Multidisciplinary Treatment of Rectal Cancer
Authors: James W. Fleshman
Journal: JAMA Surgery (2013)

Russell et al1 have addedmore information to thedebate over the treatment of rectal cancer in institutions focused on the treatment of rectal cancer. Although the treatment of patients with rectal cancer in higher-volume academic centers with neoadjuvant protocols does not guarantee good surgical outcomes, it seems to help. Because no type of hospital (even a high-volume academic hospital) was immune to high outlier status for circumferentialmargins positive for cancer, the need for quality assurance and improvement in processes is extremely important for anyhospital/institution that treatspatients with rectal cancer. TheAmericanSocietyofColonandRectalSurgeons, inconjunctionwith the Society of Surgical Oncology, the American College of Surgeons, the Society for Surgery of the Alimentary Tract, and the Society of American Gastrointestinal and EndoscopicSurgeons,has initiated a project to optimize treatment of rectal cancer; OSTRiCh (Optimizing Surgical Treatment of Rectal Cancer) is a group of interested institutionsand individuals attempting todevelopaprogramin the United States similar to that in the United Kingdom, Scandinavia, and Europe. Out of this effort, a set of criteria for centers of excellence should become available. Rather than focusing solely on surgeon credentialing, the OSTRiCh group is embracing the institution with a multidisciplinary approach to rectal cancer. Someof the criteria includeddedicatedhighvolumesurgeonsusing totalmesorectal excisionof rectal cancer; radiologists experienced in magnetic resonance imaging stagingof rectal cancer;medical and radiationoncologistswho understand the nuances of neoadjuvant chemoradiation and adjuvant chemotherapy for rectal cancer; pathologists focused on macroscopic specimen grading, circumferential radial margin reporting, and whole-specimen processing for cross-sectionmounts; gastroenterologistswithhigh-level endoscopic intervention skills; and genetic counselors, asmembers of a multidisciplinary team, whomanage, evaluate, and assesseseverypatient treatedwithcolorectal cancer.Thesecriteria should improve the outcomes of patients treated for rectal cancer. Russell et al1 havealso shownus that apatient’s awareness of theappropriate treatmentof rectal cancer is important.Older individuals and those without private insurance had a higher likelihood of choosing low-volume, nonteaching hospitals, which have a greater likelihood of high outlier status for radial margins positive for cancer. As patients become more aware and/or educated about rectal cancer, this trend should change. This study1 has some issues that may never be resolved, even with the use of a database as sophisticated as the NationalCancerDataBase.Thepatientpopulation includedyoung patientswhomust,bydefinition,beconsideredhighrisk forhereditary cancer, which behaves differently from sporadic cancer. The inclusionof rectosigmoid cancers, simplybecause the patients underwent irradiation, may bias or negatively influence the outcomes because only the most advanced rectosigmoid cancers would require neoadjuvant therapy. The change in the awareness of the requirements for the pathologicevaluationofa rectal cancerspecimenbegan in2007 and seems to be associatedwith the increase in circumferentialmarginpositivity. Similarly, surgeonsaremoreawareof the need for total mesorectal excision and the avoidance of circumferential radial margin positivity. The use of a 9% to 10% baseline level of circumferential radial positivity and a 100% complete total mesorectal specimen can become an objectivemeasureof surgicalquality forhospitals treating rectal cancer.On thewhole,Russell et al1 are tobecongratulated for their superb effort to improve the surgical procedure for and the treatment of rectal cancer.