title: Appropriate customization of radiation therapy for stage II and III rectal cancer: Executive summary of an ASTRO Clinical Practice Statement using the RAND/UCLA Appropriateness Method.
abstract: OBJECTIVE
  To summarize results of a Clinical Practice Statement on radiation therapy for stage II-III rectal cancer, which addressed appropriate customization of (neo)adjuvant radiation therapy and use of non-surgical therapy for patients who are inoperable or refuse abdominoperineal resection.
  
  
  METHODS
  The RAND/University of California, Los Angeles, Appropriateness Method was applied to combine current evidence with multidisciplinary expert opinion. A systematic literature review was conducted and used by the expert panel to rate appropriateness of radiation therapy options for different clinical scenarios. Treatments were categorized by median rating as Appropriate, May Be Appropriate, or Rarely Appropriate.
  
  
  RESULTS
  In the neoadjuvant setting, chemoradiation was rated Appropriate and the ratings indicated short-course radiation therapy, chemotherapy alone, and no neoadjuvant therapy are potential options in selected patients. However, neoadjuvant endorectal brachytherapy was rated Rarely Appropriate. For adjuvant therapy, chemoradiation (plus ≥4 months of chemotherapy) was rated Appropriate and chemotherapy alone May Be Appropriate for most scenarios. For medically inoperable patients, definitive external beam radiation therapy and chemotherapy alone were rated May Be Appropriate, whereas endorectal brachytherapy and chemoradiation plus endorectal brachytherapy were possible approaches for some scenarios. The last option, definitive chemoradiation, was rated Appropriate to May Be Appropriate based on performance status. Finally, for patients with low-lying tumors refusing abdominoperineal resection, definitive chemoradiation alone, chemoradiation plus endorectal brachytherapy, and chemoradiation plus external beam radiation therapy were all rated Appropriate.
  
  
  CONCLUSIONS
  This Clinical Practice Statement demonstrated the central role of radiation therapy in stage II-III rectal cancer management and evaluated ways to better individualize its use in the neoadjuvant, adjuvant, and definitive settings. Ongoing trials may clarify areas of continuing uncertainty and allow further customization.
authors.affiliation: Department of Radiation Oncology, University of Colorado, Aurora, Colorado. Electronic address: karyn.goodman@ucdenver.edu.
authors.forename: Karyn A
authors.initials: KA
authors.lastname: Goodman
authors.affiliation: American Society of Radiation Oncology, Fairfax, Virginia.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Patton
authors.affiliation: Department of Medical Oncology, Stanford University, Stanford, California.
authors.forename: George A
authors.initials: GA
authors.lastname: Fisher
authors.affiliation: Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Hoffe
authors.affiliation: Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Haddock
authors.affiliation: Department of Radiation Oncology, Washington University, St. Louis, Missouri.
authors.forename: Parag J
authors.initials: PJ
authors.lastname: Parikh
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Kim
authors.affiliation: Division of General Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
authors.affiliation: Department of Radiation Oncology, Duke University, Durham, North Carolina.
authors.forename: Brian G
authors.initials: BG
authors.lastname: Czito
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Theodore S
authors.initials: TS
authors.lastname: Hong
authors.affiliation: Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Crane
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hoffman
mesh_terms: D006801:Humans; D020360:Neoadjuvant Therapy / Q000379:methods*; D009367:Neoplasm Staging; D012004:Rectal Neoplasms / Q000532:radiotherapy*