Download PDF
Clin Colon Rectal Surg 2002; 15(1): 055-062
DOI: 10.1055/s-2002-23568
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Adjuvant Therapy for Rectal Cancer

Clifford Y. Ko1, 2 , Michael J. Stamos1, 3 , Arthur Zimmerman4 , Henry C. Yang1, 5
  • 1Department of Surgery, UCLA School of Medicine, Los Angeles, CA
  • 2RAND Corporation, Santa Monica, CA
  • 3Section of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Los Angeles, CA
  • 4Department of Radiation Oncology, Harbor-UCLA Medical Center, Los Angeles, CA
  • 5Department of Medicine, Harbor-UCLA Medical Center, Los Angeles, CA
Further Information

Publication History

Publication Date:
03 April 2002 (online)

Also available at
    Permissions and Reprints

ABSTRACT

In 1990, the National Institutes of Health consensus statement for the treatment of rectal cancer concluded that ``combined postoperative chemotherapy and radiation therapy improves local control and survival in stage II and III patients and is recommended.'' Following the publication of this consensus statement, the conventional treatment for rectal cancer was bowel resection followed by adjuvant radiation and chemotherapy. In the years that followed, however, several new findings have been published and a multitude of issues has arisen. This article will attempt to succinctly focus on the best current evidence in the literature. Where possible, we include only Level I evidence (i.e., evidence from randomized controlled trials [RCTs]). Since the role of adjuvant therapy for rectal cancer is continuing to be modified, the purpose of this article is to describe and interpret the most current literature.

