External beam radiotherapy and high dose rate brachytherapy for medically unfit and elderly patients.

In the treatment of rectal cancer, total mesorectal excision surgery is now the standard of care. In most patients, surgery will be preceeded by radiotherapy, either in a short course (25 Gy/five fractions) or in a conventional schedule (45-50 Gy/25 fractions) with chemotherapy. For patients unfit for surgery or unwilling to undergo a procedure resulting in a permanent colostomy, radiotherapy without surgery is the alternative. From published studies it is clear that for relatively small tumours, local treatment with either contact X-rays or intraluminal brachytherapy is a reasonable option. For patients with larger tumours, the risk of nodal involvement makes the combination of local radiotherapy with external beam radiotherapy necessary. So far, this combination has mainly been given with contact X-rays and only sporadically with intraluminal brachytherapy. In this overview, a summary of published studies will be given, with a proposal for a trial for medically unfit patients with T2-T4 tumours.