Pelvic exenteration is the standard of care, and only potentially curative treatment option, for selected patients with locally advanced or recurrent rectal cancer. This complex procedure involves surgical resection of all anatomical structures involved by the tumour and typically requires the removal of multiple pelvic viscera, as well as major pelvic bone, blood vessels, and nerves, generally followed by complex reconstruction of these systems. Although potentially curative, such radical surgery may be associated with major morbidity (up to 60%), functional impairments, and reduction in quality of life. Therefore, whether or not pelvic exenteration should be recommended for an individual patient is a major and often difficult decision. The consequences of surgery must be weighed against the potential for cure, with consideration given to a patient’s individual treatment goals and priorities.
Currently, decision-making around whether to recommend pelvic exenteration is based on individual surgeon or team experiences and does not follow an evidence-based approach. These decisions have traditionally been made with anticipated survival benefit as the main outcome of interest, with relative neglect of quality-of-life and functional outcomes. Furthermore, the views of patients, carers, and clinicians regarding which outcomes are most important and should guide decision-making have not been previously determined. It is also clear from recent comparative studies that there are dramatic differences in practices between specialist exenteration centres with respect to both patient selection and treatment approach. This unwarranted variation in treatment decision-making may be, at least in part, due to lack of a standardized, reproducible, evidence-based approach to decision-making in this group of patients.
The aim of this study was to identify the pelvic exenteration outcomes that are considered most important by patients with locally advanced or recurrent rectal cancer, their carers, and treating clinicians. This will inform the development of an evidence-based surgical decision-making tool that can be used at the time of diagnosis to predict a range of individual patient outcomes (beyond survival alone).
Kilian G M Brown, James Morkaya, Michael J Solomon, Kheng-Seong Ng, Kate White, Paul Sutton, Desmond C Winter; EvigSurg Collaborative Group; Daniel Steffens
Disease Category: Cancer
Disease Name: Rectal cancer
Age Range: 18 - 120
Sex: Either
Nature of Intervention: Surgery
- Clinical experts
- Consumers (caregivers)
- Consumers (patients)
- Prioritising
- Recommendations made
- Delphi process
- Interview
- Systematic review
This study was coordinated by the Surgical Outcomes Research Centre (SOuRCe) in conjunction with the Institute of Academic Surgery (IAS) at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia. The study involved two phases. First, a longlist of outcomes of pelvic exenteration was generated by systematically reviewing the literature5 and conducting in-depth interviews with patients who had undergone exenteration surgery and their carers6. Second, longlisted outcomes were reviewed by a multidisciplinary committee and used to populate a three-round Delphi survey of patients, carers, and clinicians to identify the outcomes of highest priority to these stakeholder groups. The study protocol was published a priori7 and was reported according to the Conducting and REporting of DElphi Studies (CREDES) recommendations8. Ethical approval for this study was granted by the Royal Prince Alfred Hospital Human Research Ethics Committee (X22-0422 and 2022/ETH02659).