Best practice parameters for management of rectal cancer: recommendations of the Colorectal Surgical Society of Australia

Rectal cancer in Victoria in 1994: patterns of reported management

BACKGROUND

A retrospective survey of medical practitioners was conducted to describe the management of patients newly diagnosed with rectal cancer in 1994, prior to the publication of best practice guidelines.

METHODS

A sample of 908 patients with rectal cancer diagnosed between 1 January and 31 December 1994 was identified from the Victorian Cancer Registry. Questionnaires were then sent to the treating doctor(s) for completion. The topics covered by the questionnaires included: reported management by method of diagnosis; staging investigations; and treatment by surgery, chemotherapy and radiotherapy.

RESULTS

Seven hundred and twenty-six (80%) of 908 eligible patients were surveyed. Surgery was the primary treatment in 681 (93.8%) with curative intent in 483 (70.9%) of these cases. One- third (163; 33.7%) of curative cases were pathologically staged as Dukes' C. Almost all patients (96%) were symptomatic, and three-quarters were referred by general practitioners to 166 surgeons. One-third (221; 32.5%) underwent liver computed tomography or ultrasound, and only three cases had transrectal ultrasound. Restorative anterior resection was the most common surgical procedure (431; 63.3%) with 160 (23.5%) and 34 (5.0%) patients being managed with abdominoperineal resections and local excision, respectively. Chemotherapy and radiotherapy were administered as part of the initial management to 216 (31.7%) and 171 (25.1%) patients, respectively. In five of the 171 cases, radiotherapy was given preoperatively.

CONCLUSIONS

There was considerable variation in preoperative assessment. Staging was less complete than expected by today's standards. The diversity of surgical techniques observed may reflect both the lack of clinical trials and disparity in surgical training and experience. Referral to stomal therapists, and medical and radiation oncologists was lower than would now be expected, as was the use and timing of adjuvant therapies. These findings will be useful as a baseline for comparison with subsequent surveys conducted since the introduction of evidence-based guidelines.

Rectal cancer: changing patterns of referral for radiation therapy 1982-1997

BACKGROUND

The purpose of the present study was to evaluate the changing role of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period.

METHODS

From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospital: 79% of patients had locoregional disease alone and 21% had distant metastasis. Radiation therapy consisted of irradiation (definitive or palliative) alone to the primary tumour in 9.7% of cases; preoperative radiation in 7.3% of cases: preoperative chemoradiation in 7.5% of patients: postoperative radiation in 15.3% of patients: postoperative chemoradiation in 12.31% of patients: treatment of pelvic recurrence in 23.5% of patients and treatment of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated (13.4%).

RESULTS

There was an average annual 14% increase in referrals over the accrual period. Recurrent rectal cancer decreased from approximately 30% of referrals during 1982-91 to approximately 10% in 1995-7. The use of postoperative adjuvant radiation reached a peak of 50% in 1993. The use of preoperative radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatment. The median survival time from initial diagnosis was 35 months, with 2- and 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, respectively.

CONCLUSIONS

The present study illustrates the changing role of radiation therapy in the management of rectal cancer. The increase in referrals over the observation period was due to increased multidisciplinary input into the initial management of these patients, based on reported clinical trials. The steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical results. The sequencing of adjuvant therapy is changing currently, with greater emphasis on preoperative adjuvant treatment. Currently most adjuvant therapy includes chemotherapy.

Rectal cancer in the Kingdom of Saudi Arabia: the King Faisal Specialist Hospital experience

BACKGROUND

No survival data have yet been published from the Kingdom of Saudi Arabia for patients with rectal cancer. The present paper reports experience with these patients over an 8-year period.

METHODS

All patients referred to the King Faisal Specialist Hospital (KFSH) between March 1990 and February 1998 for the primary management of rectal cancer were entered into a computerized database. Prior to 1993 patients did not receive adjuvant therapy. Kaplan-Meier survival curves and the log-rank test were used to compare outcome data.

