- Email: [email protected]
Overview: epidemiology, indications, goals, extent, and nature of work-up
Overview: Epidemiology, Indications, Goals, Extent, and Nature of Work-up David A. Rothenberger, M.D.
Each year in the United States, it is estimated that there will be 42,000 new cases of rectal cancer and 8,500 deaths.1,2 Some patients present with an incurable rectal cancer but more often death follows development of recurrent rectal cancer after failed curative-intent therapy. Knowledge of the natural history of rectal cancer and limitations of treatment options coupled with sound clinical judgment and compassion are essential prerequisites for the clinician providing palliative care. ( J GASTROINTEST SURG 2004;8:259–261) 쑖 2004 The Society for Surgery of the Alimentary Tract KEY WORDS: Rectal cancer, palliation, recurrent rectal cancer, incurable rectal cancer
EPIDEMIOLOGY In most series of rectal cancers, curative-intent resections are performed in 70%–90% of cases, sometimes after neoadjuvant chemoradiation. The remaining 10%–30% of patients are treated for palliation. It is logical to assume that the percentage of patients requiring palliative care is higher among those presenting with late-stage disease, but the epidemiology of late-stage rectal cancer is not well characterized. Morris and Baxter3 used the Surveillance Epidemiology and End Results (SEER) database that represents 14% of the new cases in the United States to assess new colorectal cancer patients between 1988 and 1999. Among patients of known stage in the SEER database, 31,341 patients (17%) had stage IV disease at presentation (colon cancer ⫽ 23,865; rectal cancer ⫽ 7,476). One third of the 31,341 patients with stage IV colorectal cancer did not undergo resection and were presumably treated for palliation. The SEER database does not record the intent of therapy for the two-thirds of patients with stage IV colorectal cancer treated by resection but it is reasonable to assume that at least some of these resections were palliative. In addition to palliation in the setting of a primary rectal cancer, approximately 40% of patients who previously underwent curative-intent therapy of rectal cancer will develop recurrence. Of those with recurrence, the vast majority cannot be retreated
with curative intent. Thus, palliative care for rectal cancer patients remains a major health issue.
INDICATIONS Palliative therapy is indicated for all patients with incurable rectal cancer and may be operative or nonoperative. Palliative-intent operations leave local or metastatic residual cancer, varying from a small microscopic focus causing no symptoms to an extensive tumor producing major symptoms. Operative palliative therapy is indicated if a patient is judged able to tolerate a surgical procedure that has a high likelihood of relieving significant symptoms and/or maintaining normal functions to maximize the quality of remaining life. For some, extirpative radical surgery is the most likely way to provide relief of symptoms without undue morbidity. For others, operative palliation is achieved by symptom-relieving but less radical surgery. Nonoperative palliative therapy may include chemotherapy, radiation therapy, pain control measures, and other comfort care. Nonoperative palliative therapy is generally indicated for locoregional disease if work-up shows that the pelvic cancer has caused sciatic nerve pain, bilateral ureteral obstruction, extensive pelvic side wall involvement (especially if in the upper 2/3 of the pelvis), neural or bony involvement
From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota. Reprint requests: David A. Rothenberger, M.D., Department of Surgery, University of Minnesota Medical School, 420 Delaware St. SE, Mayo MC 806, Minneapolis, MN 55455. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2003.11.020
259
260
Rothenberger
at or higher than S1–S2, bilateral lymphedema, or deep venous thrombosis. Nonoperative palliative therapy is also indicated for patients who present with multiple peritoneal metastases, metastases fixed, or invading vital structures not amenable to safe resection or multiple metastases to the liver, lungs, or other organs. Such patients have a dismal prognosis and comfort measures are generally the only therapy of value. Whereas incurability is most often a function of the patient’s cancer status, general health and treatment preferences are also important factors. Curative therapy may have to be compromised because of the patient’s debility and/or comorbidities and a palliative approach taken instead. Similarly, palliative treatment may be necessary to accommodate a patient’s refusal to accept the morbidity of a proposed curative therapy. In many cases, the need for a palliative approach is obvious after pretreatment evaluation. Counseling and treatment can be tailored accordingly but in a surprising number of cases, despite intensive investigations and modern imaging, the surgeon finds that the extent of disease was understaged and the need for palliative therapy is not apparent until laparotomy. The decision-making in these two scenarios is quite different. In the former, the morbidity of a laparotomy can be avoided whereas in the latter, the patient has already been subjected to the morbidity of a major operation before it is recognized that cure is impossible.
