Perspective on the PROSPECT: The Conundrum of Managing T3n0-N1 Mid and Upper Rectal Cancer

The standard of care for the management of locally advanced rectal cancer is surgical resection. Older studies have revealed a very high local recurrence rate in the range of 25% after traditional proctectomy alone.

The development of the total mesorectal excision (TME) technique by Dr. Heald significantly decreases local recurrence when the entire mesorectal fat, including all lymphatics, is completely and sharply dissected along a well-defined “holy plane.” Prospective randomized trials are required to discern whether radiation therapy is still necessary to improve the locoregional control rate beyond that achievable by TME alone. Van Gijn et al1 reported the long-term results of a seminal Dutch randomized trial enrolling 1861 patients. The trial compared the local recurrence rate after TME alone or a preoperative short course of radiotherapy followed by TME. Radiation therapy decreased the local recurrence rate observed after TME alone by approximately 50% (5% vs 11%). Sebag-Montefiore et al2 reported the results of a similar British study in 1350 patients, in which preoperative radiation therapy decreased the risk of local recurrence by 61% (4% vs 10.7%). Radiation therapy, when indicated, is currently recognized to be better when delivered preoperatively than postoperatively and is usually administered concurrently with 5-fluorouracil–based chemotherapy. Planned postoperative radiation is seldom used in contemporary radiation oncology practice.