Rectal Cancer: Second Most Important Decision

Of course, before the surgery, other considerations such as pre-operative radiotherapy, pre-op chemo-radiotherapy, post-op radiotherapy, post-op chemo-radiotherapy, short course radiotherapy, long course radiotherapy and adjuvant chemotherapy all need to be discussed with your oncologist in order to get the best outcome.

The second most important decision after finding yourself a good colorectal surgeon is deciding on appropriate pre-operative or post-operative treatment options that can improve treatment outcome further.

I will try to make it simple.

I assumed you had found a good colorectal surgeon already who is every ready to operate and also have MRI pelvis ready for assessment.

Assuming Already Operated – Post-Operative Treatment

Post-operative chemo-radiation improve both overall survival and reduce local recurrence when compared with just post-operative radiation only.

Krook JE (1991): Improvement in 5-year survival rate from 40% with radiation alone to 55% with radiation + chemotherapy
Krook JE (1991): Reduction of local recurrence from 63% with radiation alone to 41% in with radiation + chemotherapy

Side effects such as nausea, vomiting, oral ulcers, diarrhoea and low blood counts are mostly tolerable and manageable.

Post op chemo-radiation is normally given to patients whose histopathology report showed T3, T4, N+ or positive circumferential margin (CRM+).

Other than that, no further treatment for T1, T2 or N-.

TNM staging system for colorectal cancer

Assuming Not Operated Yet – Pre-Operative Treatment

Unless very early stage tumor, those with operable tumor can have equal local recurrence and overall survival but lower acute toxicity with short course radiotherapy (SCRT = 5 fractions, followed by surgery) when compared with long course radiotherapy (LCRT). Swedish Rectal Cancer Trial even reported improve in overall survival.

Overall five-year survival rates in these two groups were 58 percent in SCRT group followed by surgery and 48 percent in surgery group only. Addition of radiotherapy was associated with an increase of 21% in overall survival (SCRT, 1997)

For inoperable/ locally advanced rectal cancer, pre-operative chemo-radiation is the standard treatment. Both radiotherapy (25-28 fractions) and chemotherapy is given concurrently over 5-6 weeks, followed by surgery 6-8 weeks later.

It’s is recommended for all T3 tumor with mesorectal invasion, T4 tumor or positive lymph nodes (LN+) in order to get the best chance of R0 (no cancer cells seen microscopically at the resection margin) surgery.

These are just very brief summary (my prof had 200-300 ppt slides on this topic alone) of pre-op and post-op treatment that are available for rectal cancer. I hope this will help you to prepare for your consultation with your oncologist.

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