ESMO WCGC 2013 Report – When is neoadjuvant chemotherapy (without radiotherapy) an option

A review of the presentation by Professor David Cunningham (pictured), London, UK.  The risk profile of rectal tumours varies with the position and profile of the disease. David Cunningham pointed out that there are advantages and disadvantage to radiotherapy in this setting. The advantages include downsizing and down staging of the tumour with a reduced risk of local recurrence. The disadvantages include acute side effects; mid and long term toxicities including bowel function and sexual function; and increased risk of second cancers. Radiotherapy does not increase overall survival in patients receiving TME surgery. A number of trial results were presented where radiotherapy played a positive role.

Prof Cunningham explained that a stratified approach to resectable rectal cancer is feasible. Surgery alone (TME) is appropriate for some patients (30-40%) with a low risk of both local and systemic recurrence. A multimodality approach is necessary for other patients (60-70%). Radiotherapy (or chemotherapy) is preferred for those patients for whom the benefit of systemic chemotherapy is low. Neoadjuvant chemotherapy should be explored as an alternative approach for patients with high risk of distant relapse (N+, invasion into mesorectum >5mm, CRM+) and candidate for adjuvant chemotherapy. It is imperative to identify valid imaging strategies (PET scan) to assess response to neoadjuvant chemotherapy.