Effect of interval between neoadjuvant chemoradiotherapy and surgery on disease recurrence and survival in rectal cancer: long-term results of a randomized clinical trial

Erhan Akgun, Cemil Caliskan, Osman Bozbiyik, Tayfun Yoldas, Basak Doganavsargil, Serdar Ozkok, Timur Kose, Bulent Karabulut, Nevra Elmas, Omer Ozutemiz, Erhan Akgun, Cemil Caliskan, Osman Bozbiyik, Tayfun Yoldas, Basak Doganavsargil, Serdar Ozkok, Timur Kose, Bulent Karabulut, Nevra Elmas, Omer Ozutemiz

Abstract

Background: The optimal timing of surgery following chemoradiotherapy (CRT) is controversial. This trial aimed to assess disease recurrence and survival rates between patients with locally advanced rectal adenocarcinoma (LARC) who underwent total mesorectal excision (TME) after a waiting interval of 8 weeks or less (classic interval; CI) versus more than 8 weeks (long interval; LI) following preoperative CRT.

Methods: This was a phase III, single-centre, randomized clinical trial. Patients with LARC situated within 12 cm of the anal verge (T3-T4 or N+ disease) were randomized to undergo TME within or after 8 weeks after CRT.

Results: Between January 2006 and January 2017, 350 patients were randomized, 175 to each group. As of February 2022, the median follow-up time was 80 (6-174) months. Among the 322 included patients (CI, 159; LI, 163) the cumulative incidence of locoregional recurrence at 5 years was 10.1 per cent in the CI group and 6.9 per cent in the LI group (P = 0.143). The cumulative incidence of distant metastasis at 5 years was 30.8 per cent in the CI group and 18.6 per cent in the LI group (sub-HR = 1.78; 95 per cent c.i. 1.14 to 2.78, P = 0.010). The disease-free survival (DFS) in each group was 59.7 and 69.9 per cent respectively (P = 0.157), and overall survival (OS) rates at 5 years were 73.6 versus 77.9 per cent (P = 0.476).

Conclusion: Incidence of distant metastasis decreased with an interval between CRT and surgery exceeding 8 weeks, but this did not impact on DFS or OS.

Registration number: NCT03287843 (http://www.clinicaltrials.gov).

© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.

Figures

Fig. 1
Fig. 1
CONSORT flow diagram Classic interval group (28–56 days), long interval group (57–84 days). CI, classic interval; LI, long interval; TME, total mesorectal excision.
Fig. 2
Fig. 2
Cumulative incidences of locoregional recurrence and distant metastasis among 322 patients randomly assigned to classic interval (CI) and long interval (LI) groups using competing risk regression analysis for events a Locoregional recurrence. b Distant metastasis.
Fig. 3
Fig. 3
Overall survival and disease-free survival among 322 patients randomly assigned to classic interval (CI) or long interval (LI) groups using Kaplan–Meier estimation a Overall survival. b Disease-free survival.

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