Contact X-ray Brachytherapy for Older or Inoperable Rectal Cancer Patients: Short-Term Oncological and Functional Follow-Up

Abstract

Total mesorectal excision for rectal cancer is a major operation associated with morbidity and mortality. For older or inoperable patients, alternatives are necessary. This prospective study evaluated the oncological and functional outcome and quality of life of older or inoperable rectal cancer patients treated with a contact X-ray brachytherapy boost to avoid major surgery. During follow-up, tumor response and toxicity on endoscopy were scored. Functional outcome and quality of life were assessed with self-administered questionnaires. Additionally, in-depth interviews regarding patients' experiences were conducted. Nineteen patients were included with a median age of 80 years (range 72-91); nine patients achieved a clinical complete response and in another four local control of the tumor was established. The 12 month organ-preservation rate, progression-free survival, and overall survival were 88%, 78%, and 100%, respectively. A transient decrease in quality of life and bowel function was observed at 3 months, which was generally restored at 6 months. In-depth interviews revealed that patients' experience was positive despite the side-effects shortly after treatment. In older or inoperable rectal cancer patients, contact X-ray brachytherapy can be considered an option to avoid total mesorectal excision. Contact X-ray brachytherapy is well-tolerated and can provide good tumor control.

Keywords: contact X-ray brachytherapy; functional outcome; older patients; oncological outcome; quality of life; rectal cancer.

Figure 1

Response and survival. Abbreviations: CR = complete response; PR = partial response; SD = stable disease; PD = progressive disease; CXB = contact X-ray brachytherapy. * Four patients received salvage surgery. ** Deceased.

Figure 2

Endoscopic responses following contact X-ray brachytherapy of three patients. (A) Regrowth following chemoradiotherapy (50 Gy/25 fractions) for a cT3N0M0 rectal tumor before contact X-ray brachytherapy; (B) partial response showing a deep ulcer three months following contact X-ray brachytherapy (90 Gy/3 fractions); (C) endoscopic complete response six months following treatment; (D) residual tumor following radiotherapy (25 Gy/5 fractions) for a cT2N1M0 rectal tumor before contact X-ray brachytherapy; (E) partial response showing a deep ulcer three months following contact X-ray brachytherapy (90 Gy/3 fractions); (F) partial response showing a healing ulcer six months following treatment; (G) residual lesion of 4 cm following high-dose-rate brachytherapy for a cT2N0M0 rectal tumor before contact X-ray brachytherapy to achieve symptom control; (H) partial response showing a deep ulcer three months following contact X-ray brachytherapy (60 Gy/2 fractions); (I) sustained partial response showing a deep ulcer six months following treatment.

Figure 3

Kaplan-Meier curves for the organ-preservation rate (A) and progression-free survival (B).

Figure 4

Quality of life according to the EORTC-QLQ-C30 (A) and EORTC-QLQ-CR29 (B). Functional scales, higher scores mean better results; GHS = Global health status; PF = Physical functioning; SF = Social functioning. Symptom scales, lower scores mean better results; PA = Pain; CO = Constipation; DI = Diarrhea; AP = Abdominal pain; BP = Buttock pain; BF = Bloating; BMS = Blood and mucus in stool; FL = Flatulence; FI = Fecal incontinence; SS = Sore skin; SF = Stool frequency. * Difference of 10 points is considered clinically relevant.

Figure 5

Defecation problems according to the LARS (A) and Vaizey score (B).