Optimizing the outcome for patients with rectal cancer

Historically, rectal cancer with transmural spread and/or lymph node involvement has presented a major challenge to surgeons, with a variable and often high risk of local recurrence and poor survival outcomes. In recent years a large amount of literature has focused attention on the importance of surgical technique, tumor staging, and the optimal integration of CT and radiation therapy.

This article reviews the clinical trials that have defined the current approach to rectal cancer, the controversies regarding what should be considered the standard of care, and the ongoing clinical studies that will resolve some of these issues.

The preoperative staging of rectal cancer can be improved with the use of endorectal ultrasound and (where available) magnetic resonance imaging. Careful pathologic analysis, particularly of the radial margin, provides important prognostic information that enables better allocation of postoperative care. Although both radiation therapy and CT have a proven role in adjuvant therapy, the interpretation of many studies is confounded by unacceptably poor outcomes in the control arm, and in older studies the use of inferior chemotherapy and radiation therapy techniques. Ongoing studies will better define the optimal combination and timing of chemotherapy and radiation therapy, with respect to both toxicity and survival endpoints.

A combined modality approach to rectal cancer, integrating the colon and rectal surgeon, pathologist, medical oncologist, and radiation oncologist, is necessary to achieve optimal outcomes. The achievements to date and the ongoing vigorous debates regarding standard care continue to highlight the importance of quality ongoing research in a rapidly changing clinical environment.