Defecation into clothing without forewarning and mean radiation dose to bowel and anal-sphincter among gynecological cancer survivors

Figures & data

Figure 1. (a) Organs at risk, frontal view. (b) Organs at risk, lateral view. (c) Organs at risk, lateral view Dark green – anal-sphincter; Light green – rectum; Orange – sigmoid; Yellow – small intestines; Pink – vagina; Blue – urinary bladder; Grey – sacrum, femoral heads, pubic bone.

Table 1. Demographic and clinical characteristics for 519 gynecological cancer survivors with and without defecation into clothing without forewarning after pelvic radiation therapy.

	Survivors with defecation into clothing without forewarning	Survivors without defecation into clothing without forewarning
	N = 63	N = 456	Unadjusted relative risks
	n (%)	n (%)	RR (95 % CI)	p-Value*
Age				0.108
28–49	8 (15)	47 (85)	1
50–59	4 (5)	78 (95)	0.3 (0.1–1.1)
60–69	25 (13)	173 (87)	0.9 (0.4–1.8)
70–79	26 (14)	158 (86)	1.0 (0.5–2.0)
Smoking				0.461
Never smoker	28 (12)	215 (88)	1
Former smoker	17 (11)	139 (89)	0.9 (0.5–1.7)
Current smoker	18 (16)	97 (84)	1.4 (0.8–2.4)
BMI				0.37
<18.5 (underweight)	2 (14)	12 (86)	1.0 (0.3–3.7)
18.5–25.0 (normal weight)	31 (14)	185 (86)	1
25.0–30.0 (overweight)	15 (9)	157 (91)	0.6 (0.3–1.1)
≥30.0 (obese)	12 (14)	72 (86)	1.0 (0.5–1.8)
No. of births				0.826
0	15 (11)	118 (89)	1
1–3	44 (13)	302 (87)	1.1 (0.7–2.0)
>3	4 (10)	36 (90)	0.9 (0.3–2.5)
Delivery
Fast <5 h, no	35 (11)	275 (89)	1
Fast <5 h, yes	27 (13)	174 (87)	1.2 (0.7–1.9)	0.471
Slow >24 h, no	45 (11)	348 (89)	1
Slow >24 h, yes	17 (14)	101 (86)	1.3 (0.7–2.1)	0.397
Vacuum, no	56 (12)	419 (88)	1
Vacuum, yes	6 (17)	30 (83)	1.4 (0.7–3.1)	0.408
Forceps, no	61 (12)	440 (88)	1
Forceps, yes	1 (10)	9 (90)	0.8 (0.1–5.4)	0.83
Episiotomy, no	48 (12)	354 (88)	1
Episiotomy, yes	14 (13)	95 (87)	1.1 (0.6–1.9)	0.799
Cesarian, no	60 (12)	428 (88)	1
Cesarian, yes	2 (9)	21 (91)	0.7 (0.2–2.7)	0.589
Breech birth, no	60 (12)	433 (88)	1
Breech birth, yes	2 (11)	16 (89)	0.9 (0.2–3.4)	0.891
Delivery with birth weight >4 kg				0.045
0	49 (12)	367 (88)	1
1	5 (8)	60 (92)	0.7 (0.3–1.6)
≥2	9 (26)	26 (74)	2.2 (1.2–4.1)
Pelvic floor injury
Vaginal and perineal injury, no	45 (11)	368 (89)	1
Vaginal and perineal injury, yes	16 (17)	78 (83)	1.6 (0.9–2.6)	0.113
Anal-sphincter injury, no	57 (12)	433 (88)	1
Anal-sphincter injury, yes	4 (29)	10 (71)	2.5 (1.0–5.8)	0.093
Co-morbidities
Previous abdominal surgery, no	31 (11)	261 (89)	1
Previous abdominal surgery, yes	32 (14)	196 (86)	1.3 (0.8–2.1)	0.23
Diabetes mellitus, no	54 (12)	413 (88)	1
Diabetes mellitus, yes	9 (18)	42 (82)	1.5 (0.8–2.9)	0.23
Heart failure, no	50 (10)	432 (90)	1
Heart failure, yes	10 (36)	18 (64)	3.4 (2.0–6.0)	0.001
Other cardiovascular disease^a, no	31 (10)	275 (90)	1
Other cardiovascular disease, yes	29 (14)	175 (86)	1.4 (0.9–2.3)	0.164
Crohn’s disease and or ulcerative  colitis, treatment for, no	57 (12)	424 (88)	1
Crohn’s disease and or ulcerative  colitis, treatment for, yes	2 (33)	4 (67)	2.8 (0.9–9.0)	0.612
Irritable bowel syndrome,  treatment for, no	52 (11)	428 (89)	1
Irritable bowel syndrome,  treatment for, yes	5 (20)	20 (80)	1.8 (0.8–4.2)	0.194
Hemorrhoids, treatment for, no	54 (12)	398 (88)	1
Hemorrhoids, treatment for, yes	5 (10)	45 (90)	0.8 (0.4–2.0)	0.679
Lactose intolerance and/or gluten  intolerance, no	53 (11)	429 (89)	1
Lactose intolerance and/or gluten  intolerance, yes	9 (28)	23 (72)	2.6 (1.4–4.7)	0.011
Pelvic organ prolapse, treatment  for, no	60 (12)	436 (88)	1
Pelvic organ prolapse, treatment  for, yes	1 (9)	9 (91)	0.8 (0.1–4.9)	0.753
Rheumatism, no	52 (11)	424 (89)	1
Rheumatism, yes	8 (24)	26 (76)	2.2 (1.1–4.2)	0.046
Neurological disorders^b, no	58 (12)	440 (88)	1
Neurological disorders, yes	2 (17)	10 (83)	1.4 (0.4–5.2)	0.612

