Original Study|Articles in Press

Patient-reported Bowel Function and Bowel-related Quality of Life After Pelvic Radiation for Rectal Adenocarcinoma: The Impact of Radiation Fractionation and Surgical Resection

Published:February 15, 2023DOI:



      Multimodality treatment for locally advanced rectal cancer (LARC) can include long-course radiotherapy (LCRT) or short course radiotherapy (SCRT). Nonoperative management is increasingly pursued for those achieving a complete clinical response. Data regarding long-term function and quality-of-life (QOL) are limited.


      Patients with LARC treated with radiotherapy from 2016 to 2020 completed the Functional Assessment of Cancer Therapy- General (FACT-G7), the Low Anterior Resection Syndrome Score (LARS) and the Fecal Incontinence QOL Scale (FIQOL). Univariate and multivariable linear regression analyses identified associations between clinical variables including radiation fractionation and the use of surgery versus non-operative management.


      Of 204 patients surveyed, 124 (60.8%) responded. Median (interquartile range) time from radiation to survey completion was 30.1 (18.3-43) months. Seventy-nine (63.7%) respondents received LCRT, and 45 (36.3%) received SCRT; 101 (81.5%) respondents underwent surgery, and 23 (18.5%) pursued nonoperative management. There were no differences in LARS, FIQoL or FACT-G7 between patients receiving LCRT versus SCRT. On multivariable analysis, only nonoperative management was associated with lower LARS score signifying less bowel dysfunction. Nonoperative management and female sex were associated with a higher FIQoL score signifying less disruption and distress from fecal incontinence issues. Finally, lower BMI at the time of radiation, female sex, and higher FIQoL score were associated with higher FACT-G7 scores signifying better overall QOL.


