Non surgical treatment of operable rectal cancer: Reducing harm from the standard of care in elderly patients


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Arthur Sun Myint1,Fraser Smith2,Karen Whitmarsh1,Helen Wong1,Mark Pritchard3
1Clatterbridge Cancer Centre,2Royal Liverpool and Broadgreen University Hospital,3Department of Cellular and Molecular Physiology,University of Liverpool

Abstract

Background

The standard of care for early rectal cancer is surgery. However, mortality  and morbidity is high following surgery in elderly patients. UK population is ageing and the majority with rectal cancer are over 70 years. The surgical mortality(12-25%) increases with age. We present our single institute data using non-surgical approach for elderly to reduce surgical mortality & morbidity.

Method

Our study reviewed the outcomes between 2003 to 2012. Mean age 74 years (range 32-94). There were 134(67%) males. Histology confirmed in all patients. Stages  were T1 21(10.5%); T2 89(44.5%); T3 87(43.5%); T4 3 (1.5%). All patients had contact X-ray brachytherapy (CXB)[Papillon] 90-110 Gy/3-4 fractions over 4-6 weeks. This was followed by EBRT in 184 (92%).   Watch and wait policy adopted in all patients who achieved complete clinical response (cCR).

Results

Initial complete clinical response was achieved in 136(68%). Residual abnormality seen in 64(32%). Immediate salvage surgery was carried out in 38(68%) who are fit.  Those with cCR 116(85%) maintained complete response.  At median follow up of 2.49 years,16(11.7%) developed local relaspe after cCR. Ten patients with loco regional relaspe only who are fit had delayed surgery. Distant relaspe developed in 17(8.5%).  Over all survival (88%) and disease free survival (80%) were better for responders. There were no deaths related to CXB. The main toxicity was bleeding in 30% of cases. At the end of treatment 160 patients (80%) are disease free with good quality of life.

Conclusion

Elderly patients with early rectal cancer not suitable for surgery should be offer CXB (Papillon) to avoid high surgical mortality in elderly.  OPERA which is a randimised trial is due to open in the UK to evaluate CXB efficacy . NICE has recommended CXB as safe with acceptable toxicity for patients not suitable for surgery. Data base is set up at Guildford for a prospective audit.