Rectal cancer is bowel cancer that is situated in the lower part of the bowel within 15cms (6 inches) of the skin. Low rectal cancers – those within 6 cm of the anal verge – require careful consideration and discussion. They are not straightforward due to their position so low in the body. Each treatment decision has to suit each individual patient. Therefore Pelican has been running the Low Rectal Cancer Research Study and the LOREC development programme to ensure that the most recent research results and surgical techniques can be shared with colorectal cancer teams throughout England.
Every bowel cancer is discussed by the multi-disciplinary cancer team (MDT). This group includes at least the clinical nurse specialist (CNS), surgeon, radiologist, oncologist and pathologist.
Bowel cancer patients all have different needs and preferences as well as additional health issues (co-morbidities) to consider. Therefore it is very important that the CNS, and preferable that the surgeon, sees the patient before the MDT so as to represent their preferences accurately. A surprising number of MDT decisions are overturned because these factors are not represented to the MDT.
Thanks to improved MRI techniques, images of the tumour position can be provided for the multi-disciplinary team (MDT) discussion. Clear imaging provides an indication of the stage and position of the tumour – showing if the margins are clear for surgery, if there are involved lymph nodes and whether there is likely to be vascular invasion (EMVI).
Over the last few years it has become common for many patients with low rectal cancer to be offered neo-adjuvant (before surgery) therapy – normally radiotherapy (RT) or chemo-radiotherapy (CRT). Early results showed that RT could reduce the size of a tumour (down-staging) and help avoid recurrence of disease. However recent research results have demonstrated that there is no survival benefit in patients with operable tumours. This means that after 10 years those patients who have chemo-radiotherapy and then surgery and those who have surgery alone survive after their treatment for the same amount of time. This applies to patients who can have surgery straight away but not to those who need treatment to make the tumour operable.
Therefore there is a current reassessment of the use of neo adjuvant chemotherapy and RT, considering the stage of tumour, the risks and the benefits.
There are also particular challenges in the anatomy of the low rectum – there is poor access and visibility for the surgeon. There are a number of surgical options, but the critical thing is always to provide the best outcomes in terms of cancer control for survival, taking into account the patient’s wishes and quality of life. For some not having a stoma is the most important factor, though this may not be the best for curing the tumour.
There are a range of surgical options
- Low anterior resection, which uses the TME plane of surgery, retains the sphincters and allows patients to retain function. However, low rectal cancer means that the anastomotic join is very low in the body and it carries a high risk of faecal incontinence, especially if there has been any neo-adjuvant radiotherapy.
- Abdomino-perineal excision (APE) removes the rectum, including the anus. This means that patients have to have a permanent stoma.
- There is a ‘standard’ APE that follows the anatomy of the rectum
- Intersphincteric APE, a middle path, leaving the external sphincter
- An ‘extended’ procedure, which takes out additional tissue including the levators, to avoid large tumours – this is called an extra levator APE or ELAPE
After surgery patients with unresolved lymph to nodes are often offered chemotherapy to help prevent the disease recurring. Again there are side effects, and the advantages and risks have to be considered.