Role of local excision in the management of rectal cancer: what does the future hold?

Excerpt

Why is the treatment of rectal cancer such a controversial issue for colon and rectal surgeons? Perhaps we believe it is the disease (and treatment) and that truly separates us from general surgeons. Many colon and rectal surgeons can quote their personal local recurrence and survival rates (and perhaps even their anastomotic leak rates) for rectal cancer. However, I imagine few can quote their patients’ FISI scores, fecal and urinary incontinence rates, and sexual dysfunction rates. We often pride ourselves on our ability to cure rectal cancer, and many believe the more radical the operation the better, but we rarely talk about the functional consequences our patients must suffer as a result of the operations we perform. Many surgeons believe if they accurately perform a radical resection, with a complete total mesorectal excision, and achieve negative resection margins (and provide appropriate (neo) adjuvant therapy) if a patient subsequently develops recurrence, it is due to the disease process, and nothing more could have been done. Yet if a local excision (with or without neoadjuvant therapy) was performed for an appropriately staged tumor, and negative resection margins achieved, and a patient develops recurrence, then an inadequate operation was performed, and a more radical resection would have prevented that recurrence. Surgeons consider that a personal failure, rather than a consequence of the disease process. I am certain that it is not that simple. “Bigger” is simply not always “better,” and “bigger” operations essentially always have “bigger” complications and “bigger” functional consequences. More radical treatments for rectal cancer may, in certain circumstances, result in higher disease-free survival, but not in improvements in overall survival, and certainly not a better functional result, and subsequent quality of life. In selecting treatment options, one must understand multiple important factors regarding the tumor and the patient in which it resides. …