Rectal cancer: Changing patterns of referral for radiation therapy 1982-1997

Background: The purpose of the present study was to evaluate the changing r ole of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period. Methods: From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospi tal; 79% of patients had locoregional disease alone and 21% had distant met astasis. Radiation therapy consisted of irradiation (definitive or palliati ve) alone to the primary tumour in 9.7% of cases; preoperative radiation in 7.3% of cases; preoperative chemoradiation in 7.5% of patients; postoperat ive radiation in 15.3% of patients: postoperative chemoradiation in 12.3% o f patients; treatment of pelvic recurrence in 23.5% of patients and treatme nt of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated(13.4%). Results: There was an average annual 14% increase in referrals over the acc rual period. Recurrent rectal cancer decreased from approximately 30% of re ferrals during 1982-91 to approximately 10% in 1995-7. The use of postopera tive adjuvant radiation reached a peak of 50% in 1993. The use of preoperat ive radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatmen t. The median survival time from initial diagnosis was 35 months, with 2- a nd 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, resp ectively. Conclusions: The present study illustrates the changing role of radiation t herapy in the management of rectal cancer. The increase in referrals over t he observation period was due to increased multidisciplinary input into the initial management of these patients. based on reported clinical trials. T he steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical res ults. The sequencing of adjuvant therapy is changing currently, with greate r emphasis on preoperative adjuvant treatment. Currently most adjuvant ther apy includes chemotherapy.