BUFFALO, NYOver the past several years, the focus of
breast cancer treatment has shifted from late detection and radical
surgery to early detection, breast-conserving surgery, and
multimodality treatment. This paradigm shift may also be
applicable to colorectal cancer, Glenn D. Steele, Jr., MD, PhD, dean
of the Biological Sciences Division, Pritzker School of Medicine,
University of Chicago, said at a surgical oncology symposium hosted
by Roswell Park Cancer Institute. Dr. Steele was the recipient of the
Roswell Park Centennial Award.
For patients with distal rectal adenocarcinoma, there is now a focus
on sphincter-preserving surgery and postoperative adjuvant treatment
rather than radical abdominoperineal resection, he said. This is
similar to the shift from radical mastectomy to lumpectomy and
radiation in breast cancer.
The issues between colorectal cancer and breast cancer are
remarkably similar. Early detection and multimodality treatment
work for both, but the data have some surprises,
Dr. Steele said, referring to an unexpected number of local
recurrences seen in a nonrandomized CALGB trial exploring
sphincter-sparing surgery in early stage rectal cancer patients.
Randomized trials are needed to confirm that this shift to less
radical surgeries that improve quality of life will not compromise
survival or local recurrence, Dr. Steele emphasized. For sphincter
preservation to be analogous to breast-conserving treatment, he said,
salvage abdominoperineal resection must produce outcomes as
good as if such resection was used at the time of the initial
Dr. Steele described the results of a CALGB Coordinated Intergroup
Trial, which he also presented at the 35th annual meeting of the
American Society of Clinical Oncology (Atlanta).
The study looked at 177 patients with distal rectal adenocarcinoma.
Patients with T1 lesions (tumor in the submucosa) underwent local
excision only, and those with T2 lesions (tumor in the muscularis
propria) received local excision plus chemotherapy and radiotherapy.
Of the original 177 patients, 161 underwent a full thickness
excision, and 110 were eligible to remain on the study (51 patients
did not make the second cut, mostly due to inadequately defined free
margins on pathology or free margins that were very difficult to
document as being free pathologically). Of the 110 eligible patients,
59 patients were originally classified as T1, and 51 were classified
as T2. These patients have currently been followed for 52 months.
Overall, 13 of the 110 patients (12%) had tumor recurrence. In the T1
group, there were four failures. Salvage therapy was used for local
recurrence in two patients. One remains disease free and the other
died of liver metastases, although a retrospective review of the
liver scan suggested that the liver disease may have been present at
the time of presentation. The other two patients died of distant metastases.
In the T2 group, there were nine failures. Three had distant disease
only and did not receive salvage resection. Salvage therapy was used
to treat local recurrence in six patients. Of these six patients, two
had local and distant disease and died of their distant disease, and
four had local recurrence only at the original site. Of these four
patients, three remain disease-free, and one patient died of distant
metastases, although this patient was free from local recurrence at
the time of death.
Prognostic factors for increased risk of disease recurrence included
the presence of perineural invasion, poor differentiation, and
There has been no plateauing of local recurrences in this study.
We expected a moderate number of recurrences, but actually have
seen continuing and rather significant recurrences, he said.
Since there are no prospective studies of years to recurrence for T1
and T2 patients, this expectation was based on mostly anecdotal
reports in the literature. However, an analysis of a national cancer
database indicates that recurrences in these patients may be more
frequent and may continue for longer periods than the anecdotal
reports suggest, he said.
So far, salvage after local recurrence seems to be quite effective,
he said. If we could salvage almost all of our failures, we
would have a situation quite analogous to the biology in breast
cancer and the rationale for using a conservative approach first for
these early distal rectal carcinomas.
The caveat about salvage in this study, he said, is the length
of follow-up. The median time of follow-up after salvage is still
less than 3 years, so we have more time to go before were
comfortable with the duration of the salvage.
He added that more research is needed to confirm these early
Additionally, we will also evaluate preoperative therapy and
other surgical techniques, to learn what effect they have on overall
survival. We must also continue to focus on quality of life issues
for our patients, Dr. Steele said.