Editor’s Note
	A call to action

Several years ago we presented a case at the Miami Breast Cancer Conference that stands as a permanent testimonial to second opinions. The patient presented with a four-centimeter primary breast lesion and symptomatic metastatic disease. After chemo-therapy was administered, the breast lesion was reduced to one centimeter and the woman's symptoms abated.

Utilizing electronic keypad polling, we asked an audience of almost 1,000 physicians what they would recommend regarding surgery for the primary breast tumor. About one-fourth of the audience voted to do a mastectomy, one-half selected lumpectomy and the remaining quarter of attendees stated they would not recommend surgery.

The implications of this case are striking. Depending on which physician this patient visited, she might have had any one of three vastly different treatment options: no surgery, lumpectomy or mastectomy. I related this anecdote to Dr Mark Roh, a surgical oncologist interviewed for this issue of Colorectal Cancer Update, because there appears to be a similar disparity in treatment approaches to surgery for cancer of the rectum.

During the interview, Mark presented the case of a 63-year-old woman who sought a second opinion after being told she required an abdominoperineal (AP) resection and colostomy for a recently diagnosed rectal tumor. Dr Roh was not convinced that this was necessary, and he referred the patient to a medical oncologist for preoperative chemotherapy and radiation therapy.

This treatment resulted in an excellent tumor response. Mark was then able to remove the lesion without doing an AP resection. Today, the patient is free of cancer and has relatively normal bowel function. When I asked Mark how this experience affected this woman's perception of the medical community, he said, "It made her a believer in second opinions. She was alarmed that the physicians she had trusted for years would steer her down one road when it clearly was not the only road to travel. She was grateful that someone in her family suggested that she seek out other perspectives on how to treat the problem."

In interfacing with surgical and radiation oncologists for this series, it is apparent that this patient's story is far from unique. In an upcoming interview, Memorial Sloan-Kettering radiation oncologist Dr Bruce Minsky reiterates Dr Roh's concerns that many community-based surgeons overutilize AP resections, which results in thousands of patients receiving unnecessary colostomies every year.

What will it take to see this disturbing pattern change? Twenty years ago vocal breast cancer survivors, like Rose Kushner, stridently challenged the surgical community to present lumpectomy as an option. In prostate cancer, the open stories of champions like General Norman Schwarzkopf and Andrew Grove have led to more discussion about nonsurgical treatment options. Will the same type of approach be required for cancer of the rectum? Will the social taboo of this disease prevent this from happening?

This is an appeal to all physicians who listen to or read this program. Is there someone in your practice who might be interested in "stepping up to the plate" and helping future patients?

Please let me know.

-Neil Love, MD
NLove@ResearchToPractice.net

Select publications

Bretagnol F et al. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Dis 2003;5(5):451-3. Abstract

Crane CH et al. The addition of continuous infusion 5-FU to preoperative radiation therapy increases tumor response, leading to increased sphincter preservation in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2003;57(1):84-9. Abstract

Crane CH, Skibber J. Preoperative chemoradiation for locally advanced rectal cancer: Rationale, technique, and results of treatment. Semin Surg Oncol 2003;21(4):265-70. Abstract

Guerrieri M et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years' experience. Dig Liver Dis 2003;35(12):876-80. Abstract

McNamara DA, Parc R. Methods and results of sphincter-preserving surgery for rectal cancer. Cancer Control 2003;10(3):212-8. Abstract

Shirouzu K et al. A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer. Tech Coloproctol 2003;7(3):203-6. Abstract

Tiret E et al. Ultralow anterior resection with intersphincteric dissection - what is the limit of safe sphincter preservation? Colorectal Dis 2003;5(5):454-7. Abstract

Tytherleigh MG, McC Mortensen NJ. Options for sphincter preservation in surgery for low rectal cancer. Br J Surg 2003;90(8):922-33. Abstract

Ueno H et al. Preoperative parameters expanding the indication of sphincter preserving surgery in patients with advanced low rectal cancer. Ann Surg 2004;239(1):34-42. Abstract