BMI: body mass index; CI: confidence interval; EBRT: external beam radiation therapy.

Significant results in bold. *p-values from log-binomial model type III tests.

^a Angina pectoris, cardiac infarction and hypertension; ^bParkinson’s disease, multiple sclerosis and epilepsy.

Table 2. Diagnosis and treatment characteristics for 519 gynecological cancer survivors with and without defecation into clothing without forewarning after pelvic radiation therapy.

	Survivors with defecation into clothing without forewarning	Survivors without defecation into clothing without forewarning
	N = 63	N = 456	Unadjusted relative risks
	n (%)	n (%)	(95% CI)	p-Value*
Diagnoses				0.092
Endometrial cancer	30 (9)	292 (91)	1.0
Cervical cancer	19 (17)	93 (83)	1.8 (1.1–3.1)
Ovarian and fallopian tube cancer	4 (10)	38 (90)	1.0 (0.4–2.8)
Uterine sarcoma	7 (26)	20 (74)	2.8 (1.4–5.7)
Vaginal cancer	2 (18)	9 (82)	2.0 (0.5–7.2)
Vulvar cancer	1 (20)	4 (80)	2.1 (0.4–12.8)
Stage of malignancy				0.075
I	29 (9)	286 (91)	1.0
II	22 (18)	98 (82)	2.0 (1.2–3.3)
III	10 (14)	63 (86)	1.5 (0.8–2.9)
IV	0 (0)	3 (100)	0.0 (-)
Unknown	2 (25)	6 (75)	2.7 (0.8–9.5)
Surgery				0.006
None	15 (29)	37 (71)	1.0
TAH +/− SOE +/− omentectomy	42 (11)	333 (89)	0.4 (0.2–0.6)
TAH +/−SOE +/− omentectomy +/− lymph node sampling	1 (4)	27 (96)	0.1 (0.0–0.9)
Radical hysterectomy + pelvic lymphadenectomy	4 (7)	50 (93)	0.3 (0.1–0.7)
Vulvar resection +/− lymph node resection	1 (20)	4 (80)	0.7 (0.1–4.2)
Other	0 (0)	5 (100)	0.0 (-)
EBRT				0.011
Doses (Gy)
≤40	22 (9)	217 (91)	1.0
40–45	8 (9)	79 (91)	1.0 (0.5–2.2)
45–55	26 (15)	147 (85)	1.6 (1.0–2.8)
>55	7 (35)	13 (65)	3.8 (1.8–7.8)
Field technique				0.682
Four-field box	50 (12)	371 (88)	1.0
Two opposing fields	13 (13)	84 (87)	1.1 (0.6–2.0)
Target area				0.774
Pelvic field	49 (12)	364 (88)	1.0
Abdominal field	9 (15)	52 (85)	1.2 (0.6–2.4)
Pelvic field + paraaortic lymph nodes	3 (9)	31 (91)	0.7 (0.2–2.3)
Pelvic or vulvar field + inguinal lymph nodes	2 (18)	9 (82)	1.5 (0.4–5.5)
