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Neoadjuvant Radiotherapy vs Up-Front Surgery for Resectable Locally Advanced Rectal Cancer
Po-Chuan Chen1, Avery Shuei-He Yang2,3, Alessandro Fichera4
1Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
JAMA Network Open
|May 7, 2025
Summary
Neoadjuvant radiotherapy (NRT) followed by surgery improves survival for locally advanced rectal cancer (LARC) but increases permanent stoma rates. NRT benefits were not seen in upper rectal cancer, suggesting caution for this group.
Area of Science:
- Oncology
- Surgical Oncology
- Radiotherapy
Background:
- Current guidelines recommend neoadjuvant radiotherapy (NRT) followed by surgery for resectable locally advanced rectal cancer (LARC).
- Recent studies question the oncological benefits of NRT for middle or lower rectal cancer.
- The optimal treatment strategy for resectable LARC remains under investigation.
Purpose of the Study:
- To compare the oncological and surgical outcomes of NRT followed by surgery versus up-front surgery for resectable LARC.
- To evaluate the impact of tumor location on treatment outcomes.
Main Methods:
- A cohort study using a target trial emulation framework with nationwide registries in Taiwan.
- Included patients with resectable LARC (cT1-2N1-2, cT3Nany) undergoing curative resection between 2014-2017.
- Primary outcomes included overall survival (OS) and local recurrence (LR); secondary outcome was diverting stoma rates.
Main Results:
- NRT followed by surgery was associated with improved 3-year OS rates (88.5% vs 85.2%) but higher permanent diverting stoma rates (20.6% vs 11.1%) compared to up-front surgery.
- Local recurrence rates were similar between groups (5.7% vs 6.6%).
- NRT benefits were observed in middle/lower rectal cancer but not upper rectal cancer, where stoma rates were significantly higher with NRT.
Conclusions:
- NRT followed by surgery improves oncological outcomes for overall resectable LARC but at the cost of increased permanent stoma rates.
- NRT demonstrated no benefit for upper rectal cancer and was associated with increased harm (stoma nonreversal).
- Caution is advised when considering NRT for upper rectal cancer due to potential harm and lack of oncological benefit.
