How can surgeons improve surgical management in colorectal cancer?
Prof Riccardo Audisio - University of Liverpool, Liverpool, UK
Surgeons have the curative modality in cancer, that’s a truism almost. In the context of colorectalcancer how can surgeons improve their game right at the moment?
I wish it was true that surgeons had the cure for everyone, unfortunately this is not the case but it is definitely true that the largest majority of colorectal cancer patients who are cured from their nasty disease are cured by surgeons. So surgeons are really offering the curative treatment.
But what can surgeons do to improve cure rates right now?
Surgeons should improve or enhance awareness. Symptoms are aspecific, they come with signs that have been reported for many years by these patients and because of associated conditions but it’s only the early detection that would allow better surgical care.
So there’s a stress here between going for screening and going for just symptomatic detection. What have you discovered about this?
We have discovered that screening can be helpful. We are fully aware that the largest part of colorectal cancer patients are elderly, are beyond age 65-70, and we also are very well aware that the emergency setting is the most dreadful situation for colorectal cancer patients. The mortality in the elderly group is very high, almost 50%, so this is something that we should try to avoid at all times. There is a trick here, there is the possibility of bridging the gap to surgery with stents that control obstruction.
What’s your feeling about the screening methods available because there’s some controversy, colonoscopy is universally known to be very good but what about the other modalities?
I don’t think that we have the complete answer, particularly we do not have the answer for the elderly population. But awareness is definitely the most important step we should encourage these days.
So how does the surgeon get involved with all of this? He or she might not be involved very early.
Yes, you’re right, surgeons unfortunately are most often left out of the discussion, the discussion being led by other physicians. So I generally believe that when we’re discussing screening surgeon presence and surgical leadership should be really taken into consideration.
And, of course, the multidisciplinary team, presumably you would hold, should include a surgeon very early on or from the very start?
Yes, yes indeed. This is definitely the case.
What about the issue of very late presentation of colorectal cancer?
Late presentation meaning the locally advanced disease presented with obstruction therefore no possibility to optimise the perioperative fitness of the patient. The best setting is when you have the time to offer prehabilitation to these vulnerable and frail patients, it’s the situation where you can correct anaemia, the hydroelectrolytic balance, malnourishment and active physio, depression, demotivation, you have one, two, three months during the neoadjuvant treatment planning that you can successfully use to the purpose and bring these patients to the optimal condition to succeed the surgical procedure.
So, to summarise, what do you hold to be the key points of action that surgeons involved with colorectal cancer should bear in mind and put into action?
Enhancing awareness amongst the general population and being able to assess for frailty. So understand how frail is the individual in order to discuss the risk, the advantages, the short-term and long-term outcomes, and willingness to offer the best treatment for every single individual older patient.
And that’s specifically for older patients, how big an improvement can doctors or surgeons get from this more refined approach.
I think that a more holistic approach towards elderly patients with colorectal cancer could well improve over 10-15% survival for this specific population.