PubMedCrossRefGoogle Scholar
  5. 5.
    Das P, Cantor SB, Parker CL et al (2010) Long-term quality of life after radiotherapy for the treatment of anal cancer. Cancer 116(4):822PubMedCrossRefGoogle Scholar
  6. 6.
    Welzel G, Hägele V, Wenz F, Mai SK (2011) Quality of life outcomes in patients with anal cancer after combined radiochemotherapy. Strahlenther Onkol 187:175–182PubMedCrossRefGoogle Scholar
  7. 7.
    Ward WL, Hahn EA, Mo F et al (1999) Reliability and validity of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) quality of life instrument. Qual Life Res 8(3):181–195PubMedCrossRefGoogle Scholar
  8. 8.
    Yost KJ, Cella D, Chawla A et al (2005) Minimally important differences were estimated for the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) instrument using a combination of distribution- and anchor-based approaches. J Clin Epidemiol 58(12):1241–1251PubMedCrossRefGoogle Scholar
  9. 9.
    Yoo HJ, Kim JC, Eremenco S (2005) Quality of life in colorectal cancer patients with colectomy and the validation of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), Version 4. J Pain Symptom Manage 30(1):24–32PubMedCrossRefGoogle Scholar
  10. 10.
    Jephcott CR, Paltiel C, Hay J (2004) Quality of life after non-surgical treatment of anal carcinoma: a case control study of long-term survivors. Clin Oncol (R Coll Radiol) 16(8):530Google Scholar
  11. 11.
    Provencher S, Oehler C, Lavertu S et al (2010) Quality of life and tumor control after short split-course chemoradiation for anal canal carcinoma. Radiat Oncol 5:41PubMedCrossRefGoogle Scholar
  12. 12.
    Barraclough LH, Routledge JA, Farnell DJ et al (2012) Prospective analysis of patient-reported late toxicity following pelvic radiotherapy for gynaecological cancer. Radiother Oncol 103(3):327–332PubMedCrossRefGoogle Scholar
  13. 13.
    Güth U, Hadwin RJ, Schötzau A, McCormack M (2012) Clinical outcomes and patterns of severe late toxicity in the era of chemo-radiation for cervical cancer. Arch Gynecol Obstet 285(6):1703–1711PubMedCrossRefGoogle Scholar
  14. 14.
    Wolf JK (2006) Prevention and treatment of vaginal stenosis resulting from pelvic radiation therapy. Commun Oncol 3:665–671CrossRefGoogle Scholar
  15. 15.
    Bruner DW, Lanciano R, Keegan M (1993) Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma. Int J Radiat Oncol Biol Phys 27(4):825–830PubMedCrossRefGoogle Scholar
  16. 16.
    Kucera H, Skodler W, Weghaupt K (1984) Complications of postoperative radiotherapy in uterine cancer (German). Geburtshilfe Frauenheilkd 44(8):498–502PubMedCrossRefGoogle Scholar
  17. 17.
    White ID, Allan H, Faithfull S (2011) Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy? Br J Cancer 105(7):903–910PubMedCrossRefGoogle Scholar
  18. 18.
    Chen YJ, Liu A, Tsai PT et al (2005) Organ sparing by conformal avoidance intensity-modulated radiation therapy for anal cancer: dosimetric evaluation of coverage of pelvis and inguinal/femoral nodes. Int J Radiat Oncol Biol Phys 63:274–281PubMedCrossRefGoogle Scholar
  19. 19.
    Menkarios C, Azria D, Laliberte B et al (2007) Optimal organsparing intensity-modulated radiation therapy (IMRT) regimen for the treatment of locally advanced anal canal carcinoma: a comparison of conventional and IMRT plans. Radiat Oncol 2:41PubMedCrossRefGoogle Scholar
  20. 20.
    Kachnic L, Tsai HK, Willins J et al (2006) Dose-painted intensity modulated radiation therapy for anal cancer: dosimetric comparison and acute toxicity [abstract]. Int J Radiat Oncol Biol Phys 66:S280 (Abstract 2126)CrossRefGoogle Scholar
  21. 21.
    Milano MT, Jani AB, Farrey KJ et al (2005) Intensity-modulated radiation therapy (IMRT) in the treatment of anal cancer: toxicity and clinical outcome. Int J Radiat Oncol Biol Phys 63:354–361PubMedCrossRefGoogle Scholar
  22. 22.
    Mai SK, Welzel G, Hermann B et al (2009) Can the radiation dose to CT-enlarged but FDG-PET-negative inguinal lymph nodes in anal cancer be reduced? Strahlenther Onkol 185(4):254–259PubMedCrossRefGoogle Scholar
  23. 23.
    Brocker KA, Alt CD, Eichbaum M et al (2011) Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT: part 1. Strahlenther Onkol 187(10):611–618PubMedCrossRefGoogle Scholar
  24. 24.
    Alt CD, Brocker KA, Eichbaum M, Sohn C et al (2011) Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT: part 2. Strahlenther Onkol 187(11):705–714PubMedCrossRefGoogle Scholar
  25. 25.
    Fraunholz I, Rabeneck D, Weiß CH, Rödel C (2010) Combined-modality treatment for anal cancer. current strategies and future directions. Strahlenther Onkol 186:361–366PubMedCrossRefGoogle Scholar
  26. 26.
