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.
Enker WE, Thaler HT, Cranor ML et al.. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995;181:335–346.
Folkesson J, Birgisson H, Pahlman L et al.. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005;23:5644–5650.
Kapiteijn E, Marijnen CA, Nagtegaal ID et al.. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638–646.
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 2007;246:693–701.
Camma C, Giunta M, Fiorica F et al.. Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA 2000;284:1008–1015.
Douglass HO Jr, Moertel CG, Mayer RJ et al.. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315:1294–1295.
Prolongation of the disease-free interval in surgically treated rectal carcinoma. Gastrointestinal Tumor Study Group. N Engl J Med 1985;312:1465–1472.
Gerard JP, 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.
Chau I, Brown G, Cunningham D et al.. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. J Clin Oncol 2006;24:668–674.
Sauer R, Becker H, Hohenberger W et al.. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731–1740.
Benson AB III, Venook AP, Bekaii-Saab T et al.. NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer. Version 2, 2014. Available at: NCCN.org. Accessed January 16, 2014.
Desch CE, McNiff KK, Schneider EC et al.. American Society of Clinical Oncology/National Comprehensive Cancer Network quality measures. J Clin Oncol 2008;26:3631–3637.
Charlson ME, Pompei P, Ales KL et al.. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.
Roh MS, Colangelo LH, O’Connell MJ et al.. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol 2009;27:5124–5130.
Park JH, Yoon SM, Yu CS et al.. Randomized phase 3 trial comparing preoperative and postoperative chemoradiotherapy with capecitabine for locally advanced rectal cancer. Cancer 2011;117:3703–3712.
Kuo I, Wong JH, Roy-Chowdhury S et al.. The use of pelvic radiation in stage II rectal cancer: a population-based analysis. Am Surg 2010;76:1092–1095.
Mak RH, McCarthy EP, Das P et al.. Adoption of preoperative radiation therapy for rectal cancer from 2000 to 2006: a Surveillance, Epidemiology, and End Results patterns-of-care study. Int J Radiat Oncol Biol Phys 2011;80:978–984.
Baxter NN, Rothenberger DA, Morris AM et al.. 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.
Ayanian JZ, Zaslavsky AM, Fuchs CS et al.. Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol 2003;21:1293–1300.
Morris AM, Wei Y, Birkmeyer NJ et al.. Racial disparities in late survival after rectal cancer surgery. J Am Coll Surg 2006;203:787–794.
In H, Neville BA, Lipsitz SR et al.. The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence. Ann Surg 2012;255:890–895.
Neugut AI, Fleischauer AT, 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.
Schrag D, Gelfand SE, Bach PB et al.. 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.
Dobie SA, Warren JL, Matthews B et al.. Survival benefits and trends in use of adjuvant therapy among elderly stage II and III rectal cancer patients in the general population. Cancer 2008;112:789–799.
Gunderson LL, Sargent DJ, Tepper JE et al.. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol 2004;22:1785–1796.
Howard JH, Gonzalez Q, Arnoletti JP et al.. Prognostic factors and preoperative radiation therapy associated with sphincter preservation in patients with resectable rectal cancer. Am J Surg 2008;195:239–243.
Meyerhardt JA, Tepper JE, Niedzwiecki D et al.. Impact of body mass index on outcomes and treatment-related toxicity in patients with stage II and III rectal cancer: findings from Intergroup Trial 0114. J Clin Oncol 2004;22:648–657.