KEYWORD

Rectal cancer - radiation therapy - chemotherapy - chemoradiation therapy

REFERENCES

  • 1 NIH Consensus Conference. Adjuvant therapy for patients with colon and rectal cancer.  JAMA . 1990;  264 1444-1450
    CrossrefPubMedSearch in Google Scholar
  • 2 Corman M L. Carcinoma of the rectum. Colon and Rectal Surgery. Philadelphia: Lippincott-Raven 1998: 733-762
    Search in Google Scholar
  • 3 Gordon P H. Malignant neoplasms of the rectum In: Gordon PH, Nivatvongs S, eds. Principles and the Practice of Surgery for the Colon, Rectum, and Anus. St. Louis: Quality Medical Publ Inc; 1999: 720-809
    Search in Google Scholar
  • 4 Nogueras J. Adjuvant therapy for rectal cancer In: Beck D, Wexner S, eds. Fundamentals of Anorectal Surgery. London: WB Saunders; 1998: 368-381
    Search in Google Scholar
  • 5 Stearns M, Deddish M, Quan S, Leaming R. Preoperative roentgen therapy for cancer of rectum and rectosigmoid.  Cancer . 1974;  37 2866-2874
    PubMedSearch in Google Scholar
  • 6 Roswit B, Higgins G J, Keehn R. Preoperative irradiation for carcinoma of the rectum and rectosigmoid colon: report of a national Veterans Administration randomized study.  Cancer . 1975;  35 1597-1602
    PubMedSearch in Google Scholar
  • 7 Rider W, Palmer J, Mahoney L, Robertson C. Preoperative irradiation in operable cancer of the rectum: report of the Toronto trial.  Can J Surg . 1977;  20 335-338
    PubMedSearch in Google Scholar
  • 8 Second Report of an MRC Working Party. The evaluation of low dose preoperative X-ray therapy in the management of operable rectal cancer: results of a randomly controlled trial.  Br J Surg . 1984;  71 21-25
    PubMedSearch in Google Scholar
  • 9 Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial [comments] [published erratum appears in N Engl J Med 1997;May 22;336(21):1539].  N Engl J Med . 1997;  336 980-987
    CrossrefPubMedSearch in Google Scholar
  • 10 Camma C, Giunta M, Fiorica F, Pagliaro L, Craxi A, Cattone M. Preoperative radiotherapy for resectable rectal cancer: a meta-analysis.  JAMA . 2000;  284 1008-1015
    CrossrefPubMedSearch in Google Scholar
  • 11 Cedermark B, Johansson H, Rutqvist L E, Wilking N. The Stockholm I trial of preoperative short-term radiotherapy in operable rectal carcinoma. A prospective randomized trial. Stockholm Colorectal Cancer Study Group.  Cancer . 1995;  75 2269-2275
    PubMedSearch in Google Scholar
  • 12 Goldberg P A, Nicholls R J, Porter N H, Love S, Grimsey J E. Long-term results of a randomised trial of short-course low-dose adjuvant preoperative radiotherapy for rectal cancer: reduction in local treatment failure [comments].  Eur J Cancer . 1994;  11 1602-1606
    PubMedSearch in Google Scholar
  • 13 Swedish Rectal Cancer Trial. Initial report from a Swedish multicentre study examining the role of preoperative irradiation in the treatment of patients with resectable rectal carcinoma. Swedish Rectal Cancer Trial.  Br J Surg . 1993;  80 1333-1336
    CrossrefPubMedSearch in Google Scholar
  • 14 MRC Rectal Cancer Working Party. Randomised trial of surgery alone versus surgery followed by radiotherapy for mobile cancer of the rectum.  Lancet . 1996;  348 1610-1614
    CrossrefPubMedSearch in Google Scholar
  • 15 Frykholm G J, Glimelius B, Pahlman L. Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects.  Dis Colon Rectum . 1993;  36 564-572
    CrossrefPubMedSearch in Google Scholar
  • 16 Gastrointestinal Tumor Study Group. Prolongation of the disease-free interval in surgically treated rectal carcinoma.  N Engl J Med . 1985;  312 1465-472
    CrossrefPubMedSearch in Google Scholar
  • 17 Douglass H, Moertel C G, Mayer R J. Survival after postoperative combination treatment of rectal cancer.  N Engl J Med . 1986;  315 1294-1295
    PubMedSearch in Google Scholar
  • 18 Thomas P, Lindblad A, and the GITSG. Adjuvant post-operative radiotherapy and chemotherapy in rectal carcinoma: a review of the Gastrointestinal Study Group experience.  Radiother Oncol . 1988;  13 245-252
    CrossrefPubMedSearch in Google Scholar
  • 19 Fisher B, Wolmark N, Rockette H. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01.  J Natl Cancer Inst . 1988;  80 21-89
    PubMedSearch in Google Scholar
  • 20 Hafstrom L, Domellof L, Rudenstam C. Adjuvant chemotherapy with 5-fluorouracil, vincristine and CCNU for patients with Dukes' C colorectal cancer.  Br J Surg . 1990;  77 1345-1348
    PubMedSearch in Google Scholar
  • 21 Laurie J, Moertel C G, Fleming T. Surgical adjuvant therapy of large-bowel carcinoma: an evaluation of levamisole and the combination of levamisole and fluorouracil: The North Central Cancer Treatment Group and the Mayo Clinic.  J Clin Oncol . 1989;  7 1447-1456
    PubMedSearch in Google Scholar
  • 22 Moertel C G, Fleming T, Macdonald J S. Levamisole and fluorouracil for adjuvant therapy of resected colon carcinoma.  N Engl J Med . 1990;  322 352-358
    CrossrefPubMedSearch in Google Scholar
  • 23 Moertel C G, Fleming T, Macdonald J S. The intergroup study of 5-FU + levamisole and levamisole alone as adjuvant therapy for stage C colon cancer: a final report.  Proc Am Soc Clin Oncol [abstract] . 1992;  11 161
    PubMedSearch in Google Scholar
  • 24 Moertel C G, Fleming T, Macdonald J S. Fluorouracil plus levamisole as effective adjuvant therapy after resection of stage III colon carcinoma: a final report.  Ann Intern Med . 1995;  122 321-326
    CrossrefPubMedSearch in Google Scholar
  • 25 Wolmark N, Rockette H, Mamounas E. Clinical trial to assess the relative efficacy of fluorouracil and leucovorin, fluorouracil and levamisole, and fluorouracil, leucovorin, and levamisole in patients with Dukes' B and C carcinoma of the colon: results from the National Surgical Adjuvant Breast and Bowel Project C-04.  J Clin Oncol . 1999;  17 3553-3559
