Oncology Referral for Resected Rectal Adenocarcinoma
Yes, patients with resected adenocarcinoma near the rectum should be referred to oncology for evaluation of adjuvant therapy. 1
Rationale for Oncology Referral
- Patients with resected rectal cancer require multidisciplinary management to determine appropriate adjuvant therapy based on pathologic staging and risk factors 1
- The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant therapy for patients with stage II or III rectal cancer to reduce local recurrence and improve survival 1
- Referral to medical oncology is one of the most important factors associated with receipt of appropriate adjuvant therapy 2
Adjuvant Therapy Recommendations by Stage
T1-T2, N0 Disease
- For patients with T1-T2, N0 disease with favorable characteristics (well to moderately differentiated, no lymphovascular invasion, negative margins), observation may be appropriate 1
- However, if adverse features are present (grade 3-4, lymphovascular invasion, positive margins), adjuvant therapy should be considered 1
T3-T4 or Node-Positive Disease
- Patients with T3-T4 disease or node-positive disease should receive adjuvant radiotherapy and chemotherapy (category 1 recommendation) 1
- Options include infusional 5-FU/RT, capecitabine/RT, FOLFOX, or CAPEOX depending on the specific pathologic findings 1
- After resection of any node-positive tumor, chemotherapy with 5-FU plus leucovorin or other appropriate regimens should be considered 1
Factors Affecting Oncology Referral
- Studies show that approximately 25% of eligible patients do not receive guideline-directed adjuvant therapy 3
- Patient factors associated with lower referral rates include:
- System factors affecting referral include:
Importance of Oncology Consultation
- Patients who see a medical oncologist are 10 times more likely to receive appropriate adjuvant therapy 2
- Oncologists can provide expertise regarding the specific benefits and risks of adjuvant therapy for individual patients 5
- Oncology consultation facilitates appropriate surveillance planning and monitoring for recurrence 1
Surveillance Recommendations
- For patients who have undergone resection, NCCN recommends:
- History and physical examination every 3 months for the first 2 years, then every 6 months for the next 5 years 1
- CEA testing at baseline and every 3 months for 2 years, then every 6 months for the next 2-5 years for patients with T2 or greater lesions 1
- Colonoscopy within 1 year of resection (or 3-6 months postoperatively) 1
Common Pitfalls to Avoid
- Failing to refer older patients to oncology based solely on age rather than functional status and comorbidities 4, 2
- Assuming patients with node-negative disease after neoadjuvant therapy don't need oncology consultation (they still require evaluation for potential adjuvant therapy) 6
- Delaying referral, which can lead to delays in initiating appropriate adjuvant therapy 5
- Making treatment decisions without multidisciplinary input, which may result in suboptimal care 1
Decision Algorithm for Oncology Referral
- All patients with resected rectal adenocarcinoma should be referred to medical oncology 1
- Priority referrals (should be seen within 2-4 weeks):
- Standard referrals (should be seen within 4-6 weeks):
- Patients with T1-T2, N0 disease without adverse features 1
Remember that oncology referral is essential for determining appropriate adjuvant therapy, planning surveillance, and optimizing long-term outcomes for patients with rectal cancer 1, 2.