The treatment of colorectal cancer is changing, contributing to changing the history of the disease, especially for advanced forms of rectal cancer. In fact, we are increasingly starting to talk about the possibility of not operating on patients, in some selected cases. This is an attitude for now shy by professionals, still engaged in data collection, but the premises indicate that sometimes – after medical and radiotherapy treatments – the path could be that of careful observation rather than that of surgery.
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Advanced rectal tumors: reviewing standards of care?
To this day, he says Uberto Fumagalli Romariodirector of Digestive System and Neuroendocrine Tumor Surgery at the IRCCS IEO Milan (among the structures of excellence for Gastroenterology), the standard of care for advanced rectal cancer generally involves chemoradiotherapy followed by surgery and then chemotherapy again. “The initial chemo-radiotherapy treatment leads in some cases to the disappearance of the tumor. We therefore asked ourselves whether surgery was really necessary to treat these patients,” explains the expert. But not only. “The second consideration was that of wanting to verify the results of a treatment that includes all the necessary chemotherapy before (possible) surgery: the so-called total neoadjuvant therapy (total neoadjuvant therapyndr.)”.
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The risks associated with surgical interventions
The option of not proceeding with surgery would have undoubted advantages from the point of view of quality of life: “Surgeries to remove the rectum have a series of significant problems: on the one hand there is the problem of whether or not the sphincter apparatus is preserved – continues Fumagalli Romario – In tumors with a particularly low location, near the anus, it may in fact be necessary to remove not only the rectum but also the anal canal and the anus, with the consequence of a permanent stoma. In cases where it is possible to maintain the sphincter complex, the removal of the rectum determines the loss of its function as a ‘faeces reservoir’. This leads to the onset of the syndrome called LARS, or Low Anterior Rectal Resection Syndrome, which is characterized by various types of disorders, such as fractional defecation or alterations in continence, with a significant impact on the patients’ quality of life”. it should then be forgotten – continues the expert – that rectal resection operations can have a complicated post-operative course in relation to the appearance of anastomotic dehiscences or stenoses which also affect prolonged anatomical-functional recovery times. It therefore appears clear that to avoid this. where possible, resective interventions, their consequences and complications would be a significant gain for these patients, explains Fumagalli Romario – who together with colleagues discussed the topic in the meeting “Current issues in the field of integrated therapies for rectal tumors”. ” of the Italian Society of Surgery (SIC) at the IEO in Milan – is to understand when it is appropriate to do so.
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Frequent check-ups without surgery
One of the possible cases concerns some particular forms of rectal cancer, those with the so-called microsatellite instability. “These are in fact the forms that respond in a high percentage and significantly to immunotherapy treatments – continues the expert – But they are quite rare neoplasms, and represent approximately 3% of rectal tumors”. Different story for the rest of rectal tumors. In this case, the candidates not to be operated on could find themselves among those who, following complete neoadjuvant therapy for advanced stage cancer, achieve a complete response. How many? Many considering that every year there are over 50 thousand new diagnoses of colorectal tumors in Italy, and that rectal adenocarcinoma is among the most common. “Up to almost a third of patients treated with these therapies, as emerges from international studies, some in the process of being published, have a complete or almost complete response to the treatment at the time of pre-surgical re-evaluation,” he recalls Fumagalli Romario.
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The IEO took part in one of these, the NoCut study coordinated by the oncology of the Niguarda Hospital in Milan led by Salvatore Siena (also among the structures of excellence for the Gastroenterology). “Until recently, even when faced with complete responses after chemo-radiotherapy, patients were advised to undergo surgery – continues the expert – today we can think of including some of these in a program of close surveillance, avoiding early surgery . This is in order to identify, on the one hand, the patients who have actually recovered from the pharmacological treatment, and on the other to quickly identify the patients who instead show a growth of the neoplasm and who therefore need to undergo surgery. However, it is important – concludes the expert – that the follow-up is carried out at dedicated centres, with close timing (every three-four months), and with specific diagnostics that include endoscopy and magnetic resonance imaging”.