RESULTS

There were 70 men (average age: 55.6 years) and 75 women (average age: 52.8 years). Twelve per cent of patients admitted a family history of colorectal carcinoma (CRC). Twenty-seven per cent of tumours were circumferential. Most tumours were larger than 4 cm and the lowest edge of the majority of tumours was less than 6 cm from the anal verge. Fifty-four per cent of tumours were fixed; 69% of patients received either pre-operative or postoperative radiotherapy. A total of 106 patients underwent 'curative' surgery. Equal numbers of patients had abdomino-perineal resection (APR) and anterior resection (AR) of the rectum. Thirty-five patients received blood peri-operatively (APR, 34%; AR, 12%). Major anastomotic leakage following AR occurred in two patients. Two patients died within 30 days of surgery. Ten patients were lost to follow-up. Following curative AR, eight patients had a distal resection margin of < 2 cm and two patients (Dukes' C) developed local recurrence (25%); 37 patients had a margin > 2 cm and seven developed local recurrence (18.9%). A total of 48 patients underwent curative APR, and four patients developed local recurrence (8.3%). Overall local recurrence was tumour stage-dependent (Dukes' B, 8.8%; Dukes' C, 29.3%). Recurrence was local in 13 patients. Pre-operative radiotherapy seemed to reduce average tumour size (3.6 vs 4.3 cm). The crude overall 5-year survival rate was 39%. The 5-year survival rate for patients with Dukes' stage C cancers following 'curative' surgery was 25%.

CONCLUSION

Curative surgery can be performed with a relatively low requirement for blood transfusion, a low mortality and morbidity, and comparable outcomes to Western studies in spite of the large, low and often advanced stage of the tumours managed. Local recurrence rates following curative resection and re-anastomosis for low rectal cancers may be reduced by resisting patient pressure to avoid stomata.

Decision-making in rectal cancer surgery: survey of North American colorectal residency programs

PURPOSE

Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer.

METHODS

A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America.

RESULTS

One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies.

CONCLUSIONS

There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.

Independently predictive prognostic variables after resection for colorectal carcinoma

BACKGROUND

Clinical variables such as surgical morbidity, comorbidity and follow-up have been claimed to influence ultimate survival in patients who have resection for colorectal cancer. It is unclear whether the effect of clinical covariates is confounding or independent. We have attempted to build a comprehensive model, which is capable of testing the dependence and importance of prognostic factors.

METHODS

A consecutive series of patients admitted between 1970 and 1988 and followed until 1992 had data recorded about presentation, pathology, hospitalization, aftercare and long-term outcome. The patients were also divided into two approximately equal groups that were cared for by one and seven surgeons, respectively. Clinical and pathological covariates were built into a Cox (multivariate) proportional hazard model of crude survival. This was achieved with the SPSS advanced statistical package version 6.1. Comparison between groups was then performed of clinical and pathological factors and subsequent cancer management.

RESULTS

There were 207 patients whose average age was 75 years, median survival was 43 months and operative mortality was 4%. The Cox model was robust. Covariates that had independent survival effects were pathological stage (P = 0.0000), grade (P = 0.014), age (P = 0.018), heart disease (P = 0.001), and group (P = 0.0008). Some of the dependent variables were symptoms, type of surgery, complications and length of stay. The groups, however, were well matched for age, stage, substage and comorbidity. Furthermore there were no substantial differences in mortality, complications or follow-up frequency. There was a significant survival difference (P = 0.0003) between groups, which was restricted to patients who were in clinicopathological stages B and C. Within stages B and C there was a significant (P = 0.008) survival difference between patients who were or were not treated for recurrent disease. Diagnosis of recurrence was pursued more aggressively (P < 0.01), and decisions to treat recurrent disease were made more frequently in group 1 (P = 0.0002).

CONCLUSIONS

Pathology, comorbidity and management of recurrence all have a significant independent effect upon crude survival after colorectal carcinoma resection.

Total mesorectal excision: evaluating the evidence

The present paper reviews information from pathological and clinical studies examining the role of total mesorectal excision (TME) in the treatment of rectal cancer. The pathological studies provide information about the spread of rectal cancer within the mesorectum, and the adequacy of excision obtained with conventional surgery and TME. The clinical studies provide information about the safety of TME and the reported local recurrence rates. Taken together, these studies provide a rationale for using TME to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from randomized controlled trials.