Multidisciplinary Management of Resectable Rectal Cancer

This review nicely summarizes the current state of combined-modalitytherapy for resectable rectal cancer, largely covering trialscurrently in progress in the United States. Although the article'stitle is "Multidisciplinary management of resectable rectalcancer," it really doesn't emphasize how multiple specialistsmanage rectal cancer patients per se, and thus, the article wouldprobably be more appropriately titled, "Combined-modalitytherapy in resectable rectal cancer." It would have beeninteresting if the article had included more details on how radiationoncologists, medical oncologists, and surgeons can cooperate todeliver combined-modality therapy in higher proportions of patientswith resectable rectal cancer, but this is a minor criticism.

Since there very much is an issue in the surgical community asto whether or not adjuvant therapy is necessary if "effective"surgery is performed, it is worth noting that in several centersin Europe, radical rectal cancer surgery using the "totalmesorectal excision" technique popularized by R. J. Heald[1]is undergoing serious study. In Sweden and the Netherlands, totalmesorectal excision alone is being compared with total mesorectalexcision plus adjuvant chemoradiotherapy.[personal communication,Lars Påhlman, md, phd, Department of Surgery, Uppsala University,June 1996] Accrual of a sufficient number of patients (numberingin the hundreds) should help answer the question of whether ornot adjuvant therapy really has something to offer when "effective"surgery is performed.

European Trials of Preoperative Radiation Given Short Shrift

My main criticism of this article is that Dr. Minsky may havegiven short shrift to some of the European trials of preoperativeradiation therapy. First of all, a recent randomized trial fromSweden, reporting on over 1,100 patients, showed that both localrecurrence and overall survival were significantly better in apreoperative radiation-therapy group than in a surgery-alone group.[2]This is the first study to report a significant impact of radiationtherapy alone on survival. This study utilized a 25-Gy dose givenover 5 days before surgery--a type of regimen that Dr. Minskybelieves may not be worthwhile. There may be some significantadvantages to this therapy, in that it permits the patient toundergo a very short course of preoperative treatment that seemsto be quite simple. Economic considerations could also be importantwith this treatment regimen, and its demonstrated effectivenessis at least worthy of further serious consideration in North America,as well as in Europe.

Dr. Minsky appears to be most favorably impressed with the 5,040-cGypreoperative radiation scheme that he and others have used extensively.In nonrandomized trials, these researchers have seen impressiveshrinkage of the tumor with this radiation scheme, perhaps permittingbetter sphincter preservation. Although I believe that this sphincter-preservationstrategy probably does not lead to an increase in local recurrence,Dr. Minsky makes no comment about local recurrence in patientswho undergo sphincter-preservation procedures after preoperativeradiation.

Summary

Dr. Minsky has been one of the pioneers of combined-modality therapyin the treatment of resectable rectal cancer. His article nicelysummarizes the current issues related to the adjuvant therapyof resectable rectal cancers, and he notes that many importantquestions should be answered by the ongoing North American randomizedtrials (particularly the National Surgical Adjuvant Project forBreast and Bowel Cancers [NSABP] R-03 and Intergroup 0147 trials).I hope that Dr. Minsky and other North American investigatorswill remain sensitive to the very important trials being conductedin Europe, which are quite different in design than the NorthAmerican trials and often accrue much larger numbers of patientsover far shorter periods of time.

References:

1. Heald RJ, Karanjia ND: Results of radical surgery for rectalsurgery. World J Surg 16:848-857, 1992.

2. Swedish rectal cancer trial: Increased 5-years survival afterpreoperative irradiation in rectal cancer: Meeting of AmericanSociety of Colon and Rectal Surgeons 1996 (abstract). Dis ColonRectum 39:A19, 1996.