Brachytherapy isotope				0.052
Ir	35 (10)	327 (90)	1.0
Ra +/− Cs	0 (0)	15 (100)	0.0 (-)
Cs	9 (18)	42 (82)	1.8 (0.9–3.6)
Time relation				0.056
No brachytherapy	19 (21)	72 (79)	1.0
Preoperative	2(6)	32 (94)	0.3 (0.1–1.1)
Postoperative	33 (9)	319 (91)	0.4 (0.3–0.8)
During EBRT (irradiation alone)	9 (21)	33 (79)	1.0 (0.5–2.1)
Treatment
Chemotherapy, no	38 (11)	315 (89)	1.0	0.385
Chemotherapy concurrent, yes	4 (14)	24 (86)	1.3 (0.5–3.5)
Chemotherapy sequential, yes	21 (15)	117 (85)	1.4 (0.9–2.3)
Brachytherapy, no	19 (21)	72 (79)	1.0	0.026
Brachytherapy dose Ir ≤0–11.25 Gy	33 (10)	302 (90)	0.5 (0.3–0.8)
Brachytherapy dose Ir >11.25 Gy or Ra +/− Cs	11 (12)	82 (88)	0.6 (0.3–1.1)
Time since EBRT treatment (years)				0.147
2–5	19 (9)	184 (91)	1.0
5–10	36 (15)	201 (85)	1.6 (1.0–2.7)
10–14	8 (10)	71 (90)	1.1 (0.5–2.4)

Significant results in bold. *p-values from log-binomial model type III tests. BMI: body mass index; CI: confidence interval; Cs: cesium; EBRT: external beam radiation therapy; Ir: iridium; Ra: radium.

Table 3. Potential risk factors for defecation into clothing without forewarning after pelvic radiation therapy in 519 gynecological cancer survivors.

	Defecation into clothing without forewarning	Unadjusted RR	Unadjusted OR	Adjusted OR^a
	n/N (%)	(95% CI)	(95% CI)	(95% CI)
Delivery with birth weight >4 kg
0	49/416 (12)	1.0	1.0	1.0
1	5/65 (8)	0.7 (0.3–1.6)	0.6 (0.2–1.6)	0.7 (0.2–1.7)
≥2	9/35 (26)	2.2 (1.2–4.1)	2.6 (1.1–5.9)	2.6 (1.0–6.3)
Missing values	3
Heart failure
No	50/482 (10)	1.0	1.0	1.0
Yes	10/28 (36)	3.4 (2.0–6.0)	4.8 (2.1–11.0)	4.1 (1.7–10.0)
Missing values	9
Lactose intolerance and/or gluten intolerance
No	53/482 (11)	1.0	1.0	1.0
Yes	9/32 (28)	2.6 (1.4–4.7)	3.2 (1.4–7.2)	2.9 (1.2–6.9)
Missing values	5

CI: confidence interval; OR: odds ratio; RR: relative risk.

Significant results in bold.

^a Adjustment for high birth weight, heart failure and lactose and/or gluten intolerance.