GOALS The two primary goals of palliative therapy for rectal cancer are (1) to maximize the quality of remaining life by controlling symptoms and preserving normal bodily functions and (2) to help the patient, their family, and friends develop realistic expectations about their impending death from the incurable cancer. Most patients with incurable rectal cancer fear development of severe pain. They can be reassured that pain control is achieved in almost all cases with modern pain management. Other symptoms such as obstruction, tenesmus, urgency, incontinence, and bleeding can usually be controlled as described below. Preservation of anorectal and genitourinary functions is desirable but often a colostomy and/or urostomy with or without concomitant tumor resection can eliminate miserable symptoms and improve the quality of remaining life. Creating realistic expectations about the natural history of incurable rectal cancer and its treatment is a complex undertaking made more difficult by the
Journal of Gastrointestinal Surgery
fact that cancer patients tend to overestimate the probability of long-term survival.4–6 There is no convincing evidence that palliative resection improves survival. Weeks et al.7 performed a prospective cohort study of 917 patients hospitalized because of advanced stage lung or colorectal cancer. They found that physicians estimated the prognosis accurately but their patients overestimated their survival probabilities and that these estimates influenced their preferences about treatment. Patients who thought they were going to live for at least 6 months were more likely to favor life-extending therapy over comfort care compared with patients who thought there was at least a 10% chance they would not live 6 months. Patients who preferred life-extending therapy were more likely to undergo aggressive treatment but after controlling for known prognostic factors, their 6-month survival was no better. For some patients with a small focus of microscopic residual cancer, survival of high quality can be anticipated for a reasonable period of time. Realistic counseling regarding the pros and cons of palliative therapy options in this setting is difficult. Unfortunately, there is little hard data on which to base a recommendation. Steele’s review from the National Cancer Database on colorectal cancer noted that 42% of patients with metastatic colorectal cancer received chemotherapy but 58% did not.8 The decisionmaking process is unclear. For other patients, a large burden of residual cancer makes death imminent. A multidisciplinary team including the treating physicians, pain control experts, nurses, clergy, and spiritual counselors can help create realistic expectations essential to shared decision-making as death approaches. The team needs to be aware of cultural sensitivities and psychological states that may make acceptance of some palliative measures such as construction of a colostomy unacceptable. It is essential that all personnel involved in palliative care communicate a clear message to the patient, the family, and others caring for the patient without prematurely removing hope of meaningful survival. This is time consuming and emotionally draining but an ethical imperative for our profession. The surgeon has the responsibility of making certain that the physical and psychological burdens of palliative measures are commensurate with the hopedfor improved quality of life achieved by such treatments. Palliative operations for colorectal cancer have been associated with a mortality as high as 10% so it behooves the clinician to fully evaluate the patient, accurately stage the extent of disease, and provide the patient with a realistic prognosis and alternative treatment options.9 Every test or treatment should be intended to improve the patient’s comfort.
Vol. 8, No. 3 2004
WORK-UP Clinical evaluation and diagnostic testing should provide information needed to answer four fundamental questions: (1) Is palliative therapy necessary?, (2) What is the patient’s prognosis and what component of their disease is most likely to cause significant symptoms in the near-term?, (3) Do prior treatments, underlying comorbidities, or patient choices limit palliative options?, and (4) Of the palliative options available, which will be most likely to provide meaningful palliation with the least morbidity? The distinction between curative and palliative therapy is blurring because of the ability of some centers to safely conduct major resections such as pelvic exenterations and the ability to treat and control more than one sight of distant metastasis. Clinical judgment is needed to realistically estimate the patient’s prognosis. In general, the more radical the contemplated treatment, the more extensive the work-up must be to assure that the treatment’s morbidity is justified by the expected outcome. Conversely, when clinical findings such as significant malnutrition, ascites, extensive lymphadenopathy, and palpable metastases make it obvious that the prognosis is guarded, work-up is minimized. In between these two extremes are many patients who benefit from a limited work-up focused on (1) confirming the clinical impression that curative-intent therapy is not possible, (2) understanding the etiology of the patient’s symptoms, and (3) obtaining additional information to appropriately tailor a palliative treatment plan. Symptoms and physical findings should direct the work-up. For example, if obstructive symptoms dominate the clinical presentation, endoscopy and contrast gastrointestinal studies are indicated to define the areas of intrinsic or extrinsic obstruction. If digital rectal and pelvic examinations identify a fixed rectal primary cancer or a recurrence invading pelvic sidewalls or other adjacent viscera in a patient who is a candidate for radical surgery, a computed tomograph
Palliative Therapy of Rectal Cancer
261
of the pelvis ⫾ endorectal ultrasonography (ERUS) are done to determine resectability. If these studies are equivocal or do not confirm the clinical impression, additional studies, such as a pelvic MRI, may better define the pelvic mass. If pelvic imaging studies suggest there is a realistic consideration of performing radical surgery, CT of the abdomen and chest and positron emission tomographic scanning are done to exclude distant metastases. Their presence generally precludes undertaking a potentially morbid radical resection. A negative work-up for distant metastases may lead to a laparotomy to determine whether palliative resection would benefit the patient. In some instances, diagnostic laparoscopy is useful to identify widespread disease not amenable to palliative resection. REFERENCES 1. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun M. Cancer statistics, 2003. CA Cancer J Clin 2003;53:5–26. 2. Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23–47. 3. Morris A, Baxter N. University of Minnesota Department of Surgery and Cancer Center. Personal communication, January 2003 (unpublished). 4. Siminoff LA, Fetting JH, Abeloff MD. Doctor–patient communication about breast cancer adjuvant therapy. J Clin Oncol 1989;7:1192–1200. 5. Bernheim JL, Ledure G, Souris M, Razav D. Differences in perception of disease and treatment between cancer patients and their physicians. Monogr Ser Eur Organ Res Treatment Cancer 1987;17:285–295. 6. Eidinger RN, Schapira DV. Cancer patients’ insight into their treatment, prognosis, and unconventional therapies. Cancer 1984;53:2736–2740. 7. Weeks JC, Cook FE, O’Day SJ, Peterson LM, Wenger N, Reding D, Harrell FE, Kussin P, Dawson NV, Connors AF, Lynn J, Phillips RS. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA 1998;279:1709–1714. 8. Steele GD. The National Cancer Data Base report on colorectal cancer. Cancer 1994;74:1979–1989. 9. Joffe J, Gordon PH. Palliative resection for colorectal carcinoma. Dis Colon Rectum 1981;24:355–360.
Each year in the United States, it is estimated that there will be 42,000 new cases of rectal cancer and 8,500 deaths.1,2 Some patients present with an incurable rectal cancer but more often death follows development of recurrent rectal cancer after failed curative-intent therapy. Knowledge of the natural history of rectal cancer and limitations of treatment options coupled with sound clinical judgment and compassion are essential prerequisites for the clinician providing palliative care. ( J GASTROINTEST SURG 2004;8:259–261) 쑖 2004 The Society for Surgery of the Alimentary Tract KEY WORDS: Rectal cancer, palliation, recurrent rectal cancer, incurable rectal cancer
EPIDEMIOLOGY In most series of rectal cancers, curative-intent resections are performed in 70%–90% of cases, sometimes after neoadjuvant chemoradiation. The remaining 10%–30% of patients are treated for palliation. It is logical to assume that the percentage of patients requiring palliative care is higher among those presenting with late-stage disease, but the epidemiology of late-stage rectal cancer is not well characterized. Morris and Baxter3 used the Surveillance Epidemiology and End Results (SEER) database that represents 14% of the new cases in the United States to assess new colorectal cancer patients between 1988 and 1999. Among patients of known stage in the SEER database, 31,341 patients (17%) had stage IV disease at presentation (colon cancer ⫽ 23,865; rectal cancer ⫽ 7,476). One third of the 31,341 patients with stage IV colorectal cancer did not undergo resection and were presumably treated for palliation. The SEER database does not record the intent of therapy for the two-thirds of patients with stage IV colorectal cancer treated by resection but it is reasonable to assume that at least some of these resections were palliative. In addition to palliation in the setting of a primary rectal cancer, approximately 40% of patients who previously underwent curative-intent therapy of rectal cancer will develop recurrence. Of those with recurrence, the vast majority cannot be retreated
with curative intent. Thus, palliative care for rectal cancer patients remains a major health issue.
