Dr. Ciombor on Sequencing Therapies in Locally Advanced Rectal Cancer

Kristen K. Ciombor, MD, MSCI, an assistant professor of medicine in the Division of Hematology/Oncology, Department of Medicine at Vanderbilt University Medical Center, Vanderbilt-Ingram Cancer Center, discusses sequencing treatment options for patients with locally advanced rectal cancer.

The process of sequencing therapies in this patient population has undergone various changes in recent years, according to Ciombor. Previously, patients with locally advanced disease would receive chemoradiation followed by total mesorectal excision followed by adjuvant chemotherapy, says Ciombor.

In light of new data from multiple clinical trials, several approaches can be used for these patients, Ciombor adds. Sequencing decisions can be difficult, as this must be tailored to each individual patient. Recent findings from several studies presented during the 2020 ASCO Virtual Scientific Program have helped to clarify which therapies are best suited to each patient, Ciombor says. 

The total neoadjuvant approach is commonly used at Vanderbilt University Medical Center, according to Ciombor. Chemotherapy is being used either as a first-line treatment or preoperatively in that setting. Many patients with locally advanced rectal cancer tend to have bulky disease with either T4 lesions or many nodes, which could put them at risk for distant metastases, adds Ciombor. For those patients, it's important to start with chemotherapy as a frontline treatment, Ciombor explains. Surgery still has a place in the treatment paradigm, but chemotherapy and chemoradiation are best used in the up-front setting, Ciombor concludes.