title: Effective surgical adjuvant therapy for high-risk rectal carcinoma.
abstract: BACKGROUND
  Radiation therapy as an adjunct to surgery for rectal cancer has been shown to reduce local recurrence but has not improved survival. In a previous study, combined radiation and chemotherapy improved survival significantly as compared with surgery alone, but not as compared with adjuvant radiation, which many regard as standard therapy. We designed a combination regimen to optimize the contribution of chemotherapy, decrease recurrence, and improve survival as compared with adjuvant radiation alone.
  
  
  METHODS
  Two hundred four patients with rectal carcinoma that was either deeply invasive or metastatic to regional lymph nodes were randomly assigned to postoperative radiation alone (4500 to 5040 cGy) or to radiation plus fluorouracil, which was both preceded and followed by a cycle of systemic therapy with fluorouracil plus semustine (methyl-CCNU).
  
  
  RESULTS
  After a median follow-up of more than seven years, the combined therapy had reduced the recurrence of rectal cancer by 34 percent (P = 0.0016; 95 percent confidence interval, 12 to 50 percent). Initial local recurrence was reduced by 46 percent (P = 0.036; 95 percent confidence interval, 2 to 70 percent), and distant metastasis by 37 percent (P = 0.011; 95 percent confidence interval, 9 to 57 percent). In addition, combined therapy reduced the rate of cancer-related deaths by 36 percent (P = 0.0071; 95 percent confidence interval, 14 to 53 percent) and the overall death rate by 29 percent (P = 0.025; 95 percent confidence interval, 7 to 45 percent). Its acute toxic effects included nausea, vomiting, diarrhea, leukopenia, and thrombocytopenia. These effects were seldom severe. Severe, delayed treatment-related reactions, usually small-bowel obstruction requiring surgery, occurred in 6.7 percent of all patients receiving radiation, and the frequencies of these complications were comparable in both treatment groups.
  
  
  CONCLUSIONS
  The combination of postoperative local therapy with radiation plus fluorouracil and systemic therapy with a fluorouracil-based regimen significantly and substantively improves the results of therapy for rectal carcinoma with a poor prognosis, as compared with postoperative radiation alone.
authors.affiliation: Duluth Community Clinical Oncology Program, Minn.
authors.forename: J E
authors.initials: JE
authors.lastname: Krook
authors.forename: C G
authors.initials: CG
authors.lastname: Moertel
authors.forename: L L
authors.initials: LL
authors.lastname: Gunderson
authors.forename: H S
authors.initials: HS
authors.lastname: Wieand
authors.forename: R T
authors.initials: RT
authors.lastname: Collins
authors.forename: R W
authors.initials: RW
authors.lastname: Beart
authors.forename: T P
authors.initials: TP
authors.lastname: Kubista
authors.forename: M A
authors.initials: MA
authors.lastname: Poon
authors.forename: W C
authors.initials: WC
authors.lastname: Meyers
authors.forename: J A
authors.initials: JA
authors.lastname: Mailliard
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D003131:Combined Modality Therapy; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D005500:Follow-Up Studies; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010349:Patient Compliance; D011379:Prognosis; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D012044:Regression Analysis; D012307:Risk Factors; D012673:Semustine / Q000008:administration & dosage
chemical_list: D012673:Semustine; D005472:Fluorouracil