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Should radiotherapy be avoided or delivered differently in elderly patients with rectal cancer?

Published:August 23, 2007DOI:https://doi.org/10.1016/j.ejca.2007.06.014

      Abstract

      Purpose is to give an overview of treatment possibilities of rectal cancer over time, but also of the real management of rectal cancer especially in relation to age. From literature search representative randomised studies on patients with resectable rectal cancer, comparing only surgery, post- and preoperative radiotherapy with or without chemotherapy, are reviewed. We also reviewed the literature regarding radiotherapy for rectal cancer described in population-based studies.
      The overview of the trials showed that preoperative radiotherapy improves local control in relation to no or postoperative radiotherapy. Adding chemotherapy did not significantly improve survival. No relations were seen between age and complications. All population-based studies showed that increasing age is associated with less (neo)adjuvant treatment.
      To avoid local recurrence, the best possible treatment, being preoperative RT, should be given to all patients with resectable rectal cancer, irrespective of age.

      Keywords

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      References

        • Camma C.
        • Giunta M.
        • Fiorica F.
        • Pagliaro L.
        • Craxi A.
        • Cottone M.
        Preoperative radiotherapy for resectable rectal cancer: a meta-analysis.
        JAMA. 2000; 284: 1008-1015
      1. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Colorectal Cancer Collaborative Group. Lancet 2001;358:1291–1304.

      2. Preoperative short-term radiation therapy in operable rectal carcinoma. A prospective randomized trial. Stockholm Rectal Cancer Study Group. Cancer 1990;66:49–55.

      3. 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;80:1333–6.

      4. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997;336:980–7.

        • Folkesson J.
        • Birgisson H.
        • Pahlman L.
        • Cedermark B.
        • Glimelius B.
        • Gunnarsson U.
        Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate.
        J Clin Oncol. 2005; 23: 5644-5650
        • Pahlman L.
        • Glimelius B.
        Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Report from a randomized multicenter trial.
        Ann Surg. 1990; 211: 187-195
        • 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
        • Krook J.E.
        • Moertel C.G.
        • Gunderson L.L.
        • et al.
        Effective surgical adjuvant therapy for high-risk rectal carcinoma.
        N Engl J Med. 1991; 324: 709-715
        • Kapiteijn E.
        • Marijnen C.A.
        • Nagtegaal I.D.
        • et al.
        Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.
        N Engl J Med. 2001; 345: 638-646
        • Nagtegaal I.D.
        • Marijnen C.A.
        • Kranenbarg E.K.
        • van de Velde C.J.
        • van Krieken J.H.
        Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit.
        Am J Surg Pathol. 2002; 26: 350-357
        • Marijnen C.A.
        • Kapiteijn E.
        • van de Velde C.J.
        • et al.
        Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial.
        J Clin Oncol. 2002; 20: 817-825
        • Marijnen C.A.
        • van de Velde C.J.
        • Putter H.
        • et al.
        Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial.
        J Clin Oncol. 2005; 23: 1847-1858
        • Peeters K.C.
        • van de Velde C.J.
        • Leer J.W.
        • et al.
        Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients – a Dutch colorectal cancer group study.
        J Clin Oncol. 2005; 23: 6199-6206
      5. Peeters KC, Marijnen CA, Nagtegaal ID, et al. The TME-trial after a median follow up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg [in press].

