3%, P<0.004). There were no differences in hospitalizations or urinary function. Furthermore, overall perceived health did not differ in patients who did or did not receive radiation (P=0.38) (40). The Swedish prospective randomized of short course preoperative radiation therapy also demonstrated a small but tangible risk of radiation induced malignancy exists (relative risk 1.8 compared to

no radiation) (41). Currently in the United States, long course chemoradiation (about 45-50 Gy in 1.8-2 Gy fractions) is typically used rather than short course radiation. Haddock et al. reported slight worsening of bowel function Inhibitors,research,lifescience,medical one year after long course chemoradiation compared to baseline (median bowel http://www.selleckchem.com/products/Belinostat.html movement frequency increased from 1 to 2, with increased urgency, clustering, and continence scores persistent one year after Inhibitors,research,lifescience,medical therapy). Despite worsened continence scores, the need for protective clothing did not increase

above baseline (42). Other prospective trials using long course chemoradiation report severe (grade 3 or higher) late gastrointestinal toxic effects in 2-15% of patients (21), (43). Stricture at the anastomic site occurs in 4-12% of patients, Inhibitors,research,lifescience,medical with lower likelihood if radiation is delivered preoperatively (21). Severe late bladder toxicity occurs in less than 1-4% of patients, and femoral head fractures occur in less than 1% (21), (43). In summary, radiation therapy is associated with increased Inhibitors,research,lifescience,medical incidence of late side effects, most commonly gastrointestinal. Further study is needed to determine the degree to which these side effects impact quality of life, and the risk of side effects needs to be balanced with the expected improvements in local control. Conclusion Neoadjuvant chemoradiotherapy is recommended Inhibitors,research,lifescience,medical in the majority of patients with transmural or node

positive rectal cancer. However, some patients are in a favorable subgroup in which the incremental benefit of radiotherapy may be small. Factors to consider are proximal location (>8-10 cm from the anal verge), negative margins (>1-2 mm), and absence of nodal disease. Additional factors including low preoperative CEA (<5 ng/mL) and absence of lymphovascular space invasion have been reported as risk factors for local recurrence, though their use in deciding whether or not to use radiation require validation Cilengitide in prospective studies. Randomized data from the MRC CR07 study and the Dutch study both show that the addition of radiation to TME improves local control. However, in patients with proximal location, negative circumferential margins, and node negative disease, the absolute reduction in local recurrence is <5%. This raises the possibility that patients with proximal, T3N0 lesions with negative CRM may represent an extremely favorable subgroup eligible to forego neoadjuvant radiotherapy and instead receive adjuvant radiation only in the setting of positive margins or surgical up-staging.