STOCKHOLM—For rectal cancer patients, a multidisciplinary team is critical to success because it increases the possibility of a curative resection, Andres Cervantes, MD, associate professor of medicine at University Hospital, Valencia, Spain, said at ESMO 2008. “Every patient should be treated within an expert multidisciplinary team,” he emphasized.
Core team members include an imaging specialist with experience in MRI, at least two surgeons well trained in total mesorectal excision (TME), a pathologist familiar with the particulars of rectal tumors, a radiation oncologist with a focus on rectal cancer, a medical oncologist, and clinical nurse specialists.
“The anticipated benefits of such a group include improved coordination of care, ability to consider each case from different perspectives and offer a range of treatments, an environment that supports the sharing of professional concerns, feedback from pathologists to other team members, and an optimal setting for clinical research,” Dr. Cervantes said.
The convergence of these various perspectives has led to a new approach to treating rectal cancer that involves MRI staging, multidisciplinary team discussion, TME resection, pathology assessment and risk estimation, and optimal selection of patients for preoperative treatment and postoperative chemotherapy if indicated.
Discussions among a multidisciplinary team have been shown to change care in a large percentage of cases. Gina Brown, MD, and colleagues showed that when potentially curative cases were not discussed by a team, 100% of patients were treated with surgery alone. When multidisciplinary discussions were held, 59% had surgery alone while 41% also underwent preoperative chemoradiotherapy on the basis of tumor size, nodal involvement, or predicted circumferential resection margin (CRM) positivity. Without team discussion, more patients also had histologically positive CRMs, 26% vs 1% when cases were discussed (Br J Cancer 94:391-397, 2006).
Make MRI mandatory
For staging, the use of high-resolution MRI, which consistently shows the mesorectal fascia, optimizes the selection of patients at risk of a positive CRM, and identifies other prognostic factors, such as venous invasion, distance to the mesorectal fascia, and sphincter involvement. This approach, therefore, can prevent incomplete surgical resection and can identify patients who need preoperative chemoradiotherapy.