when do you use SCRT (25Gy/5fr) within a total neoadjuvant approach for Rectal Ca?

[Kroll2013]

Dear Colleagues,

I am interested to know when do you favor standard LCRT versus SCRT in the setting of a TNT approach for rectal cancer?
What are the criterias you follow ? does the age matter (young versus elderly)?
location (lower/upper rectum)? sphincter involvement? sequencing (induction chemo versus upfront RT)?
Any other considerations?

ty a lot for sharing your thoughts

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[Palex80]

To answer in short, one of these three criteria need to apply, in order to choose LCRT over SCRT:

1. Tumors were doubts exist concerning complete resection (T4, CRM involvement)

2. Tumors were we think omitting surgery would be of great benefit (low lying tumors requiring an APR)

3. Doubts regarding whether or not the patient would tolerate the full chemotherapy component of TNT, but risk factors that would make us want to deliver TNT (age could be one issue here).


Generally, we give SCRT/LCRT followed by chemo, only exception being M1-patients with a couple of liver mets for instance, but those were not part of the TNT trials anyway.

 

[Kroll2013]

To answer in short, one of these three criteria need to apply, in order to choose LCRT over SCRT:

1. Tumors were doubts exist concerning complete resection (T4, CRM involvement)

2. Tumors were we think omitting surgery would be of great benefit (low lying tumors requiring an APR)

3. Doubts regarding whether or not the patient would tolerate the full chemotherapy component of TNT, but risk factors that would make us want to deliver TNT (age could be one issue here).


Generally, we give SCRT/LCRT followed by chemo, only exception being M1-patients with a couple of liver mets for instance, but those were not part of the TNT trials anyway.

very helpful ty

 

[Mandelin Rain]

Our approach:

Short course if oligometastatic and planning LAR + Metastectomy. Start with chemo > SCRT > Surgery.

Otherwise, concurrent chemorads > chemo > surgery.

 

[Fpg1245]

My approach

If you’re considering SCRT, then should also seriously consider No RT.

 

[metallica81788]

My institution recommends short course as part of TNT for nearly every rectal that needs RT except for low/obstructing tumors or anybody considering watch and wait; they're very aggressive about it

I was pretty hesitant at first but it hasn't been terrible - anecdotally half of them have bad proctitis and other half do fantastic
That was a battle I didn't deem worthy enough to fight since it's not a huge portion of my practice

 

[madchemist89]

Doing long course TNT without any significant issues

 

[evilbooyaa]

I recommend SCRT if oligometastatic with definite plans for resection. I've already gotten burned once when a patient got SCRT but then had significantly delayed primary resection due to a previously undiagnosed brain met. By the time he went for surgery, + margin, which has since lead to local recurrence. Maybe LCRT would've lead to the same issue, but we know cCR rates well based on OPRA. SCRT-NOM is in progress but wouldn't consider it SOC for someone not planned for resection within 8-12 weeks of completion of RT.

I otherwise prefer LCRT for all other scenarios. Don't offer SCRT for patients with lower tumors or T4 disease.

I do prefer TNT for all patients in a vaccuum (LCRT --> Chemo --> Surgery in any patient not N2 or M1), but will go along with med/onc and surgeon preference in terms of sequencing (Chemo --> ChemoRT --> Surgery vs ChemoRT --> Surgery --> Chemo).

 

[NotMattSpraker]

Dear Colleagues,

I am interested to know when do you favor standard LCRT versus SCRT in the setting of a TNT approach for rectal cancer?
What are the criterias you follow ? does the age matter (young versus elderly)?
location (lower/upper rectum)? sphincter involvement? sequencing (induction chemo versus upfront RT)?
Any other considerations?

ty a lot for sharing your thoughts

If you can get it, Emma Holliday's ASTRO refresher lecture on lower GI was one of the best lectures on these questions I've seen.

 

[deleted1116990]

I have little interest in moving to SCRT on a routine basis. LCRT is well tolerated and works well. The few times I have done SCRT it has resulted in significantly worse acute toxicity.

 

[Kroll2013]

If you can get it, Emma Holliday's ASTRO refresher lecture on lower GI was one of the best lectures on these questions I've seen.

totally agree.

 

[medgator]

I have little interest in moving to SCRT on a routine basis. LCRT is well tolerated and works well. The few times I have done SCRT it has resulted in significantly worse acute toxicity.

Also an issue if someone is borderline for surgery and it doesn't end up happening, things can be more tenuous when the colorectal surgeon is 1-2 hours away from your facility

 

[deleted1116990]

Also an issue if someone is borderline for surgery and it doesn't end up happening, things can be more tenuous when the colorectal surgeon is 1-2 hours away from your facility

Also totally agree. There is a disconnect from the academics with everyone under one roof who preach that 5 fractions is always the best way to do this and those that have to deal with coordinating multimodality care like this in a freestanding PP setting in a less populated area.

 

[evilbooyaa]

Also totally agree. There is a disconnect from the academics with everyone under one roof who preach that 5 fractions is always the best way to do this and those that have to deal with coordinating multimodality care like this in a freestanding PP setting in a less populated area.

It's always like "Tell med onc not to start FOLFOX until 2 weeks after all their severe post-RT ends"

Like my dude/dudette, you think med onc is gonna listen to me about when to start their chemo and wait an extra amount of time because the timeline of diarrhea recovery is more? I just better not cause that severe of diarrhea in the first place, or better be able to say the patient is still receiving RT please do not start chemo until X weeks after

 

[taserlaser]

Our chemo RT coordination is a disaster the past few weeks. We just switched to EPIC across a large health services region, with little thought to existing processes. Turns out it totally broke chemoRT coordination.

Patients showing up to chemo with no PICC.
Patients showing up to RT with no chemo booked
Patients getting chemo and asking when RT is starting and no one’s picked up the plan yet
A local journalist got their chemoRT cancelled and it made the news.

It’s been three weeks of meetings and no one can agree how to figure this out. Like… this is One thing we really should be good at. ‘Oh but the existing booking staff is already too busy we can’t ask them to do more’. It is absolute madness and infuriating really.

thankfully I don’t treat GI or do much chemo RT but my colleagues have lost all their hair follicles trying to fix this stupid ****

 

[sirspamalot]

Our chemo RT coordination is a disaster the past few weeks.

Don't feel too bad. Sometimes this nonsense happens even without installation of Epic. Patient wants to talk one more time with medonc, PICC line placement isn't available, yada yada.

In the "Real world" we do what we can. Thats all we can do. I push artfully, sometimes with some grumbling back and forth, but you have to use those cards sparingly or yaint gonna have friends here ya'll.

 

[Mandelin Rain]

Our chemo RT coordination is a disaster the past few weeks. We just switched to EPIC across a large health services region, with little thought to existing processes. Turns out it totally broke chemoRT coordination.

Patients showing up to chemo with no PICC.
Patients showing up to RT with no chemo booked
Patients getting chemo and asking when RT is starting and no one’s picked up the plan yet
A local journalist got their chemoRT cancelled and it made the news.

It’s been three weeks of meetings and no one can agree how to figure this out. Like… this is One thing we really should be good at. ‘Oh but the existing booking staff is already too busy we can’t ask them to do more’. It is absolute madness and infuriating really.

thankfully I don’t treat GI or do much chemo RT but my colleagues have lost all their hair follicles trying to fix this stupid ****

Oncology Patient Navigators can be an amazing resource

 

[medgator]

Oncology Patient Navigators can be an amazing resource

Like dieticians, nutritionists etc..... None of that comes free though

 

[salubalu]

Like dieticians, nutritionists etc..... None of that comes free though

Yall don't have a money tree?