title: The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline.
abstract: BACKGROUND
  This systematic review with meta-analysis was designed to evaluate the literature and to develop recommendations regarding the use of preoperative radiotherapy in the management of patients with resectable rectal cancer.
  
  
  METHODS
  The MEDLINE, CANCERLIT and Cochrane Library databases, and abstracts published in the annual proceedings of the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were systematically searched for evidence. Relevant reports were reviewed by four members of the Gastrointestinal Cancer Disease Site Group and the references from these reports were searched for additional trials. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.
  
  
  RESULTS
  Two meta-analyses of preoperative radiotherapy versus surgery alone, nineteen trials that compared preoperative radiotherapy plus surgery to surgery alone, and five trials that compared preoperative radiotherapy to alternative treatments were obtained. Randomized trials demonstrate that preoperative radiotherapy followed by surgery is significantly more effective than surgery alone in preventing local recurrence in patients with resectable rectal cancer and it may also improve survival. A single trial, using surgery with total mesorectal excision, has shown similar benefits in local recurrence.
  
  
  CONCLUSIONS
  For adult patients with clinically resectable rectal cancer we conclude that: Preoperative radiotherapy is an acceptable alternative to the previous practice of postoperative radiotherapy for patients with stage II and III resectable rectal cancer. Both preoperative and postoperative radiotherapy decrease local recurrence but neither improves survival as much as postoperative radiotherapy combined with chemotherapy. Therefore, if preoperative radiotherapy is used, chemotherapy should be added postoperatively to at least patients with stage III disease.
authors: Hamilton Regional Cancer, McMaster University, Hamilton, Ontario, Canada. alvaro.figueredo@hrcc.on.ca
authors: Alvaro
authors: A
authors: Figueredo
authors: Lisa
authors: L
authors: Zuraw
authors: Rebecca K S
authors: RK
authors: Wong
authors: Olusegun
authors: O
authors: Agboola
authors: R Bryan
authors: RB
authors: Rumble
authors: Ved
authors: V
authors: Tandan
mesh_terms: D000328:Adult; D006801:Humans; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D011300:Preoperative Care; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery; D012680:Sensitivity and Specificity; D017211:Treatment Failure