British Columbia Medical Journal, December 2010 issue Please download or visit this entire issue online at http://bcmj.org/issue/december-2010

1. P. Terry Phang, MD, R. Cheifetz, MD, C.J. Brown, MD, C.E. McGahan, MSc,
Manoj Raval, MD
Revisiting rectal cancer
management in British
Columbia
A high local recurrence rate for rectal cancer has been reduced with
the help of new clinical practice guidelines.
n 1996 a high local recurrence rate awareness among family doctors, out-
I
ABSTRACT: An audit of data from
1996 found a high rate of local recur- for rectal cancer was identified in comes analysis using data from pa-
rence in patients treated for rectal an audit of outcomes for patients tient follow-up, and provision of feed-
cancer in British Columbia. The Col- treated for rectal cancer in BC.1 Pelvic back to participating specialists and
orectal Surgical Tumour Group of the recurrence at 4 years occurred in 16% family physicians.
Surgical Oncology Network of the BC of rectal cancer patients for all stages
Cancer Agency addressed the high and in 27% of Stage 3 patients. In con- Step 1: Outcomes review
rate of local recurrence with treat- trast, local recurrence from colon can- Our review of 1996 rectal cancer man-
ment strategies of short-course pre- cer is estimated at 5% to 10%. agement in BC1 determined that only
operative radiation and total meso- Factors contributing to a higher about 10% of operative reports includ-
rectal excision. Education sessions rate of local recurrence after surgical ed statements that the rectal cancer
were given for surgeons, oncologists, resection of rectal cancer than after was resected with clear gross radial
and pathologists. Initial outcomes resection of colon cancer include more margins and that all mesorectal lymph
following implementation of this difficult surgical anatomy in the pelvis nodes were removed in keeping with
management plan indicate a reduc- compared with the abdomen, nonstan- the tenants of oncological surgical
tion in local recurrence in BC. Issues dardized technique for resection of the resection. Only about 50% of pathol-
identified that require further im- rectum, and poor adherence to inter- ogy reports assessed whether radial
provement include facilitation of pre- national standards in the provision of margins were histologically free of
operative MRI staging and strategies adjuvant radiotherapy. cancer. The mean number of lymph
to decrease high positive resection nodes identified at pathology evalua-
margin rates for distal third rectal Management plan tion was 6 instead of 12, the minimum
cancer location. This communica- Having recognized this significant recommended for accurate staging.
tion to the BC medical community problem for rectal cancer patients, the
completes the feedback loop for this Colorectal Surgical Tumour Group All authors are members of the Colorectal
quality improvement project using a of the Surgical Oncology Network Surgical Tumour Group of the Surgical
multidisciplinary approach. (SON) of the BC Cancer Agency de- Oncology Network of the BC Cancer
signed a management plan aimed at Agency. Additionally, Dr Phang is an asso-
standardizing care across the province ciate professor of surgery at the University
and reducing local recurrence. The of British Columbia; Dr Cheifetz is an assis-
plan included an outcomes review tant professor of surgery at UBC; Dr Brown
to define the problem, strategy devel- is a clinical assistant professor of surgery at
opment to address the problem, an UBC; Dr Raval is chair of the Colorectal Sur-
education program for specialists, gical Tumour Group of the Surgical Oncolo-
implementation of the strategy includ- gy Network and clinical assistant professor
This article has been peer reviewed. ing an information campaign to raise of surgery at UBC.
510 BC MEDICAL JOURNAL VOL. 52 NO. 10, DECEMBER 2010 www.bcmj.org

2. Revisiting rectal cancer management in British Columbia
Adjuvant radiation was given to about
50% of eligible patients with Stages 2
1. Diagnosis is made on biopsy obtained during sigmoidos-
and 3 disease.
copy or colonoscopy.
