Rectal cancer is an important disease not just because it is one of the most common cancers in the developed world but also because it’s prognosis and complications following treatment are so dependent on the colorectal surgeon managing the patient.

Outcomes following the treatment of any disease are intimately related to

1. The stage of the disease
2. The health of the patient
3. The skill and treatment regimen of the doctor in-charge

The first two factors are not directly dependent on the skill nor management strategy of the surgeon except as an indirect result of earlier detection by increased screening. Management of rectal cancer however is directly affected by the operative skill of the surgeon as well as by the management strategies of the surgeon.

Operative skill affects the final result of treatment as surgery unlike internal medicine is not just science but an art as well. As a science the sort of resection undertaken by the surgeon eg TME, APR, Hartmann’s procedure or sphincter saving techniques etc will have proven permanent and temporary consequences on the patient’s prognosis and quality of life. As an art, the surgical skill and the way the knife is brandished by each individual differs one from the next, surgery will therefore have as great if not a greater effect as the science that it represents. A distance from the anal verge of 3 to 4 cm may be scientifically destined for anal ablation in the case of a low rectal cancer for most surgeons but artistically it may be just another anus to save for the skilled artistic surgeon.

The use or misuse of chemo and radiotherapy by surgeons will also affect the outcomes of patients under the care of the surgeons. Again science certainly will help some patients with big bulky or stuck rectal cancers by the addition of radiotherapy and chemotherapy to enable a more conservative or curative surgery when the alternative was ablative surgery pr death by recurrence. Oncologists however also point to science to show that local pelvic recurrence drops significantly from 6 to 3 percent with the addition of chemotherapy and radiotherapy to TME and therefore all rectal cancer patients; typically stages 2 to 3; require adjuvant therapy. Science puts the necks of surgeons out on the chopping block for the 3 out of a hundred patients who will recur without adjuvant treatment forgetting that 93 out of a hundred will get expensive and potentially harmful treatment for a disease that was cured by surgery. Art however lets the experienced and skillful surgeon select which of his patients might be at higher risk than others and who might need adjuvant therapy. This artistic eye is honed by scientific education as well as the knowing that comes through a master craftsman who at a glance differentiates art from trash and is able to tell which strokes brings healing and which needs further work to bring them up to par.

The surgeon by his education in the science of surgery is able to evaluate the merits of the various therapeutic options be they surgical or medical as to their applicability to his patient and by his skill in the surgical art to assess the accuracy and beauty of his craft to determine the need for additional treatment beyond what he has already provided his patient with during the removal of the cancer.