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Study Faults Laparoscopic Surgery for Colon Cancer

Researchers caution method still needs to be proven safe, effective

TUESDAY, Jan. 15, 2002 (HealthDayNews) -- Given the choice between abdominal surgery requiring a foot-long incision and a week-long hospital stay and an operation using a few narrow incisions and only a few days in the hospital, a patient's choice might seem clear.

But a new study suggests that the benefits of the latter type of surgery -- which uses a camera called a laparoscope -- to remove colon cancer are not dramatic enough to replace the standard open procedure. The researchers say that until laparoscopic-assisted colectomy is proven to be as safe and effective as conventional colon cancer surgery, it should be viewed as experimental and offered only as part of clinical trials.

Colon cancer affects approximately 107,300 Americans every year and 48,100 people will die of the disease.

"Minimally invasive surgery using fiber optics has been around for noncancerous conditions and has caught on like wildfire over the last decade or so," says lead investigator Dr. Jane Weeks. "The advantages are that patients have smaller scars, and they tend to leave the hospital earlier."

But when it comes to colon cancer, "the stakes are higher," says Weeks, an associate professor of medicine at the Dana-Farber Cancer Institute in Boston. "Any quality-of-life benefits have got to be weighed against the possibility that it might not be as effective a procedure in keeping the cancer from coming back."

The technique that uses this minimally invasive surgery for colon cancer was developed in the last 10 years. In a laparoscopic-assisted colectomy, or LAC, surgeons make small slits in a patient's abdomen and insert a probe with a small video camera on the tip. Using this image, they locate the cancerous section of the colon, then pull the affected section out of a slit and remove the tumor.

On average, patients who have this procedure can go home a day earlier than those who undergo an open colectomy procedure. They also experience less pain and require less medication.

But Weeks says that questions remain about whether the less-invasive surgery is safe or cost-effective, and whether colon cancer patients benefit. While this study couldn't address the first two issues, it provides some answers about the surgery's effect on short-term quality of life.

Weeks and her colleagues at the Dana-Farber Cancer Institute and the Mayo Clinic in Rochester, Minn., followed 428 colon cancer patients at 37 different medical centers who were randomly assigned to have either an open colectomy or a LAC.

The patients' surgeons had full discretion about switching from a LAC to an open colectomy during the procedure if they felt it was medically necessary. Ultimately, 213 patients who underwent an open colectomy and 215 LAC patients completed the follow-ups, which took place two days, two weeks and two months after the surgery. The average age among the patients was 69.

Weeks found that the LAC patients needed less pain medication and, on average, went home less than a day sooner than the open colectomy patients did.

At the follow-up points, the researchers surveyed each patients using a 13-point Symptom Distress Scale and a quality-of-life index that measured the patients' activity, daily living, health, support and outlook.

But Weeks was surprised to find that while the patients in the LAC group reported some modest benefits, they didn't experience statistically significant quality-of-life improvements compared to the open colectomy patients.

"We expected to see fairly substantial quality-of-life differences," she notes.

"These benefits -- while there is a slight advantage that we observed -- are really very, very modest," she adds. "It just makes it even clearer that we should continue to consider this procedure for colon cancer as experimental, and it should not be offered to patients… until the long-term results about safety become available."

Weeks says that during an open colectomy, surgeons have the chance to visually examine and feel around the abdomen for any evidence that the cancer might have spread. This isn't possible during a LAC.

She also notes that the actual removal of the tumor differs between the procedures, and that some studies suggest the tumor might recur at one of the small LAC incision sites.

The research is published in tomorrow's isue of the Journal of the American Medical Association.

Dr. Nicholas Petrelli, medical director of the Helen F Graham Cancer Center in Newark, Del., and the author of an accompanying editorial in JAMA, agrees that LAC as a potential cure for colon cancer must still be considered an investigational procedure.

He says that these results point to a wider need for rigorous clinical trials to provide information about prevention, early detection and treatment of colon cancer.

"This study in laparoscopic colectomy versus open colectomy … demonstrates the importance of a clinical trial," says Petrelli. "We cannot assume that one procedure or one treatment is better than the other."

What To Do

Check out these illustrated, but graphic, images of LAC from the Mayo Clinic.

You can also find out about colon cancer from the American Gastroenterological Association or the American Cancer Society.

SOURCES: Interviews with Jane C. Weeks, M.D., associate professor of medicine, Dana-Farber Cancer Institute, Boston; Nicholas J. Petrelli, M.D., medical director, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, Del.; Jan. 16, 2002, Journal of the American Medical Association
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