Challenges and Barriers to Using Rectal Cancer MRI and Structured Reporting

Anuradha Chandramohan, MD, FRCR, FICR

The first demonstration of high-resolution magnetic resonance imaging (MRI) for rectal cancer was published nearly 25 years ago.[1] This seminal study reported a good radiopathological concordance for circumferential resection margin (CRM) and extramural spread (EMS).[1] Ever since, numerous publications (>6,000 on PubMed only) have underpinned the clinical utility of MRI, both for staging and for restaging of rectal cancer following neoadjuvant treatment. Despite this, the adoption of rectal cancer MRI in India has only been modest. This could be due to the inadequate number of MRI scanners, training gaps among radiographers, lack of quality indicators prescribing minimal standards for diagnostic quality rectal cancer MRI, and lack of consensus on the numbers needed to train the radiographers and radiologists. In addition, there are access and affordability issues. The incidence of rectal cancer among the young is on the rise.[2] However, the comparative prevalence of rectal cancer in the community remains low compared with the other indications for MRI, providing fewer opportunities for learning on the job for those practicing outside of large teaching institutions and specialized hospitals delivering cancer care.

Structured reporting generally ensures consistency and uniformity in communication, report's completeness that includes all critical information for clinical decision-making, and provides continuous service improvement opportunities through audits. A survey of radiologists practicing onco-imaging from 51 countries reported a favorable view of structured reporting, which was perceived to improve report quality, error rates, and communication.[3] Structured reporting significantly increased the proportion of optimal reports compared with unstructured reports in rectal cancer patients.[4] [5] However, there is a perceived imbalance between the quality of patient care and radiologist's productivity.[6] While “What use is a radiology report when it adds little value to patient care?” is an idealistic thought, it cannot be realized unless the barriers and challenges are reflected upon and addressed.

There are unmet training needs and a lack of opportunities to interact with clinical referrers in a multidisciplinary team (MDT) setting. This can disconnect radiologists from the management pathways, depriving them of essential clinical interactions that are critical for understanding the management implications of rectal cancer MRI reports. Such lack of clinical feedback will, in turn, result in poor accountability, disengagement, and less motivation to use structured reporting. In India, where subspeciality radiology expertise is still evolving, general radiology is the most readily available career option. Radiologists in general radiology practice are expected to report imaging studies of all modalities and all anatomical regions irrespective of their subspecialty interests or expertise. This could make radiologists who get paid per imaging study that is reported to choose quantity over quality, discouraging them from adopting structured reporting. Moreover, the payouts per rectal cancer MRI and body MRI reports are perceived as insufficient compared with other MRI studies that take far less time and effort to report. The widespread practice of teleradiology and the shortage of subspecialized radiologists in India further exaggerate these barriers.

This dedicated special issue of the Journal of Gastrointestinal and Abdominal Radiology (JGAR) journal on rectal cancer MRI was designed to address some unmet training needs. We have put together practical material relevant to our practice contributed by expert radiologists and dedicated colorectal surgeons from high-volume institutions around the country. Each article justifies the recommendations with evidence-based guidelines; provides image acquisition parameters, practical tips and tricks, and structured reporting templates; and addresses common pitfalls in image interpretation.

In a dedicated article by A. Goyal et al dealing with the rationale for the imaging referral guidelines in rectal cancer patients, the authors describe the rationale and the importance of choosing certain imaging modality over others at different time points during staging, restaging, and surveillance of rectal cancer patients. Readers can use these to guide the imaging referrals for rectal cancer patients. P. Gupta et al take us through staging MRI of rectal cancer where they describe with illustrative figures the MRI protocol, relevant pelvic anatomy, and definitions pertaining to the interpretation of MRI.[7] The articles by Sheshadri et al and R. Mittal et al describe how MRI findings influence the MDT decision-making and the management of rectal cancer patients. Through these articles, the readers can understand the value addition brought by good-quality rectal cancer MRI and structured reporting.[8] [10] In an exclusive article on restaging MRI for response assessment following neoadjuvant treatment, Chandramohan A. et al describe in detail the steps of interpreting response assessment MRI with illustrative figures and case examples. They also provide a structured reporting format for restaging MRI.[9] Wani et al describe the common pitfalls and challenges in the interpretation of rectal cancer MRI.[11] Finally, in an article on “Pelvic compartments and imaging considerations beyond TME surgery for rectal cancer patients” from a dedicated cancer center performing high volumes of pelvic exenterations, Baheti A.D. et al take the readers through clinical aspects, imaging modalities, and imaging findings that must be described in patients who are being considered for beyond total mesorectal excision type of procedure. I do hope that the technologists, residents, fellows, and practicing radiologists alike dealing with rectal cancer patients can use this special issue of JGAR as reference material for rectal cancer MRI.

Publikationsverlauf

Artikel online veröffentlicht:
24. Juni 2025

• References

• 1 Brown G, Richards CJ, Newcombe RG. et al. Rectal carcinoma: thin-section MR imaging for staging in 28 patients. Radiology 1999; 211 (01) 215-222
• 2 Patel A, Hande V. Rising colorectal cancer in young adults: a warning for all! Let us adopt a healthy lifestyle and colorectal cancer screening. Indian J Cancer 2022; 59 (03) 307-309
• 3 Leithner D, Sala E, Neri E. et al. Perceptions of radiologists on structured reporting for cancer imaging-a survey by the European Society of Oncologic Imaging (ESOI). Eur Radiol 2024; 34 (08) 5120-5130
• 4 Gupta NA, Mahajan S, Sumankumar A, Saklani A, Engineer R, Baheti AD. Impact of a standardized reporting format on the quality of MRI reports for rectal cancer staging. Indian J Radiol Imaging 2020; 30 (01) 7-12
• 5 Sahni VA, Silveira PC, Sainani NI, Khorasani R. Impact of a structured report template on the quality of MRI reports for rectal cancer staging. AJR Am J Roentgenol 2015; 205 (03) 584-588
• 6 Weiss DL, Langlotz CP. Structured reporting: patient care enhancement or productivity nightmare?. Radiology 2008; 249 (03) 739-747
• 7 Garg D, Mehta V, Gulati A. et al. Staging of rectal cancer: MRI protocol, pelvic anatomy, and definitions. J Gastrointestinal Abdominal Radiol 2025; 8(2);--
• 8 Ramakrishnan AS, Pradeep J. How do MRI findings influence rectal cancer management?. J Gastrointestinal Abdominal Radiol 2025; 8(2);--
• 9 Chandramohan A, Augustine A, Hiriyanna S. et al. Response assessment after neoadjuvant chemoradiotherapy in rectal cancer. J Gastrointestinal Abdominal Radiol 2025; 8(2);--
• 10 John A, Mittal R. Role of the multidisciplinary team (MDT) meetings in rectal cancer management. J Gastrointestinal Abdominal Radiol 2025; 8(2);--
• 11 Wani AH, Choh NA, Syed HM. et al. Pitfalls and challenges in the interpretation of rectal cancer magnetic resonance imaging. J Gastrointestinal Abdominal Radiol 2025; 8(2);--