Step 2: Strategy development 2. Preoperative clinical stage is determined by CT (abdomen,
After recognizing these management pelvis) to assess distant spread (clinical stage M) and by
deficiencies, we recommended a new MRI (pelvis) or endorectal ultrasound to assess local
surgical technique, total mesorectal
invasion (clinical Stage T and N, and predicted radial
excision (TME), for excision of the
resection margin).
rectal cancer and all mesorectal lymph
nodes within an intact mesorectal fas- 3. Preoperative radiation is indicated for clinical Stages 2
cial envelope.2 Local recurrence rates and 3 (T3-4, N1-2).
at 10 years for curative resections using a. Short-course preoperative radiation over 5 days is
TME were reported to be as low as recommended for mobile lesions with clear predicted
4%. A new protocol for preoperative
radial resection margins.
short-course radiation recommended
b.Long-course preoperative radiation (with concurrent
by Pahlman and colleagues in Sweden
reduced local recurrence to 11% from chemotherapy) over 5 weeks is recommended for
27% after follow-up for a minimum clinically fixed lesions or for close/involved predicted
of 5 years.3 The combination of short- radial resection margins in order to maximize tumor
course preoperative radiation and TME shrinkage prior to surgery.
resulted in a 2-year local recurrence
4. Postoperative adjuvant chemotherapy over 4 to 6 months
of 2.4% in a Dutch national trial.4 On
is given for clinical Stages 2 and 3 lesions.
the basis of this and other studies, the
clinical guidelines for rectal cancer a. Postoperative adjuvant radiation is given for clinical
management in BC (see Figure ) were Stages 2 and 3 lesions if radiation is not given
changed to recommend short-course preoperatively.
preoperative radiation for Stages 2 and 5. Surveillance is recommended in Stages 2 and 3 patients
3 rectal cancers followed by surgical
for 5 years: office visits for rectal examination and
resection using TME. The guidelines
carcinogenic embryonic antigen testing every 3 to 4
also include preoperative clinical stag-
ing using CT, MRI, and endorectal months for 3 years, then every 6 months for years 4 and 5;
ultrasound in order to recommend pre- liver imaging (ultrasound or CT) every 6 to 12 months in
operative radiation where appropri- the first 3 years, then annually for years 4 and 5; chest
ate. Guidelines for pathology report- X-ray every 6 to 12 months; colonoscopy at year 1 and
ing include assessment of the radial year 4, then every 5 years thereafter. Flexible sigmoidos-
resection margin and examination of copy every 6 to 12 months should also be considered.
at least 12 lymph nodes. The recom-
mendations were not changed for long-
course preoperative chemoradiation Figure. Clinical guidelines for rectal cancer management in BC.
for clinically fixed tumors and lesions Adapted from BC Cancer Agency web site (www.bccancer.bc.ca).5
having predicted close resection mar-
gins or for adjuvant postoperative care of patients with rectal cancer. (neoadjuvant) and postoperative (ad-
chemotherapy for Stage 3 cancers.5 Held in 2002 and 2003, the education juvant) setting, pelvic anatomy, the
sessions consisted of lectures, live sur- surgical technique of total mesorectal
Step 3: Education program gery with a video link to the audience, excision,6 gross pathology of the resect-
To implement the new treatment strat- and hands-on dissection of the pelvis ed TME specimen, and standardized
egies, we designed an education pro- in cadaver labs. Session topics includ- operative reporting. A parallel course
gram for surgeons, pathologists, and ed preoperative imaging, radiation, of lectures and live demonstration was
radiation oncologists involved in the and chemotherapy in the preoperative held for pathologists, including TME
www.bcmj.org VOL. 52 NO. 10, DECEMBER 2010 BC MEDICAL JOURNAL 511

3. Revisiting rectal cancer management in British Columbia
Use of preoperative imaging mo-
Use of preoperative imaging modalities dalities of MRI and endorectal ultra-
sound continue to be limited because
of MRI and endorectal ultrasound of resource limitations in BC and
continue to be limited because of because radiologists have not yet
adopted a standardized report form for
resource limitations in BC and rectal cancer. BC Cancer Agency cen-
because radiologists have not yet tres in Victoria, Vancouver, Surrey,
Kelowna, and Abbotsford, and soon
adopted a standardized report in Prince George, offer potential for
form for rectal cancer. creating rectal cancer care pathways
to improve accessibility of MR scan-
ning and radiation. The Colorectal
Surgical Tumour Group of the Surgi-
cal Oncology Network has preopera-
tive MR imaging on its working agen-
specimen processing, gross and mi- for Stage 3 rectal cancers and from da and invites radiologists to join the
crosopic findings, and standardized 9.6% to 6.9% overall.14 Use of adju- community of family physicians, sur-
pathology reporting.7,8 World experts vant radiation increased to 65%, most- geons, oncologists, and pathologists
from the UK, Sweden, the Nether- ly given preoperatively. Negative as integral contributors to the care of
lands, and the US were invited to teach radial margins were achieved in 87% rectal cancer patients.
