Book Review

Challenges in Colorectal Cancer

N Engl J Med 2000; 343:893September 21, 2000

Article

Challenges in Colorectal Cancer
Edited by John H. Scholefield. 230 pp., illustrated. Malden, Mass., Blackwell Science, 2000. $139.95. ISBN: 0-632-05116-7

Colorectal cancer presents some of the most challenging problems for basic scientists, clinical investigators, and practitioners. It will be important to facilitate an ongoing exchange among these three groups if we are to transform many small steps into a major advance in the treatment of colorectal cancer. Surgery remains the center of attention, for two reasons. First, in any high-risk case, the surgeon must coordinate the various treatment options (e.g., preoperative, intraoperative, and postoperative adjuvant treatment); second, the surgeon determines the prognosis, since inadequate surgical technique can influence a patient's outcome more than can the stage of the disease. But there are new trends, such as risk-adjusted screening, brought about by molecular techniques that have deepened our understanding of the pathogenesis of colorectal cancer. The demonstration of micrometastases in stage II and III cancers has sharpened the need for effective adjuvant therapy.

This book deals with these challenges and presents important new developments. A consensus has evolved with respect to diagnostic and therapeutic strategies in dominantly inherited colorectal cancers (familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer); by contrast, the rules for the early diagnosis of and screening for sporadic cancer remain undefined. Screening of the general population is effective but costly.

It is increasingly evident that preoperative chemotherapy or the combination of radiation therapy and chemotherapy can improve results in the treatment of rectal cancer. Experience during the past 15 years has clearly demonstrated the value of chemotherapy in high-risk colorectal cancer. It will become necessary to change the usual postoperative treatment with radiation or a combination of radiation therapy and chemotherapy to a preoperative combination, perhaps with additional intraoperative irradiation followed by postoperative chemotherapy. It is still debatable whether the excellent results of total mesorectal excision in patients with rectal cancer eliminates the need for preoperative, intraoperative, or postoperative radiation therapy. Tumor that has spread to the lymph nodes along the mesenteric border can easily be removed surgically, but removal of tumor that has spread to the pelvic wall is not part of the standard surgical procedure. Extended surgical procedures lead to high rates of irreversible loss of bladder control and impaired sexual function.

A number of new chemotherapeutic agents (oxaliplatin, irinotecan, and topotecan) and several types of immunotherapy are promising and may have clinical applications, but only if minimal residual disease can be diagnosed reliably. Dormant tumor cells are a reality and can be treated with the monoclonal antibody 17-1A. In the end, however, the solution will probably be a combination of immunotherapy and chemotherapy.

More knowledge of molecular biology, better definition of risk groups, better screening, further development of risk-oriented combination therapy, and more meticulous surgery may yield much higher cure rates for colon and rectal cancer. Scholefield's book is one of the best starting points for a journey through the world of established, new, and evolving treatments for these diseases.

Christian Herfarth, M.D.
University of Heidelberg, 69120 Heidelberg, Germany