The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline

Abstract

BackgroundThis systematic review with meta-analysis was designed to evaluate the literature and to develop recommendations regarding the use of preoperative radiotherapy in the management of patients with resectable rectal cancer.MethodsThe MEDLINE, CANCERLIT and Cochrane Library databases, and abstracts published in the annual proceedings of the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were systematically searched for evidence. Relevant reports were reviewed by four members of the Gastrointestinal Cancer Disease Site Group and the references from these reports were searched for additional trials. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.ResultsTwo meta-analyses of preoperative radiotherapy versus surgery alone, nineteen trials that compared preoperative radiotherapy plus surgery to surgery alone, and five trials that compared preoperative radiotherapy to alternative treatments were obtained. Randomized trials demonstrate that preoperative radiotherapy followed by surgery is significantly more effective than surgery alone in preventing local recurrence in patients with resectable rectal cancer and it may also improve survival. A single trial, using surgery with total mesorectal excision, has shown similar benefits in local recurrence.ConclusionFor adult patients with clinically resectable rectal cancer we conclude that:• Preoperative radiotherapy is an acceptable alternative to the previous practice of postoperative radiotherapy for patients with stage II and III resectable rectal cancer;• Both preoperative and postoperative radiotherapy decrease local recurrence but neither improves survival as much as postoperative radiotherapy combined with chemotherapy. Therefore, if preoperative radiotherapy is used, chemotherapy should be added postoperatively to at least patients with stage III disease.

Lymphovascular invasion in rectal cancer following neoadjuvant radiotherapy: A retrospective cohort study

“…38 (36.9) 60 (27.0) Chinese Anti-Cancer Association (CACA) [11] , based on some high-level clinical evidence [12,13] . Surgery was performed 2-3 weeks after full dose radiation.…”

Current neoadjuvant strategies in rectal cancer

“…This study concluded preoperative radiotherapy, at doses !30 Gy, reduces the risk of local recurrence and death from rectal cancer. A third meta-analysis of RCTs by Figueredo et al [11] found local recurrence rates were lower with preoperative radiation but also concluded postoperative chemotherapy should be used in adjunct to radiation due to the survival benefit.…”

“…Study outcomes were inconsistent due to differences in treatment algorithms, i.e., dosage and duration of irradiation, timing of surgery, stage of cancer, quality of resection, and duration of follow-up. Three meta-analyses have been conducted to better understand inconsistencies between these trials [9][10][11]. All three studies reported a significant decrease in the local recurrence rate of stage II and III rectal cancers treated with radiation prior to resection.…”

Impact of pre‐ and postoperative multimodality therapy on rectal cancer

“…Three meta-analyses pooled the results from 22 randomized trials of preoperative radiation [27][28][29]. All three reported significant reductions in the risk of local recurrence and moderate improvement in overall survival, although Figueredo et al noted that postoperative radiation therapy combined with chemotherapy also improved longterm survival [27][28][29].…”