The whole course of neoadjuvant treatment for rectal cancer: the order of chemotherapy and radiochemotherapy

This article comes from the NEJM Journal Watch Sequencing of Total Neoadjuvant Therapy for Rectal Cancer.
The review author: David H.
Ilson, MD, PhD.
Compared with chemotherapy followed by radiotherapy and chemotherapy, the reverse order is improved.
It improved the pathological complete remission rate, and did not have a negative impact on disease-free survival, toxicity and quality of life
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The whole course of neoadjuvant therapy (administration of chemotherapy and radiotherapy [CRT] and chemotherapy [CT] before surgery) has been shown to increase the clinical and pathological complete remission rate (PCR)
.

However, the best solution for CRT and CT in this situation has not yet been determined
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A previous multicenter, randomized phase 2 trial in Germany enrolled 306 patients with stage II or III rectal cancer who received a full course of neoadjuvant therapy (CAO/ARO/AIO-12; J Clin Oncol 2019; 37:3212).
The results showed that the PCR rate (primary endpoint) of CT after CRT (5-FU + oxaliplatin combined with radiotherapy) was higher than the reverse sequence (25% vs.
17%), and the surgical outcomes of the two sequences were comparable
.

More than 80% of patients have clinical stage T3 and N1-2 stages of rectal cancer, and 41% of the tumors are ≤5 cm from the anal margin
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Now, researchers have conducted a second analysis of the CAO/ARO/AIO-12 trial
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During a median follow-up of 43 months, the 3-year disease-free survival rate of CRT followed by CT and the reverse order was similar (73%), the rate of local recurrence (5% and 6%), and the rate of distant metastasis (16% and 18%) ) And overall survival rates (88% and 92%) are also similar
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There was no difference in the quality of life and long-term toxicity index between the two groups
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Comment on this trial to supplement the supporting evidence for the whole course of neoadjuvant treatment of rectal cancer
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The results show that CT after CRT does not harm the long-term outcome, and giving CRT first may achieve a higher PCR rate
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This sequence of treatment may increase the application of non-surgical treatments for rectal cancer
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Fokas E et al.
Chemoradiotherapy plus induction or consolidation chemotherapy as total neoadjuvant therapy for patients with locally advanced rectal cancer: Long-term results of the CAO/ARO/AIO-12 randomized clinical trial.
JAMA Oncol 2021 Nov 18; [ e-pub].
(https://doi.
org/10.
1001/jamaoncol.
2021.
5445) NEJM Journal Watch is published by NEJM Group.
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