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Top Line: There’s never been a better time for short-course neoadjuvant radiation for rectal cancer.
The Study: This international “expert consensus” is headed up by none other than, you guessed it, the Dutch. Cutting to the chase, Figure 1 is where the money’s at. It outlines standard ESMO recs stratified by MR-guided risk features and in parallel offers similarly stratified recs adapted for pandemic times. To keep perspective, one needs to bear in mind the absolute incremental benefit of longer course chemoradiation over short-course or even no radiation (hint: it’s small) and weigh that against the exposure risk incurred by several more clinic visits. In short (sorry can’t help ourselves), radiation can be omitted for early to intermediate risk disease where there is no threatened mesorectal fascia or levator muscles, including low-lying cT3N0 and higher-lying cT3N+ without extracapsular extension (ECE) or extramural vascular invasion (EMVI). With cT4 tumors or ECE or EMVI but still no threatened mesorectal fascia or levator muscles, short-course radiation alone is recommended. For threatened mesorectal fascia or levator muscles, either standard chemoradiation (25-28 treatments with concurrent capecitabine) or short-course +/- sequential neoadjuvant chemo are options. Finally, per Stockholm III, the authors prefer delaying surgery 4-8 weeks after short-course radiation—as opposed to the standard 3-7 days—due to equivalent oncologic outcomes with reduced surgical morbidity, all while thinning surgical demand while resources are low.
TBL: Most rectal cancers can get away with short-course radiation with no compromise to oncologic outcomes. | Marijnen, Radiother Oncol 2020