Well I have this 87 year old patient with rectal cancer on 12 cm. MRI says it is T3c (MRF+, EMVI+) N+. CT's of abdomen and thorax are OK. She is in good condition, no other diseases, but doesn't want to be operated on.
So I contacted our oncologists and they are not very happy with my idea of neoadjuvant therapy and perhaps wait and see aproach. They probably think the patient is to old and/or sick and propose 5 x 5 Gy short term treatment.
I searched the web but didn't find any such protocols after short term radioterapy only . Does any of You have any experiences or literature about this issue?
I think that the problem is in toxicity of neodjuvant therapy. At least our oncologists claim, that the patient who is not the good candidate for rectum resection because of adjacent diseases is even worst candidate for neaodjuvant treatment. Is it really like that?
I believe that exactly those patients, who doesnt want or can't be operated on should be candidates for nonoperative treatment.
What do You think?
asist prof Bojan Krebs, MD
What would be your approach in a fit 50 yr old patient with these characteristics? Chemoradiotherapy with 25 fractions and capecitabine?
There is certainly a movement currently to treat with chemoradiation therapy and re-biopsy after 8-12 weeks. If the biopsy is negative, many are advocating watch and wait.
Even at age 87, the patient should be able to tolerate capcytabine 1000 mg twice daily Monday to Friday with radiation. If that dose proves too high, it can be lowered. A somewhat more invasive route would be low dose continuous infusion 5-Fu Monday through Friday but would require a central venous access and portable infusion system.
Capecitabine plus radiotherapy would definetively be the best option. A metronomic scheme could be used of 1000 mg but once daily and without interruption. Celecoxib would be a good complement.
An alternative treatment could be based on artemisinin derivates due to its very low toxicity and very low cost.
We would be very careful with chemoradiation in a 87 yr old. In our experience, most 80+ patients are not fit for this treatment. In such a case we often give 5x5 Gy with a longer waiting period. When the patient recovers well and seems fit for surgery, we restage and do the TME resection.
Well, the question here is to do surgery or not as you earlier mention that she doesn't want to be operated upon!!!!!!!!!!!!!!!!!!
As the patient does not want surgical intervention,we are left with chemoradiation depending on her fitness and the local medical oncologist"s protocol.Other option is to leave it alone as it is not bleeding or obstructing as it is T3c N+leision.
Ah excuse me, I was focusing too much on whether or not she could receive chemoradiation on her age, that I forgot that she does not want to be operated on.
In that case we still consider 5x5 Gy without further surgery for local control when the patient is believed unfit for chemoradiotherapy. This leads to pathological complete remission as well, although probably in a lower number. Bujko published a number of articles on 5x5 with longer waiting period and very recently the Stockholm III trial was published also on this subject, maybe this literature helps you further.
Doing nothing is always an option to consider, I fully agree.
Reducing fat in the diet may limit substrate for tumorigenesis and may be a viable strategy to improve the cytotoxicity of standard chemo/radiation. The tumor will utilize the pentose phosphate pathway to generate anti-oxidant activity which can limit the cytotoxic effects of chemo/radiation, a very low-carbohydrate diet may improve disease prognosis.
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