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Two countries − two different treatment strategies for rectal cancer

Interview with Dr. Marianne G. Guren

Interview Marianne G. Guren

Dr. Marianne G. Guren – Department of Oncology, Oslo University Hospital, Oslo, Norway

ECCO 2017 Poster 379: two-countries-two-treatment-strategies-rectal-cancer - ECCO 2017 abstract - Full article

Video summary:

The presentation was ‘Two Countries (Norway and Sweden), Two Different Treatment Strategies for Rectal Cancer’. The teams in both countries chose different treatment strategies for localised rectal cancer and also maintained population-based registries with good quality data. In Sweden, the treatment was based mainly on giving short course radiotherapy and then surgery. They started using preoperative chemo-radiotherapy in an increasing rate and especially since around 2004. They had compared groups in the rectal cancer registries where they looked at all patients, around 45,000 patients and then they looked at all that were Stage 1-3 rectal cancer and also for those that had major surgery but the most important group was the ones that had major radical surgery. The results showed that there are no differences in survival, no differences in overall survival, not in relative survival. In both countries the survival has improved and there is no difference between the two countries. But there was a difference in local recurrence rates. Hence perhaps a way forward is to combine radiotherapy and chemotherapy in the most optimal way. One of the major problems is that there is no difference in the rate of distant metastases. The data from various trials show that with different approaches to pre-operative radiotherapy and we can achieve low recurrence rates. However these trials also show that we still need to improve the outcomes of the patients by reducing the metastases rate, and thereby improving survival rate.

Video transcript:

Can you tell us about the background to your study in relation to the treatment of localized rectal cancer in Norway and Sweden?

The presentation was ‘Two Countries, Two Different Treatment Strategies for Rectal Cancer’ and the background is that in Norway and Sweden we have chosen different treatment strategies for localised rectal cancer and also one of the backgrounds is that we have population-based registries with good quality data in both these countries.

So in Sweden the treatment has been mainly based on giving short course radiotherapy and then surgery and in Norway initially in the nineties we chose to give surgery or perhaps post-operative chemoradiotherapy if there were narrow margins but then we started using preoperative chemoradiotherapy in an increasing rate and especially since around 2004 when we changed our guidelines to include those with those threatening resection margins, we had used more chemoradiotherapy.

So we have had different treatments and then we wondered if that would have a different impact on the outcomes.

Are there any differences in outcomes for patients with these different approaches?

What we did is we tried to find comparable groups in the rectal cancer registries.  We looked at all patients, around 45,000 patients and then we looked at all that were Stage 1-3 rectal cancer and those that had had major surgery but the most important group was the ones that had major radical surgery.  There was no residual tumour because in those patients we could look at the local recurrence rates and the distant metastases rates also and not only just survival.

So what we found is that when you look at these patient groups, there are no differences in survival, no differences in overall survival, not in relative survival.  In both countries the survival has improved so it’s better during these 20 years but there is no difference between the two countries.

But we did find a difference in local recurrence rates.  In the first time period when radiotherapy was very little used in Norway we had higher local recurrence rates than they did in Sweden, but if you look at the last time period we had exactly the same local recurrence rates, they were about 4% which we consider to be good.

Is there any way to select patients with rectal cancer for different treatments? Do all patients need radiotherapy?

That’s a very good question because that’s what we now need to look into.  We need to look into it in Norway and they also need to look into it in Sweden because we need to know what the optimal radiotherapy rate should be. 

We know that some people do need radiotherapy.  The most locally advanced, they need that in order to not get a recurrence, but for the majority of patients we might consider that they should irradiate fewer patients in Sweden since they have a high rate of radiotherapy and in Norway we use mostly chemotherapy but I believe we should consider giving short course radiotherapy to some of our patients.  Those are things we need to discuss and we also need guidance from other studies that also are being discussed at this meeting in order to find the right treatment for the right patients.

There is one major problem still and that is that there is no difference in the rate of distant metastases; it’s still 20% in both countries and the most important thing for the treatment choices is to find a way to decrease the rate of distant metastases.  And perhaps a way forward would be to combine radiotherapy and chemotherapy in the most optimal way.

Are there any new developments in treating localized rectal cancer which might change these standards of care?

Yes, we are waiting for the results of some of those trials.  There are interesting trials ongoing.  One of them is the Stockholm III trial which is expected to come with their results soon.  They have randomised between different ways of giving short course or long course radiotherapy and different waiting times until surgery and another trial that will I think be able to guide us is the RAPIDO trial and many others that are like it that combine short course radiotherapy with more extensive chemotherapy with the aim of improving survival, but we don’t have these results yet.

Any take home messages?

I am very happy that we can use the population-based quality registries to find results for these large patient groups with real-world data and I think that can supplement the information we get from the randomised controlled trials.  These data show that with the different approaches to pre-operative radiotherapy, we can achieve low recurrence rates, but they also show that we still need to try to improve the outcomes of the patients by reducing the metastases rate, and thereby improving survival. So there’s still a way to go!

- Ends -

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