Advertisement

Current Practice Patterns in Locally Advanced Rectal Cancer at Academic Institutions: A National Survey Among Radiation Oncologists, Medical Oncologists, and Colorectal Surgeons

Published:September 16, 2022DOI:https://doi.org/10.1016/j.clcc.2022.06.001

      Highlights

      • Among academic radiation oncologists, medical oncologists, and colorectal surgeons, the traditional regimen of long-course chemoradiation, surgery, and adjuvant chemotherapy is now infrequently recommended for locally advanced rectal cancer.
      • Total neoadjuvant therapy has been widely adopted for locally advanced node positive rectal tumors with variable patterns of care with respect to sequencing of chemotherapy and radiotherapy.
      • Fractionation with long-course chemoradiation remains the majority; however, short-course radiotherapy is gaining acceptance, notably for mid- and upper rectal tumors.
      • Non-operative management after a clinical complete response in low rectal tumors has gained traction, transforming locally advanced rectal cancer from a once classically perceived surgical disease.

      ABSTRACT

      Purpose

      To assess the current treatment patterns in locally advanced rectal cancer (LARC) among radiation oncologists (RO), medical oncologists (MO), and colorectal surgeons (SR) specializing in gastrointestinal (GI) malignancies at academic institutions.

      Methods

      An online survey consisting of seven LARC clinical vignettes was distributed to GI specialists practicing at ACGME accredited academic institutions. Treatment paradigms consisted of long-course chemoradiation (LC-CRT) and short-course (SCRT) radiotherapy, chemotherapy (CHT), and surgery. The survey was open from January to April 2021.

      Results

      36 RO, 14 MO and 21 SR (71/508 physicians) replied resulting in a response rate of 14.0%. For low rectal node positive tumors, 88.7% of primary recommendations incorporated TNT (73.1% LC-CRT, 26.9% SCRT). NOM was preferred by 41.3% if a clinical complete response (cCR) was achieved. The presence of high-risk features led 95.8% of physicians to employ TNT (79.4% LC-CRT, 20.6% SCRT). For a cT3N1-2 mid-rectal tumor without high-risk features, 85.9% would primarily recommend TNT (56.6% LC-CRT, 43.4% SCRT). For a cT4bN2a mid-rectal tumor without high-risk features, 97.2% of primary recommendations included TNT (76.9% LC-CRT, 23.1% SCRT).

      Conclusions

      Among academic RO, MO, and SR, the traditional regimen of LC-CRT, surgery, and adjuvant CHT is now infrequently recommended for LARC. TNT has been widely adopted for locally advanced node positive rectal tumors with variable patterns of care with respect to sequencing of CHT and RT. Fractionation with LC-CRT remained the majority. Non-operative management after a cCR in low rectal tumors has gained traction transforming LARC from a once classically perceived surgical disease.
      MicroAbstract
      The treatment landscape of rectal cancer has evolved from neoadjuvant long-course chemoradiation, surgery, followed by adjuvant chemotherapy to a total neoadjuvant approach (TNT) for most locally advanced rectal tumors. There remains a preference for conventionally fractionated long-course radiotherapy. Non-operative management after TNT in lieu of surgery has gained increasing acceptance at academic centers.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Colorectal Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      Reference

