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Clinical trials have demonstrated that administering neoadjuvant chemoradiotherapy reduces the rate of recurrence in advanced rectal cancer. In most cases, Johanna Bendell, MD, states, neoadjuvant chemoradiation is still the standard of care for patients with rectal cancer; however, several questions have been raised regarding this approach, including overtreatment concerns. In general, she states, the optimal approach taken may vary based on the location and size of the primary tumor.
Claus-Henning Kohne, MD, PhD, notes that neoadjuvant chemoradiotherapy results in fewer colostomies, less recurrence, and is better tolerated than adjuvant radiotherapy. Some surgeons believe that surgery alone is sufficient; however, Kohne states, even following ideal surgeries trials have shown that neoadjuvant treatment is still beneficial.
Axel Grothey, MD, believes that for tumors in the lower and mid rectum, neoadjuvant therapy should remain the standard. However, for patients with higher rectum tumors, surgery may be sufficient to avoid the long-term side effects of radiation. Additionally, trials examining neoadjuvant chemotherapy without radiotherapy are using FOLFOX-based regimens with or without bevacizumab.
A challenge facing the treatment of early stage T1 and T2 rectal cancer is determining if there is lymph node involvement, which may occur in approximately 10% of cases. This makes the initial treatment selection more challenging and calls for a multidisciplinary treatment environment, Heinz-Josef Lenz, MD, says. Furthermore, he states, selecting the proper surgery in this population represents a big dilemma for patients and physicians.