Clinical Trials and Genetic Screening
As a new patient, your tumor will be tested for molecular alterations, the results of which will help form the basis of your therapy. Our specialists are actively involved in research, and apply the latest knowledge to your care. Our clinical trials are a significant part of our treatment approach, and many of our patients choose to participate.
Treatment for Rectal Cancer
There are different types of treatments – from standard therapies to those being tested in clinical trials. Standard treatments include:
Surgery
Surgery (removing the cancerous growth in an operation) is often the key component of treatment for patients with rectal cancer. It is the most common treatment for people with all stages of the disease.
Rectal surgeons at Brigham and Women's Hospital (BWH) are the surgical team for the Dana-Farber Brigham Cancer Center's Gastrointestinal Cancer Treatment Center, a unique center uniting some of the world's foremost GI cancer experts. Our surgeons are leaders in rectal cancer surgery, performing a large volume of minimally-invasive, sphincter-sparing surgical techniques, including total mesorectal excision and transanal endoscopic microsurgery.
The surgical team has two main goals: removing all cancerous tissue and sparing the anal sphincter to avoid a permanent colostomy. These surgical techniques can include:
- Low anterior resection: performed if the cancer is located well above the anus. Through an abdominal incision, surgeons remove all or part of the rectum and take healthy bowel from the colon. They then connect it to the remaining rectum.
- Occasionally, if the connection is very close to the anus (or anal sphincter), the patient needs a temporary colostomy, or bag.
- This bag allows the complicated surgery that has been performed to heal without stool passing across the new connection.
- After a few months, the colostomy can be taken away with a second surgery.
- Local excision: performed through the anus or through the tailbone area to remove the small cancer without a colostomy. The tumor is removed through the anus and the surgical excision is stitched closed. The lymph nodes near the rectum are removed.
- Sometimes this procedure can be done on an outpatient basis.
- Depending on the extent of the small cancer, extra therapy with radiation and chemotherapy is recommended.
- The advantage of this procedure is that it preserves the muscles of the anus so that a patient does not need a permanent colostomy. However, patients who do have a local excision need to be followed very closely to monitor for any possible cancer recurrence.
- Abdominoperineal resection: performed if there is a lower rectal cancer, or if it involves the muscles of continence (the anal sphincters).
- The advantage of this operation is that it removes all of the cancerous tissue, but it does require a permanent colostomy.
- If you should need this operation, you will see one of our enterostomal therapists before the procedure to discuss living with a colostomy. This education continues after the surgery, both in the hospital and at several follow-up outpatient visits.
- Patients' quality of life has been shown to be good to excellent with a well-functioning colostomy.
Even if the doctor removes all the cancer possible during an operation, you may be given chemotherapy with or without radiation therapy to eliminate any remaining cancer cells. This treatment aims to lower the risk that the cancer will come back. It is called adjuvant therapy.
Your surgeon and medical oncologist will discuss with you whether adjuvant therapy is advisable. Often, patients receive both chemotherapy and radiation before surgery, based on the stage of disease. The stage is determined by either endoscopic ultrasound or MRI (see How We Diagnose Rectal Cancer).
If your cancer has spread, you may have surgical treatment options. There are times when a metastasis can be removed, and we have a team of surgical oncologists that specializes in the removal of metastases (a cancer that has spread) from the liver. Being able to identify which patients are candidates for surgery is essential in order to optimize outcomes. Dana-Farber Brigham Cancer Center's team approach allows for thorough discussions about which patients with metastatic disease should have surgical removal of metastases.
Additional Procedures
In addition to surgery, there are certain procedures for metastases that are done by our interventional radiologists at Brigham and Women's Hospital. Their procedures include:
- Radiofrequency ablation: the use of a special probe with tiny electrodes that eliminate cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen.
- Cryosurgery: a treatment that uses an instrument to freeze and destroy abnormal tissue. This type of treatment is also called cryotherapy.
Chemotherapy
When indicated, our medical oncologists use chemotherapy, a cancer treatment that uses drugs to stop the growth of cancer cells, either by eliminating the cells or by stopping them from dividing. For example, you may be given chemotherapy with or without radiation therapy to eliminate any remaining cancer cells. This treatment aims to lower the risk that the cancer will come back. It is called adjuvant therapy.
Our 25 medical oncologists are national leaders in improving the use of chemotherapy for rectal cancer through clinical trials and laboratory research. They are highly experienced in optimizing chemotherapy and reducing side effects, and use their extensive expertise to determine the most appropriate care plan for you.
While on chemotherapy at Dana-Farber Brigham Cancer Center, you will have a medical oncologist and nurse practitioners involved in your care. Our medical oncologists have experience with the latest therapies and have the expertise to tailor these therapies to you for the greatest likelihood of a good outcome.
- Throughout your treatment, your team of medical oncologists, nurse practitioners, nurses, dietitians, social workers, and other staff will work to minimize the side effects of chemotherapy and maximize your quality of life.
- Our team will address other symptoms you may be experiencing, such as weight loss and emotional distress.
Targeted Therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Some targeted therapies used in rectal cancer focus on certain changes that occur around tumors, specifically the blood supply to tumors. These therapies are called angiogenesis inhibitors, and they stop the growth of new blood vessels that tumors need in order to grow and spread.
