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P
rofessor Richard J Heald, Director of Surgery at
the Pelican Cancer Foundation and Director of the
National/MDT TME Development Programme,
delivered the Johnson & Johnson lecture, entitled
"The importance of the `complete response' concept
for the future of rectal cancer management", at
RCSI's Charter Day Meeting 2014
According to Professor Heald: "Surgeons need to know when not to
operate. Professor Abraham Vergese, Professor for the Theory and
Practice of Medicine at Stanford University Medical School, and
Senior Associate of the Department of Internal Medicine, California,
US, said, `sometimes the operation with the best outcome is the one
you decide not to do'. I agree with this statement. To know when not
to operate is of the utmost importance."
He discussed cases where he made the decision against operating on
specific rectal cancer patients. "These patients are still living a quality
lifestyle 20 years on. Sometimes tumours disappear and sometimes
they don't have to be removed. There are many cases where, after
patients have had tumours removed, they are left with severe
abdominal scarring, or have to live with permanent colostomy bags.
Subsequently, in many instances, the removed tumours are shown to
be cancer-free."
CASE STUDY
In 2007, Mr Paul Murphy, Consultant in Colorectal and General
Surgery, Warwickshire Hospital, UK, invited Professor Heald to
investigate a 42-year-old, previously healthy woman, who was
diagnosed with large carcinoma of the rectum. "She was a remarkably
religious woman and her husband was very supportive. I examined
her, then re-examined her and examined her again. I could not feel
the tumours that were supposed to be operated on. I told her I would
not advise her to partake in any operation. We would monitor her
very closely but I wanted her to trust my medical opinion. Six years
on her tumours have disappeared and she is still in good health,"
Professor Heald said. "The big problem with surgery is the balance of
benefit. The risk of operation should be pitched against the benefit of
operation."
Professor Heald referenced the RAPIDO (Rectal Cancer and
Preoperative Induction Therapy Followed by Dedicated Operation)
Trial Stockholm 3 as a reputable trial to study in relation to
showcasing this `balance of benefit'.
RAPIDO TRIAL
The trial, detailed in the research paper, "Short-course radiotherapy
followed by neo-adjuvant chemotherapy in locally advanced rectal
cancer the RAPIDO Trial" compared two different preoperative
regimens for locally advanced rectal cancer
1
.
According to this trial, current standards for most of the locally
advanced rectal cancers are preoperative chemoradiotherapy, and,
variably per institution, post-operative adjuvant chemotherapy. Short-
course preoperative radiation with delayed surgery has been shown to
induce tumour down-staging in both randomised and observational
studies. The concept of neo-adjuvant chemotherapy has also proven
of some value in gastric cancer, hepatic metastases from colorectal
cancer and is currently tested in primary colon cancer.
In the trial, patients with rectal cancer with high-risk features for local
or systemic failure on magnetic resonance imaging were randomised
to either a standard arm or an experimental arm. The standard arm
consisted of chemoradiation preoperatively, followed by selective
postoperative adjuvant chemotherapy. Post-operative chemotherapy
was optional and could be omitted by participating institutions.
The experimental arm included short-course radiotherapy followed
by full-dose chemotherapy in six cycles before surgery. In the
experimental arm, no post-operative chemotherapy was prescribed.
Surgery was performed according to TME principles in both study
arms. The hypothesis is that short-course radiotherapy with neo-
adjuvant chemotherapy increases disease-free and overall survival
without compromising local control. Primary end-point is disease-
free survival at three years. Secondary endpoints include overall
survival, local control, toxicity profile, and treatment completion rate,
rate of pathological complete response and microscopically radical
WHEN NOT TO OPERATE
- THE FUTURE OF RECTAL CANCER MANAGEMENT
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