I was invited because of the two trials we did in Poland comparing very short radiation treatment consisting of only five fractions compared to chemo-radiation that consisted of 25 or 28 fractions with chemotherapy. This trial, and also the similar Australian trial, showed that the long-term outcomes were much the same but the acute toxicity with short course radiotherapy was much lower. So our preference is to give the patients short course radiotherapy, it can reduce waiting lists for example, it’s less costly and, of course, more convenient. There is also a special type of cancer, a very ugly cancer, the cancer that involves other structures. So the conventional treatment is long course radiotherapy with chemotherapy and we just published a randomised trial comparing this routine treatment with short-course radiotherapy, once more only five fractions so it’s cheaper with three courses of chemo given separately. So overall treatment time is the same, the same interval between start of radiation and surgery and the results, I must say that there is a rather short follow-up of three years, but the results showed that the overall survival is better, surprisingly, but also the acute toxicity is a little bit better but statistically significant. So based on these trial results we have changed our routine treatment in Poland to give two options, to stay with chemo-radiation or to switch to the new schedule. So maybe this new schedule will be also beneficial in India.
The third topic I would like to cover is only partly related to pre-operative radiotherapy but it’s a most important topic in rectal cancer. Almost all guidelines recommend in patients given perioperative radiotherapy then surgery to give them chemotherapy, postoperative chemotherapy, because the distant metastases is around 30% so there is the hope that postoperative chemotherapy can reduce these distant metastases. But just recently there were two meta-analyses and some randomised trials and all this new evidence showed that there is no benefit from postoperative chemotherapy and the chemotherapy is obviously a toxic treatment. Despite this new evidence, the guidelines still recommend postoperative chemotherapy. So I would like to convey in this meeting that delivery of chemotherapy in patients who had previously radiation therapy is not evidence-based and even is harmful.
What are some of the similarities between Poland and India with neoadjuvant chemotherapy?
In India there are much less resources. We are trying to catch up with the Western world so the availability of treatment machines, linear accelerators, is of course better in Poland than in India but we still have a shortage of machines. So it’s better for the patients, for convenience and also for economic reasons to give five fractions instead of 25 or 28 fractions.