Recent advances in the treatment and outcome of locally advanced rectal cancer

Objective To compare the outcomes of treatment of locally advanced rectal c ancer of the early era (1975-1990) with those of the late era (1991-1997). Background Preoperative therapy has been used in locally advanced rectal ca ncer to preserve sphincter function, decrease local recurrence, and improve survival. At the University of Florida, preoperative radiation has been us ed since 1975, and it was combined with chemotherapy beginning in 1991. Methods The records of 328 patients who underwent preoperative radiation or chemoradiation followed by complete resection for locally advanced rectal cancer defined as tethered, annular, or fixed tumors were reviewed. The cli nicopathologic characteristics, adjuvant treatment administered, surgical p rocedures performed, and local recurrence-free and overall survival rates w ere analyzed. Results There were 219 patients in the early era and 109 in the late era. N o significant differences were seen in patients (age, gender, race) or tumo r characteristics (mean distance from the anal verge, annularity, fixation) . Preoperative radiation regimens were radiobiologically comparable. No pat ient in the early era received preoperative chemotherapy, compared with 64 in the late era. Of those receiving any pre- or postoperative chemotherapy, three patients received chemotherapy in the early era, compared with 76 in the late era. Sphincter-preserving procedures increased from 13% in the ea rly era to 52% in the late era. Pathologic downstaging for depth of invasio n increased from 42% to 58%, but lymph node negativity remained similar. Th e 1-, 3-, and 5-year local recurrence-free survival rates were comparable. However, in the late era, 1-, 3-, and 5-year overall survival rates improve d significantly compared with those of the early era, and also compared wit h each of the preceding 5-year intervals. Conclusion The addition of a chemotherapy regimen to preoperative radiation therapy improves survival over radiation therapy alone. Likewise, an impro vement in downstaging is associated with an increase iii sphincter-preservi ng procedures.