Outcomes Of Surgery For Rectal Cancer Research Articles

Robotic-assisted surgery for rectal cancer: Current state and future perspective.

Interest in minimally invasive surgery has increased in recent decades. Robotic‐assisted laparoscopic surgery (RALS) was introduced as the latest advance in minimally invasive surgery. RALS has the potential to provide better clinical outcomes in rectal cancer surgery, allowing for precise dissection in the narrow pelvic space. In addition, RALS represents an important advancement in surgical education with respect to use of the dual‐console robotic surgery system. Because the public health insurance systems in Japan have covered the cost of RALS for rectal cancer since April 2018, RALS has been attracting increasingly more attention. Although no overall robust evidence has yet shown that RALS is superior to laparoscopic or open surgery, the current evidence supports the notion that technically demanding subgroups (patients with obesity, male patients, and patients treated by extended procedures) may benefit from RALS. Technological innovation is a constantly evolving field. Several companies have been developing new robotic systems that incorporate new technology. This competition among companies in the development of such systems is anticipated to lead to further improvements in patient outcomes as well as drive down the cost of RALS, which is one main concern of this new technique.

Influence of Conversion and Anastomotic Leakage on Survival in Rectal Cancer Surgery; Retrospective Cross-sectional Study

BackgroundConversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery. MethodsPatients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage. ResultsOut of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (p = 0.025 and p = 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (p = 0.002 and p = 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322–3.551) and DFS (1.592, 1077–2.353). Conversion was an independent predictor of DFS (1.525, 1.071–2.172), but not of OS. ConclusionTechnical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.

Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery.

Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.

Low Anterior Resection Syndrome: Current Management and Future Directions.

Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.

Ethnic Inequalities in Rectal Cancer Care in a Universal Access Healthcare System: A Nationwide Register-Based Study.

Ethnic inequalities in colorectal cancer care were reported previously in the United States. Studies specifically reporting on ethnic inequalities in rectal cancer care are limited. This study aimed to explore potential ethnic inequalities in rectal cancer care in the Netherlands. This was a nationwide, population-based observational study. The study linked data of the Netherlands Cancer Registry with the Dutch population registry and the Social Statistics Database of Statistics Netherlands. Data were analyzed using stepwise multivariable logistic regression models. All of the patients diagnosed with rectal carcinoma in 2003-2011 in the Netherlands (N = 27,159) were included. We analyzed 2 rectal cancer treatment indicators (preoperative radiotherapy and sphincter-sparing surgery) and 2 indicators of short-term outcome of rectal cancer surgery (anastomotic leakage and 30-day postoperative mortality). Patients of Western non-Dutch and non-Western origin with rectal cancer were significantly younger and had a higher tumor stage than ethnic Dutch patients. Considering preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality, no ethnic inequalities were detected. After adjustment for age, sex, disease characteristics, and socioeconomic status, Western non-Dutch and non-Western patients were significantly more likely to receive sphincter-sparing surgery than ethnic Dutch patients (OR = 1.27 (95% CI, 1.04-1.55) and OR = 1.57 (95% CI, 1.02-2.42)). This study was limited by the relatively low numbers of non-Dutch patients with rectal cancer. Non-Dutch ethnic origin was associated with a higher rate of sphincter-sparing surgery. The absence of ethnic inequalities in preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality suggests that ethnic minority patients have similar chances of optimal rectal cancer care outcomes as Dutch patients.

Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation

BackgroundPreoperative chemoradiation has become a routine modality in the treatment of rectal carcinoma that may impair a patients general condition. In these patients, it is important to identify factors that influence postoperative recovery. Visceral obesity(VO) as a metabolic risk factor was studied in rectal cancer patients receiving preoperative chemoradiation. AimThe impact of VO on post-operative outcome in rectal carcinoma surgery after preoperative chemoradiation was studied. In addition, the effect of chemoradiation on body composition was studied. MethodThe visceral fat area(VFA), total fat area(TFA) and skeletal muscle area(SMA) were measured on cross-sectional CT-slides in 74 patients who underwent rectal cancer surgery after chemoradiation. CT-scans taken before and after chemoradiation were analysed. Associations between VFA, per- and postoperative complications were studied. A VFA of 100 cm2 and 130 cm2 was used to differentiate between non-VO and VO. ResultsUsing a VO cut-off point of a VFA of 100 cm2, the VO patients had more per-operative blood loss(471 mL vs 271 mL p = 0.020), a higher complication rate(10% vs 49% p = 0.001), more ileus(2% vs 28% p = 0.027) and a longer length of stay(9.7days vs 13days p = 0.027). When a VFA of 130 cm2 was used, VO patients showed more complications(17% vs 55%, p = 0.001) and ileus(10% vs 32% p = 0.017).During chemoradiation the SMA increased(Mean difference: 2.2 cm2 p = 0.024), while the VFA showed no change. ConclusionIt appears that VO is associated with co-morbidity and poor outcome in rectal cancer patients. Using different cutoff values for VO different associations with outcome were found. SMA increased during chemoradiation, a phenomenon that remains to be explained.

