Abstract
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.
Similar content being viewed by others
References
American Cancer Society. Cancer facts and figures-1996. New York: Lippincott-Raven Publishers, 1996.
Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following “curative” surgery for large bowel cancer: I. The overall picture. Br J Surg 1984;71:12–6.
McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. BMJ 1991;302:1501–5.
Beart RW, Steele GD Jr, Menck HR, Chmiel JS, Ocwieja KE, Winchester DP. Management and survival of patients with adenocarcinoma of the colon and rectum: a national survey of the commission on cancer. J Am Coll Surg 1995;181:225–36.
Hermanek P, Wiebelt H, Staimmer D, Riedl S. Prognostic factors of rectum carcinoma-experience of the German multicentre study SGCRC. Tumori 1995;81:60–4.
Hermanek P, Henson DE, Hutter RV, Sobin LH. UICC. TNM Supplement: a commentary on uniform use. Berlin: Springer-Verlag, 1993;1993:30–2.
Turnbull RB Jr, Kyle K, Watson FR, Spratt J. Cancer of the colon: the influence of the no-touch isolation technic on survival rates. Ann Surg 1967;166:420–7.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 1982;69:613–6.
Raina S, Rocko JM, Rush BF, Lazaro EJ. Changing attitudes toward management of cancer of the colon and rectum. Am Surg 1985;51:26–30.
Chapuis PH, Killingback MJ. Best practice parameters for management of rectal cancer: recommendations of the Colorectal Surgical Society of Australia. Aust N Z J Surg 1996;66:508–14.
Saclarides TJ, Bhattacharyya AK, Britton-Kuzel C, Szeluga D, Economou SG. Predicting lymph node metastases in rectal cancer. Dis Colon Rectum 1994;37:52–7.
Brodsky JT, Richard GK, Cohen AM, Minsky BD. Variables correlated with the risk of lymph node metastasis in early rectal cancer. Cancer 1992;69:322–6.
Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients survival. Br J Surg 1983;70:150–4.
Cedermark B, Johansson H, Rutqvist LE, Wilking N. Randomized study on preoperative radiotherapy in rectal carcinoma: Stockholm Colorectal Cancer Study Group. Ann Surg Oncol 1996;3:423–30.
Haghbin M, Sischy B, Hinson J. Combined modality preoperative therapy in poor prognostic rectal adenocarcinoma. Radiother Oncol 1988;13:75–81.
Chari RS, Tyler DS, Anscher MS,et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 1995;221:778–87.
Dahl O, Horn A, Morild I,et al. Low-dose preoperative radiation postpones recurrences in operable rectal cancer. Cancer 1990;66:2286–94.
Cedermark B, Dahlberg M, Glimelius B, Påhlman L, Rutqvist LE, Wilking N. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997;336:980–7.
Minsky BD, Cohen AM, Enker WE, Paty P. Sphincter preservation with preoperative radiation therapy and coloanal anastomosis. Int J Radiat Oncol Biol Phys 1995;31:553–9.
Minsky BD, Cohen AM, Enker WE, Sigurdson E. Phase I/II trial of preoperative radiation therapy and coloanal anastomosis in distal invasive resectable rectal cancer. Int J Radiat Oncol Biol Phys 1992;23:387–92.
Rouanet P, Fabre JM, Dubois JB,et al. Conservative surgery for low rectal carcinoma after high dose radiation: functional and oncological results. Ann Surg 1995;221:67–73.
Stewart PJ, Chu JM, Kos SC, Chapuis PH, Bokey EL. Intra-operative ultrasound for the detection of hepatic metastases from colorectal cancer. Aust N Z J Surg 1993;63:530–4.
Nelson JC, Nimr AN, Thomford NR. Criteria for the selection of “early” carcinomas of the rectum: are they valid? Arch Surg 1987;122:533–6.
Ng AK, Recht A, Busse PM. Sphincter preservation therapy for distal rectal carcinoma [A review]. Cancer 1997;79:671–83.
Minsky BD, Rich T, Recht A, Harvey W, Mies C. Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer. Cancer 1989;63:1421–9.
Author information
Authors and Affiliations
About this article
Cite this article
Hool, G.R., Church, J.M. & Fazio, V.W. Decision-making in rectal cancer surgery. Dis Colon Rectum 41, 147–152 (1998). https://doi.org/10.1007/BF02238240
Issue Date:
DOI: https://doi.org/10.1007/BF02238240