Cohort study of long-term survival and quality of life following pelvic exenteration

Abstract

Background: Pelvic exenteration (PE) is the preferred treatment available for selected patients diagnosed with locally advanced or recurrent cancer confined to the pelvis. Currently, the majority of the literature reports only on short-term survival and quality-of-life (QoL) outcomes. The aim of this prospective cohort study was to describe long-term survival and QoL outcomes following PE.

Methods: This was a cohort study of consecutive patients undergoing PE from 1994 to 2016 at a major teaching hospital in Sydney, Australia. From 2008, consenting patients were also included in a prospective QoL study. Main outcomes were long-term survival and QoL assessed with SF-36^® and FACT-C questionnaires. Survival was estimated using the Kaplan-Meier method.

Results: Some 515 patients underwent PE for locally advanced or recurrent cancer. The cumulative 5- and 10-year overall survival rates were 48·6 and 37·8 per cent respectively. The survival estimates were significantly higher for patients with advanced primary rectal cancer (P = 0·045) and those in whom a clear resection margin was achieved (P < 0·001). Some 287 patients were enrolled into the QoL study. Response rates at baseline, 6 months and 5 years were 92·0, 70·0 and 33 per cent respectively. Patients had recovered to their preoperative QoL status by 6 months and, among survivors, QoL remained essentially unchanged during the 5-year follow-up.

Conclusion: Patients who underwent PE owing to advanced primary rectal cancer or achieved a clear resection margin had a greater chance of survival. Overall, QoL returned to baseline within 6 months after surgery.

Figure 1

Flow diagram showing the numbers of a patients who had pelvic exenteration surgery between 1994 and 2016, and b the subgroup of patients who had exenteration in 2008–2016 and were enrolled in the quality‐of‐life (QoL) study

Figure 2

Kaplan–Meier estimates of long‐term survival in patients undergoing pelvic exenteration (PE) surgery: a overall cohort, b according to margin status, c according to cancer presentation (primary or recurrent), d according to partial or complete PE. b P < 0·001, c P = 0·045, d P = 0·128 (log rank test)

Figure 3

Quality‐of‐life scores over 5 years in patients who underwent pelvic exenteration (PE): a SF‐36^® physical component score (PCS), b SF‐36^® mental component score (MCS), c Functional Assessment of Cancer Therapy ‐ Colorectal (FACT‐C) total score, d PCS according to type of PE (partial or complete), e MCS according to type of PE, f FACT‐C total score according to type of PE. Mean values are shown with 95 per cent confidence intervals. SF‐36^® scores range from 0 to 100, FACT‐C scores from 0 to 136; higher scores represent better quality of life. *P < 0·050 (Student's t test)