Advances in the treatment of rectal cancer

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Published: 20 Oct 2011
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Dr Colette van den Broek - Leiden University Medical Centre, Netherlands

The EURECCA (European Registration of Cancer Care) study, initiated by ECCO, compared the treatment of 6,597 patients in Sweden, Norway, Denmark and The Netherlands who were diagnosed with rectal cancer between 2008 and 2009. The study also compared the numbers of deaths 30 days after surgery and was set up to improve the treatment of rectal cancer across Europe.

Dr Colette van den Broek discusses this study and explains how she hopes the results can be used to identify aspects of cancer care that have played a role in improving clinical practice, treatments, survival levels and the limiting of undesired side effects. This information would help clinicians develop a more consistent level of clinical practice across Europe.

Dr van den Broek explains how much advances such as TME surgery have improved the outlook for rectal cancer patients and talks about research into the effectiveness of neoadjuvant therapies. Neoadjuvant radiotherapy has been shown to decreases post-surgery disease, however results of long term trials have also suggested that there is an associated danger of over-treatment.

European Multidisciplinary Cancer Congress (EMCC) 2011, 23-27 September, Stockholm

Advances in the treatment of rectal cancer

Dr Colette van den Broek – Leiden University Medical Centre, Netherlands

Continuing now at the European Multidisciplinary Cancer Conference here in Stockholm. We’re looking at rectal cancer and there has been a big study, called the EURECCA study, so we’ve found it – eureka! And we’ve actually found one of the co-authors of this study, Colette van den Broek from Leiden. Colette, can you tell me about the EURECCA study? First of all, what were you trying to do?

Well EURECCA is a collaboration of many big European societies like ECCO, ESMO, the European Society of Coloproctology, ESTRO, ESMO. All these work together and they made a collaboration of audits throughout Europe and they joined together being a European audit and that’s what...

Now the aim was to do what?

The aim is to improve the treatment of colorectal cancer patients throughout Europe and get guidelines all throughout Europe.

Now that’s colorectal cancer but this first result is about rectal cancer, isn’t it?

Yes, this first initiative is only about rectal cancer, to show the differences and similarity between the treatment of the patients in four countries at this moment.

What were the difficulties, then, that you were expecting in this investigation? What kind of difficulties in treatment did you think you would unearth?

The biggest difficulty in the beginning would be that we had to work with four different countries who each had their own system, registration system. So every country has its own protocol and its own definitions about how to register certain facts about patients and all those facts…

And the countries were?

The countries are the Netherlands, Norway, Sweden and Denmark at this moment.

So what did you find?

We found a lot of differences in the use of neoadjuvant treatment, there are enormous differences. The groups of patients that were operated depended on the country. We also found that the thirty day mortality of the operated patients differed, mainly Denmark had a higher thirty day mortality when you didn’t adjust the thirty day mortality.

Can we establish some of the treatments that are now accepted for rectal cancer, because your university, Leiden, has been at the forefront of developing the optimal approach to treating rectal cancer. You mentioned neoadjuvant therapy, this has now been spotlighted as hugely important, can you fill me in on what is known about neoadjuvant therapy and what is known about optimal therapy for this disease?

Well, there have been some trials in the past 20-30 years and they have shown that neoadjuvant treatment is better than adjuvant treatment, so after surgery. So that’s why they are providing neoadjuvant treatment at this moment all throughout Europe. And, depending on the stage of the tumour, they get either only radiotherapy or chemoradiation. Then every patient has to get an operation and depending on the location of the tumour is depending on which kind of operation they provide for the patient, they give the patient. Depending on the country where you live, actually, is whether you get adjuvant chemotherapy after the surgery, it’s depending on the country.

Now in your view, though, there is a sort of optimal protocol, looking from Leiden’s perspective.

As we saw after the TME trial, is that neoadjuvant radiotherapy will decrease the recurrence of the disease after surgery so the Netherlands has a high percentage of the use of neoadjuvant radiotherapy. If you look at the TM stage and you look at the percentage of patients receiving neoadjuvant treatment, you will see that in stage 1 up to 70% of the patients receive neoadjuvant radiotherapy. But if you look at recent results of the twelve year follow-up of the TME trial you see that the twelve year follow-up has shown that actually for the patients with stage 1, there are high numbers needed to treat and the actual effect of the neoadjuvant treatment is very low. So the best achievement they achieved in stage 3. So that has been improved a lot in the Netherlands by the TME trial but, in the end, it might have been over-treatment now, it might have been over-treatment.

Now, across the stages of the disease could you give me some idea of just how much treatment for this disease has improved? For instance, in Leiden using your approaches.

I can say about the Netherlands that before, rectal cancer they had an inferior survival compared with colon cancer and at this moment the survival of rectal cancer patients is superior to colon cancer.

So you’ve made a big difference.

There has been made a big difference, mainly by using TME surgery, so standardised surgery.

But reading between the lines of what you’re saying, or perhaps not even between the lines, there was a lot of variation among the different countries. Why might that be?

The use of treatment is varying between the countries. The TME trial has been a national trial in the Netherlands while in Sweden only a part of Sweden has participated and Norway and Denmark didn’t participate in the TME trial. So they have achieved their own guidelines based on their results and results they have in the literature and their own trials. So based on these, you build your own guidelines being a country.

Now presumably EURECCA will help to tie all of these ideas together and help, perhaps, to unify Europe. Could you distil for me the one or two bottom line messages that you feel are coming out of your discoveries and your findings?

One of the main results we’ve found at this moment is the big variation in use of neoadjuvant treatment and the large variation in… the thirty day mortality of Denmark is significantly higher but, although it’s higher, if you correct for age, gender, stage and neoadjuvant treatment there is no difference after adjusting. So we should try to look more in detail in what treatments have been given to the patients depending on the stage and what treatment has been given depending on the country, and more in detail we have to look at that before we can say anything. So in the future we would like to have European guidelines.

And you’ve mentioned that doctors can be very pleased to know that mortality success overall has improved in this disease. What should individual doctors, busy doctors, take home from this session here in Stockholm from the sorts of things you and your centre have been presenting here about EURECCA?

I think that’s dependent on each country. Each country will have its…

But maybe the message is to listen to some of the findings you’ve made?

Yes, maybe, but the findings are dependent on which country you’re from, actually. So they have to provide us with more information and use a similar protocol all over Europe so we could have one big registration throughout Europe using one protocol defining what the definitions are so we could have optimal data and provide the optimal care for patients throughout Europe.

So just in a few words, make your call for what you would like to see happening then, to make this all happen.

Yes, that’s very difficult because at this moment we just would like to gain the trust of all the countries so we could provide and in the end work together. So we will have a consensus meeting in December 2012, hopefully, so we could provide the first step in having guidelines throughout Europe. So hopefully all the doctors will just provide us with optimal information and have good registrations about the patients they treat.

Well, Colette van den Broek, you’ve gone one important step along that path making it all happen. Thank you for joining us on

Thank you.