Quality statement 4: Preoperative treatment of rectal cancer

Quality statement

People with rectal cancer are offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.

Quality measure

Structure: Evidence of local arrangements, including written clinical protocols, to ensure people with rectal cancer are offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.

Process:

a) Proportion of people with low-risk operable rectal cancer who do not receive short-course preoperative radiotherapy or chemoradiotherapy unless as part of a clinical trial.

Numerator – the number of people in the denominator who do not receive short-course preoperative radiotherapy or chemoradiotherapy, unless as part of a clinical trial.

Denominator – the number of people with low-risk operable rectal cancer.

b) Proportion of people with high-risk operable rectal cancer who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.

Numerator – the number of people in the denominator who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.

Denominator – the number of people with high-risk operable rectal cancer.

c) Proportion of people with high-risk locally advanced rectal cancer who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.

Numerator – the number of people in the denominator who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.

Denominator – the number of people with high-risk locally advanced rectal cancer.

Outcome:

a) Local recurrence.

b) Circumferential resection margin.

What the quality statement means for each audience

Service providers ensure systems are in place for people with rectal cancer to be offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.

Healthcare professionals offer people with rectal cancer a preoperative treatment strategy appropriate to their risk of local disease recurrence.

Commissioners ensure they commission services that offer people with rectal cancer a preoperative treatment strategy appropriate to their risk of local disease recurrence.

People with rectal cancer are offered treatment before surgery that takes into account the likelihood of the cancer returning.

Source guidance

NICE clinical guideline 131 recommendations 1.2.1.2 (key priority for implementation), 1.2.1.3, 1.2.1.4, 1.2.1.6 and 1.2.1.7.

Data source

Structure: Local data collection.

Process: a), b) and c) The National Bowel Cancer Audit records preoperative radiotherapy.

a) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 2.

b) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 3.

c) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 5.

Outcome:

a) Local data collection.

b) The National Bowel Cancer Audit records whether the circumferential margin was involved, not involved or not known. It also records the distance between the cancer and the circumferential margins.

Definitions

NICE clinical guideline 131 uses the following categorisations of risk of local disease recurrence:

  • High – a threatened (less than 1 mm) or breached resection margin; or low tumours encroaching onto the inter-sphincteric plane or with levator involvement.

  • Moderate – any cT3b or greater, in which the potential surgical margin is not threatened; or any suspicious lymph node not threatening the surgical resection margin; or the presence of extramural vascular invasion (this feature is also associated with high risk of systemic recurrence).

  • Low – cT1, cT2 or cT3a and no lymph node involvement.

NICE clinical guideline 131 also uses the following categorisations:

  • Low-risk operable rectal cancer – primary rectal tumours which appear resectable at presentation.

  • High-risk operable rectal cancer – primary rectal tumours which appear resectable at presentation.

  • High-risk locally advanced rectal cancer – primary rectal tumours which appear unresectable or borderline resectable.