This review nicely summarizes the current state of combined-modality therapy for resectable rectal cancer, largely covering trials currently in progress in the United States. Although the article's title is "Multidisciplinary management of resectable rectal cancer," it really doesn't emphasize how multiple specialists manage rectal cancer patients per se, and thus, the article would probably be more appropriately titled, "Combined-modality therapy in resectable rectal cancer." It would have been interesting if the article had included more details on how radiation oncologists, medical oncologists, and surgeons can cooperate to deliver combined-modality therapy in higher proportions of patients with resectable rectal cancer, but this is a minor criticism.
Since there very much is an issue in the surgical community as to whether or not adjuvant therapy is necessary if "effective" surgery is performed, it is worth noting that in several centers in Europe, radical rectal cancer surgery using the "total mesorectal excision" technique popularized by R. J. Heald is undergoing serious study. In Sweden and the Netherlands, total mesorectal excision alone is being compared with total mesorectal excision plus adjuvant chemoradiotherapy.[personal communication, Lars Påhlman, md, phd, Department of Surgery, Uppsala University, June 1996] Accrual of a sufficient number of patients (numbering in the hundreds) should help answer the question of whether or not adjuvant therapy really has something to offer when "effective" surgery is performed.
European Trials of Preoperative Radiation Given Short Shrift
My main criticism of this article is that Dr. Minsky may have given short shrift to some of the European trials of preoperative radiation therapy. First of all, a recent randomized trial from Sweden, reporting on over 1,100 patients, showed that both local recurrence and overall survival were significantly better in a preoperative radiation-therapy group than in a surgery-alone group. This is the first study to report a significant impact of radiation therapy alone on survival. This study utilized a 25-Gy dose given over 5 days before surgery--a type of regimen that Dr. Minsky believes may not be worthwhile. There may be some significant advantages to this therapy, in that it permits the patient to undergo a very short course of preoperative treatment that seems to be quite simple. Economic considerations could also be important with this treatment regimen, and its demonstrated effectiveness is at least worthy of further serious consideration in North America, as well as in Europe.
Dr. Minsky appears to be most favorably impressed with the 5,040-cGy preoperative radiation scheme that he and others have used extensively. In nonrandomized trials, these researchers have seen impressive shrinkage of the tumor with this radiation scheme, perhaps permitting better sphincter preservation. Although I believe that this sphincter-preservation strategy probably does not lead to an increase in local recurrence, Dr. Minsky makes no comment about local recurrence in patients who undergo sphincter-preservation procedures after preoperative radiation.
Dr. Minsky has been one of the pioneers of combined-modality therapy in the treatment of resectable rectal cancer. His article nicely summarizes the current issues related to the adjuvant therapy of resectable rectal cancers, and he notes that many important questions should be answered by the ongoing North American randomized trials (particularly the National Surgical Adjuvant Project for Breast and Bowel Cancers [NSABP] R-03 and Intergroup 0147 trials). I hope that Dr. Minsky and other North American investigators will remain sensitive to the very important trials being conducted in Europe, which are quite different in design than the North American trials and often accrue much larger numbers of patients over far shorter periods of time.