Rectal Cancer: Neoadjuvant Therapy
Neoadjuvant therapy is a critical component of the multidisciplinary treatment of patients with rectal cancer. The objective of neoadjuvant therapy, either radiotherapy, combined chemoradiotherapy, or chemotherapy alone, is to reduce the risk of local rec
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Key Concepts • Neoadjuvant radiotherapy is associated with an improvement in local pelvic control following proctectomy for rectal cancer as compared to surgery alone. • Neoadjuvant chemoradiotherapy is associated with an improvement in local pelvic control and has lower toxicity as compared to postoperative chemoradiotherapy. • Short-course neoadjuvant radiotherapy has been demonstrated to have similar outcomes in terms of overall survival, disease-free survival, and local pelvic control when compared to long-course neoadjuvant chemoradiotherapy and is associated with lower cost and shorter time to multidrug systemic cytotoxic chemotherapy. • Current research is focused on limiting the morbidity of therapy, by omitting either proctectomy or radiotherapy in select patients.
term oncologic outcomes [1–3]. In addition, neoadjuvant therapy could potentially enable the consideration of organ preservation by allowing for more effective local excision and nonoperative management (NOM) strategies. Finally, delivering systemic chemotherapy before surgery in patients at risk for distant metastasis has the potential to improve survival by addressing micrometastatic disease earlier and improving treatment compliance. Maximizing neoadjuvant treatment response can therefore have a profound effect on both oncologic and quality-of-life outcomes. In this chapter, we will focus primarily on neoadjuvant therapy for LARC, widely accepted to be clinical stage II (cT3–4, cN0) or stage III (any cT, cN1–2) invasive adenocarcinomas of the rectum. We will review various treatment paradigms and the data supporting each.
Historical Context Introduction Neoadjuvant therapy is a critical component of the multidisciplinary treatment of patients with rectal cancer. The objective of neoadjuvant therapy, either radiotherapy, combined chemoradiotherapy, or chemotherapy alone, is to reduce the risk of local recurrence in patients with locally advanced rectal cancer (LARC) undergoing surgical resection. But neoadjuvant therapy provides other potential advantages to rectal cancer patients. It allows early assessment of tumor responsiveness to therapy, which is closely correlated with longA. Cercek, M.D. Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA J. Garcia-Aguilar, M.D., Ph.D. (*) Department of Surgery, Memorial Sloan Kettering Cancer Center, 1233 York Avenue, New York, NY 10065, USA e-mail: [email protected]
The story of neoadjuvant radiotherapy and chemoradiotherapy for patients suffering from rectal cancer is long and convoluted, and although much has been published on the topic, there is no universally agreed-upon treatment strategy. It is important for the reader to understand how we arrived at our current state of affairs so that the data from published trials can be put in the proper context. The concept of neoadjuvant therapy for rectal cancer was first introduced by Janeway and Quick in c. 1917, who noted significant tumor response when gold filtered radon emanation seeds were implanted directly into rec
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