Individualizing Rectal Cancer Care: Integrating Science to Optimize Outcomes

Individualizing Rectal Cancer Care: Integrating Science to Optimize Outcomes

I am often asked what makes a surgeon an expert in rectal cancer surgery. Many colorectal and oncologic surgeons can do most of the operations in the rectal cancer surgical armamentarium, often with varying levels of success; but most do so with formulaic approaches based on outdated standard guidelines. 

The truth is, modern rectal cancer care is no longer a one-size-fits-all endeavor. Surgeons and multidisciplinary teams can now harness pivotal clinical trials and cutting-edge protocols to tailor therapy, balancing the two primary but often competing goals of rectal cancer treatment: 1) oncologic cure and 2) functional preservation and quality of life. 

The evolution of this tailored approach is shaped by trials such as MERCURY, PROSPECT, PRODIGE 23, OPRA, GRECCAR-2, and other emerging studies testing selective use of radiation and with more aggressive upfront chemotherapy regimens. In order to be an expert in rectal cancer surgery, not only does the surgeon have to have the technical expertise to perform these complex operations safely and proficiently, he/she must also have to have the knowledge to recognize exactly when to operate, exactly which operation to perform, and exactly which non-surgical therapies to use before or after surgery to maximize both the chance of oncologic cure and the preservation of function. I believe this is where my team and I excel

The Competing Goals of Rectal Cancer Treatment: Oncologic Cure vs. Functional Preservation

Curative therapy remains the priority in rectal cancer for both the surgeon and the patient, yet it often comes with the prospect of significant changes to function and quality of life, especially for rectal cancers located near the anal sphincter. While oncologic control through surgery, radiation, and chemotherapy offers the highest chance of cure, these interventions can risk loss of continence or necessitate permanent colostomy.

Ultimately, preserving function means doing less, the question is less of what? This is what your treatment team must balance. The two key approaches to doing less include:

• Doing less surgery - reducing the extent of surgery or in very select cases eliminating surgery altogether. This requires relying more on non-surgical therapies such as aggressive chemotherapy and radiation.

• Omitting radiation – eliminating the functional downsides of radiation by focusing on more aggressive and more meticulous surgery. 

The simplest I explain this to my patients is, upper rectal cancers = less radiation, lower rectal cancers = less surgery if possible, though sometimes the best laid plans to do not always materialize. 

Upper Rectal Cancers: Reducing Radiation, Focusing on Surgery

For patients with upper rectal tumors, organ and especially sphincter preservation are less of a technical or functional challenge. Here, the existing data is very helpful:

• The MERCURY and PROSPECT trials have helped us identify patients who can safely avoid radiation, particularly when permanent colostomy is not a risk.

Low Rectal Cancers: Escalating Nonoperative Therapy for Sphincter Preservation

Tumors in the low rectum pose a unique challenge: surgery may threaten the sphincter, risking permanent colostomy. The modern response is to leverage aggressive nonoperative approaches to maximize function. In this regard, the PRODIGE 23, OPRA and GRECCAR-2 trials have helped us escalate non-surgical therapies, to increase the chance of cure and use less aggressive surgical approaches such as local excision, TAMIS and even cautious observation without surgery (watch-and-wait)

Dr. Avo Artinyan’s Individualized Approach:

Dr. Artinyan’s clinical experience is at the forefront of rectal cancer surgery In Los Angeles, CA and exemplifies these principles. 

• We adapt surgery and multimodal therapy to each  patient's tumor location, stage, and treatment response—never a formulaic approach.

• For upper-mid rectal cancer, we often try to omit radiation per MERCURY and PROSPECT findings, relying on precise imaging and multidisciplinary planning for better functional outcomes.

• For low rectal cancer, we maximizes organ and sphincter preservation via a robust nonoperative protocol often consistent of both chemotherapy and radiation; offering local excision and even “watch-and wait” when safe—always emphasizing cure without sacrificing quality of life.

• Our patients are diverse and so are their goals, so each is presented with a menu of options, and through shared decision making, we choose the approach most appropriate for each patients ultimate goals.

The future of rectal cancer management is individualization—deploying the wealth of clinical evidence to ensure both cure and function, utilizing fewer and less harmful interventions whenever possible. That is what sets us apart from all other practices throughout the country, big or small.