Preoperative chemoradiation followed by surgical resection has been the standard of care in the management of locally advanced rectal cancer. Patients with T3-T4 or node-positive disease have a significant risk of both local and distant failure after surgery alone.1 Initially, studies of radiotherapy (RT), either as postoperative or preoperative therapy, and more recently studies of combined modality therapy with radiation-sensitizing chemotherapy showed an improvement in local control and a reduction in anastomotic recurrences.2-9 This benefit persists in the era of total mesorectal excision (TME).3,10 To determine the optimal sequence for surgery and chemoradiation, a landmark German rectal study compared preoperative and postoperative 5-FU-based chemoradiotherapy in 823 patients. It showed improved local control, increased rates of sphincter preservation, and lower toxicity in patients receiving preoperative chemoradiation.11
Based on this trial, the current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for locally advanced resectable rectal cancer include neoadjuvant RT with capecitabine or concurrent 5-FU infusion, followed by TME and an adjuvant course of consolidative chemotherapy (to view the most recent version of these guidelines, visit NCCN.org).12 The goal of evidence-based treatment guidelines is to decrease variability and improve the quality of cancer care. Adherence to practice guidelines is a useful indicator of quality of care. In particular, the NCCN/ASCO expert panel has recommended that receipt of pelvic RT for patients younger than 80 years with stage II-III rectal cancer within 6 months of diagnosis be included in the quality measures used in accountability programs.13 In addition to providing a measure of quality of care with regard to neoadjuvant RT in advanced rectal cancer, the NCCN Oncology Outcomes Database for Colorectal Cancers offers a unique opportunity to study factors associated with omission of RT. Clinical decision-making is a complex process that often involves subjective assessment of the potential risks and benefits associated with a given treatment. Using this database, the authors sought to elucidate the potential factors associated with nonadherence to the NCCN Guidelines recommendations regarding neoadjuvant RT for locally advanced rectal cancer.
The authors would like to thank Eve Ferdman for editorial assistance.
The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
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