From the Guidelines
The treatment for rectal cancer typically involves a combination of surgery, radiation therapy, and chemotherapy, tailored to the stage and location of the cancer, with the most recent guidelines suggesting total neoadjuvant therapy (TNT) as a potential standard of care to improve adherence, decrease distant metastases, and ultimately improve overall survival 1.
Key Considerations
- Surgery is the primary treatment, with options including local excision for early-stage tumors or more extensive procedures like low anterior resection or abdominoperineal resection for advanced cases.
- Neoadjuvant therapy (given before surgery) often includes radiation therapy combined with chemotherapy drugs such as 5-fluorouracil (5-FU), capecitabine, or oxaliplatin to shrink the tumor and improve surgical outcomes.
- For locally advanced rectal cancer, a common regimen is 5-FU or capecitabine with radiation for 5-6 weeks before surgery.
- After surgery, adjuvant chemotherapy may be recommended for 3-6 months, particularly for stage II or III disease, using combinations like FOLFOX (5-FU, leucovorin, and oxaliplatin) or CAPOX (capecitabine and oxaliplatin).
Recent Developments
- Total neoadjuvant therapy (TNT), which includes neoadjuvant chemotherapy and either short-course radiation or long-course CRT, has been proposed as a way to improve adherence, decrease the occurrence of distant metastases, and ultimately improve OS 1.
- Omission of radiation therapy (RT) in certain scenarios and a possible nonoperative strategy for patients whose tumors have a clinical complete response (cCR) to initial treatment are also being considered.
Patient-Specific Factors
- Treatment decisions consider the tumor's distance from the anal verge, stage, patient's overall health, and preservation of bowel function.
- Regular follow-up care is essential after treatment completion to monitor for recurrence, typically including physical exams, colonoscopies, imaging studies, and blood tests for carcinoembryonic antigen (CEA) levels.
Evidence-Based Recommendations
- The most recent guidelines from the American Society of Clinical Oncology (ASCO) provide recommendations on the management of locally advanced rectal cancer, including the use of TNT and other recent developments in treatment 1.
- The Chinese Society of Clinical Oncology (CSO) also provides guidelines for the diagnosis and treatment of colorectal cancer, including rectal cancer, with recommendations on neoadjuvant chemotherapy, chemoradiotherapy, and adjuvant treatment 1.
From the FDA Drug Label
XELODA is used to treat: – cancer of the colon after surgery – cancer of the colon or rectum (colorectal cancer) that has spread to other parts of the body (metastatic colorectal cancer)
The treatment for rectal cancer includes XELODA (capecitabine), which is used to treat colorectal cancer that has spread to other parts of the body.
- Key points:
- XELODA is taken orally
- It is changed in the body to 5-fluorouracil (5-FU), which stops cancer cells from growing and decreases the size of the tumor
- XELODA is used in combination with other medicines for the treatment of rectal cancer 2
From the Research
Overview of Rectal Cancer Treatment
- Rectal cancer treatment involves a multidisciplinary approach, including surgery, chemotherapy, and radiation therapy 3, 4.
- The goal of treatment is to optimize disease-free and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy 3.
Surgical Treatment
- Surgery is the cornerstone of rectal cancer treatment, with total mesorectal excision (TME) being the standard of care for mid and distal rectal cancers 4.
- Local excision may be an option for early rectal cancer, but its use requires careful selection of patients 4, 5.
Chemoradiotherapy
- Combined chemoradiotherapy offers the lowest rates of local and distant relapse for stage II and III rectal cancers, and is typically delivered neoadjuvantly to improve tolerability and optimize surgical outcomes 3, 5.
- Capecitabine is an oral prodrug of 5-fluorouracil (5-FU) that can safely and effectively replace intravenous continuous infusion of 5-FU in the preoperative chemoradiation setting for rectal cancer management 6, 7.
Multidisciplinary Approach
- The successful management of rectal cancer requires a multidisciplinary approach, involving enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists, and surgeons 3.
- Preoperative staging is crucial in planning treatment, and the identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes 3, 4.