Rectal cancer

The panel believes that a multidisciplinary approach, including representation from gastroenterology, medical oncology, surgical oncology, RT oncology, and radiology, is necessary when treating patients with rectal cancer. Adequate pathologic assessment of the resected lymph nodes is important, with a goal of evaluating at least 12 nodes when possible. Patients with T1 or T2 lesions that are node-negative on endorectal ultrasound and who meet carefully defined criteria can be managed with a transanal excision. A transabdominal resection is appropriate for all other rectal lesions. Preoperative chemoRT is preferred for most patients with suspected or proven T3/T4 disease and/or regional node involvement, and adjuvant chemotherapy is recommended, although upfront surgery is an option for some of these patients, particularly those with a medical contraindication to chemoRT. Patients with recurrent localized disease should be considered for resection with or without RT. Patients with metastatic disease in the liver or lung should be considered for surgical resection if they are candidates for surgery and if complete resection (RO) or ablation can be achieved. Preoperative chemotherapy can be considered for initial therapy in patients with synchronous or metachronous resectable metastatic disease (neoadjuvant) or when a response to chemotherapy can convert a patient from an unresectable to resectable state. Another option for these patients is initial treatment with chemoRT. Resection should be followed by adjuvant therapy based on prior therapy. The recommended posttreatment surveillance program for patients with rectal cancer includes serial CEA determinations; periodic chest, abdominal, and pelvic CT scans; and periodic evaluations using colonoscopy and proctoscopy. Recommendations for patients with previously untreated disseminated metastatic disease represent a continuum of care in which lines of treatment are blurred rather than discrete. Principles to consider at initiation of therapy include preplanned strategies for altering therapy in the presence and absence of disease progression and plans for adjusting therapy for patients who experience certain toxicities. Recommended initial therapy for advanced or metastatic disease includes bevacizumab plus FOLFOX, FOLFIRI, capecitabine, or 5-FU/LV. For patients with progressive disease who have received a 5-FU-based regimen or capecitabine as initial therapy, treatment options include chemotherapy consisting of FOLFIRI, CapeOX, FOLFOX, or irinotecan alone or, in the case of irinotecan and FOLFIRI, in combination with cetuximab. Monotherapy with either cetuximab or panitumumab is also an option after first or second progression. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy.