We have identified a problem with high local recurrence rates for rectal cancer in BC. Our overall local recurrence rates are about 16%,[1] compared to 4% to 8% in trials using preoperative adjuvant radiation and the surgical technique total mesorectal excision (TME).[2-4] The Netherlands,[2] Sweden,[3] and Norway[4] have all achieved marked reduction in local recurrence rates for rectal cancer patients by altering their management of rectal cancer in national projects. These countries point the way to improved outcomes in BC if we choose to follow these rectal cancer management strategies already proven to be effective.

In the first part of this double theme issue on rectal cancer management (BCMJ 2003;45[6]:252-264), we covered the topics of colorectal cancer screening, cancer imaging using CT, MR and endorectal ultrasound, and adjuvant therapy favoring preoperative short-course radiation.

In this second part of the theme issue, internationally known surgeon Cornelis van de Velde provides insights from the Netherlands on the Dutch experience  [9]to educate and to improve rectal cancer outcomes. We present new data on practice patterns for management [10] and on pathology reporting of rectal cancer in BC [11]. The data show deficiencies in our management in 1996 and provide possible strategies for changing practice patterns in order to improve outcomes. Specifically, previous practice patterns brought patients urgently for conventional surgical resection of the cancer without preoperative radiologic imaging. Cancer stage was determined in the pathology of the resected specimen and then recommendation was made for postoperative adjuvant therapy. In view of successful decrease in local recurrence rates by the Dutch and others, we need to change practice patterns in BC by using preoperative imaging studies (endorectal ultrasound, MR, CT), preoperative adjuvant radiation, and the surgical technique of TME. We also need improved pathology reporting designed to assess quality of the resected surgical specimen, radial margin involvement, and better assessment of lymph node involvement. Surgeons need education on technical aspects of TME and interdisciplinary management. Further, feedback must be provided to surgeons to assure continued improvement. Up-to-date feedback can only be provided by prospective data collection and collaborative input by all surgeons providing rectal cancer care. An overview of the BC Cancer Agency Surgical Oncology Network initiative on rectal cancer is presented.

The aim of this theme issue is to improve awareness of the problem of high local recurrence from conventional rectal cancer management in BC. I sincerely hope that we can achieve improved outcomes using proven strategies of change employed successfully by others. The changes required to improve outcomes can be achieved only through collaborative interdisciplinary management and cooperative efforts of surgeons in BC.

—P. Terry Phang, MD

References

1. Phang PT, MacFarlane J, Taylor RH, et al. Effects of positive resection margin and tumour distance from anus on rectal cancer treatment outcomes. Am J Surg 2002;183:504-508. PubMed Abstract [12] Full Text [13] 
2. Kapiteijn E, Marijnen CAM, Nagtegall ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-646. PubMed Abstract [14] Full Text [15] 
3. Martling AL, Holm T, Rutqvist LE, et al. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 2000;356:93-96. PubMed Abstract [16] Full Text [17] 
4. Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89:327-334. PubMed Abstract [18]