Sphincter saving is the primary objective for local treatment of cancer of the lower rectum

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In 2002, more than 1 million patients developed colorectal cancer worldwide, accounting for about a tenth of all cancers. By 2030, the total number of new cases of cancer per year is estimated to rise to about twice that in 2002. Fortunately, for colorectal cancer, these alarming statistics are tempered by advances in surgery, surgical training and expertise, postoperative pathology, and adjuvant treatment, which together have contributed towards a substantial increase in patients’ survival. Indeed, many surgeons now believe that an oncologically safe procedure might also be possible without sacrifi cing the patient’s long-term quality of life, especially continence and sexual function. Parallels can be drawn in this shift in emphasis with the surgical developments in breast-cancer treatment, in which many centres now place equal weight on oncological and cosmetic considerations in their surgical planning. In this Debate, Eric Rullier from University of Victor Segalen, Bordeaux, France, and David Sebag-Montefi ore from the Leeds Cancer Centre, Leeds, UK, argue the case for and against surgery for cancer of the lower rectum where the primary objective is no longer oncological, but that of sphincter preservation. The primary endpoints for rectal-cancer management have been local control and long-term survival, with surgery still used as the main treatment. During the past decade, optimisation of surgery with the introduction of the total mesorectal excision technique has greatly aff ected the oncological outcome of patients. 1 Local control has been achieved in 90% of patients, and survival can be expected in up to 70% of the patients. 2 In highly specialised teams of surgeons, these results can be obtained without neoadjuvant treatment, whereas preoperative radiotherapy remains the standard for locally advanced (stage III) disease. 3 This exceptional improvement of local control and survival in patients treated for rectal cancer modifi ed the objectives for treatment. Goals are focusing on patients’ functional abilities and quality of life rather than oncological outcomes. Indeed, the quality of life can be altered by an abdominal colostomy and by sexual dysfunctions, especially after treatment of cancer of the lower rectum. 4