Recently the Association of Medical Oncologists of India (AMOI) conducted a meeting to discuss and understand recent developments in the understanding and treatment of cancer of the rectum. I was privileged to be invited in my role as a surgical oncologist to share my views, especially regarding the newer trends in the surgical treatment of rectal cancer. It was an insightful meeting. Although the discussion was confined to cancer of a single organ (the rectum), similar changes are occurring in the management of many other cancers as well. There were several important takeaways from the meeting. In the following list, I have tried to put down the key points in a simplified manner for non-oncologic medical colleagues and others specifically looking for updates on rectal cancer treatment:
- Increasing use of Total Neoadjuvant Therapy (TNT): Radiation and all or most chemotherapy is now preferably given prior to surgery, unlike earlier when chemotherapy used to follow surgery.
- Advances in imaging: Newer MRI techniques provide very accurate assessment of rectal cancer staging before initiating treatment, as well as after TNT, helping us to plan surgery much better.
- Pushing boundaries in surgical treatment: The availability of minimally invasive and robotic technologies, along with use of TNT, have allowed surgeons to offer sphincter preserving surgery (where a permanent colostomy is not required) to an increasing number of patients, without compromising cure rates.
- Increasing use of non-operative treatment: In very carefully selected patients in whom the cancer completely disappears after TNT (a complete clinical response), we can choose to avoid surgery and instead closely observe. There are many caveats to this approach, but it is feasible in certain individuals.
- Local excision: Growing number of patients seen at very early stages where just a local excision of the cancer done through the anal opening is sufficient treatment (in contrast to major abdominal surgery). Again, there are many caveats to this approach and patient selection has to be done very carefully.
- Advances in systemic therapy: This of course, is the domain of medical oncologists, and there are a lot of promising advances – many newer developments related to choice of chemotherapy, role of newer drugs including immunotherapy, and different ways of sequencing of treatment (radiation first or chemotherapy first).
Though this is a technical article, I hope it is of some help to those seeking a quick update on rectal cancer developments.