Table 4. Mean dose to organs at risk and risk of defecation into clothing without forewarning after pelvic radiation therapy.

	All survivors N = 519
Mean EBRT dose to OARs (Gy)	n/N (%)	Unadjusted RR(95% CI)	Unadjusted OR(95% CI)	Adjusted OR^a(95% CI)
Anal-sphincter region
≤35	27/317 (9)	1.0	1.0	1.0
>35–40	14/92 (15)	1.8 (1.0–3.3)	1.9 (1.0–3.9)	2.3 (1.1–4.7)
>40–45	12/79 (15)	1.9 (0.9–3.4)	1.9 (0.9–4.0)	2.3 (1.0–5.1)
>45–50	3/28 (17)	2.0 (0.7–5.8)	2.1 (0.6–7.9)	2.8 (0.7–10.6)
>50	7/11 (64)	7.5 (4.2–13.3)	18.8 (5.2–68.3)	22.7 (5.7–89.7)
Rectum
≤35	3/45 (7)	1.0	1.0	1.0
>35–40	23/217 (11)	1.6 (0.5–5.1)	1.7 (0.5–5.8)	1.6 (0.4–6.1)
>40–45	10/91 (11)	1.6 (0.5–5.7)	1.7 (0.5–6.6)	1.9 (0.4–8.1)
>45–50	18/136 (13)	2.0 (0.6–6.4)	2.1 (0.6–7.6)	2.6 (0.7–10.4)
>50	9/27 (33)	5.0 (1.5–16.9)	7.0 (1.7–29.0)	6.8 (0.4–6.1)
Sigmoid
≤35	4/62 (6)	1.0	1.0	1.0
>35–40	21/224 (9)	1.5 (0.5–4.1)	1.5 (0.5–4.5)	1.3 (0.4–4.0)
>40–45	19/151 (13)	2.0 (0.9–8.2)	2.1 (0.7–6.4)	2.3 (0.7–7.3)
>45–50	11/62 (18)	2.8 (0.9–8.2)	3.1 (0.9–10.4)	3.2 (0.9–11.1)
>50	8/19 (42)	6.5 (2.2–19.3)	10.5 (2.7–41.2)	9.3 (2.2–39.2)
Small intestines
≤35	4/56 (7)	1.0	1.0	1.0
>35–40	25/228 (11)	1.5 (0.6–4.2)	1.6 (0.5–4.8)	1.5 (0.5–4.9)
>40–45	12/134 (9)	1.3 (0.4–3.7)	1.3 (0.4–4.2)	1.3 (0.4–4.8)
>45–50	14/64 (22)	3.1 (1.1–8.8)	3.6 (1.1–11.8)	4.2 (1.2–14.9)
>50	7/20 (35)	4.9 (1.6–15.0)	7.0 (1.8–27.6)	7.1 (1.6–31.9)
Number of OARs with mean dose >50 Gy
0	49/456 (11)	1.0	1.0	1.0
1	4/15 (27)	2.5 (1.0–6.0)	3.0 (0.9–9.9)	2.6 (0.7–9.1)
2	1/7 (14)	1.3 (0.2–8.3)	1.4 (0.2–11.7)	2.2 (0.3–19.1)
3	2/11 (18)	1.7 (0.5–6.1)	1.8 (0.4–8.8)	2.5 (0.5–12.2)
4	6/9 (67)	6.2 (3.6–10.6)	16.6 (4.0–68.5)	18.5 (4.1–83.1)

BT: brachytherapy; CI: confidence interval; EBRT: external beam radiation therapy; Ir: iridium; OAR: organ at risk; OR: odds ratio; RR: relative risk.

Significant results in bold. Doses corrected to 2 Gy per fraction.

^a Adjustment for high birth weight, heart failure and lactose and/or gluten intolerance.

Figure 2. Mean dose-volume histograms over the anal-sphincter region, the rectum, the sigmoid and the small intestines with p-values. DVH for small intestines shows absolute volumes, while for the other structures relative volumes are shown.