Pre-Surgical Chemotherapy May Spare Certain Patients With Rectal Cancer From Major Surgery

Pre-surgical chemotherapy may shrink early-stage rectal cancer enough that patients can have organ-preserving surgery, thereby avoiding functional disturbances or permanent ostomy use, according to recent research published in the Journal of Clinical Oncology.

"Although locoregional relapse rates with modern (presurgical) therapy are low and survival is excellent, (total mesorectal excision) results in issues with bowel function, incontinence and sexual function,” the authors wrote.

The phase 2 trial included 58 patients with stage 1 or early-stage 2 rectal cancer that did not spread to the lymph nodes. Participants underwent three months of a chemotherapy regimen that consisted of modified folinic acid–fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin.

Those whose tumors shrunk enough from the chemotherapy then went on to receive transanal endoscopic surgery two to six weeks later.

Transanal endoscopic surgery is a minimally invasive procedure that involves going through the anus and/or rectum to remove tumors. This process is less invasive than total mesorectal excision, which often include a major incision in the abdominal, lengthy hospital stay and results in the use of an ostomy, which is an opening in the abdomen used to allow feces to drain out of the body.

Fifty-six of the 58 patients went on to receive surgery: 53 underwent transanal endoscopic surgery and three underwent a local excision. Of the 56 who underwent the minimally invasive procedure, 10 then received total mesorectal excision, based on residual disease found on the tumor specimen that was resected.

Study results showed that 79% of patients were able to preserve their organs, including 13 patients who declined total mesorectal excision.

In the entire study population, the observed organ preservation rate was 79%, which included 13 patients who were recommended to receive, but declined total mesorectal excision.

For patients who underwent transanal endoscopic surgery, the researchers reported few postoperative complications, with no patients being readmitted to the hospital after the procedure. Early quality of life results suggested that transanal endoscopic surgery had only minor effects on bowel function, which tended to improve over time.

Low-anterior resection syndrome (organ disturbance) improved six months after transanal endoscopic surgery, and improved to baseline levels at the 12-month mark, the researchers noted. There were also minimal changes in fecal incontinence (the inability to control bowel movements, which may cause feces to leak unexpectedly from the rectum).

“In conclusion, three months of induction chemotherapy … may successfully downstage a significant proportion of patients with favorable-risk, early-stage rectal cancer, allowing well-tolerated organ-preservation surgical therapy with minimal effect on organ function,” the researchers wrote.

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