Shorter regimen improves outcomes
Washington University physicians treating rectal cancer have adopted a new treatment regimen that they have shown reduces or eradicates tumors at a significantly higher rate than conventional therapy.
“The prognosis for rectal cancer tends to be worse than for some other cancers we treat because of the anatomic location of the rectum within the pelvis,” says Matthew Mutch, MD, section chief and the Solon and Bettie Gershman Chair for Colon and Rectal Surgery. “The risk of local recurrence is 4 to 10 percent, and distant recurrence occurs in 25 to 40 percent of cases.”
To improve outcomes, Mutch has teamed up with fellow colorectal surgeons, as well as radiation oncologists and medical oncologists, to develop a regimen that is nine weeks shorter than the traditional approach and gets chemotherapy into the patient much sooner.
Traditionally, the order of treatment has been radiation (five weeks), surgery and then chemotherapy — a 46-week process, with chemotherapy beginning roughly at week 23. The new protocol changes the order, starting with short-course radiation (five days), followed by chemotherapy (16 weeks) and then surgery. The regimen takes 37 weeks, with chemotherapy starting at week four.
The multidisciplinary team reported positive results in the International Journal of Radiation Oncology, Biology and Physics: After radiation and chemotherapy, severity of cancer decreased in 71 percent of patients, and 25 percent showed a complete absence of tumor — results significantly better than those seen with the traditional protocol. “We hope to see a reduction in the rate of distant recurrence as well,” says Mutch.
Colorectal surgeons also are standardizing preoperative imaging, cancer staging procedures and multidisciplinary conference planning for rectal cancer patients. Resident William Chapman Jr., MD, will study clinical outcomes, costs and patient-reported outcomes.
Mutch says rectal cancer patients are eligible for a non-surgical approach to care when radiation and chemotherapy eradicate their tumor. In hopes of making this a viable option for more patients, he is working with Washington University biomedical engineers to develop better imaging methods to sharpen the evaluation of the presence or absence of cancer after radiation and chemotherapy.
Highlights
A NEW TREATMENT PROTOCOL for colorectal surgery care reduced surgical site infections, hospital length of stay and readmissions over a three-year period. The colorectal Enhanced Recovery After Surgery (ERAS) protocol won a Barnes-Jewish Hospital award for quality improvement. Results were reported at the annual American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) meeting in July 2016. The protocol — led by surgeon Matthew Silviera, MD, clinical nurse manager Angelia McBride, RN, and nurse practitioner Bonnie Johnston, BSN, RN — is part of an ongoing effort to test and implement evidence-based patient care pathways. Among their findings:
- Johnston found that educating colorectal surgery patients about proper pre- and post-surgical self care reduced the surgical-site infection rate to 5 percent, half the rate for all patients.
- Johnston and surgeon Steven Hunt, MD, concluded that, among patients who received an ostomy, follow-up calls 48 hours after discharge did not affect the rate of readmission, even though this intervention has been effective in other patient groups at high risk for readmission; a follow-up office visit with an ostomy nurse proved more effective.
A COMPREHENSIVE PATIENT INFORMATION guide promoting continuity of care is now in use at Barnes-Jewish Hospital and Barnes-Jewish West County Hospital. Hospital clinic staff developed the guide and use it to prepare patients for surgery, discharge and recovery at home. In addition, staff developed surgery-specific guides for patients, families and caregivers, outlining expected outcomes following surgery.
MATTHEW MUTCH, MD, colon and rectal surgery chief, has been installed as the Solon and Bettie Gershman Chair for Colon and Rectal Surgery.