A review of the last decade of care for rectal cancer has found evidence of significant progress in improving patient outcomes despite a number of challenges.
For their review, researchers led by Nader N Massarwah, MD, MPH, Michael E DeBakey VA Medical Center (Houston, TX), focused on the use of chemotherapy and radiation therapy (XRT) as part of multi-modality treatment (MMT) for patients with rectal cancer. To do so, they gathered practice data and current guideline recommendations from cancer organizations and clinical trials. They published their assessment in the Journal of Surgical Oncology.
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In their review, researchers first made reference to a Swedish rectal cancer trial, which found that XRT in addition to surgery significantly improved recurrence rate, 5-year overall survival, and 9-year cancer specific survival. When total mesorectal excision (TME) was later introduced as the surgical standard, it too demonstrated improvement in recurrence rate in another study when paired with neoadjuvant XRT. And in a third study comparing pre- and post-operative use of chemoradiation (CRT), findings favored the use of pre-operative CRT to not only improve local disease control, but also the likelihood of sphincter preservation.
In all, researchers made note of three key conclusions derived from a literature review of studies relating XRT as a part of MMT: first, that XRT in combination with TME provides a meaningful reduction in the risk of local recurrence; second, that, although obtaining a negative CRM is likely the most important prognostic factor, XRT may be of further benefit in reducing the risk for local failure; and third, that administration of CRT may influence the surgeon’s ability to perform a sphincter-preserving operation for patients with low rectal tumors.
In comparing whether short- or long-term regimens lead to better outcomes for patients, researchers wrote that there is still too little data to make a definite assessment. In the United States, longer XRT regimens are preferred, but some European studies have suggested that outcomes with short-term regimens compare favorably to longer ones while costing up to 50% less. Additionally, research will need to be conducted to assess why longer regimens seem to be preferred in the United States.
From the patient’s perspective, this issue of cost and the social burdens of an extended period of aggressive care is one that is important and often overlooked.
“A protracted period of treatment can often overwhelm even the most resolute patients and may result in an inability to perform common leisure activities and/or to work,” researchers wrote.
Long-term XRT regimens by definition are associated with a longer treatment course, which likely means more time spent in the hospital, more time missed at work, and overall greater inconvenience. These factors should be carefully considered when care strategies are presented to patients.
Other challenges for XRT therapy in the future will be to ensure that there is better surgical quality control during accrual, as this can be a critical factor for adjunctive therapeutic effect. Further, there is growing interest in determining whether patients who have a pathologic complete response during adjuvant treatment can be managed without surgical intervention. Overcoming these challenges and introducing XRT to more patients presents an opportunity to introduce greater value into rectal cancer care.
In conclusion, the researchers wrote that the care of patients with rectal cancer has been dynamic over the last 20 years and has opportunities to continue to grow. More in-depth research will be needed to inform the cost–benefit ratio of XRT and other treatment avenues as well as direct the future of MMT for patients with locally advanced disease.—Sean McGuire
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