Appropriate use of neoadjuvant chemoradiotherapy in patients with rectal cancer

During the last several decades significant advances have been made in the evaluation and management of locally advanced rectal cancer. The diagnosis has been improved by high resolution rectal cancer protocol MRI in which a synoptic report is issued. The surgical technique has been standardized as total mesorectal excision whether performed through a standard or one of the many available minimally invasive approaches. Prognosis by pathology has evolved to our current appreciation that it is not the distal margin or the status of the nodes which predicts local recurrence but the quality of the TME specimen and the status of the circumferential resection margin. In addition other prognosticators such as tumor budding, the growth border, and extramural vascular invasion have become more widely understood. All of these factors are analyzed within the practice standards of the American College of Surgeons (ACS) Commission on Cancer (CoC) National Accreditation Program for Rectal Cancer (NAPRC) (Wexner et al). However, there is wide disparity in the US in terms of the appropriate recommendation of neoadjuvant chemoradiotherapy. One of our Cleveland Clinic Florida alumni, John Migaly, along with many of his colleagues from the Duke University Department of Surgery performed a query of the National Cancer Database (NCDB) to assess this issue. They assessed 32,978 patients of whom 21,204 (64.3%) received chemoradiotherapy, 9,714 (29.5%) received no neoadjuvant therapy of any description, and 890 (2.7%) received only chemotherapy. The authors found that neoadjuvant chemoradiotherapy was associated with a lower likelihood of surgical margin positivity, a decreased rate of permanent colostomy construction, and an increased rate of overall survival. This study clearly highlights, as has been shown in numerous recent studies, the wide disparity in adherence to guidelines in the US as well as the importance of adherence to those guidelines. It also furthers the importance of the new American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer. I congratulate the authors including our alumnus Dr. Migaly upon introducing more important data in the literature to support this essential new quality improvement program.