        • Sauer R.
        • Becker H.
        • Hohenberger W.
        • et al.
        Preoperative versus postoperative chemoradiotherapy for rectal cancer.
        N Engl J Med. 2004; 351: 1731-1740
        • Bosset J.F.
        • Collette L.
        • Calais G.
        • et al.
        Chemotherapy with preoperative radiotherapy in rectal cancer.
        N Engl J Med. 2006; 355: 1114-1123
        • Gerard J.P.
        • Conroy T.
        • Bonnetain F.
        • et al.
        Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203.
        J Clin Oncol. 2006; 24: 4620-4625
        • Bujko K.
        • Nowacki M.P.
        • Nasierowska-Guttmejer A.
        • Michalski W.
        • Bebenek M.
        • Kryj M.
        Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer.
        Br J Surg. 2006; 93: 1215-1223
        • Paszat L.F.
        • Brundage M.D.
        • Groome P.A.
        • Schulze K.
        • Mackillop W.J.
        A population-based study of rectal cancer: permanent colostomy as an outcome.
        Int J Radiat Oncol Biol Phys. 1999; 45: 1185-1191
        • Schrag D.
        • Gelfand S.E.
        • Bach P.B.
        • Guillem J.
        • Minsky B.D.
        • Begg C.B.
        Who gets adjuvant treatment for stage II and III rectal cancer? Insight from surveillance, epidemiology, and end results – Medicare.
        J Clin Oncol. 2001; 19: 3712-3718
        • Schroen A.T.
        • Cress R.D.
        Use of surgical procedures and adjuvant therapy in rectal cancer treatment: a population-based study.
        Ann Surg. 2001; 234: 641-651
        • Dharma-Wardene M.W.
        • de Gara C.
        • Au H.J.
        • Hanson J.
        • Hatcher J.
        Ageism in rectal carcinoma? Treatment and outcome variations.
        Int J Gastrointest Cancer. 2002; 32: 129-138
        • Neugut A.I.
        • Fleischauer A.T.
        • Sundararajan V.
        • et al.
        Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study.
        J Clin Oncol. 2002; 20: 2643-2650
        • Ayanian J.Z.
        • Zaslavsky A.M.
        • Fuchs C.S.
        • et al.
        Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort.
        J Clin Oncol. 2003; 21: 1293-1300
        • Phelip J.M.
        • Milan C.
        • Herbert C.
        • et al.
        Evaluation of the management of rectal cancers before and after the consensus conference in France.
        Eur J Gastroenterol Hepatol. 2004; 16: 1003-1009
        • Phelip J.M.
        • Launoy G.
        • Colonna M.
        • et al.
        Regional variations in management of rectal cancer in France.
        Gastroenterol Clin Biol. 2004; 28: 378-383
        • Baxter N.N.
        • Rothenberger D.A.
        • Morris A.M.
        • Bullard K.M.
        Adjuvant radiation for rectal cancer: do we measure up to the standard of care? An epidemiologic analysis of trends over 25 years in the United States.
        Dis Colon Rectum. 2005; 48: 9-15
        • Vulto A.J.
        • Lemmens V.E.
        • Louwman M.W.
        • et al.
        The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995 to 2002.
        Cancer. 2006; 106: 2734-2742
        • Cohen S.M.
        • Neugut A.I.
        Adjuvant therapy for rectal cancer in the elderly.
        Drugs Aging. 2004; 21: 437-451
        • Pasetto L.M.
        • Rossi E.
        • Jirillo A.
        • Monfardini S.
        Colorectal cancer adjuvant treatment in elderly patients.
        Crit Rev Oncol Hematol. 2005; 55: 201-206
        • Lemmens V.E.
        • Janssen-Heijnen M.L.
        • Verheij C.D.
        • Houterman S.
        • Repelaer van Driel O.J.
        • Coebergh J.W.
        Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer.
        Br J Surg. 2005; 92: 615-623
        • Pignon T.
        • Horiot J.C.
        • Bolla M.
        • et al.
        Age is not a limiting factor for radical radiotherapy in pelvic malignancies.
        Radiother Oncol. 1997; 42: 107-120
        • Shahir M.A.
        • Lemmens V.E.
        • van de Poll-Franse L.V.
        • Voogd A.C.
        • Martijn H.
        • Janssen-Heijnen M.L.
        Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study.
        Eur J Cancer. 2006; 42: 3015-3021
        • 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 pre-operative radiotherapy for rectal cancer: reduction in local treatment failure.
        Eur J Cancer. 1994; 30A: 1602-1606
      6. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. Mercury Study Group. Br Med J 2006;333:779–82.

        • Francois Y.
        • Nemoz C.J.
        • Baulieux J.
        • et al.
        Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial.
        J Clin Oncol. 1999; 17: 2396
      7. Rutten HJ, Den Dulk M, Lemmens VE, et al. Rectal cancer treatment in the elderly. Eur J Cancer 2007 [this issue].

        • Ratto C.
        • Ricci R.
        • Valentini V.
        • et al.
        Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications.
        Am Surg Oncol. 2007; 14: 853-861