    PubMedSearch in Google Scholar
  • 26 Haller D G, Catalano P, Macdonald J S. Fluorouracil, leucovorin, and levamisole adjuvant therapy for colon cancer: Five year final report of INT-0089 [abstract].  Proc Am Soc Clin Oncol . 1998;  17 256a
    PubMedSearch in Google Scholar
  • 27 Boulis-Wassis S, Gerard A, Loygue J. Final results of a randomized trial on the treatment of rectal cancer with preoperative radiotherapy alone or in combination with 5-fluorouracil followed by radical surgery: Trial of the European Organization for Research and Treatment of Cancer. Gastrointestinal Tract Cancer Cooperative Group.  Cancer . 1984;  53 1811-1818
    PubMedSearch in Google Scholar
  • 28 Krook J E, Moertel C G, Gunderson L L. Effective surgical adjuvant therapy for high-risk rectal carcinoma [comments].  N Engl J Med . 1991;  324 709-715
    CrossrefPubMedSearch in Google Scholar
  • 29 O'Connell M J, Martenson J A, Wieand H S. Improving adjuvant therapy for rectal cancer by combining protracted-infusion fluorouracil with radiation therapy after curative surgery.  N Engl J Med . 1994;  331 502-507
    CrossrefPubMedSearch in Google Scholar
  • 30 Wolmark N, Wieand H S, Hyams D M. Randomized trial of postoperative adjuvant chemotherapy with or without radiotherapy for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project Protocol R-02 [comments].  J Natl Cancer Inst . 2000;  92 388-396
    CrossrefPubMedSearch in Google Scholar
  • 31 Tveit K M, Guldvog I, Hagen S. Randomized controlled trial of postoperative radiotherapy and short-term time-scheduled 5-fluorouracil against surgery alone in the treatment of Dukes' B and C rectal cancer. Norwegian Adjuvant Rectal Cancer Project Group.  Br J Surg . 1997;  84 1130-1135
    CrossrefPubMedSearch in Google Scholar
  • 32 Tepper J E, O'Connell M J, Petroni G R. Adjuvant postoperative fluorouracil-modulated chemotherapy combined with pelvic radiation therapy for rectal cancer: initial results of intergroup 0114.  J Clin Oncol . 1997;  15 2030-2039
    PubMedSearch in Google Scholar
  • 33 Roh M, Petrelli N, Wieand H S. Phase III randomized trial of preoperative versus postoperative multimodality therapy in patients with carcinoma of the rectum (NSABP R-03) [abstract].  Proc Am Soc Clin Oncol . 2001;  20 123a
    PubMedSearch in Google Scholar
  • 34 Heald R J, Moran B J, Ryall R D, Sexton R, MacFarlane J K. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997.  Arch Surg . 1998;  133 894-899
    CrossrefPubMedSearch in Google Scholar
  • 35 Kapiteijn E, Marijnen C, Nagtegaal I. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.  N Engl J Med . 2001;  345 638-646
    CrossrefPubMedSearch in Google Scholar
  • 36 Kligerman M. Preoperative radiation therapy in rectal cancer.  Cancer . 1975;  36 691-695
    PubMedSearch in Google Scholar
  • 37 Higgins G, Humphrey E, Dwight R. Preoperative radiation and surgery for cancer of the rectum: Veterans' Administration Surgical Oncology Group Trial II.  Cancer . 1986;  58 352-359
    PubMedSearch in Google Scholar
  • 38 Gerard J P, Buyse M, Nordlinger B. Preoperative radiotherapy as adjuvant treatment of rectal cancer.  Ann Surg . 1988;  308 606-612
    PubMedSearch in Google Scholar
  • 39 Reis Neto J, Guilici F, Reis Neto Jr J. A comparison of nonoperative vs preoperative radiotherapy in rectal carcinoma.  Dis Colon Rectum . 1989;  32 702-710
    PubMedSearch in Google Scholar
  • 40 Horn A, Morild I, Dahl O. Tumour shrinkage and downstaging after preoperative radiation of rectal adenocarcinomas.  Radiother Oncol . 1990;  18 19-28
    PubMedSearch in Google Scholar
  • 41 Stockholm Rectal Cancer Study Group. Preoperative short-term radiation therapy in operable rectal carcinoma. A prospective randomized trial. Stockholm Rectal Cancer Study Group.  Cancer . 1990;  66 49-55
    CrossrefPubMedSearch in Google Scholar
  • 42 Marsh P J, James R D, Schofield P F. Adjuvant preoperative radiotherapy for locally advanced rectal carcinoma. Results of a prospective, randomized trial.  Dis Colon Rectum . 1994;  37 1205-1214
    PubMedSearch in Google Scholar
  • 43 Stockholm Colorectal Cancer Study Group. Randomized study on preoperative radiotherapy in rectal carcinoma.  Ann Surg Oncol . 1996;  3 423-430
    CrossrefPubMedSearch in Google Scholar
  • 44 Baslev I, Pedersen M, Teglbjaerg P S. Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid. A randomized multicentre study.  Cancer . 1986;  58 22-28
    PubMedSearch in Google Scholar
  • 45 Treurniet-Donker A D, van Putten L W, Wereldsma J C. Postoperative radiation therapy for rectal cancer. An interim analysis of a prospective, randomized multicenter trial in The Netherlands [comments].  Cancer . 1991;  67 2042-2048
    PubMedSearch in Google Scholar
  • 46 Arnaud J P, Nordlinger B, Bosset J F. Radical surgery and postoperative radiotherapy as combined treatment in rectal cancer. Final results of a phase III study of the European Organization for Research and Treatment of Cancer.  Br J Surg . 1997;  84 352-357
    CrossrefPubMedSearch in Google Scholar
  • 47 Rockette H, Deutsch M, Petrelli N. Effect of postoperative radiation therapy when used with adjuvant chemotherapy in Dukes' B and C rectal cancer: results from NSABP R-02 [abstract].  Proc Am Soc Clin Oncol . 1994;  13 193
    PubMedSearch in Google Scholar
  • 48 Merchant N B, Guillem J G, Paty P B. T3N0 rectal cancer: results following sharp mesorectal excision and no adjuvant therapy.  J Gastrointest Surg . 1999;  3 642-647
    CrossrefPubMedSearch in Google Scholar
  • 49 Willett C G, Badizadegan K, Ancukiewicz M, Shellito P C. Prognostic factors in stage T3 N0 rectal cancer: do all patients require postoperative pelvic irradiation and chemotherapy?.  Dis Colon Rectum . 1999;  2 167-173
    PubMedSearch in Google Scholar