Steven Hunt, MD, performs a transanal endoscopic microsurgical (TEM) excision. The minimally invasive tumor removal technique preserves function and is one of many advances improving quality of life for rectal cancer patients.

In the 1970s, the Washington University colon and rectal surgery service became one of the earliest to offer radiation therapy in combination with surgery to treat rectal cancer. Operative treatment has since evolved, improving patients’ quality of life, and stands at the threshold of several new frontiers.

“In the earliest days, if you had cancer in the lower part of the rectum, you ended up with a colostomy bag — because the technology didn’t allow us to take out very small tumors without  using this option,” says Steven Hunt, MD, Washington University colorectal surgeon at Barnes-Jewish Hospital. “We’ve come a long way in avoiding  these types of resection.”

Although open surgery has improved to preserve bowel function in many cases, the use of a minimally invasive technique — transanal endoscopic microsurgical (TEM) excision — is further transforming rectal cancer surgery. During this procedure, a 20-cm-long proctoscope placed through the anus allows surgeons to visualize and
resect tumors without removing the rectum and without an abdominal incision.

“We began using the TEM procedure for polyps in 2006,” says Hunt. “In the early stages, we only used the procedure in rectal cancer patients who we did not think would survive a large abdominal operation.”

But when the medical literature showed TEM alone could be curative for early-stage rectal cancer, Hunt began offering it. And now that studies show TEM with chemoradiation may be effective for some advanced rectal cancers, its use may be expanded in coming years.

TEM is not the only advancement in rectal cancer treatment at Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine. Radiation oncologist Parag Parikh, MD, is now working with colorectal surgeons to offer patients a one-week radiation course, followed by early chemotherapy, before surgery. This compares to a traditional regimen of about three months before surgery, which may allow some cancers to spread to the liver and other organs.

A new technology called gene expression profiling may also shape the future of treatment. Washington University colorectal surgeon Matthew Mutch, MD, is collaborating with Matthew Kalady, MD, of the Cleveland Clinic to see whether the technique can identify who will benefit from radiation and chemotherapy, and what regimen to use.

“If we can accomplish that, we will develop a therapeutic trial,” Mutch says.