Scientific letter
Importance of the LARS Score and POLARS score predictive scale in the ideal treatment of rectal cancer
Importancia de las escalas predictivas LARS Score y POLARS score en el tratamiento ideal del cáncer de recto
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Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Importancia de las escalas predictivas LARS Score y POLARS score en el tratamiento ideal del cáncer de recto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0035" class="elsevierStylePara elsevierViewall">Colorectal cancer is the most commonly diagnosed cancer in our setting.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Technological advances and multidisciplinary treatment have made it possible to add sphincter preservation to the therapeutic objectives. In rectal cancer, the standard surgery is anterior resection with excision of the mesorectum and preservation of intestinal continuity. However, some patients will develop <span class="elsevierStyleItalic">low anterior resection syndrome</span> (LARS) as a consequence of anatomical and functional modifications of the pelvic floor. This syndrome consists of a group of different symptoms: increased frequency of bowel movements, fecal incontinence, defecation urgency, <span class="elsevierStyleItalic">soiling</span> and obstructive defecation with incomplete evacuation. These symptoms usually improve in the first few months after surgery, so are significant if they persist after the first year. Clinical, aetiological and therapeutic variability has made a comparative analysis between series difficult. However, in 2016 the LARS score was developed, an international scoring system enabling symptomatic severity to be quantified and outcomes compared, classifying patients into major LARS (significant compromise of quality of life), minor LARS (mildly affected) and non-LARS.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> A new tool has subsequently been incorporated which can quantify the risk of developing LARS after rectal cancer surgery preoperatively <span class="elsevierStyleItalic">(pre-operative LARS-score</span> [POLARS score]), available at: <a href="http://www.pelicancancer.org/bowel-cancerresearch/polars">http://www.pelicancancer.org/bowel-cancerresearch/polars</a>.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of our study was to determine the incidence and severity of LARS among our patients undergoing rectal cancer surgery with anterior resection. We carried out a descriptive observational study in a population of adult patients operated on for rectal cancer less than 15 cm from the anal margin in 2019. All the patients underwent anterior resection with sphincter preservation. We started applying the LARS questionnaire from the first postoperative consultations, and follow-up was carried out with telephone interviews for a period of at least one year after surgery, or restoration of gastrointestinal transit in patients with protective stoma. This included LARS scale, Wexner incontinence scale and quality of life survey with visual analogue scale (1–10). The POLARS scale prediction was subsequently determined according to preoperative data.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We included 57 patients who met the inclusion criteria in the study. There was a predominance of females (52.6%) and the mean age was 69.9 ± 9.6 years. Partial mesorectal excision was performed in 35 patients (61.4%) compared to 22 with total excision. Half of the patients received neoadjuvant radiotherapy. The approach used was mostly laparoscopic (91,2%) and protective ileostomy was associated in 19 cases (33.3%). The mean quality of life score was 8.20 ± 1.63. A total of 72% of patients had some symptoms after surgery, but the LARS scale identified 15.1% (3.8% minor LARS and 11.3% major LARS) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The statistical processing of the POLARS score prognostic index using the ROC curve set the cut-off point from which LARS appears at 23 (AUC = 0.786; sensitivity 1 and specificity 0.511) and at 27 for major LARS (AUC = 0.861; sensitivity 1 and specificity 0.702).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">LARS is a common and limiting condition that remains hidden unless surgeons investigate the functional surgical outcomes. The LARS score has enabled us to classify affected patients, which is of particular interest when indicating hygiene and dietary measures, colonic irrigation, neuromodulation of sacral roots or personalised permanent diverting stoma. One year after surgery, 72% of our patients had at least one LARS symptom, although in most cases it did not affect their quality of life (major LARS 11.3%). Comparing our results with those of Carrillo et al., we have a lower overall incidence (15.1% vs. 65.9%) as well as less major LARS (11.3% vs. 47%).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although in our series the patients who received neoadjuvant radiotherapy represent the same proportion (50.8%), the proportion of patients who required total excision of the mesorectum is clearly lower (38.6% vs. 73.5%), the average distance to the anal margin being 10.6 ± 3.4 cm. Our results are similar to those of international series.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Statistical analysis showed that the POLARS scale has predictive validity in our case series, and could be a useful tool in clinical practice to help in shared decision-making and planning adequate postoperative treatment.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the use of validated scales to identify and predict LARS syndrome enables us to audit our data, predict the therapeutic needs of our patients and compare our outcomes with other centres.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no sources of funding to declare.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SD: standard deviation.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Low anterior resection syndrome</span> (LARS) scale score: non-LARS (0–20); minor LARS (21–29); major LARS (30–42).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable (n = 57)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age: mean (SD), median (range), years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.9 ± 9.6, 69 (43−88) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender: female/male (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (52.6)/27 (47.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distance from the lesion to the anal margin (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.6 ± 3.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neoadjuvant treatment (radiotherapy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (50.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neoadjuvant treatment (chemotherapy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (45.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery/type of approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Anterior resection of rectum</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoscopic: 52 (91.2%)</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0010" class="elsevierStylePara elsevierViewall">Open: 4 (7%)</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">Conversion: 1 (1.8%)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Protective stoma (ileostomy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Visual analogue scale quality of life score (mean, SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.20 ± 1.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wexner incontinence scale (score > 0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (33.3%). Mean score 7.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any LARS symptoms one year after surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41 (72%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LARS diagnosis according to LARS scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">Non-LARS: 49 (84.9%)</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Minor LARS: 2 (3.8%)</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">Major LARS: 6 (11.3%)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3670337.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the sample.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Sociedad Española de Oncología Médica. 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