Comparing outcomes following total neoadjuvant therapy and following neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer

Abstract

Background: There is recent interest in treating locally advanced rectal cancer (LARC) patients with total neoadjuvant therapy (TNT). However, whether TNT is associated with improved overall survival (OS) remains unknown. This study compares outcomes following TNT and following neoadjuvant chemoradiation therapy (nCRT) in patients with LARC, clinically defined cT3/4 or node positive disease, using the National Cancer Database.

Methods: LARC patients diagnosed between 2004-2015 were included. TNT was defined as multi-agent chemotherapy given at least 2 months before RT followed by pre-operative chemoradiation therapy and definitive surgery without adjuvant chemotherapy. nCRT was defined as pre-operative RT and chemotherapy started within 2 weeks from each other followed by definitive surgery with or without adjuvant chemotherapy. Kaplan-Meier curve with logrank test and multivariable Cox proportional hazards regression modelling were used to analyse the primary endpoint of overall survival (OS). Multivariable logistic regression modelling was used for secondary outcomes to determine if TNT is associated with pathological complete response (pCR), defined as ypT0N0, and negative circumferential resection margin (CRM).

Findings: Data from 372 TNT patients and 707 nCRT patients were analysed after a 2:1 propensity matching with replacement. Kaplan-Meier curve showed that OS with TNT was comparable to that with nCRT (p = 0•16). The 5-year OS rates for TNT and nCRT were 73•6% vs. 78•5% (p = 0•20). Multivariable Cox proportional hazards regression modelling confirmed no difference in OS between TNT and nCRT (HR = 1•21, p = 0•25). With TNT, 16•9% patients achieved pCR, whereas 13•1% patients achieved pCR with nCRT (p = 0•12). TNT was not found to be significantly associated with pCR (OR = 1•36, p = 0•13) or negative CRM (OR = 1•77, p = 0•19) in multivariable logistic regression modelling.

Interpretation: With results from current clinical trials pending, our data suggested that TNT and nCRT resulted in similar survival, while TNT led to higher pCR and CRM negative rate, albeit not statistically significant.

Keywords: National Cancer Database; Total neoadjuvant therapy; locally advanced rectal cancer; neoadjuvant chemoradiation.

Fig. 1

CONSORT diagram illustrating the patient selection for this study. TNT was defined as (1) RT started at least 60 days after chemotherapy (2) Multi-agent chemotherapy (3) No chemotherapy after surgery. nCRT was defined as (1) Not receiving TNT (2) RT started within 14 days of chemotherapy induction.

Fig. 2

The overall survival of patients receiving TNT and nCRT for the unmatched and matched cohorts. Number of patients at risk zero, two, four, six, eight, and ten years from diagnosis are displayed at the bottom. No statistically significant difference was found in either cohort (logrank p = 0•85; Wilcoxon-Breslow p = 0•59 for the unmatched cohort, and logrank p = 0•16; Wilcoxon-Breslow p = 0•80 for the matched cohort).