Established data and practical recommendations for neoadjuvant and adjuvant chemotherapy for rectal cancer.

Adjuvant chemotherapy appears to be active in stage II-III rectal cancers; the NSAPB R01 trial demonstrated a survival advantage for patients receivin g chemotherapy using the MOF protocol and 3 metaanalyses are in favor of th e efficacy of adjuvant chemotherapy in rectal cancer. Three randomized tria ls have also demonstrated that combinations of radiation and chemotherapy a re superior to surgery alone or adjuvant radiotherapy and demonstrated the major role of systemic chemotherapy combined with radiotherapy. However thi s efficacy of adjuvant chemotherapy alone or combined with radiation therap y is still debated and specific trials must be conducted to test the value of chemotherapy using more active regimens than those previously tested and taking into account the quality of surgery and radiotherapy; such trials a re in progress, especially the trial conducted by the EORTC and the FFCD. T he efficacy of neoadjuvant chemotherapy has never been clearly demonstrated , although a combination of radiotherapy and chemotherapy as first-line tre atment for locally advanced rectal cancer and in the case of synchronous me tastasis seems to facilitate surgical resection. It is a reasonable and tol erable approach with manageable toxicity which gives substantial results in 2/3 of patients. This strategy also allows better selection of patients li kely to benefit from surgical resection of their primary tumor and in some cases of their synchronous metastases. However, the efficacy of perioperati ve treatments should not decrease the quality of the surgical resection and especially mesorectal excision as well as the need for high quality pathol ogical examination which must be very thorough with analysis of a sufficien t number of lymph nodes. The efficacy of combined treatment in advanced rec tal cancers is a major argument in favor of the multidisciplinary coordinat ion required for optimal treatment of patients with rectal cancer.