Medical Oncology, Monash Medical Centre, Clayton, Australia; School of Clinical Sciences, Monash University, Clayton, Australia.
Medical Oncology, Monash Medical Centre, Clayton, Australia; Oncology Department, University Hospital Antwerp, Antwerp, Belgium.
Clin Colorectal Cancer. 2021 Mar;20(1):29-41. doi: 10.1016/j.clcc.2020.12.005. Epub 2021 Jan 5.
Locally advanced rectal cancer has a rising global incidence. Over the last 4 decades, advances first in surgery and later in radiotherapy and chemoradiotherapy have improved outcomes, particularly with regard to local recurrence. Unfortunately, distant metastases remain a significant problem. In clinical trials of patients with stage II and III disease, distant relapse occurs in 25% to 30% of patients regardless of the treatment approach. Recent phase 3 trials have therefore focused on intensification of systemic therapy for localized disease, with an aim of reducing the distant relapse rate. Early results of trials of total neoadjuvant therapy with combination systemic therapy provided in the neoadjuvant setting are promising; for the first time, a significant improvement in the rate of distant relapse has been noted. Longer-term follow-up is eagerly awaited. On the other hand, trimodal therapy with chemotherapy, radiotherapy, and surgery is toxic. Several trials are currently assessing the feasibility of a watch-and-wait approach, omitting surgery in those with complete response to neoadjuvant treatment, in an attempt to reduce the burden of treatment on patients. The future for rectal cancer patients is likely to be highly personalized, with more intense approaches for high-risk patients and omission of unnecessary therapy for those whose disease responds well to initial treatment. Biomarkers such as circulating tumor DNA will help to more accurately stratify patients into risk groups. Improvements in survival and quality of life are expected as the results of ongoing research become available throughout the next decade.
局部晚期直肠癌的全球发病率呈上升趋势。在过去的 40 年中，手术技术的进步，以及放疗和放化疗的后续发展，改善了治疗效果，尤其是降低了局部复发率。但不幸的是，远处转移仍然是一个重大问题。在 II 期和 III 期疾病的临床试验中，无论采用何种治疗方法，25%至 30%的患者都会出现远处复发。因此，最近的 III 期临床试验集中于强化局限性疾病的系统治疗，以降低远处复发率。在新辅助治疗中联合应用系统治疗的完全新辅助治疗试验的早期结果令人鼓舞；首次观察到远处复发率显著降低。人们急切地期待着更长期的随访结果。另一方面，化疗、放疗和手术的三联疗法具有毒性。目前，多项试验正在评估在新辅助治疗完全缓解的患者中，不进行手术的“观察等待”方法的可行性，以试图减少治疗对患者的负担。直肠癌患者的未来可能是高度个体化的，对于高危患者采用更强化的方法，对于那些对初始治疗反应良好的患者则不进行不必要的治疗。循环肿瘤 DNA 等生物标志物将有助于更准确地将患者分层为风险组。随着未来十年内研究结果的不断出现，预计患者的生存和生活质量将得到改善。
