Rectal cancer is becoming more prevalent,” says Jonathan Efron. “And because the care for rectal cancer varies so much across the country, there’s a nationwide push to establish centers of excellence for rectal cancer.”
In 2011, Efron, who heads Johns Hopkins’ Division of Colorectal Surgery, joined with other specialists from societies for surgery, radiology, pathology and oncology in an effort to establish standards for care and optimize treatment outcomes. Called the OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Consortium, the group aims to provide access to high-quality rectal cancer care for everyone in the U.S., not just those living in proximity to existing expert centers.
Over the years, OSTRiCh has devised five core principles (see sidebar) that it recommends for centers of excellence for rectal cancer. In 2015, these principles were presented to the American College of Surgeons, which will ultimately decide where to establish the first pilot programs.
Efron says The Johns Hopkins Hospital is already using the principles. For example, a multidisciplinary team coordinates patients’ care from diagnosis to recovery. Colorectal surgeons, radiation oncologists, medical oncologists, pathologists and other surgeons all take part in patients’ care as needed.
In addition, the radiologists on the team obtain a standard preoperative diagnosis and workup using an MRI scan, which delivers high contrast of the soft tissues in the rectum and is highly accurate at staging rectal tumors and spread. MRI also has a higher sensitivity than CT imaging to detect local recurrence. “For a better understanding of the size and depth of the tumor, we also use transrectal ultrasound before surgery,” says Efron.
Depending on the radiotherapy and chemotherapy regimen prescribed, Johns Hopkins Hospital patients can participate in a nationwide trial. One is looking at the results of systemic treatment prior to surgery. “The goal is to see if delivering systemic treatment before operating allows for better overall survival than waiting five or seven months after surgery,” says Efron.
Another clinical trial is a prospective study evaluating endorectal brachytherapy for early-stage rectal cancer, in which radiation therapy is given directly to the tumor and surrounding area for just five days.
During surgery, Efron uses a total mesorectal excision to remove rectal cancer without any violations of the tumor. When the pathologists examine the specimen, they employ standard pathology assessment techniques for reporting, including the intactness of the mesorectum, the distal margin, the circumferential margin, lymph nodes and genetics.
“These practices enhance the overall experience of patients,” says Efron. “We also think they will lead to better outcomes.”
Video from Jonathan Efron
See a Q-and-A about rectal cancer with Johns Hopkins colorectal surgeon Jonathan Efron here.
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5 CORE PRINCIPLES OF EVIDENCE-BASED RECTAL CANCER CARE*
1.Total mesorectal excision
2.Measurement of surgery quality by specific techniques of pathology assessment
3.Use of specialist imaging techniques to identify patients at high risk of local recurrence
4.Use of newer, more effective neoadjuvant and adjuvant therapies, including radiotherapy and chemotherapy
5.A multidisciplinary approach that identifies, coordinates, delivers and monitors the ideal treatment on a patient-by-patient basis
*From the OSTRiCh Consortium