A: Standard treatment for rectal cancer usually involves surgery, chemotherapy and radiation. Depending on multiple clinical and tumor factors, decisions are made as to which of those treatments is given and in what sequence. To make those decisions, it’s important to have experts from each field involved in the discussion to make sure the appropriate care plan is developed. Working together allows each of the specialties to view their treatment within the larger context of total care.
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From diagnosis to decision-making
Rectal cancer is diagnosed by tissue biopsy. That biopsy is usually done at colonoscopy, which can be done to evaluate symptoms or as part of routine screening. The multidisciplinary team is involved right from the beginning.
A gastroenterologist or a colorectal surgeon usually does the colonoscopy scope and identifies and biopsies the tumor. That biopsy is then processed and interpreted by a pathologist who makes the formal tissue diagnosis. Then a surgeon typically evaluates further by physical examination and clinical staging. A pelvic MRI interpreted by a radiologist determines the depth of the tumor invasion, as well as if it directly invades any other organs, and if mesorectal lymph nodes are involved.
Additional staging is done by CT scans of the chest and pelvis to determine if there is spread to other organs, which most commonly is the liver or lungs. The clinical staging then sets the stage for treatment decisions, which are formulated and vetting at our colorectal cancer multidisciplinary tumor board conference.
The value of tumor boards
At tumor board, surgeons, oncologists, radiation oncologists, pathologists and radiologists review all new cases together to ensure the best outcomes.
Usually, the surgeon who saw the patient will present the case, giving relevant history and medical issues, along with his or her impression of the tumor on physical exam and proctoscopy. The pathologist then presents and reviews the biopsy to confirm the diagnosis and provide any unusual characteristics of the tumor. The radiologist next presents the imaging for both local and distant staging. Together, with all the presented information, the clinical stage is derived.
The treatment plan is based on both national and institution-specific standards considering the stage and specific patient factors. In general, patients with locally advanced tumors receive neoadjuvant radiation with sensitizing chemotherapy prior to surgery. Neoadjuvant chemoradiation before surgery has been shown in large clinical trials to decrease local recurrence. For early stage rectal cancers, there is no benefit and potentially some harm to giving chemoradiation. These patients are treated with surgery alone. Patients who have distant spread of their disease are usually treated with chemotherapy first to try to minimize diffuse metastasis.
All of these things need to be considered by a multispecialty group since the treatment and the sequence varies by case. In a study published by the Colorectal Comprehensive Colorectal Cancer Program, initial presentation of rectal cancer cases at the tumor board resulted in some change in patient management decisions in nearly 25 percent of cases. The case is also reviewed again after the surgery is completed to present the final pathologic staging and give recommendations about adjuvant therapy.
In addition to aiding in clinical management, the tumor board serves as an impetus for quality control. The imaging and pathology are reviewed by a second set of eyes with specialized training in rectal cancer. The surgical specimen is also reviewed for technical quality of the resected specimen, assuring that the mesorectal envelope around the tumor is intact and that margins are clear, both factors that affect outcome and are indicators of surgical quality.
When cancer is locally advanced or recurs
Locally advanced rectal cancer or recurrent disease in the pelvis present a challenge, as often other organs are involved. The narrow space and proximity of many important structures in the pelvis make treatment particularly challenging. In addition to oncologists and radiation oncologists, the colorectal surgeons again must coordinate with additional surgical specialties that work as a team in the operating room to assure complete removal of the tumor. Examples include urologists to resect the bladder, ureter and/or prostate; gynecologists to resect the uterus, ovaries and/or vagina; and orthopaedic surgeons to resect the coccyx or lower sacrum.
The best chance of curing the cancer is to assure complete removal with negative margins. For that, the team often needs to be aggressive and work beyond the normal tissue planes ― and that requires specialists from several different fields. If we think that the margin may be close or microscopically involved, we will employ intraoperative radiation therapy to help improve outcomes. After the specimen is removed, often the specialized skills of plastic surgery are required to reconstruct the perineum and help with wound closure after a large amount of soft tissue and muscle is removed. There are cases in which we have many different specialists working on the patient at the same time, or sequentially, in a surgery.
Support from the NAPRC for a multidisciplinary approach
The newly developed National Accreditation Program for Rectal Cancer (NAPRC), which has just been released by the American College of Surgeons’ Commission on Cancer, has standards which are largely written around having a multidisciplinary skill team to deliver appropriate care from diagnosis to treatment to follow-up.
Cleveland Clinic is one of the initial pilot sites that helped get that program going and hopefully we’ll be one of the first to be accredited for that in spring 2018.
― Matthew Kalady, MD
Department of Colorectal Surgery, Co-Director of Cleveland Clinic’s Comprehensive Colorectal Cancer Program, Director of the Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia
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