Current therapeutic strategies for rectal cancer.

surgery was introduced by Stearns et al. in 1959 [2]. On the other hand, Heald et al. demonstrated the usefulness of total mesorectal excision (TME) as the surgical procedure for rectal cancer [3]. Therefore, TME plus preoperative radiotherapy became the standard treatment for advanced rectal cancer [4]. However, in order to further improve the outcome of rectal cancer surgery, different modalities have been attempted, including preoperative chemoradiotherapy and postoperative chemoradiotherapy. Recent advances in chemotherapy for colorectal cancer have made it possible to use new chemotherapeutic agents in preoperative chemoradiotherapy including biological agents. Accordingly, a multidisciplinary approach is now considered to be important in the treatment of rectal cancer. Another epoch-making advancement in surgery for rectal cancer is the introduction of minimally invasive surgery. Laparoscopic surgery for colon cancer was reported in 1991 [5]. Today, there is an increasing number of patients undergoing laparoscopic surgery for colorectal cancer. Large-scale trials have shown that laparoscopic surgery is effective for colorectal cancer, especially regarding the short-term outcome. In Japan, more that 60 % of rectal cancer patients undergo laparoscopic surgery according to the National Clinical Database (NCD). However, there are some limitations associated with laparoscopic surgery, such as the limited range of movement of laparoscopic devices which has been noted. To overcome these limitations, robotic surgery has received attention in recent years. In robotic surgery, increased freedom of movement of the forceps becomes available, which may be very useful for a patient with a narrow pelvis. Consequently, more robotic surgery is now being performed for rectal cancer worldwide. However, the true benefits of robotic surgery Introduction

The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery

Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections. The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches. We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery. An open approach is often used in rectal cancers with higher pathologic stages. Matched patient analysis suggests minimally invasive approaches are associated with improved R0 resections.

German Bowel Cancer Center: An Attempt to Improve Treatment Quality.

Background. Colorectal cancer remains the second most common cause of death from malignancies, but treatment results show high diversity. Certified bowel cancer centres (BCC) are the basis of a German project for improvement of treatment. The aim of this study was to analyze if certification would enhance short-term outcome in rectal cancer surgery. Material and Methods. This quality assurance study included 8197 patients with rectal cancer treated between 1 January 2008 and 31 December 2010. We compared cohorts treated in certified and noncertified hospitals regarding preoperative variables and perioperative outcomes. Outcomes were verified by matched-pair analysis. Results. Patients of noncertified hospitals had higher ASA-scores, higher prevalence of risk factors, more distant metastases, lower tumour localization, lower frequency of pelvic MRI, and higher frequencies of missing values and undetermined TNM classifications (significant differences only). Outcome analysis revealed more general complications in certified hospitals (20.3% versus 17.4%, p = 0.03). Both cohorts did not differ significantly in percentage of R0-resections, intraoperative complications, anastomotic leakage, in-hospital death, and abdominal wall dehiscence. Conclusions. The concept of BCC is a step towards improving the structural and procedural quality. This is a good basis for improving outcome quality but cannot replace it. For a primary surgical disease like rectal cancer a specific, surgery-targeted program is still needed.