INDICATIONS Palliative therapy is indicated for all patients with incurable rectal cancer and may be operative or nonoperative. Palliative-intent operations leave local or metastatic residual cancer, varying from a small microscopic focus causing no symptoms to an extensive tumor producing major symptoms. Operative palliative therapy is indicated if a patient is judged able to tolerate a surgical procedure that has a high likelihood of relieving significant symptoms and/or maintaining normal functions to maximize the quality of remaining life. For some, extirpative radical surgery is the most likely way to provide relief of symptoms without undue morbidity. For others, operative palliation is achieved by symptom-relieving but less radical surgery. Nonoperative palliative therapy may include chemotherapy, radiation therapy, pain control measures, and other comfort care. Nonoperative palliative therapy is generally indicated for locoregional disease if work-up shows that the pelvic cancer has caused sciatic nerve pain, bilateral ureteral obstruction, extensive pelvic side wall involvement (especially if in the upper 2/3 of the pelvis), neural or bony involvement
From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota. Reprint requests: David A. Rothenberger, M.D., Department of Surgery, University of Minnesota Medical School, 420 Delaware St. SE, Mayo MC 806, Minneapolis, MN 55455. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2003.11.020
259
260
Rothenberger
at or higher than S1–S2, bilateral lymphedema, or deep venous thrombosis. Nonoperative palliative therapy is also indicated for patients who present with multiple peritoneal metastases, metastases fixed, or invading vital structures not amenable to safe resection or multiple metastases to the liver, lungs, or other organs. Such patients have a dismal prognosis and comfort measures are generally the only therapy of value. Whereas incurability is most often a function of the patient’s cancer status, general health and treatment preferences are also important factors. Curative therapy may have to be compromised because of the patient’s debility and/or comorbidities and a palliative approach taken instead. Similarly, palliative treatment may be necessary to accommodate a patient’s refusal to accept the morbidity of a proposed curative therapy. In many cases, the need for a palliative approach is obvious after pretreatment evaluation. Counseling and treatment can be tailored accordingly but in a surprising number of cases, despite intensive investigations and modern imaging, the surgeon finds that the extent of disease was understaged and the need for palliative therapy is not apparent until laparotomy. The decision-making in these two scenarios is quite different. In the former, the morbidity of a laparotomy can be avoided whereas in the latter, the patient has already been subjected to the morbidity of a major operation before it is recognized that cure is impossible.
GOALS The two primary goals of palliative therapy for rectal cancer are (1) to maximize the quality of remaining life by controlling symptoms and preserving normal bodily functions and (2) to help the patient, their family, and friends develop realistic expectations about their impending death from the incurable cancer. Most patients with incurable rectal cancer fear development of severe pain. They can be reassured that pain control is achieved in almost all cases with modern pain management. Other symptoms such as obstruction, tenesmus, urgency, incontinence, and bleeding can usually be controlled as described below. Preservation of anorectal and genitourinary functions is desirable but often a colostomy and/or urostomy with or without concomitant tumor resection can eliminate miserable symptoms and improve the quality of remaining life. Creating realistic expectations about the natural history of incurable rectal cancer and its treatment is a complex undertaking made more difficult by the
Journal of Gastrointestinal Surgery
fact that cancer patients tend to overestimate the probability of long-term survival.4–6 There is no convincing evidence that palliative resection improves survival. Weeks et al.7 performed a prospective cohort study of 917 patients hospitalized because of advanced stage lung or colorectal cancer. They found that physicians estimated the prognosis accurately but their patients overestimated their survival probabilities and that these estimates influenced their preferences about treatment. Patients who thought they were going to live for at least 6 months were more likely to favor life-extending therapy over comfort care compared with patients who thought there was at least a 10% chance they would not live 6 months. Patients who preferred life-extending therapy were more likely to undergo aggressive treatment but after controlling for known prognostic factors, their 6-month survival was no better. For some patients with a small focus of microscopic residual cancer, survival of high quality can be anticipated for a reasonable period of time. Realistic counseling regarding the pros and cons of palliative therapy options in this setting is difficult. Unfortunately, there is little hard data on which to base a recommendation. Steele’s review from the National Cancer Database on colorectal cancer noted that 42% of patients with metastatic colorectal cancer received chemotherapy but 58% did not.8 The decisionmaking process is unclear. For other patients, a large burden of residual cancer makes death imminent. A multidisciplinary team including the treating physicians, pain control experts, nurses, clergy, and spiritual counselors can help create realistic expectations essential to shared decision-making as death approaches. The team needs to be aware of cultural sensitivities and psychological states that may make acceptance of some palliative measures such as construction of a colostomy unacceptable. It is essential that all personnel involved in palliative care communicate a clear message to the patient, the family, and others caring for the patient without prematurely removing hope of meaningful survival. This is time consuming and emotionally draining but an ethical imperative for our profession. The surgeon has the responsibility of making certain that the physical and psychological burdens of palliative measures are commensurate with the hopedfor improved quality of life achieved by such treatments. Palliative operations for colorectal cancer have been associated with a mortality as high as 10% so it behooves the clinician to fully evaluate the patient, accurately stage the extent of disease, and provide the patient with a realistic prognosis and alternative treatment options.9 Every test or treatment should be intended to improve the patient’s comfort.
