Adjuvant radiochemotherapy - what is the patients benefit?

Background: Local relapse is a major problem after potentially curative rec tal cancer surgery. Although the incidence of local recurrences may be redu ced by specialized surgical techniques such as total mesorectal excision (T ME), local relapse rates of 20% or higher are the surgical reality today. S tudies using adjuvant postoperative radiotherapy, chemotherapy, radiochemot herapy or immunotherapy have tried to reduce local relapse rates and distan t progression. Postoperative radiochemotherapy has been the recommended sta ndard, after complete resection of Union Internationale Contra In Cancrum ( UICC) stages II and III rectal cancers. In view of recent positive results with preoperative radiotherapy of TME without adjuvant therapy, we found it important to review the literature to update the recommendable adjuvant pr ocedure in rectal cancer. Method/Patients: The literature from 1985 to May 1998 was reviewed for studies trying to either confirm or improve adjuvant therapy in rectal cancer. Only randomized controlled trials were analyzed w ith regard to their effectiveness in reducing the absolute rates of local r ecurrence and improving survival. Results: Two trials applying adjuvant rad iotherapy were able to demonstrate the reduction of local relapse rates, on e trial with marginal significance, both without impact on survival. Four t rials involving 1104 patients with rectal cancer stages UICC II-III compare d postoperative radiochemotherapy with either surgical controls, adjuvant r adiotherapy or conventional radiochemotherapy. In these trials, local relap se rates were significantly reduced by 11-18%, and survival rates significa ntly improved by 10-14%. Severe acute toxicities occurred in 50-61% of the patients, compromising compatibility, and caused death in 0-1%. Small-bowel obstruction leading to surgery was noted in 2-6% and to death in up to 2% of the patients. Intraoperative radiotherapy (IORT) improved local control and survival after surgery of locally advanced disease/local relapse. Concl usion: In view of four trials demonstrating a significant benefit of postop erative radiochemotherapy and with regard to recent still-debatable results of preoperative short-term radiotherapy optimal surgery with lowest local relapse rates plus postoperative radiochemotherapy remains the actual recom mendable standard for rectal cancer surgery in RO resected tumors stages UI CC II+III.