Is it the mindset and experience or the Surgeon/institution, the patients perception of risk or national guidelines that are the most important in the decision process? Would the same patient recieve the same treatment when the initial staging is performed in a "non-TEM institution", as he/she would in a "TEM institution"?
Thank you for your excellent answer. I am sorry if my question was not focussed enough, but my question was more regarding how we convey risk, rather then pertaining the current evidence of rectal sparing strategies for rectal cancer.
The UK TREC trial experienced problems in recruiting patients for the randomization, as a substantial proportion of the patients opted for the organ sparing SCRT + TEM rather than TME for T1/T2 tumours. As demonstrated by Lezoche et.al. a lot of Italian patients prefer extensive taTME by TEM rather than facing the risk of a stoma.
I've experienced the dilemma between the low procedure related morbidity (or "patient scare of stoma") vs higher risk of recurrence. Some patients of significant age and with substantial comorbidities leading to increased risk of procedure related mortality opts for maximum treatment, while young low-risk patients prefer risk of recurrence over a (probably) well functioning stoma.
SO: To which extent are the decisions in this complex cross-road between risk, QoL, evidence based medicine and socio-cultural aspects driven by the mindset/personality of either the surgeon or the patient? And does anyone have good references on studies on this area?
I am an old, retired, proctologist.
Therefore, I am avare of ancient, forgotten, methods.
In my office, Dr A Poirier designed inthe 40ies electrocoagulation for small rectal cancers with a high percentage of cure, providing a good indication i.e.
Jo
GB and I were discussing this very recently and are keen to explore this further. Have you seen these composite risk tables in a very well written open access article by Taylor and hosie:
http://www.intechopen.com/books/colonoscopy-and-colorectal-cancer-screening-future-directions/the-malignant-polyp-polypectomy-or-surgical-resection-
The tables they present are very thought provoking NNT by completion TME after clear excision of a T1Sm2 to acheive one life saved at 5 yrs is 40!....This is in a young fit patient & ignoring morbidity of TME!
There are also some interesting articles on patients surprising willingness to gamble life expectancy to avoid morbidity. A recent systematic review I'm sure you have already seen: Colorectal Dis. 2014 Aug 23. doi: 10.1111/codi.12754. [Epub ahead of print] A systematic review of patient preference elicitation methods in the treatment of colorectal cancer. Currie A1, Askari A, Nachiappan S, Sevdalis N, Faiz O, Kennedy R.
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