Treatment guidelines for patients with rectal cancer – 2018

In this study, the Clinical Practice Guidelines in Oncology (NCCN) updated the recommendations for treating patients with localized rectal cancer.

Colorectal cancer is the fourth most common cancer in the United States. A decrease in the number of new cases of colorectal cancer has been seen in the last decade. However, an increase in colorectal cancer in patients with less than 50 years old has been reported. This study summarizes the guidelines for the treatment of localized rectal cancer (the last section of the large intestine).

This study addresses the need to carefully select the treatment for each patient. They recommend the use of chemotherapy and radiation therapy (CRT) along with rectal surgery.

The assessment of the clinical stage of the tumor is essential to determine the best treatment option for each patient. This is done through medical exams and evaluation.

First, an MRI (medical device that produces a detailed image of the body tissues and bones) to the pelvic area is recommended. This is needed to assess if the tumor has spread to nearby lymph nodes. Metastasis (when cancer spreads to other parts of the body) should also be assessed by chest and abdominal MRI or CT scan (another imaging technique).

After a primary treatment with CRT, a new clinical evaluation of the tumor is recommended to plan the surgery. This is also important to determine if additional therapy can be avoided. Different surgeries can be performed. The choice of surgery depends on the location and the stage of the tumor. The surgery can be performed locally or with more invasive methods.

• Transanal excision is a localized method recommended for small, early-stage tumors. This uses surgical instruments put into the rectum through the anus. This surgery is less invasive (without cutting the belly) and is associated with less pain after the surgery and quick recovery.
• Transabdominal surgery (classical surgery performed by cutting the abdomen) is recommended for stage 2 or high-risk patients. This surgery is also used to remove the nearby lymph nodes and the tissue around the tumor.
• Laparoscopic surgery (removal of the tumor by using a cable with a camera inserted near the tumor) can also be performed in low-risk patients.   

The combination of CRT and surgery is recommended for most patients with stage 2 and 3 rectal cancer, for no longer than 6 months. CRT before surgery is recommended for patients with stage 2 and 3 rectal cancer. CRT after surgery is recommended when stage 1 patients are changed to stage 2 after the surgery, and for patients who did not receive CRT before surgery. Chemotherapy can also be received while undergoing radiation therapy.

The NCCN recommends an interval of 5 to 12 weeks following CRT before surgery to allow patients to recover from CRT side effects. Surgery after CRT in may not be necessary for specific patients.  

The current recommendations have suggested that treatment for patients with stage 2 and 3 rectal cancer should be individualized. The assessment of the tumor stage should be considered when deciding on a treatment plan. This way treatments would be more effective with fewer side effects.