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To our knowledge, Gelber et al. (7) have provided the first quantitative scrutiny of quality-of-life management of patients treated for locally advanced rectal cancer. The authors conclude, "Use of combined chemotherapy and radiation therapy as an adjuvant to surgery for patients with poor-prognosis resectable rectal cancer is justified." To which may be added—in comparison with postoperative adjuvant radiation therapy alone. There also appears to be an assumption, which generally conforms with the literature, that adjuvant postoperative radiation therapy alone does not improve survival. However, the usual treatment decision confronting the patient is combined treatment versus no treatment. In the absence of a comparison, have the authors examined their data by deleting the impact of those toxic events or delayed reactions attributable to radiation therapy in the control group? Such complications, including death, were cited in the published manuscript from which the current study is derived (2). Reasonably predictive estimates of quality of life after various treatment options are valuable in helping the patient with rectal cancer to make difficult choices. By embracing the side effects of treatment alternatives, Gelber et al. are to be congratulated for their accomplishment in this difficult field. However, quality of life has many elements. Some dimensions, such as performance status and economic considerations, can be quantified. Other elements, such as pain, psychological factors, and genitourinary function, are more difficult to integrate. We have a long way to go before reliable clinical utility can be achieved.

journal of the national cancer institute

Re: A Quality-Adjusted Time Without Symptoms or Toxicity (Q-TWiST) Analysis of Adjuvant Radiation Therapy and Chemotherapy for Resectable Rectal Cancer