Adjuvant chemotherapy appears to be active in stage II-III
rectal cancers; the NSAPB R01 trial demonstrated a survival advantage for patients receiving
chemotherapy using the
MOF protocol and 3 meta-analyses are in favor of the efficacy of
adjuvant chemotherapy in
rectal cancer. Three randomized trials have also demonstrated that combinations of radiation and
chemotherapy are superior to surgery alone or
adjuvant radiotherapy and demonstrated the major role of systemic
chemotherapy combined with
radiotherapy. However this efficacy of
adjuvant chemotherapy alone or combined with
radiation therapy is still debated and specific trials must be conducted to test the value of
chemotherapy using more active regimens than those previously tested and taking into account the quality of surgery and
radiotherapy; such trials are in progress, especially the trial conducted by the EORTC and the FFCD. The efficacy of
neoadjuvant chemotherapy has never been clearly demonstrated, although a combination of
radiotherapy and
chemotherapy as first-line treatment for locally advanced
rectal cancer and in the case of synchronous
metastasis seems to facilitate surgical resection. It is a reasonable and tolerable approach with manageable toxicity which gives substantial results in 2/3 of patients. This strategy also allows better selection of patients likely to benefit from surgical resection of their primary
tumor and in some cases of their synchronous
metastases. However, the efficacy of perioperative treatments should not decrease the quality of the surgical resection and especially mesorectal excision as well as the need for high quality pathological examination which must be very thorough with analysis of a sufficient number of lymph nodes. The efficacy of combined treatment in advanced
rectal cancers is a major argument in favor of the multidisciplinary coordination required for optimal treatment of patients with
rectal cancer.