      These results suggest long-term patient-reported bowel function and QOL may be similar for individuals receiving SCRT and LCRT for the treatment of LARC, but nonoperative management may lead to improved bowel function and QOL.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Colorectal Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Conroy T
        • Bosset JF
        • Etienne PL
        • et al.
        Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial.
        Lancet Oncol. 2021; 22: 702-715
        • Bahadoer RR
        • Dijkstra EA
        • van Etten B
        • et al.
        Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial.
        Lancet Oncol. 2021; 22: 29-42
      1. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer v1.2022.
        National Comprehensive Cancer Network, 2022 (Published February 25,chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/)
        • Peeters KCMJ
        • Marijnen CAM
        • Nagtegaal ID
        • et al.
        The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma.
        Ann Surg. 2007; 246: 693-701
        • Roh MS
        • Colangelo LH
        • O'Connell MJ
        • et al.
        Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03.
        J Clin Oncol. 2009; 27: 5124-5130
        • Sauer R
        • Becker H
        • Hohenberger W
        • et al.
        Preoperative versus postoperative chemoradiotherapy for rectal cancer.
        N Engl J Med. 2004; 351: 1731-1740
        • Erlandsson J
        • Holm T
        • Pettersson D
        • et al.
        Optimal fractionation of preoperative radiotherapy and timing to surgery for rectal cancer (Stockholm III): a multicentre, randomised, non-blinded, phase 3, non-inferiority trial.
        Lancet Oncol. 2017; 18: 336-346
        • Ansari N
        • Solomon MJ
        • Fisher RJ
        • et al.
        Acute adverse events and postoperative complications in a randomized trial of preoperative short-course radiotherapy versus long-course chemoradiotherapy for T3 adenocarcinoma of the rectum: trans-tasman radiation oncology group trial (TROG 01.04).
        Ann Surg. 2017; 265: 882-888
        • Dijkstra EA
        • Hospers GAP
        • Kranenbarg EMK
        • et al.
        Quality of life and late toxicity after short-course radiotherapy followed by chemotherapy or chemoradiotherapy for locally advanced rectal cancer - The RAPIDO trial.
        Radiother Oncol. 2022; 171: 69-76
        • Flores LT
        • Bennett AV
        • Law EB
        • Hajj C
        • Griffith MP
        • Goodman KA.
        Patient-reported outcomes vs. clinician symptom reporting during chemoradiation for rectal cancer.
        Gastrointest Cancer Res. 2012; 5: 119-124
        • Lim SHS
        • Ip E
        • Ng W
        • et al.
        Health-related quality of life during chemoradiation in locally advanced rectal cancer: impacts and ethnic disparities.
        Cancers (Basel). 2019; 11: E1263
        • Freites-Martinez A
        • Santana N
        • Arias-Santiago S
        • Viera A.
        Using the Common Terminology Criteria for Adverse Events (CTCAE - Version 5.0) to Evaluate the Severity of Adverse Events of Anticancer Therapies.
        Actas Dermosifiliogr (Engl Ed). 2021; 112: 90-92
        • Juul T
        • Ahlberg M
        • Biondo S
        • et al.
        International validation of the low anterior resection syndrome score.
        Ann Surg. 2014; 259: 728-734
        • Sun R
        • Dai Z
        • Zhang Y
        • Lu J
        • Zhang Y
        • Xiao Y.
        The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis.
        Support Care Cancer. 2021; 29: 7249-7258
        • van der Sande ME
        • Hupkens BJP
        • Berbée M
        • et al.
        Impact of radiotherapy on anorectal function in patients with rectal cancer following a watch and wait programme.
        Radiother Oncol. 2019; 132: 79-84
        • Jones HJS
        • Al-Najami I
        • Cunningham C.
        Quality of life after rectal-preserving treatment of rectal cancer.
        Eur J Surg Oncol. 2020; 46: 2050-2056
        • Reddy AV
        • Safar B
        • Jia AY
        • et al.
        Nonoperative management following complete response in rectal cancer after short-course radiation therapy and consolidation chemotherapy: clinical outcomes and quality of life measures.
        Am J Clin Oncol. 2022; 45: 298-305
        • Hupkens BJP
        • Martens MH
        • Stoot JH
        • et al.
        Quality of life in rectal cancer patients after chemoradiation: watch-and-wait policy versus standard resection - a matched-controlled study.
        Dis Colon Rectum. 2017; 60: 1032-1040
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Yanez B
        • Pearman T
        • Lis CG
        • Beaumont JL
        • Cella D.
        The FACT-G7: a rapid version of the functional assessment of cancer therapy-general (FACT-G) for monitoring symptoms and concerns in oncology practice and research.
        Ann Oncol. 2013; 24: 1073-1078
        • Emmertsen KJ
        • Laurberg S.
        Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.
        Ann Surg. 2012; 255: 922-928
        • Rockwood TH
        • Church JM
        • Fleshman JW
        • et al.
        Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence.
        Dis Colon Rectum. 2000; 43 (discussion 16-17): 9-16
        • Fields EC
        • Kaplan BJ
        • Karlin J
        • et al.
        Phase 1 study of neoadjuvant short-course radiation therapy concurrent with infusional 5-fluorouracil for the treatment of locally advanced rectal cancer.
        Adv Radiat Oncol. 2019; 4: 605-612
        • Owens R
        • Mukherjee S
        • Padmanaban S
        • et al.
        Intensity-modulated radiotherapy with a simultaneous integrated boost in rectal cancer.
        Clin Oncol (R Coll Radiol). 2020; 32: 35-42
        • Bregendahl S
        • Emmertsen KJ
        • Lous J
        • Laurberg S.
        Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study.
        Colorectal Dis. 2013; 15: 1130-1139
