Colorectal carcinoma is one of the most common cancers affecting western populations.1 With the introduction of bowel screening and improvements in patient selection and perioperative management, the proportion of patients surviving 5 to 10 years has risen.2 Nevertheless, the literature has shown that 20% to 30% of patients present with disease that cannot be surgically resected.3–5 When aggressive care designed to cure is no longer effective, patients are managed in a palliative care setting that focuses on management of symptoms such as those caused by untreated bowel obstruction, perforation, or hemorrhage.
The main goal of palliative care is symptom relief and maximizing health-related quality of life.2 , 5 This can be done via a number of palliative modalities: ostomy formation, colonic bypass, partial tumor resection, or stent insertion. Determining the optimum treatment for each patient is difficult and must consider alternative approaches such as palliative chemotherapy and/or radiotherapy. As a result, decision-making evolves from an interdisciplinary discussion involving care providers, patients, and families.6 The multimodal management of end-stage bowel cancer may have increased survival beyond a few months in certain subgroups.6 Studies have shown median survival rates of 121 days after ostomy formation alone.7
A meta-analysis of palliative treatment for inoperable colorectal carcinoma suggests that palliative surgery is associated with high morbidity and mortality; therefore, it poses an ethical and clinical dilemma for healthcare professionals.8 The surgical risks and recovery time must be weighed against the patients' chronological/physiological age and their informed preferences.8 When life expectancy is limited, time becomes even more precious as does the need to provide patients and their family with the best possible quality of life and dignity for whatever time remains.9–11
The purpose of this study was to review 30-day and 1-year mortality of patients who underwent ostomy formation as the sole treatment for the symptomatic relief of their inoperable colorectal cancers. No other adjuvant therapy or palliative chemotherapy was offered in this group.
We studied patients undergoing palliative stoma formation without colonic resection between October 1998 and January 2009 at a single District General NHS Lanarkshire Hospital, University Monklands Hospital, Scotland, UK. Patients were identified from a prospectively maintained colorectal cancer audit database. Individuals having colorectal stent placement and bypass surgery were excluded from analysis. This study was registered and approved by the NHS Lanarkshire Department of Clinical Effectiveness (Project Number 3430). The data were deidentified on a bespoke database (a custom database designed to follow a particular group of patients) created for the sole purpose of reviewing these data. Cross reference was made to data that were collected, again prospectively, on a database of persons with a stoma.12 Data on all stomas performed in our hospital have been collected prospectively and formed the basis for previous publication.12 As this study was a retrospective review of prospectively collected clinical data, individual patient consent and formal ethical approval were not required.
Data on all patients with a diagnosis of colorectal cancer have been collected since 1998 and maintained on the bespoke database described earlier. The accuracy of the dataset has been confirmed independently on 4 separate occasions by Audit Scotland (102 West Port, Edinburgh EH3 9DN); therefore, we are confident that the figures presented in the article are an accurate reflection of colorectal cancer presentation and management within our hospital catchment area.13 The protocol for data collection determined that all cancers in this setting were given a clinical stage of T4. We acknowledge that this may differ somewhat from histological grading.
Results are presented as a median (interquartile range). Patients were followed up to death or date of last censure (date at which last formal clinical review took place), which was a minimum of 1 year postprocedure.
The study population comprised 86 patients (55 male; 64%) who underwent palliative ostomy surgery from October 1998 to January 2009. These patients were all obstructing cancers, and therefore considered emergency procedures. Only 1 patient during this period elected not to have surgical treatment; this individual died 4 days later and was not included in the analysis. The median survival following ostomy creation was 103 days (interquartile range, 19-263 days). Sixty-nine percent of participants (n = 59) survived 30 days and 18% (n = 16) survived 12 months.
