1 Recommendations | Low-energy contact X-ray brachytherapy for rectal cancer | Guidance

Early-stage and locally advanced rectal cancer

1.1

Low-energy contact X-ray brachytherapy can be used as an option to treat early-stage and locally advanced rectal cancer:

when the tumour is 3 cm or less and has not spread beyond stage T3b N1 M0 (with limited nodal involvement), and:
- the person chooses not to have surgery, or
- the risks of surgery are unacceptably high.
  
  People with larger tumours (with limited nodal involvement) may become eligible for this procedure if neoadjuvant treatment (external beam radiotherapy with or without chemotherapy) reduces the tumour to 3 cm or less and it has not spread beyond stage T3b N1 M0.

Metastatic rectal cancer

1.2

More research is needed on low-energy contact X-ray brachytherapy to treat metastatic rectal cancer before it can be used in the NHS.

1.3

This procedure should only be done as part of formal research and a research ethics committee needs to have approved its use.

What research is needed

More research, in the form of randomised controlled trials and prospective registries for metastatic rectal cancer, is needed on:

patient selection including tumour type and suitability of surgery
role of neoadjuvant treatment
treatment intent
patient-reported outcomes (such as quality of life and functional outcomes)
survival
long-term outcomes.

What this means in practice

Early-stage and locally advanced rectal cancer

There is enough evidence on the safety and efficacy of this procedure for healthcare professionals to consider low-energy contact X-ray brachytherapy as an option for early-stage and locally advanced rectal cancer.

Healthcare professionals should always discuss the available options with the person with rectal cancer before a joint decision is made (see NICE's page on shared decision making).

Hospital trusts will have their own policies on funding procedures and monitoring results. NHS England may also have policies on funding of procedures.

Metastatic rectal cancer

There is not enough evidence on the safety and efficacy of this procedure for metastatic rectal cancer. Low-energy contact X-ray brachytherapy for metastatic rectal cancer should only be done as part of formal research.

For everyone having the procedure

Auditing of outcomes

Healthcare professionals doing this procedure should collect data on safety and outcomes of the procedure. Enter details about everyone having this procedure into the ColoRectal database (CR-DB). Regularly review the data on outcomes and safety.

Who should be involved in the procedure

Patient selection should be done by a colorectal cancer multidisciplinary team that includes a clinical oncologist and a colorectal surgeon with specific training in this procedure and expertise in local excision techniques. The procedure should only be done in centres specialising in managing rectal cancer.

Why the committee made these recommendations

Clinical evidence for this procedure includes randomised controlled trials and observational studies. This shows that, in people with early-stage or locally advanced rectal cancer, low-energy contact X-ray brachytherapy can achieve long-term control of the condition while preserving the rectum and surrounding structures. Because radical surgery is avoided, patients may not need a permanent stoma. This substantially improves their quality of life. So, the procedure can be used as an option for early-stage and locally advanced rectal cancer.

For people with metastatic rectal cancer, there is not enough evidence on the efficacy and safety of this procedure. So, it should only be done in research in this population.