        • Quezada-Diaz F
        • Jimenez-Rodriguez RM
        • Pappou EP
        • et al.
        Effect of neoadjuvant systemic chemotherapy with or without chemoradiation on bowel function in rectal cancer patients treated with total mesorectal excision.
        J Gastrointest Surg. 2019; 23: 800-807
        • Chen TYT
        • Wiltink LM
        • Nout RA
        • et al.
        Bowel function 14 years after preoperative short-course radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomized trial.
        Clin Colorectal Cancer. 2015; 14: 106-114
        • Bohlok A
        • Mercier C
        • Bouazza F
        • et al.
        The burden of low anterior resection syndrome on quality of life in patients with mid or low rectal cancer.
        Support Care Cancer. 2020; 28: 1199-1206
        • Ihnát P
        • Slívová I
        • Tulinsky L
        • Ihnát Rudinská L
        • Máca J
        • Penka I
        Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study).
        J Surg Oncol. 2018; 117: 710-716
        • Filips A
        • Haltmeier T
        • Kohler A
        • Candinas D
        • Brügger L
        • Studer P.
        LARS is associated with lower anastomoses, but not with the transanal approach in patients undergoing rectal cancer resection.
        World J Surg. 2021; 45: 873-879
        • Nicotera A
        • Falletto E
        • Arezzo A
        • Mistrangelo M
        • Passera R
        • Morino M.
        Risk factors for Low Anterior Resection Syndrome (LARS) in patients undergoing laparoscopic surgery for rectal cancer.
        Surg Endosc. 2022; 36: 6059-6066
        • Nesbakken A
        • Nygaard K
        • Lunde OC.
        Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer.
        Br J Surg. 2001; 88: 400-404
        • Plastiras A
        • Korkolis D
        • Frountzas M
        • Theodoropoulos G.
        The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients.
        Discov Oncol. 2022; 13: 52
        • Bedard K
        • Heymen S
        • Palsson OS
        • Bharucha AE
        • Whitehead WE.
        Relationship between symptoms and quality of life in fecal incontinence.
        Neurogastroenterol Motil. 2018; 30
        • Emmertsen KJ
        • Laurberg S
        • Rectal Cancer Function Study Group
        Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer.
        Br J Surg. 2013; 100: 1377-1387
        • Walma MS
        • Kornmann VNN
        • Boerma D
        • de Roos MAJ
        • van Westreenen HL.
        Predictors of fecal incontinence and related quality of life after a total mesorectal excision with primary anastomosis for patients with rectal cancer.
        Ann Coloproctol. 2015; 31: 23-28
        • Kornmann VNN
        • Walma MS
        • de Roos MAJ
        • Boerma D
        • van Westreenen HL.
        Quality of life after a low anterior resection for rectal cancer in elderly patients.
        Ann Coloproctol. 2016; 32: 27-32
        • Lin YH
        • Chen HP
        • Liu KW.
        Fecal incontinence and quality of life in adults with rectal cancer after lower anterior resection.
        J Wound Ostomy Continence Nurs. 2015; 42: 395-400
        • Hudson D
        • Entriken F
        • Hodder R
        • Warner M.
        Functional outcomes and local control are acceptable following hand-sewn colo-anal anastomoses for rectal cancer: Results of long-term follow-up.
        ANZ J Surg. 2022; 92: 390-396
        • Gunjur A
        • Chazan G
        • Newnham G
        • McLachlan SA.
        Pilot study of patients’ preferences for immediate resection versus a watch and wait approach after neoadjuvant chemoradiation for locally advanced rectal cancer.
        JCO Oncol Pract. 2021; 17: e149-e157
        • Garcia-Aguilar J
        • Patil S
        • Gollub MJ
        • et al.
        Organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy.
        J Clin Oncol. 2022; 40: 2546-2556
        • De B
        • Corrigan KL
        • Rooney MK
        • et al.
        Patient-reported bowel and urinary function in long-term survivors of squamous cell carcinoma of the anus treated with definitive intensity modulated radiation therapy and concurrent chemotherapy.
        Int J Radiat Oncol Biol Phys. 2022; 114: 78-88
        • Bach SP
        • Collaborative STAR-TREC
        Can we Save the rectum by watchful waiting or TransAnal surgery following (chemo)Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC)? Protocol for the international, multicentre, rolling phase II/III partially randomized patient preference trial evaluating long-course concurrent chemoradiotherapy versus short-course radiotherapy organ preservation approaches.
        Colorectal Dis. 2022; 24: 639-651
      2. Rodel C. Short-course Radiotherapy versus Chemotherapy, followed by consolidation chemotherapy, and selective organ preservation for MRI-defined Intermediate and High-risk Rectal Cancer Patients.;

      3. Alliance for Clinical Trials in Oncology. PROSPECT: Chemotherapy Alone or Chemotherapy Plus Radiation Therapy in Treatment Patients With Locally Advanced Rectal Cancer Undergoing Surgery.;

        • Theodoropoulos GE
        • Liapi A
        • Spyropoulos BG
        • Kourkouni E
        • Frountzas M
        • Zografos G.
        Temporal changes of low anterior resection syndrome score after sphincter preservation: a prospective cohort study on repetitive assessment of rectal cancer patients.
        J Invest Surg. 2022; 35: 354-362
        • Laforest A
        • Bretagnol F
        • Mouazan AS
        • Maggiori L
        • Ferron M
        • Panis Y.
        Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?.
        Colorectal Dis. 2012; 14: 1231-1237
        • Allgayer H
        • Dietrich CF
        • Rohde W
        • Koch GF
        • Tuschhoff T.
        Prospective comparison of short- and long-term effects of pelvic floor exercise/biofeedback training in patients with fecal incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: clinical, functional and endoscopic/endosonographic findings.
        Scand J Gastroenterol. 2005; 40: 1168-1175