Vol. 8, No. 3 2004
WORK-UP Clinical evaluation and diagnostic testing should provide information needed to answer four fundamental questions: (1) Is palliative therapy necessary?, (2) What is the patient’s prognosis and what component of their disease is most likely to cause significant symptoms in the near-term?, (3) Do prior treatments, underlying comorbidities, or patient choices limit palliative options?, and (4) Of the palliative options available, which will be most likely to provide meaningful palliation with the least morbidity? The distinction between curative and palliative therapy is blurring because of the ability of some centers to safely conduct major resections such as pelvic exenterations and the ability to treat and control more than one sight of distant metastasis. Clinical judgment is needed to realistically estimate the patient’s prognosis. In general, the more radical the contemplated treatment, the more extensive the work-up must be to assure that the treatment’s morbidity is justified by the expected outcome. Conversely, when clinical findings such as significant malnutrition, ascites, extensive lymphadenopathy, and palpable metastases make it obvious that the prognosis is guarded, work-up is minimized. In between these two extremes are many patients who benefit from a limited work-up focused on (1) confirming the clinical impression that curative-intent therapy is not possible, (2) understanding the etiology of the patient’s symptoms, and (3) obtaining additional information to appropriately tailor a palliative treatment plan. Symptoms and physical findings should direct the work-up. For example, if obstructive symptoms dominate the clinical presentation, endoscopy and contrast gastrointestinal studies are indicated to define the areas of intrinsic or extrinsic obstruction. If digital rectal and pelvic examinations identify a fixed rectal primary cancer or a recurrence invading pelvic sidewalls or other adjacent viscera in a patient who is a candidate for radical surgery, a computed tomograph
Palliative Therapy of Rectal Cancer
261
of the pelvis ⫾ endorectal ultrasonography (ERUS) are done to determine resectability. If these studies are equivocal or do not confirm the clinical impression, additional studies, such as a pelvic MRI, may better define the pelvic mass. If pelvic imaging studies suggest there is a realistic consideration of performing radical surgery, CT of the abdomen and chest and positron emission tomographic scanning are done to exclude distant metastases. Their presence generally precludes undertaking a potentially morbid radical resection. A negative work-up for distant metastases may lead to a laparotomy to determine whether palliative resection would benefit the patient. In some instances, diagnostic laparoscopy is useful to identify widespread disease not amenable to palliative resection. REFERENCES 1. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun M. Cancer statistics, 2003. CA Cancer J Clin 2003;53:5–26. 2. Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23–47. 3. Morris A, Baxter N. University of Minnesota Department of Surgery and Cancer Center. Personal communication, January 2003 (unpublished). 4. Siminoff LA, Fetting JH, Abeloff MD. Doctor–patient communication about breast cancer adjuvant therapy. J Clin Oncol 1989;7:1192–1200. 5. Bernheim JL, Ledure G, Souris M, Razav D. Differences in perception of disease and treatment between cancer patients and their physicians. Monogr Ser Eur Organ Res Treatment Cancer 1987;17:285–295. 6. Eidinger RN, Schapira DV. Cancer patients’ insight into their treatment, prognosis, and unconventional therapies. Cancer 1984;53:2736–2740. 7. Weeks JC, Cook FE, O’Day SJ, Peterson LM, Wenger N, Reding D, Harrell FE, Kussin P, Dawson NV, Connors AF, Lynn J, Phillips RS. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA 1998;279:1709–1714. 8. Steele GD. The National Cancer Data Base report on colorectal cancer. Cancer 1994;74:1979–1989. 9. Joffe J, Gordon PH. Palliative resection for colorectal carcinoma. Dis Colon Rectum 1981;24:355–360.