    Johnson N, Miles TP, Cornes P (2010) Dilating the vagina to prevent damage from radiotherapy: systematic review of the literature. BJOG 117(5):522–531PubMedCrossRefGoogle Scholar
  27. 27.
    Jeffries SA, Robinson JW, Craighead PS, Keats MR (2006) An effective group psychoeducational intervention for improving compliance with vaginal dilation: a randomized controlled trial. Int J Radiat Oncol Biol Phys 65(2):404–411PubMedCrossRefGoogle Scholar
  28. 28.
    Craighead P, Shea-Budgell A, Nation J et al (2011) Hyperbaric oxygen therapy for late radiation tissue injury in gynecologic malignancies. Curr Oncol 18(5):220–227PubMedCrossRefGoogle Scholar
  29. 29.
    Bui QC, Lieber M, Withers HR et al (2004) The efficacy of hyperbaric oxygen therapy in the treatment of radiation-induced late side effects. Int J Radiat Oncol Biol Phys 60(3):871–878PubMedCrossRefGoogle Scholar
  30. 30.
    Schwarz R, Hinz A (2001) Reference data for the quality of life questionnaire EORTC QLQ-C30 in the general German population. Eur J Cancer 37:1345–1351PubMedCrossRefGoogle Scholar
  31. 31.
    Eypasch E, Williams JI, Wood-Dauphinee S et al (1995) Gastrointestinal quality of life index: development, validation and application of a new instrument. Br J Surg 82:216–222PubMedCrossRefGoogle Scholar
  32. 32.
    Sailer M, Bussen D, Debus ES et al (1998) Quality of life in patients with benign anorectal disorders. Br J Surg 85:1716–1719PubMedCrossRefGoogle Scholar
  33. 33.
    Oehler-Jänne C, Seifert B, Lütolf UM et al (2007) Clinical outcome after treatment with a brachytherapy boost versus external beam boost for anal carcinoma. Brachytherapy 6:218–226PubMedCrossRefGoogle Scholar
  34. 34.
    Tournier-Rangeard L, Mercier M, Peiffert D et al (2008) Radiochemotherapy of locally advanced anal canal carcinoma: prospective assessment of early impact on the quality of life (randomized trial ACCORD 03). Radiother Oncol 87:391–397PubMedCrossRefGoogle Scholar
  35. 35.
    Brucker PS, Yost K, Cashy J et al (2005) General population and cancer patient norms for the functional assessment of cancer therapy-general (FACT-G). Eval Health Prof 28(2):192–211PubMedCrossRefGoogle Scholar
  36. 36.
    Janda M, DiSipio T, Hurst C et al (2009) The Queensland Cancer Risk Study: general population norms for the Functional Assessment of Cancer Therapy-General (FACT-G). Psychooncology 18(6):606–614PubMedCrossRefGoogle Scholar
  37. 37.
    Holzner B, Kemmler G, Cella D et al (2004) Normative data for functional assessment of cancer therapy—general scale and its use for the interpretation of quality of life scores in cancer survivors. Acta Oncol 43(2):153–160PubMedCrossRefGoogle Scholar
  38. 38.
    Wilailak S, Lertkhachonsuk AA, Lohacharoenvanich N et al (2011) Quality of life in gynecologic cancer survivors compared to healthy check-up women. J Gynecol Oncol 22(2):103–109PubMedCrossRefGoogle Scholar
  39. 39.
    Heemsbergen WD, Peeters ST, Koper PC et al (2006) Acute and late gastrointestinal toxicity after radiotherapy in prostate cancer patients: consequential late damage. Int J Radiat Oncol Biol Phys 66:3–10PubMedCrossRefGoogle Scholar
  40. 40.
    Jereczek-Fossa BA, Jassem J, Badzio A (2002) Relationship between acute and late normal tissue injury after postoperative radiotherapy in endometrial cancer. Int J Radiat Oncol Biol Phys 52:476–482PubMedCrossRefGoogle Scholar
  41. 41.
    Liu M, Pickles T, Berthelet E et al (2005) Urinary incontinence in prostate cancer patients treated with external beam radiotherapy. Radiother Oncol 74:197–201PubMedCrossRefGoogle Scholar
  42. 42.
    Bentzen SM, Overgaard M (1991) Relationship between early and late normal-tissue injury after postmastectomy radiotherapy. Radiother Oncol 20:159–165 PubMedCrossRefGoogle Scholar

Copyright information

© Urban & Vogel 2013

Authors and Affiliations

  • K. Fakhrian
    • 1
    • 2
  • T. Sauer
    • 2
  • A. Dinkel
    • 3
  • S. Klemm
    • 2
  • T. Schuster
    • 4
  • M. Molls
    • 2
  • H. Geinitz
    • 2
    • 5
  1. 1.Department of Radiation OncologyMarienhospital Herne, Universitätsklinikum der Ruhr-Universität BochumHerneGermany
  2. 2.Department of Radiation OncologyKlinikum rechts der Isar, Technische Universität MünchenMunichGermany
  3. 3.Department of Psychosomatic Medicine and PsychotherapyKlinikum rechts der Isar, Technische Universität MünchenMunichGermany
  4. 4.Institute of Medical Statistics and EpidemiologyKlinikum rechts der Isar, Technische Universität München MunichGermany
  5. 5.Department of Radiation OncologyKrankenhaus der Barmherzigen SchwesternLinzAustria

Personalised recommendations