UF Physicians Report New Treatment Helps Some Cancer Patients Avoid Major Surgery

May 30, 2002

GAINESVILLE, Fla. — A high-fat, low-fiber diet is a nutritionist’s nightmare for good reason: It predisposes people to a host of troublesome medical problems, rectal cancer among them. Each year, thousands develop the cancer and face major abdominal surgery to remove diseased tissues, an operation that often leads to sizeable complications, a long, painful recovery and a life-altering permanent colostomy.

Now select patients with an advanced form of rectal cancer could avoid all that, University of Florida physicians report in this month’s issue of the Journal of the American College of Surgeons. A treatment that uses chemotherapy and radiation to shrink tumors followed by a much more minor operation is the key.

Only patients whose tumors respond to chemotherapy and radiation by virtually disappearing are candidates-about 10 percent of the 37,000 Americans who will develop rectal cancer this year. But for this small group, the new treatment approach could make a substantial difference in the quality of their lives.

“Since the ’70s, UF has been a pioneer in giving both radiation and chemotherapy prior to surgery,” said Dr. Scott Schell, an assistant professor of surgery and of molecular genetics and microbiology at UF’s College of Medicine and the UF Shands Cancer Center. “Our studies have shown quite plainly that by giving the treatment before surgery, you can decrease the chance the tumor will come back, improve the patient’s likelihood of surviving their cancer and decrease the likelihood the patient needs to have an operation that will leave them with a permanent colostomy, which is the standard treatment for this kind of cancer.”

Postoperative discomfort also is significantly less and the hospital stay drops from nearly a week to a day, Schell said. Furthermore, the approach was safe and patients were just as likely to be alive four years after surgery as their counterparts who underwent the traditional surgery, he said.

UF physicians treated 74 patients who had advanced rectal cancer with chemotherapy and radiation. Of those, 11 had tumors that virtually disappeared. In each of these patients, surgeons operated through the rectum to remove the scar where the tumor had been, a procedure that took less than two hours and is akin to hemorrhoid surgery. In contrast, standard surgery lasts up to five hours and requires a large abdominal incision through which the rectum and portions of the large bowel are removed. A colostomy, which involves bringing part of the large intestine through an incision in the abdominal wall, is necessary to allow waste to empty into a lightweight bag attached to the skin.

“If during the surgery when we had the pathologist examine that scarred area under the microscope there was no sign of any remaining tumor, that was all the surgical treatment that the patients would require,” Schell said.

“The question is whether this approach is as safe and effective,” he added. “The answer is, in patients we performed this procedure on, there were no deaths from surgery, compared to up to a 4 percent or higher mortality rate for patients who undergo removal of the rectum and receive a permanent colostomy. And none experienced recurrence of their cancer in the pelvis or the rectum. That’s the same as or better than the best standard therapy.”

During the follow-up period, one patient’s cancer was found to have spread to the lungs. That patient is still alive and is undergoing treatment, Schell said.

In the same issue of the journal, Dr. Eugene F. Foley, an associate professor of surgery at the University of Virginia School of Medicine, wrote that he was cautiously optimistic about the approach, which is supported by a growing body of published data. Yet he noted the UF study was limited to a very small, unique group of patients who represented only 14 percent of all patients initially treated.

“The vast majority of patients with locally advanced rectal cancer do not have enough tumor response to chemoradiation therapy to proceed with local excision,” Foley wrote. “If this approach is ultimately to work, it probably will do so on the basis of preoperative chemoradiation therapy’s ability to [treat] unusual, very favorable tumor [types] that don’t require radical surgery. Second, we must be extremely careful in abandoning our traditional, proved treatment for locally advanced rectal cancer on the basis of a single institutional experience with 11 patients. Although the follow-up means are seemingly acceptable, six of 11 patients are four or less years out from treatment. We obviously need more patients with longer follow-up before we accept this approach as standard of care.”

UF physicians agree the number of patients was small but say the results are encouraging and build on mounting evidence that supports using chemotherapy and radiation to treat rectal cancer patients before surgery-instead of afterward. When administered later, the treatments don’t always work as well because surgery can alter the blood supply to the tumor and cause scarring that interferes with the therapies’ effectiveness, said Schell, whose UF collaborators are Dr. Robert A. Zlotecki, Dr. William M. Mendenhall, Dr. Robert W. Marsh, Dr. J. Nicholas Vauthey, and Dr. Edward M. Copeland III.

Those who are candidates for the new approach are examined regularly in the months and years after surgery. If the cancer returns, the option to undergo the standard operation is still available, Schell said.

“Particularly for younger patients, a permanent colostomy has strong social and psychological implications,” Schell said. “There are body image issues, and a colostomy can interfere with certain activities, such as swimming. Although rectal cancer really starts to peak during the fifth and sixth decades of life, certainly in our practice and even in this series we’ve seen patients develop it in their late 30s and 40s. If cured, they can potentially live another 30 to 40 years without having to cope with a colostomy.”