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Leading article

Improving outcomes in gastrointestinal cancer
D. Alderson1 and D. C. Winter2
University Department of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK and 2 St Vincent’s University Hospital and University College Dublin, Dublin, Ireland (e-mail:

Published online in Wiley Online Library ( DOI: 10.1002/bjs.9004

Malignancies affecting the gastrointestinal (GI) tract have always been considered aggressive tumours with a poor prognosis. Less than 25 years ago many clinicians viewed pancreatic cancer as incurable, and patients with oesophageal and gastric cancer were thought to have only a 5 per cent chance of long-term survival. Although colorectal cancer was associated with a better outcome, metastatic disease was still considered a terminal event. Critical clinical trials have disproved most of the above. The European Study Group for Pancreatic Cancer (ESPAC) and Medical Research Council OE02 and Adjuvant Gastric Infusional Chemotherapy (MAGIC) trials demonstrated that, for the foregut cancers, longterm survival could be achieved1 – 3 . Although no-one has randomized patients with resectable colorectal metastases to resection versus observation, it is difficult to argue with a 40 per cent 5-year survival rate in these patients. Despite these achievements, the surgical community continues to face nihilism among the medical profession when dealing with GI cancers. This issue of BJS looks at some of the topical issues relating to patients with these tumours. The review articles were selected specifically to focus on those contemporary issues where progress has been made recently or where greater attention needs to be paid to see benefits in the future. The original articles reflect some of these themes. The notion that GI cancers might be viewed as chronic diseases, rather than conditions that are cured or cause death, may seem fanciful
 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

to some, but it is not so long ago that breast cancer was seen in the latter light. For many women nowadays, breast cancer becomes a chronic condition that responds to sequential treatments targeting new disease as it emerges. Among the GI malignancies, this situation is perhaps not so far away for patients with colorectal cancer. Nobody doubts that ‘prevention is better than cure’, yet screening in the hope of detecting premalignant disease and surveillance of high-risk populations to find early-stage disease are difficult. Reducing risk factors is a health education issue, but surgeons should play their part. Obesity is important in cancer development, and smoking is still a substantial contributor to the co-morbidities that make treatment of GI cancers hazardous. Although the surgeon may not be well placed to influence these issues for an individual patient, there is every opportunity to optimize the patient’s condition before treatment is instigated. Both of these themes are explored in this issue4,5 . The technological advances that have allowed scientists to gain a greater understanding of cancer at a molecular level have already been translated into clinical benefit for patients. Genomics is widely employed, and proteomic and metabolomic information that impacts directly on diagnosis and management seems inevitable. No review issue would be complete without consideration of the current situation6 . Most current targeted therapies focus on growth inhibitors, and, although admittedly the results are as yet

modest, this should not detract from the principles that are being learned – again perhaps the analogy with breast cancer might be drawn. Each treatment has only a small incremental effect on mortality, but when multiple successive treatments are available the cumulative effect is substantial. Randomized clinical trials change surgical practice. The Conventional versus Laparoscopic-Assisted Resection in Colorectal Cancer (CLASICC) trial has certainly influenced colorectal cancer surgery and the long-term results provide reassurance that oncological principles are not compromised by laparoscopic surgery7 . It is reasonable that surgeons should consider clinical endpoints such as recurrence rates and mortality, but patient-reported outcomes should not be overlooked. Many surgeons see these as subjective, but carefully designed and validated instruments are available and should be used more. This issue contains guidelines regarding when and how to use instruments that will provide reliable information about health-related quality of life8 . One of the most topical areas of clinical research in GI cancer relates to reducing complications, decreasing operative mortality, and achieving a faster recovery and return to normal life. This involves a number of components. Identification of the degree of risk posed by a specific procedure, optimization of the patient’s physiological state, minimizing trauma during surgery and implementing protocols to achieve rapid recovery are key elements in this process. All of
British Journal of Surgery 2013; 100: 1–2

355: 11–20. 100: 75–82. Taylor MHG. Contemporary perioperative care strategies.bjs. Br J Surg 2013. C. Lassen K. 100: 105–112. Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg 2013. 100: 55–65. what else can be done to minimize local recurrence when the patient needs an abdominoperineal excision. Plum LM. Stocken DD. 7 References 1 Neoptolemos JP. Integration of clinical and patient reported outcomes in surgical oncology. 100: 3–4.2 D. Lancet 2002. Principles. N Engl J Med 2006. including overviews of optimization and enhanced recovery programmes9 . Sodergren MH. Br J Surg 2013. Br J Surg 2013. Link K. Preston SR. Br J Surg 2013. Dunn JA. 100: 1–2 . Cunningham D. Winter these points are covered in this issue. Srinivasa S. Br J Surg 2013. Why is there such a difference in outcome for oesophagogastric cancer across Europe. Waddell T. Bretthauer M. Patient optimization for gastrointestinal cancer surgery. Macefield RC. Markar SR. Beger H et al. Christensen BM et al. Evaluation of a fast-track programme for patients undergoing liver resection. Many of the articles that the Editors have chosen to appear in this issue might raise some eyebrows. 100: 5–14. Frederiksen HJ. 100: 38–54. through robotics10 and goal-directed fluid replacement11 to studies indicating that patients can usually go home 5 days after a major liver resection12 and a week after oesophagectomy13 . Carli F. Soon Y. Br J Surg 2013. We look forward to hearing from you. Br J Surg 2013. Green BL. Schultz British Journal of Surgery 2013. Impact of multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Low DE. Avery KNL. Larsen PN. 100: 138–143. Lancet 2001. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. Singh PP. Baker CR. Singh S. Stenning SP. Gie O. the correspondence columns of BJS will contain some thought-provoking comments. Medical Research Council Oesophageal Cancer Working Group. Guillou P. 359: 1727–1733. Long term follow up of the Medical Research Council CLASICC trial of conventional versus 8 9 10 11 12 13 laparoscopically assisted resection in colorectal cancer. 100: 15–27. Impact of targeted neoadjuvant therapies in the treatment of solid organ tumours. effectiveness and caveats in screening for cancer. Marshall HC. Collinson F. 100: 66–74. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Blazeby JM. Jayne DG et al. Van de Velde CJ. 358: 1576–1585. Cunningham D. Klarskov B. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Alderson and D. Yu and are we seeing the beginning of an epidemic of operations for cancer in patients with metabolic syndrome? Hopefully. Disclosure 2 3 4 5 6 The authors declare no conflict of interest. Adamina M.  2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www. Kalager M. Nicolson M et al. Br J Surg 2013. Demartines N. Hill AG. Darzi A. Almond J. Quirke P. Allum WH. Jenkins I. Br J Surg 2013. Thompson JN. Soop M. Robotic cancer surgery. European Study Group for Pancreatic Cancer. Ris F. 100: 28–37. Fearon K.