We talked to Professor Eric Rullier, who presented the keynote lecture 'Rectal cancer - is it time to do less?' at Barcelona 2014…

“There are around 12,000 new cases each year of rectal cancer in France, and along with breast and prostate cancer it is one of the most common cancers, and is successfully treated in approximately 50% of patients, if all patients with and without metastases are considered” said Professor Eric Rullier from the University of Bordeaux in France.

Photo of Eric RullierHe explained that the main treatment option for rectal cancer remains surgery and it has the best outcomes of all the options available. Patients can also receive radiotherapy prior to surgery, particularly for large tumours, and chemotherapy after surgery to prevent metastases.

“The multi-disciplinary team must take several factors into account when deciding optimum treatment for their patient,” said Professor Rullier. “The primary factor influencing this decision is tumour stage, so in locally advanced rectal cancer the treatment course would be radiotherapy followed by rectal excision. Without surgery there really is no chance of cure.”

“Of course, surgery involves rectal excision and so has the potential to result in mortality and high morbidity,” he added. “This includes post-operative complications and long-term side-effects such as gastrointestinal disorders, anal incontinence, impotence, the risk of colostomy, and pelvic pain.”

With regards to outcomes, Professor Rullier said that in a patient without metastases the survival rate is close to 70%, so the concentration of the surgical team is now focused on the quality of life and the current controversy is whether to continue with the current surgical standard or not.

With regards to new advances, Rullier said that Transanal Endoscopic Microsurgery (TEM) - surgery that removes the tumour but leaves the rectum - in the future will offer solutions for low/mid-rectal cancer and allow organ preservation.
In addition, new pharmalogical treatments can increase the chance of response, which may lead to a new strategy using pre-surgical chemotherapy and radiochemotherapy to increase the chance of complete response and organ preservation.

Organ preservation

“After radiochemotherapy the chances of completely eradicating the tumour are around 15-20% without surgery,” he explained. “As I have said the main controversy is side-effects or complications from surgery. Therefore, we are now assessing the impact of organ preservation, not removing the rectum. “However, we have no long-term data for the option of not removing the rectum, but at the moment there are considerable advantages. The only disadvantage is local recurrence of the cancer, but again, we need more robust long-term results.”

“The concept of organ preservation has been developped in Brazil where no operation at all (‘watch and wait’ what happens to the tumour) has been proposed, and supported recently by the Dutch surgeons. However evidence based is coming from the United States where a phase 2 trial assessing small T2 lesions treated by local excision after radiochemotherapy has been done. Defintive results are still attending.”

“The only multicentre randomised trial is the French GRECCAR II study, comparing local excision with radical surgery in good responders after radiochemotherapy - the preliminary results were presented at last year’s ESCP meeting and the definitive results are eagerly awaited,” he explained.

“Organ preservation is a modern and new approach in management of rectal cancer. It is very exciting because many questions are still open: for which patients, which tumours, what kind of neoadjuvant therapy, how to define and assess the good responder, and how to manage suboptimal response? He concluded: “The only thing we learned from our experience is that the patient is verry happy to save its rectum; so, clearly it is time to think doing less in treatment of rectal cancer.”