The landscape of rectal cancer in the UK is such that from the surgical point of view all cancers get specifically treated by colorectal cancer surgeons. They very often work in multidisciplinary teams and, as a result, they come to a tailor-made… they try to focus that the patients get the best treatment that is best for them. That’s one of the challenges of rectal cancer because traditionally, of course, we have been performing big operations, so major operations with big resections. There is now more and more a move with the introduction of chemoradiotherapy and local resection for a more minimal approach where, in a way, less can be more.
Are there any challenges in tailoring the best treatment for the patient?
There are lots of different aspects of rectal cancer. As a surgeon the rectum is well away, deep in the pelvis, so for a surgeon to get access to a tumour, to a cancer, is very challenging. Especially, of course, in a man who has got a very narrow pelvis access can be very difficult. In the UK a lot of patients are obese which makes it far more difficult to get to the tumour and to resect it. As a result one then tries to look at are there any other alternative means of getting rid of the tumour or do a procedure which requires a smaller operation with better outcomes, with better results for the patient in the sense of functionality. Because, of course, one of the aspects of rectal cancer surgery is for major surgery there is a very high complication rate. So about a third of our patients have a complication and that can be devastating for the patient in the short term as well as the long term and therefore it may then subsequently sometimes hinder subsequent cancer treatment in the form of chemotherapy or it may affect their quality of life later on.
What can be done to address these challenges?
Make an accurate diagnosis. Obviously the earlier you diagnose a cancer in the earliest stage you have, perhaps, an option to do more minimal surgery rather than more radical surgery. Obviously then the complications associated with that are, as such, reduced.
How important is the collaboration between medical oncologists and surgical oncologists?
It’s extremely important because from diagnosis the most important thing is to get a very accurate staging before you propose treatment. So it’s very important to have accurate pathology and accurate imaging, so with MRI, all the imaging modalities, to get an accurate stage. Because you can obviously over-treat a patient or you can under-treat a patient which both can be potentially bad for the long-term outcome of somebody. So it’s very important that before you start any treatment that you have as much information as possible to tailor the treatment to that specific patient.
What can we expect in the future?
What we’re seeing in the future, for me, what we’ll see is a better understanding on a microscopic level and have more understanding of the biological nature of the tumours. So it’s not the case that every bowel cancer is the same; it has all different characteristics and if you identify them at the moment there are certain treatments which may work for some patients but for other patients they don’t work at all. So what you try to do is that you try to get personalised medicine that you have specific treatment regimes which are specific for that patient but may not work or are not specific for somebody else. Yet they will both have bowel cancers but the treatment may be tailored to that individual patient. What we have been doing too much is giving the same treatment for everybody and that will need to change to improve in the future.
Is there a timescale on when this might happen?
You always hope for some revolutionary research but it’s usually step by step approaches. What is an improvement, what we have, for instance, seen in surgery that you have seen an improvement in surgical technique, so for rectal cancer there has been a huge improvement in achieving a very good surgical specimen. So you basically get a very good resection which leads away to a better outcome and improvement. Obviously we have seen changes in how radiotherapy is administered in a far more targeted, localised manner and obviously we have seen huge changes in radiotherapy, in chemotherapy. And that altogether, and sometimes a change in one aspect and a change in another aspect, it’s not one plus one, it’s suddenly you see a better, more improvement, if you combine two modalities and suddenly you see a very big improvement. So that’s probably what could happen.