Laparoscopic Surgery Decreases the Surgical Risks Associated With Hyperlipidemia in Rectal Cancer

Epidemiologic studies provide evidence for a link between disorders of lipid metabolism and the risk for colorectal cancer, hyperlipidemia is a common feature of rectal cancer patients. However, information about the effects of hyperlipidemia on rectal cancer surgery is scarce. The aim of this study was to investigate whether hyperlipidemia affected short-term outcomes of rectal cancer surgery, and determine the preferable surgery method based on the comparison of laparoscopic surgery and open surgery. Clinical data of 495 rectal cancer patients who received traditional open or laparoscopic radical resection between March 2006 and December 2010 were retrospectively reviewed. Compared with normal blood lipid group (n=232), hyperlipidemia group (n=263) showed increased intraoperative bleeding (P<0.001), prolonged time for resuming food intake (P<0.001), peritoneal drainage (P<0.001), and hospital stay (P=0.019). However, there was no difference in operation time. Compared with those receiving open surgery, patients receiving laparoscopic surgery exhibited less intraoperative bleeding (P<0.001), less time for resuming food intake (P<0.001), peritoneal drainage (P<0.001), and hospital stay (P<0.001), whereas more operation time was needed (P<0.001). Among patients receiving laparoscopic surgery, no differences were shown on hospital stay, time for resuming food intake, and peritoneal drainage between hyperlipidemia group and normal blood lipid group, although more intraoperative bleeding was still presented in the hyperlipidemia group (P<0.001). Hyperlipidemia has adverse effects on rectal cancer surgery. Laparoscopic surgery can eliminate postoperative recovery retardation caused by hyperlipidemia.

Intraoperative complications have a negative impact on postoperative outcomes after rectal cancer surgery

PurposeThe impact of intraoperative complications on the postoperative outcome in rectal cancer surgery is only poorly studied in literature. Thus, the aim of the present study was to assess the frequency of intraoperative complications during rectal resections for malignancies and its influence on the short term outcome. Material and methodsWe analyzed 605 consecutive patients, who had operations for rectal cancer at a single institution between 1995 and 2010. Retrospective data from the surgical procedure and postoperative course were obtained from the institutional colorectal database and individual chart reviews. Intraoperative complications were recorded and its influence on postoperative course was investigated. ResultsIntraoperative complications occurred in 66 (10.9%) patients, with injury to the spleen (n = 35 of 66, 53%) being the most frequent complication.Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7–92) compared to patients without complications (median: 12 days, range 2–135; p = 0.0102). In addition, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (p = 0.0536), whereas no impact on postoperative medical complications could be found (p = 0.8043).Pulmonary disorders were the only predictive marker for intraoperative complications (p = 0.0247) by univariate analysis. ConclusionWe found that intraoperative complications during rectal cancer surgery significantly prolonged hospital length stay. The overall morbidity rate was not affected.

Obesity was associated with a decreased postoperative recurrence of rectal cancer in a Japanese population.

Obesity contributes to the technical difficulty of rectal surgery and is considered to be a risk factor for postoperative complications. The impact of obesity on the long-term outcomes of rectal cancer surgery remains unclear. A total of 263 consecutive rectal cancer patients who underwent surgery were categorized into two groups according to the body mass index (BMI) based on the Asian BMI classification: non-obese (BMI <25 kg/m(2)) and obese (BMI ≥25 kg/m(2)). The postoperative survival and recurrence rates and oncological surgical quality indicators were compared between groups using the univariate and multivariate analyses. The differences in recurrence patterns were assessed by a competing risk regression analysis. 64 (24%) patients were included in the obese group. The number of retrieved lymph nodes was significantly greater in the non-obese group than in the obese group (22.4 vs. 16.0, P < 0.01). The 5-year disease-free survival (DFS) rates were 86.5 and 68.8% in the obese and non-obese groups, respectively (P = 0.01). The multivariate analysis demonstrated that obesity significantly decreased the postoperative recurrence rate (P = 0.04). Moreover, the BMI was significantly associated with distant metastasis (P = 0.04). Obese rectal cancer patients have high DFS rates and a decreased incidence of distant metastases compared to non-obese patients. The BMI may be a key factor for predicting the postoperative prognosis and determination of an appropriate strategy for the treatment of rectal cancer patients.

The first Phuket International Symposium on Colorectal Disease: postgraduate course of the Asia Pacific Federation Congress 2013 of the International College of Surgeons

The first Phuket International Symposium on Colorectal Disease: postgraduate course of the Asia Pacific Federation Congress 2013 of the International College of Surgeons

The Need for Standardized International Reporting Criteria on Postoperative Outcomes in Rectal Cancer Surgery

Aberdeen, Scotland, United Kingdom Financial Disclosure: None reported. Correspondence: Emad H. Aly, M.B.B.Ch., M.S., M.D., F.R.C.S., M.Ed., F.F.S.T.Ed., Laparoscopic Colorectal Surgery & Training Unit, Aberdeen Royal Infirmary, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZN, United Kingdom. E-mail: [email protected]

