Introduction: This study reports the outcomes of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by surgery in a local population of Singapore.Materials and Methods: The records of 85 patients who underwent neoadjuvant chemoradiation for locally advanced rectal cancer followed by surgery at the Tan Tock Seng Hospital (TTSH) between November 2002 and January 2012 were reviewed. The treatment protocol comprised radiotherapy to a total dose of 50.4 Gy concurrent with 5-fluorouracil-based chemotherapy. Patients underwent total mesorectal excision surgery following the completion of neoadjuvant chemoradiation. Local control, disease-free survival and overall survival were analysed using Kaplan-Meier methods. Results: Median age of the patients was 61 years. All of them completed radiotherapy. One patient did not complete neoadjuvant chemotherapy. The median time to surgery was 52 days. Fifty-five percent (47 of 85) of patients achieved pathological downstaging and 13% (11 of 85) of patients had a pathologic complete response to preoperative treatment. The neoadjuvant chemoradiation was well tolerated. Four percent of patients had grade 3 diarrhoea and 4% of them had grade 3 dermatitis. There were no grade 4 toxicities. With a median follow-up of 41 months, the 5-year actuarial local recurrence, disease-free survival and overall survival rates were 7%, 71.9%, and 83.2% respectively. Univariate analysis showed that patients with positive surgical margins had significantly worse disease-free survival and overall survival (P = 0.012 and P <0.001 respectively) and a trend towards a higher rate of local recurrence (P = 0.08). Conclusion: Our study provides evidence that neoadjuvant chemoradiation is an effective treatment for locally advanced rectal cancer. Our outcomes are comparable with internationally published data and demonstrate the reproducibility of the neoadjuvant approach in an Asian population.
In Singapore, colorectal cancer is the most common cancer in males and second most common cancer in females, with rectal cancers accounting for 30% to 40% of all colorectal cancers. Local recurrence after treatment of rectal cancer results in significant morbidity and mortality and poses significant management challenges. Advances in surgical techniques with the adoption of total mesorectal excision (TME) surgery and improvement in chemoradiation strategies have led to better outcomes but local recurrence remains difficult to manage. The optimal management of locally advanced rectal cancer consists of a combined modality approach with surgery as the cornerstone of cure. Randomised trials in the 1990s have shown that for patients with locally advanced cancer, postoperative chemoradiotherapy improves local control and overall survival. Further efforts to improve local control and preserve the function of the anal sphincter have led to the consideration of neoadjuvant approaches. The results of a large randomised trial comparing neoadjuvant versus adjuvant chemoradiation clearly demonstrated that toxicity is reduced and local control is improved with a neoadjuvant approach, thus representing the prevailing paradigm for treatment at this time.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.