Pioneering techniques in cancer surgery

Deaths from bowel cancer have halved for women and fallen by a third among men over the past 40 years, although the disease is still the third leading cause of death from cancer, according to new figures from the Office of National Statistics. “We can cure between two-thirds and three-quarters of people with bowel cancer depending on the location – in some regions people tend to go to the doctor only when it is too late,” said Professor Bill Heald OBE, director of surgery at the Pelican Cancer Foundation. “With good screening and greater willingness to discuss bowel cancer, there are much better opportunities now to achieve positive outcomes. It is unquestionably the most important of the cancers, where the most impact can be achieved.” Through early surgical intervention, the disease can often be cured. However, while surgery cures more patients than any other intervention for cancer, only 1.3% of cancer research money is spent on the advancement of superior surgical techniques. In fact, there is an increasing body of evidence to suggest that colorectal cancer is the most technique dependent of all malignancies. There is a greater difference in outcome in terms of cure, the number of permanent colostomies necessary and in various other disabilities, including impaired sexual function, than any other cancer. Striving to address this issue is the Pelican Cancer Foundation, which focuses on advancing the most effective techniques in precision surgery for bowel, liver and urological cancer. (The charity’s name is derived from the words “pelvic” and “liver cancer”.) The organisation has grown from the pioneering work in bowel cancer surgery of Prof. Heald; Brendan Moran, Pelican’s colorectal director; and other colleagues, who identified a need to address the variation seen in surgery outcomes across the UK – both in terms of survival and in the quality of life experienced by patients.

TME surgery

Prof. Heald developed the Total Mesorectal Excision (TME) technique for rectal cancer, which has now become the “gold standard” for rectal cancer surgery. Importantly, refinement of bowel cancer surgery, particularly TME has been proven to save more lives than conventional methods. “TME is concerned with the precise removal of the optimal block of tissue to safely encompass the cancer – including its local spread,” Prof. Heald explained. “When Pelican was first established, it was apparent that there was a need to ensure the best possible planning of an operation, precise performance of the operation, along with a programme of teaching on how to achieve excision of exactly the right area of tissue.” Prof. Phil Quirke, a pathologist from Leeds, observed that there were significant variations in outcomes from rectal cancer surgery. “The reason for these huge differences lay with the precision of the surgeon,” explained Prof. Heald. “Prof. Quirke introduced the idea of auditing the TME specimen to look at the margins to see if there are any microscopic ‘tentacles’ of cancer. This can indicate whether malignant cells have been left behind, which would explain why regrowth of the cancer may have occurred.” Unfortunately, if cancer is detected at the circumferential resection margin (CRM) of the removed specimen then local recurrence and poor survival are highly probable. Studies have shown that rates of cancer found at the CRM are greater than 20% and vary from surgeon to surgeon. While the importance of auditing the excised specimen became evident, Pelican was simultaneously working with pioneering radiologists – including Dr Gina Brown at the Royal Marsden Hospital, who saw the value in the application of MRI in planning the management of rectal cancer surgery. “The use of MRI has been major step forward,” commented Prof. Heald. “Advances in imaging techniques have made it possible to identify, preoperatively, those rectal cancers which could threaten the surgical margins, which enables the team to make appropriate pre-operative treatment decisions on an individual patient basis.” As development of the TME approach gained momentum, Prof. Heald and Brendon Moran were asked to organise a series of TME workshops in Stockholm, Sweden, and the results subsequently caused shockwaves across the international community of colorectal surgery.