OncoAlert’s consensus on the PROSPECT trial in rectal cancer

The OncoAlert Network presents its collective expert view on the PROSPECT trial in rectal cancer, presented at ASCO 2023. The statement was drafted by our radiation therapy and GI oncology faculty, inclusive of patient advocates, and is in agreement with the statements from our partners at ASTRO and our colleagues at ESTRO.

What the trial asked

The study looked at whether patients with low-risk rectal cancer who responded to an initial six cycles of FOLFOX chemotherapy could safely omit pre-operative chemoradiation and receive additional chemotherapy after surgery. The study group received 12 cycles of FOLFOX in total, compared with 8 cycles with chemoradiation in the control group.

The goal was to establish a new option for selected patients, particularly those living far from radiation centers and those interested in fertility preservation.

What it found

The study began in 2011, when treatment options for rectal cancer were more limited, and included over 1,000 patients. It assessed side effects, quality of life, disease-free survival and time to recurrence in the two groups. Only patients whose cancer could be treated with surgery without a permanent colostomy were included.

Cancer outcomes were similar in both groups, but the side-effect profiles differed notably. The FOLFOX group had more toxicity before surgery; by one year the profiles were comparable. Sexual function was worse for patients who received chemoradiation.

What it highlights

The study highlights the importance of tailoring therapy to the aggressiveness and location of the cancer, and to patient preferences.

It emphasized collecting prospective data, both short- and long-term, in response to the chemotherapy intensification strategy, and suggests that intensified chemotherapy might offer better long-term sexual outcomes than radiation therapy. We await longer-term results for key patient-centered measures such as fertility preservation and activity-limiting peripheral neuropathy.

Our position

There is now a strong focus on shared decision-making in rectal cancer, taking into account tumor characteristics, patient age and preferences. These results should be interpreted within current practice, to minimize side effects and maximize the benefit for patients.

It is crucial to avoid articles or discussions that promote one treatment over another. Instead, we should highlight the different side-effect profiles and discuss every available option, so that patients and clinicians can decide together. Inflammatory language can harm patients who have no alternative options.