Surgeons and oncologists: Optimising surgery within multimodality treatment


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David Sebag-Montefiore1, Simon Bach2
1University of Leeds, Leeds, UK, 2Queen Elizabeth Hospital, Birmingham, UK

Abstract

Rectal cancer is an excellent example of a disease in transition. Early diagnosis through screening increases the opportunity to evaluate novel strategies that preserve the organ and its function. The challenge is to retain excellent oncological outcomes.

Clinical trials in locally advanced disease established that the addition of radiotherapy to radical resection results in a significant reduction in local recurrence. Prospective studies of both preoperative radiological staging and histopathological assessment have dramatically improved our ability to appropriately select patients for multimodal therapy. Currently rectal cancer is associated with rapidly reducing disease-associated mortality, but treatment related morbidity and mortality unfortunately remain high. The majority of long term toxicity is caused by radical surgery.

Bowel cancer screening provides us with an opportunity to re-evaluate the therapeutic strategy for rectal cancer. Radical surgery achieves complete rectal and mesorectal excision, providing definitive information about T stage and local nodal metastasis. If no involved nodes are found then there is little risk of regional recurrence and diminished risk of systemic relapse. The majority of T1 and T2 rectal cancers, (80-85%), are limited to the bowel wall without lymph node involvement. Routine lymph node dissection in these patients is over-treatment and could potentially be avoided.

An alternative is to target only the small area of bowel directly affected by the tumour, preserving the remaining rectum and its function. The primary tumour may be treated by either excision or radiotherapy. The challenge of comparing the current standard of care with an organ preserving approach within clinical trials will be discussed including our experience with a Cancer Research UK funded trial (TREC) addressing this question. We will also discuss approaches to evaluate the different approaches to organ preservation.