27 May 2016

In a series of interviews, guest reporter Owen Haskins from Dendrite Clinical Systems, will be previewing this year’s ACPGBI annual meeting in Edinburgh, Scotland, July 4-6. He talked to Professor Søren Laurberg about his presentation 'The harm we cause by treating rectal cancer and how to minimise it', which emphasised the need to understand the side-effects of treatment and why healthcare professionals should concentrate on the long-term quality of life of patients...

“There are about 1,600 new cases of rectal cancer each year in Denmark and because survival rates have improved dramatically over the last 20-30 years, the number of people living with rectal cancer increases each year,” said Professor Laurberg. “Survival from rectal cancer depends on how advanced a patient’s condition is, but with improvements in detection and treatment, the majority of patients will live.”

He explained that the treatment a patient receives depends on how advanced the cancer is - a very early, very small polyp – will be remedied by localised treatment, with the number of these early cases increasing due to better screening programmes.

“If the cancer is too advanced to be treated locally, the patient will undergo a surgical resection, sometimes combined with chemo-radiotherapy,” he added. “Rates vary from country to country, in Denmark about 25% of patients will have a resection combined with chemo-radiotherapy. However, I would expect that in the next 10-20 years the number of cases that require major surgery to decrease substantially and the combination of resection and chemo-radiotherapy, which I call ‘poison therapy’, will be much rarer. This is primarily due to screening and identifying early stage cancer, but we have also realised how potent the combination therapy is. In the future, we will treat more patients with chemo-radiation therapy and watchful waiting, without resectional surgery.”

Anastomotic leak

Professor Laurberg explained that despite the mortality rate from surgery falling dramatically, the morbidity rate from surgery is still quite high at about 30%. One of the most important early complications following rectal surgery is an anastomotic leak and he cited some recent developments, which it is hoped will help reduce the leakage rate. The first is intraoperative fluorescence imaging that assesses whether the bowel is viable and if the blood supply is good enough for tissue perfusion. This technology is currently under review in several major clinical trials. The second is a fibrin sealing glue that is applied around the anastomosis to prevent leaks, promote haemostasis and wound healing.

“With regards to minimally invasive surgery, I think in 10 or 15 year we will see more robotic surgery possibly combined with intra-operative imaging,” he added. “At the moment, there is a debate about these low cancers and whether they should be approached through the abdomen or transanally. However, the most important aspect of any treatment is, in consultation with the multidisciplinary team, choosing the right treatment for the needs of the individual patient.”

LARS score

As the number of patients surviving rectal cancer has increased, many patients are living with the side-effects from their treatment. Previously, the focus was on survival and these side-effects were not considered an issue, he explained. However, Professor Laurberg and his colleagues recognised that about 40% of surgical resection patients have severe bowel dysfunction, which has a considerable impact on their quality of life as they urgently require the toilet, and may have to re-visit it in a short while, thereby restricting their ability to leave their homes and have a fulfilling life.

“In order to assess the impact of surgery on a patient’s quality of life, in 2008 we started to research, and subsequently developed, the Low Anterior Resection Syndrome (LARS) Score. This is a simple, valid and reliable scoring system for bowel dysfunction after LAR for rectal cancer, on the basis of symptoms and the impact on a patient’s quality of life. The LARS is now used for all our patients, has been translated into 25 different languages and is universally accepted in studies and trials all over the world.”

He emphasised that LARS is now an important tool that allows healthcare professionals to post-operatively assess the condition of the bowel as a consequence of surgery, and assists them in treating any ongoing conditions such as severe bowel dysfunction, incontinence and frequent bowel movements.

“What we do know is that that the risk of severe bowel dysfunction increases if you make a very low anastomosis and if you combine resectional surgery with chemo-radiotherapy. It has a very severe impact on a patient’s quality of life. Approximately 80% of patients - who have combined therapy - present with substantial bowel dysfunction. This is why I call this combined therapy, a ‘poison therapy’, because it does enormous harm in the long-term and must be restricted.

Encouragingly, he said that there is growing evidence that many of these patients can be treated successfully with advice about diet, non-constipating agents, small suppositories or by using refined procedures such transanal irrigation or faecal nerve stimulation. “So many patients are now surviving that we need to recognise that we don’t need to give them ‘hard treatments’ because we risk subjecting them to substantial side-effects. In addition to bowel dysfunction, patients also present with bladder and sexual dysfunction and we know that the combined treatment damages sexual health, and 10-15% of patients will get chronic pain. This is a whole new era and we need to adapt our thinking. We need to think about the post-operative well-being of our patients and focus on the long-term impact from treatment because so many are now surviving.”

“My key message is that all clinics that treat rectal cancer must prospectively record and register the side effects of these treatments, and must have an evidenced based programme to prevent harm - and if they do harm - an evidenced based programme to help the patient. Until now we have not recognised side effects, we did not care and we did not treat, it is a universal problem. We must think beyond curing cancer to treating the patient in long-term.”

Professor Søren Laurberg's Plenary BJS lecture is on Wednesday 6th July at 12:30pm.

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