Palliative Therapy For Rectal Cancer
Indications for Palliation
Palliative therapy is indicated for all patients with incurable
rectal cancer. It may be operative or nonoperative.
Rectal cancer may be deemed incurable for a variety of reasons.
Patients may have advanced or recurrent locoregional
disease or distant metastasis. Significant comorbidities may
preclude chemo- or radiation therapy or a surgical resection
in patients with technically resectable cancer. Patients
who are limited to a bed-to-chair existence should not
receive surgical treatment or chemotherapy.
In some cases, the patient with a resectable primary
lesion will decline the extent and consequences of radical
surgery (eg, if it is likely to result in the formation of a permanent
colostomy). Finally, a few patients decline surgery
even if the cancer is technically resectable and a need for
a colostomy is not anticipated.
Goals of Palliation
Patients requiring palliation for rectal cancer are a heterogeneous
population with a wide spectrum of clinical presentations
ranging from a microscopic focus of local tumor
with distant metastases causing no symptoms to a large
tumor causing major symptoms. The primary goals of palliative
therapy are to maximize the quality of remaining
life by controlling symptoms and preserving normal bodily
functions, and helping the patient and their family and
friends to develop realistic expectations about their
impending death from the incurable cancer. This begins
with a multidisciplinary approach to each individual
patient involving physicians, nurses, social workers, and
spiritual counselors.
Although physicians often estimate their patients’ life
expectancies accurately, many times the patients themselves
overestimate their survival probabilities and these inaccurate
impressions will influence their treatment choices
(Weeks et al, 1998). They will then be more likely to choose
more aggressive therapy regimens and this can decrease
their quality of life without any survival benefit. It is therefore
of paramount importance that the team communicates
a clear and accurate message to the patient regarding
prognosis and treatment options. This information should
be based on a thorough evaluation of the patient’s general
health and an accurate staging of cancer. Treatment
should focus on prevention and management of symptoms
and pain with the main focus on improving the patient’s
quality of life.
Clinical Evaluation
After the initial diagnosis of rectal cancer is made, further
workup should determine if the patient is a candidate for
different palliative therapy regimens and what aspect of the
patient’s disease is likely to cause symptoms. This diagnostic
workup is initially based on physical findings and
symptoms. If these first data suggest the presence of
advanced disease, then further workup should be minimized.
In other words, patients who have clear evidence
for disseminated rectal cancer or who are in frail health
often do not require further computed tomography (CT)
or magnetic resonance imaging (MRI) scans. In every case
of incurable rectal cancer, the extent of the workup must
assure that the potential treatment morbidity is justified
by the anticipated outcome. In patients who are candidates
for surgery, a CT of the abdomen/pelvis is performed to
determine resectability and extent of abdominal metastases.
Endorectal ultrasound or pelvic MRI can be used if
findings on CT are unable to determine resectability. If the
rectal cancer appears resectable, then CT of the upper
abdomen and chest and positron emission tomography
scanning are done to exclude distant metastases. In addition,
diagnostic laparoscopy can be used to identify widespread
disease prior to laparotomy in patients with an
otherwise negative workup. Despite recent advances in
imaging technologies and intensive investigations, the surgeon
often finds that the preoperative workup underestimated
the full extent of the disease. The true extent of local
involvement and distant spread, and thus the need for palliative
treatment, only become evident at examination of
the abdomen in the operating room.
More Articles
Preparation for Colorectal Cancer SurgeryScreening Guidelines for Colorectal Cancer
Diagnosis for Colorectal Cancer
Colorectal Carcinoma Adjuvant and Chemotherapy
Colorectal Cancer Information