May 1, 2022
My congratulations to Drs. Phang, Buie, and Cirocco for their thorough documentation and delineation of a changing paradigm, specifically rectal cancer management. The authors detailed the issues of recent anatomical designations defined through advanced radiographic imaging, new neoadjuvant and adjuvant interventions through multidisciplinary teams and guidelines, and, finally, standardization of operative techniques and operative/pathologic reporting. Furthermore, they recognize the barriers and limitations of surgical specialty access and geographic disparities, holding to the idea that whenever possible, deliver surgical care where the patients are.
The American College of Surgeons (ACS) Commission on Cancer (CoC) and the American Society of Colon and Rectal Surgeons (ASCRS) collaborated to create the National Accreditation Program for Rectal Cancer (NAPRC) to help standardize and, ultimately, improve outcomes and survival for our patients with rectal cancer. A standards manual was created to delineate expectations for centers that manage rectal cancer. These standards pertain not only to surgeons, but also to the multidisciplinary teams that provide care throughout the cancer event. Unsurprisingly, these centers are populated by experienced colorectal surgeons and possess the resources to fulfill all requirements.
As a non-colorectal surgeon in a state with fewer than five colorectal surgeons, rural general surgeons in South Dakota typically are involved in the diagnosis of rectal cancer and overall treatment of patients. Given the broad geographic expanse of our state and region and extremes of weather, travel to tertiary centers is certainly a concern, particularly for emergent care. Thankfully, these urgent interventions have been addressed through our state’s trauma system. However, the diagnosis of a rectal malignancy rarely has been considered for emergent transfer, and, thus, most patients can travel electively to higher levels of care when needed. Therefore, the question has been raised: What is the role of the rural general surgeon in rectal cancer, and could a disparity or deficiency of rectal cancer care exist in those communities?
I queried many surgeons from South Dakota about their practice patterns for rectal cancer. Although not a scientific analysis, most said they would make the diagnosis, contact a tertiary care surgeon, and then help arrange for patient transfer as needed. All of these surgeons agreed that they would not subject their patients to lesser care locally.
Harris and colleagues in 2010, Cogbill and colleagues in 2017, and Stinson and colleagues in 2021, all compiled data on a rural surgeon’s yearly case log.*†‡ All authors noted that fewer than 5% of colorectal procedures were performed annually. The “loss” of that surgical caseload and income in those communities would not be a significant factor in the decision to transfer.
The surgeons with whom I spoke also acknowledged the changes in standard surgical technique, as well as the necessary resources required for total comprehensive rectal cancer care. However, some components of the total care could still be obtained at their rural locations, such as port placement, some neoadjuvant and adjuvant therapies, and surveillance endoscopy and follow-up—all in coordination with the management plan of the involved tertiary center. Most of our rural surgical practices have an affiliation with these tertiary centers and can participate in virtual gastrointestinal multidisciplinary clinics as needed or requested. Furthermore, some rural general surgeons work in CoC-accredited hospitals and subscribe to the NAPRC standards and expectations, providing surgical care and outcomes comparable with the tertiary care centers.
Finally, I cannot exclude those instances in which emergent intervention is indeed required (acute obstruction or hemorrhage) or family members simply refuse travel to tertiary centers. I also would note that access to the Fundamentals of Rectal Cancer Surgery course appears to be a wonderful resource for non-colorectal surgeons in these circumstances and is available for purchase from the ASCRS website.
Thank you for the opportunity to comment.
*Harris JD, Hosford CC, Sticca RP. A comprehensive analysis of surgical procedures in rural surgery practices. Am J Surg. 2010;200(6):820-825.
†Cogbill TH, Bintz M. Rural General Surgery. A 38-year experience with a regional network established by an integrated health system in the midwestern United States. J Am Coll Surg. 2017;225(1):115-123.
‡Stinson WW, Timmerman GL, Bjordahl PM, et al. Current trends in surgical procedures performed in rural general surgery practice. Am Surg. 2021;87(7):1133-1139.