Key message
The use of guideline-concordant pre-operative radiation therapy for rectal cancer was relatively consistent among the reporting provinces.
Indicator definition
The percentage of patients diagnosed with Stage II or III rectal cancer from 2009 to 2012 who received pre-operative radiation therapy. The results are presented by province, age group and sex.
Measured since
The 2010 Cancer System Performance Report.
Why measure this?
The delivery of radiation therapy (along with chemotherapy) prior to surgical resection for Stage II or III rectal cancer has been shown to improve local disease control (i.e., decrease the incidence of local recurrence) compared with surgery alone or post-operative radiation therapy.1-3 In addition, pre-operative radiation has been associated with a reduction in treatment-related toxicity compared with post-operative radiation therapy.1 Clinical practice guidelines therefore recommend pre-operative radiation therapy (combined with chemotherapy) for patients with Stage II or III rectal cancer.4 Measuring concordance with clinical practice guidelines can identify variations in clinical practice across the country.
What are the key findings?
- In the 2012 diagnosis year, the percentage of patients with Stage II or III rectal cancer who received guideline-concordant pre-operative radiation therapy ranged from 41.5% in Nova Scotia to 50.4% in Manitoba (Figure 4.14). It is important to note, however, that this indicator includes cancers of the rectum and recto-sigmoid junction. Pre-operative radiation therapy is guideline-recommended only for patients with cancers of the rectum; guideline concordance may therefore be higher than reported (see Box 1 for pre-operative radiation therapy use in provinces that were able to exclude tumours of the recto-sigmoid junction).
- Generally, the use of pre-operative radiation therapy for rectal cancer decreased with age (Figure 4.15): 52.6% of rectal cancer patients aged 18–59 received pre-operative radiation compared with 29.6% of those aged 80 or older.
- There were no notable sex-related differences (data not shown).
Box 1. Pre-operative radiation therapy use for patients with Stage II or III rectal cancer, excluding tumours of the recto-sigmoid junction
Why measure this?
The benefit of pre-operative radiation therapy for patients with tumours of the recto-sigmoid junction is not clear, but there is a generally held perception that it is not appropriate.5 We therefore examined the use of pre-operative radiation therapy for Stage II or III rectal cancer, excluding tumours of the recto-sigmoid junction.
What are the key findings?
- The use of pre-operative radiation therapy for patients with Stage II or III rectal cancer, excluding tumours of the recto-sigmoid junction, ranged from 46.3% in Nova Scotia to 58.9% in Alberta, of the four reporting provinces (Figure 4.16).
- The use of pre-operative radiation therapy increased in all reporting provinces when cancers of the recto-sigmoid junction were excluded; New Brunswick had the greatest change, with a 12 percentage point increase in the use of guideline-concordant pre-operative radiation therapy (Figure 4.16).
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Why do these findings matter?
The use of guideline concordant pre-operative radiation therapy for rectal cancer was relatively consistent among the reporting provinces. Providing patients with early-stage rectal cancer with pre-operative radiation may have positive implications for patient outcomes, such as improved local disease control and reduced treatment-related toxicity.1-3
It is important to note that evidence is emerging that pre-operative chemo-radiation can be safely omitted in some patients with Stage II rectal cancer.6 The results of subsequent randomized trials in this area will be important to better refine the role of pre-operative radiation in rectal cancer.
References
- Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004 Oct 21;351(17):1731-40.
- Rahbari NN, Elbers H, Askoxylakis V, Motschall E, Bork U, Buchler MW, et al. Neoadjuvant radiotherapy for rectal cancer: meta-analysis of randomized controlled trials. Ann Surg Oncol. 2013 Dec;20(13):4169-82.
- Peeters KC, van de Velde CJ, Leer JW, Martijn H, Junggeburt JM, Kranenbarg EK, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients–a Dutch colorectal cancer group study. J Clin Oncol. 2005 Sep 1;23(25):6199-206.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer Version 1.2016. 2015.
- O’Neill B, Brown G, Wotherspoon A, Burton S, Norman A, Tait D. Successful downstaging of high rectal and recto-sigmoid cancer by neo-adjuvant chemo-radiotherapy. Clin Med Oncol. 2008 Mar 1;2:135-44.
- Taylor F, Quirke P, Heald RJ, Moran, BJ, Blomqvist, L, Swift, IR, Sebag-Montefiore, D, Tekkis, P, Brown G Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol. 2014 Jan 1;32(1):34-43.
