Author: By Hagen Kennecke, M.D., MHA, FRCPC, medical director, gastrointestinal oncology, Providence Cancer Institute
The results of a recent clinical trial at Providence Cancer Institute of Oregon reveal that patients with certain stages of rectal cancer can safely avoid radiation treatment and achieve better quality of life. Patients who received preoperative fluorouracil, leucovorin and oxaliplatin (FOLFOX) chemotherapy, instead of radiation, followed by surgery had similar rates of treatment success and fewer long-term side effects that can reduce patients’ quality of life.
Known as PROSPECT, this study was sponsored by the U.S. National Cancer Institute and was open to patients at multiple Providence locations in Oregon.
I co-authored an article featuring the results of the trial that appeared in the New England Journal of Medicine in June 2023, and the abstract was presented in a plenary session at the 2023 American Society of Clinical Oncology Annual Meeting.
New treatment option
For decades, pelvic radiation therapy with surgery has been standard treatment for patients with locally advanced rectal cancer. Radiation therapy before surgery was used to decrease the chance of the cancer coming back in the pelvis but can result in potentially life-altering side effects.
In addition to causing diarrhea, nausea and vomiting, radiation therapy can damage and impair the bowel and bladder. It also can weaken bones, which increases the risk of fractures to the pelvis or hip. In premenopausal women, pelvic radiation can initiate menopause and affect sexual function, a side effect experienced by men as well. Additionally, the risk of a second malignancy increases with pelvic radiation.
Younger adults diagnosed with rectal cancers will benefit
A report released in March from the American Cancer Society shows that in 2023, an estimated 153,020 people will be diagnosed with colorectal cancer, including 19,550 who are younger than age 50. Considering the rise in younger patients receiving treatment, side effects that can lead to infertility and diminish quality of life are particularly concerning.
PROSPECT reflects a shift in how we’re approaching rectal cancer research to address these issues. Rather than intensify standard treatment – in this case, radiation – studies such as PROSPECT evaluate the safety and efficacy of treatment without radiation when possible. This is known as a de-escalation study.
Quality of life outcomes favor no radiation
PROSPECT is a multicenter trial open to patients whose cancer had spread to lymph nodes or tissues around the bowel. From June 2012 through December 2018, there were 1,194 patients randomly assigned to one of the following treatments:
- No initial radiation: This group received FOLFOX chemotherapy once every two weeks for three months, followed by surgery if the tumor had shrunk. If the tumor did not respond to chemotherapy, patients received radiation, which occurred in 9% of patients.
- Radiation: The other group of patients received radiation for 5 ½ weeks, followed by surgery and up to four months of FOLFOX chemotherapy. At a median follow-up of five years, survival without recurrence of cancer was 80.8% in the FOLFOX group and 78.6% in the group that received chemotherapy and radiation.
In both groups, the risk of cancer coming back in the pelvis was less than 2%. However, patients treated with chemotherapy instead of radiation experienced better bowel and sexual function, which are indicators of a higher quality of life.
What does this mean for the future of rectal cancer treatment?
The treatment of rectal cancer is becoming increasingly complex and personalized. The days of treating all patients with rectal cancer the same are behind us. We can tailor treatments according to the cancer stage and patient preferences.
Other current options include novel chemotherapy agents and treatment escalation with more radiation and more chemotherapy, which can omit surgery as a follow-up. Because of these complexities, rectal cancer patients are increasingly referred to high volume centers such as Providence Cancer Institute for dedicated expertise in treating rectal cancer.
In 2021, Providence’s Rectal Cancer Program earned accreditation from the National Accreditation Program for Rectal Cancer (NAPRC). Providence Portland and Providence St. Vincent medical centers were the first in the Pacific Northwest and among the first 25 in the U.S. to earn this honor. For patients with rectal cancer, that means lower rates of cancer recurrence, lower rates of requiring a permanent colostomy and better long-term survival.
To refer a patient, call 503-215-6014, or visit ProvidenceOregon.org/colorectalcancer to learn more.
To refer a patient for a trial:
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