The emerging options of total neoadjuvaant therapy (TNT) and non-operative management (NOM) for locally advanced rectal cancer are controversial. In rectal preservation treatment protocols for rectal cancer, or the so-called “watch-and-wait strategy,” some patients may be treated with neoadjuvant therapy and throughout the course of treatment intermittently examined with a flexible sigmoidoscopy, digital rectal exam, and rectal MRI to assess the degree of tumor response. Once neoadjuvant treatment is completed, a decision on the degree of tumor response, which can be complete in up to 40%, is made regarding whether close observation without surgery is appropriate.
Data supporting the integration of endorectal brachytherapy to improve complete clinical response is evolving. Optimization of patient selection for each approach is not yet well defined. Moffitt's GI Oncology team continues to lead rectal organ preservation research and commentary, with encouraging data that suggests the potential for highly selected patients to achieve cure without compromising quality of life.
Controversies in Rectal Cancer Management
To further discussion on rectal organ preservation, Moffitt invites interested providers to attend a meeting taking place on April 26-27 at The Westin Tampa Waterside. This course will examine the current data to guide treatment recommendations in this complex area and those clinical scenarios when TNT and NOM may be appropriate.
Individualizing Active Management
Current standard of care is concurrent preoperative chemoradiation and surgery. New guidelines indicate that total neoadjuvant therapy is an acceptable alternative and in select clinical circumstances may have advantages. Moreover, with an aging population, an increasing percentage of patients may not be optimal candidates for surgery. However practical application of a NOM strategy is lacking and concern remains regarding the development of unsalvageable disease while monitoring.
Moffitt physician scientists have studied the reproducibility of clinical tools in assessing rectal cancer response to neoadjuvant therapy. Specifically, current research has contributed to the investigation of the endoscopic treatment response of rectal cancer to neoadjuvant chemoradiation and chemotherapy. Collaboration among oncologists, surgeons and radiologists in correlating treatment response of MRI findings with the endoscopic findings aids in determination of whether a patient may be a candidate for avoiding oncologic surgery.
Novel strategies such as endorectal brachytherapy may increase the potential of a clinical complete reponse. A multitude of radiosensitizing agents continue to be investigated as well as the concept of radiation dose-escalation and potentially biologically prescribed radiation dosages accounting for the heterogeneity of tumors. With mathematical modeling, individualizing response to chemoradiation therapy or total neoadjuvant therapy prospectively may become possible so that treatments can be more precisely tailored to the specific genomics of the patient’s tumor.