HJBR Mar/Apr 2020

HEALTHCARE JOURNAL OF BATON ROUGE I  MAR / APR 2020 39 this involves several cycles of intensive chemotherapy and a course of chemoradi- ation prior to definitive surgical resection. TNT is associated with increased down staging by the time of surgery, and the ear- ly introduction of systemic chemotherapy addresses occult micrometastatic disease early on in the treatment process. Further- more, delivering chemotherapy pre-oper- atively allows the patient to receive this intensive course when they are more fit to tolerate it, and eliminates post-operative systemic treatment when surgical recov- ery and deconditioning might interfere with the ability to receive the full course of intended systemic treatment—sometimes concurrently with a diverting ileostomy and stoma. Most significantly, it opens up the potential in some patients with a com- plete clinical response to TNT to eliminate the need for surgical resection at all. While surgical resection with a total me- sorectal excision remains the standard of care, there is a growing body of evidence that some patients may be able to be suc- cessfully treated for locally advanced rec- tal cancer with non-operative manage- ment. After a patient receives neoadjuvant therapy with chemotherapy and radiation, he or she is reevaluated for disease regres- sion and resectability with physical exam, endoscopic luminal evaluation and imag- ing. In a patient that shows complete dis- ease eradication with no clinical evidence of any remaining tumor, non-operative treatment can be considered in hopes of eliminating the morbidity associated with surgical resection. Most data on non-op- erative management comes from cohort studies, and many ongoing investigations are aiming to evaluate its efficacy com- pared to surgical resection in a select group of patients that demonstrate com- plete response to chemotherapy and radi- ation. In a large data set from Memorial Sloan Kettering Cancer Center that compared patients who received TNT with those that received preoperative radiation followed by postoperative chemotherapy, it was noted that the TNT group was more like- ly to complete chemotherapy as intend- ed with fewer dose reductions. Moreover, nearly a fifth of the TNT group ended up not undergoing surgical resection in the year after completing TNT, and the vast majority of those had a promising and sustained complete response to TNT, and continued with close observation, without surgical resection. In patients that under- went resection after TNT, a pathologic complete response in which there was no residual disease, was in the range of one in four to one in three. Indeed, studies such as this, as well as other trials from Europe, led to the inclu- sion of TNT in the National Comprehen- sive Cancer Network’s (NCCN) guidelines for rectal cancer. Yet to be clear, larger and longer-term studies are needed to deter- mine if the TNT approach will translate to improved survival rates, the ability to avoid radical surgical resection entire- ly, or improved long-term quality of life. Furthermore, TNT is not for every LARC patient. For example, those with impend- ing complete obstruction due to advanced disease, or frail patients that are unlikely to tolerate chemotherapy, are likely not ide- al candidates. Optimal timing of resection relative to the completion of pre-operative treatment also needs to be clearly estab- lished. Ongoing large, multi-center trials such as the PROSPECT trial will compare Suchit H. Patel, MD, PhD Radiation Oncologist Mary Bird Perkins–Our Lady of the Lake Cancer Center neoadjuvant chemotherapy with selective chemoRT before surgery to standard pre- op chemoRT and post-op chemotherapy to help address some of these questions. Though LARC remains challenging, par- ticularly for Louisianans, multifaceted ap- proaches to tackling this cancer will be key to ongoing advances. Improved screening through efforts such as Louisiana Cancer Prevention’s Colorectal Health Project will help reduce the burden of LARC head on. For those that, unfortunately, still will con- tinue to present with advanced disease, approaches such as TNT will be critical to personalizing the precision care that LARC demands, and help to optimize each pa- tient’s journey through this often curable disease. n Kelly Finan, M.D., MSPH, FACS, FASCRS, colorectal surgeon, Mary Bird Perkins–Our Lady of the Lake Cancer Center, obtained a doctorate of medicine from the University of Cincinnati. She completed a general surgery residency at the University of Alabama, and earned a Master of Science in Public Health. Dr. Finan then went on to complete a col- orectal fellowship at Washington University. She is board certified in general surgery by the American Board of Surgery, and in colorectal surgery by the American Board of Colorectal Surgery. Dr. Finan is also a Fellow of the American College of Surgeons and the American Society of Colorectal Surgery. She serves as chair of the rectal cancer multidisci- plinary care team, and is a member of the colorec- tal multidisciplinary care team at Mary Bird Per- kins–Our Lady of the Lake Cancer Center. Suchit H. Patel, MD, PhD, radiation oncologist, Mary Bird Perkins–Our Lady of the Lake Cancer Center, obtained a medical degree at Cornell Medical Col- lege, along with a PhD in neuroscience from The Rockefeller University, as part of the Tri-Institutional MD-PhD Program. In addition, Dr. Patel completed residency training at the Memorial Sloan Kettering Cancer Center in NewYork City, where he served as chief resident. Dr. Patel currently serves on Mary Bird Perkins–Our Lady of the Lake Cancer Center’s lung, colorectal, and hepatobiliary multidisciplinary care teams.