Background and purpose: Radiochemotherapy (RChT) as adjuvant treatment for rectal cancer UICC stage II/III has been recommended by the National Cancer Institute (NCI) since 1991 and in Germany since 1994. Quality and results of postoperative treatment in day-to-day clinical practice in a complete region are evaluated retrospectively in a multi-institutional approach.
Patients and methods: 534 patients from six institutions treated between 1993 and 1998 were evaluated. The institutions covered a complete region with radiotherapeutic care. Patients were staged as follows: UICC I 1%, II 28%, III 69%, and IV 2%. 92% received RChT, 8% radiotherapy (RT) alone. Median follow-up of patients was 47 months (17-91 months).
Results: Only about 37% of expected patients were referred for postoperative treatment. The 5-year actuarial rate was as follows: local control 75% (63-84%), freedom from distant metastases 56% (44-63%), disease-free survival (DFS) 53% (42-59%), and overall survival (OS) 53% (45-64%). In multivariate analysis, local control was significantly influenced by T- and N-category, tumor grading, and RChT instead of RT alone. 6% (2-11%) of patients showed involved resection margins, in 33% of patients categorized pN0 less than the required twelve lymph nodes were examined, both leading to a significant decrease of local control.
Conclusion: While the quality of adjuvant treatment followed consensus guidelines, the number of referred patients which was lower as expected and the inferior treatment results as compared to randomized studies indicate that the consensus recommendations for adjuvant treatment have not been fully accepted. Instead of patient referral according to UICC stage, patient selection by the surgeons has been performed according to individual risk factors. Efforts have to be made not only to improve treatment results in randomized studies but also to transfer and control these standards in daily practice.