Research article

The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline

Alvaro Figueredo¹ , Lisa Zuraw² , Rebecca KS Wong³ , Olusegun Agboola⁴ , R Bryan Rumble² , Ved Tandan¹ and the members of Cancer Care Ontario's Program in Evidence-based Care's Gastrointestinal Cancer Disease Site Group

¹  Hamilton Regional Cancer; McMaster University, Hamilton, Ontario, Canada

²  Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada

³  Princess Margaret Hospital; University of Toronto, Toronto, Ontario, Canada

⁴  Ottawa Regional Cancer Centre; University of Ottawa, Ottawa, Ontario, Canada

author email corresponding author email

BMC Medicine 2003, 1:1doi:10.1186/1741-7015-1-1

Published:	24 November 2003

Abstract

Background

This systematic review with meta-analysis was designed to evaluate the literature and to develop recommendations regarding the use of preoperative radiotherapy in the management of patients with resectable rectal cancer.

Methods

The MEDLINE, CANCERLIT and Cochrane Library databases, and abstracts published in the annual proceedings of the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were systematically searched for evidence. Relevant reports were reviewed by four members of the Gastrointestinal Cancer Disease Site Group and the references from these reports were searched for additional trials. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.

Results

Two meta-analyses of preoperative radiotherapy versus surgery alone, nineteen trials that compared preoperative radiotherapy plus surgery to surgery alone, and five trials that compared preoperative radiotherapy to alternative treatments were obtained. Randomized trials demonstrate that preoperative radiotherapy followed by surgery is significantly more effective than surgery alone in preventing local recurrence in patients with resectable rectal cancer and it may also improve survival. A single trial, using surgery with total mesorectal excision, has shown similar benefits in local recurrence.

Conclusion

For adult patients with clinically resectable rectal cancer we conclude that:

• Preoperative radiotherapy is an acceptable alternative to the previous practice of postoperative radiotherapy for patients with stage II and III resectable rectal cancer;

• Both preoperative and postoperative radiotherapy decrease local recurrence but neither improves survival as much as postoperative radiotherapy combined with chemotherapy. Therefore, if preoperative radiotherapy is used, chemotherapy should be added postoperatively to at least patients with stage III disease.