Minimizing the Therapy-Related Morbidity in the Rectal Cancer Patient

A decades long challenge for clinicians caring for patients with adenocarcinoma of the rectum has been to optimize oncologic outcomes while minimizing both disease- and treatment-associated morbidities. This review summarizes the landmark trials that have defined the current standard of adjuvant care for rectal cancer and ongoing/planned trials that may help shape future standards. The 1980s and 1990s witnessed validation of total mesorectal excision (TME) and 5-fluorouracil (%-FU)-based adjuvant chemoradiation therapy (CRT) as feasible and effective pillars of care for adenocarcinoma of the rectum. The parallel advancements in preoperative staging, colorectal surgery, radiation, and medical oncology during this time culminated in a trial reported by Sauer and colleagues in 2004. Not only did this trial effectively compare preoperative and postoperative adjuvant CRT but it also advocated the use of total mesorectal excision as the standardized resection in all patients. While this trial addressed important issues surrounding preoperative adjuvant CRT and TME, further evolution of rectal cancer treatment will address additional issues, such as the incorporation of the oral 5-fluorouracil prodrug capecitabine (Xeloda) and oxaliplatin in adjuvant programs and development of strategies to individualize treatment based on the location (upper, mid, or distal) and molecular features of rectal cancer. The evolution of these modalities will hopefully enable physicians to individualize care plans so that optimal outcomes may be achieved.