Surgical Management of Advanced Pelvic Cancer

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Dennis P. Schaap1, Joost Nederend2, Harm J.T. Rutten1, and Jacobus W.A. Burger1

1 Department of Surgery, Catharina Hospital Eindhoven, The Netherlands

2 Department of Radiology, Catharina Hospital Eindhoven, The Netherlands

Multidisciplinary team meetings (MDTMs) have been implemented to deal with the complexity of cancer care [1]. The aim of these meetings is to provide a structured discussion platform to plan patient care [2–7]. The goal is to benefit from the collective knowledge of all specialties in order to optimize staging, treatment, and follow‐up. Furthermore, it can facilitate assessment for patients’ inclusion in clinical trials.

The organization of the MDTM is time consuming and comes with costs. Delaying decisions until the MDTM has taken place can sometimes delay treatment. MDTM results in a significant change in diagnosis or treatment planning, ranging from 18.5 to 36% and 11.0 to 14.5% respectively [8–14].The role of adequate preoperative tumor staging and discussion in an MDTM resulted in more patients receiving neoadjuvant treatment, increased local control, and R0 resections [15].

The governing body for the quality of care for patients with cancer in the Netherlands is the Stichting voor Oncologische Samenwerking (Foundation for Oncological Collaboration, SONCOS) [16]. SONCOS represents 29 national societies involved in cancer care, including the Society for Medical Oncology, the Society of Surgical Oncology, and the Society of Radiation Oncology. SONCOS delivers a yearly report stating the conditions that must be fulfilled by any multidisciplinary team caring for cancer patients. Dutch physicians are obliged to adhere to these conditions. Furthermore, all Dutch medical centers have agreed to standardize data registry with a national database to monitor the effect of changes in treatment strategy on quality measurements as shown in Figure 2.1. Hence, factors improving the quality of care can be identified and applied easily in order to improve patient outcome. MDTMs across the Netherlands can deal with the majority of patients with pelvic cancer from gastroenterological, urological, or gynecological origin. However, patients with locally advanced and recurrent pelvic cancer should be discussed in a specialized MDTM [16].

Patients with locally advanced primary and recurrent pelvic cancers are associated with a higher risk of local recurrence, distant metastases, and poor survival. Furthermore, these complex pelvic tumors require several specialties for an accurate preoperative evaluation, neoadjuvant and/or adjuvant therapy with a multidisciplinary surgical approach, ( Table 2.1). Preoperative treatments providing downstaging are essential to both increase the chance of radical resections and prevent unnecessarily extensive resections that lead to impairment. Centralization is warranted, to identify those patients who require this specialized care.

Figure 2.1 National registries help to monitor outcome. In this control chart for proportions, a decrease in R+ resection rate seems to be statistically significant and leads to differences in the mean R+ resection rate. This moment (referred to as ‘out of control’) coincides with the change of preoperative treatment in locally recurrent pelvic cancer patients (unpublished data). CL, Control limit; UCL, upper control limit.

In order to work toward a situation in which all patients with locally advanced cancers are discussed in a complex cancer MDTM, it is essential that it is easily accessible for physicians outside the specialized center.

Radiologic assessment of local and distant disease in the setting of advanced pelvic cancer can be challenging. Therefore all diagnostic imaging is assessed by radiologists and nuclear medicine physicians with specific expertise in cancer imaging prior to the MDTM. An expert radiologist familiar with surgical principles may anticipate the expected organ involvement. Regular contact in the oncological network ensures that referring hospitals know which scan sequences and modalities that are required.

Table 2.1 Differences between hospitals caring for “regular” colorectal cancer patients and hospitals caring for locally advanced and recurrent pelvic cancer patients (Example from The Netherlands).