Neoadjuvant Therapies and Less Invasive Surgeries May Have Improved Survival for Rectal Cancer Care Over Time

Treatments before surgery for rectal adenocarcinoma, a type of rectal cancer, have increased and correlated with preservative surgeries and improved overall survival in the last 16 years, though improvements may still be needed for disease screening, an expert said.

Increased use of immunotherapy and chemotherapy, in addition to sphincter-saving and minimally invasive surgeries, may have significantly improved survival in patients with rectal adenocarcinoma, a type of rectal cancer, from 2004 to 2019, recent study results demonstrated.

“Patients are doing better,” said study author Dr. Steven D. Wexner, chair of the colorectal surgery department at the Cleveland Clinic in Weston, Florida, in an interview with CURE®. “We have a more appropriate and much more frequent use of evidence-based best practices like neoadjuvant chemotherapy and neoadjuvant radiotherapy (therapy administered before surgery) rather than adjuvant (therapy administered after surgery, as well as) more efficacious and better risk profiles.”

In the study, which was published in JAMA Oncology, researchers analyzed data from 318,548 patients with rectal cancer from 2004 to 2019. The data were then divided into four periods:

  • Period one from 2004 to 2007 (73,720 patients).
  • Period two from 2008 to 2011 (74,727 patients).
  • Period three from 2012 to 2015 (81,431 patients).
  • Period four from 2016 to 2019 (88,670 patients).

As evidenced by the increasing number of patients in each period, more patients were diagnosed with rectal cancer over time, for a total increase of 20.3% between period one and period four. Patients in period four more often presented with disease at stage 3 or 4, indicating a need for improvements in disease screening, as they’re only being diagnosed after disease has progressed, according to the study.

“Benjamin Franklin said it much better than I ever could: ‘an ounce of prevention is better than a pound of cure,’” Wexner said. “It is more true with colorectal cancer, I believe, than any other malignancies. If you go in with a colonoscope, find a polyp and remove that polyp, that polyp will never live to become a cancer. We know the precursor lesion of most colorectal cancers are colorectal polyps. So we know that we can remove those polyps before they get to be cancers. Screening is key.”

Several advancements to treat the disease after diagnosis were made during this time period including an increase in neoadjuvant therapies and the introduction of immunotherapy. In addition, the use of radiotherapy was cut in half, which is particularly beneficial to patients with rectal cancer considering the proximity of tumors to other organs, according to the study. Of note, localized radiation may cause potential damage to these nearby organs.

The time from initial diagnosis to surgery increased by 11 days from period one to period four, corresponding to the increased usage of neoadjuvant therapies, while the number of patients who did not ultimately undergo surgery also increased.

“In addition, (we found that patients underwent) more minimally invasive surgery and less open surgery,” Wexner told CURE®. “We know that minimally invasive surgery in and of itself confers numerous benefits not just less pain and shorter hospitalization, but less surgical site infection and less hernias but ultimately — in numerous, numerous randomized-controlled trials — better oncologic outcomes. In some cases, (this has led to) the histopathologic surrogate (clinical marker in tissue examination of tumors) short-term outcomes, in some, the long-term local recurrence and survival outcome.”

Wexner urged all patients exhibiting potential rectal cancer symptoms regardless of age to pursue disease screening. “This disease is largely preventable,” he said. “When not preventable, (it is) certainly vastly more easily treatable with a better outcome when it's caught early.”

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