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
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Article Info
Publication History
Accepted:
June 7,
2022
Received in revised form:
March 18,
2022
Received:
February 8,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding: This work was supported by the STOP Cancer Award.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
