ESMO E-Learning: Peri-Operative Treatment of Locally Advanced Rectal Cancer

In this E-Learning module, the author elaborates evidence for a number of questions related to the peri-operative treatment of locally advanced rectal cancer. Any peri-operative treatment, either before or after conventional surgery, improves outcomes as compared to surgery alone.

The topics covered include answering questions such as:

• is peri-operative treatment still necessary in case high-quality total mesorectal excision (TME) surgery is performed;
• should radiotherapy be delivered before or after surgery;
• what are the standard pre-operative treatment regimens;
• what is the best timing for surgery after long-course chemoradiotherapy;
• is there any role for adjuvant chemotherapy after pre-operative treatment;
• what is the rationale of intensifying pre-operative therapy, and what type of intensified treatment strategies have been investigated;
• what are the new standard pre-operative treatment regimens;
• do all stage II-III tumours have the same recurrence risk;
• are there any additional risk factors that could help to refine patient stratification and inform treatment decisions;
• is radiotherapy an essential component of the pre-operative treatment and could it be omitted;
• is there any role for organ-sparing management strategies.

The author emphasizes historical rationale for peri-operative treatment of locally advanced rectal cancer, in particular high rates of local recurrence and overall poor survival outcomes after curative resection of rectal cancer, especially before the routine use of TME. Local recurrence is associated with a number of disabling symptoms. While it may not improve overall survival, delivering radiotherapy before surgery reduces the risk of local recurrence. Radiotherapy is more effective and less toxic when delivered before surgery.

Long-course, fluoropyrimidine-based, chemoradiotherapy and short-course radiotherapy have been standard pre-operative treatment regimens with largely equivalent results. However, recent results with induction mFOLFIRINOX followed by long-course chemoradiotherapy and short-course radiotherapy followed by oxaliplatin-based chemotherapy, show improved survival outcomes and pCR rate as compared with chemoradiotherapy alone and will likely become new standards of care.

After elaborating evidence for each topic covered in the presentation, the author also provides a very useful summary of clinical recommendations. This E-Learning module is an excellent educational material for all those interested in the management of patients with locally advanced rectal cancer.