at the sessions. Favorable feedback of cases. Pathology reporting showed Technical problems with surgical
from course participants regarding the increased assessment of the radial resection of rectal cancer persist in
educational value of the sessions and margin to 97% of cases and an aver- BC. Positive radial margins for rectal
tests of knowledge retention suggest- age of 12 lymph nodes per case. These cancer location in proximity to the
ed good knowledge transfer.9 improvements were statistically and anal sphincter were recorded in 35%
clinically significant. of specimens with cancers in the
Step 4: Implementation with distal-third of the rectum (located less
information campaign Step 6: Feedback than 5 cm from the anus).15 Also, the
Our next step was to implement the The final step of the quality improve- rate of permanent colostomy for distal-
treatment plan and to inform family ment process involved providing feed- third rectal cancer location was not
doctors in BC of the new rectal cancer back to participants. Ongoing reports decreased after the education courses.
management strategy. This informa- were provided to BC surgeons at their It seems reasonable to recommend
tion was transmitted via the BC Med- annual spring meeting (BC Surgical that surgeons who operate for rectal
ical Journal in a two-part theme issue Society) and to oncologists at their cancer less frequently should consid-
in July-August and September of annual fall meeting (BC Cancer Agen- er referral of difficult distal-third rec-
2003.10-13 cy), as well as through the SON news- tal cancers to subspecialist surgeons
letter. A rectal cancer education course in higher-volume centres.16
Step 5: Outcomes analysis update was held in 2008 that reported
Data on patient outcomes were col- on the final outcomes. Conclusions
lected and analyzed by the Colorectal Feedback to family doctors in BC Quality improvement in rectal cancer
Surgical Tumour Group of the SON. will continue to be provided through treatment will ideally continue in cy-
We audited patients treated with cura- the BC Medical Journal. cles of assessment, strategy, and execu-
tive-intent major resection of their tion. We have identified improvements
rectal cancer in the year after the edu- Further improvements needed in the care of rectal cancer
cation courses. This group of patients needed patients and hope to use the recently
was compared with patients treated in As with many quality improvement developed cancer surgeon network to
our initial study. The main finding of projects, important aspects of care promote these. With a multidisciplinary
this audit was a decrease in 2-year requiring further attention have been approach to care, physicians and sur-
pelvic recurrence from 18.2% to 9.2% identified. geons continue seeking to improve
512 BC MEDICAL JOURNAL VOL. 52 NO. 10, DECEMBER 2010 www.bcmj.org

4. Revisiting rectal cancer management in British Columbia
patient outcomes. However, limita-
tions in resources and geography pose
challenges for quality improvement in
our large province. Patient awareness, Surgeons who operate for rectal
education, and advocacy will be im-
cancer less frequently should
portant drivers in the quest to beat col-
orectal cancer in British Columbia. consider referral of difficult distal-
third rectal cancers to subspecialist
Competing interests
None declared. surgeons in higher-volume centres.
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