Another kind of targeted therapy for rectal cancer attacks a protein on the cell – called the epidermal growth factor receptor (EGFR) – that drives cells to divide and spread.
More and more, targeted therapies focus on specific molecular changes in a patient's individual tumor. Dana-Farber Brigham Cancer Center is a leader in precision cancer medicine (also called personalized medicine). You are offered testing of your tumor for genetic mutations. This may help guide your care using standard treatment and also direct you to the right clinical trial for your tumor to find better therapies.
Clinical Trials
Our specialists are actively involved in research, and apply the latest knowledge to your care. Our many targeted therapies through clinical trials are a significant part of our treatment approach and provide you with the most innovative treatment options, which may not be available elsewhere.
Typically, we have multiple clinical trials open at a time for patients with rectal cancer.
What are clinical trials?
Clinical trials study the safety and efficacy of new treatments or new combinations of treatments. Most of today's standard treatments for cancer are based on earlier clinical trials.
Some clinical trials include only patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not improved. There are also clinical trials that test new ways to stop cancer from recurring or reduce the side effects of treatment. Patients can enter clinical trials before, during, or after cancer treatment, depending on the design of the trial.
When you have your first visit – and throughout the course of your care at Dana-Farber Brigham Cancer Center – we will discuss with you whether enrolling in a clinical trial would be good to consider for your specific type of cancer.
Radiation Therapy
Our radiation oncologists are national leaders in the use and study of radiation therapy. You will receive a carefully considered, customized plan to use radiation therapy when and where it is likely to be most effective.
Radiation therapy uses high-energy x-rays to kill cancer cells or keep them from growing.
- External radiation therapy uses a machine outside the body to send radiation toward the cancer.
- Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
Radiation is often used as part of rectal cancer treatment before surgery, but it may be given after, as well. If you have stage II or III rectal cancer, you may have radiation therapy to reduce the risk of the cancer coming back in the rectum (local recurrence). Radiation may also help relieve symptoms from specific metastases, and reduce pain in that area.
A Summary of Treatment by Stage
Stage 0
- Local excision surgery.
- Polypectomy.
- Resection (this is done when the tumor is too large to remove by local excision).
- Internal or external radiation therapy.
Stage I
- Local excision surgery.
- Resection.
Stages II and III
- Resection plus a combination of chemotherapy and radiation therapy before or after surgery.
- Resection with or without chemotherapy after surgery.
- A clinical trial of a new treatment.
Stage IV
- Resection with or without a combination of radiation therapy and chemotherapy before surgery.
- Resection or pelvic exenteration to relieve symptoms and improve the quality of life.
- Radiation therapy, chemotherapy, or a combination of both, to relieve symptoms from the cancer.
- Placement of a stent to help keep the rectum open if it is partly blocked by the tumor; used to relieve symptoms.
- Clinical trials of chemotherapy and/or targeted therapy.
- For certain patients, surgery to remove parts of other organs, such as the liver, lungs, and ovaries, where the cancer may have recurred or spread. Radiofrequency ablation or cryosurgery may be used for patients who cannot have surgery.
Supportive Resources
To address all of your physical and emotional needs, we encourage you and your family to explore our comprehensive range of support services and integrative therapies.
Survivorship Care
If you have early-stage rectal cancer or metastatic rectal cancer in which all the disease has been removed, our medical oncologists and nurse practitioners will follow you for several years after your therapy. At the end of treatment, your team will discuss with you what testing should be done, and when, including certain blood tests, imaging, and colonoscopies.
In addition, our Adult Survivorship Program helps you find expertise, education, and support to help manage issues related to surviving cancer. The Survivorship Program works with specialists focused on challenges that you may face. Specialists include cardiology, endocrinology, bone health, sexual health, reproductive health, nephrology (kidneys), and exercise physiology.
Experts at the Gastrointestinal Cancer Treatment Center at Dana-Farber Brigham Cancer Center are leaders in studying diet and lifestyle factors in rectal cancer survivors. We were the first to report that patients who exercise have lower risk of cancer recurrence. We have done many studies on the potential benefit of diet and vitamin D in rectal cancer survivors. We offer research studies that rectal cancer survivors may be eligible to participate in.
Recurrent Rectal Cancer
While many new treatments for rectal cancer are effective, the cancer can return despite doing all recommended therapies.
If the cancer does come back, it is usually in the first two to three years after surgery. The cancer may return back in the rectum or in other parts of the body, such as the liver, lungs, or both. Sometimes surgery can be performed in the area where the cancer returned. However, more often, recurrent rectal cancer is treated with chemotherapy and targeted therapy, including clinical trials.
Our physician-scientists are studying ways to reduce the risk of recurrence.
Your Hospital Care
Post-surgical and additional inpatient care are provided by the Dana-Farber Brigham Cancer Center team either at Brigham and Women's Hospital or at Dana-Farber's Inpatient Hospital located within Brigham and Women's Hospital.
All outpatient therapy is provided at the Yawkey Center for Cancer Care at Dana-Farber Cancer Institute, one of the most advanced outpatient cancer centers in the country.
Radiation Oncology has two separate units, one at Brigham and Women's Hospital and the other at Dana-Farber. These are staffed by 25 radiation oncologists who work at both locations.
