The authors concluded that there were no differences in general quality of life in patients with rectal cancer who had undergone anterior resection compared with abdominoperineal excision. The reliance upon predominantly retrospective observational studies, although likely to represent the best available evidence, means that the reliability of the authors’ conclusions is unclear.

To evaluate the quality of life (QoL) of patients with rectal cancer who have undergone anterior resection (AR) compared with abdominoperineal excision (APER).

MEDLINE, PubMed, EMBASE and the Cochrane Library were searched for studies published between 1966 and October 2006; the search terms were reported. No language restrictions were applied. In addition, the reference lists of included studies were screened and articles traced using the 'Related articles' function in PubMed.

Studies that compared the QoL of patients with rectal cancer who had undergone AR with that of patients who had undergone APER were eligible for inclusion. Studies had to use validated tools to assess QoL.

The review assessed general health scores for QoL and individual domains (including emotional, cognitive and physical function, bodily pain, vitality, fatigue, sexual function, male sexual problems and future perspective). The included studies assessed QoL using the Short-Form 36 (SF-36), and the QLQ C30 and QLQ CR38 questionnaires. The mean duration of follow-up was 43.9 months for APER and 46.1 months for AR. Where reported, QoL was assessed at least 1 year after surgery.

Two reviewers independently selected the studies.

The validity of non-randomised studies was assessed using the Newcastle-Ottawa Scale (patient selection methods,comparability of treatment groups and assessment of outcome). Studies awarded 8 or more stars were considered to be of a high quality.

Two reviewers independently assessed validity.

Two reviewers independently extracted the data. Standard deviations were calculated where required.

Pooled weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Separate meta-analyses were conducted for the QLQ C30, QLQ CR38 and SF-36 measures. Statistical heterogeneity was assessed using the χ² statistic. A sensitivity analysis was undertaken by separately analysing only larger studies (>100 patients), higher-quality studies and studies in which the questionnaire was self-administered. These analyses were conducted for all rectal cancers and for rectal cancers within 8 cm of the anal verge. Publication bias was assessed using funnel plots.

Eleven comparative studies (n=1,443: 486 patients had undergone APER and 957 had undergone AR) were included. Three studies were prospective and eight were retrospective.

In 3 studies the groups were matched on at least one variable; the other studies reported no matching. Four studies were classified as high quality. There were no significant differences between treatment groups in the mean age of the patients.

There was no significant difference in general health score between APER and AR.

Vitality (WMD -9.82, 95% CI: -27.01, -2.04, p=0.01; 3 high-quality studies using the SF-36) and sexual function (WMD -2.73, 95% CI: -4.93, -0.64, p=0.01; 5 studies using the QLQ CR38) were greater for AR patients than for APER patients.

Physical function was greater for patients with low AR than for APER patients (WMD -4.67, 95% CI: -9.10, -0.23, p=0.004; 5 studies using the QLQ C30).

Cognitive function scores (WMD 3.57, 95% CI: 1.41, 5.73, p<0.001; 5 studies using the QLQ C30) and emotional function scores (WMD 3.51, 95% CI: 1.40, 5.62, p<0.001; 5 studies using the QLQ C30) were greater for APER patients than for AR patients.

The results of other individual domains were reported.

There were no differences in general QoL in patients with rectal cancer who had undergone AR compared with APER. The treatment of these patients should be individualised.

The review question was stated clearly. Several relevant sources were searched and attempts were made to minimise language bias. No attempts were made to minimise publication bias; the potential for publication bias was assessed but was of limited value in view of the small number of plotted studies. Appropriate methods were used to minimise reviewer error and bias during the review process. Validity was assessed using a specified scale but the results were not reported in full. Separate meta-analyses were conducted for each assessment tool and each individual domain and this led to a multiplicity of results, some of which may have been statistically significant by chance. Heterogeneity was assessed and various predefined subgroup analyses were conducted. The evidence appears to support the authors’ conclusions but the reliance upon predominantly retrospective observational studies, although likely to represent the best available evidence, means that the reliability of the authors’ conclusions is unclear.

Practice: The authors stated that it is important that decisions about the treatment of patients with rectal cancer are made on an individual basis and take into account QoL outcomes, function, and oncological and technical factors. Information about differences between APER and AR in individual QoL domains may aid decision-making.

Research: The authors stated the need for more comparative studies with longer follow-up to evaluate QoL of patients with rectal cancer undergoing APER and AR.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.