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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

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Date submitted: June 01, 2011

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
For patients with rectal cancer, what is the comparative effectiveness of different imaging modalities, alone or in combination (i.e., incremental benefit from using more than one modality) for preoperative staging and treatment selection?
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
1. Computerized Tomography (CT) scans
2. Positron Emission Tomography (PET)
3. Magnetic Resonance Imaging (MRI)
4. Endorectal Ultrasound (ERUS)
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Adults with newly diagnosed rectal cancer
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
Patients with primary resectable rectal cancer.
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
Improvements in preoperative tumor staging and prediction of tumor-free resection margin (local extension of rectal cancer).

Appropriate selection of patients for treatment (e.g., neoadjuvant therapy, local excision of tumors, or radical surgery) resulting in decreased local recurrence, improved quality of life and overall survival. For example, more accurate staging may decrease need for more extensive surgery in some patients.
Describe any health-related risks, side effects, or harms that you are concerned about.
Harms associated with inaccurate (preoperative) clinical staging resulting in
inappropriate treatment selection. For example, indications for surgery that is more
extensive than warranted by the “true” stage, or inadequate margins that require re-
operation or expose patients to a higher risk of recurrence.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Cancer
AHRQ Priority Populations
  • Low income groups
  • Minority groups
  • Women
  • Elderly
  • Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care
Federal Health Care Program
  • Medicaid
  • Medicare


Describe why this topic is important.
Rectal cancer is a relatively common malignancy. There were 39,670 estimated new cases from rectal cancer in the United States in 2010.* Over the last two decades multimodality treatment has led to important improvements in the treatment of this disease. Preoperative radiation therapy, often combined with chemotherapy, followed by surgery has become the standard of care for most patients. In this respect, modern imaging techniques in the preoperative workup are extremely important for treatment decision making.
* National Cancer Institute (PDQ®). Rectal cancer treatment (2010)
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
This topic was given a high priority by a multi-disciplinary stakeholder panel (including patient advocates/representatives) convened to identify and select important research questions on cancer amenable for systematic and comparative effectiveness review. Assessment of the evidence-base supporting clinical utility of the available imaging modalities used for preoperative staging is needed to ensure appropriate patient selection for neoadjuvant therapy and extent of surgery.
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
There is uncertainty on the optimal preoperative imaging modalities, and on incremental benefit from using multiple modalities, to differentiate between rectal cancers by severity/stage of disease. There is also variation across centers on types of modalities used for preoperative clinical staging.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
A report would inform clinical decision-making for patients, payers and providers.
Describe the timeframe in which an answer to your question is needed.
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
Being age 40 years or older is one of the risk factors of developing rectal cancer. Among all racial groups in the United States, African Americans have the highest sporadic colorectal cancer incidence and mortality rates.*
* It is difficult to separate epidemiological considerations of rectal cancer from those of colon cancer because epidemiological studies often consider colon and rectal cancer (i.e., colorectal cancer) together (National Cancer Institute (PDQ®). Rectal cancer treatment (2010)).

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Other
Are you making a suggestion as an individual or on behalf of an organization?
Organization - BlueCross BlueShield Association Technology Evaluation Center
Please tell us how you heard about the Effective Health Care Program
The BlueCross BlueShield Association Technology Evaluation Center is an Evidence-based Practice Center of AHRQ.