Rectal cancer management in BC—Part 1

We have identified a problem with high local recurrence rates for rectal cancer in BC. Our overall local recurrence rates are about 16%,[1] compared to 4% to 8% in trials using preoperative adjuvant radiation and the surgical technique total mesorectal excision (TME).[2-4] The Netherlands,[2] Sweden,[3] and Norway[4] have all achieved marked reduction in local recurrence rates for rectal cancer patients by altering their management of rectal cancer in national projects. These countries point the way to improved outcomes in BC if we choose to follow these rectal cancer management strategies already proven to be effective.

In this theme issue on rectal cancer management, we present new data on practice patterns for management and on pathology reporting of rectal cancer in BC. The data show deficiencies in our management in 1996 and provide possible strategies for changing practice patterns in order to improve outcomes. Specifically, previous practice patterns brought patients urgently for conventional surgical resection of the cancer without preoperative radiologic imaging. Cancer stage was determined in the pathology of the resected specimen and then recommendation was made for postoperative adjuvant therapy. In view of the successful decrease in local recurrence rates by the Dutch and others, we need to change practice patterns in BC by using preoperative imaging studies (endorectal ultrasound, MR, CT), preoperative adjuvant radiation, and total mesorectal excision. We need improved pathology reporting, designed to assess radial margin involvement and to better assess lymph node involvement. Surgeons need education on technical aspects of total mesorectal excision and interdisciplinary management. Further, feedback must be provided to surgeons to assure continued improvement. Up-to-date feedback can only be provided by prospective data collection and collaborative input by all surgeons providing rectal cancer care.

In this, the first of our two-part theme issue on rectal cancer management in BC, Norman Phillips and Andy Coldman provide insight on the ultimate strategy of colorectal cancer prevention through screening. Recommendations for preoperative radiology imaging are provided by Dr David Malfair and colleagues. Finally, Drs John Hay and Amil Shah make recommendations for adjuvant therapies.

In the second part of this theme issue in September, internationally known surgeon Dr Cornelis van de Velde will share insights from the Netherlands on the Dutch experience to educate and to improve rectal cancer outcomes. My colleagues and I will provide an overview of the BC Cancer Agency Surgical Oncology Network initiative on rectal cancer. From data gathered from a chart review, questionnaire, and telephone calls, we will also examine practice patterns and appropriateness of rectal cancer management in BC, establishing possible factors that could result in suboptimal rectal cancer management outcomes. In the final paper of the series, I will present a proposal to improve rectal cancer management in British Columbia.

The aim of this theme issue is to improve awareness of the problem of high local recurrence from conventional rectal cancer management in BC. I sincerely hope that we can achieve improved outcomes using proven strategies of change employed successfully by others. The changes required to improve outcomes can be achieved only through collaborative interdisciplinary management and cooperative efforts of surgeons in BC.

—P. Terry Phang, MD

References

1. Phang PT, MacFarlane J, Taylor RH, et al. Effects of positive resection margin and tumour distance from anus on rectal cancer treatment outcomes. Am J Surg 2002;183:504-508. PubMed Abstract Full Text
2. Kapiteijn E, Marijnen CAM, Nagtegall ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-646. PubMed Abstract Full Text
3. Martling AL, Holm T, Rutqvist LE, et al. Effect of a surgical training programme on outcome of rectal cancer in the county of Stockholm. Lancet 2000;356:93-96. PubMed Abstract Full Text
4. Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89:327-334. PubMed Abstract

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Dr Phang is a colorectal surgeon at St. Paul’s Hospital in Vancouver and an associate professor in the Department of Surgery at the University of British Columbia.