We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failure, and less metastases than chemoradiation -> surgery (Hospers, ASCO, 2020).

Since the pandemic, people have reached out to me for guidance on this, and I'm happy take a look at fields/doses/cases for those who are looking to use short course radiation for the first time. Even more importantly, I can hook up medical oncologists and surgeons who also may have concerns about chemotherapy tolerance after pelvic radiation or the longer time between radiation and surgery. pparikh2@hfhs.org

(1) Same results, 20% of the cost: Short-course total neoadjuvant therapy. (Parikh PJ, Chapman W, Int J Radiat Oncol Biol Phys. 2020)

(2)  Hospers et al. Short-course radiotherapy followed by chemotherapy before TME in locally advanced rectal cancer. The randomized RAPIDO trial. ASCO, 2020.

This is a difficult scenario where none of us has enough information to make a completely informed decision. However, all of the modeling that I've seen suggests that personal contact and exposure are the primary drivers of the pandemic. To that end, we've tried to minimize this as much as possible.

For the typical locally advanced rectal cancer, we are attempting to treat as many patients as possible with induction chemotherapy (CapOx instead of FOLFOX, in order to minimize visits to the hospital). If patients are starting now, this would typically run 4 1/2 months. Of course, it is impossible to predict whether we will be out of the woods by then, but I hope so. Nevertheless, our current plan is short course radiation to follow this. We are also extending our interval from the end of radiation to surgery if necessary from the usual 8-10 weeks. This applies to patients who are already part way through this paradigm. Furthermore, if a patient has completed chemoradiation and would ordinarily go to surgery, we are discussing chemotherapy now instead of post-op. The goals are as few trips to the hospital as possible and more importantly to delay as many surgeries as possible.

Discuss every case in MDC and favor neoadjuvant chemo and short course RT unless concern about circumferential margin, low lying lesion with plan to possible assess for non surgical approach or side wall nodes.

I've been offering and administering short course more routinely but have noted that patients have significant radiation proctitis (tenesmus, frequency, sometimes bleeding) for at least 2-3 weeks post treatment, if not longer.

Other than Imodium and low residue diet, do you recommend additional therapies for such symptoms (e.g. systemic steroids or steroid suppositories/enemas?)