      1. USCS Data Visualizations. Accessed May 2, 2021. https://gis.cdc.gov/grasp/USCS/DataViz.html

        • Sauer R
        • Liersch T
        • Merkel S
        • et al.
        Preoperative Versus Postoperative Chemoradiotherapy for Locally Advanced Rectal Cancer: Results of the German CAO/ARO/AIO-94 Randomized Phase III Trial After a Median Follow-Up of 11 Years.
        J Clin Oncol. 2012; 30: 1926-1933https://doi.org/10.1200/JCO.2011.40.1836
        • Cedermark B
        • Dahlberg M
        • et al.
        • Swedish Rectal Cancer Trial
        Improved survival with preoperative radiotherapy in resectable rectal cancer.
        N Engl J Med. 1997; 336: 980-987https://doi.org/10.1056/NEJM199704033361402
        • van Gijn W
        • Marijnen CAM
        • Nagtegaal ID
        • et al.
        Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial.
        Lancet Oncol. 2011; 12: 575-582https://doi.org/10.1016/S1470-2045(11)70097-3
        • Ngan SY
        • Burmeister B
        • Fisher RJ
        • et al.
        Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology Group trial 01.04.
        J Clin Oncol Off J Am Soc Clin Oncol. 2012; 30: 3827-3833https://doi.org/10.1200/JCO.2012.42.9597
        • Pettersson D
        • Cedermark B
        • Holm T
        • et al.
        Interim analysis of the Stockholm III trial of preoperative radiotherapy regimens for rectal cancer.
        Br J Surg. 2010; 97: 580-587https://doi.org/10.1002/bjs.6914
        • Ludmir EB
        • Palta M
        • Willett CG
        • Czito BG.
        Total neoadjuvant therapy for rectal cancer: An emerging option.
        Cancer. 2017; 123: 1497-1506https://doi.org/10.1002/cncr.30600
        • Beard BW
        • Rao AR
        • Schumacher A
        • Attaluri V
        • McLemore L.
        Watchful Waiting after Clinical Complete Response to Neoadjuvant Chemoradiation for Rectal Cancer.
        Int J Radiat Oncol Biol Phys. 2019; 105: E161https://doi.org/10.1016/j.ijrobp.2019.06.2133
      2. Preliminary results of the organ preservation of rectal adenocarcinoma (OPRA) trial.
        | Journal of Clinical Oncology. 2021; (Accessed May 2)
        • Bahadoer RR
        • Dijkstra EA
        • van Etten B
        • et al.
        Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial.
        Lancet Oncol. 2021; 22: 29-42https://doi.org/10.1016/S1470-2045(20)30555-6
      3. rectal.pdf. Accessed November 21, 2021. https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf

        • R Core Team
        R: A language and environment for statistical ## computing.
        R Foundation for Statistical Computing, Vienna, Austria2019 (URL)
        • Conroy T
        • Bosset JF
        • Etienne PL
        • et al.
        Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial.
        Lancet Oncol. 2021; 22: 702-715https://doi.org/10.1016/S1470-2045(21)00079-6
        • Cercek A
        • Roxburgh CSD
        • Strombom P
        • et al.
        Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer.
        JAMA Oncol. 2018; 4e180071https://doi.org/10.1001/jamaoncol.2018.0071
        • Fokas E
        • Allgäuer M
        • Polat B
        • et al.
        Randomized Phase II Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: CAO/ARO/AIO-12.
        J Clin Oncol Off J Am Soc Clin Oncol. 2019; 37: 3212-3222https://doi.org/10.1200/JCO.19.00308
        • Suit HD
        • Gallager HS.
        INTACT TUMOR CELLS IN IRRADIATED TISSUE.
        Arch Pathol. 1964; 78: 648-651
        • Raldow AC
        • Chen AB
        • Russell M
        • et al.
        Cost-effectiveness of Short-Course Radiation Therapy vs Long-Course Chemoradiation for Locally Advanced Rectal Cancer.
        JAMA Netw Open. 2019; 2e192249https://doi.org/10.1001/jamanetworkopen.2019.2249
        • Moore A
        • Den RB
        • Gordon N
        • et al.
        The Financial Impact of Fractionation Scheme and Treatment Planning Method for Rectal Cancer in the United States.
        Clin Colorectal Cancer. 2019; 18: 209-217https://doi.org/10.1016/j.clcc.2019.05.005
        • Pach R
        • Sierzega M
        • Szczepanik A
        • Popiela T
        • Richter P.
        Preoperative radiotherapy 5 × 5 Gy and short versus long interval between surgery for resectable rectal cancer: 10-Year follow-up of the randomised controlled trial.
        Radiother Oncol. 2021; 164: 268-274https://doi.org/10.1016/j.radonc.2021.10.006
        • Bujko K
        • Wyrwicz L
        • Rutkowski A
        • et al.
        Long-course oxaliplatin-based preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal cancer: results of a randomized phase III study.
        Ann Oncol Off J Eur Soc Med Oncol. 2016; 27: 834-842https://doi.org/10.1093/annonc/mdw062
        • Abdel-Rahman O
        • Elhalawani HM
        • Allen PK
        • Holliday EB.
        Utilization of short-course radiation therapy for patients with nonmetastatic rectal adenocarcinoma in the United States.
        Adv Radiat Oncol. 2018; 3: 611-620https://doi.org/10.1016/j.adro.2018.07.007
        • Mowery YM
        • Salama JK
        • Zafar SY
        • et al.
        Neoadjuvant long-course chemoradiation remains strongly favored over short-course radiotherapy by radiation oncologists in the United States.
        Cancer. 2017; 123: 1434-1441https://doi.org/10.1002/cncr.30461
        • Prionas ND
        • Koong AC
        • Chang DT.
        Short-Course Vs Long-Course Radiotherapy: Pros and Cons.
        in: Schlachta CM Sylla P Current Common Dilemmas in Colorectal Surgery. Springer International Publishing, 2018: 329-339https://doi.org/10.1007/978-3-319-70117-2_29
        • Dalwadi SM
        • Nakhleh L
        • Gomber G
        • Bogany M
        • Ludwig MS.
        Healthcare Cost Analysis of Short-Course vs. Long-Course Pre-Operative Radiotherapy Schedules for Rectal Cancer.
        Int J Radiat Oncol Biol Phys. 2021; 111: e341https://doi.org/10.1016/j.ijrobp.2021.07.1031
        • Romesser PB
        • Wu AJ
        • Cercek A
        • et al.
        Management of Locally Advanced Rectal Cancer During The COVID-19 Pandemic: A Necessary Paradigm Change at Memorial Sloan Kettering Cancer Center.
        Adv Radiat Oncol. 2020; 5: 687-689https://doi.org/10.1016/j.adro.2020.04.011
        • Martens MH
        • Maas M
        • Heijnen LA
        • et al.
        Long-term Outcome of an Organ Preservation Program After Neoadjuvant Treatment for Rectal Cancer.
        J Natl Cancer Inst. 2016; 108https://doi.org/10.1093/jnci/djw171
        • Appelt AL
        • Pløen J
        • Harling H
        • et al.
        High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study.
        Lancet Oncol. 2015; 16: 919-927https://doi.org/10.1016/S1470-2045(15)00120-5
      4. Alliance for Clinical Trials in Oncology. A Phase II/III Trial of Neoadjuvant FOLFOX With Selective Use of Combined Modality Chemoradiation Versus Preoperative Combined Modality Chemoradiation for Locally Advanced Rectal Cancer Patients Undergoing Low Anterior Resection With Total Mesorectal Excision (PROSPECT). clinicaltrials.gov; 2020. Accessed April 29, 2021. https://clinicaltrials.gov/ct2/show/NCT01515787

        • Kim H
        • Pedersen K
        • Olsen JR
        • et al.
        Nonoperative Rectal Cancer Management With Short-Course Radiation Followed by Chemotherapy: A Nonrandomized Control Trial.
        Clin Colorectal Cancer. 2021; 20: e185-e193https://doi.org/10.1016/j.clcc.2021.03.003
        • Chin RI
        • Roy A
        • Pedersen KS
        • et al.
        Clinical Complete Response in Patients With Rectal Adenocarcinoma Treated With Short-Course Radiation Therapy and Nonoperative Management.
        Int J Radiat Oncol. 2021; 12 (Published online October)https://doi.org/10.1016/j.ijrobp.2021.10.004
      5. Rödel PD med C. Short-Course Radiotherapy Versus Chemoradiotherapy, Followed by Consolidation Chemotherapy, and Selective Organ Preservation for MRI-Defined Intermediate and High-Risk Rectal Cancer Patients. clinicaltrials.gov; 2021. Accessed January 27, 2022. https://clinicaltrials.gov/ct2/show/NCT04246684

      6. University of Birmingham. STAR-TREC:Can the Rectum Be Saved by Watchful Waiting or TransAnal Surgery Following (Chemo)Radiotherapy Versus Total Mesorectal Excision for Early REctal Cancer. clinicaltrials.gov; 2018. Accessed January 27, 2022. https://clinicaltrials.gov/ct2/show/NCT02945566

        • KELLEY K
        • CLARK B
        • BROWN V
        • SITZIA J
        Good practice in the conduct and reporting of survey research.
        Int J Qual Health Care. 2003; 15: 261-266https://doi.org/10.1093/intqhc/mzg031