The main finding of our study was the 30-day and 1-year mortality rate of those undergoing palliative stoma formation for obstruction. While many patients with colorectal cancer are able to undergo curative resection of their tumor without the need for a permanent stoma, others will require a permanent colostomy. A previous publication from our department demonstrated that patients presenting as emergencies were older than those undergoing elective operations and many had a limited life expectancy, which was due, at least in part, to comorbid conditions.13 In those cases presenting as noncurative emergencies, we believe it essential to provide realistic expectations, counseling patients and their caregivers about what we can reasonably achieve with the formation of a palliative stoma.8 Although not derived from a randomized clinical trial, our results for palliative stoma formation are similar to those published previously from our department for palliative stenting of obstructing colorectal cancer.14
Knight and colleagues15 reported on outcomes of 686 patients diagnosed with colorectal cancer when they were 80 years or older. Fourteen underwent palliative stenting; stents were placed successfully in a high proportion of these cases (89%), but relief of obstructive symptoms was less certain (71%). The 1-year survival rate following palliative stent placement was 23%.15
This study is limited by the retrospective nature of the data review. In addition, although the date of death is accurately recorded for all cases deceased prior to the date of censure, this represents all-cause mortality as opposed to cancer-specific mortality. It should be noted that the patients we provided care for reside in one of the most economically deprived communities in the United Kingdom. Therefore, findings from this study may not apply to patients from more affluent communities.
Study findings indicate that a palliative stoma can be created toward the end of life, with an acceptable 30-day mortality rate and measurable improvement in life expectancy. Further study is required to assess the quality of that extended life and how it compares to other treatment options such as placement of a self-expanding metallic stent. It is difficult to engage in quality-of-life studies toward the end of a patient's life, but perhaps the time has come for a prospective randomized trial of stoma formation versus stent placement for inoperable obstructing colorectal cancer that measures health-related quality of life and associated concerns for both patients and their caregivers.
We would like to acknowledge the support of our stoma care nurses, colorectal nurse specialists, and our Clinical Governance Department who facilitated the prospective collection of the data contained within this article.
1. Oliphant R, Czerniewski A, Robertson I, McNulty C, Waterston A, Macdonald A. The effect of adjuvant chemotherapy on stoma-related complications after surgery for colorectal cancer: a retrospective analysis. J Wound Ostomy Continence Nurs. 2015;42(5):494–498.
2. Cunningham D, Atkin W, Lenz HJ, et al Colorectal cancer. Lancet. 2010;375(9719):1030–1047.
3. Mann CD, Norwood MGA, Miller AS, Hemingway D; Leicester Colorectal Specialist Interest Group. Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer. Colorectal Dis. 2010;12(10):1039–1043.
4. Rosen SA, Buell JF, Yoshida A, et al Initial presentation with stage IV colorectal cancer: how aggressive should we be?Arch Surg. 2000;135(5):530–535.
5. Amersi F, Stamos MJ, Ko CY. Palliative care for colorectal cancer. Surg Oncol Clin N Am. 2004;13(3):467–477.
6. Costi R, Leonardi F, Zanoni D, Violi V, Roncoroni L. Palliative care and end-stage colorectal cancer management: the surgeon meets the oncologist. World J Gastroenterol. 2014;20(24):7602–7621.
7. Johnson R, Marsh R, Corson J, Seymour K. A comparison of palliation of large bowel obstruction due to irremovable colon cancer. Ann R Coll Surg Engl. 2004;86:99–103.
8. Montgomery v Lanarkshire Health Board, March 15, 2015, UKSC 11.
9. Zhao XD, Cai BB, Cao RS, Shi RH. Palliative treatment for incurable malignant colorectal obstructions: a meta-analysis. World J Gastroenterol. 2013;19(33):5565–5574.
10. Bhardwaj R, Parker MC. Palliative therapy of colorectal carcinoma: stent or surgery?Colorectal Dis. 2003;5(5):518–521.
11. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum. 1999;42(12):1569–1574.
12. Robertson I, Leung E, Hughes D, et al Prospective analysis of stoma-related complications. Colorectal Dis. 2005;7(3):279–285.
13. MacDonald AJ, McEwan H, McCabe M, Macdonald A. Age at death of patients with colorectal cancer and the effect of lead-time bias on survival in elective vs emergency surgery. Colorectal Dis. 2011;13(5):519–525.
14. Stenhouse A, Page B, Rowan A, Giles L, Macdonald A. Self expanding wall stents in malignant colorectal cancer: is complete obstruction a contraindication to stent placement?Colorectal Dis. 2009;11(8):854–858.
15. Knight K, Oliphant R, Maxwell F, et al Colorectal cancer in the elderly and the influence of lead time bias: better survival does not equate with improved life expectancy. Int J Colorectal Dis. 2016;31(3):553–559.