Addressing variation in treatment decision-making and outcomes in patients with locally advanced and recurrent rectal cancer

Abstract

Approximately 10% of patients with primary rectal cancer have a T4 tumour at presentation which may locally invade adjacent pelvic organs, bone, neurovascular or other soft tissue structures (T4b tumours). In addition, up to 10% of patients treated for primary rectal cancer may subsequently develop local recurrence in the pelvis. For both patients with locally advanced primary rectal cancer (LARC) and locally recurrent rectal cancer (LRRC), pelvic exenteration surgery, which refers to radical multi-visceral resection for advanced pelvic tumours, represents the only potentially curative

treatment option. Refinement of surgical technique, combined with significant developments in perioperative medicine and imaging technology in the last three decades, have translated to dramatic improvements in outcomes for patients undergoing pelvic exenteration for LARC and LRRC. As a result, pelvic exenteration has evolved from a controversial, palliative procedure to the established standard of care for selected patients with LARC and LRRC. In 2025, the goal at exenteration units globally is to build on the highly encouraging results reported in recent decades by identifying and implementing technical, oncological and systems improvements that may contribute to the incremental improvement in patient outcomes. With this in mind, standardisation of this treatment may represent an opportunity to further improve patient outcomes by reducing variation in the way it is delivered both between and within centres. This thesis aimed (i) to address variation in treatment decision-making in patients with LARC and LRRC, and (ii) to establish internationally applicable surgical quality benchmarks for pelvic exenteration surgery.