Uptake of an innovation in surgery: observations from the cluster-randomized Quality Initiative in Rectal Cancer trial

Theory suggests the uptake of a medical innovation is influenced by how potential adopters perceive innovation characteristics and by characteristics of potential adopters. Innovation adoption is slow among the first 20% of individuals in a target group and then accelerates. The Quality Initiative in Rectal Cancer (QIRC) trial assessed if rectal cancer surgery outcomes could be improved through surgeon participation in the QIRC strategy. We tested if traditional uptake of innovation concepts applied to surgeons in the experimental arm of the trial. The QIRC strategy included workshops, access to opinion leaders, intraoperative demonstrations, postoperative questionnaires, and audit and feedback. For intraoperative demonstrations, a participating surgeon invited an outside surgeon to demonstrate optimal rectal surgery techniques. We used surgeon timing in a demonstration to differentiate early and late adopters of the QIRC strategy. Surgeons completed surveys on perceptions of the strategy and personal characteristics. Nineteen of 56 surgeons (34%) requested an operative demonstration on their first case of rectal surgery. Early and late adopters had similar perceptions of the QIRC strategy and similar characteristics. Late adopters were less likely than early adopters to perceive an advantage for the surgical techniques promoted by the trial (p = 0.023). Most traditional diffusion of innovation concepts did not apply to surgeons in the QIRC trial, with the exception of the importance of perceptions of comparative advantage.

Early Outcomes for Rectal Cancer Surgery in the Republic of Ireland Following a National Centralization Program

Following a national audit of rectal cancer management in 2007, a national centralization program in the Republic of Ireland was initiated. In 2010, a prospective evaluation of rectal cancer treatment and early outcomes was conducted. A total of 29 colorectal surgeons in 14 centers prospectively collated data on all patients with rectal cancer who underwent curative surgery in 2010. Data were available on 447 patients who underwent proctectomy with curative intent for rectal cancer in 2010; 23.7% of patients underwent abdominoperineal excision. The median number of lymph nodes identified was 12. The 30-day mortality rate was 1.1%. Compared with 2007, there was a reduction in positive circumferential margin rate (15.8 vs 4.5%, P<0.001), clinical anastomotic leak rate (10.8 vs 4.3%, P=0.002), and postoperative radiotherapy use (17.8 vs 4.0%, P<0.001). Also, 53.9% received preoperative radiotherapy in 2010. Four centers gave statistically more patients (high-administration), and four centers gave fewer patients (low-administration) preoperative radiotherapy for T2/T3 tumors (P<0.05). On multivariate analysis, being treated in a "high-administration center" increased the likelihood (likelihood ratio [LR], 2.9; 95% CI 1.7-4.8; P<0.001) while attending a "low-administration center" (LR, 0.3; 95% CI 0.2-0.5; P<0.001) reduced the likelihood of receiving preoperative radiotherapy for a T2/T3 rectal cancer. Patients undergoing rectal cancer surgery in hospitals following a national centralization initiative received high-quality surgery. Significant heterogeneity exists in radiotherapy administration, and evidence-based guidelines should be developed and implemented.

A Novel Risk-Adjusted Nomogram for Rectal Cancer Surgery Outcomes

The circumferential resection margin is the primary determinant of local recurrence and a major factor in survival in rectal cancer. Neither chemotherapy nor chemoradiation compensates for a margin positive for cancer. To identify treatment-related factors associated with hospital margin-positive resection and to develop a tool that could be used by individual hospitals to assess their outcomes based on their unique mix of patient and tumor characteristics. Retrospective review of the National Cancer Data Base, 1998-2007. Community and academic/research hospitals. Individuals with histologically confirmed localized rectal/rectosigmoid adenocarcinoma. All individuals underwent radical resection for rectal cancer with or without neoadjuvant therapy. Rate of margin positivity determined and adjusted for patient- and tumor-related factors to calculate expected margin positivity per hospital. An observed to expected ratio was calculated based on patient- and tumor-related factors to identify treatment-associated variation. The overall margin-positive resection rate was 5.2%. Patients with margins positive for cancer were more likely to be older, male, and African American; not have private insurance; and have their cancer diagnosed later in the study period. Associated tumor-related factors include rectal location, higher American Joint Committee on Cancer stage, signet/mucinous histology, and poor/undifferentiated grade. Among hospitals that were significantly low outliers, 47% were comprehensive community hospitals, and 43.9% were academic/research hospitals; of those that were significantly high outliers, 52.3% were comprehensive community hospitals, and 17.8% were academic/research hospitals. High-volume centers made up 80% of significantly low outlier hospitals and 17% of significantly high outlier hospitals. The rates of chemotherapy and radiation were similar, but low outlier hospitals gave more neoadjuvant radiation (26.3% vs 17%). After adjustment for patient- and tumor-related factors, we identified both low and high outlier hospitals for margin positivity at resection, as well as potentially modifiable risk factors. The nomogram created in this model allows for the evaluation of observed and expected event rates for individual hospitals, providing a hospital self-assessment tool for identifying targets for improvement.

Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review

Elderly people represent almost all patients diagnosed with and treated for rectal cancer, and this trend is likely to become more apparent in the future. Surgical management and treatment decisions for this disease are becoming increasingly complex, but only a few reports deal specifically with older patients. In this systematic review, we provide an overview of published studies of outcomes after curative surgery for rectal cancer in elderly people (>70 years). We identified 48 studies providing information about postoperative results, survival, surgical approach, stoma formation, functional results, and quality of life after rectal resection for cancer. We found that advanced chronological age should not, by itself, exclude patients from curative rectal surgery or from other surgical options that are available for younger patients. Although overall survival is lower in elderly patients than in younger patients, cancer-specific survival does not decrease with age. However, the level of evidence for most studies was weak, emphasising the need for high-quality clinical trials for this population.

Volume and outcome in rectal cancer surgery: the importance of quality management

For many years, the impact of the surgeon volume on short- and long-term outcome after rectal carcinoma surgery is controversially discussed. Literature and own department data were reviewed in order to clarify the impact of surgeon volume in the current era of total mesorectal excision surgery, multimodal therapy, quality management, and centralization of cancer care. Uni- and multivariate analysis of data from 1,028 patients with solitary rectal carcinoma, treated between 1995 and 2010 at the Department of Surgery, University Hospital, Erlangen, Germany, was performed. Surgeons were subdivided according to the number of operations/year into high- (at least seven/year), medium- (three to six), and low- (less than three) volume surgeons. Of 1,028 patients, 800 (77.8 %) were operated by five high-volume surgeons, 193 (18.8 %) by seven medium-volume surgeons, and 35 (3.4 %) by 12 low-volume surgeons. Surgeon volume was significantly associated with postoperative mortality and the rate of positive pathological circumferential resection margin. In risk-adjusted analysis, after primary surgery, surgeon volume had a significant impact on observed overall survival and disease-free survival, but not on locoregional recurrence. After neoadjuvant radiochemotherapy, only observed overall survival was significantly influenced by surgeon volume. In surgical departments with special interest in rectal carcinoma, surgeon volume has some influence on short- and long-term outcome. Irrespective of this fact, specialization, experience, individual skill, hospital organization, and regular quality assurance are essential prognostic factors ensuring good results in rectal carcinoma surgery.

The Myth of Informed Consent in Rectal Cancer Surgery

Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process. The aims of this study were to describe the decisional needs of adult patients with rectal cancer when deciding on the surgical treatment of their disease and to identify gaps in patients' recollection of the informed consent discussion. Face-to-face interviews were conducted with the use of a questionnaire based on the validated Ottawa Decision Support Framework Needs Assessment. This study was performed at a university-based academic Cancer Assessment Center, in Ottawa, Ontario, Canada. Adult patients with rectal cancer treated with low anterior resection or abdominoperineal resection were included. The primary outcomes measured were patients' knowledge and understanding of decision and their decisional needs. Thirty patients were interviewed between November 2009 and July 2010. Eighty percent were male, with a median age of 65. None of the patients perceived having a choice of surgical options. When questioned about the main outcomes of rectal cancer surgery, 47% could not recall a preoperative discussion of risks to bowel function, 47% could not recall a preoperative discussion of risks to sexual function, and 57% could not recall a preoperative discussion of risks to urinary function. Patients would like information regarding functional outcomes, body image, and the immediate postoperative period. A minority of patients desire information regarding cure rate, need for a second surgery, or the ability of surgery to treat their symptoms. Patients would like information that is portable and trusted by their health care team that they can review at their own time. To avoid introducing decisional conflict before surgery, patients were interviewed at the first postoperative visit. Preoperative informed consent discussions were not standardized. Despite a comprehensive educational oncology pathway, patients retain little of the informed consent discussion. This study highlights the dichotomy between the outcomes that surgeons and patients value most. The results of this study will guide future efforts to improve informed consent.