Select Excerpts from the Interview

Track 1

DR LOVE: Can you describe your initial evaluation of patients with rectal cancer?

DR WEXNER: First, I review the colonoscopy report from the gastroenterologist or the referring colorectal surgeon to ensure the patient has no synchronous lesions.

The next questions to ask are as follows: How close is the tumor to the sphincter? Will we be able to perform sphincter-saving surgery? What stage is the lesion?

The most important exam to start answering these questions is the “good old-fashioned” rectal exam. Anterior versus posterior positioning of the tumor can make a big difference in males because of the difficulty of getting under the prostate for distal dissection and in females because of the possibility of needing a posterior vaginectomy.

With posterior tumors, you have the luxury of a little more space to work with near the rectum. However, an advanced tumor could involve a posterior exenteration. So the first step is to observe the position of the tumor.

Another step in evaluating the patient is visualization of the lesion using either rigid proctosigmoidoscopy or, far more commonly, flexible sigmoidoscopy. For the most distal lesions, flexible sigmoidoscopy won’t allow for an adequate visual analysis.

For a surgeon, it’s better to evaluate the lesion by feel. For the higher lesions — midrectum and upper rectum — visualization with flexible sigmoidoscopy is possible.

Once the initial questions are answered, the next step in the algorithm is the ultrasound exam, which is performed immediately. Within an hour or two, the results are returned, and I know the tumor stage.

If the cancer is T3 and/or N1, the patient will be referred for chemotherapy and radiation therapy. If the tumor is T1 or T2, I have a different discussion with the patient.

Track 2

DR LOVE: How does neoadjuvant chemoradiation therapy impact the tumor and your ability to perform surgery?

DR WEXNER: The efficacy and safety of the chemotherapeutic agents and the method and modality of radiation therapy delivery have vastly improved over the last two decades.

We used to fear preoperative chemoradiation therapy because of the possibility of extreme skin damage, terrible radiation proctitis or making the tissue planes difficult to handle and increasing the morbidity of perineal wound healing.

Now we’ve gone from that extreme to the other extreme. In most cases I can only tell a patient underwent preoperative chemoradiation therapy by examining the site of the tumor, which is left with only a scar in one third of my patients.

Neoadjuvant chemoradiation therapy has dramatically improved, and it has made surgery easier to perform because large bulky tumors that seemingly used to become more fixed and more fibrotic with the treatment are now disappearing.

The tissue planes become a little edematous, but neoadjuvant treatment is facilitating dissection in most cases.

Track 3

DR LOVE: The standard for neoadjuvant therapy has been to administer continuous infusion 5-FU with radiation therapy. What have you observed in patients treated with capecitabine?

DR WEXNER: Clearly, not having a pump is advantageous from a quality-of-life standpoint (2.1), and the safety profile speaks for itself. The anecdotal reports are that patients are continuing to work and are not interrupting their schedules.

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Editor:
Neil Love, MD

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Alan P Venook, MD
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Steven D Wexner, MD
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Christopher Willett, MD
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J Randolph Hecht, MD
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