Current Status of Surgical Treatment of Rectal Cancer in China

Current Status of Surgical Treatment of Rectal Cancer in China

Introduction Rectal cancer is a significant health concern in China, with its incidence and mortality rates steadily increasing over the past few decades. This trend contrasts with the declining rates observed in the United States, largely due to early screening and standardized treatment protocols. In China, rectal cancer constitutes the largest proportion of colorectal cancer (CRC) cases, and its treatment is complex and multifaceted. Surgical intervention remains the cornerstone of rectal cancer treatment, supported by advancements in neoadjuvant chemoradiotherapy, targeted therapy, and immunotherapy. The Chinese guidelines for CRC diagnosis and treatment, first issued in 2010 and revised in 2020, have played a pivotal role in standardizing and internationalizing CRC management in China. This article provides a comprehensive review of the current status and research progress in the surgical treatment of rectal cancer in China.

Incidence Trend and Overall Survival The incidence and mortality of CRC vary significantly across different countries, influenced by socio-economic development and lifestyle factors. In China, the incidence of CRC has been rising, with an average annual increase of 4.2% from 2000 to 2005 and 1.3% from 2006 to 2011. The mortality rate has also increased by 1.6% annually during the same period. In contrast, the United States has seen a decline in CRC incidence and mortality rates since 2000, attributed to effective screening programs. In China, rectal cancer accounts for more than 50% of all CRC cases, with a notable shift in tumor location from the rectum to the proximal colon over the years. The 5-year overall survival (OS) rate for CRC in China is lower than in the United States, with significant disparities between urban and rural areas. Early-stage diagnosis remains a challenge in China, with less than 10% of cases detected at an early stage, compared to higher rates in Japan and South Korea.

Early Screening and Clinical Staging Early screening is crucial for reducing the incidence and mortality of CRC. In the United States, 68% of adults aged 50 to 75 years undergo CRC screening, while in China, screening programs are limited to certain developed cities. The compliance rate for CRC screening in China is only 44%, significantly lower than in developed countries. The primary methods for rectal cancer staging in China include magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS). MRI is particularly effective for assessing advanced-stage rectal cancer and identifying positive lymph nodes, mesorectal fascia, and extravascular vascular invasion. High-resolution MRI is considered the best method for evaluating the involvement of the circumferential margin in rectal cancer. The National Comprehensive Cancer Network, European Society for Medical Oncology, and Chinese CRC guidelines all recommend MRI as the optimal imaging method for pre-operative diagnosis and staging of rectal cancer.

Surgical Treatment Surgical treatment remains the most important approach for rectal cancer in China. However, the standardization of surgical practices varies across hospitals, with a significant proportion of clinicians lacking a thorough understanding of the diagnosis and treatment guidelines. The Chinese guidelines for CRC diagnosis and treatment, first published in 2010 and revised in 2017 and 2020, have helped align surgical practices with international standards. The development of comprehensive treatment methods, including chemoradiotherapy, targeted therapy, and immunotherapy, has improved the post-operative quality of life and prognosis for patients with rectal cancer.

Early Rectal Cancer (T1N0M0) For early rectal cancer, endoscopic resection (endoscopic mucosal resection/endoscopic submucosal dissection) and local surgical resection are the primary treatments. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are commonly used for early rectal cancer. TEM, first reported in 1983, offers several advantages, including improved surgical visualization and accurate evaluation of surgical margins. Studies have shown no significant difference in the R0 resection rate, post-operative recurrence rate, or tumor complete resection rate between TEM and ESD. TAMIS, developed in 2010, is based on single-incision laparoscopic surgery and is used for the resection of benign and early middle- and high-rectal cancer. TAMIS has a lower cost than TEM but requires extensive experience in laparoscopic operations.

Locally Advanced Rectal Cancer (LARC) (T2–4N0–2M0) Neoadjuvant chemoradiotherapy (nCRT) plays a key role in the treatment of locally advanced mid-low rectal cancer, improving the R0 resection rate, anal preservation rate, and local control rate of tumors. The classic neoadjuvant treatment includes pre-operative concurrent chemoradiotherapy, with long-course (50.4 Gy/25 fractions) and short-course (5 Gy × 5) radiotherapy being widely used. In China, a modified short course of 30 Gy/10 fractions has been developed based on the tolerance of the Chinese population. Studies have shown that 15% to 20% of rectal cancer patients achieve pathologic complete response (pCR) after nCRT, leading to the adoption of the “watch and wait” (W&W) strategy for patients with clinical complete response (cCR). The W&W strategy has shown promising results, with a 5-year OS rate of 85% for patients achieving cCR after nCRT.

Total Mesorectal Excision (TME) TME, first reported in 1982, has become the standard surgical procedure for rectal cancer in China. Studies have shown that TME reduces the local recurrence rate and improves the 5-year survival rate compared to traditional surgical procedures. The quality of the TME operation significantly impacts prognosis, with complete resection associated with higher disease-free survival rates and lower local and distant recurrence rates. Laparoscopic TME has been widely adopted in China, with studies showing comparable outcomes to open surgery in terms of short-term and long-term prognosis. The proportion of colorectal laparoscopic surgeries performed in China in 2019 was 56.7%, similar to rates in the UK and other developed countries.

Minimally Invasive Surgery Laparoscopic rectal cancer surgery has been performed in China for nearly 20 years, with studies demonstrating its safety and efficacy. Laparoscopic surgery reduces blood loss, shortens hospitalization, and accelerates bowel function recovery compared to open surgery. Robotic surgery, introduced in China in 2009, offers advantages in precision and visualization but remains limited due to high costs and advanced requirements for operators. Cylindrical rectal dissection, first reported in 2007, increases the resection volume of peripheral tissues and reduces the positive rate of the circumferential resection margin. Transanal total mesorectal excision (TaTME), introduced in China in 2010, has shown comparable outcomes to laparoscopic surgery, with benefits in achieving a longer distal margin.

Lateral Lymph Node Dissection The management of lateral lymph node metastasis in rectal cancer remains controversial. In Europe and North America, TME combined with radiotherapy and chemotherapy is recommended, while in China and Japan, intra-operative lateral lymph node dissection is commonly performed. Studies have shown that lateral lymph node dissection reduces the local recurrence rate but is associated with increased complications, including urinary and sexual dysfunction. The necessity of lateral lymph node dissection in rectal cancer surgery continues to be debated in China.

Advanced Rectal Cancer (T1–3NanyM1) Advanced rectal cancer often presents with distant metastases, with the liver being the most common site. Surgical resection of liver metastases improves survival, with a 5-year OS rate of approximately 40% for patients undergoing hepatectomy. Multidisciplinary team (MDT) approaches have been developed in China to improve the management of advanced rectal cancer, significantly enhancing the 5-year OS rate. Lung and peritoneal metastases are also common in advanced rectal cancer, with surgical resection and other treatments such as stereotactic body radiation therapy and hyperthermic intraperitoneal chemotherapy being employed to improve outcomes.

Conclusion The treatment of rectal cancer in China has made significant progress, with surgical intervention remaining the cornerstone of management. The standardization of surgical practices, advancements in neoadjuvant therapies, and the adoption of minimally invasive techniques have improved patient outcomes. However, challenges remain, including the need for early screening, better compliance with guidelines, and the management of advanced disease. With continued efforts in standardization and internationalization, the inflection point of the rising incidence and mortality of rectal cancer in China is expected to be reached in the near future.

doi.org/10.1097/CM9.0000000000001076

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